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.

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?

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.

Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction.

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

Clinical features and management of eyelid margin nevi.

PURPOSE: Acquired melanocytic nevi are common eyelid lesions; however, their clinical presentation is not well documented. METHODS: In this retrospective study, clinical records were reviewed in patients evaluated between 2005 and 2022. RESULTS: Eyelid margin nevi (n = 150) were more commonly excised in female (78%) and Caucasian (86%) patients. Change in appearance/size were frequent presenting complaints, and 17% experienced ocular symptoms. Referring diagnosis included other benign lesions (11.3%), and concern for malignancy (16.7%). Many individuals (38.7%) noted their lesion for ≤5 years. Nevi were distributed across the 4 margins (9% peripunctal), and 88% had a regular base. Visible pigmentation was more common in non-Caucasians (95.2%) than Caucasians (41.1%). Lashes grew through 60.7% of nevi and were often misdirected.Nevi were treated with superficial excision and cauterization. Histologic subtypes included: dermal (86.6%), compound (9.4%), blue (2.7%), junctional (0.7%), lentiginous dysplastic (0.7%). An irregular base (p=0.042) and pigmentation (p=0.056) were more common in compound than dermal nevi. Lash line quality and appearance were improved in the majority of patients returning for follow-up, although postoperative trichiasis, marginal erythema, and residual pigmentation were observed. CONCLUSIONS: Melanocytic nevi commonly involve the eyelid margins and have a variety of presentations and appearances. Existing nevi can change, and new lesions appear throughout adulthood. Stable, benign appearing nevi can be observed. Shave excision provides a diagnosis and improved appearance for symptomatic or suspicious lesions, with few serious complications. Malignant transformation is rare, although evidence for recurrence warrants further evaluation.

Comparison of the clinical characteristics of benign and malignant eyelid lesions: an analysis of 1423 eyelid lesions, compared between ophthalmology department and plastics department.

PURPOSE: Oculoplastic surgeons excise and reconstruct eyelid tumors, although plastic surgeons have traditionally managed these cases. Current demand of this surgery is growing, and planning referral services is a health management necessity. This pilot study retrospectively reviewed same population eyelid specimens excised by both disciplines comparing data. METHODS: Clinical and epidemiologic features of 1423 eyelid lesions biopsied between 2015- 2020 in Emek Medical Center (EMC), Israel were reviewed. RESULTS: Among 1423 specimens, 1210 (85.0%) were benign and 213 (15.0%) were malignant/pre-malignant. Mean age at diagnosis was significantly higher in malignant tumors than in benign tumors (76 and 59 years respectively, p value < 0.001). The most common benign eyelid lesions were soft fibroma (20.1%), seborrheic keratosis (11.0%) and melanocytic nevus (10.3%). The most common malignant/pre-malignant eyelid tumors were basal cell carcinoma (BCC) (9.2%), actinic keratosis (2.6%) and Bowen's disease (1.9%). Ophthalmology removed 37 malignant/pre-malignant lesions (5.4%) out of 683 compared to plastics removing 142 malignant/pre-malignant lesions out of 740 (19.2%) specimens. Eyelid malignancy in the plastics department was significantly higher than in the ophthalmology department (p value < 0.001). 270 (70.0%) lesions caused by UV exposure were removed by plastics and 116 (30.0%) were removed by ophthalmology (p value < 0.001). CONCLUSIONS: Eyelid lesions in patients aged 76 or older are more likely to be malignant. Ophthalmology eyelid specimens in younger patients are more commonly benign and related to inflammation. Specimens from the plastics department are more commonly malignant, related to UV-exposure, and are from older patients. This difference may be due to a misconception that plastic surgeons have more eyelid cancer reconstruction experience than oculoplastic surgeons, or less awareness of the oculoplastic expertise available today.

Squamous cell carcinoma of the eyelid.

Eyelid squamous cell carcinoma is a major type of rare eyelid cancer, together with basal cell carcinoma and sebaceous gland carcinoma. It is a painless disease that progresses slowly and is often detected by the appearance of nodules or plaques. Risk factors include exposure to ultraviolet light, fair skin, radiation and human papillomavirus infection. The standard treatment is surgical removal, and in cases of orbital invasion, orbital content removal is required. If sentinel node biopsy reveals a high risk of lymph node metastasis, adjuvant radiotherapy may be considered. Local chemotherapy, such as imiquimod and 5-fluorouracil, may be used for eyelid squamous cell carcinoma in situ. When surgery or radiotherapy is not recommended for distant metastases or locally advanced disease, drug therapy is often according to head and neck squamous cell carcinoma in Japan. The treatment often requires a multidisciplinary team to ensure the preservation of function and cosmetic appearance.

Pericanalicular eccrine hidrocystoma of the upper eyelid in a child.

