This Live Lecture covers how to diagnose and treat common periocular skin cancers. Strategies for eyelid reconstruction after excision of skin cancers are also discussed.
Lecturer: Dr. Andrew Harrison
DR HARRISON: Good evening and welcome. Thanks for joining us tonight. I’m Dr. Andrew Harrison, and I’m from the University of Minnesota. I’m an oculoplastic surgeon, and I have a special interest in periocular malignancies. I think reconstruction after periocular malignancy resection is probably my favorite procedure that we get to do as oculoplastic surgeons, so I’m really excited to share this talk with you tonight. Today we’re gonna talk about the management of periocular skin cancers, and I’m gonna talk a little bit about the cancers themselves, but mostly about management of periocular skin cancers. We’re gonna talk about some of the common eyelid skin cancers, management options for removal of eyelid skin cancers, and how you reconstruct the eyelid after the skin cancer has been removed. Okay. So our first polling question is: I’d like to see who’s out there, listening to this talk, just so I know who I’m talking to. So if you could answer with the following numbers: Number 1 if you’re a medical student, number 2 if you’re an ophthalmology resident, number 3 if you’re an ophthalmologist, number 4 if you’re an oculoplastic surgeon, or if none of the above. So we’ll give you a couple seconds to click on your screen. Okay. Let’s see who’s out there. So it looks like most of you are ophthalmologists. There’s a few residents and a few oculoplastic surgeons. And one other. All right. So let’s keep going. Thank you. So eyelid neoplasms in general tend to be benign. And this is all lesions on the lids. About 2/3 are benign and 1/3 are malignant. And then if you look at the malignancies — and I like to call it the rule of 9s. 90% are basal cell carcinomas, 9% are squamous cell, and the rest include things like sebaceous cell carcinoma. So let’s talk about some of the features of malignancies, things that make you worry that a lesion might be malignant. Destruction of the lid architecture. The eyelid should have a nice smooth margin, all the way across, and the lashes should follow. If you see lash loss or destruction of that margin, that suggests it could be a malignancy. Other signs are telangiectasias, rapid growth of a lesion, a nodular appearance to the lesion, central ulceration or crater, and if they recur after you excise them. Basal cell carcinoma is the most common, like I said earlier. 90% of what we see around the eye are basal cell carcinomas. And of the 700,000 new basal cells diagnosed each year, 90% are in the head and neck region, and 10% of those are in the lid. This is typically in the 6th to 7th decade. But some of them do appear in younger patients, in their 20s or 40s. And I always bring up the case — I had a 27-year-old nurse who presented with a basal cell carcinoma that had undergone multiple procedures with another surgeon, and actually got to the point where she required exenteration. And that’s not to say that all basal cells end up with an exenteration, but just to say they do exist in younger people, and they can be a bit more aggressive. They tend to occur in patients with fair complexion, and as you’ll look, you’ll see most of these patients with basal cells have light skin and light-colored eyes. Most of them appear on the lower eyelid and the medial canthus. And the reason for that is that your eyebrow tends to shade the eye, the upper lid, and the lateral canthus from sun exposure. They can appear in different forms. You see all the pictures I’m showing here are of basal cell carcinomas. This is more of what we’d call a more filiform lesion, where it spreads underneath the skin, rather than forming a nodular growth. This is the typical rodent ulcer, which is one of the terms that people use for basal cell carcinomas. And this woman presented with this lesion, and the reason she came in was she felt she could no longer go to church, because this became such an aesthetic concern for her. And you can see it’s quite an aggressive lesion that had spread into the bone and cartilage around her nose. It ended up involving both of her upper and lower medial eyelids, and a fair amount of her nose as well. But they can get quite large, if they’re left untreated. This guy in the upper right corner of the slide described this syndrome that we see here in this patient, and he actually came from the University of Minnesota. And this is Bob Gorlin, and this is Gorlin syndrome, also known as basal cell nevus syndrome. It’s an autosomal dominant disorder. It’s fairly rare, although I do have some of these patients in our clinic at the University of Minnesota. And most of these folks develop basal cell carcinomas either in early adolescence or early adulthood. It’s also associated with a plethora of other findings. And the reason it came to Bob Gorlin, who was actually a dentist or oral pathologist — it came to his clinic — was because they had these odontogenic tumors or cysts that you see on the bottom of the slides. They also had these typical pits within their soles and palms of their hands that you see up above the slide there, of the Panorex of the mouth. But it’s associated with a whole host of musculoskeletal and systemic issues. Gorlin syndrome is caused by a defect in the Patched 1 gene. And we’ll talk about this just for a little bit, because it becomes interesting with regards to new treatments for basal cell carcinoma. Patched 1 is a tumor suppressor gene that inhibits the hedgehog signaling pathway. And you see on the bottom of the screen there three different hedgehogs. But this is not the one that we’re talking about. Sonic Hedgehog on the far right my 13-year-old is well aware of. But here’s Sonic Hedgehog, here, with the hedgehog pathway. And what the hedgehog pathway is involved in is in fetal development. So it’s involved in limb development, neural differentiation, as well as facial morphogenesis. And the thought is that it becomes switched back on in these folks with Gorlin syndrome, and leads to these multiple basal cell carcinomas. (audio missing) The FDA in 2012 that blocks the hedgehog pathway, by inhibiting the SMO protein. And the name is Erivedge or vismodegib. And you can see there it’s quite expensive. I put on the slide — it’s $250 a pill. But I’ll show you, it’s quite an amazing drug. This was the first article describing it in the New England Journal, from 2012. 