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Skin cancer excision and reconstruction

Excising basal and squamous cell carcinoma under local anaesthetic: margins, closure by suture, flap, graft or secondary intention, and aftercare.

Last clinically reviewed

1. Indications

2. Contraindications

  • Tumours for which margin-controlled surgery is clearly better: recurrent, ill-defined, morphoeic or infiltrative BCCs and high-risk SCCs at critical facial sites (nose, eyelids, lips, ears), where Mohs micrographic surgery gives the lowest recurrence and the greatest tissue economy27. These are referred rather than excised conventionally.
  • Tumours whose excision would need a general anaesthetic, a regional or free flap, or a multidisciplinary plan (deep invasion, bone or parotid involvement, nodal disease) — beyond the scope of this page3.
  • Active infection at the site.
  • Anticoagulant and antiplatelet drugs are not a contraindication and are continued. In a cohort of 302 head and neck full-thickness grafts, continued antithrombotic treatment did not increase the adjusted risk of complications (necrosis, bleeding or infection), with a non-significant trend towards graft necrosis on warfarin11, and in a series of 5,091 lesions no patient stopped warfarin or aspirin and infection was no more frequent in those taking them12. Warfarin does carry more bleeding — a meta-analysis found severe complications in 5.7 per cent on warfarin and 1.3 per cent on aspirin13 — so a recent INR within range is confirmed, adrenaline and bipolar haemostasis are relied on, and a pressure dressing is used where a flap or graft has been raised.
  • Smoking is a relative contraindication to a flap or full-thickness graft rather than to excision: heavy smokers (a pack or more a day) had necrosis of flaps and full-thickness grafts about three times as often as never-smokers, and when necrosis occurred in current smokers it involved about three times as much of the flap14. Smokers are advised to stop, or at least to cut down to under a pack a day, from the time of listing until the wound has healed; excision of the cancer is not delayed for it.

3. Relevant anatomy

The keratinocyte cancers arise in the epidermis. BCC infiltrates locally and almost never metastasises; SCC grows faster and metastasises in a small proportion of cases (under 4 per cent), particularly when large, thick, poorly differentiated, perineurally invasive, on the ear or lip, or in the immunosuppressed115910. Both extend microscopically beyond their visible edge, which is why a clinical margin is added: for BCC a 4 mm margin removed the tumour completely in more than 95 per cent of cases in Wolf and Zitelli's Mohs-mapped series16, and pooled data from 16,066 lesions give recurrence rates of 3.96, 2.56, 1.62 and 0.39 per cent after 2, 3, 4 and 5 mm margins, with a 3 mm margin achieving 95 per cent cure for non-morphoeic BCCs of 2 cm or less5. For SCC, 4 mm is adequate for most low-risk tumours, and 6 mm is needed for tumours 2 cm or larger, grade 2 or higher, in high-risk sites or invading fat17.
The deep plane is the subcutaneous fat; the tumour is excised with a cuff of fat, down to but not including the fascia unless the tumour approaches it. Incomplete excision is most likely on the nose, eyelids and ears, where margins are kept small to protect function18; a margin is reported as clear when at least 1 mm of normal tissue surrounds the tumour24.
The run at right angles to the pull of the underlying muscles; an ellipse placed along them heals with a thinner, less conspicuous scar and closes under less tension. The blood supply of the skin — the subdermal plexus fed by perforators — determines what can be closed directly, what needs a flap, and where a graft will take: a flap keeps its own supply through its base, a graft survives by imbibition and then inosculation from a vascular bed, and neither survives on bare bone, cartilage or tendon without periosteum, perichondrium or paratenon1920.

4. Patient positioning

Supine for the face, scalp, trunk and limbs, with the head turned or the table tilted so that the lesion faces the surgeon; lateral or prone for the back and the posterior ear. The arm rests on a hand table for upper-limb lesions. No tourniquet is used: haemostasis relies on the adrenaline in the infiltration and on bipolar diathermy. The lesion and the planned ellipse are marked before infiltration, because the anaesthetic distorts the skin and the margin.
Skin preparation follows the site: povidone-iodine 10 per cent aqueous for facial and periocular sites, where alcoholic chlorhexidine is avoided near the eye; 0.5 per cent chlorhexidine in alcohol elsewhere. Standard drapes.

