Coral Martes Villalobos
Iván Pérez Vicente, MD

Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico
University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico

Introduction

Basal cell carcinoma (BCC) is the most prevalent skin cancer worldwide, with its incidence steadily increasing. In 2005, skin cancer affected 6,568 individuals in Puerto Rico, with BCC as the predominant type. As skin malignancies rise, treatment modalities have diversified, with Mohs micrographic surgery (MMS) serving as the gold standard for high-risk anatomical locations on the head and neck. MMS ensures precise margin control, preserving normal tissue while achieving a 99% cure rate. However, surgical site infections (SSIs) remain a common postoperative complication, leading to significant morbidity, delayed healing, increased healthcare costs, and cosmetic impairment. High-risk scenarios include skin grafting, nasal flaps, and wedge repairs. Staphylococcus aureus is the most common causative organism, with endogenous nasal carriage tripling the risk of SSI.

Description

We present the case of an 82-year-old female who underwent two-stage MMS for BCC on the right supratip of the nose, reconstructed using crescentic advancement flaps with layered closure. Surgery was uneventful, but within a week, she developed a purulent SSI, unresponsive to clindamycin. She was referred to the emergency department with frontal cellulitis, periorbital swelling, fever, and chills. Laboratory findings revealed leukocytosis, neutrophilia, and elevated inflammatory markers. CT imaging showed diffuse thickening across the right maxillary region, extending to preseptal tissues but sparing the globe. Empiric antibiotics were initiated before culture results confirmed methicillin-susceptible Staphylococcus aureus (MSSA), prompting a switch to doxycycline. Within six days, swelling and suppuration improved, with partial reopening of the right eye, though minor visual blurring persisted. She was discharged on oral doxycycline with outpatient wound care.

Lessons Learned / Conclusions

This case highlights the serious complications of SSIs in MMS, emphasizing the need for tailored preoperative protocols and rigorous postoperative prophylaxis to minimize infection risks and optimize patient outcomes.

Keywords

Surgical site infections, Mohs micrographic surgery, MSSA, Basal cell carcinoma