41 patients with basal cell nevus. And what they found is that when they treat these patients with vismodegib, it’s one pill a day — what they found was a lower rate of new basal cells, and a larger decrease in size in the patients who had multiple basal cells. Here’s a patient from that paper, and you can see a marked decrease in both the size and number of basal cell carcinomas. So the problem with vismodegib — and there are several similar drugs that are either in the pathway or out now — is that they have significant side effects, including loss of taste, muscle cramps, hair loss, and weight loss. They do resolve once you stop the drug, and the hair growth does resume within 3 months. The problem is once you stop the drug, the basal cells and the other findings come back. The place that I think we have for these new drugs — and I’m kind of getting ahead of myself — but we’ll be talking about resection in a little bit. But is in shrinking the size of larger basal cells that invade the orbit and the face. And I want to show one patient here that we treated at the University of Minnesota earlier this year. So this patient came in with this very aggressive, very extensive basal cell carcinoma, and was treated with vismodegib, and in three months, you can see the tumor has shrunk significantly. There still was some residual tumor in the medial canthal area that underwent resection, but you can see with these drugs, you can get a nice effect. All right. Let’s move on to squamous cell carcinoma. Similar risk factors to basal. Sun exposure. Fair complexion. And also radiation exposure. The metastatic potential of basal cell carcinoma is essentially zero. It’s a locally aggressive drug (sic), but it doesn’t metastasize. Where squamous cell does have some metastatic potential. Especially to the regional lymph nodes, as well as distant sites. The thing to remember about basal cell is it can go along the nerves. And the place it goes along the nerves — around the orbit — is in the supraorbital nerve. So we see patients who present with superior orbital issues or supero-orbital — into the cavernous sinus — issues, related to a previous squamous cell carcinoma. So in patients with a previous squamous cell carcinoma who present with motility issues and things like this, it’s important to get orbital imaging to make sure that that is not the case. Just a couple more very large squamous cell carcinomas. Again, most patients present before the lesions get this large. But you can see, especially in the slide on the right, you can see the keratin within the lesion, which is suggestive of a squamous cell carcinoma. Sebaceous cell is less common. Especially in this part of the world. But it’s known as the great masquerader. It can present as a blepharoconjunctivitis, blepharitis, chalazion, that typically affects just one eye, and usually one lid, but does spread. And you can see both of these pictures are sebaceous cell carcinoma. The one on the bottom you might think just has a chalazion, but it’s actually a thicker lesion that has this yellowish appearance. It’s more common in the upper eyelid, because the upper eyelid has more glands — more sebaceous glands that can become sebaceous gland carcinoma. Most of the patients are female and tend to be older. As I said, it’s less in Europe and in the States, and it’s much higher in Asia. And this does have a fairly high mortality. These are just a couple more pictures of sebaceous gland carcinoma. You can see it can present in a nodular appearance, as in the slide left, on the top you can see more of this Pagetoid spread, where the tumor spreads over the eye, and onto both eyelids. Melanoma, fortunately for us, is rare in the periocular region, although lentigo maligna, an in situ form of melanoma, are common, especially in the cheeks, in the periocular region. You can have malignant transformation of normal skin melanocytes that turn into melanoma. Again, it tends to occur in blond haired, blue eyed individuals. And it’s more common in areas with higher UV exposure. The history typically involves unprotected extensive sun exposure, or it can become — or a preexisting pigmented lesion can become melanoma. Or it can occur de novo. But they have this historical change of pigment change within the lesion. The other thing that’s suggestive of a melanoma is a new nodule or new growth within a flat pigmented lesion. And this is the ABCDE diagnostic criteria for melanoma. So asymmetry, abnormal borders, color changes within the lesion, the diameter is greater than 6 millimeters, which is the diameter of a pencil eraser, and if it’s evolving or changing. That suggests melanoma, rather than a more benign lesion. These are some old data. And the way we stage melanoma is by the depth. And you can see on the right the deeper the tumor goes within the skin, the higher the mortality. One thing that’s been… Kind of is newer. It’s probably been around for the last five, ten years, but it’s become standard of care in patients with melanoma — especially in other parts of the body — is sentinel lymph node biopsy. And I think it’s important that you understand this. And this is treating — this is basically trying to find the first lymph node that a tumor would spread to. And it can be done either with radioactive tracer or with dye or with both. Both are injected. One or the other — both are injected around the lesion, and then the head and neck surgeon typically will go and find the area where the radioactive