palpebral tumours - Dr. Jacques C. van der Meulen

CHAPTER
12
PALPEBRAL TUMOURS
A]] Emmett
]] Sullivan
EYELID TUMOURS
JC van der Meulen
]S Gruss
Tumours around the eye and eyelids may present as a macule, a
lump, an ulcer, an irritation or inflammation, or as a pigmented or
scaly patch.
Chronic chalazion, a type of granulomatous inflammation of the
eyelid that represents a response to extravasated liquid internally
from the meibomian glands, may present as a hard nodule or may
rupture through the tarsal conjunctiva. It presents with granulations
and may simulate a polypoid pyogenic granuloma.
Sebaceous gland carcinoma may present as a chalazion as may,
more rarely, a meibomian cell carcinoma.
EXAMINATION
BENIGN LESIONS
Recognition of malignant eyelid tumours at an early stage in their
biological development is the goal, so that adequate treatment may
produce more effective results . General examination of the eyelids
and facial skin in a good balanced light, preferably daylight, is essential. The differentiation of benign from malignant tumours is often
possible without biopsy for the experienced clinician, however many
tumours require histopathology for diagnosis. Surface examination
with magnification- either a strong hand lens, or with a dermatoscope (Heine) - is a must for diagnosis.
With the stronger surface magnification, there is a learning
process involving recognition of the characteristics of each tumour
when viewed in this mode. Recognition of the characteristics of
melanoma with the dermatoscope is important in terms of the radial
streaming, brown globules, black spots and grey cloud, which are
described by Pehamberger.
Surface characteristics are identified - smooth, irregular, crusting, fungating, etc. - in addition to colour and type of edge.
Palpation will tell whether a lump is hard or soft, mobile or fixed,
whether it is situated in the more superficial layers of skin and eyelid
margin or deeper. Transillumination will detect the more cystic characteristics.
Biopsy is imperative when the diagnosis is in doubt, and this may
be by way of excision biopsy of the whole lesion when it is small,
shave excision of superficial keratotic lesions, punch biopsy with
a small trephine or punch, or excision of a peripheral part of the
tumour as an ellipse running out into normal tissue. The biopsy
specimen must be large enough for an adequate histological study
and must be free of crush artefact.
Most eyelid nodules or lumps will be found to be benign. However,
all should be subject to histopathology, as many of the aggressive
malignant tumours have an inconspicuous early stage.
Cystic-looking lesions with smooth overlying skin may be sebaceous cysts with opaque whitish yellow contents, epidermal, dermal,
or subcutaneous. Translucent cysts may be hydrocystomas or
syringomas. Deeper cysts may also occur, and dermoid cysts are
deeper again, and occur medially or laterally under the eyebrow.
Smooth surfaced pinkish firm nodule may be a variety of tumour,
such as trichoepithelioma, benign intradermal naevus, or well-localized nodular or cystic basal cell carcinoma. They can also be an early
version of a more malignant tumour.
Other benign tumours include the common 'squamous papilloma', which may vary from the smooth-surfaced fibroepithelial polyp
to the papillomatous and verrucoid squamous papilloma.
Seborrhoeic keratoses are common. They may be pink or brown
with an uneven raised surface and are well circumscribed. When
larger they have a greasy keratotic surface with pores visible.
A]] Emmett
INFLAMMATORY LESIONS
Tumours may present with irritation or inflammation, especially on
the eyelid margin, and a mucoid discharge with crusting may occur.
Blepharitis and meibomian gland inflammation involving a localized area may be associated with an early malignant tumour; this
will be more recognizable after the inflammation has been treated.
Solar keratosis
These may be red or grey, and are flat, scaling lesions of the type
found in sun-exposed areas, including the eyelids. They are usually
not found on the lid margin. They tend to come and go, with increasing solar exposure bringing them on, and protection from the sun
often allowing them to regress. While they are thin and flat, they may
be simply observed or treated superficially. When they begin to thicken, they are better excised and examined histologically.
Chalazion
This localized inflammation of the eyelid glands presents as a chronic inflamed eyelid. Microscopic examination shows a lipogranulomatous reaction with dilated ducts of blocked glands.
Verruca vulgaris
This presents as a well-defined tumour with a papillomatous keratotic surface. Human papilloma virus (HPV-2) is the usual causative
PALPEBRAL TUMOURS
agent. Long-standing lesions may have focal areas resembling tricholemmoma or inverted follicular keratosis, and controversy exists
a bout the relationship between these entities.
Epidermal cyst (infundibular)
These are usually well defined and circumscribed. They may be
dermal or subcutaneous. They are mobile, slowly enlarging, occasionally inflamed, and contain cheesy material.
Dermoid cysts
These present as a soft lump, sometimes subcutaneous, present at
birth, resulting from epidermal entrapment and enclosure along the
line of embryonic fusion. They may be deeper and at the inner or
outer canthus they can be close to the bone, occasionally with deeper
extension. Histology shows epidermal characteristics of the wall
with pilosebaceous structures.
Hydrocystoma
Both eccrine and apocrine lesions are proba bly best classified as cystadenomas as they are not simply retention cysts.
Apocrine type
T hese are solitary translucent cystic nodules from the glands of moll,
best regarded as cystadenomas, not as simple retention cysts. They
present as a well-circumscribed, mobile lump.
Eccrine type
These are seen as translucent, cystic lumps. They are common on
the face and eyelids, and are sometimes multiple.
12.1 Typical molluscum contagiosum with well-defined molluscum
bodies.
lar conjunctivitis. It is umbilicated and contains viral particles. The
histology is characteristic.
Pyogenic granuloma
This follows minor trauma. It appears as a reddish-pink lump with
superficial ulceration. The lesion bleeds easily. Local excision is usually curative.
HAEMANGIOMAS
Strawberry Naevus
There is usually a history of growth after birth with enlargement
and then regression. It appears as a reddish, raised lesion that
blanches on pressure. There are immature capillaries.
Tricholemmoma
This is a benign tumour of the ha ir follicle. It is not uncommon
on the eyelids, where is has a controversial relationship to longstanding verruca vulgaris. It presents as a nodule w ith a rough surface.
Flame naevus (port-wine stain)
This appears as a red, flat discolouration of the skin, which tends
to becomes raised in middle age. They are present at birth , and are
sometimes reddish to purple. T hey have mature capillaries.
Trichoepithelioma
This is a round firm pink nodule. It may be multiple, and is slow
growmg over many years.
Cavernous haemangioma
This is located more deeply, and appears in the first to fourth decade
of life. They tend to enlarge slowly.
Pilomatrixoma
This is a localized solid or cystic tumour that is mobile, usually pinkish white, though it may be pigmented. It is subcutaneous and often
seen in eyelids. The lesion is well demarcated. T he microscopic findings are of masses of central eosinophilic shadow cells and peripheral basophilic cells with frequent calcification.
ADNEXAL TUMOURS
Xanthelasma
This is a slightly elevated yellowish plaque often found in the inner
canthus and medial eyelids. The microscopic appearance is of lipidladen histiocytes. Treatment is by excision. It may recur.
Basal cell carcinoma (BCC)
This the most common malignant tumour of the eyelids. It most
often occurs on the lower eyelid . The author's series of 559 eyelid
tumours included 308 BCCs. Of these, 135 (44%) were on the lower
lid, 14 (4.5%) on the upper lid, 133 (43%) on the medial canthus,
and 26 (8.5 %) on the lateral canthus.
This tumour may be deceptive, as its various forms behave quite
differently. United by the common basal cell characteristic described
by Krompecher, they look and act as quite different tumour types
and need to be recognized as such.
The commonest BCC is the Papulo nodular (PN-BCC, 12.2- 12.6),
which occurred in 45% (1030 cases) in one series of 2277 BCCs. It
corresponds to the classical description of a nodular circumscribed
tumour with a pearly edge and fine surface vessels at the edge. It is
Neural tumours
Palisaded and encapsulated neuromas sometimes occur on the eyelids .
Inflammatory pseudotumours
Molluscum contagiosum
This is a dome-shaped nodule that contains yellow cheesy material (12.1). It may be on the lid margin and often produces a follicu-
Adnexal tumours of various types may occur, usually as pinkish
nodules that can be differentiated by histopathology.
MALIGNANT TUMOURS
EYELID TUMOURS
frequently well circumscribed and feels hard to palpation; it is mobile
in the skin, and it often has a central hollow that may ulcerate, especially in larger BCCs. Microscopically, it shows rounded clumps of
basophilic cells with well-marked peripheral palisading.
In some areas of the lesion, the evidence of spontaneous cell death
called apoptosis may be seen as dark bodies of chromatin material, described by John Kerr as programmed cell death. This process
accounts for the slow growth of many BCCs despite frequent mitotic figures (and may be one factor in the reason why some incompletely excised BCCs fail to recur).
Keratin whorls also may be present in some areas, and do not
represent a squamous cell differentiation.
Pink areas of amyloid may also be present and may represent the
by-product of past cell death in the tumour.
Lymphocytic infiltrate in the area of the lesion may be associated with some tumour regression.
Treatment of the papule-nodular BCC (PN-BCC) is preferably
by excision, with histology to confirm the type and margin of excision. Some PN-BCCs may develop a more diffuse edge, and this generally indicates that the tumour has developed an infiltrating
component and so requires wider excision.
A well-defined PN-BCC (12.2) may be excised with a small margin
of 1 mm or 2 mm, while the more diffuse variety with an infiltrating
component (12.3- 12.6) requires wider excision, and a more prolonged and careful follow-up. Margins of the wider excision can vary
from 4-10 mm, and frozen section control is desirable if doubt exists.
This can be taken as a shaving from the resection edges or by vertical or horizontal sections of the specimen. The diffuse thin strands
or clumps of basal cells may be hard to recognize in frozen section,
and follow-up examination with paraffin block section combined
with Indian ink marking of the edge and haematoxylin and eosin
staining is required as confirmation of the clear margins.
12.2 a Cystic BCC of eyelid margin, wh ich is able to be excised w ith
narrower margins. b Sharply circumscribed BCC with central cystic
change and little tendency to recurrence.
12.3 a Recurrent nodu lar BCC with some ulceration. The medial edge is
scarred and poorly defined where previous BCC 'burnt out' some 2.5
years previously. b The tumour is of mixed solid and infiltrating type.
Perineura l infi ltration can be clearly seen in the lower field.
