Eyelid Cancer and Reconstruction

Laurence Z. Rosenberg,M.D.Southeastern Plastic Surgery

Benign Lesions

Chalazion

Benign Lesions

Chalazion

Caused by a blocked duct from a meibomian gland

This is not a sty (glands of Zeis)

Initial treatment warm compresses

May require surgical excision

Benign Lesions

Chalazion

Cautious observation for a limited time.

If the lesion is not getting better, refer or do a biopsy.

If you excise the lesion, always send the specimen to pathology

Benign Lesions

Trichoepithelioma

Benign Lesions

Trichoepithelioma

Benign lesion, often develop after puberty

May be numerous

Obsevation is indicated

Benign Lesions

Trichoepithelioma

Desmoplastic trichoepithelioma may resemble a basal cell carcinoma

If there is change, never hesitate to biopsy

Benign Lesions

Verruca

Benign Lesions

Verruca

Caused by Human Papilloma Virus. Over 150 strains

Filliform warts: long thin lesions on the face

Different from genital warts

Benign Lesions

Verruca

Usually clear up in children without treatment

May be more persistent in adults

Multiple treatments, but on eyelid, careful excision o cauterization

20% recurrence

Benign Lesions

Inclusion Cyst

Benign Lesions

Inclusion Cyst

Often called a sebaceous cyst, this is a misnomer

May resemble a basal cell carcinoma

May become inflamed or infected

Benign Lesions

Inclusion Cyst

Usually no treatment is required

Often removed for appearance or because of infection

Remove entire cyst and punctum if possible.

Benign Lesions

Nevus

Benign Lesions

Nevus

Atypical Nevus

Size >5 mm diameter

Ill-defined or blurred borders

Irregular margin resulting in an unusual shape

Varying shades of color (mostly pink, tan, brown, black)

Flat and bumpy components

Benign Lesions

Nevus

Dysplastic Nevi –pathologic diagnosis

The lesion may be a junctional naevus or more frequently a compound naevus (the cells are found at the epidermodermal junction and within the dermis).

The nevus cells form a row along the dermoepidermal junction (called lentiginous proliferation), with or without nevus cells in nests

(called theques).

Benign Lesions

NevusDysplastic Nevi –pathologic diagnosis

These theques are often irregular in size and shape and may 'bridge' or join together.

The cells may be odd-looking i.e. they have cytologic atypia, and they may be spindle-shaped (elongated) or epithelioid (resembling epidermal keratinocytes i.e., broad).

There may be fibrosis or scarring in the dermis.

Benign Lesions

Nevus

Dysplastic Nevi –pathologic diagnosis

Inflammatory cells may infiltrate the lesion.

Associated blood vessels may be increased in number or enlarged.

Benign Lesions

Nevus

Treatment

May be for cosmetic purposes

Excision dependent on the degree of atypia (moderate or severe)

not an exact science

Malignant Lesions

Basal Cell Carcinoma

Malignant Lesions

Basal Cell Carcinoma

Most common human cancer

More common in fair skinned people

May be heritable: Basal Cell Nevus Syndrome

Malignant Lesions

Basal Cell Carcinoma

Nodular BCC

Most common type on the face

Small, shiny, skin colored or pinkish lump

Blood vessels cross its surface

May have a central ulcer so its edges appear rolled

Often bleeds spontaneously then seem to heal over

Malignant Lesions

Basal Cell Carcinoma

Superficial BCC

Often multiple

Anywhere

Pink or red scaly irregular plaques

Slowly grow over months or years

Bleed or ulcerate easily

Malignant Lesions

Basal Cell Carcinoma

Morpheaform BCC

Also known as sclerosing BCC

Usually found in mid-facial sites

Prone to recur after treatment

May infiltrate cutaneous nerves (perineural spread)

Malignant Lesions

Basal Cell Carcinoma

Pigmented BCC

Brown, blue or greyish lesion

Nodular or superficial histology

May resemble melanoma

Malignant Lesions

Basal Cell Carcinoma

Basisquamous BCC

Mixed BCC and Squamous Cell Carcinoma

More Aggressive

Malignant Lesions

Basal Cell Carcinoma

Treatment

Currettage and cautery: Margins unknown

Excision: Margins known, but not circumferential

Mohs: Best for high risk lesions, most definitive margin assessment

Photodynamic Therapy: superficial BCC. Lower Cure Rate

Imiquimod: Immune modulator

Radiation: May be used in elderly or as adjuvant therapy

Malignant Lesions

Squamous Cell Carcinoma

Malignant Lesions

Squamous Cell Carcinoma

Directly related to UV exposure

Smoking

Chronic wounds

Human Papiloma Virus

Malignant Lesions

Squamous Cell Carcinoma

Treatment:

Surgery

Excision

Mohs

Patient may require assessment of the lymph nodes

Large tumors may require pre-operative radiographic imaging

Malignant Lesions

Squamous Cell Carcinoma

5% metastasize to other sites

more likely in transplant patients, old age, alcoholics etc.

May require adjuvant radiation therapy

Malignant Lesions

Melanoma

Malignant Lesions

MelanomaCancer of the melanocytes

Prognosis dependent of tumor thickness

Stage IA: Melanoma <1.0mm

Stage IB: Melanoma is <1.0mm with ulceration or Mitoses >1

or > 1.0mm and ≤ 2.0mm

Stage IIC: Melanoma > 4.0mm, with Ulceration

Stage IIIC: Nodal Involvement or Intransit spread

Stage IV: Spread to distant organs

Malignant Lesions

Melanoma

Stage IA: The 5-year survival rate is around 97%. The 10-year survival is around 95%.

Stage IB: The 5-year survival rate is around 92%. The 10-year survival is around 86%.

Stage IIC: The 5-year survival rate is around 53%. The 10-year survival is around 40%.

Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.

Malignant Lesions

Melanoma

Stage IV: The 5-year survival rate for stage IV melanoma is about 15% to 20%.

The 10-year survival is about 10% to 15%.

Malignant Lesions

MelanomaTreatment:

Dependent on tumor thickness

in-situ 0.5cm

< 1.0mm 1cm

1.0 – 2.0mm 1 – 2cm

>2.0mm 2cm

If the tumor is > 1.0mm thick, or ulcerated or mitotic index ≥ 1

Perform sentinel lymph node biopsy

Reconstruction

Mohs defect45 by 55mm

50% lower Lid30% Upper lidResection of lateral canthusLoss of temporal skin

Reconstruction

Repair of the eyelid, like all reconstruction:

Knowledge of the anatomy

Function of the part to be reconstructed

Application of technique

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

Reconstruction

1. Lower Lid Posterior LamellaTemporalis fascial flap

2. Lower Lid anterior Lamella1.Cervical facial flap

3. Reconstruct upper lid1.Primary attachment to New lower lid

Reconstruction