activity is the greatest, and go and take that lymph node. And it’s usually the same lymph node that’s taken up the blue dye. And that’s the first lymph node that that tumor would spread to. And if that is negative, that’s a good sign that the tumor has not spread. But it can identify 20% to 25% of patients who have occult nodal disease. And patients who might need adjuvant therapy, including a lymphadenectomy. And there are several studies that show this does improve survival. So a 30% improvement in 10-year survival when you perform the sentinel lymph node biopsy. And the way we do it is typically at the time of resection — I have one of our head and neck surgeons perform the sentinel lymph node biopsy at the same time. Melanoma is a little different from the other tumors that we’re gonna be talking about, so I wanted to put this slide in here, just to talk about — melanoma needs a wide excision. You can’t do frozen section monitoring of melanomas. In other areas of the body, they recommend a 1 centimeter margin. That’s pretty wide for the eyelid, and that would encompass essentially the entire eyelid on every patient with a melanoma. So most studies recommend eyelid margins of 5 millimeters on either side of the tumor, in patients with thinner melanomas. If they’re thicker than 2 millimeters, you probably do need to do a wider resection. So let’s talk about management of periocular malignancies. And the first step is to biopsy. And I always like to quote this study by Bob Kersten. It’s 20 years old now. But Bob is a very well known and experienced oculoplastic surgeon, and what he did was he biopsied every lesion he saw in the eyelid, and he tried to guess whether it was benign or malignant, and he tried to guess the diagnosis. And what he found was that 2% of the lesions that he thought were benign turned out to be malignant. And the bottom line from the paper was that all excised lesions should be sent. And that if your clinical suspicion is high and the pathology is benign, then the recommendation is rebiopsy. And I would say this is a reasonable approach, although there certainly are patients who come in with multiple skin tags or other clearly benign lesions that I don’t send for pathology. But in general, if I don’t know, which usually you don’t, I do send it for pathologic evaluation. So the next question is: Where to biopsy? And I put this slide in just to remind you not to take from the center of the lesion, because in many of these tumors, the center is necrotic, and that’s why we see that ulcerative appearance in the basal cell carcinoma, which you can see here. But what you want to biopsy is clearly active tumor and some normal skin. And that way the pathologist can see the transition. So my line is shave, incise, excise. Just do it. Just do the biopsy and get the pathology. All right. My next polling question is what is your preferred method for removing a basal cell carcinoma from the eyelid? So we’ll pull up the poll. Number 1 is resect in the OR with wide margins. Number 2 is resect in the OR with frozen section margin control with the pathologist, number 3 is Mohs surgery, and number 4 is electrodesiccation with curettage. We’ll give you a few minutes — or a few seconds here — to click on your screen. And then let’s see what you guys like to do. We’ll get the poll. Here comes the poll results. All right. Interestingly, 50% like to resect in the OR with wide margins. 29% resect with frozen margin control. 18% perform Mohs surgery. And 1 performs electrodesiccation with curettage. All right. Let’s close the poll and let’s move on. So these are the options for managing these skin cancers. Like we talked about, you can resect — I like to resect with frozen sections or Mohs micrographic surgery. Those are my top two. Other options: Radiation, chemo, cryo, electrodesiccation, or immunotherapy with Aldara. And I really say the top two are really what work the best and have the best data behind them. So the first one is surgical resection in the operating room with the pathologist helping you with the frozen sections. So the problem with this is it requires coordination with the pathologist. So you need a pathologist available. And you need somebody who can perform the frozen sections. This can be done usually within 20 to 30 minutes. If you’re lucky. Some take 40 minutes to an hour. I operate at one hospital where they have to send it via cab to another hospital to do the frozens, and then they call with the results, and that can take up to an hour. So it sometimes takes a fair amount of time. The benefits are it’s a single procedure. So the patient doesn’t have to go to multiple places. And the recurrence rate — and we’re talking about primary basal cells here — is 5.5% for primary basals, and the recurrence rate for a recurrent basal is 18%. So let’s move on to Mohs surgery. So this was described by Fred Mohs, who’s shown on the slide right here. He was a general surgeon, actually, at the University of Wisconsin, the next state over from me here. I’ve actually seen one patient who had chart notes from Fred Mohs, which was kind of cool. But he described this micrographic chemosurgery, where he removed tumors, he color coded their margins, and then went back and took more tumor in each margin that was positive. So here’s how it came about. In the 1950s, he was filming the removal of an eyelid carcinoma, and instead of using fixed sections, he used frozen sections, and then that moved it to a frozen section technique. His first paper in 1969 showed a 100% cure rate with basal cell and squamous cell carcinomas. The benefits of Mohs surgery, I’d say, are the recurrence rates — as you can see on the bottom of the slide — are better. So recurrence rate with a primary basal cell is 1%. With a recurrent is 8%. The other benefits are that it allows the separation of the person who’s taking out the tumor with the person who’s doing the reconstruction. And the reason that’s important is because if you’re the