®
12.4 Nodu lar ulcerated BCC w ith margin diffuse in parts, indicating
need for w ider excision and carefu l histopathologica l monitori ng.
E
12.5 a BCC of the eyelid margin, showing ulcerated nodule w ith poorly
defined edge. b BCC of lid margin producing widespread obstruction
w ith chalazion formation .
I7I
PALPEBRAL TUMOURS
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12.6 Large ulcerated BCC that has been present a number of yea rs.
Excision of who le lower lid, inner and outer canthus, and much of the
cheek, monitored with frozen section histopathology and repaired
primarily.
12.8 Centre of a healing BCC with multifocal tumour around the
tumour periphery, showing as nodu les with 'pearly edge' in places.
12.7 a Ectropion and
multifocal superficial BCC of
eyelid (R) with some squamous
cell carcinomas (SCC) also, in a
fair-skinned blue-eyed man
w ith sun damage acquired
over many years. Note the
keratosis of skin and scarring
from previous treatments by
cryotherapy, diathermy, and
radiotherapy over a number
of years. b Extensive
intraepiderma l sec extending
down hair foll icles. Elsewhere,
typical BCC was present.
12.9 a Infiltrating BCC of
eyelid margin, poorly defined
and relative ly inconspicuous in
appearance, with tendency to
recurrence and widespread at
times. b Strands of tumour
cells are infiltrating dense
fibrous tissue. Obstruction of
the meibomian glands has
lead to dilatation of their
ducts and elswehere to
chalazion formation. When
recurrent, this type of BCC
requires careful monitoring
w ith wider margins.
The multifocal BCC is of completely different appearance (12. 7).
The multifocal superficial (MFS BCC) accounts for approximately
27% of BCCs. It presents as a red scaling lesion without a definite
edge. It needs to be differentiated from Bowen's disease (intraepidermal carcinoma), some solar keratoses, and eczema. Microscopic
characteristics show buds of basal cell tumour, usually with prominent palisading growing at intervals from the base of the basal cell
layer.
The 'field fire' or centre healing variety of multifocal BCC (12.8)
is rare in the eyelid, having mostly a larger size with an active red
rim and a quiescent paler centre.
There is also the multifocal nodular BCC, which has a series of
separated PN-BCC nodules.
The infiltrating BCC (12.9 ) accounts for 8% of BCCs. It has no
distinctive appearance. It may present as an ulcer or an ulcerated
nodule, as a red scaling tumour, as a grey patch, which is sometimes
depressed, or as a subcutaneous attached nodule. It has a diffuse
edge and may be indurated with some tethering.
Microscopy may show elongated strands with spiking projections; the spiky pattern lacks palisading.
The different infiltrating BCC types can make up as much as
24.5% of BCCs. These include the morphoeic infiltrating BCC and
the infiltrating subtypes of the papulonodular, multifocal, and
metatypical BCC.
The microscopic characteristics are of the infiltrating front,
defined by the presence of spiky patterns, sma ll cell clumps, and
172
EYELID TUMOURS
finger extensions of cells with no palisading, fibrous stroma between
cell clumps, and, at times, cell columns one to four cells thick reaching out in the looser stroma. Anaplasia may be present.
The micronodular type (12.10) presents with small cell clumps,
at times in an adenoid pattern of growth, with a poorly circumscribed edge. Palisading may be present. It may occur separately
or as an extension of another BCC type. It can have any of the clinical appearances of other BCC types.
All infiltrating types have a tendency to recur and require wide
margins of excision.
It is our practice to mark the tumour edge with dots around the
macroscopic tumour margins and then to mark a margin of excision appropriate ro the particular tumour type. It can be difficult to
specify just which tumour margin is adeq uate for which particular
BCC.
The pathologist should be asked to define the margin of excision
in the four quadrants of the specimen and in depth, noting millimetres from tumour extension to specimen edge. Since all specimens are marked with a 12 o'clock stitch and accompanying
drawings as needed, it is possible to define any areas of close or
incomplete excision. This is important in order to achieve complete
excision and it requires the surgeon and pathologist ro work closely together.
Primary re-excision should be carried out where histology shows
the margins to be too close. An advantage of MOH's technique
using serial shave excisions, is that the tumour is viewed in horizontal sections (12.11), which may show infiltration of the BCC
towards the specimen edge more clearly than the common vertical
sections. The other advantage of the classic MOH technique is that
the surgeon is looking at the pathology slides. MOH's technique
may also use vertical sections of marked specimen edges at the time
of excision, as with the usual frozen section examinations.
The morphoeic BCC (8 .9% occurrence) presents as a whitish or
grey plaque in the skin. There is no definite edge and it is almost
impossible ro outline the edge accurately, so wider margins of excision, perhaps 5-8 mm, can be advisable, especially as there is often
an infiltrating margin. Histologically, there are small clumps of BCC
scattered through a dense sclerotic stroma of fibrous tissue.
Metatypical and basosquamous BCCs are rare in the eyelid, as
they are mostly the larger, older, neglected BCCs. This type is seen
with the BCC cells either merging into larger paler eosinophilic cells
or partially differentiating into a squamous cell carcinoma. They
rarely metastasize. It has long been realized that the BCC is stromadependent and this sharply limits its ability to metastasize.
The recurrent BCC
These vary considerably in appearance depending on BCC type and
previous treatment (12.3, 12.10, 12.12). At times they may look like
a lump or ulcer or a fibrotic area. Often they are poorly defined and
the edge is difficult to define .
12.11 Horizontal
section of a BCC
showing the
infiltrating pattern of
spread with long
strands and small cell
clumps.
12.10 a Inconspicuous BCC
that has recurred three times
after apparent wide excisio n,
with diffuse infiltrating
character now identified as
'micronodular', though
previously classed as
multifocal infi ltrating. b
'Micronodular' type of BCC,
with rounded cell clumps of
small size. These BCCs tend
to be less well circumscribed
and will recur, behaving like
the infiltrating type.
a
I73
\Tl
12.12 a Recurrent BCC
of inner canthus.
Initia lly treated with
radiotherapy and then
by excision, it recurred
despite apparent
'adequate' excision.
This patient is fina lly
recurrence free 10
years after wide
excision. b BCC with
apparent
circumscribed growth
pattern continuous
with hyperplastic
lacrimal duct
epithelium, indicating
invasive character in
parts.
PALPEBRAL TUMOURS
12.13 a Pigmented BCC of inner canthus. b
Deposits of melanin pigment in BCC.
®
Histologically, they may be more diffuse and they are often fibrotic or sclerotic in appearance. There may be small cell clumps and
strands, as it is often the infiltrating element that is recurring. Spiky
thin strands of BCC or micronodules may be present.
Recurrence can be very slow and may occur over a period of
years, so that 10-year follow-up is necessary for suspicious BCCs.
This is particularly so aro und the inner canthus.
Recurrent tumours demand wider excision - often 5-8 mm or
even 10 mm- and careful histological monitoring with frozen section and haematoxylin and eosin paraffin blocks, using either vertical or horizontal sections, to ensure a good margin of clearance at
the edges.
It is preferable that the surgeon either sees the histology himself
with infiltrating or recurrent BCCs or has a close working relationship with the pathologist.
by cryotherapy or 5-fluorouracil ointment. Primary excision with
histology is preferred.
Otherwise, the SCC may present as a plaq ue, a thickened keratotic tumour, a nodule, or a fleshy ulcerated lesion.
T he microscopic appearance shows typical squamous cells with
variable degrees of keratinization. T he degree of anaplasia or lack
of differentiation may give a guide to its ma lignancy, a long with
its rate of growth.
Thickness has been suggested as a prognostic indicator, w ith
greater than 4 mm thickness being less favo urable. However, even
\ve!! -differentiated SCC's may be quite malignant with a tendency
to lympha tic and perineural invasion recognized as factors to be
looked for in the microscopic analysis.
Treatment is best by excision with a margin of clearance of
5-10 mm, depending on size and rate of growth . Radiotherapy
alone may be used when surgery is not possible or as an adjunct
to surgery with a more anaplastic tumour that is seen to be fleshy,
more ra pidly growing, and to have more diffuse induration and
adhesion to adjacent tissues, indicating tumour infiltration.
Follow-up of tumour and observation of lymph glands over a 10year period are necessary.
Pigmented BCCs
Any BCC type may be pigmented. Pigmented BCCs (12.13) occur
more in those with olive or oriental skins with more pigmentation.
T he importance lies in differentiating them from melanomas.
SQUAMOUS CELL CARCINOMAS (SCC)
PIGMENTED TUMOURS
Squamous cell carcinoma (12.14-12.16) is less common than the
BCC; in our series it was found to be 23 times less common. It varies
in appearance from a fleshy ulcerated tumour to a flat kera totic
lesion. Of the 13 SCCs in our eyelid series, fo ur were in the inner
canthus, six in the lower eyelid, and two in the upper eyelid.
While SCCs may develop from solar keratoses that have undergone a thickening of tissue deep to the keratotic crust, only some
solar keratoses will progress in this way. Protection of a solar keratosis from the sun appears to promote reso lution, pro ba bly by
removing the solar-related inhi bitio n of the immune system a nd
Langerhans cells, so that conservative treatment is often quite reasonable. O nce keratoses start to thicken, they are better removed.
An SCC that has developed from a solar dysplasia or a solar keratosis, tends to be slow to grow and slow to metastasize, so that the
lymph glands may be observed and then removed only if they
become enlarged. The keratotic solar SCC often tends to be a more
slowly growing tumour than the fleshy sec, which may be rapidly growing and may be more anaplastic. This la tter type of tumour
is often more likely to metastasize and it may be related to other
causative factors, as well as ultraviolet radiation.
The clinical appearance of the SCC varies. It may present as a flat
reddened intraepiderma l carcinoma with some scaling and irregular outline (Bowen's disease). T hese may be treated by excision or
Intradermal naevus
Intradermal naevi (12.17) may be elevated pink or brown, often on
the eyelid margin. They are to be differentiated from melanoma and
are best excised, with histopathology, when there is dou bt or concern about them.
Compound naevus
This is the intradermal naevus with junctional components (12.18,
12.19). It is better excised if growing, becoming darker, or causing
concern.
Junctional naevus
This is a flat brown naevus that has naevus cells at the dermoepidermal junction. It may have recently appeared or be seen to be
growing and is then better removed, with examination.
