Step ladder VY advancement flap for lower eyelid reconstruction after resection eyelid malignant tumors.

BACKGROUND: In oculoplastic surgery, reconstruction of a large defect after the removal of a massive malignant lower lid tumor still represents a unique challenge. We will report on this case, including a presentation of the case using step ladder V-Y advancement flap. METHODS: During November 2018 to March 2023, five patients of lower eyelid malignant tumor had wide resection with safety margin and reconstructed using step ladder V-Y advancement flap. The flap was used step ladder V-Y advancement flap. RESULTS: No complications, including ectropion deformity, occurred. This flap does not sacrifice healthy skin as seen with the cheek rotation flap, and the area of dissection is very small and can be performed in a short time. CONCLUSIONS: Step ladder V-Y advancement flap is highly useful in cases that require a reconstruction of a large defect after the removal of a massive malignant lower lid tumor from viewpoints of operating time, ease of procedure, aesthetics, and complications.

Total lower eyelid reconstructions with septal chondromucosal graft and pedicled flap on the superficial temporal artery.

BACKGROUND: Subtotal and total lower eyelid tissue loss after tumour excision is a complex issue for reconstructive surgeons. The anterior and posterior flaps must be restored to avoid compromising the functional and aesthetic prognosis of the eye. This study used a septal chondromucosal graft for the posterior lamella and a fasciocutaneous flap pedicled on the temporal artery for the anterior lamella. METHOD: We conducted a 10-year monocentric retrospective study, including 18 patients who were treated using a septal chondromucosal graft with a temporal artery pedicle flap following tumour excision. We collected demographic and medico-surgical data related to flap survival, absence of ectropion, lagophthalmos and other post-operative complications. The aesthetic outcome was judged using a grading scale during the last follow-up consultation. RESULTS: All grafts and flaps survived, whereas 2 patients required early repeat surgery (1 for ectropion and 1 for graft site haematoma). None of the patients developed lagophthalmos. Two patients had distal flap injuries that healed with local care. All patients were satisfied with the aesthetic outcome at the last follow-up visit. CONCLUSION: Combining a septal chondromucosal graft with a fasciocutaneous flap pedicled to the temporal artery for total lower eyelid reconstruction is a reliable method with satisfactory functional and cosmetic outcomes.

Solitary eosinophilic granulocytic sarcoma in a dog.

A 6-year-old male golden retriever presented with swelling of the left upper eyelid of 2 months duration, which did not improve following a course of antibiotics. Routine serum biochemistry, complete blood count and diagnostic imaging identified no clinically significant abnormalities. The mass was surgically excised, and histopathologic examination was performed. Eosinophilic granulocytic sarcoma (GS) was diagnosed based on the results of histopathology and immunohistochemistry. This is the first report of GS affecting the eyelid of a dog.

Medial Canthal Tendon Reflecting in Lower Eyelid Reconstruction After Palpebral Cancer Surgery: Description of a New Technique.

PURPOSE: The aim of this article is to describe a new reconstructive technique of the lower eyelid in the surgery of tumors involving the medial canthal tendon. METHODS: Our new technique consists of detaching and reflecting the most medial portion of the anterior medial canthal tendon and reinserting it into the posterior lamella. We describe the cases in which our technique can be useful, as well as the results we have obtained. RESULTS: The result after a year of follow-up showed no disruption of the angulation of the lower eyelid line and no changes in eyelid position. CONCLUSIONS: The medial canthal tendon reflection could provide both aesthetic and functional results that may be superior to the usual techniques.

Complications and Recurrences after Excision and Reconstruction of Eyelid Tumours.