reconstructing surgeon, you want to preserve as much tissue as possible, and maybe you’ll skimp on a margin to allow you to have that extra little canthus to put back together. But when the Mohs surgeon does it, they’re going for tumor removal. The other benefit of it is that they actually do preserve the most normal tissue. And I’ll show you why. Here’s how Mohs works. You can see the obvious tumor on the far left. And the Mohs surgeon removes that tumor and then they breadloaf it, and they slice it, and they color code it in this technique that Fred Mohs described. And then they look at any areas that have residual tumor — they go back and they take more tumor. And that would be the third slide there. You can see the areas with more tumor. And up above, you can see where they take each of those areas out. They look at each of those areas separately under the microscope. And you can see that area between number 4 and 5 has residual tumor. So they go back and remove that. And that’s clear. And then they send it for reconstruction. So if Mohs surgery is so great, why would I do resection with frozen sections? There’s a couple of reasons. One, if it’s a small central nodular-appearing basal cell carcinoma, I will do a central wedge resection, and do frozen section margins on that. And I have many older patients who desire a single procedure. They don’t want to go to a dermatologist and then come see me. And so in those cases, I do the resection with frozen section monitoring. I always do monitoring of the margins, and the reason is I want to make sure all the tumor’s gone, before I reconstruct. I just want to show you a patient here. This guy refused to go to the operating room. He’s like — take off my tumor. I’m leaving. I’m done. And you can see, we resected the tumor with a wedge resection. And he got a nice reconstruction, never to be seen again. But you can do removal of fairly large tumors with a wedge resection in the eyelid. So, again, we talked about using what we call slow Mohs for melanocytic lesions. You can’t do frozen sections on those. So we do a resection with margins, we wait for permanent sections, and then we go back the next day. Or a day or two later. Sebaceous gland carcinoma’s another one where we perform wide margin resection of the eyelid lesion, and then if there is residual tumor, just involving the conjunctiva or the cornea, that can be treated with topical mitomycin, and that’s been described very well by the Shields group out of Wills in Philadelphia. So now we’ve taken out the tumor. Now what next? And this is really the fun part of oculoplastic surgery, I think. It’s trying to figure out how to put eyelids back together and get a nice functional and aesthetic result. So just some general principles. There is a reconstructive ladder. And this has been described by the plastic surgeons. If you pull out any plastic surgery textbook, you’ll see this kind of ladder of how to reconstruct the defects. And the place where I kind of disagree is with local tissue transfers or flaps versus skin grafts. And we’ll talk about that as we move along. The other point I always make is: Don’t burn bridges. You might have to come back in the future. So don’t use multiple flaps if you can use one. Don’t use a skin graft if you can use a flap. Because you might need that other form of reconstruction later down the road. Some other principles. Try as best you can to avoid vertical transaction on the eyelid margin. And if you can’t avoid vertical traction, make sure you support the lateral canthus. And the medial canthus as well. The lateral is a little easier to support. You see this patient here who has a very obvious lower eyelid retraction on the left side. Some other basic principles. Close the deep tissue first with the appropriate suture, which we’ll talk about. To avoid undue tension on the skin edges. Undermine widely. This often allows — and we’ll show several examples here — often allows you to close it without doing any flaps or grafts. And then finally the anterior and the posterior lamellae need to be reconstructed separately. Only one can be a free graft. You can’t put a free graft on top of a free graft, or it won’t live. Okay. This is just the basics. You have two lamellae to the eyelid. The eyelid’s a bilamellar structure, involving the anterior lamella, which I describe as the skin and orbicularis, and the posterior lamella, which is the tarsus and the conjunctiva. So one of these can be a graft, and the other one either needs to be a flap or needs to be brought in from somewhere else. Which is a flap, of course. The other important point is to make sure that the tension of the eyelid is pulled against the globe. And the way to do that is to make sure your tension medially and laterally is in the correct anatomic position laterally, by the lateral orbit of the tubercle here, and medially, by the posterior lacrimal crest. All right. Let’s talk about some anterior lamellar defects. This is not a polling question. But look at this defect in the eyelid. What would you do? I think there’s a lot of options for this. You can skin graft it. You can pull a flap in. You can rotate a flap in. There’s lots of ways to close this. I just want to show you… Whoops. Well, I’ll show you what I did in a second. I do have a polling question. So let’s see. What would you do? Skin graft it? Do some sort of advancement flap? Or would you allow this to granulate in? So we’ll do a quick poll. We’ll give you a few seconds to answer. Can we pull up the polling question? Maybe not. Oh, there it is. All right. So how would you close that skin defect in the cheek lower lid area? The options are: Skin graft, advancement flap, or granulate? All right. Let’s see what you guys put. So it looks like most would do some sort of advancement flap. 60%. Skin graft, 40%. And 1 would allow it to granulate. All right. Close this and let’s move along. I’ll show you what I did. So I did an advancement flap, extending laterally. And I widely