Blue naevus
This appears bluish grey in a deeper dermal location, and has a n
indefinite edge. This appearance causes concern a nd examples are
usually removed by local excision with histop athology. It is rarely
maligna nt.
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EYELID TUMOURS
12.14 a sec of upper l id in an old woman.
The SCC presented as a fleshy keratotic
tumour w ith induration and eyelid
irritation, redness and discharge. b sec of
well -differentiated type growing as
cohesive masses continuous w ith the surface
epithelium.
12.15 a sec of upper eyelid recurrent after
' diathermy' 1 year previously, presenting as
a subcutaneous nodule adherent to the
tarsal plate. b Moderately welldifferentiated sec w ith invasion of a
lymphatic vesse l showing in midfield.
12.16 a Ulcerated fungating SCC of lower
lid w hich began as a small pimple some 7-8
mont hs previously. Bi opsy showed SCC.
Treated with w ide excision and repair
primarily. The patient has been f ree of
recurrence for 10 years. bAn sec w ith
verrucous growth pattern and superficial
invasion.
12.17 Benign pigmented naevus of eyelid
margin enlarging into visual field .
12.18 Benign compound naevus of eyelid
margin. It w as excised, since it was of
suspicious appearance.
175
12.19 Congenital pigmented naevus of
upper and lower eyelids ('kissing'), treated
by complete excision and repa ir in
childh ood .
PALPEBRAL TUMOURS
Malignant melanoma
This may present as several different forms (12.20-12.23 ). Tumours
may be pigmented or non-pigmented.
Lentigo maligna melanoma (LMM)
This presents as a flat, brown, spreading pigmented lesion (12.21).
LMM may undergo a malignant change, which is usually signalled
®
12.20 a Maiignant meianoma of cutaneous aspect of upper iid margin arising from a pre-existing
non-pigmented compound melanocytic naevus. There was a history of enlargement over 1 year.
Note meibomian gland obstruction. b The junctional cell nests have become confluent, with
atypical melanocytes and an occasional mitotic figure.
a
12.22 a Diffuse pigmentation of lower eyelid. The patient presented
with black spot that had a 3 mm melanoma on biopsy. This is a
multifocal lesion tending to recur when on ly· one area is removed. b
Adequate treatm ent required excision of the whole lower eyelid. It was
12.21 Hutchinson's melanotic freckle with
central nodule of invasive malignant
melanoma. The 'E' is a 1 em measure.
© ·
sutured and stretched out for pathologist to fix and section, allowing
better identification and orientation. c S-1 00 protein stain indicating
extent of proliferation of invasion of malignant melanocytes.
12.23 a Cellular nodule of malignant
melanoma at lid margin. (Case of Dr Trevor
Harris.) b Histopathology showing melanoma
nodule.
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EYELID TUMOURS
by a deepening of colour, thickening, scaling, the appearance a pink
area in the surrounding darker colour, or a circumscribed darker
area in a diffuse pigmented lesion.
Histology of the LMM, previously called Hutchinson's melanotic
freckle (HMF), shows cellular atypia in the proliferated melanocytes
in the basal layer of the epidermis, freq uently with some lymphocytic reaction in the dermis.
Superficial spreading melanoma
The superficial spreading melanoma is a darker pigmented flat area
and has an irregular outline, again perhaps with pinker areas within
representing some area of regression.
Microscopic appearance shows a degree of epidermal (radial
growth phase) invasion by atypical melanocytes, often with some
lymphocytic reaction. The depth of invasion of the underlying dermis
(vertical growth phase) is of critical importance in prognosis.
Thickness measured with the ocular micrometer has been shown
to be a more accurate indicator of malignancy tha n the Clark levels
of histological invasion.
Nodular melanoma
T he nodular melanoma with deeper invasion represents the vertical
growth phase with increasing thickness related to worsening prognosis.
Desmoplastic melanoma
Desmoplastic melanoma usually has non-pigmented spindle cells
and a tendency fo r perineural invasion. It is frequently inconspicuous in appearance and diagnosed only on histology. The S-100 protein stain has greatly facilitated the recognition of this entity.
Clinically, desmoplastic melanoma may be a non-pigmented papule,
perhaps with crusting. It is frequently neutrophic. A keratin stain
(to identify SCC) and a vimentin stain (to identify atypical fibrozanthoma) are of help to the pathologist in the differentiation of spindle-celled lesions.
Treatment of melanoma is by surgical excision. Depending on
size and thickness, a 5-10 mm margin may be adequate, although
wider margins may at times be appropriate, for example in desmoplastic melanoma.
Observation of lymph nodes and biopsy removal if one or more
enlarges is common practice. Malignant involvement of the lymph
nodes can be shown by frozen section biopsy of a node, usually
the 'sentinel' node, w hich is identified as the first gland in the
drainage line by injection of blue-violet dye in the dermis near the
lesion. Scintillography also may be used to identify this node by isotope drainage to it from the region of the lesion.
Block dissection may follow if this gland is found to have malignant cell involvement.
OTHER TUMOURS
Sebaceous carcinoma
This is rare in Caucasians, and we have seen no cases in our series.
It may present as a chalazion with blockage and inflammation of
glands. One series shows that 96% of cases occur in Chinese people.
The incidence varies from a reported 72% for the upper lid and
24% for the lower lid.
Poorly differentiated tumours with infiltration have a higher mortality.
Treatment is by wide excision with frozen section histology and
primary reconstruction.
Lymphatic metastasis occurs in 17- 28% of cases, the spread
being to pre-auricular, submaxillary, and neck lymph nodes. Distant
metastasis also tends to occur.
Merkel cell carcinoma
In our experience this is rare in the eyelids, and, of the 85 cases of
Merkel cell carcinoma in Queensland, none has occurred in the eyelids. Other series have reported Merkel cell tumours of this region,
however- in one paper, 1 in 10 Merkel cell tumours are said to
occur in the eyelids .
The tumour may be smooth, pink-red, and non-tender. There
may be telangiectasia, and later there may be ulceration. It may
appear near the eyelid margin as a firm nodule, and it tends to local
recurrence and lymphatic invasion with metastasis.
Treatment is by wide resection and postoperative radiotherapy.
They are seldom diagnosed clinically. Histopathology shows large
nests of rounded cells of characteristic type with hyperchromatic
crowded nuclei somewhat resembling the cells of oat cell carcinoma of the lung. The cytokeratin stain is diagnostic.
Keratoacanthoma
The macroscopic appearance (12.24 ) is of a fleshy, pink-coloured,
rapidly growing nodule developing a central keratin plug and characteristic crateriform architecture.
Keratoacanthomas in mucocutaneous junctional areas appear to
behave more aggressively. Although they may resolve, one cannot
afford to wait as they may in fact be the rapidly growing anaplastic SCC with a tendency to early metastasis. This is especially a risk
in older people.
The scar from a resolved keratoacanthoma may be depressed and
unsatisfactory.
12.24 a Keratoacanthoma of inner canthus
present for 8 w eeks. It was treated by excision
and flap repair. b Keratoacanthoma with
typical crateriform architecture. There is no
significant cytological atypia or infi ltrative
growth pattern.
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P ALPEBRAL T UMOURS
RECONSTRUCTION OF MINOR DEFECTS
JC van der Meulen
Eyelid defects may be formed in several ways. Their size and shape
may differ widely. They may be small or large, rectangular, circular or semicircular, rhomboid or semi-rhomboid.
The defect may involve only conjunctiva or skin or both layers.
In this section, further subdivision is made between minor defects
involving less than one-third of the rim and major defects involving
more than one-third.
Whatever their nature, the defects may be repaired using the principles that are outlined below. The procedures used will be discussed
and illustrated with examples from clinical practice.
L OWER EYELID
Skin defects
T he procedure to be used is dictated by the location and size of t he
defect and by the quality and quantity of the donor skin.
12.25 a . Tumour of the lower eyeli d. b Defect
produced by resection. c.Ciosure by advance of
redundant skin. d Long-term result.
12 .26 a Defect produced by resection of tumour in
lower eyelid. b Desig n of transposit ion f lap.
d Transpositio n of f lap. d Lo ng-ter m resu lt .
RECONSTRUCTION OF MINOR DEFECTS
Apposition of skin (12.25) may be effective for closure of a small
defect when there is sufficient skin in the immediate vicinity.
Attention should, however, be paid to the direction of the main
diameter of the defect. If it runs obliquely or at right angles to the
lines of tension, appropriate measures should be taken to change
this direction by a transposition procedure.
Transposition of skin (12.26) may be indicated when the defect
is too large for closure by apposition or in those cases when apposition w ill inevitably be associated with the formation of a contracture. In 12.27, some procedures are shown that can be used
for this purpose. They all have the advantage that the donor skin
matches that of the lower eyelid.
Transplantation of skin (12.28-12.30) is indicated when transposition is not possible or when additional scarring is to be avoided. There are several possible donor areas, but again the first choice
should always be the upper eyelid because of the perfect match.
Retro-auricular and pre-auricular skin are second choices, followed
by a full-thickness graft taken from the inside of the upper arm. A
last choice, to be used only in emergency or as a temporary solution, is the split-thickness graft. The reluctance is because it con-
12.27 Transposition flaps used for closure of
defects in lower eyelid involving skin or skin and
conjunctiva.
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12.28 a Tumour of the lower eyelid. b Long-t erm result following resection and closure of defect with full-thickness graft from upper eyelid skin.
179
PALPEBRAL TUMOURS
®
12.29 a Defect produced by resection of tumour, including ca nalicu lus. The presence of sufficient conjunctiva permits closure with full-thickness skin
graft. b Long-term result.
12.30 a Neonate presenting with massive benign melanoma of lower eyelid. b Long-term result following resection of tumour and reconstruction of
eyelid with full-thickness skin graft using conjunctival remnants as receptor surface. Further correction is indicated but the patient refuses. (The
purpose of this procedure was to avoid conspicuous scarring by extensive rearrangeme nt of skin.)
Transplantation of mucous membrane is without question an
extremely useful procedure. A full-thickness graft virtually always
takes. Contraction is minimal and there are several donor areas in
the immediate vicinity. A conjunctival graft, with or without tarsus
from the upper eyelid, is ideal in quality, but unfortunately only
small amounts can be taken and there may be some morbidity at
the donor site.
