A 90-year-old man presented for evaluation of an incompletely excised squamous cell carcinoma above the right brow, with pathology demonstrating tumor extending to resection margins with perineural invasion. A cord of tumor was noted to extend past the orbital rim and towards the posterior orbit. Mohs excision versus coordinated resection and reconstruction with colleagues in the head and neck surgery and craniofacial plastic surgery departments were considered. Multidisciplinary consensus was to proceed with radical resection in the operating room followed by adjuvant radiation therapy. One year later, the patient presented to our Mohs unit with a 3cm eroded multinodular plaque. Following an in-depth discussion regarding the options of further surgery versus systemic treatment, the patient and his family opted to pursue consultation with a medical oncology consultant to discuss restaging and potential systemic therapy. A PET scan with concurrent CT revealed a hypermetabolic right temporal scalp mass without evidence of bony invasion or extension into the nodal basin. Immunotherapy with cemiplimab was started at a dose of 350mg IV every three weeks. After 7 cycles, the patient demonstrated complete clinical resolution with a repeat PET scan showing interval near resolution of abnormal metabolic activity.