undermined — like I said — widely undermining really allows you to get a fair amount of closure. And here she is, about 2 weeks out. And as you can see, I also — I did make an incision here, and supported her lower lid. Because I was worried about this big flap pulling her eyelid down. But you can see: Even these big defects you can get closed with flaps. Especially in older individuals. Here’s another patient after Mohs surgery for a basal cell carcinoma. And he has a fairly large defect in the lower lid, which we repaired with what I call an O-Z double advancement flap. And you can see the flaps drawn in there. And there the flaps are incised and elevated. And then rotated into place. And here you can see it’s closed up. So we closed the deep tissue first to take the tension off. And the skin I usually close with 6-0 plain gut, and my deep sutures are usually 5-0 or 6-0 vicryl in this area. You can see here he is with the defect and after. And there’s the O to Z, kind of drawn in there. There’s another form of the O to Z, which I like. This is a woman with a basal cell on the left lower lid you can see there. Which I call the IOL flap. It looks like a little IOL to me, with the haptics coming off. But it’s basically the same thing. It’s an O to Z double advancement flap. You elevate the tissue, rotate it into place, and you can get really nice closures. And these heal up incredibly well. Another double advancement flap that works really well on the eyelid, and actually, in the eyebrow is somewhere I like this a lot. I’m gonna show you with the — so I advance the skin from medially and laterally. And that works really well on defects of the brow, and you can line it up with the brow hairs, and that way you have a continuous brow. But I did it here in this eyelid, and just followed the eyelid margin here. And there it is, probably again — that’s probably at a two-week visit. The flap’s healing in. And there it is after it’s healed in. But these actually heal in very well. And they put no tension — no vertical tension on the eyelid margin. All the tension is horizontal, not vertical. So if you do need to do a skin graft, where can you get skin from, to match? Especially — let’s talk about lower lid, which is more common. You can use the upper lid, which has a great skin match, and has a fair amount of skin, especially in older individuals. You can get skin from pre- or postauricular tissue. I like preauricular tissue. I think it’s easier to get. And I think the skin tone, since the sun exposure is the same as the eyelid, matches better. The supraclavicular and the neck area — you can get large amounts of skin. And then finally, for fairly large amounts of skin, you can get it from the inner arm surface. Although I will tell you that skin tends to be lighter in color than these other ones. And the match isn’t quite as good. So here’s showing the preauricular skin graft. And I usually do an ellipse around this. So the graft area that we’re gonna use as a template for this lower eyelid — I draw preauricular incision, following the kind of anterior lid crease here. Or the ear crease. And then create an ellipse around it. So I show this case just to show that occasionally skin grafts can work quite well in the cheek and the lower eyelid. So this is a patient that had a full thickness lower eyelid defect and this large skin defect over the check as well. And I did this with my facial plastic surgery colleague, and they came up with all these flaps and things. But after they started tugging on this gentleman’s skin, who had had multiple prior skin cancers, they just decided to do a skin graft. And you can see the area the skin came from is this supraclavicular area here. And you can get a lot of skin from that area. This whole graft came from that supraclavicular area. I did a Hughes flap to close the posterior lamella, and we did a little advancement flap to close the anterior lamella of the lower eyelid, and then they did a big skin graft. And it actually turned out, I think, fairly well. Here he is after. There he was before. So a big defect closed with a skin graft. So in general, these are full thickness lower eyelid defects. This is what we’re talking about here. You can close directly, up to about a quarter of the lid. If you add a lateral canthotomy and inferior cantholysis, you can probably get another 5 millimeters or so. If it’s greater than that, I like the Tenzel semicircular flap, and then in the 50-plus range, we’ll talk about some of these other options, including Hughes flap, what I call the Hewes flap, or a Mustarde flap. My next polling question is about closing the lid margin. And this is what we’ll talk about first. How do you close the eyelid margin? So this is another one of our polling questions. The standard technique which has been taught is the 3 non-absorbable sutures across the eyelid margin. And some people use a vertical mattress suture, and then others use a buried vertical mattress suture. So we’ll give you 10, 15 seconds here to click on your screen. And I’ll tell you, I’ve used all three. And we’re gonna talk about how I got to where I am now, and hopefully I can turn you to my dark side. All right. Let’s see what the poll shows. So 8 people use a vertical mattress, 5 use the standard 3 non-absorbable technique, and 4 use the buried vertical mattress, or as I say the dark side, because the suture is buried inside. All right. Let’s close it and let’s talk about it. This is the standard eyelid margin closure that’s in all of the old textbooks. And I’ll tell you, I totally abandoned this. I think it works well. The problem is it’s a lot of stitches across the margin. It’s really hard to take those sutures out. And I think there’s a better way. So this is how I used to do it. I used to put a margin stitch through, and then a lash stitch through, pull down, close the tarsus, and then close the rest of the wound, and then suture those into the vertical incision. And then this is from Jeff