A nasal graft with cartilage from the septal or upper cartilage area
is a good al ternative if one prefers to include cartilage. A buccal
mucous membrane graft provides excellent replacement material
if one shares the opinion of this author that the inclusion of cartilage is not essential, and that a palatal graft offers no additional
value.
tracts too much and the hyperpigmentation, which inevitably
occurs, makes it undesirable from a cosmetic point of view.
Conjunctival defects
Defects restricted to the conjunctiva are rare. The skin is generally
involved and the range of possibilities for closure of a conjunctival defect is small compared to that for a skin defect.
Apposition of the conjunctiva is indicated in smaller defects. A
defect of less than one-third of the eyelid rim can be closed in this
way. Exact limits are difficult to give, owing to individual differences in tissue laxity, but the production of entropion or lagophthamos should be avoided at all cost.
Transposition of conjunctiva is feasible, but in general this is not
to be advocated. Lower eyelid flaps have a restricted range of motion
and distortion of the eyelid rim can easily be produced. A directly
transposed upper eyelid flap may destroy the integrity of the mucosal lining and is difficult to transfer. An indirectly transposed upper
eyelid flap is a well-known alternative but it is not without some disadvantages. Firstly, it is a two-stage procedure; secondly, it prevents
vision and inspection of the eyeball for a certain period; and thirdly its potential is limited, owing to the risk of entropion or lagophthalmos.
Conjunctival and skin defects
Minor defects
Apposition of the conjunctiva is virtually always possible if less than
one-third of the eyelid rim is to be reconstructed (12.31, 12.32) .
Once this objective has been reached, it is only the skin defect that
remains to be closed, and this can be done either by apposition,
transposition, or transplantation of skin.
==========,_ - -- 180
RECONSTRUCTION OF MINOR DEFECTS
12.31 a Defect of lower eyelid prod uced by resection of tumour invo lving less than one-third of rim near latera l canthus. b Reattachment of rim. c
Cl osure of skin incision and resection of redundant skin. d Long-term result.
12.32 a Defect of lower eyelid prod uced by resection of tumour involving one-third of rim near medi al ca nthus. b Closure of defect by advancement
of conjun ctiva and skin.
• The transfer of skin flap fro m the upper eyelid, from the lower
eyelid, or from the temp oromalar area, lined with a mucosa l
graft.
• The transfer of a mucosal flap and a mucosa-lined skin flap fro m
the lower eyelid in opposite directions.
• The transfer of a muscular or fascial flap lined with a mucosal
graft and covered w ith a skin graft.
Major defects
Techniques for reconstruction of these defects w ith soft and pliable tissues that offer sufficient support and a good colour match
are based on:
• T he transfer of a composite flap from the upper or lower eyelid .
• The transfer of a mucosa l flap from the upper eyelid lined with
a skin graft.
I8I
PALPEBRAL TUMOURS
Transfer of a composite flap from the upper or lower eyelid
With the upper eyelid as donor area, three different modalities can
be used (12.33 ). T he first and oldest is the V-shaped artery flap
based on the upper eyelid rim (Esser's procedure).
The second (one stage) is a V-shaped laterally based cutaneous
flap lined with an elliptical tarso-conjunctival segment (Gorney's
procedure).
The third is a U- or T-shaped superiorly based cutaneous flap
lined with an elliptical tarsoconjunctival segment. This is in fact a
modified reversed Cutler-Beard flap.
With the lower eyelid as donor area, only one modality can be
used. T his is the transfer of a composite flap from the lateral part
of the lower eyelid in order to close a defect in the medial part
(12.34). Mobilization of this segment, by partial cantholysis, is
always performed in conjunction with a larger or smaller temporomalar flap. The conjunctival defect that is formed laterally may
require insertion of a small mucosal graft. This is a popular onestage method, useful in experienced hands, but not without its disadvantages .
-
I
I
Transfer of a mucosal flap from the upper eyelid lined with
a skin graft
This old procedure first advocated by Landolt has proved its value
in experienced hands. Unfortunately, it also requires two stages.
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Transfer of a skin flap from the upper or lower eyelid or from the
temporomalar area, lined with a mucosal graft
This approach offers important advantages over other techniques.
T he conjunctival lining of the upper eyelid can be left intact and
inspection of the eye remains possible. If the transfer of this flap
should leave a substantial defect in the donor area, this defect, in its
turn, can be closed with a skin graft.
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12.33 Composite flaps from upper eyelid.
12.34 Composite flap from lower eyelid.
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I8 2
RECONSTRUCTION OF MINOR DEFECTS
Defects involving only the rim can sometimes be closed by the
insertion of a mucous membrane graft that is covered by advancement of redundant skin from the lower eyelid (12.35, 12.36).
Defects in the medial part of the lower eyelid can be closed with
medially (12.37, 12.38) or laterally based V-flaps from the lower
eyelid (12.39). A medially based V-flap from the upper eyelid is difficult to tra nspose. It tends to form an epicanthal fold a nd is not
very well vascularized. A medially based V-flap from the lower
eyelid, extending downwards provides an alternative, but this flap
is less manoeuvrable and too thick.
12.35a Tumo ur involving the centre of the lower eyelid. b Conjunctival defect produced by resection of more then one-third of eyelid rim has been
closed w ith bucca l graft. c Skin defect is closed by advancement and lateral rotation of the lower eyelid skin. d Long-term resu lt.
®
12 .36. Defect following resection of tumour in the centre of the lower eyelid. b Conjunctival defect has been closed with buccal graft. c Skin defect
is closed by adva ncement and interpositioning of lower eyelid skin. d Long-term resu lt.
PALPEBRAL TUMOURS
12.37 a Defect in media! ha!f of !eft lower eyelid fo llovving resection of rim. b Design of tra nsposition f lap following closure of conjunctivai defect
with buccal graft. c Resurfacing of buccal graft w ith transposition flap. d Long-term result.
12.38 a Defect invo lving the centre and med ia l part of t he lower eyelid following resection of tu mour. b Design of transposition flap foll owing
closure of conjunctival defect. c Resurfacing of buccal graft w ith t ransposition flap. d Long-term result.
RECONSTRUCTION OF MINOR D EFECTS
Defects in the central or central and lateral parts of the lower
eyelid can be closed with a V-flap from the lower eyelid when skin
is redundant (12.40). Laterally based V-flaps (12.41 , 12.42 ), visor
flaps (12.43-12.45), or island flaps (12.46) seem to give the best
results.
Rotation of a temporomalar flap facilitated by the inclusion of a
lateral Z-plasty is frequently advocated in spite of a significant disadvantage - the technique produces a dog-ear, the removal of which
results in a scar at righ t angles to the eyelid rim. Sagging may therefore occur. A second Z-plasty in the medial sector of its periphery
has provided a solution for this problem (12.47).
12.39 a Defect involving medial half of lower eyelid. b Desig n of laterally based t ranspositi on flap fo llowing closu re of conjunctiva l defect .
c Resurfacing of buccal graft wit h transposition flap. d Long-term result.
12.40 a Design of transposition flap fo llowing closure of conjunctiva l defect. b Resurfacing of buccal graft w ith transposition flap.
r8s
PALPEBRAL TUMOURS
12.41 a Defect involving two-thirds of lower eyelid. b Closure of co njunctiva l defect w ith bucca l graft. c Resurfacing of buccal graft with laterally
based V-sha ped flap from upper eyelid. d Long-term resu lt.
12.42 a Defect involving two-thirds of lower eyelid. b Closure of conjunctiva l defect with buccal graft. c Resurfacing of bucca l graft w ith laterally
based V-shaped flap from upper eyelid. d Long-term result. (Note th at the length of the t ransposition flap is sufficient for almost complete
reconstruction of the lower eyelid.)
186
RECONSTRUCTION OF MINOR DEFECTS
12.43 a Defect following almost complete resection of lower eyelid. b Design of bipedicled visor flap from upper eyelid following closure of
conjunctival defect. c Resurfacing of buccal graft with visor flap. d Long -term result following secondary replacement of pedicles.
12.44 a Maximal extent of defect that can be reconstructed w ith buccal graft and visor flap from upper eyelid. b Postoperative result.
PALPEBRAL TUMOURS
12.45 a Closure of extensive lower eyelid defect w ith buccal graft. b Resurfacing of graft with visor flap . c Secondary correction or repositioning of
pedicles. d Long-t erm result.
12.46 a Mobilization of bipedicled island flap in the centre of the upper eyelid. b Defect of lower eyelid following resection tumour.
c Resurfacing of buccal graft with upper eyelid island flap. d Long-term result.
r88
REcoNSTRUCTION OF MINoR DEFECTS
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12.47 Z-plasties to facilitate rotation and
derotation of semicircular (-flap over a buccal
graft.
12.48 a Defect involving medial half of lower eyelid. b Subciliary incision is fol lowed by lateral canthotomy and med ial transposition of lat eral lower
eyelid half. c Result ing conjunctival defect in lateral half of lower eyelid. d Closure of conjunctival d efect w ith buccal graft. e Resurfacing of bucca l
graft by lateral rotation of lowe r eyelid skin. f Long-term resu lt .
Transfer of a mucosal flap and a mucosa-lined skin flap from the
lower eyelid in opposite directions
Trans fer of a muscular or fascial flap lined with a mucosal graft
and covered with a skin graft
This is known as the switch split-lid procedure (12.48). The technique has been used successfully for reconstruction of defects in the
medial half of the lower eyelid. For more extensive defects, the use
of other techniques is indicated.
This technique can be used when the situation has become desperate because adequate donor sites are not availa ble. Such a situation
may occur when the anterior and posterior lamella of the lower
eyelid have disappeared owing to some disease, but when orbicularis
PALPEBRAL TUMOURS
12.49 a Symblepharon due to complete obliteration of the inferior fornix in a patient with xeroderma pigmentosa. b Mobilization of atrophi c skin. c
Mobilization of orbicularis muscle and formation of the inferior fornix. d Lining of orbicularis muscle with buccal graft and restoration of inferior
forni x. e Repositioning of orbicularis muscle. f Resurfacing of muscle with full-thickness skin graft.
muscle is still intact although displaced (12.49). This muscle can then
be repositioned and used as 'nursing' tissue for both mucosa and skin
graft. When the orbicularis muscle is also a bsent, transfer of a fascial flap to serve as a nursing element should be considered.