5. Approach

Local infiltration with 0.4 per cent lignocaine and 1:250,000 adrenaline, 1–1.5 mL/kg subcutaneously into the marked area, allowed seven minutes for vasoconstriction. Adrenaline is used on the face, nose, ears and digits alike: a prospective multicentre series of 3,110 elective injections of low-dose adrenaline into the hand and fingers recorded no tissue loss and no need for phentolamine21, and the older prohibition has been refuted22. Where a larger field or active movement is wanted, the mix is used instead: 1 per cent lignocaine with 1:100,000 adrenaline buffered 10:1 with 8.4 per cent sodium bicarbonate, infiltrated and allowed 25 minutes.
The approach is the excision itself: an elliptical incision along the relaxed skin tension lines with a length-to-width ratio of about 3:1, so that the wound closes without standing cones ("dog ears") at its ends. Where a flap or graft is planned, the defect is excised as a circle or the minimum shape that clears the tumour, and the reconstruction is designed after the specimen is off.

6. Key steps

  1. 1. Marking the tumour and the margin

    Mark the visible and palpable edge of the tumour under good light, then the clinical margin: 3 mm for a small, well-defined BCC (the default in the operation-note template, on the pooled data; Wolf and Zitelli's own series needed 4 mm for 95 per cent clearance even under 2 cm), 4 mm for a larger or less well-defined BCC516, and 4 mm for low-risk and 6 mm for high-risk SCC174; the deep margin is through the subcutaneous fat down to, but not including, the fascia, which is included when the tumour approaches it. Draw the ellipse along the relaxed skin tension lines with a 3:1 ratio, or mark the circular defect if a flap or graft is planned.

  2. 2. Infiltration

    Infiltrate 0.4 per cent lignocaine with 1:250,000 adrenaline subcutaneously around and beneath the marked area and wait seven minutes; on the face the field blanches visibly. Do not exceed 1–1.5 mL/kg.

  3. 3. Excision

    Incise the skin with a No. 15 blade perpendicular to the surface — not bevelled inwards — along the marked ellipse, and excise the specimen en bloc with the subcutaneous fat down to the deep subcutis. Place an orientation suture as soon as the specimen is free (short suture superior, long suture lateral) and send it in formalin with a request form that states the site, the clinical diagnosis and the orientation.

  4. 4. Haemostasis and undermining

    Achieve haemostasis with bipolar diathermy and irrigate with saline. Undermine the wound edges widely in the subdermal plane (above the fascia on the trunk and limbs, in the subcutaneous plane on the face) until the edges meet without tension; on the scalp undermine in the subgaleal plane.

  5. 5. Choosing and performing the reconstruction

    Close directly when the edges meet without tension after undermining — the commonest closure, leaving a straight scar20. Where they do not, choose between a local flap (the closest colour and thickness match; advancement, rotation or transposition designs on the cheek, forehead and perioral region)20, a from the pre- or post-auricular skin, the supraclavicular fossa, the upper inner arm or the groin19, a for large defects of the scalp, trunk or limbs, or secondary intention for small concave facial defects and for frail patients or lower-leg wounds where closure is not achievable2324. In practice the choice follows the site: a flap first on the nose, cheek, forehead and lip where adjacent skin is available; a full-thickness graft for the nasal tip and ala, the ear, the eyelid and the temple, and for older patients with lax neck or pre-auricular skin; a split-thickness graft for large defects of the scalp, trunk and limbs and for the lower leg; secondary intention for small concave facial defects and for frail patients.
    For a full-thickness graft: harvest a template-sized ellipse from the chosen donor site, defat the graft completely, close the donor site, and inset the graft with interrupted 4-0 Vicryl Rapide, which is never removed. A tie-over bolster secured with 4-0 silk anchors is the default and stays undisturbed for seven days; in a series of 96 facial grafts without bolsters, 94 took completely25, so a bolster is a preference rather than a requirement. For a split-thickness graft: harvest with a dermatome, secure with staples or sutures under negative-pressure therapy or a tie-over dressing, and dress the donor site with a silicone contact layer and absorbent pad that is reinforced rather than changed. For a flap: raise it in the plane of the undermining with its base wide enough to carry the blood supply, inset without tension, and avoid pressure or dependent positioning afterwards.

  6. 6. Secondary intention, when chosen

    Leave the wound open after haemostasis, with or without a purse-string suture (3-0 Monocryl or PDS, nothing to remove; 3-0 nylon or Prolene, out at 14–21 days) to reduce the defect. Dress with a paraffin tulle on a facial site or a hydrofibre elsewhere, keeping the bed moist — never dry to a crust; no dressing has been shown to heal these wounds faster than another26 — and expect healing in four to eight weeks27, or eight to twelve weeks or longer on the lower leg28. Concave sites give the most favourable results: in 95 head and neck wounds left open, 43 per cent had an excellent cosmetic result, with size and concavity as independent predictors24.