INTRODUCTION: The eyelids are a common site for skin tumours and account for 5-10% of all skin tumours. Treatment is mainly surgical and aims to preserve the anatomical structure of the eyelid, its function and not least its aesthetic appearance. AIM: Presentation of recurrence and complication rates of tumour-related eyelid surgery in a cohort of 450 tumours. RESULTS: Analysis of a cohort of 450 tumours operated on revealed 13 (2.8%) operations with recurrences and 32 (7%) with complications. The statistical significance of recurrences was observed for the involved and uninvolved ciliary margin. At the temporal canthus, 23.1% of recurrences occurred compared to 7.7% at the medial canthus. SGC has the highest recurrence rate. Complications include the following: ectropion, dehiscence, gross cicatrix with normal function, retraction, post-radiation damage, sub-graft haemorrhage and graft rejection. CONCLUSIONS: The recurrence rate of eyelid tumours is lower than that of complications. The choice of surgical technique determines the frequency of complications and histological control of the excised tissue, as well as the frequency of recurrences.

Frozen Section Histoanatomy of the Peritarsal Eyelid.

BACKGROUND: Mohs surgery of eyelid skin cancers requires detailed knowledge of anatomy for precise surgery and accurate evaluation of histology. OBJECTIVE: To review the histology of the peritarsal eyelid using frozen sections as encountered intraoperatively by Mohs surgeons. METHODS: The authors review the literature describing the anatomy and histology of the peritarsal eyelid from the lens of a Mohs surgeon. Histology from select Mohs cases is used to frame the discussion of the microanatomy of this region. RESULTS: The peritarsal eyelids contain a unique mixture of skin, muscle, tarsus, glandular tissue, and conjunctiva. The histologic appearance of many of these structures differs from skin found outside of this anatomic region. Tumors of the eyelid and periocular region may mimic normal histologic structures found within the peritarsal eyelid. CONCLUSION: The peritarsal eyelids have unique anatomy and associated histologic structures. Knowledge of the detailed histoanatomy is required for confident execution of Mohs surgery in this anatomic region.

The effect of traction force on eyelid blood perfusion during closure of defects.

PURPOSE: In oculoplastic surgery the eyelid tissue is frequently stretched in order to repair defects after tumor surgery. However, there is a paucity of research regarding how stretching affects eyelids. The purpose of this study was to gain insight into how traction force affects eyelid stretch as well as tissue perfusion, using a laser-based in vivo monitoring technique. METHOD: Lower-lid pentagonal resections were performed in eight patients and a total of nine eyelids. The medial section of the eyelid was then stretched using a dynamometer up to a force of 2.3 Newtons (N), and eyelid stretching and blood perfusion were continuously measured using laser speckle contrast imaging. RESULTS: Tissue perfusion decreased exponentially when eyelid tissue was stretched, with an initial sharp decline followed by a more gradual reduction. Perfusion approached zero at a force of approximately 2.0 N. The length of the eyelid increased with increasing force up to 1.5 N, after which there was only a very slight increase in length. CONCLUSIONS: Eyelid tissue seems to respond to traction in a non-linear fashion, where the initial force results in the greatest eyelid stretching and reduction in blood perfusion. The results provide information on the effects of a large force for direct closure of large eyelid defects. Considering how quickly perfusion approaches zero, the high success rate of eyelid reconstruction surgery is likely a testament to the extensive vascularization of the periocular region.

Surgical margins and outcomes for eyelid melanoma: a systematic review and meta-analysis.

No randomized trials exist to inform the peripheral surgical margins or depth of wide excision for eyelid melanoma. We performed a meta-analysis examining surgical margins and Breslow depth for eyelid melanomas. A systematic review was performed in August 2022 using PubMed, Cochrane, and Medline databases (1/1/1990 to 8/1/2022). Inclusion criteria included studies reporting surgical treatment of primary cutaneous melanomas of the eyelid with reported surgical margins. Ten articles were included. The studies were examined by surgical margin size (group 1: ≤ 0.5 cm; group 2 > 0.5 cm and ≤ 1.5 cm) and Breslow depth (group 1: ≤ 1 mm; group 2: > 1 mm). The odds ratio (OR) for local recurrence was 2.55 [95% CI 0.36-18.12], p = 0.18; regional metastasis was 0.70 [95% CI 0.00-23671.71], p = 0.48; and distant metastasis was 2.47 [95% CI 0.00-1687.43], p = 0.66. When examining by Breslow depth, the OR for local recurrence was 0.53 [95% CI 0.14-1.94], p = 0.34; regional metastasis was 0.14 [0.00-176.12], p = 0.54; and the OR for distant metastasis was 0.24 [95% CI 0.01-8.73], p = 0.46. There was a trend toward higher likelihood of recurrence and metastasis in the ≤ 0.5 cm group. Similarly, there is a trend toward higher likelihood of recurrence and metastasis with Breslow depth > 1 mm. A surgical margin of at least 0.5 cm and achievement of negative margins via permanent sections or MMS are likely needed to prevent adverse outcomes. En face sectioning may be a superior method of histological processing for eyelid melanoma.

