Objective: To investigate the clinical efficacy and recurrence rate of minimally invasive surgery for basal cell carcinoma (BCC) guided by dermoscopy combined with reflectance confocal microscopy (RCM). Methods: A total of 80 patients with primary BCC were enrolled and assigned to an observation group and a control group according to the different surgical methods, with 40 cases in each group. Prior to surgery, patients in the observation group underwent tumor localization, margin assessment, and depth evaluation using dermoscopy combined with reflectance confocal microscopy (RCM). Based on the imaging findings, individualized minimally invasive surgical plans were formulated. In contrast, patients in the control group received preoperative tumor margin determination via conventional visual inspection and subsequently underwent standard minimally invasive surgical treatment. All patients were followed up for 12 months postoperatively. Surgical-related indicators, incidence of complications, recurrence rates, and cosmetic satisfaction were compared between the two groups. Results: The observation group demonstrated reduced mean operative time, intraoperative blood loss, surgical defect area, and the positive rate of incision margin compared to the control group (P <0.05). The rate of primary wound closure was higher in the observation group (P<0.05). During the 12-month postoperative follow-up, no statistically significant difference in recurrence rates was observed between the two groups (P>0.05). However, the observation group reported higher cosmetic satisfaction at 12 months post-surgery (P<0.05). Conclusion: Minimally invasive surgery for BCC guided by dermoscopy combined with RCM enables precise tumor margin delineation, reduces the rate of positive surgical margins, minimizes surgical trauma, and improves aesthetic outcomes. This approach may also mitigate long-term recurrence risk, serving as a complementary strategy to Mohs micrographic surgery (MMS) and offering a more precise, minimally invasive therapeutic option for BCC patients.