When a Skin Cancer Is More Than a Simple Excision

Most non-melanoma skin cancers encountered in general practice can be managed effectively with straightforward surgical excision. However, some lesions present challenges that extend beyond just removing the cancer. Factors such as location, recurrence, tumour subtype, and planned reconstructive requirements can significantly influence management and outcomes of skin cancers.

Recognising these higher risk cases early can help ensure optimal oncological clearance while preserving function and appearance.

High Risk Areas

Not all skin cancers are equal from a surgical perspective. Lesions occurring in cosmetically and functionally important areas often require careful planning before excision.

These areas include the nose, eyelids, ears, lips, temple area, forehead, scalp, hands and fingers.

Even relatively small lesions in these areas can create complex defects following excision. Preservation of critical structures and natural contours is often as important as margin clearance itself.

For example, a 5 mm basal cell carcinoma on the nasal ala may require a significantly more complex reconstruction than a larger lesion located on the trunk. Inadequate planning can result in distortion of the nostril, eyelid malposition, functional impairment, or a suboptimal cosmetic outcome.

Recurrent Skin Cancers

Recurrent lesions should always raise concern.

Previous treatment can alter normal tissue planes, making margins less predictable and increasing the risk of further recurrence. Scar tissue may also obscure the true extent of tumour spread.

When assessing a recurrent lesion, it is important to consider:

  • Previous pathology findings
  • Prior treatment method
  • Time since treatment
  • Clinical evidence of subclinical extension

Recurrent skin cancers often require wider excision and more complex reconstruction than primary lesions. Early specialist involvement can assist in treatment planning and may reduce the likelihood of multiple procedures.

Histological Subtypes

Histological subtype plays an important role in determining biological behaviour and treatment requirements.

For basal cell carcinoma, higher-risk subtypes include infiltrative BCC, morphoeic BCC, micronodular BCC and basosquamous carcinoma.

These subtypes frequently demonstrate subclinical spread beyond visible skin cancer margins and are associated with higher recurrence rates if not adequately treated.

For squamous cell carcinoma, features associated with increased risk include , poor differentiation, perineural invasion, deep invasion, rapid growth, recurrent disease.

Skin cancers with these characteristics may warrant more extensive excision, closer follow-up, and multidisciplinary management.

Reconstruction Is Part of the Treatment

Successful management of skin cancer involves more than complete tumour removal.

Following excision, reconstruction should aim to restore function, preserve normal anatomy, achieve durable wound healing and optimise cosmetic outcomes

Reconstructive options may include direct closure, local flap reconstruction, skin grafting, or more complex staged procedures depending on the size and location of the defect.

The reconstructive plan should ideally be considered before the initial excision, particularly when operating on the face.

When to Refer to a Plastic Surgeon

Consider referral when any of the following are present:

  • Skin cancers involving the nose, eyelids, ears, lips, or other cosmetically sensitive areas
  • Recurrent lesions
  • Aggressive histological subtypes
  • Large lesions where closure may be difficult
  • Tumours requiring complex reconstruction
  • Lesions located near important functional structures
  • Cases where preservation of form and function is a priority

Early referral can facilitate comprehensive treatment planning and may improve both oncological and aesthetic outcomes.

While many skin cancers can be managed with routine excision, some lesions require a more strategic approach. High-risk anatomical sites, recurrent disease, and aggressive histological subtypes can all increase the complexity of treatment. Early recognition of these factors allows for appropriate referral and helps ensure the best possible functional, cosmetic, and oncological outcomes for patients.

*This article is for general information and educational purposes only. It is not intended to substitute professional medical advice, diagnosis, or treatment. All surgery carries risk, and individual results may vary. Dr Andre Safvat, MBBS FRACS, Specialist Plastic Surgeon (MED0001155201), provides consultations at Ethique Plastic Surgery. A referral from your GP is required before consultation.

Scroll to Top