It is claimed by some surgeons that sta bility of the lower eyelid
cannot be achieved without the insertion of cartilage as a substitute
fo r the tarsus. To avoid sagging they use either a conjunctivotarsal
(Hubner) graft, a nasoseptal (M usta rde) graft, or a naso-alar
(Texier) graft. H owever, sagging is mainly due to laxity of tissues or
lack of muscul ar tonus. Long experience w ith the use of buccal
mucous membrane for lining has shown that these grafts, inserted
under some tension and always subject to some shrinkage, provide
excellent stability. It seems that the supportive function of the tarsus,
if it exists, is taken over by the scarred interface between graft and
the cutaneous or myocutaneous flap. This hypothesis does not imply
that laxity of a completely reconstructed eyelid coul d not occur.
As in facia l p aralysis, the absence of m uscular tonus will then be
respo nsible. Such cases are rare, however, and correction of laxity
is rela tively sim ple. Would a pa latal graft be superior to a buccal
graft? So fa r there is no evidence for this, and harvesting of such a
graft is much more awkward. There is also a higher incidence of
morbidity at the donor site.
UPPER EYELID
Defects of the upper eyelid are less frequent than those of the lower
eyelid. This is fortunate, because the upper eyelid functions as a protective shield for the cornea, and defects are also more difficult to
repair. While the upper eyelid may serve as an excellent source of
donor mate ria l (in particular the skin ) for the lower eyelid, the
reverse is only partially true. The principles for reconstruction are,
however, the same in both areas.
Skin defects
Apposition of skin can be used in many patients (12.50 ). A relative surplus is nearly always present and correct application of this
principle may wor k wonders at times.
Transposition of skin (12.51) may be necessary when appositio n
is not possible or w hen future scar contracture is to be prevented .
Skin of the lower eyelid can be transferred occasionally as a later-
RECONSTRUCTION OF MINOR D EFECTS
12.50 a Tumour of the upper eyelid. b Defect fo llowing resectio n of tumour. c Closure of defect by adv ancement of redundant sk in. d Long-term
result.
12.51 Transposition flaps
used for closure of defects
in upper eyelid involving
skin or skin and conjunctiva.
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PALPEBRAL T UMOURS
ally or medially based V-flap, or even as a bipedicled visor flap,
raised in the lower eyelid, if one is prepared to resurface the donor
area with a graft. Forehead skin is useful only in emergencies and
will never produce normal function and cosmesis.
Transplantation of skin is indicated whenever there is an absolute
shortage of skin, or when scarring is to be minimized. The longer
diameter of the graft should always follow the course of the tension
lines, and the best donor area is, as usual, the other upper eyelid.
Conjunctival defects
The repair of conjunctival defects is complicated by the fact that the
conjunctiva of the lower eyelid is less suitable as donor material.
Apposition of the conjunctiva may be obtained in small defects
of less than one-third of the upper eyelid.
Transposition of conjunctiva using flaps from the upper eyelid
itself has only limited potential, owing to the rigidity of the tarsus,
and the insertion of the levator muscle to its upper rim. The transfer of conjunctival flaps from the lower to the upper eyelid should
not be considered, in view of the lack of donor material in this area.
Transplantation of a mucous membrane will make it possible to
close almost any upper eyelid defect. As explained before, several
grafts can be used, but the buccal graft is the one used exclusively
by this author.
Conjunctival and skin defects
Minor defects (12.52)
When less than one-third of the eyelid rim is involved, the defect
is closed in a manner similar to that used for the lower eyelid. The
conjunctival edges are first brought together by apposition. This
technique may be associated with the formation of a small tarsal
dog-ear, and this must be resected. After this, the skin defect can be
closed by apposition, transposition, or transplantation.
Major defects
Patients with a defect involving more than one-third of the eyelid
rim are, fo rtuna tely, rare -reconstruction of the upper eyelid is
much more demanding tha n that of the lower lid. The following
principles have been described:
• The transfer of a composite flap from the lower eyelid.
• The transfer of a conjunctival flap from the lower lid lined with
a graft or with a flap.
• The transfer of a mucosa-lined skin flap from the upper or lower
eyelid.
Transfer of a composite flap from the lower lid
A V-shaped flap that is based on the eyelid rim has been advocated for closure of upper eyelid defects that involve little more than
one-third of the rim. The donor defect can then be closed with ease.
This, however, is a two-stage procedure.
Larger defects of the upper eyelid require a more ela borate
approach because simple closure of the donor defect in the lower
eyelid by apposition is not feasible. This problem was solved by
Mustarde, who was the fi rst to reconstruct the upper lid by transposition of the whole lower lid as a compound flap in conjunction
with a temporomalar flap. Medial rotation of the latter flap lined
with a mucosal or nasoseptal graft permits reconstruction of the
lower lid. This delicate procedure should, however, be executed only
by experienced hands.
Transfer of a conjunctival flap from the lower lid lined with a
skin graft or flap
This should no longer be considered a serious alternative, in view
of the limited donor tissue and the fact that this also is a two-stage
procedure.
12.52 a Tumour of the upper eyelid. b Defect involving one-third of the eyelid rim. c Closure of defect by advancement of skin and conjunctiva. d
Long-term result.
RECONSTRUCTION OF MiNOR DEFECTS
Transfer of a mucosa-lined skin flap from the upper or lower lid
This is extremely effective when larger defects in the upper eyelid
need to be closed. As in the lower eyelid, the buccal graft can be covered with a variety of unilateral flaps or visor flaps; these may be
raised in the upper as well as the lower eyelid (12.51, 12.53-12.55 ).
Recently, an elegant procedure has been proposed by Yoshimura
et al., who advocate the use of a flap that is raised in the temporomalar area. Pedicled on the inferior eyelid rim, it is turned 180° to
close the defect in the upper eyelid, following insertion of a mucosal
graft.
@
12.53 a Defect of the upper eyelid involving more then one-third of the rim. b Design of transposition flap following closure of conjunctiva l defect
with buccal graft. c Resurfacing of bucca l graft with transposition flap. d Long-term result .
@
12.54 a Unsuccessful reconstruction of upper eyelid repair with skin flap shows shortage of mucosal li ning. b Shortage corrected by insertion of
mucosal graft covered by original skin f lap. c Preoperative appearance. d Postoperative appearance.
I93
PALPEBRAL TUMOURS
®
f
12 .55 a Ext ensive def ect of t he upper eyelid fo llowing resection of
t umour. b Closure of defect w ith bucca l g raft and design of visor f lap in
lower eyel id. c Resurf acing of buccal graft by tran spositi on of visor flap.
d Closure of don or def ect in lowe r eyelid w ith full-thick ness skin graft
from opposite upper eyelid. e Long -term result showing normal
appearance. f Long-t erm result showing perfect cl osure of
reconstructed upper ey elid.
A donor defect in the upper eyelid, with its surplus of skin, can
usually be closed with ease. If not, it should be closed with a graft
harvested from the opposite upper lid. When the flap is taken from
the lower eyelid, with its relative shortage of skin, it will virtually
always be necessary to resurface the donor defect with a graft.
One-stage procedure
The best solution, obviously, would be to close each conjunctival
defect separately with a graft, and cover this graft with a flap raised
in the eyelid itself. If this is not possible, the immediate vicinity
(frontal or temporomalar area) provides an alternative donor site.
Defects involving both eyelids in the medial or lateral canthal region
can be closed in this way. The flaps are made two- tongued, and
the apex of the space between the two tongues is fixed to the canthus. T hese flaps are necessary to nourish the graft, but whereas
thick skin in the lower eyelid may be advantageous because of the
support it provides to this structure, it is less suitable for the upper
eyelid, w ith its particular pliability.
This quality, as well as the presence of a functioning levator
palpebrae are the principal req uirements for an optimal recover y of
the upper eyelid. The quantity of thick skin should therefore be kept
to a minim um and, if possible, thick skin should be removed or
replaced by a more suitable transplant once it has fulfilled its nursing function (12.57).
DEFECTS OF BOTH EYELIDS
Skin or conjunctival defects
Defects of both eyelids following tumor resection are relatively rare.
In general, however, bipalpebral reconstruction does not pose many
problems. The defects can then be closed by application of some
of the principles described for each eyelid separa tely (12.56).
Skin and conjunctival defects
Reconstruction is difficult when more the one-third of the eyelid rim
is involved and the cornea h as lost its protection. T he first decision to be made is whether to choose a one-stage procedure or twostage procedure.
194
RECONSTRUCTION OF MINOR DEFECTS
12.56 a Naevi of the upper and lower eyelid. b Result of bipalpebral resection and res urfacing w ith full-thickness graft.
12.57 a Defect follow ing resection of half of the upper and lower eyelids. b Closure of conjunctival defect with buccal grafts. c Transposition of
suprabrow flap. d Resurfacing of buccal graft w ith transposition flap. e Short-term result . f Long-term resu lt following reduction of skin flap .
195
PALPEBRAL TUMOURS
Two-stage procedure
In theory, numerous combinations of defects in the upper and lower
eyelid are possible, and one may even be faced with the task of
reconstructing an entire upper and lower eyelid. In practice, however, most reconstruction is always possible if the choice of procedure is based on the following criteria:
1. The eyeball can be covered with the conjunctival remnants but
an important skin defect remains; in these cases, the conjunctival mucous membra ne defect is closed by apposition of its
edges, and the remaining skin defect is covered with a graft from
the opposite upper eyelid or from ancther suitable donor area.
The eyelids are separated in a second stage.
12.58 a Defects of the upper and lower eyelids fo llowing resection of
tumour in a patient with adenoca cystica. Most of the face had already
been resurfaced with spl it-thickness grafts. b Closure of conjunctival
defect with buccal graft. c Reinsertion of levator muscle. d Resurfacing
of buccal graft with adjacent visor flap and closure of resulting defect
w it h skin graft. e Separation of reconstructed palpebral unit in second
stage. f Repositioning of 'nursing' flap and resurfacing of eyelids with
thick-split skin grafts. g Postoperative appearance with open eye. h
Postoperative appearance with closed eye.
Rf.CONSTRUCflON OF MINOR DEFECTS
2. The eyeball can be covered by the remaining eyelid skin, but
below this surface a substantial conj unctival defect remains; in
such a situation, the conjunctival defect is closed with a graft
joining the two eyelids. This graft is then covered by approx imation of the cutaneous edges of the defects. Once healing has
occurred, the upper and lower eyelid are separated. If there is
still a shortage of skin, more should be added by means of a
graft until adequate closure is obtained.