Surgical reconstruction of medial eyelid defects using margin transposition, tarsal graft, and periosteal strip.

PURPOSE: Surgical reconstruction of medially located lower eyelid defects can be challenging. The Hughes procedure, considered the standard for reconstruction in such cases, often falls short in terms of cosmetic outcomes. An alternative approach that combines medial transposition with a tarsal graft and periosteal strip has shown promise. Here, we aim to demonstrate the cosmetic advantages of medial transposition of a preserved temporal lower eyelid over other techniques. METHOD: We conducted a retrospective study involving seven well-documented patients who underwent the procedure described below. The study was approved by the University's Ethics Committee. RESULTS: All patients were followed up for one year. Lower eyelid defects spanned 50-80% of their total length, situated in the central third of the eyelid or the central to medial portion. Postoperative complications were minimal, with all patients exhibiting good cosmetic, functional, and anatomical outcomes at follow-up. CONCLUSION: The absence of eyelashes is well tolerated if it is lateral, but when the defect is medial, medial transposition could be a good alternative to the familiar Hughes surgical intervention.

Modified Mustardé and Superolateral Periosteal Flaps for Full-Thickness Defects of Medial and Central Lower Eyelid: A Case Series.

BACKGROUND: Reconstructing full-thickness defects involving 50% to 75% of the horizontal length of the lower eyelid after medial and central full-thickness block resection can be challenging. As a disadvanatge, 1-stage reconstructions may require a free graft reconstruction of the posterior lamella. In addition, 2-stage reconstructions are associated with several complications, including erythema, and the eye must be temporarily closed after surgery. METHODS: The present study describes a single-surgeon retrospective case series. Five patients diagnosed with basal cell carcinoma underwent wide full-thickness block resection with optimal excision margins (3-5 mm). Subsequently, 1-stage reconstruction was performed using the modified Mustardé flap, incised using the transconjunctival approach. This flap comprised the skin, muscle, tarsus, and conjunctival flap raised from the lateral canthus through a lateral cantholysis procedure, and then extended to the lateral cheek. The flap was medially transposed to cover the medial and central lower eyelid defect. The superolateral periosteal flap was harvested from the superolateral orbital rim attached to the lateral border of the tarsus of the modified Mustardé flap. The lateral forniceal conjunctiva was released from the retractor and advanced superiorly to cover the inner surface. RESULTS: The study included 3 men and 2 women, with a mean age of 71 years (range, 62-90 years). Histological evaluations confirmed tumor-free margins in all cases. The average follow-up duration was 20 months (6-60 months), with no tumor recurrence. None of the patients developed long-term complications, such as ectropion, entropion, lagophthalmos, trichiasis, symblepharon, erythema, wound dehiscence, or flap necrosis. All patients had minimal scarring, and no secondary surgical interventions were necessary. CONCLUSIONS: This case series demonstrates the efficacy of the combined modified Mustardé and superolateral periosteal flaps in 1-stage reconstruction of full-thickness defects involving 50% to 75% of the horizontal length of the medial and central lower eyelid without compromising functional and aesthetic outcomes.

Cystic-Appearing Eyelid Lesion in a 62-Year-Old Man.