A rare case of pericanalicular eccrine hidrocystoma of the upper eyelid is reported in a child who underwent surgical excision and canalicular repair with a successful outcome.

The Utility of the Paramedian Forehead Flap in Lower Eyelid Reconstruction.

BACKGROUND: Malignant cutaneous eyelid tumors account for approximately 10% of all cutaneous cancers. Like other cancerous skin lesions, treatment commonly involves excision with wide margins, requiring tissue reconstruction. The use of the paramedian forehead flap (PMFF) has been described for reconstruction of the medial and upper eyelid, but literature is lacking for its use in lower eyelid anterior lamella reconstruction. We present a case series of patients who underwent reconstruction of lower eyelid defects using the PMFF. CASE PRESENTATIONS: We present 2 patients who underwent reconstruction of lower eyelid defects using the PMFF surgical technique. The patients had previous history of lower lid repair with other reconstructive methods because of cancerous eyelid lesions. In addition, both received adjuvant radiation therapy, which led to development of ectropion. Postoperative signs, symptoms, and photographs were collected to monitor outcomes. MANAGEMENT AND OUTCOMES: Reconstructions were performed by the collaborative efforts of a facial plastic reconstructive surgeon and oculoplastic surgeon using a staged PMFF approach. Postoperatively, both patients had significant improvement in ophthalmologic symptoms, particularly ectropion and lagophthalmos. At their most recent follow-up visit, they were satisfied with their functional and aesthetic outcomes. CONCLUSION: The PMFF may be safely used to reconstruct defects of the lower eyelid anterior lamella. In this study, the PMFF has proven to be an excellent option for patients with complications after previous lower eyelid reconstructions or history of radiation therapy. Overall, the PMFF should be considered as part of the surgeon's reconstructive ladder when addressing lower eyelid defects.

Post-oncological full-thickness eyelid defect reconstruction: An aesthetical overview.

Purpose of the current study was to introduce a new detailed aesthetical subunit (ASU) involvement chart to localize the defect configuration on the eyelids, and, to evaluate the aesthetical and functional outcomes of the post-oncological full-thickness eyelid defect reconstruction surgery by using a modified aesthetical rating guideline. Medical records of subjects who were diagnosed with a primary malignant full thickness eyelid tumor involving the eyelid margin and underwent full-thickness eyelid defect reconstruction surgery between April 2016 and May 2022 were retrospectively reviewed. Age, sex, pathological diagnosis, follow-up time, the ASU of the eyelid involvement, and surgical methods used to reconstruct the anterior and posterior lamella were examined from medical records. The reconstructed eyelid photos were scored according to the modified aesthetical rating guideline to analyze the aesthetical and functional outcomes of the surgeries. A total of 31 subjects were included to the study, and the overall mean aesthetical score was 3.5. Seventeen subjects with aesthetical scores greater than 3.5 were included in the more aesthetically pleasing (AP) group, and 14 subjects with aesthetical score less than 3.5 were included in less AP group. Anterior lamella repair was mainly performed using myo-cutaneous flaps in the more AP group and multiple flap combinations in the less AP group (P: 0.13). Posterior lamella reconstruction was performed using tarso-conjunctival tissue in both groups. In more AP group, tissue scarring, lash line disruption, eyelid thickness, and retraction or ectropion scores were significantly higher when compared with less AP group (P:0.03, P:0.03, P:0.02, and P:0.01, respectively). Subjects with fair eyelash color were significantly more common in more AP group (P: 0.009). The ASU involvement chart and outcomes of the current study may aid novice surgeons to determine which method will provide the best result for an individual patient for full-thickness eyelid defect repair and may offer some insight into the different surgical techniques used for repairing similar wounds.

Resección tarsal vertical limitada en un caso de carcinoma basocelular de párpado inferior / Limited vertical tarsal resection in a case of basal cell carcinoma of the lower eyelid

Exponemos el caso clínico de una mujer de 71 años de edad con antecedente de múltiples carcinomas basocelulares (CBC) que presenta una lesión nodular en la totalidad de la extensión del borde libre de párpado inferior. Se realiza un abordaje de la lesión mediante exéresis del margen palpebral con resección limitada vertical de tarso y colgajo de Tripier con un resultado estético y funcional correcto, márgenes histológicos libres y ausencia de recidiva en un seguimiento de 12 meses (AU)

We present the clinical case of a 71-year-old woman with a history of multiple basal cell carcinomas (BCC) who presented a nodular lesion in practically the entire extension of the free edge of the lower eyelid. The lesion was approached by excision of the palpebral margin with limited vertical resection of the tarsus and Tripier flap with a correct aesthetic and functional result, free histological margins and no recurrence in a 12-month follow-up (AU)

Postoperative clinical analyze of 450 eyelid tumors.

