Craniofacial Basal Cell Carcinoma: Contemporary Concepts and Surgical Frontiers

Craniofacial basal cell carcinoma (CFBCC) accounts for the majority of basal cell carcinomas (BCCs) by anatomic distribution yet represents only a small proportion of head and neck malignancies, with disproportionate morbidity due to involvement of anatomically complex and functionally critical facial regions. Management is challenged by subclinical tumor spread along embryologic fusion planes, perineural invasion, and proximity to ocular, neural, and skull base structures. This narrative review synthesizes contemporary evidence on epidemiology, histopathologic subtypes, molecular pathogenesis, diagnostic evaluation, surgical management, reconstruction, and emerging therapies for CFBCC. High-risk and advanced disease includes aggressive histologic variants, chronically neglected or large tumors, recurrent lesions, and cases with orbital, bone, or skull base involvement. Clinical assessment, including regional nodal evaluation, is complemented by advanced imaging modalities, including magnetic resonance imaging, computed tomography, reflectance confocal microscopy, and optical coherence tomography. Mohs micrographic surgery provides optimal margin control for high-risk facial subsites, while deeply invasive tumors may require craniofacial resection. Advances in Hedgehog pathway-targeted therapies, digital surgical planning, and multidisciplinary reconstruction continue to expand treatment options and improve functional and aesthetic outcomes.