There is no consensus on elective lymphatic dissection of the parotid and neck for nonmelanoma skin cancer (NMSC) due to challenges in detecting occult spread to these regions. This study aimed to summarize clinical data and evaluate correlations between risk factors, nodular metastasis, and the need for elective parotidectomy in patients with cutaneous squamous cell carcinoma (CSCC), Merkel cell carcinoma (MCC), and apocrine carcinoma (AC) of the head and neck, all with clear surgical margins and negative imaging results for regional metastases.We retrospectively reviewed 166 patients with CSCC, one with MCC, and one with AC of the head and neck, all treated surgically between September 2006 and July 2022. The neck and parotid nodes were imaged preoperatively, and nodular metastases were verified by pathological examination. Age, maximum primary tumor dimension, and primary tumor depth were evaluated in patients with and without nodular metastases.Seven patients developed nodular metastases after primary tumor excision. Facial paralysis occurred in three of five patients with parotid spread. Age and primary tumor size differed significantly between patients with and without nodular metastases (P < 0.05). Tumor depth did not differ significantly between these groups (P > 0.50).Negative imaging results of nodular metastases before primary tumor excision and clear margins did not imply exemption from nodular metastases postoperatively. Nodular spread of CSCC is associated with multiple risk factors rather than any single factor. Elective parotidectomy is recommended to prevent facial nerve invasion by occult nodular metastasis in patients with CSCCs with advanced age, large primary tumor size (≥T3), critical tumor locations, and/or pathological types with high metastatic potential.Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.