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Basal cell carcinoma in an elderly DM/HPT
88 year old man, a diabetic hypertensive presented to our facility with a raised lesion on the left cheek of a 2 years duration. Patient was initially refereed to regional teaching hospital where biopsy was done. The histologic confirmation of the diagnosis of the lesion led to the a course of radiotherapy. Patient stopped the follow up to the teaching hospital due to financial constraints .
He presented again 2year down the line expressing desire to have the lesion excised.
Examination :
Lesion was on the left cheek . most medial border just touching the left ala nasae. Lesion extended inferiorly and laterally in its longest axis 4cm , and 3cm in width. The edges were raised. The was a central depression which was bordered by hyperpigmented skin.  The rest of the lesion had normal color compared to the surrounding skin. Lesion was fixed to the skin, but was mobile over the underlying subcutaneous tissues. There was an encrusted lesion in the central depression.
Diagnosis : Basal cell carcinoma
Patient was assessed to have the excision with the best  cosmetic outcome. A decision was taken to excise the lesion with 0.5cm healthy margins . A rhomboid flap/ Limberg flap offered the best tissue coverage after excision of the flap.
Preoperative assessment : Patients’  blood pressure and sugar was well controlled on his routine medications.
Full blood counts , retroscreen, and sickling test were done and found to be normal
A consent form was thumb printed  by patient
Intraoperation details
Anaesthesia was provided by skin infiltration using xylocaine 2% and adrenaline. Lesion was mapped out along with rhomboid flap cover. Face was prepared rountinely with antiseptic solution and draped with sterile towels .
An roughly rhomboid incison was made around the lesion. The incision was carried down to the subcutaneous tissues , removing the cheesy necrotic tissue base of the ulcer. Haemostasis was secured with adrenaline soaked gauze. .
The limberg flap was with the base of the flap at the inferior and lateral aspect of the face which is more lax. Simple apposition of flap and defect  was done with vicryl 2/0 suture. Sterile dressing was applied
Post operative reviews
Patient recovered well without any complication. facial symmetry was satisfactory after discharge.
Literature review 
Basal cell carcinoma is a slow growing cancer of the sun exposed areas of the skin.it is a nonmelanocytic epithelial tumour that originates from the basal layer of the epidermis. It begins a nodule and progresses to an ulcer with rolled up edges and a central depression. it rarely metastasize .it is commoner in light skin people. face arms legs are places where the cancer can be found.
Ultraviolet rays from the sun or tanning beds  is the cause of BCC. The UV rays leads to damage of the skins DNA . This occurs over years leading to cancer formation. shave or punch biopsy of the lesion can provide adequate tissu e for histopathology
It has excellent prognosis but can lead to disfigurement if allowed to progress.
Treatment: Options include Moh’s surgery where the lesion is excised and the margins examined under a microscope, topical chemotherapy, radiotherapy, photodynamic therapy ,immunotherapy, systemic chemotherapy for distant metastasis,crytherapy, electrodessication and currettage