Nerad’s textbook. I think this is an excellent technique. And I used this for a long time. Is a vertical mattress suture through the tarsal plate. So you place it through the meibomian gland, and it’s tied external, and the knot is trimmed, and you can put a second one at the lash line, or just behind the lash line. And this works great. And what we’re aiming for is eversion of the eyelid margin. So this gives you really nice eversion of the eyelid margin. And then I close the posterior lamella with partial thickness bites of 5-0 vicryl suture, and then the rest of the skin with 6-0 plain gut suture. And that margin stitch typically is a 6-0 vicryl or chromic or 7-0 vicryl. And then I figured out or heard about the buried vertical mattress margin suture, and I’m gonna show you this quick video. I’m gonna apologize in advance. It’s a little jumpy. I tried to speed it up, so it wouldn’t be so long. But you can see here the technique. The suture is passed through the inside of the wound, out through the meibomian glands, back through the meibomian glands, and back around in the same technique. And it’s tied internally. So actually, it starts with the far and then is passed near, and then back near, and then far, and it’s tied internally, and the idea is to get it through your tarsal plate. So it’s not only closing the margin and creating a nice eversion of the margin, but it also brings your tarsal plates together. All right. This is a quick video that I did a while back. And like I said, it’s a little bit jumpy, but you get the idea. So in this case, I started with the suture, and this is a 6-0 vicryl pass through the near, and then passed through the far — again, through the meibomian glands. I apologize again for the jumpiness of this video. I’ve got to slow it down. Then it’s passed far through the meibomian glands, and then back through the glands, and into the tarsus. And it’s tied, and you see when it’s tied it really creates a nice eversion. And then I use partial thickness 5-0 vicryl sutures. And you can tie that margin stitch and tag it to the drape to create some tension to help pull your tarsal plates together. But I like the vicryl for this. And the spatulated needle works really well, to get a nice lamellar bite of the tarsus on either side. But this is an excellent suture for closing tarsal plates in the posterior lamella. And if it extends superiorly, I will close the other lid tissue, the levator. I don’t close the septum. And this is tying that margin stitch. And you can see as you tie it you really get a nice eversion of the lid margin. And then I use a simple 6-0 vicryl, interrupted, to reapproximate the lashes. You can do this as a mattress stitch too. I just use a simple stitch here. And you can see just how the margin is reconstructed really nicely. Nice eversion of the margin. So that you get a nice even healing. And then in this case, since there was a bit of gap between the orbicularis muscle, I’m closing the orbicularis. I don’t always close the orbicularis on lid margins. But in this case, I did, just to get the skin edges closer together. And then I’m just using 6-0 plain gut suture here to close the skin. You can see you can get a really nice reconstruction. But that buried vertical mattress is really the stitch that has revolutionized closing the margins for me. All right. So that’s lid margin closure. Let’s move on to a little bit larger defect. And this is probably a bit aggressive for a Tenzel flap. But you’ll see it worked out well. So here’s the defect. After Mohs resection of a basal cell carcinoma. And this is the technique we use. It’s a Tenzel flap. So it’s a semicircular flap, based laterally. It’s a semicircular advancement flap. And we do a lateral canthotomy, an inferior cantholysis, and as you rotate the lid and you do your margin reconstruction in whichever technique you feel comfortable with — and then you advance that tissue, and here’s that lateral canthal tissue that’s now become lateral eyelid. And you can really probably get 60… Up to 65%, 70%, on older individuals, you can get closed with a Tenzel flap. And then I usually close the deep tissue with vicryl sutures, 6-0 vicryl sutures, and the skin with 6-0 plain. But here’s that patient. And if you need a little bit longer flap, you can do a gentler curve. Tenzel kind of has a high semicircular arch, but you can do a gentler curve, if you need to advance a little more skin. And there it is with it closed. With some Steri-Strips. And then after it’s healed, they really heal nicely. So if you have more than about 2/3 of the eyelid, you’ll need to do something to reconstruct the posterior lamella. And the most commonly used technique, I would say, is the Hughes flap. Described by Wendell Hughes. And basically you’re doing a tarsal-conjunctival flap from the upper eyelid and advancing that into the lower eyelid. And you can see here you need to leave 4 to 5 millimeters of margin, or else your tarsus will become unstable, and could fold on itself. So you need to leave a fair amount of tarsus there, and then dissect the tarsal conjunctival flap from the underlying levator muscle. This is just showing a patient that we did that on, with a Mohs defect. And there’s that flap, pulled down into your defect there. And here it is in our patient. And you can see in the original Hughes flap, the conjunctiva and the Mueller’s muscle came down. A lot of people will now do a modified Hughes flap, where it’s just conjunctiva, and leave the Mueller’s muscle behind. I think the Mueller’s muscle does bring a nice blood supply, and as long as you remove it when you do your resection, your secondary reconstruction, you don’t tend to have upper lid issues. So there’s the flap pulled in. Sutured in place. And again, I like 5-0 vicryl and a spatulated needle to close these. And then the skin graft. You can take skin from the upper eyelid, as we did in this case, or from the other areas that we discussed earlier. Or you can do an advancement