Treatment of Cutaneous

Melanoma of the Face by Mohs

Micrographic Surgery

DOI: 10.1007/s10227-002-1161-7
J Cutan Med Surg 2003; 2530

Tasha N. Bienert,1 Martin J. Trotter,2,3 and John P. Arlette1

Abstract
Background: The treatment of cutaneous malignant melanoma of the face presents a
challenge to ensure eradication of disease with maximum preservation of tissue. Mohs
micrographic surgery provides a means for histologically controlled removal of malignant melanoma.
Objective: This study evaluates the efficacy of Mohs micrographic surgery, at a single
institution, for the treatment of facial melanoma and assesses the accuracy of margin
control by frozen section techniques.
Methods: Ninety-seven patients with biopsy-confirmed melanoma in situ or invasive
melanoma of the face were treated by Mohs micrographic surgery over a 6-year period.
In 25 patients, tissue margins defined as negative for melanoma at the time of frozen
section were re-evaluated on permanent section histology of formalin-fixed, paraffinembedded tissue.
Results: Ninety-two of 97 patients had followup information available (872 months;
mean 33 months). There were no cases of local recurrence. Eighty-nine of the 92 patients were alive and well with no evidence of disease. One patient died of metastatic
melanoma. In situ or invasive melanoma was not identified on permanent sections of 117
tissue margins which had been interpreted as negative on frozen section.
Conclusion: Mohs micrographic surgery appears to be an effective treatment for facial
melanomas. Our study showed complete correlation between frozen section tissue
margins and permanent section controls.

Sommaire
Antecedents: Le traitement des melanomes du visage est un defi en soi vu quil faut
veiller a` eradiquer comple`tement la maladie tout en enlevant le moins de tissu possible.
Or, la chirurgie micrographique de Mohs presente un moyen denlever les melanomes
qui soit histologiquement controle.
Objectif: Cette etude, menee en un seul etablissement, evalue lefficacite de la chirurgie micrographique de Mohs dans le traitement des melanomes du visage ainsi que
lexactitude de la marge de controle des techniques de coupe en congelation.
Methodes: 97 patients souffrant de melanome du visage in situ ou envahissant, confirme par biopsie, ont ete traites par chirurgie micrographique de Mohs sur une periode
de 6 ans. Chez 25 des patients, les prele`vements de tissu qui ont ete juges libres de
melanome au moment de la coupe en congelation ont ete reevalues sur des sections
permanentes fixeesen formol et imbibees de paraffine.
Resultats: Des donnees de suivi etaient disponibles pour 92 des 97 patients (sur 8 a` 72
mois; moyenne de 33 mois). Aucun cas de recurrence locale na ete rapporte. 89 de ces 92
patients etaient vivants et ne presentaient aucun signe de maladie. Un patient est decede a`
la suite dun melanome. On na trouve aucun signe de melanome in situ ou envahissant
1

Department of Medicine, University of Calgary, Calgary, Alberta, Canada

Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
3
Calgary Laboratory Services, Calgary, Alberta, Canada
Online publication: 27 November 2002
This study was presented in part at the Canadian Dermatology Association, 76th Annual Conference, Halifax, Nova Scotia, 27 June1 July 2001
Correspondence to: John P. Arlette, 1107 7th Avenue, SW, Calgary, Alberta, Canada T2P 1B2, E-mail: arlette@johnarlette.com
2

25

26

Journal of Cutaneous Medicine and Surgery

Volume 7 Number 1 January 2003

sur des fragments de 117 tissus dont la coupe en conge lation a montre des re sultats
ne gatifs.
Conclusion: La chirurgie micrographique de Mohs serait un traitement efficace contre
les me lanomes du visage. Notre e tude a montre une correlation directe entre les coupes
en conge lation et les sections tissulaires sous contro le.

