In contrast, pigmented variants in lighter-presenting skin type III–IV patients are quite conspicuous (Figure 3A). However, one should not conflate the border of clinically evident pigment with the border of the tumor. Subclinical extension is not uncommon in skin of color.7 True borders often extend beyond clinically apparent pigment (Figure 3B). Our group unequivocally performs curettage to aid in the identification of tumor borders in skin of color. Consistent accuracy and tumor clearance are of utmost importance, considering the disproportionately high morbidity and mortality associated with skin cancer in individuals with skin of color.3
Approach to Reconstruction following Mohs Micrographic Surgery in Skin of Color
There are several key considerations in the approach to reconstruction following MMS in skin of color. Surgeons should anticipate the risks of post-operative postinflammatory hyperpigmentation and keloids, which are inherently higher in skin of color.8
Post-Operative Postinflammatory Hyperpigmentation
Postinflammatory hyperpigmentation (PIH) is highly distressing and long lasting. In fact, data show that dyschromia is the most common patient outcome resulting in malpractice claims in dermatology.9 This is a salient finding, as surgeons may not associate dyschromia with substantial morbidity.
A literature search on the topic of post-operative PIH yields no results. Currently, no data exist regarding the incidence of postoperative PIH, and neither are there published guidelines to mitigate its development.
PIH is a result of increased melanin production and transfer to keratinocytes in response to tissue injury or cutaneous inflammation.10 Based on the current understanding of the etiopathogenesis of PIH, we propose that three key factors contribute to postoperative PIH – intraoperative injury, postoperative injury, and post-operative inflammation (Table 1).
Tumor extirpation inherently ‘injures’ the skin and triggers the wound healing cascade. Thus, some degree of PIH may be unavoidable in certain skin types in the setting of labile and reactive melanocytes. With the exception of tumor extirpation, all factors identified are modifiable. Though additional studies are needed, the authors propose that mitigation of these factors may decrease the risk or severity of post-operative PIH in individuals of color.
Excess wound edge manipulation, tissue strangulation, and hightension closures are missteps surgeons should take meticulous care to avoid in skin of color due to the risk of PIH. Eumelanin-rich skin is particularly unforgiving to surgical complications such as wound dehiscence and flap necrosis. The risk of dyschromia should be discussed pre-operatively while obtaining informed consent. The risk of allergic contact dermatitis to adhesives also warrants discussion. An acute eczematous reaction pattern may produce long standing PIH with lichenification in patients
