Transcript Eyelid Cancer and Reconstruction

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
Nevus
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.
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
Melanoma
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
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
Melanoma
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
Reconstruction
Mohs defect
45 by 55mm
50% lower Lid
30% Upper lid
Resection of lateral canthus
Loss 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 Lamella
Temporalis fascial flap
2. Lower Lid anterior Lamella
1. Cervical facial flap
3. Reconstruct upper lid
1. Primary attachment to
New lower lid
Reconstruction