View at your own risk! Contains graphic images. This patient came to me for Mohs surgery for a pleomorphic dermal sarcoma (PDS) of the scalp. PDS is a rare and aggressive tumor with potential for recurrence and metastasis, and is considered to be a deeper variant of another entity called an atypical fibroxanthoma (AFX). I did scouting biopsies of some scaly papules in the area to make sure it had not spread beyond the initial lesion—luckily it had not. After I excised the tumor completely, I repaired the surgical defect with an O to Z rotational flap, which you can see has an excellent cosmetic result (last photo) in which you cannot see the scar, and the hair is intact. We discussed postoperative radiation as an “insurance policy,” however given that there is no definitive survival benefit reported in the literature and margins were clear, the patient and I opted against it and will monitor closely going forward. Surgical tips for this flap: 🍃The flap is undermined in the subgaleal plane, which has no nerve endings, so you actually only have to numb along the incision line and the patient can’t feel the rest. This greatly minimizes the amount of lidocaine/epinephrine needed to execute the flap. 🍃Design the curves in the direction of existing “cowlicks” so that hair curves grows in the correct direction once healed. 🍃 Using staples for the epidermal closure saves lots of time and doesn’t impact the overall cosmetic outcome. Written patient consent obtained to share these photos. #jacksonwy #jacksonhole #jacksonholedermatogist #thatdermlife #jacksondermatologist #mohssurgeon #dermatologist #skindoctor #dermatology #mohs #wyomingdermatologist #wyomingdermatology #wyoming #cowboystate #rotationflap #skincancer #skinguru #boardcertifieddermatologist #dermatologicsurgery