Radiation of a large scalp carcinoma poses an inherent risk of failure due to the large surface area and the progressive devascularization of the center of the treatment area. Radiation strips the blood supply from the periosteum and the surrounding scalp leading to hypoxia and radioresistance of tissues. The risk would be increased with scalp scarring and previous treatments. Is radiation the only reasonable option in advanced age? Surprisingly no. Local anesthesia of the scalp can be achieved with reasonable ease allowing Mohs excision to take place even in advanced age. If a patient cannot tolerate local anesthesia, adding IV sedation / anesthesia safely smooths out the process. What is more surprising for some is that skin carcinoma involving calvarial bone can be easily treated. With minimal IV anesthesia, the outer table of the calvarium can be resected. This is possible due to lack of sensory innervation of the skull. Reconstruction can be a challenge, but reasonable options exist including skin grafts, flaps, or simply leaving exposed calvarium!
For clinical example, see the Tumor Conference Case “Recurrent Squamous Cell Carcinoma of the Scalp”.