3. The eyeball cannot be covered either with mucous membrane
or with skin; in such extreme and rare cases, the conjunctival
defect is closed with a mucous membrane graft uniting the inferior and superior remnants. As always, this graft is inserted
under some tension. If necessary, the levator aponeurosis is
attached to the graft that now must be covered by nourishing
tissue. In theory two strategies can be followed. One is to resurface the graft by transposition of the remaining orbicularis
muscle, a temporal m uscle, or a galea! flap, and to cover this
flap w ith a full-thickness skin graft. Once healing has occurred
the eyelids are separated. The other is to cover the graft temporarily by a so-called 'nursing' skin flap. This flap can be raised
in the forehead or in the temporal or retroauricular region. A
simple method is to make a suprabrow relaxing incision and
transfer the 'brow-a rea' as a bipedicled flap (12.58 ). Once healing has occurred, the upper an d lower eyelids are separated.
MEDIAL CANTHUS
The medial canthal region, and more particularly the area lying over
the insertion of the canthal tendons, is of special interest to the surgeon, because intraorbital invasions of malignant tumours are more
common there than elsewhere. Radical resection is therefore imperative under all circumstances.
Closure of the resulting defects may be achieved in various ways.
Apposition by careful suturing of the edges of the defect can sometimes be performed in older patients with a surp lus of skin. If this
is not possible, closure by secondary intention (laisser-faire technique ) can be considered. Although advocated by some surgeons,
this technique has several disadvantages. There is a delay in wound
healing, and distortion of the medial canthus or ectropion of the
medial part of the eyelids may develop. In spite of these arguments
some excellent results have been obtained by this method (12.59).
Transposition of skin is a third alternative, and flaps from th e
glabellar or mediofrontal area are freq uently used in spite of important differences in thickness and texture and the risks involved when
resection has not been radical.
A medially based V-flap from the upper eyelid provides another
possibility, but transposition of this flap is awkward. A similarly
based island flap is easier to transfer, but the vascularization of such
a flap is even more precarious.
12.59 a Planned resection of tumour involving the medial canthus. b Defect in media l canthal area fol lowing resection. The burr ho les for the
transnasal canthopexy have been made, and the tips of the injection needles, havin g passed the nasal root, are visibl e. c The stumps of lower and
upper eyelid rim have been reattached and the remaining skin defect is left to heal spontaneously (laisser-faire technique). d Long-t erm result.
I97
PALPEBRAL TUMOURS
12.60 a A full-thickness graft is attached to the periosteal edges of the defect. b Tie-over sutures exert pressure on the graft during the immediate
postoperative phase. c Defect in medial canthal region following resection of tumour. d Postoperative resu lt of technique used in a and b.
12.61 a Defect following resection in medial canthal region. b Closure of defect with full-thickness graft from upper eyelid. c Tie-over sutures fix
graft to periostea l edges. d Postoperative resu lt .
Considering the various advantages and disadvantages of these
flaps transplantation of skin seems to be the best and safest alternative (12.60, 12.61).
1. A full-thickness graft that matches the size of the defect is taken
from upper eyelids or from the postauricular area.
2. The graft is placed in the canthal defect to cover the bare bone.
Contrary to what is sometimes thought, such a graft will take
provided the surface is viable, as it always is following resection
of a tumour.
3. The graft is fixed to the rigid periosteal edges of the defect
instead of to the mobile surrounding skin. To facilitate fixation,
which is obtained with slight elevation of the periosteal edges,
interrupted sutures may be necessary. This technique makes it
possible to obtain absolute immobility of the graft and thus
enhance the take of the graft.
Resection of a tumour in the medial canthal region is frequently associated with the loss of a canthal insertion. As a result, telecanthus will occur. To prevent this from happening or to correct this,
an adequate canthopexy is imperative (12.62).
RECONSTRUCTION OF MINOR DEFECTS
12.62 a Telecanthus followi ng resections of tumour in medial canthal area and inadequate ca nthopexy. b A strong dermal strip is formed in the scarred
cantha l area . c The strip replacing t he ca nthal tendon is reattached t o the skeleton using a transnasal canthopexy. d Immediate postoperative resu lt.
®
12.63 a Planned resection of i nfiltrating tumour in lateral canthal region. b Def ect follow ing extensive resection. c Reconstruction of conjunctival
lining by redistribution. d Design of sk in flap. e Resurfacing of conjunctival by transposition of skin flap. f Early resu lt.
LATERAL CANTHUS
area, as is frequently seen in older patients. Transposition of skin
from the temporal area by means of a C-flap or from the frontal
area by rotation of a V-flap is a second alternative with great potential (12.63) . Transplantation of skin is a simple procedure with
excellent results provided skin with good texture and colour is used.
T he closure of defects in the lateral canthal area is facilitated by the
presence of several donor areas in the immediate vicinity with skin
of good texture and with a perfect colour match. Apposition may
be adequate when there is a surplus of skin in the lateral canthal
I99
PALPEBRAL TUMOURS
RECONSTRUCTION OF MAJOR DEFECTS
MAJOR DEFECT WITH INTACT EYE (12.64)
JS Gruss
W hen the eye is still present, reconstruction of an eyelid requires a
minim um of three elements - an outer layer of skin, an inner layer
of m ucosa, and a semi-r igid skeleton interposed between them. The
upper lid is the most difficult to reconstruct since it must be movable. Small losses or distortions of the upper lid, particularly in the
centre, may expose the cornea during sleep, thus risking ulceration
and even loss of the eye. In contrast, apar t from epiphora, loss of
the entire lower lid can be tolerated reasonably well.
Owing to laxity of the tissues, up to a quarter of an eyelid can be
removed and the defect closed directly. In elderly patients, the tissue
may be so lax that one-third of the lid can be resected and closed
directly. Thus, because of stretching of the tissues, only three-quarters of either lid need be reconstructed.
Skin defects of the lids are reconstructed by rotation of skin from
the adjacent cheek, the malar, temporal, or forehead region. Defects
in contiguous areas of the forehead, nose, or cheek are reconstructed
with separate flaps to maintain definition and separation of the aesthetic units of the face. Reconstr uction of adjacent aesthetic units
w ith the same flap may cause obliteration of natural creases, hollows, and anatomical demarcations that are important in normal
The reconstructio n of ma jor defects of the eyelids, adnexal structures and underlying orbit presents a considerable challenge. Deficits
may involve major portions of the upper a nd lower eyelids, medial
and latera l canthal regions, the nasolacrimal apparatus, and the
underlying orbital bone. Defec ts are sometimes confined to the
orbital region itself, but often they extend medially to involve the
medial canthal region and nose, inferiorly to involve the cheek soft
tissues and underlying maxilla, superiorly to involve the eyebrow
and forehead, and laterally to involve the lateral canthus and temporal region. Occasionally, massive defects involving most or a ll
of these areas may occur in the same patient, resulting in a major
reconstructive challenge.
The reconstruction of major composite defects of the eyelids and
orbital region involves very careful planning and execution of multip le reconstructive techniques that have to be combined and integrated to produce an anatomical reconstruction. Local and regional
tissue should be used whenever possible. Only if local or regional
tissue is inadequate or unavailable should distant tissue be used.
12.64 Patient with extensive r esection of multip le recur rent BCCs of
the face and eyelids. a Note the extensive deficit of left lower eyelid
following subtotal resection of the eyelid. The tarsal plate and
conjunctiva are preserved. There are extensive defects of the forehead
and tem ple as we ll. Reconstruction is planned using large cheek-neck
rotation adva ncement flaps based in aesthetic units. The flaps t o
reconstruct the lower eyelid wi ll be rotated up along t he nasa l labial
crease and the f laps to reconstruct t he tem poral defect w ill be rotated
up the pre-auricu lar crease. Ha ir-beari ng scalp f laps wi ll augment the
reconstruction in the temporal reg ion t o reconstruct the natural
hairline. b Flaps raised and advanced and rotated upwards. c The blood
supply to the flap is maintained by leaving the central portion of the
cheek skin at tached. d The flaps are rotated into place. The dermis of
the f lap is anchored careful ly t o t he bone of the lateral canthal region
as well as t o the medial canthal region to prevent downward forces on
the lower lid reconstruction w ith postoperative sw elling and gravity. e
Tota l reconstruction of lower eyelid skin 3 years later, w it h no sagging
o r ectropion of the ey elid and normal attachment of lateral canth us.
200
RECONSTRUCTION OF MAJOR DEFECTS
facial aesthetics. Extensive skin or composite losses may need additional soft tissue coverage provided by regional temporal fascial and
muscle flaps .
Replacement of lost tarsal plate support can best be provided
by a chondromucosal graft from the nasal septum, particularly if
additional lining is needed as well. W hen sufficient lining is present,
support can be obtained by the use of a concha! cartilage graft. This
graft has the exact curvature of the eyeball and can be taken in sufficient quantity so that the graft can extend fro m the inferior orbital
rim below to the eyelid rim above. Support and lining reconstruction can also be provided by a graft of hard palate mucosa. The disadvantage of palatal mucosa is an unnatural appearing eyelid
margin and relatively poor aesthetics compared to reconstruction
using a chondromucosal graft. Additional lining, if necessary, can
be obtained from buccal mucosa grafts.
When the medial or lateral canthus is detached or excised, the
remaining or reconstructed eyelids need to be reattached laterally
and medially to allow proper repositioning of the eyelids or reconstr ucted eyelids in relation to the orbital rim and adjacent structures.
When underlying bone is resected, this may need to be accurately reconstructed with bone grafts to support the overlying soft tissue
repair. This is particularly important in the in ferior orbita l rim,
which is essential to provide lower eyelid support.
MAJOR DEFECT WITHOUT EYE (12.65, see also 12.81)
The reconstruction of major defects when the eye has been removed
follows different principles and aims. When the eyelids are intact or
eyelid reconstruction is planned, reconstructive principles are aimed
at maintaining a deep bony orbital socket and maintaining adeq uate
space in the superior and inferior fornices so tha t an ocular prosthesis can be adequately fitted and retained.
When the eyelids have been removed in continuity with the eye,
the resulting empty orbital socket should be reconstructed with bone
if needed, and then skin flaps to maintain orbital depth. This will
facilitate the fitting and retention of an orbital prosthesis. Obliteration
of the orbital socket with muscle flaps or thick composite distant skin
flaps will often preclude adequate prosthetic reha bilitation.