7. Closure

Direct closure and flaps: deep dermal interrupted 4-0 Monocryl to take the tension off the skin, then skin sutures by site — running 6-0 nylon on the face (out at five days, early removal avoiding cross-hatching), interrupted 3-0 nylon or buried 3-0 Monocryl on the trunk and limbs; nylon comes out at 10–14 days29, or at three weeks on some sites, depending on the wound and the tension on it. Buried absorbable sutures leave nothing to remove: in a randomised comparison after carpal tunnel release, buried Monocryl gave better patient- and observer-rated scars at two weeks and no difference at six30.
Full-thickness graft: graft inset with interrupted 4-0 Vicryl Rapide (sloughs at 10–14 days, never removed); donor site closed according to its location — pre- and post-auricular donors with 4-0 Monocryl deep dermal and a running 6-0 nylon out at five to seven days; supraclavicular, upper inner arm and groin donors with 3-0 Monocryl deep and a buried running 3-0 Monocryl intradermal suture, nothing to remove. Bolster and its 4-0 silk anchors off at day seven.
Split-thickness graft: staples or sutures, out at seven to ten days; negative-pressure therapy or tie-over down at five to seven days; donor site undisturbed for 10–14 days.
Secondary intention: no closure; purse-string as above.
Dressings: a non-adherent contact layer and an absorbent pad for sutured wounds, kept dry for 48 hours; the closure-specific regimens above for grafts and open wounds. No topical antibiotic: white soft paraffin gives a statistically similar infection rate to bacitracin (2.0 against 0.9 per cent; 1.5 per cent overall) with no contact dermatitis31.

8. Aftercare

  • Direct closure and flap: keep the dressing dry for 48 hours; elevate a limb wound; no pressure on a flap and no dependent positioning; sutures out at five days (face, running), five to seven days (face, interrupted) or 10–14 days (trunk and limbs)29, with some wounds keeping their sutures for three weeks. Flap "pincushioning" is massaged from three weeks; revision is not considered before six months.
  • Full-thickness graft: the bolster stays undisturbed to day seven — the "keep dry 48 hours" rule does not apply; no shearing for two weeks; then moisturiser, massage and twelve months of sun protection.
  • Split-thickness graft: negative-pressure or tie-over down at five to seven days; donor site dressing reinforced, not changed, for 10–14 days; staples out at seven to ten days; donor-site pain is warned about.
  • Secondary intention: tap-water or saline cleansing at each change, no antiseptic soaks, no topical antibiotic — there is no robust evidence that any antiseptic or antibiotic preparation speeds healing of these wounds32; dressing changes at 48–72 hours and then every three to seven days (hydrofibre) or every two to three days (tulle); practice or district nurse with written instructions. Lower leg: elevation and minimised standing; tubular or two-layer compression from the first change if the ankle-brachial index is 0.8 or more and there is no arterial disease (the HEALS study's eligibility threshold; the compression regimen is the operator's default, not a trial finding)33.
  • Analgesia: regular paracetamol with ibuprofen as needed.
  • Antibiotic prophylaxis: none, for any site or closure. The sites and procedures where infection exceeded 5 per cent in Dixon's series — below the knee, wedge excisions of the lip and ear, skin grafts and groin lesions — and the indications in the 2008 advisory statement1234 are managed by warning the patient, reviewing the wound early and treating an established infection, not by prophylaxis.
  • Histology: reviewed at clinic; an involved or close margin is discussed with the patient and, for higher-risk tumours, at the multidisciplinary meeting24.
  • Follow-up: Plastics clinic at one week for suture removal, graft check or wound check, and at six weeks with the histology when the lesion was a BCC or SCC; a GP letter is sent. A single fully excised low-risk BCC needs no further hospital follow-up2, and a low-risk SCC a single post-treatment appointment; the British guideline follows high-risk SCC four-monthly for a year and then six-monthly for a further year, and very-high-risk SCC four-monthly for two years and then six-monthly for a further year, with lifelong skin surveillance for organ transplant recipients4.
  • Scar care: scars redden and firm up before fading over about a year35; massage from a few weeks and sun protection for a year.