A 62-year-old male was referred for evaluation of a painless right lower-eyelid lesion noted during routine glaucoma follow-up. The lesion had been present for 3 years with slow, gradual enlargement. What would you do next?

Marginal resection and infracyanine green-mediated photodynamic therapy in the management of feline eyelid squamous cell carcinoma: Two cases.

OBJECTIVE: Describe the presenting features, surgical procedure, and clinical outcomes of two cats managed with marginal resection and photodynamic therapy (PDT) for eyelid squamous cell carcinoma (SCC). ANIMALS STUDIED: A 12-year-old female spayed domestic shorthair cat (case 1) and a 10-year-old female spayed domestic shorthair cat (case 2). PROCEDURES: Following marginal resection of the eyelid neoplasm, hemostasis was achieved using a handheld cautery unit then 1 mL of infracyanine green was injected into the surgical wound bed. Photodynamic therapy was performed using an 810 nm diode laser in two consecutive steps: (i) six cycles at 500 mW for 30 s per cycle, using a rapid movement; then (ii) one (case 1) or two cycles (case 2) of 30 s at 2000 mW, using a slow deliberate movement to effect (charred surface). RESULTS: Histopathology was consistent with SCC resected with incomplete margins in both cats. Follow-up duration was 416 and 161 days in case 1 and case 2, respectively. Consecutive exams and photo-documentation (in clinic or by owners) showed appropriate healing of the lower eyelid, with a smooth lid margin, and no evidence of tumor regrowth or ocular irritation. Subtle trichiasis was noted in case 1 on day 185, but not at the last follow-up. CONCLUSIONS AND CLINICAL RELEVANCE: Marginal resection followed by PDT may be a valid alternative to complete surgical resection of periocular SCC in cats. The procedure was easy to perform, post-operative recovery was uncomplicated, and neither cat developed recurrent disease during the follow-up period.

Robotic assisted orbital surgery for resection of advanced periocular tumours - a case series report on the feasibility, safety and outcome.

PURPOSE: Orbital surgery benefits from well-designed instrumentation that offers gentle tissue manipulation, high manoeuvrability and control. Nevertheless, in confined spaces, tissue manipulation must be accomplished with exceptionally high accuracy and precision. This is where robotic surgery offers an advantage. We aimed to evaluate a robotic-assisted surgical system's feasibility, safety and outcome in assisting tumour clearance. PATIENTS AND METHODS: A case series of patients with advanced periocular tumours undergoing robotic-assisted globe-sparing resection was performed using the DaVinci XI system (Intuitive Surgical, Inc). Institutional ethics and multidisciplinary approval were sought in all cases. RESULTS: Four patients with advanced periocular tumours underwent robotic-assisted orbital surgery at a mean age of 63 years (range 42-86). Two patients were diagnosed with squamous cell carcinoma, and two had basal cell carcinoma. One patient was found to have positive lymph nodes at the time of surgery and underwent simultaneous parotidectomy and lymph node clearance. Clear resection of the primary tumour was achieved in all patients; three patients underwent further resection due to narrow margins prior to reconstruction. Patients were follow-up for at least one year, and three remained disease-free. One patient with pre-existing extra-orbital disease developed metastatic disease four months post-op. All patients preserved vision peri-operatively, with no complaints of diplopia. Moderate ocular surface disease was noted in two patients. CONCLUSION: Our series highlights the potential advantage of three-dimensional optics, multi-directional instrumentation and motion scaling technology to achieve globe-sparing tumour resection in advanced periocular tumours. However, further robotic instrumentation development is required for orbital surgery.

Reconstruction of Full-Thickness Eyelid Defects Following Tumor Resection: The Bucket Handle Modification.