12.65 Patient w ith extensive orbital
exenteration followi ng recurrent BCC. There is
direct communication from the nasal cavity to
the orbit.
a Note the extensive defect and planned
cheek-neck rotation flap reconstruction. Before
insertion of the f lap, the orbital cavity has to be
separated from the nose by a septal
mucoperichondrial flap, w hich is rotated up into
the upper portion of the defect. If this is not
done, air w ill be constantly blow n under the
flap, lifting it out of th e defect. b The fl ap is
raised and rotated into the defect. Suction
drainage pulls the flap into the defect, creating
a natural orbital hollow. Th e flap is based on
the natural aesthetic units of the cheek. c The
completed reconstruction w ith maintenance of
natural orbital hollow. The reconstruction of the
orbital socket w ith a thin adjacent skin flap
allows easier fitting of an orbital prosthesis. d
Lateral view showing maintenance of depth of
orbital socket.
20 I
PALPEBRAL TUMOURS
RECONSTRUCTION OF THE INFERIOR ORBITAL RIM
(12.66-12.72)
The inferior orbital rim is extremely important in providing support
to the lower eyelid. Atrophy or loss of the rim usua lly causes sagging and ptosis of the lower eyelid. This is clearly demonstrated after
a total maxillectomy with resection of the orbital rim and floor but
preservation of the ocular globe and periorbital contents. In this situation, the globe maintains its vertical position, being supported by
Lockwood's ligament, but the eyelid sags, having lost its vital support.
Following full-thickness resection of the lower eyelid, reconstruction must provide cover, lining, and adequate support. The support must be provided by reconstruction of the tarsal plate, usually
with cartilage grafts. In order for the cartilagino us support of the
lower eyelid to be adequate, the inferior aspect of the cartilage graft
must be anchored to the inferior orbital rim.
When the inferior orbital rim is lost or resected in combination
with full-thickness loss or resect ion of the lower eyelid, then adequate reconstruction of the inferior orbital rim should precede
reconstruction of the lower eyelid.
Methods of reconstruction
It is important first to delineate the extent of the defect of the orbital
rim and wall. The defect may involve the inferior orbital rim alone,
or it may also involve the lateral or medial orbital rim or walls, the
floor of the orbit, and the anterior wall of the maxilla.
In each situation, split calvarial bone grafts tha t are carefully
shaped and contoured replace the defect in the inferior rim and any
contiguous areas. The bone grafts used to reconstruct the orbital
rim and anterior maxilla are rigidly fixed in position with lag screws
and miniplates or smaller plates. Subsequent bone graft reconstruction of orbital wall defects can usually be performed by wedging the bone grafts into place. This can be done without fixation;
alternatively fixation with miniscrews or microscrews can be used
when necessar y. The bony reconstruction of the orbital rim now
serves as a base for support of the lower eyelid. The chondromucosal or concha! cartilage used for eyelid support is anchored to the
underlying bone graft through multiple drill holes placed through
the graft after its rigid fixation. In addition, the cheek soft tissues or
flap can be suspended through the same drill holes with multiple
2/0 Dexon sutures. Rigid immobilization of the bone grafts with
plate and screw fixation provides support to cartilaginous and soft
tissue in the healing phase, without the risk of bone graft loss and
subsequent soft tissue displacement.
12.66 This ma le patient had osteomyelitis of the right infraorbital rim as a child, resulting in severe hypoplasia of the rim. a The vertical position of
the globe is maintained, but there is sagging and inferior displacement of the eyelid, w hich has lost its inferior support. b Inferior view showing
maintenance of globe position. There is obvious inferior and posterior displacement of the right lower eyelid.
12.67 Post-traumatic destruction of the infraorbital rim. a Threedimensional CT scan showing the effects of multiple comminuted
fractures of the infraorbital rim. These have not been adequately
repaired and so result in loss of natural contour and projection of the
infraorbital rim. c There is slight vertical displacement of the globe but
the major effect is the loss of lower eyelid support. c Inferior view
showing maintenance of globe position with severe sagging of lower
eyelid due to loss of support from infraorbital rim .
202
RECONSTRUCTION OF MAJOR DEFECTS
©
rigidly fixed with microplates and microscrews and lag screws. d Resu lt
at 3 years, showing perfect restoration of posit ion of the right lower
eyelid fo llowing accurate restoration of the inferior orbital rim. Normal
f r onta lis function can be seen w ith preservation of the fronta l branch
of the f acial nerve following t he approach to the zygomatic arch and
orbit through the coronal incision. e Inferior view showing perfect
restoration of orbital volume and lower eyelid support.
12.68 A fema le patient w it h a rapidl y expanding vascular tumour of
the inferior orbital rim and wal l and body of t he zygoma, ca using
destruction of the inferi or orbital rim. a Coronal CT scan showing
massive tumour invo lving the inferior orbital rim. b Exposure of the
orbit and zygoma through a coronal incision, showing complete
isolation of tumour in the inferior orbital rim. c Drawing showing
complete reconstruction of the entire infraorbital rim, a portion of the
lateral orbital rim, and the zygoma, with split cranial bone grafting
12.69 Cartilage grafting may be necessary to
restore adequate support to the lower eyelid.
Th is may be in the f orm of a composite
chondromucosal graft from the nasal septum
or cartilage grafts alone from the nasal
septum or conchae of the ear. a When
cartilage grafts are used in the lower eyelid, it
is essential that they should be long enough
to allow the lower edge of the graft to rest
on the inf raorb ital rim. The g raft it self can be
fixed to the upper inner aspect of the orbita l
rim by through-and-through drill holes. The
graft needs to be high enough to extend from
the infraorbital rim to close to the eyelid
margin. b Large piece of cartilage carefully
fixed to the infraorbital rim. The lateral aspect
of the cartilage, as well as the lower eyelid
reconstruction, can then be attached through
separate drill holes in the lateral canthal
reg ion to provide additional support to the
lower eyelid reconstruction and complete the
lateral canthal reconstruction.
203
PALPEBRAL TUMOURS
12.70 A 60-year-old man w ith recurring sec involving the r ight lower
eyelid and anterior cheek, and invading the underlying maxilla and
inferior orbital margin. a Full-thickness resection of two-thirds of the
lower eyelid, the enti re inferior orbital margin, the anterior half of the
orbita l f loor, the anterior wa ll of t he maxilla, and the cheek skin. Lateral
sutures placed in the remaining eyelid. The r econstruction is planned
with a large cheek-neck rotatio n flap co mbined w ith a lateral
canthotomy and medial rotation of the rema ining eyelid skin, tarsal
plate, and conjunctiva. b Split calvaria l bone grafts reconstruct the
missing orbita l rim and anterior wa ll of the maxil la. A ll bone grafts are
carefully fixed in place with multiple lag screws. c Chondromucosal graft
harvested from the nasal septum is now used to reconstruct t he medial
half of the eyelid. Th is is anchored inferiorly to the underlying bone
graft. The lateral portion of the eyelid is brought across as a co mposite
flap and anchored to the chondromucosa l graft medially. d The large
cheek-neck rotation flap is now used to resurface the remaining eyelid
and cheek in one large aesthetic unit. e Result at 3 years shows good
restoration of lower eyel id anatomy and support. There is a slight
ectropion of the medial portion of the eyelid. Note the excellent contour
restoration of t he cheek and orbital rim and th e support it provides to
t he lower eyelid. f Inferior view showing maintenance of ocu lar globe
position. Position of the lower eyelid reconstruction can be seen as we ll
as contour restoration of the anterior wal l of the maxilla and inferior
orbital rim.
12.71 A 62-year-old patient w ith more radical resection of the total lower
eyelid combined w ith the entire orbital rim, floor of the orbit, and
anterior wa ll of the maxillary antrum following a recurrent sec. a Deficit
involving the entire lower eyelid and infr aorbital rim. b Careful
reconstruction of the missing bone of t he infraorbital rim, the orbital
floor, and the anterior wall of th e maxilla, w ith split cranial bone grafts
held rig idly in place w ith mini plates and screws. There is total lowe r
eyelid skin reconstruction w it h a large cheek-neck rotation flap. c A large
chondromucosa l graft from the nasal septum is shown anchored to the
reconstructed infraorbital rim inferiorly. This supports the cartilaginous
and mucosa l part of the reconstruction . d The total eyelid skin is now
reconstructed by the cheek-neck rotation flap. Care is taken to anchor
the flap superiorly in the lateral orbital region and medially in the
medial canthal region to provide additi onal support. e One-stage
reconstruction at 5 yea rs. Note the good retention of support of the
tota l lower eyelid reconstruction with on ly slight degree of ectropion.
f Inferior view shows maintenance of globe position and lower eyelid
support by underlying bony reconstruction.
204
RECONSTRUCTION OF MAJOR DEFECTS
12.72 A 65-year-old woman with massive recurrent BCC involving the
lateral nose, medial canthus, and lower eyelid. a Defect following
resection involves full thickness of the right heminose and nasal bone,
the medial orbital rim, and complete medial canthal region, the medial
third of the upper and low er eyelids, the entire inferior orbital rim, and
the anterior wall of the maxilla and the anterior half of the orbital
floor. The ocular globe has been preserved by careful dissection of the
periorbital tissue with frozen section by modified Mohs technique.
b Bony deficit of infraorbital rim, medial orbital rim, orbital floor, and
anterior wa ll of the maxilla is carefully reconstructed with split cranial
bon e grafts rigidly fixed in place with plates and screws. Nasal
reconstruction is planned with septal hinge f lap for lining and fo rehead
flap for cover. Eyelid and cheek reconstruction is to be performed with
large cheek-neck rotation flap. cAs the septal cartilage and mucosa
has been needed for the lining of the nose, the lining and support for
the recon stru cted eyelid is provided by a free septal mucosal flap
harvested from one side of the septum sutured in place to the
remaining conjunctiva and a large concha l cartilage graft from the ear
anchored inferiorly to the reconstructed infraorbital rim. The forehead
flap has been used to reconstruct the heminose, and the cheek-neck
rotation f lap has been raised prior to rotation into the eyelid and cheek
defect. The cartilage graft of the lower eyelid, as we ll as the remaining
tarsal plate of the upper eyelid, is anchored to the reconstructed
medial orbital rim by a separate wire suture to reposition the medial
canthal reg ion. d The reconstruction at 2 years. Lower eyel id support
has been well maintained by the underlying bony reconstruction. The
importance of separating the cheek and eyelid reconstruction from the
nasal reconstruction is seen by maintenance of the natural crease
between the nose and cheek. Medial canthal position has been
maintained. e Oblique view showing excellent support to the lower
eyelid. f Inferior view showing maintenance of globe position and
lower eyelid support.
