1. Eyelid Cancer and Reconstruction
Laurence Z. Rosenberg,M.D.
Southeastern Plastic Surgery

2. Benign Lesions
Chalazion

3. 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

4. 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

5. Benign Lesions
Trichoepithelioma

6. Benign Lesions Trichoepithelioma
Benign lesion, often develop after puberty
May be numerous
Obsevation is indicated

7. Benign Lesions Trichoepithelioma
Desmoplastic trichoepithelioma may resemble a basal cell carcinoma
If there is change, never hesitate to biopsy

8. Benign Lesions
Verruca

9. Benign Lesions Verruca
Caused by Human Papilloma Virus. Over 150 strains
Filliform warts: long thin lesions on the face
Different from genital warts

10. 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

11. Benign Lesions
Inclusion Cyst

12. Benign Lesions Inclusion Cyst
Often called a sebaceous cyst, this is a misnomer
May resemble a basal cell carcinoma
May become inflamed or infected

13. Benign Lesions Inclusion Cyst Usually no treatment is required
Often removed for appearance or because of infection
Remove entire cyst and punctum if possible.

14. Benign Lesions
Nevus

15. 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

16. 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).

17. Nevus Benign Lesions Dysplastic 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.

18. Nevus Benign Lesions Dysplastic Nevi –pathologic diagnosis
Inflammatory cells may infiltrate the lesion.
Associated blood vessels may be increased in number or enlarged.

19. Nevus Benign Lesions Treatment May be for cosmetic purposes
Excision dependent on the degree of atypia (moderate or severe)
not an exact science

20. Malignant Lesions
Basal Cell Carcinoma

21. Basal Cell Carcinoma Malignant Lesions Most common human cancer
More common in fair skinned people
May be heritable: Basal Cell Nevus Syndrome

22. Basal Cell Carcinoma Malignant Lesions 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

23. Basal Cell Carcinoma Malignant Lesions Superficial BCC Often multiple
Anywhere
Pink or red scaly irregular plaques
Slowly grow over months or years
Bleed or ulcerate easily

24. Basal Cell Carcinoma Malignant Lesions Morpheaform BCC
Also known as sclerosing BCC
Usually found in mid-facial sites
Prone to recur after treatment
May infiltrate cutaneous nerves (perineural spread)

25. Basal Cell Carcinoma Malignant Lesions Pigmented BCC
Brown, blue or greyish lesion
Nodular or superficial histology
May resemble melanoma

26. Basal Cell Carcinoma Malignant Lesions Basisquamous BCC
Mixed BCC and Squamous Cell Carcinoma
More Aggressive

27. Basal Cell Carcinoma Malignant Lesions 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

28. Squamous Cell Carcinoma
Malignant Lesions
Squamous Cell Carcinoma

29. Squamous Cell Carcinoma
Malignant Lesions
Squamous Cell Carcinoma
Directly related to UV exposure
Smoking
Chronic wounds
Human Papiloma Virus

30. Squamous Cell Carcinoma
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

31. Squamous Cell Carcinoma
Malignant Lesions
Squamous Cell Carcinoma
5% metastasize to other sites
more likely in transplant patients, old age, alcoholics etc.
May require adjuvant radiation therapy

32. Malignant Lesions
Melanoma

33. Melanoma Malignant Lesions Cancer 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

34. Melanoma Malignant Lesions
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%.

35. Melanoma Malignant Lesions
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%.

36. Melanoma Malignant Lesions Treatment: 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

37. Reconstruction Mohs defect 45 by 55mm 50% lower Lid 30% Upper lid
Resection of lateral canthus
Loss of temporal skin

38. Reconstruction Repair of the eyelid, like all reconstruction:
Knowledge of the anatomy
Function of the part to be reconstructed
Application of technique

39. Reconstruction

40. Reconstruction

41. Reconstruction

42. Reconstruction

43. Reconstruction

44. Reconstruction

45. Reconstruction

46. Reconstruction

47. Reconstruction

48. Reconstruction

49. Reconstruction

50. Reconstruction

51. Reconstruction Lower Lid Posterior Lamella Temporalis fascial flap
Lower Lid anterior Lamella
Cervical facial flap
Reconstruct upper lid
Primary attachment to New lower lid

52. Reconstruction