he treatment of cutaneous malignant melanoma of

the face, including melanoma in situ and invasive
melanoma, presents a challenge when the goal is eradication of malignant disease with maximum preservation
of tissue. Histologically, melanoma in situ on the face
most commonly has a lentigo maligna pattern (LM) but
may also show a superficial spreading pattern (MIS).
Invasive melanoma may have an associated LM in situ
component (LMM), a superficial spreading in situ component (MM), or no in situ component (nodular MM).
Therapeutic guidelines for MIS and LM recommend a 5mm margin from the clinical edge of the lesion. For invasive melanoma, a 10-mm margin is recommended for
lesions with Breslow thickness <1.00 mm,1,2 although
recent guidelines suggest that a 10-mm margin may be
adequate for lesions <2.00 mm deep.3
The treatment of LM and LMM has included
conventional surgery as well as the destructive modalities of cryotherapy and radiotherapy.47 Incomplete
removal/destruction because of unrecognized, subclinical extension of melanoma cells can result in lesion
recurrence. Previous studies have identified the margins
of LM by sequential removal of levels of tissue around
lesions using fixed histopathologic specimens and
HMB-45 monoclonal antibody staining.8 There have
been a number of studies using rush paraffin embedded
tangential sections as well as immunoperoxidase staining and staged excision of LM and LMM.912 The use
of Mohs micrographic surgery aided by rush permanent
sections has been demonstrated to successfully treat
LM and LMM.1316 In the present study, cases of LM,
MIS, LMM, and MM were treated with Mohs micrographic surgery by the fresh frozen tissue technique.
Clinical followup, demographics, evaluation of cases,
and use of permanent section quality control are presented.

Methods and Materials

Subject Selection
Ninety-seven patients with confirmed LM, MIS, LMM,
and MM were treated by Mohs micrographic surgery
between January 1994 and December 2000. All patients
had an incisional biopsy processed by standard methods
and interpreted by a dermatopathologist as melanoma in
situ or invasive melanoma, using conventional criteria.17,18 The histologic criteria for diagnosis of LM are
controversial, but in this study we used the modified
criteria suggested by Cohen.19 Only patients with clinical
lesions larger than 1 cm were considered for treatment.

Patient followup was conducted by repeat clinical inspection (85/97), letter followup, phone survey, or contact with the referring physician. All patients were
American Anesthesia Society (ASA) Class I (healthy patient, no medical problems) or Class II (mild systemic
disease).

Mohs Micrographic Surgery Method

The clinical border of the lesion was demarcated under
Woods light illumination in a darkened room.20 A 5-mm
margin was then outlined beyond this border. The lesion
was excised with an incision tangential to the skin surface
carried out through fat. This resection specimen was
mapped and divided as in the classic Mohs micrographic
surgical technique. The central disk ("debulk" specimen)
was submitted for a routine permanent section pathology
examination for determination of the presence or absence
or dermal invasion and to evaluate prognostic factors if
invasive melanoma was present. Fresh frozen sections
were obtained from the entire peripheral margins and
stained with hematoxylin and eosin and then examined
microscopically. If margins were considered positive, a
further 2-mm margin was removed from the area of
positivity. The subsequent levels of tissue were again
processed for fresh frozen sections and stained. Once the
margins were considered to be free of tumor, the defect
was appropriately repaired.
Histopathologic Denition
Tissue margins were involved if in situ or invasive malignant melanoma was present. The lower limit of positivity was defined as the presence of groups of 3 atypical
melanocytes present together (nested) or in close proximity (single-cell hyperplasia) along the epidermal basal
cell layer (Fig. 1). The presence of isolated, single atypical melanocytes, mitoses, or starburst cells was not sufficient to establish margin involvement. The definition of
melanocytic atypia included variable nuclei size and
shape, nuclear hyperchromatism, and granular cytoplasm, often with retraction artifact. No attempt was
made to examine for inflammatory changes or papillary
dermal fibrosis.
Quality Control
Twenty-five consecutive cases, in which negative margins
had been diagnosed by frozen section at the time of Mohs
surgery, underwent assessment of formalin-fixed, paraffin-embedded sections. For margins considered negative
at the time of frozen section, tissue blocks were thawed

T.N. Bienert et al.

