Sir: Surgeons who excise basal cell carcinomas of the head and neck have long struggled with the problem of the occasional positive margin. One purported solution is the technique of delineating curettage as an adjunct to presurgical tumor definition.1,2 In our application of this method, lateral margins are defined with a skin-marking pencil and then all tissue is curetted that feels different from normal tissue or until the premarked lateral margins are encountered. We used delineating curettage from January 20, 2004, until September 15, 2005, in 334 sequential cases in 233 patients ranging in age from 31 to 93 years (mean age, 75.2 years). There were 219 men and 115 women with primary basal cell carcinoma of the head and neck, either as a confirmatory biopsy or immediately preoperatively. The curetted site was excised with mean minimal lateral margins of 0.3 mm and deep margins to at least the mid subcutis. All specimens were placed in formalin and examined according to accepted protocols by board-certified dermatopathologists (Ackerman Academy of Dermatopathology, New York, N.Y.) for margins and histopathologic subtype. Results are detailed in Tables 1 through 3. Tumor-free margins were reported in 324 of 334 cases (97.0 percent). Two sites demonstrated significantly higher rates of marginal tumor involvement than the remaining: five of 55 cases (9.1 percent) (p = 0.004) on the lower third of the nose and two of 13 cases (15.4 percent) on the temple (p = 0.007). The rate of aggressive subtypes was 78 of 334 (23.4 percent). Nevertheless, we did not find a significantly higher rate of such subtypes in cases with marginal involvement or recurrence. Suspected recurrences underwent biopsy during 2783 reexaminations. Basal cell carcinomas within 0.5 cm of the original site were recorded as recurrences. Mean follow-up of 995 days disclosed four recurrent cases (1.2 percent).Table 1: Tumor Location DataTable 2: Summary of Lateral Margins DataTable 3: Summary of the 10 Cases with Positive MarginsWe believe that a 9.1 percent rate of positive margins on the lower nose, where complicated closure is the norm, is unacceptable. This site, in our opinion, requires frozen section examination, wider margins, or Mohs’ surgery before repair. Furthermore, although a 97 percent rate of tumor-free margins is encouraging, one must ultimately compare that to the potential of even higher rates of marginal clearance of tumor and a low false-negative rate after Mohs’ surgery. However, excluding the lower nose, this slight advantage comes with increased cost and a substantial increase in patient time and inconvenience. Most of the cases in this study required less than 40 minutes in the office and none required more than 1 hour. It is possible that the success in obtaining low rates of positive margins and recurrences may be attributable to factors unrelated to delineating curettage itself. Contemporary reports show a high percentage of tumor-free margins (95 to 98 percent) when excising primary basal cell carcinomas of the head and neck with lateral margins of between 2 and 4 mm when using visual delineation alone.3–5 Accordingly, we believe that careful and disciplined examination has also contributed to the results presented in this article. Nevertheless, the easily learnable technique of delineating curettage, which adds little time and no extra cost, may be a useful adjunct before excision in some cases of basal cell carcinoma of the head and neck. Thomas Connelly, M.D. Stuart, Fla. Anthony Dixon, M.B.B.S., F.A.C.R.R.M. Geelong, Victoria, Australia