For an elderly patient with basal‑cell carcinoma of the cheek, dementia/Alzheimer’s disease and significant cardiac, pulmonary and metabolic comorbidities who wants surgery, what is the appropriate surgical management and peri‑operative considerations?

Surgical Management of Cheek BCC in Elderly Patient with Dementia and Multiple Comorbidities

For this elderly patient with basal cell carcinoma on the cheek who desires surgery, Mohs micrographic surgery is the definitive treatment of choice, achieving 99% cure rates for primary facial BCC while maximizing tissue preservation critical for cosmetic outcomes. 1, 2

Why Surgery is Appropriate Despite Comorbidities

The cheek location automatically classifies this BCC as high-risk regardless of size or clinical appearance, because it lies within the facial H-zone designated by the National Comprehensive Cancer Network (NCCN). 1, 2 This high-risk classification mandates definitive treatment rather than observation, as untreated BCC causes progressive local tissue destruction. 3

Critical Peri-operative Considerations for This Patient

The combination of dementia/Alzheimer's disease with cardiac, pulmonary, and metabolic comorbidities requires careful anesthetic planning:

• Mohs surgery is typically performed under local anesthesia only, making it feasible even for patients with significant cardiac and pulmonary disease who cannot tolerate general anesthesia. 4, 5
• The staged nature of Mohs surgery allows rest periods between excision stages, accommodating patients with limited tolerance for prolonged procedures. 4
• Dementia/Alzheimer's disease requires assessment of the patient's capacity to cooperate during awake surgery and remain still during the procedure. If cooperation is questionable, consider involving family/caregivers in pre-operative counseling and having them present during the procedure for reassurance.

Mohs Micrographic Surgery: The Gold Standard

Mohs surgery achieves 5-year cure rates of 99% for primary facial BCC compared to approximately 88% with standard excision, while examining 100% of surgical margins through en face horizontal sectioning. 1, 6, 2

Key Advantages for This Patient

• Real-time margin control allows immediate re-excision of any positive margin during the same procedure, eliminating the need for staged surgeries that would require multiple anesthetic exposures. 2
• Maximal tissue preservation is achieved through precise tumor mapping, critical for facial cosmesis and minimizing the size of surgical defects requiring reconstruction. 1, 2
• Complete peripheral and deep margin assessment during surgery prevents the 26.8% recurrence risk associated with positive margins. 1, 2

Alternative if Mohs Surgery Unavailable

If Mohs surgery is not accessible, standard excision with intra-operative frozen section margin control and 5-10mm clinical margins is the recommended alternative, though it carries approximately 10% recurrence risk versus 1% with Mohs. 1, 2

Requirements for Standard Excision

• Complete circumferential peripheral and deep margin assessment (CCPDMA) using frozen sections must be performed intra-operatively. 2
• Never close complex facial defects before confirming negative margins, as tissue rearrangement obscures residual tumor. 2
• Clinical margins of 5-10mm are required for high-risk facial BCC—substantially wider than the 4mm margin used only for low-risk trunk/extremity lesions. 1, 2

Treatments That Are Contraindicated

The following modalities must be avoided for facial BCC in the H-zone:

• Curettage and electrodesiccation show 47% residual tumor rates on facial sites and 19-27% recurrence rates—unacceptable for high-risk facial locations. 4, 1, 2
• Topical therapies (imiquimod, 5-fluorouracil, photodynamic therapy) are reserved exclusively for superficial, low-risk BCCs on non-facial sites. 2
• Cryotherapy carries 6-39% recurrence rates and is inappropriate for facial BCC. 2
• Radiation therapy should only be considered if the patient refuses surgery or develops absolute contraindications to anesthesia, as it carries 7.5% recurrence versus 0.7% for surgery, with 56% of recurrences occurring beyond 5 years. 2

Specific Peri-operative Management Algorithm

Pre-operative Assessment

1. Cardiology clearance for local anesthesia with epinephrine: Assess cardiac stability for vasoconstrictors, though local anesthesia alone rarely requires formal clearance unless cardiac status is severely decompensated.
2. Pulmonary assessment: Ensure patient can tolerate supine positioning for 1-3 hours (typical Mohs procedure duration). 5
3. Cognitive assessment: Evaluate capacity to consent and cooperate during awake surgery. Consider involving psychiatry or neurology if capacity is questionable.
4. Medication review: Continue anticoagulation/antiplatelet therapy in most cases, as bleeding risk with facial surgery under local anesthesia is manageable. 4

Intra-operative Considerations

• Use minimal sedation or none: Local anesthesia alone is preferred to avoid respiratory depression in patients with pulmonary disease and cognitive impairment. 4
• Monitor vital signs continuously: Cardiac and pulmonary comorbidities warrant continuous pulse oximetry and blood pressure monitoring.
• Plan for caregiver presence: Dementia patients often tolerate procedures better with familiar faces present for reassurance.

Post-operative Management

• Arrange home health nursing if dementia impairs wound care compliance: Facial wounds require meticulous care to prevent infection and optimize healing.
• Schedule close follow-up at 1 week, 1 month, then every 3-6 months for 5 years, then annually for life, as 56% of recurrences occur beyond 5 years. 2
• Educate caregivers on signs of recurrence: New nodules, non-healing areas, or changes at the surgical site require immediate evaluation.

Critical Pitfalls to Avoid

• Do not treat this as low-risk BCC based on clinical appearance—facial location alone mandates high-risk management. 1, 2
• Do not use 4mm margins for facial BCC; this margin is appropriate only for low-risk trunk/extremity lesions. 1, 2
• Do not assume well-defined borders mean limited subclinical extension—BCCs characteristically show asymmetrical subclinical spread beyond visible margins. 1
• Do not defer surgery solely due to age or comorbidities—untreated facial BCC causes progressive disfigurement and functional impairment that severely impacts quality of life. 3