27

Cutaneous Melanoma of Face

FIGURE 1 In situ malignant melanoma, lentigo maligna pattern

showing confluent proliferation of large atypical melanocytes in
basal epidermis (hemotoxylin and eosin, 125).

TABLE I
Lesion demographics for facial melonoma
Type of lesion
Lentigo maligna
Lentigo maligna
melanoma
Malignant melanoma
in situ
Invasive malignant
melanoma

No. of cases

Female

Male

Mean age
(range) (yr)

67
8

33
5

34
3

68 (4189)
72 (5186)

62 (4677)

13

58 (2284)

Depth of Invasion
The lentigo maligna melanomas had an average Breslow
thickness of 0.60 mm with a range of 0.241.60 mm.
Invasive malignant melanomas had an average Breslow
thickness of 0.81 mm with a range of 0.493.00 mm.
and cleaned of mounting medium, and then the tissue
placed negative side down on filter paper in formalin.
After formalin fixation, these negative sections were then
processed in the usual way and embedded in paraffin with
the negative side up; then 5-lm sections were cut and
stained with hematoxylin and eosin. Slides were reviewed
by a dermatopathologist.

Results
Patient Demographics and Followup
Complete followup information was available on 92/97
patients treated (95%); the followup interval was 8 and 72
months (mean 33 months). Two patients had died from
natural causes and had no evidence of local disease at the
time of death. In An 84-year-old male with a level IV,
Breslow thickness 3.0 mm lesion on the left side of the
nose died from metastatic malignant melanoma. The
lesion had been present for one year at the time of diagnosis. There was no evidence of local recurrence.
Eighty-nine patients were alive and well without disease
at the end of the study period.
Fifty patients were female and 47 were male. The
average age was 68 years with a range of 2289 years. All
patients were Caucasian with skin types I, II, or III.
Lesion Demographics
The number of primary lesions was 83, and 14 lesions
were recurrent and had been previously excised. Data is
summarized in Table I. All three patients <30 years of
age had invasive malignant melanomas. Lesion sites are
given in Table II. The most common location of these
melanomas was the cheek. Ear lesions were more
common in males and forehead lesions were more
common in females. There was no correlation between
gender and the side on which the melanoma occurred
(right versus left).

Mohs Micrography Surgery Data

The average number of levels of tissue removal in order
to obtain a tumor-free margin was 2.75 with a range of
26 levels. There was no difference in the average
number of levels of tissue needed to remove any of the
histological subtypes of melanoma. The size of the
surgical defect was measured across the two largest
perpendicular diameters of the defect. Defect size was
adjusted for its approximate elliptical shape by multiplying the two measured diameters of the postoperative
defect using the mathematical formula ((p)) L W.21
The defect size of LM averaged 11.91 cm2, for LMM
16.47 cm2, for MIS 9.00 cm2, and for MM 9.69 cm2.
Overall, the largest lesions were found on the forehead,
with an average defect of 15.7 cm2, and the smallest
lesion were present on the nose, with defects averaging
5.86 cm2.
Quality Control
Formalin-fixed, paraffin-embedded permanent sections
of 117 tissue margins from 25 consecutive cases were
examined. All margins had been read as negative on
frozen section at the time of Mohs surgery. Invasive or in
situ melanoma was not identified on any of the permanent
sections. One out of 117 margins (0.9%) showed a small,
isolated focus of atypical melanocytic hyperplasia (scattered single atypical melanocytes in basal epidermis) on
deeper levels. Thirty-one of 117 levels (26%) showed
increased melanocytic number in basal epidermis, consistent with melanocytic hyperplasia in sun-damaged skin
(Fig. 2). Foci of actinic keratosis were identified in 17/117
levels (15%).

Discussion
This study reviews a series of patients treated for cutaneous melanoma of the face using a fresh frozen tissue

28

Journal of Cutaneous Medicine and Surgery

FIGURE 2 Mild melanocytic hyperplasia in sun-damaged skin in

a negative margin from lentigo maligna removal by Mohs
procedure. Relatively small melanocytes, without atypia, are
evenly distributed inbasal epidermis. Grouped melanocytes or
nest formation are absent (hematoxylin and eosin, 125).