BACKGROUND: The eyelids are a small anatomical structure, yet they contain several histological layers from which benign and malignant tumors can originate. Compared to other parts of the face, the eyelids are often the first place where neoplasms or disease changes are noticed. AIM: To analyze localization and its predictive malignancy of eyelid tumors over a 10-year period. METHOD: A retrospective study of 436 (450 eyes) patients operated on over a 10-year period. Descriptive, dispersion and correlation analyzes were performed. RESULTS: The results provide a clear assessment of the distribution and incidence of eyelid tumors according to the localization of the defect, involvement of the lash line, inflammatory response, etc. Tumor distribution is significantly skewed in favor of the medial canthus, 80% to 20% by all tumors. The involvement of the lid margin occurs in 83% of malignant tumors and has significant predictive value. CONCLUSION: The lower eyelid and the medial canthus are preferred locations for malignant tumors, and the upper eyelid for benign ones. Our study does not affect the types of surgical techniques; its purpose is to show the expected malignancy of the different combinations by location. The location of the tumor is a leading factor in the choice of the oculoplastic reconstructive procedure.

The effectiveness and safety of eyelid defect reconstruction after sebaceous carcinoma of the eyelid surgery: A protocol for systematic review and meta-analysis.

INTRODUCTION: Sebaceous carcinoma of the eyelid is the third most common eyelid malignancy, after basal cell carcinoma and squamous cell carcinoma. It is highly malignant and potentially aggressive. Surgical excision is currently the best treatment option for this condition. Patients often require reconstruction surgery to repair eyelid defects to achieve normal eyelid function and appearance. However, no comprehensive systematic review has assessed the efficacy and safety of eyelid defect reconstruction. This protocol was developed to conduct a systematic review and meta-analysis to evaluate evidence related to the efficacy and safety of reconstruction. METHODS: We will systematically search the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure, WanFang Database, and Chinese Biomedical Literature Database from their inception to February 2023 for studies on eyelid defect reconstruction. We will identify other potential studies using multiple methods such as manual searching. The outcomes were eyelid function, eyelid morphology, patient satisfaction, recurrence rate, metastasis rate, tumor-related mortality, and adverse events. Two researchers will independently screen titles and abstracts, identify full-text studies for inclusion, extract data, and appraise the risk of bias in the included studies. A meta-analysis will be conducted using Review Manager 5.4 and R software. The certainty of evidence will be appraised by grading of recommendations, assessment, development, and evaluation system. RESULTS: This full-text will adhere to the preferred reporting items for systematic reviews and meta-analyses statement to ensure clarity and completeness of reporting in all phases of the systematic review. DISCUSSION: This study provides evidence of the efficacy and safety of reconstruction methods for sebaceous carcinoma of the eyelid.

A comparison of novel silicone plate vs. auricular cartilage in upper eyelid reconstruction following excision of malignant tumor.

Purpose: To compare surgical and functional outcomes, safety, efficacy and cost of silicone plate vs. autogenous auricular cartilage (AAC) as alternate material to tarsal plate for upper eyelid reconstruction after excision of malignant tumor. Methods: A prospective, comparative, interventional study of over 3 years was conducted on two groups of twenty patients each. All the patients had undergone the Modified Cutler Beard procedure with AAC being used as tarsal substitute in one group and a novel silicone plate in the other. Post-operative MRD 1, LPS action, Central Lid Thickness, and Lid contour were recorded at one week, one month and six months follow-up. Results: The pre-operative MRD 1 in the silicone plate and AAC group was -2.95 ± 1.19 mm and -3.05 ± 1(1).05 mm, post-operative in the silicone plate group 3.8 ± 0.4 mm, and in the AAC group, 3.8 ± 0.41 mm. The pre-operative LPS action in the silicone plate and AAC group was 1.2 ± 1.1 mm and 1.0 ± 0.9 mm and post-operative it was 13.8 ± 0.4 mm for the silicone plate group and 13.7 ± 0.4 mm for the AAC group. The post-operative lid thickness for the silicone plate group was 4.4 ± 0.17 mm and for the AAC group it was 4.4 ± 0.08 mm. Conclusion: The cosmetic outcome in terms of lid contour maintenance is better in the silicone plate group, in which it markedly reduces the surgical time, provides earlier rehabilitation, and eliminates disease transmission. Harvesting of AAC is a skillful and time-consuming procedure and adds to the post-operative morbidity due to the presence of a second surgical site. The low manufacturing cost of silicone plate as opposed to other allogenic and synthetic tarsal substitutes makes it readily available to resource limited populations. The silicone plate is reckoned to become the material of choice as tarsal substitute in the future. Abbreviations: AAC = Autogenous auricular cartilage, MRD-1 = Margin reflex distance-1, LPS = levator palpebrae superioris, PFH = palpebral fissure height.