Introduction / Reconstruction

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There are some topical treatments, such as cytotoxic ointments (Effudix), Imiquimod (Aldara) as well as radiotherapy and cryotherapy (freezing therapy), which are useful but are not part of the discussion here. Generally these treatments are less suitable around the eyes due to toxic effects and collateral damage to important structures.

The aim of management is removal of the tumour with a margin of healthy tissue, preferably at the first attempt, followed by reconstruction and restoration of function.

Biopsy

Usually a small sample of tissue will be taken as a biopsy – with a local anaesthetic injection – and sent to the lab for examination by a pathologist under the microscope.

Once the tumour (lump) has been characterized, a plan will be made for excision and reconstruction of the structures involved.

Most commonly the tumour is excised with a margin of normal tissue on either side so that the surgeon can be confident that it has all been removed at the first attempt. This is usually done where the margins of the tumour are obvious and where there is sufficient normal tissue around it to enable safe removal.

Sometimes the tumour is close to other sensitive structures, or the borders of the tumour are hard to define. In these circumstances a form of surgery called Moh’s micrographic surgery may be offered. With this technique the surgeon can remove the tumour and immediately study it under the microscope. It’s a bit like having a super quick pathologist in the room. This way, if there is still some tumour left behind, a further piece of tissue can be removed, and so on until there is no tumour left. This method ensures that the tumour is excised completely with minimal disruption to surrounding tissues. This method has a slightly higher first time cure rate. It may, however, not be possible to schedule the reconstruction on the same day, in which case a further session within 48 hours will be required.

Following excision the defect may often be closed directly by undermining the tissues and stretching them closed. This works particularly well in the eyelid for small lesions.

Courtesy Elsevier Science Publications

The defect has been closed with direct closure

If there is not enough stretch in the tissues, an advancement or transposition skin/muscle flap may be performed, allowing closure of the defect with a pleasing cosmetic result.

This defect has been closed by mobilising a skin flap and advancing it into
the defect with an excellent cosmetic result

Sometimes it is not possible to close a large defect in the eyelid directly, and a combination of flap and an overlying skin graft is required. The flap may be from the upper to lower lid or vice versa. Under these circumstances the eye is closed for a month or less whilst the tissues heal into place, after which the flap is cut and reversed restoring anatomy to the area of previous defect.

This series (from different patients) shows a larger defect which needs a flap from
the inside of the upper lid to be placed in the lower lid.  This will restore blood
supply to the lower lid. A skin graft is placed over the upper lid flap.  After a period
of several weeks the lid flap is divided. The result is excellent.  Unfortunately the
lashes cannot be transplanted, which is more of an issue for ladies

In this case following tumour removal, 1/3 of both upper and lower lids has been lost, as well as the lacrimal drainage system and tissue from the side of the nose.  The defect has been repaired by advancing a flap from above the nose, in combination with a sliding flap along the lower lid.
Despite losing a lot of tissue, a very acceptable and functional result has been achieved.

If you have been diagnosed with a tumour of the eyelid or have any suspicious lesions around the eyes I would be happy to see you and discuss the management.

For more useful information regarding eyelid tumours try this link:

www.eyecancer.com