TABLE II
Anatomic site of facial melanomas
Site
Cheek
Nose
Ear
Forehead
Lip

No. of cases

Female

Male

45
18
18
14
2

20
9
4
10
2

25
9
14
4
0

technique. Mohs micrographic surgery offers the advantage of limiting tissue removal in anatomically sensitive
areas by the direct histological observation of the peripheral margins immediately adjacent to proven malignancy. This permits preservation of the maximum
amount of tissue in the achievement of the highest possible cure rate. There was no evidence of local recurrence
of cutaneous melanoma in any of the 92 patients followed
for a mean of 33 months.
Previous studies have evaluated the effectiveness of
frozen section margins in the treatment of melanoma.22
Mohs micrographic surgery offers survival and metastatic rates as good as wide surgical excision, but allows
narrow margins and without the risk of local recurrence
because of incomplete excision.16 Mohs micrographic
surgery has been successful in the treatment of LM and
LMM in 45 patients whose surgery was aided by rush
permanent sections.13 Long-term followup over 58
months demonstrated one recurrence, giving a 97% cure
rate.14 Low-recurrence rates for LM/LMM treated by
Mohs surgery have also been documented by several
other groups (reviewed by Cohen).19 Similarly, a
square technique, using staged excision with permanent peripheral vertical section margin control, has
shown a very low local recurrence rate (1/150) but with

Volume 7 Number 1 January 2003

short-term (<5 years) followup.11,12 In comparison, conventional surgical excision has a reported recurrence rate
of 9% (reviewed by Cohen).19
The demographics of the patients and their lesions
are helpful in understanding the nature of this disease and
the imperative for selecting effective treatment. Facial
malignant melanomas occurred in a wide patient age
range. Patients with invasive malignant melanoma (nonLMM) had the youngest average age (58 years), and,
interestingly, patients with melanoma in situ (non-LM)
were older (average age 62 years) than those with invasive
lesions. Patients with invasive malignant melanoma often
gave histories of rapid appearance and growth of their
lesions. LM occurred at an average age of 68 years, four
years less than for LMM (72 years). No patient developed
LMM before the age of 50. Patients with LMM had the
longest history of gradual evolution of their lesions, some
up to 40 years. Although not statistically significant, the
mean age of patients with LMM was four years older
than patients with LM. All patients with LMM were >50
years of age, while the earliest age of diagnosis of LM in
this series was 41 years. These data support a progressive
change to invasive disease in these lesions over time.
Patients with LMM had an average lesion size of 16.47
cm2 versus LM patients with 11.91 cm2. These two factors (age at diagnosis and size of the defect) emphasize
the importance of early diagnosis and treatment of LM in
order to prevent progression to invasion and greater
surgical defect size.
Most authors consider LM a form of melanoma in
situ.19,23 There have been attempts to subdivide LM into
more aggressive,24 or less aggressive lesions,24 however,
these variants likely represent points on the progression of atypical melanocytic hyperplasia to invasive melanoma.25 Although the risk of progression of LM to
LMM is thought to be low,26 simply following LM does
not prevent the potential for the development of invasive
malignant melanoma.27 This is especially important in
light of the fact that LMM has the same prognosis as any
melanoma of similar depth of invasion.28
The site of lesions revealed that men were three times
more likely to develop cutaneous melanoma on the ear
than women. This is likely related to males having little
protection on their ears through life and women more
often having their ears protected by hair. It is more difficult to hypothesize why women were twice as likely than
men to develop cutaneous melanoma on the forehead,
although men may be more disposed than women to
wearing a cap to cover their forehead. Continuous sunlight exposure leads to melanoma development on the
face in older age group,29 and this is supported by our
findings that the cheek and nose were the most common
sites for developing facial cutaneous melanoma, with
equal distribution between men and women and no
predilection for right versus left side of the face. The
epidemiology of cutaneous melanoma of the head and
neck also shows that the mean age at diagnosis is older

T.N. Bienert et al.

