This article focuses on the surgical treatment of nonmelanoma skin cancers of the head and neck. The risk factors of nonmelanoma skin cancers for recurrence and metastases that are important for choosing the best treatment option are summarized. Surgical treatment options including surgical excision with standard margins, frozen section, staged surgery, and Mohs micrographic surgery are described. Indications, techniques, outcomes, and advantages and disadvantages of each approach are reviewed. Finally, management of incomplete excisions is discussed.
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Define the risk factors of the tumor.
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Identify clinical margins under optimal lighting and magnification.
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Dermoscopy may be helpful to identify clinical margins better.
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In selected cases, prior curettage may help to delineate clinical margins; however, it is controversial.
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Mark surgical margins using scale before local anesthetic infiltration.
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For surgical excision, minimal surgical margin is recommended to be 3 to 4 mm for BBCs with well-defined clinical borders. Leave at least 4 to 6 mm healthy tissue around the SCCs.
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For the excision of high-risk tumors, prefer Mohs’ micrographic surgery, if it is available.
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Surgical excision with intraoperative margin assessment with frozen section or preferably staged surgery can also be used safely.
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Do not perform complicated reconstructions without achieving tumor-free margins.
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In the management of incomplete excised NMSCs consider surgery primarily, and consider wait-and-see approach in selected cases.
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Late recurrences may occur; follow patients at least 5 years.
Introduction
The term “nonmelanoma skin cancer” (NMSC) is used to define basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin, and other rare primary cutaneous malignancies. Because most NMSCs originate from the epidermis, the upper layer of the skin, it is often detected at an early stage and can be treated locally. Treatment of NMSC can be broadly classified into surgical and nonsurgical treatment. Surgical excision is the most effective treatment option for most NMSCs. This article focuses on surgical treatment for NMSC; repair of the defect after excision is beyond the scope of this article.
The treatment of a facial skin cancer aims to achieve complete eradication of the cancer with a good and acceptable cosmetic and functional outcome; however, complete eradication of the tumor should be the primary goal. Although surgery is the treatment of choice for high-risk NMSCs, low-risk NMSCs may be treated by either nonsurgical or surgical treatment options. Therefore, the most important step in the treatment planning of the NMSCs is to determine if the tumor has high risk or low risk to recur or metastasize. Presence of characteristics associated with recurrence or metastasis make a tumor high risk, whereas a tumor that is unlikely to recur or metastasize is determined to be low risk.
Risk factors of recurrence and metastases
Location
Location of the tumor is one of the most important factors affecting the outcome of treatment of NMSCs. Certain sites of the head and neck region are more likely to recur and metastasize. Swanson illustrated high-risk locations of face as an “H” zone, because of the higher recurrence rate and the functional and cosmetic importance ( Fig. 1 ). Recurrences are most commonly seen on nose, cheek, auricular area, periocular area, scalp, and forehead. SCCs located on ear, temple, forehead, and anterior scalp that drain to parotid gland and lower lip are associated with higher incidence of metastases.
