Introduction: Basal Cell Carcinoma (BCC) is the most common non-melanomatous skin cancer in the world, however BCC of the head and neck (H&N) with large nerve perineural spread (PNS) is rare and has little evidence to guide management. This study evaluated relapse and survival in patients with H&N BCC with PNS (clinical and radiographic) at a large Skull Base Centre in Australia. Methods: A review of a prospective database of patients treated for BCC with PNS from 2015 to 2025 was performed. Descriptive analysis patient characteristics, details of diagnosis, treatment and outcomes for the ten patients meeting inclusion criteria treated at the institution was performed. Results: Mean (SD) age at time of surgery was 63 (11) years, 7/10 (70%) were male and 5/10 had a history of previous BCC excision of the index lesion. 8/10 patients had single nerve involvement with the most common nerves being V1 (n=5) and V2 (n=4). Two patients had both V1 & VII and V2 & V3 involvement. 9/12 cases of PNS were Zone 1 on pathology, one patient with single nerve involvement had Zone2a one patient had Zone 2a in V2 and Zone 2b in V3. MRI zonal classification agreed with pathology classification for 11/12 nerves. All patients received postoperative radiotherapy with a median dose of 60Gy (range 48-70Gy). 5-year relapse free survival was 90%. One patient relapsed perineurally in peripheral zone 1 salvaged with surgery. Conclusion: H&N BCC with PNS may carry an excellent relapse-free survival when treated with skull-base surgery and radiotherapy.