Cutaneous Melanoma of Face

than for patients with cutaneous melanoma of non-headand-neck sites.30

The present study describes quality control of frozen
section negative margins by permanent section evaluation
of 117 margins in 25 consecutive patients. Once negative
margins had been obtained by the fresh frozen section
technique, the tissue was then examined by a dermatopathologist after formalin fixation and paraffin embedding.
A major problem in assessment of both frozen and permanent sections is the differentiation of melanoma in situ
from melanocytic hyperplasia in sun-damaged skin
(solar melanocytosis). In one study,31 the most valuable
criteria for the diagnosis of melanoma in situ, as opposed
to melanocytic hyperplasia, were (1) nests of melanocytes,
(2) irregular distribution of melanocytes, (3) descent of
melanocytes far down adnexal epithelial structures, (4)
irregular distribution of pigment, (5) presence of melanocytes above the epidermal basal layer, (6) a high
number of melanocytes, and (7) pleomorphism and
atypical nuclei. These criteria also allow the differentiation of melanoma in situ from facial solar lentigines,
which may show a mild increase in melanocyte number
compared with normal-sun-exposure facial skin.
Using the above criteria, no features of invasive or in
situ melanoma were detected in any of the blocks submitted for permanent section evaluation. In one margin, a
small, isolated focus of atypical melanocytic hyperplasia
was noted, but only after deeper levels into the block had
been examined. The true surgical margin was uninvolved.
This type of quality control further substantiates the
usefulness of classic Mohs micrographic surgical techniques in the removal of cutaneous melanoma.
This analysis demonstrates that Mohs micrographic
surgery is an effective treatment for the local control of
cutaneous melanoma of the face. There were no local
recurrences during this study, although a followup period
of 510 years will be required for definite conclusions.
There was complete correlation between fresh frozen
preparation and permanent section histology of tissue
specimens. Examination of the data reveals that lentigo
maligna melanoma occurs in the eldest group of patients
and results in the largest postsurgical defect.

Acknowledgments
The authors would like to thank the technologists in the office of
Dr. Arlette and at Calgary Laboratory Services for preparation of histologic material. Assistance with manuscript preparation was provided by Lori Hanninen.

References
1. Balch CM, Buzaid AC, Soong SJ, et al. Final version of the
American Joint Committee on Cancer staging system for cutaneous
melanoma. J Clin Oncol 2001; 19:36353648.
2. Houghton A, Coit D, Bloomer W, et al. NCCN Melanoma
Practice Guidelines. National Comprehensive Cancer Network,
Oncology (Huntingt) 1998; 12:153177.

