We read with interest the paper by Hamada et al,¹ which draws a number of conclusions from a 5 year follow up study of 69 periocular basal cell carcinomas (BCCs) treated by conventional surgery and, in particular, suggests that there is no place for Mohs micrographic surgery (MMS) in patients with periocular BCCs. MMS is the serial saucerisation excision with mapped horizontal tissue sections examining 100% of the surgical margins to produce histological evidence of tumour negative margins. Unfortunately, the data included in the paper are incomplete and if such conclusions are to be considered, then further clarification is required.

Risk of BCC recurrence relates directly to the nature of the tumours treated.² The principal risk factors for recurrence include previous treatment, large tumour size, and an infiltrative or micronodular histological growth pattern. No information is given on the first two factors and the histological subtype was non-specified in approximately 45% of cases. We calculate from the data provided that the authors experienced a 19% 5 year recurrence rate in patients with a histologically infiltrative BCC.

If most of the “non-specified” tumours in Hamada’s series were small nodular tumours, as the paper implies, then Hamada’s series also differs significantly from other larger series in that it represents a group of patients with an inherently better prognosis. Other comments hint at this, in that 76% of BCCs were on the …