flap. Many of these patients are older and have plenty of lower lid skin that you can advance and place on top of your Hughes flap. Here’s that skin graft. It came from the upper eyelid. And closed over. With a bolster dressing. And then the second stage, where you open the flap, and I like to pass a little grooved director, a little thin malleable… And I don’t resuture the conjunctiva as shown in this slide. I just resect the tissue. And let the margin heal. And these heal up really nicely. It’s hard to tell which lid is the reconstructed lid, many times, after Hughes flaps. Another form of a Hughes flap is what I call the Hewes flap. It’s actually the Hughes flap. Just to differentiate it. When you borrow tarsus and conjunctiva again, as a flap, and a skin-muscle flap on top of it. But instead of leaving it superiorly based, it’s laterally based. And this works out really nicely. Especially for these lateral carcinomas. And lateral Mohs defects. And you can see here the patient after Mohs surgery — and I’ve drawn in a little blepharoplasty flap for the skin. And we evert the lid, and you can see, again, you need to leave 3 to 4 millimeters from the margin to your incision line here. And then borrow a tarsal-conjunctival flap. And suture it in place. And then a skin and/or skin-muscle flap from the upper eyelid and suture that on top. And that makes for a really nice lateral reconstruction. I use this a lot for the lateral 50% or so of the eyelid. Here it is before, and sutured in place. And just another Hewes flap. There it is. The tarsoconjunctival flap from the upper eyelid. You’d see a pretty big anterior lamellar defect in this patient. And what I did is I took that blepharoplasty flap, used it on top of my Hughes flap here, and then took the extra skin and sutured that as a free graft. So you can do a combination of things. And then later, we went back and resected this little triangle of tissue. But here he is before and after. The Mustarde flap is used for larger defects. Almost the entire eyelid can be reconstructed. And the Mustarde is a cervicofacial rotation flap, with a graft behind it. So you can do a Hughes flap. You can use — in this case, they used a nasal cartilage graft. But cow use a tarsus graft from the other eyelid, and like I said, I typically use a Hughes flap from the upper lid. This is a patient that we did a Mustarde flap on. You can see these flaps heal pretty well, but they always tend to have a little better retraction, I think. There’s always a little bit of vertical tension on these. Especially these larger Hughes… I’m sorry, Mustarde flaps. Here’s another patient that I used a cervicofacial rotation flap recently. So that was before and after his Mohs. You can see the flap — here’s his mustache here. His nose is here. And there’s the flap sutured in place. And here he is after. So, again, you can get a large amount of skin closed with these flaps. You do need to stay in the subcutaneous plane. You don’t want to go deeper and end up injuring the facial nerve. But as long as you stay in the subcutaneous plane, you’re very safe with these flaps. So let’s talk about the medial canthus for a little bit, and then we’ll talk about upper eyelid. So there’s several ways to close a medial canthal defect. You can let it granulate in. Although my rule for granulation is less than a centimeter, and it has to span the upper and lower eyelids evenly, or else you’ll get abnormal traction as it heals in. You can treat these with skin grafts. Some larger skin grafts here. And this heals in very nicely. Here’s the problem with this area. This is thicker skin of the nose and the nasal side wall. Thinner skin of the lids. And it’s a concavity. So it’s a little tricky to get these to close, but as long as you do a nice, thin skin graft, you can get good results here. Another flap that works quite well is doing an upper eyelid blepharoplasty, and leaving it laterally attached as your pivot point, and then you can close these little medial canthal defects quite well. So here’s my blepharoplasty. Rotate it in. And sewn into this medial canthal defect. And you can get a fairly large defect closed with a blepharoplasty flap here. The other flap that’s really useful in the cheek and especially in the medial canthal region is these rhomboid flaps, which are 60-degree angles and 120-degree angles, I guess. But you can see you can take this lesion here, and I can get a rhomboid flap from here, from here, from here. You have a variety of options. And it’s basically — pick the flap that’s gonna match the tissue that you’ve removed here. So you can see there’s that rhomboid flap rotated into position. A larger form of a rhomboid flap is a glabellar flap, and in bigger medial canthal defects, we can rotate that glabellar skin in, in a similar fashion. So it’s basically like a big rhomboid rotational flap here. And these heal up very nicely in the glabellar lines here. And you can see this gentleman here before and after. There he was. And you can see how that incision heals, very nicely. Even though it’s a vertical incision. So let’s talk about the upper eyelid. And just briefly, the upper eyelid is similar to the lower eyelid, as far as the techniques that you can use. But I just wanted to make a point that when you are doing full thickness resection of lesions from the lid — and this is for the lower lid too — you want your vertical limb of your pentagon to go all the way to the top of the tarsus. Or else you’ll get — your tarsus will buckle. So you need to make your incision all the way through the vertical tarsus. So for the upper eyelid, if you have a greater than 25% or so, up to about 50% or 60%, you can do a reverse Tenzel, where instead of the flap being upgoing, it’s kind of a downgoing flap, to allow you to advance that in a similar margin. In a similar way to the lower eyelid Tenzel. And finally, for complete upper eyelid defects, the treatment is a Cutler-Beard flap. At least, the traditional treatment