29

3. Sober AJ, Chuang TY, Duvic M, et al. The Guidelines/Outcomes

Committee. Guidelines of care for primary cutaneous melanoma. J
Am Acad Dermatol 2001; 45:579586.
4. Gaspar ZS, Dawber RP. Treatment of lentigo maligna. Australas J
Dermatol 1997; 38:18.
5. SchmidWendtner MH, Brunner B, Konz B, et al. Fractionated
radiotherapy of lentigo maligna and lentigo maligna melanoma in
64 patients. J Am Acad Dermatol 2000; 43:477482.
6. Kuflik ED, Gage AA. Cryosurgery for lentigo maligna. J Am Acad
Dermatol 1994; 31:7578.
7. Tsang RW, Liu FF, Wells W, et al. Lentigo maligna of the head
and neck. Results of treatment by radiotherapy. Arch Dermatol
1994; 130:10081012.
8. Robinson JK. Margin control for lentigo maligna. J Am Acad
Dermatol 1994; 31:7985.
9. Clayton BD, Leshin B, Hitchcock MG, et al. Utility of rush paraffin-embedded tangential sections in the management of cutaneous
neoplasms. Dermatol Surg 2000; 26:671678.
10. Stonecipher MR, Leshin B, Patrick J, et al. Management of lentigo
maligna and lentigo maligna melanoma with paraffin-embedded
tangential sections: utility of immunoperoxidase staining and supplemental vertical sections. J Am Acad Dermatol 1993; 29:589594.
11. Johnson TM, Headington JT, Baker SR, et al. Usefulness of the
staged excision for lentigo maligna and lentigo maligna melanoma:
the square procedure. J Am Acad Dermatol 1997; 37:758
764.
12. Anderson KW, Baker SR, Lowe L, et al. Treatment of head and
neck melanoma, lentigo maligna subtype. A practical surgical
technique. Arch Facial Plast Surg 2001; 3:202206.
13. Cohen LM, McCall MW, Hodge SJ, et al. Successful treatment of
lentigo maligna and lentigo maligna melanoma with Mohs micrographic surgery aided by rush permanent sections. Cancer 1994;
73:29642970.
14. Cohen LM, McCall MW, Zax MH. Mohs micrographic surgery for
lentigo maligna and lentigo maligna melanoma. A follow-up study.
Dermatol Surg 1998; 24:673677.
15. Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision of
primary cutaneous melanoma. J Am Acad Dermatol 1997; 37:422
429.
16. Zitelli JA, Brown C, Hanusa BH. Mohs micrographic surgery for
the treatment of primary cutaneous melanoma. J Am Acad Dermatol 1997; 37:236245.
17. Price NM, Rywlin AM, Ackerman AB. Histologic criteria for the
diagnosis of superficial spreading malignant melanoma: formulated
on the basis of proven metastatic lesions. Cancer 1976; 38:2434
2441.
18. McCalmont TH. Melanoma and melanoma in situ: build a better
diagnosis through architecture. Semin Cutan Med Surg 1997;
16:97107.
19. Cohen LM. Lentigo maligna and lentigo maligna melanoma. J Am
Acad Dermatol 1995; 33:923936.
20. Reyes BA, Robins P. Woods lamp and surgical margins in malignant melanoma in situ. J Dermatol Surg Oncol 1988; 14:22.
21. Arlette JP, Carruthers A, Threlfall WJ, et al. Basal cell carcinoma of
the periocular region. J Cutan Med Surg 1998; 2:205208.
22. Zitelli JA, Moy RL, Abell E. The reliability of frozen sections in the
evaluation of surgical margins for melanoma. J Am Acad Dermatol
1991; 24:102106.
23. Dubow BE, Ackerman AB. Malignant melanoma in situ: the evolution of a concept. Mod Pathol 1990; 13:734744.
24. Flotte TJ, Mihm Jr MC. Lentigo maligna and malignant melanoma
in situ, lentigo maligna type. Hum Pathol 1999; 30:533536.
25. Tannous ZS, Lerner LH, Duncan LM, et al. Progression to invasive melanoma from malignant melanoma in situ, lentigo maligna
type. Hum Pathol 2000; 31:705708.
26. Weinstock MA, Sober AJ. The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol 1987; 116:303
310.
27. Kelly JW. Following lentigo maligna may not prevent the development of life-threatening melanoma. Arch Dermatol 1992;
128:657660.
28. Cox NH, Aitchison TC, Sirel JM, et al. Comparison between
lentigo maligna melanoma and other histogenetic types of malignant melanoma of the head and neck. Br J Cancer 1996; 73:940
944.

30

Journal of Cutaneous Medicine and Surgery

29. Elwood MJ, Gallagher RP. Body site distribution of cutaneous

malignant melanoma in relationship to patterns of sun exposure. Int
J Cancer 1998; 78:276280.
30. Gillgren P, ManssonBrahme E, Frisell J, et al. Epidemiological
characteristics of cutaneous malignant melanoma of the head and
neck a population-based study. Acta Oncol 1999; 38:1069
1074.

Volume 7 Number 1 January 2003

31. Weyers W, Bonczkowitz M, Weyers I, et al. Melanoma in situ

versus melanocytic hyperplasia in sun-damaged skin. Assessment of
the significance of histopathologic criteria for differential diagnosis.
Am J Dermatopathol 1996; 18:560566.
32. Andersen WK, Labadie RR, Bhawan J. Histopathology of solar
lentigines of the face: a quantitative study. J Am Acad Dermatol
1997; 36:444447.