How would you manage a high risk SCC of the scalp that has wound healing issues after Mohs surgery?

Refer the patient to plastic surgeon for wound repair. Indicate that the cancer is high risk for recurrence and warrants adjuvant RT (sooner rather than later), and that a vascularized reconstruction is preferable for that reason. In our experience, 60 Gy in 30 fractions is effective to prevent local recurrence of high risk cSCC, so that is my preferred dose/fractionation.

(Yan, BY BrJDermatol. 2019) Local recurrence and quality of life after adjuvant radiation therapy in high-risk squamous cell carcinoma

In our study, the only cases of local recurrences were after doses <60 Gy/30 fractions. We try to give this dose in most cases.