is a Cutler-Beard flap. And you can see Cutler-Beard is tissue borrowed from the lower eyelid, leaving the lower eyelid margin intact, and advancing it into the defect. So the conjunctiva is close to conjunctiva. Orbic to orbic. And skin to skin. And in between, you can put some sort of firmer tissue. In this case, an ear cartilage graft was placed, but you can use any variety of tissues. Nasal cartilage. Sorry. I’ve used Alloderm. I’ve used ear cartilage. But something that creates some stiffness to the lid, to kind of recreate the tarsus. You can use tarsus from the other eyelid. And then it’s sewn under that ridge. You can see the conjunctiva’s been closed here. Ear cartilage graft’s been placed. And the skin’s closed on top. The orbicularis is closed as well. And they look pretty rough for a while. And I usually leave these for at least 4 to 6 weeks, to heal. And then they’re opened secondarily, and the flaps are reset. But you can see in this older individual, although she has a bit of ptosis, she does have a working upper eyelid. I have another case of a younger woman — this was a sebaceous cell carcinoma. You can see she’s lost a fair amount of her canthal tissue, and her complete upper eyelid, and her bulbar conjunctiva. Here’s showing the defect on the upper left. We used a free tarsal graft from the other eyelid. Periosteal flaps. Amniotic membrane over the eye. And advanced a large Cutler-Beard flap. Here she is, as the flap is being sewn in place. With all the flaps closed. And here she is afterwards. Her pre-op and her postop. She had a nice result. Finally, just two slides on the lacrimal system. Many, many, many of these defects will involve the medial canthal area. If there is residual punctal tissue or canalicular tissue, I will intubate it with a silicone stent to try to preserve it. If it’s entirely gone, it’s really difficult to reconstruct. And what we usually do is place a Jones tube later. There’s a question on when you can place a Jones tube in an area that had a previous carcinoma. Some people say if the Mohs surgeon says it’s clear, you can go ahead and place it right at the time of reconstruction. I usually wait 6 months to a year, to make sure that there’s no recurrence of tumor before I place a Jones tube. In summary, always suspect malignancy. Especially basal cell carcinoma. Biopsy all suspicious lesions. Get to know your local Mohs surgeons, because they can become your friends, especially with these difficult recurrent tumors. And just learn some of these basic oculoplastic reconstructive procedures. Don’t forget your sunscreen. Don’t forget your sunglasses. And… I can’t wait to see what this tan will look like in 30 years. Thank you. So now we’ll take some of the questions here. I have a few that I saw pop up. And go ahead. You can type those in. Let’s see. The first question is: What other associated malignancy can one expect with periocular cancer? So I’m not quite sure what this question is getting at. But I will tell you: There’s one thing that I did not mention. Sebaceous cell carcinoma can be associated with Gardner’s syndrome, which is associated with other colorectal cancers. So the other question: I agree that margin controlled excision is probably the gold standard. However, you say it’s resource and time intensive. Would you say there’s any place to excise a well defined primary lesion, such as a nodular BCC, with 2 to 3 margins? That’s a great question. I guess I would say this: I would say you could resect a tumor with margins, but if they come back positive, you have to be prepared to go back and take more tissue. I really don’t think you can leave skin cancer cells behind. Now, that being said, basal cell carcinoma is a slowly growing tumor, and if you have an older individual who it’s difficult for them to move and they come in and you want to do it in clinic, I think it’s reasonable to go ahead and do those in clinic. Or as a kind of wide margin resection, if you will. As long as you’re prepared to do a secondary resection, if you need to, later. But I do think that’s reasonable. All right. If anybody has any other questions… What’s my experience with Merkel cell carcinoma? Very limited. Somebody asked. But Merkel cell is a very difficult, very aggressive carcinoma that can involve the periocular region. I’ve treated two patients, and they’ve ended up having extensive disease, involving (inaudible) tissue and nasal tissue, and they’ve ended up with exenteration. But I know there’s smaller Merkel cells that you can take care of with wide margin resection. But they are unlike the other skin cancers, I would say. Are rules of reconstruction of lid margin defects the same in all age groups? That’s a great question, Ahmad. I would say the older the person, the more you can get away with, as far as simple closure. So most older people, if they haven’t had multiple other surgeries, be you can do a bit more. So maybe if I said 25% to reconstruct without doing anything. In an older person, you might be able to push that to 30% of the lid without doing a canthotomy or cantholysis. And I’ve found in many older people, actually, I’ve got to say, especially involving the lower eyelid, you can almost always get away with some form of Tenzel rotational flap. Very, very rarely — only when it’s, like, canthus to canthus — will I have to resort to a Hughes flap or something a little more extensive. I’ve found with older individuals, with fairly elastic skin, you can really the get a nice reconstruction with a Tenzel flap. These are great questions. So we have a couple more minutes. If anybody has any other questions, go ahead and shoot them. Type them in. Otherwise, I’m happy to answer any questions offline. My email, direct email, is email@example.com. Or you can probably reach me through the Orbis website or Cybersight as well. I want to thank everybody for sticking around and listening. It’s been fun kind of sitting in my house, giving the talk. It’s a new experience. But thanks.