PURPOSE: To describe a modified approach for full-thickness lower eyelid defect reconstruction. METHODS: This is a retrospective review of 5 patients with large full-thickness lower eyelid defects after tumor resection requiring reconstruction. For these lower eyelid defects, a lateral-based or superior-based tarsoconjunctival pedicle flap from the upper eyelid was used to rebuild the posterior lamella. In all cases, the anterior lamella was supplied from an adjacent myocutaneous flap in a bucket handle configuration. Data collection included tumor type and location, size of eyelid defect, presence of canalicular involvement, postoperative eyelid position, patient satisfaction, and complication rates. RESULTS: Five eyelids of 5 patients underwent Mohs micrographic excision of basal cell carcinoma followed by reconstruction with a bucket handle flap. Age range was 68 to 96 years old (mean of 81 y). Five patients presented with lower eyelid involvement. The defect size ranged from 80% to 100% of the eyelid. Three patients had canalicular involvement and required bicanalicular nasolacrimal stent placement. After reconstruction, all patients showed good eyelid apposition to the globe with excellent esthetic outcome. No revision procedures were done. Average follow-up time was 13 months (range of 8 to 21 mo). CONCLUSION: The bucket handle flap for full-thickness eyelid reconstruction is a simple technique that allows for preservation of all anatomical layers of the anterior lamella. This technique shows promising functional and esthetic outcomes.

Recurrence rates of periocular basal cell carcinoma following intra-operative en-face frozen section margin controlled excision.

PURPOSE: To report the margin control process and rate of recurrence of periocular basal cell carcinomas (BCCs) managed by en-face, frozen section margin controlled (FSC), excision by a single surgeon with a 3-year follow-up. METHODS: A retrospective analysis of all histopathologically proven cases of periocular BCC who underwent surgical excision with intra-operative, en-face, FSC, excision by a single surgeon from 2015 to 2019 was performed. Patients with less than 3-year follow-up were offered a virtual appointment to determine possible recurrence. RESULTS: A total of 88 BCC excisions from 86 patients were reviewed. Minimum 3-year follow-up data is available for 73 patients. The most common location and histological subtype was the lower eyelid and nodular BCC, respectively (47% and 83% of cases). Primary BCC (pBCC) comprised 98% (86/88) of cases and recurrent BCC (rBCC) comprised 2% (2/88) of cases. Negative frozen section margins were achieved in 93% (82/88) of excisions on the day of surgery. The overall recurrence rate during this time was 1.4% (1/73) at minimum 3 years. CONCLUSION: Periocular BCC can be managed effectively by en-face, FSC, excision, with a high cure rate and low recurrence rate comparable to alternative excision techniques such as Moh's micrographic surgery. Advantages of en-face excision include same-day excision and reconstruction and reduced theatre time. Primary nodular BCCs with clear margins can be considered for early discharge with advice to self-monitor.

Chalazion-mimicked eyelid angiosarcoma in a young Asian with good prognosis: a case report.

BACKGROUND: Angiosarcoma is an extremely rare malignant tumor. So far, only about 42 cases of angiosarcoma involving the eyelids have been reported. Eyelid angiosarcoma occurs more frequently in elderly Caucasian males and is prone to misdiagnosis. We present a case report in a young Asian male patient with eyelid angiosarcoma that was misdiagnosed as a chalazion. CASE PRESENTATION: A 46-year-old South Korean male with no underlying disease had a right lower lid mass. The lesion was initially misdiagnosed as a chalazion at a local clinic, but a diagnosis of eyelid angiosarcoma was made after the first biopsy trial. PET-CT was performed to ensure that there was no metastasis in the whole body. Surgical excision with enough surgical margin was used alone for treatment and reconstruction was performed with a tarsoconjunctival advancement flap (modified Hughes procedure), which helped ensure good cosmesis. No recurrence was observed 4 years and 5 months after the surgery. CONCLUSIONS: The current study presents the first case of chalazion-mimicked eyelid angiosarcoma in a young Asian male aged under 50 years. This case shows that even if a benign eyelid disease is suspected in a young patient, an incisional biopsy must be performed to confirm whether the lesion is malignant. Since the prognosis is good for the case of eyelid angiosarcoma, if there is no clear evidence of distal metastasis, surgical resection should be performed with an enough safety margin.