Aims To investigate the correlation between preoperative head and neck keratinocyte cancer (KC) biopsies and final pathology excision specimens. Methodology Head and neck cutaneous lesions excised under local anaesthetic in the outpatient day surgery setting were reviewed from July 2023 to June 2024 inclusive. Patient demographics, lesion characteristics, preoperative biopsy and final histopathology were analysed. Results Of the 137 lesions excised, KC was confirmed on 79.7% of lesions. This confers a 20.3% negative residual rate. Of the confirmed KCs, 74.5% were basal cell carcinomas (BCCs), 21.8% were squamous cell carcinomas (SCCs), and 3.6% were SCC-in-situ. The most common BCC subtype was nodular, while well-differentiated grade was the most common for SCC. The preoperative biopsy correctly identified the KC subtype in 31.9% of excisions. In 17.4% of cases, there were higher risk KC subtypes demonstrated on formal pathology than indicated by preoperative biopsy. As a result, 9.1% of these were not able to be considered clear excisions and necessitated discussion with the patient on further management options. More favourable pathology, defined as negative residual or lower risk lesion subtype, was demonstrated in 31.9% of excisions. There was no preoperative biopsy for 18.8% of lesions excised. Conclusion Accurate preoperative biopsy allows risk assessment and appropriate clinical margin determination. This is especially important for head and neck KCs, where functional and cosmetic constraints are greatest. The expected correlation rate for head and neck KCs has not been previously investigated in the Australian regional setting. This work highlights the importance of counselling patients on the potential for higher risk pathological features when striving for clear margin status.