Original Research

Facial Malignancies in Patients Referred for Mohs Micrographic Surgery: A Retrospective Review of the Impact of Hair Growth on Tumor and Defect Size

Author and Disclosure Information

There is a lack of data characterizing tumors located within male facial hair subunits and determining if terminal hair growth obscures tumor detection, thus leading to a delay in diagnosis. Our objective was to evaluate the difference in cutaneous tumor size in men who had facial hair compared to men without facial hair. This retrospective chart review analyzed Mohs micrographic surgery cases of tumors located within facial hair subunits from January 2015 to December 2018 at The University of North Carolina at Chapel Hill. Patients and dermatologists should maintain a high index of suspicion for any concerning lesion contained within skin underlying facial hair to ensure prompt diagnosis and treatment of cutaneous tumors.

Practice Points

  • In our study, men with cutaneous tumors who had facial hair exhibited larger tumors, required more Mohs layers, and had a larger defect size compared to men who do not have any facial hair growth.
  • Both patients and dermatologists should have a high index of suspicion for any concerning lesion contained within skin underlying facial hair to ensure prompt diagnosis and treatment of cutaneous tumors.



Male facial hair trends are continuously changing and are influenced by culture, geography, religion, and ethnicity.1 Although the natural pattern of these hairs is largely androgen dependent, the phenotypic presentation often is a result of contemporary grooming practices that reflect prevailing trends.2 Beards are common throughout adulthood, and thus, preserving this facial hair pattern is considered with reconstructive techniques.3,4 Male facial skin physiology and beard hair biology are a dynamic interplay between both internal (eg, hormonal) and external (eg, shaving) variables. The density of beard hair follicles varies within different subunits, ranging between 20 and 80 follicles/cm2. Macroscopically, hairs vary in length, diameter, color, and growth rate across individuals and ethnicities.1,5

There is a paucity of literature assessing if male facial hair offers a protective role for external insults. One study utilized dosimetry to examine the effectiveness of facial hair on mannequins with varying lengths of hair in protecting against erythemal UV radiation (UVR). The authors concluded that, although facial hair provides protection from UVR, it is not significant.6 In a study of 200 male patients with actinic keratosis on the head and face, Liu et al7 demonstrated that sheltering mustaches, defined as greater than 9 mm in length, reduced the risk for developing an actinic keratosis on the lower lip by a factor of 16 (P=.0003).

We sought to determine if facial hair growth is implicated in the diagnosis and treatment of cutaneous malignancies. Specifically, we hypothesized that the presence of facial hair leads to a delay in diagnosis with increased subclinical growth given that tumors may be camouflaged and go undetected. Although there is a lack of literature, our anecdotal evidence suggests that male patients with facial hair have larger tumors compared to patients who do not regularly maintain any facial hair.


We performed a retrospective chart review following approval from the institutional review board at The University of North Carolina at Chapel Hill. We identified all male patients with a cutaneous malignancy located on the face who were treated from January 2015 to December 2018. Photographs were reviewed and patients with tumors located within the following facial hair-bearing anatomic subunits were included: lip, melolabial fold, chin, mandible, preauricular cheek, buccal cheek, and parotid-masseteric cheek. Tumors located within the medial cheek were excluded.

Facial hair growth was determined via image review. Because biopsy photographs were not uploaded into the health record for patients who were referred externally, we reviewed all historical photographs for patients who had undergone prior Mohs micrographic surgery at The University of North Carolina at Chapel Hill, preoperative photographs, and follow-up photographs as a proxy to determine facial hair status. Postoperative photographs taken within 2 weeks following surgery were not reviewed, as any facial hair growth was likely due to disinclination on behalf of the patient to shave near or over the incision. Age, number of days from biopsy to surgery, pathology, preoperative tumor size, number of Mohs layers, and defect size also were extrapolated from our chart review.

Statistical Analysis
Summary statistics were applied to describe demographic and clinical characteristics. An unpaired 2-tailed t test was utilized to test the null hypothesis that the mean difference was zero. The χ2 test was used for categorical variables. Results achieving P<.05 were considered statistically significant.


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