9. Complications

  • Wound infection: 1.47 per cent of 5,091 lesions treated without prophylaxis — 0.54 per cent after simple excision, 2.94 per cent after flaps, 8.70 per cent after grafts, 6.92 per cent below the knee and 0.81 per cent on the face12. In an Auckland randomised trial of skin cancer surgery, infection followed 5.7 per cent of lesions injected with local anaesthetic alone, 5.3 per cent with microdosed incisional flucloxacillin and 2.1 per cent with microdosed clindamycin, the only significant reduction on the primary endpoint36.
  • Bleeding and haematoma: more frequent on warfarin (severe complications 5.7 per cent) than on aspirin (1.3 per cent)13; not increased in adjusted analysis after head and neck grafts on continued antithrombotics11.
  • Incomplete excision: 11.0 per cent of BCCs and 9.4 per cent of SCCs in a meta-analysis of 110 studies37; commoner on the nose, eyelids and ears18; a positive margin recurs in about 27 per cent if untreated5.
  • Recurrence after complete excision: under 2 per cent for BCC38; 3 per cent local recurrence (20 of 615) and 4 per cent metastasis (26 of 615) for SCC in a large prospective cohort9.
  • Flap or graft necrosis: three times as likely in heavy smokers14; partial graft failure in 2 of 96 facial full-thickness grafts25.
  • Secondary intention: on the lower leg, 30 per cent wound infection, 7.5 per cent admission and a median healing time of 81 days in a cohort with a mean age of 8128.
  • Scar problems: hypertrophy, depression after secondary intention on convex sites, pincushioning of flaps, colour and contour mismatch of grafts2320; nerve injury and altered sensation around the scar.

10. Evidence

Margins. Wolf and Zitelli's Mohs-controlled study established 4 mm for BCC16 and Brodland and Zitelli's 4 and 6 mm for SCC17; Gulleth's pooled analysis of 16,066 BCCs gives the recurrence rate for each margin from 2 to 5 mm and supports 3 mm for non-morphoeic tumours of 2 cm or less5. The British guidelines translate these into margins by risk group and define a clear margin as 1 mm or more24; the European guidelines give margins by risk group13.
Mohs versus excision. The Dutch randomised trial found no significant difference for primary facial BCC and a clear advantage of Mohs surgery for recurrent tumours at five and ten years87.
Incomplete excision. Pooled rates are about 11 per cent for BCC and 9 per cent for SCC, higher than guidelines assume37; site drives the risk18, and a New Zealand series confirms that not all incompletely excised BCCs recur6.
Anticoagulants. Continuation is supported by the graft cohort11 and by the infection cohort in which nobody stopped warfarin or aspirin12; the meta-analysis quantifies the extra bleeding risk on warfarin13.
Antibiotics. Dixon's prospective series defines the sites and procedures with infection rates above 5 per cent12; the 2008 advisory statement lists largely the same indications (adding flaps on the nose and extensive inflammatory skin disease) and notes that they rest on few large trials34; the Auckland trial shows that microdosed incisional clindamycin, but not flucloxacillin, significantly reduces infection across skin cancer surgery on the primary endpoint (both antibiotics reduced the need for postoperative systemic antibiotics)36. Topical antibiotic after closure adds nothing to petrolatum31.
Adrenaline. Low-dose adrenaline is safe in the hand and fingers in a prospective series of 3,110 injections21; the wide-awake technique is reviewed by Lalonde and Martin22.
Closure and dressings. Suture removal timing depends on site and ranges from 3 to 14 days in the literature29; buried Monocryl matches nylon at six weeks30; bolsters are optional for facial full-thickness grafts25. For wounds left open, no dressing heals faster than another but dry gauze is more painful and needs more nursing time26; antiseptics and antibiotics have no proven benefit32; a single hydrocolloid was preferred to daily dressings by 97 per cent of patients39; site selection and adjuncts are reviewed in two 2025 papers4041; and a 2026 survey of Mohs surgeons found petrolatum used by 96 per cent, with routine topical antibiotics associated with more reported infections27. The lower-leg cohort quantifies the cost of leaving these wounds open2833.
For patients — plain-language summary
Basal cell and squamous cell skin cancers are usually cut out under local anaesthetic, as a day case, with a small rim of normal skin around them so that the whole tumour is removed. The anaesthetic contains adrenaline to reduce bleeding and is safe on the face, ears and fingers. The wound is closed with stitches where the skin allows; where it does not, nearby skin is moved across as a flap, a piece of skin is grafted from behind the ear, the neck, the inner arm or the groin, or the wound is left to heal on its own under dressings. Keep a stitched wound dry for two days; a graft dressing stays untouched for a week. Face stitches come out at about five days and body stitches at ten to fourteen days, sometimes three weeks; some body wounds are closed with dissolving stitches instead. Keep taking blood-thinning tablets unless told otherwise. Infection affects about 1 to 2 in 100 wounds, more on the lower leg and after grafts. About 1 in 10 excisions shows cancer at the edge under the microscope and may need a second procedure. You will be seen at one week and, for a confirmed cancer, at six weeks with the results. Protect the scar from the sun for a year and check your skin regularly, because having one skin cancer makes another more likely.

References

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