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The goal of surgical excision of malignant skin tumors is to achieve wide and complete en bloc excision of the primary tumor surrounded by a margin of normal tissue in three dimensions (Figures 4.2a–c). The extent of the surgical margin will depend on the tumor type and location. More conservative margins are appropriate for removal of benign skin tumors. En bloc surgical resection requires removal of any tissue that the tumor is in contact with, which may require removal of fascia, muscle, subcutaneous fat, or even bone. The first surgery generally provides the best opportunity to achieve local tumor control. Surgical excision of a skin tumor should be done with aseptic surgical techniques and sterile instruments. Gentle tissue handling and maintenance of blood supply with minimization of dead space and tension at the surgery site are important surgical principles to maintain during removal of cutaneous tumors. Any previous biopsy site should be removed with the resected tissues. Ideally, complete surgical excision of the tumor without entering the tumor capsule should be done to avoid tumor seeding at local or distant sites. Veins should be ligated early in the procedure to prevent hematogenous spread of tumor cells especially in large tumors.

Surgical instruments, drapes, and gloves should be changed immediately, and intraoperative lavage should be done, if the tumor is entered inadvertently or if an intracapsular resection is done and the change should be performed routinely after malignant tumor excision.

Postoperative surgical drains should be avoided as they can potentially contaminate the normal tissues through which they pass with tumor cells; however, they should be considered if surgery results in a large dead space or is in a high‐motion anatomical site that will be predisposed to seroma formation. Most seromas can be managed conservatively and will regress spontaneously.