Understanding complex skin cancers

Dec 15, 2025 | Blog

Understanding complex skin cancers

What makes a skin cancer “Complex”?

  1. High-risk location

Certain areas of the body are considered high risk because they contain:

  • Critical structures (important vessels, nerves, cartilage)
  • Limited extra skin for closure
  • High cosmetic and functional importance

Common high-risk areas include:

  • Eyelids and around the eyes
  • Nose
  • Lips
  • Ears
  • Fingers, toes, and nails
  • Genitals

In these areas, even a small tumor can cause vision problems, breathing issues, speech difficulties, or nerve damage if not carefully managed.

  1. Large size

Skin cancers become more complex when they are:

  • >2 cm on the body
  • >1 cm on the face
  • Spreading across natural boundaries (e.g., nose to cheek)

Large tumors often:

  • Require wider margins
  • Involve deeper layers (fat, muscle, cartilage, bone)
  • Leave larger defects after removal
  1. Aggressive or high-risk tumor type

Examples include:

These cancers:

  • Can spread microscopically beyond what’s visible
  • Have higher recurrence rates
  • May involve nerves (perineural invasion)
  1. Recurrent skin cancer

A tumor that has:

  • Been treated before and returned
  • Scar tissue from prior surgery or radiation

Scarred tissue hides tumor borders, making removal harder and increasing recurrence risk.

  1. Patient-specific factors

Complexity increases if the patient has:

  • Poor wound healing
  • Prior radiation in the area
  • Immune suppression
  • Limited ability to tolerate long surgery

How does surgical planning differ for complex skin cancers?

  1. More precise margin control

Instead of “cut and close,” surgeons may use:

  • Mohs micrographic surgery (layer-by-layer removal with real-time microscopic analysis). It removes all cancer while sparing as much healthy tissue as possible
  • Imaging or biopsy mapping for deeper tumors
  1. Multistage surgery

Complex cases may involve:

  • Cancer removal on one day
  • Reconstruction on the same or a later day
  • Coordination with specialists (oculoplastic, ENT, plastic surgery)
  1. Advanced reconstruction planning

Closure is often the hardest aspect or defect reconstruction.

Options include:

  • Local skin flaps (moving nearby skin)
  • Free flaps (requires microsurgical expertise)
  • Skin grafts
  • Letting wounds heal naturally in selected areas

Each option is chosen to:

  • Preserve function (eye closure, breathing, speech)
  • Minimize distortion
  • Achieve acceptable cosmetic outcomes
  1. Functional preservation takes priority

In complex cases, surgeons must balance:

  • Complete cancer removal
  • Appearance
  • Critical functions (seeing, blinking, eating, speaking)

This may mean:

  • Smaller margins with microscopic control
  • Staged repairs
  • Accepting scars to protect function
  1. Closer follow-up

Complex skin cancers often require:

  • More frequent skin exams
  • Imaging or lymph node checks
  • Long-term monitoring for recurrence