Complete surgical removal of lentigo maligna is challenging due to the difficulty in determining margins, subclinical spread and frequent facial location. In this article, we report the surgical approach of an extensive facial lentigo maligna with the "spaghetti" technique, with free margins in the third surgical step. This technique consists in the resection of a circular margin surrounding the clinical boundaries of the tumor, with histological evaluation, without removing the lesion. New steps include widening of the affected margins until the whole area is free, when tumor resection and reconstruction of the surgical defect take place simultaneously. The aim is to reach the free margins, preserving tissue in aesthetic and functional areas.

Keywords: Bloodless medical and surgical procedures; Melanoma; Skin neoplasms

The Keystone flap is a versatile and reliable option for the reconstruction of major defects, especially those located in the lower limbs. With its use, there is  a low risk of necrosis, being a way to avoid the use of a graft. We report the case of a 92-year-old female patient who was submitted to the Keystone flap after Mohs surgery for pre-tibial Bowen's disease treatment, with good evolution. The Keystone flap is based on musculocutaneous and fasciocutaneous perforators, has high flap survival rates, low risk of complications, reduced pain and morbidity of the donor site, in addition to rapid patient recovery

Keywords: Perforator flap; Mohs surgery; Lower extremity