Surgical Management of Eyelid Lesions

Some eyelid lesions can be identified by their history and clinical appearance, and then treated appropriately. However, many benign lesions can be confused with more aggressive malignant tumors from which they must be differentiated. When doubt exists as to a specific diagnosis, a biopsy should be obtained and submitted for histopathologic evaluation. Based on the findings a more directed therapeutic approach can then be planned. In some cases such as inflammatory lesions medical therapy alone might be indicated. But for malignant and premalignant neoplasms or for benign lesions that are of cosmetic or functional concern further surgery is often necessary.

When biopsy is necessary for diagnosis there are several techniques that are useful depending upon the lesion and location. In some cases representative tissue only is obtained with most of the lesion left behind. In other techniques an attempt is made to remove the entire lesion.

For elevated lesions of uncertain etiology, especially those on the lid margin, the shave biopsy is a useful procedure. It provides a representative sample of tissue for the pathologist without risking lash loss, eyelid deformity or other complications. In this procedure a scalpel is used to shave off the elevated portion of the lesion flat with the surrounding eyelid (Fig. 1). Light cautery or pressure is applied, with care taken not to injure eyelash follicles. If the lesions is benign or can be treated medically, then no further surgery is necessary. However, if the results require complete excision then a more definitive wedge resection can be performed, preferably under frozen section control.

For large lesions that cannot be removed as an initial procedure or for which a simple shave is not appropriate, a small segment of the tumor can be excised and submitted for histopathologic exam. As with the shave biopsy, some tumor is intentionally left behind to be managed by further surgery or ancillary therapy once a definitive diagnosis is available. The incisional biopsy should include a representative portion of the tumor plus a segment of the margin to show some adjacent normal tissue (Fig. 2).

BIOPSY TECHNIQUES Shave Biopsy

Incisional Biopsy

Incisional Biopsy
Figure 1 Technique of shave biopsy where a portion of the lesion is shaved flush with the surrounding eyelid skin.

Figure 2 Incisional biopsy with a representative sample of the lesion is excised leaving most of the lesion behind.

Shave Biopsy

Figure 4 The Mohs microsurgical technique employs a sequential tangential layered excision procedure with histologic examination of all margins.

Figure 3 In the excisional biopsy the entire lesion is removed with a small zone of normal tissue.

Figure 3 In the excisional biopsy the entire lesion is removed with a small zone of normal tissue.

Figure 4 The Mohs microsurgical technique employs a sequential tangential layered excision procedure with histologic examination of all margins.

Excisional Biopsy

When the lesion is small enough so that it can likely be completely removed at an initial procedure the excisional biopsy is best. This is especially true if a benign tumor is suspected so that clear margins are of less concern. A small rim of normal tissue is taken around the margins of the lesion and care is taken to remain deep to the involved tissue (Fig. 3). For suspected malignant tumors or for benign lesions with a high recurrence rate when incompletely removed, excision should be performed under frozen section control.

Mohs Microsurgical Excision

For all malignant tumors around the eyelids the Mohs procedure gives the highest cure rate, generally in the 99.0-99.5% range. Sequential tangential layers are cut and all surfaces are marked for identification. Histologic examination of the entire cut surface is performed by a trained Mohs surgeon and detailed maps are made to note the precise location of any residual tumor. Additional layers are then cut in areas where residual pathology is noted (Fig. 4). The procedure is continued until all margins are free of tumor. In most cases the defect will require reconstruction using local tissue flaps or grafts. For small defects on non-mobile areas such as the nasal bridge, cheek, or temple, it can sometimes be left to granulate spontaneously.

EYELID RECONSTRUCTION TECHNIQUES Primary Layered Closure

For smaller defects involving the non-marginal skin and muscle, or full-thickness marginal eyelid, repair can be accomplished by directly re-approximating the individual layers. Non-marginal skin defects can be excised with an elliptical incision (Fig. 5). Muscle and skin are then closed in separate layers. Some undermining of edges may be needed for slightly larger defects. For marginal eyelid defects in younger patients where tissues show less laxity, a 25% lid defect can usually be closed without difficulty. In older patients it may be possible to close 40-50% or more. With modification of the basic technique by cutting the lateral canthal tendon, even larger defects can often be closed primarily. It is important to align the lid margin and lash line first, and then the tarsus, orbicularis, and skin in separate layers to avoid any cosmetic deformity (Fig. 6).

Elliptical Excision Surgery
Figure 5 The elliptical excision is used for small lesions where the defect can be closed primarily. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.

Free Tarsoconjunctival Graft

For full thickness defects that are too large to close primarily, a graft taken from the posterior surface of the ipsilateral or contralateral upper eyelid will provide both conjunctiva and tarsus to reconstruct the posterior lamella. The donor site is left to granulate. The graft is sutured to the residual tarsus or canthal tendons in the recipient site and then covered by a sliding myocutaneous flap to reconstruct the anterior lamella (Fig. 7). This technique works equally well for the lower or upper eyelid.

Rhombic Flap

The rhombic flap is a rotational type flap for repair of small quadrangular defects in the paraorbital region. It can be designed from any of four quadrants around the defect by marking out a V-shaped cut from one of the corners (Fig. 8). When closed, tension is concentrated across the arms of the V so that the flap can be planned to avoid vertical tension that might distort the eyelid. Once the V is closed there is no residual tension on the flap. The procedure yields excellent cosmetic and functional results.

Cutler-Beard Procedure

When a total or near total upper eyelid is missing the Cutler-Beard procedure is one of the major techniques available for reconstruction. A full-thickness horizontal blepharotomy is cut 4 to 5 mm below the lower lid lash line across the entire lid, and the incisions are then extended vertically to the inferior fornix to create a flap (Fig. 9). This leaves a bridge of marginal eyelid supported

Inferior Fornix
Figure 6 Primary layered closure is used for full-thickness marginal defects where all tissues are re-apposed in layers. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.
Eyelid Chemical Lesion
Figure 7 For full-thickness partial lid defects a free tarso-conjunctival graft from upper to lower lid is then covered with a myocutaneous flap. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.
Tarso Conjunctival Flap
Figure 8 The rhombic flap is useful for non-marginal lesions where vertical tension on the eyelids can be avoided. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.
Cutler Beard Flap

by the medial and lateral palpebral arteries. Layers of the flap are advanced beneath the bridge and sutured to corresponding layers in the upper lid defect. Sclera or other material can be placed between the conjunctiva and orbicularis muscle and attached to the levator aponeurosis to approximate the tarsus. After three weeks the flap is cut at an appropriate length and the lower lid is repaired by reattaching the marginal bridge. Although lashes are lacking on the new reconstructed upper lid, the procedure gives an excellent functional and cosmetic result.

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Responses

  • j
    What is a layered leison on the eye lid?
    7 years ago
  • asphodel twofoot
    IS partial thickness eyelid biopsy disfiguring?
    6 years ago

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