Squamous cell (SCC) and basal cell (BCC) skin cancer are common presentations in elderly patients. Skin cancer are often located in sun exposed areas where damage from exposure has occurred. The sun exposed areas are often difficult to close or would require more complex measures to cover. Skin grafts or rotation flaps are commonly employed for coverage. Having tumor free margins is required to anticipate avoiding local recurrence. Mohs techniques examine the surgical margin to ensure that lesions are completely excised. When reliable frozen section is not available for immediate confirmation, permanent section may be used. Excising lesions and implementing radial identification allows margin localization of involved margins for re-excision. Divided into quartets, directed re-excision can be undertaken with minimal disturbance to the healing wound bed. Use of an ECM device (Myriad™, Aroa Biosurgery, Auckland, New Zealand) accelerates healing and leaves a cosmetically acceptable result that affords margin examination and re-excision with minimal disturbance to healing wound. Here we present an evolving technique of excision of common skin cancers utilizing ECM Matrix Graft technology and healing. This technique affords margin identification utilizing permanent section examination. Subsequent margin identification and re-excision if necessary is localized to individual quadrants of the excision site allowing more precise re-excision and not disturbing the grafted wound site. Healing seems accelerated and cosmetic appearance is acceptable to patients.