MAJOR DEFECTS IN MEDIAL CANTHAL REGION
(12.73-12.78)
The medial canthal region contains a number of intricate anatomical structures in a confined space. The thin skin of this region is
closely applied to the underlying bone with minimal interposition
of facial muscles. Invasive skin tumours in this region may involve
the underlying bone and adnexal structures. Tumour may then
spread down tissue planes into the deep orbit and eventually
intracra nially. Accurate and complete excision of tumours in this
region present a particular challenge. Careful excision using frozen
section monitoring is mandatory. Resultant defects may involve the
skin of the medial canthal region and contiguous cheek, nasal and
glabellar regions, the underlying medial and inferior orbital rims,
and underlying orbital walls, the nasal bone, medial canthal ligament, and nasolacrimal apparatus.
In the past, involvement of the intraorbital soft tissue structures
made mandatory an orbital exenteration in order to ensure adequate
removal of tumour. The ability to delineate accurately macroscopic tumour involvement of the extra conal orbital fat using MRI and
12.73 When the medial cantha l region has been resected comp letely, it
is essential to reposition the reconstructed eyelids in the correct
position to prevent lateral drift and to provide a natural appearing
medial cantha l region . The suture is placed in the remaining med ial
aspect of the tarsal plate of both the upper and lower eyelid and then
passed transnasally through drill holes made in the anterior lacrimal
crest region. These sutures need to pass d irectly through the tarsa l plate
itself to provide firm anchorage.
205
PALPEBRAL TUMOURS
right side. On the left side, the medial third of both the upper and
lower eyelids, including the entire medial canthal region, has been
resected as w ell. b Reconstruction is planned with local flaps taken
from the nasoglabella region and bilateral large cheek- neck rotation
flaps . c The first part of the reconstruction invo lves t he repositioning of
th e remaining upper and lower eyel ids to the medial canthal region .
The suture is taken through the remaining tarsal plates of both the
upper and lower eyelids and w ired transnasally. Correct repositioning
of both medial canthal reg ions can be seen. d Planned reconstruction
w ith cheek-neck rotation flaps. e Bilateral cheek-neck rotation f laps
and nasoglabella flap raised prior to insetting. f Result after healing of
all local tissue flaps prior to secondary insetting of flaps . g Result at 4
years following secondary insetting of flaps. Note perfect maintenance
of medial canthal regions w ithout telecanthus, even though both
medial cantha l regions had been resected. It can be seen that t he
reconstructed canthal region takes on a natural appearance followi ng
careful repositioning to bone.
12.74 a Extensive defect following resection of multiple recurrent
morphoeic BCC of the central facia l region. The right medial cantha l
region, including the medial canthal tendon, has been resected on the
206
RECONSTRUCTION OF MAJOR DEFECTS
12.75 a Extensive multiple time-recurrent BCC extending from one
medial cantha l region to th e other and invo lvi ng the underlying nasal
bone, f rontal sin us and ethmoids. A ful l course of radiat ion treatment
has been unsuccessful. b Massive resection of entire media l ca nthal
reg ion and the invo lved anterior wa ll of the frontal sinus, entire
ethmoi ds, nasal bone, and medial orbits. Note lat eral drift of the
rema ining upper and lower eyelids fol lowin g resection of the medial
third of both the upper and lower eyelids on both sides. c Sutures are
placed thro ugh the remaining tarsal plate of both the upper and low er
eyelids on both sides and then ancho red down to the remaining
inferior portio n of the vertical plate of the ethmo id. The w ire is
tightened unti l the correct position of the cantha l region is assessed
cl inically, even though all the bone in t he medial orbit is missing. d
Reconstruction is p lanned with loca l t issue flaps t aken from the
remai ning frontal region and bilateral cheek-neck rotation flaps. The
right side of the forehead has been used previously for a scalping flap.
The cheek-neck rotation flap can be seen. eOn the left side, the entire
rema ining forehead is raised on the left superficial temporal artery via
a narrow pedicle. The cheek-neck rotation fl ap on th is si de cuts across
the skin port ion of the pedicle, but the forehead f lap is safe ly
vascu larized by the deep art erial supply. fAll the available skin of the
f orehead and both chee ks is raised up in preparation for
reconstruction. g The forehead flap and both cheek neck rotation flaps
are rotated into place. h At a second stage, all flaps are divided and
inset. Even with this massive defect, enough local tissue is available
with careful planning of regional flaps.
i Reconstruction at 1 year. Note the advantage of using local tissue w ith
perfect match of colour and ski n co nsistency. The medial canthal
reposit ioning has resulted in the maintenance of med ia l cantha l
appearance and position. j Patient has been fitt ed w it h a nasal
prosthesis, which camouflages the underlying bony def icit.
207
PALPEBRAL TUMOURS
fine cut CT scans combined with excision of the involved area using
careful microscopic control of excisional margins allows ocular
preservation in certain carefully selected cases (12.72, 12.78).
Deeper tumour involvement of the muscle cone or globe itself necessitates orbital exenteratio n in continuity with the excision of the
external tumour.
12.76 Extensive defect follow ing resection of recurrent BCC of the
medial canthal region. The medial third of both upper and lower
Reconstruction
Skin defects should be reconstructed whenever possible with thin
facial skin taken from the adjacent facial aesthetic units. This will
allow the flap to mould and adapt to the anatomical hollows and
curvatures of this region. Care should be t aken to separate the
reconstruction of the eyelids, nose, and cheek, each of which should
be reconstructed in separate aesthetic units.
eyelids, including entire medial canthal region, has been resected. a
Extent of the deficit. b Suture placed through the medial aspect of the
tarsal plate of the remaining upper and lower eyelid and anchored to
the remaining nasal bone, restoring the correct position of the medial
canthus. c Reconstruction is now being performed with a separate
forehead flap to the nose and a cheek-neck rotation flap to the eyelid
and cheek to separate the reconstruction. An extra triangular flap on the
forehead flap w ill be used to reconstruct the defect in the upper eyelid.
d Separate flaps in place w ith repositioned medial canthus and
reconstruction of both upper and lower eyelids. e Reconstruction at 5
years with perfect symmetry of eyelids and medial cantha l region, and
important separation of the nasal and cheek reconstruction with
maintenance of the groove between the nose and cheek. f Close-up view
showing almost perfect anatomical reconstruction of the medial canthal
region. Even though the entire medial canthal region is resected,
reattachment to the bone wi ll allow the medial canthal region to take
on a natural shape.
208
RECONSTRUCTION OF MAJOR D EFECTS
Tumours adjacent to the medial canthus may require excision of
the medial portion of the upper and lower eyelids and the medial
canthus itself. If the upper and lower eyelid excision is less than onequarter to one-third of the eyelid, the remaining eyelid margins can
be adva nced medially towards the medial orbital rim aided whenever necessary by a lateral canthotomy. Care must be taken tO reposition accurately the medial eyelid margins tO bone. This prevents
eyelid malposition and will restore a natural appearing medial canthal appearance and position. A nylon or wire suture is placed
through the remaining edge of the tarsal plate and then anchored
to drill holes in the medial orbit, or passed transnasally and then
tied.
When the underlying bone is resected, resulting in a defect of the
medial orbital rim and medial portion of the inferior orbital rim,
12.77 A 55-year-o ld man with extensive deficit
of the forehead, temple, upper eyelid, and
entire medial canthus following resection of a
recurrent BCC. a Extensive defect extending
into mu ltiple different aesthetic units. b After
resection of the media l cantha l region, the
remaining eyelids are attached to bone by
separate suture, repositioning the medial
canthal reg ion.
c Reconstruction is planned w ith a smal l
midline fo rehead f lap to the nasoglabella
region and medial canthal region . There is a
large cheek-neck rotation f lap to reconstruct
the missing upper eyelid and temporal region,
and local rotation f laps on the forehead to
reconstru ct the remainder of the defect.
d Careful planning of f laps shows remaining
defect in the lower forehead after rotation of
the cheek-neck flap and midline forehead
fla p. Two non-hair-bearing flaps are now
rotated along the natural hairline to
reconstruct the remainder of the defect.
e Reconstruction of the entire defect with local
and regional skin flaps. f Result at 5 years
shows the advantage of using local tissue with
excellent colour match. The reconstructed
upper eyelid and medial canth al region can be
seen in good position.
209
PALPEBRAL TUMOURS
12.78 A 42-yea r-old man w ith multiple timerecurrent BCC of the midf ace involving the
medial cantha l region on the left. a Initia l defect
produced by Mohs surgery with residual
i nvolvement of underlying maxilla and nasal
bone and medial orbital rim and medial canthal
region. b Furth er extensive block resection of the
area, including the entire medial orbital bony
wall and rim, the entire nasal bone, and t he
remainder of ma xi lla. The medial third of both
the upper and lower eyelid s have been resected.
The ocular globe has been preserved by careful
excision using frozen section control of t he
involved medial periorbit al tissues. c Even w hen
the orbital rim and na sal bone are mi ssing, a
separate suture can still be taken through the
remainder of the upper and lower eyelids
through the tarsal plate and then positioned to
any remaining bone that is present, tightening
the wi re until the correct position of th e canthi is
obtained. This w ill prevent the almost inevitable
lateral drift of t he remain ing upper and lower
eyelids during the healing phase. d Patient at 1.5
years after reconstruction, w ith eyelid position
maintained with almost perfect restoration of
position and shape of the reconstructed left
medial canthal region. The rema inder of the
defect has been filled in by a prosthesis.
the bony loss should be anatomically reconstructed before reconstruction of the eyelid and medial canthus. Accurate bony reconstruction facilitates eyelid support and allows correct repositioning
of the medial eyelids and medial canthal reconstruction.
If the nasolacrimal apparatus is excised, adequate drainage can
be provided by a conjuctivorhinotomy using a Jones tube. However,
a drainage procedure is not always necessary. Many patients will
have minimal or no epiphora after resection of the nasolacrimal
apparatus as long as good eyelid support is maintained and exposure keratopathy is prevented. These patients will complain of
epiphora only when excess tears are produced, such as occurs with
crying or ocular irritation from the wi nd.
TEMPORAL MUSCLE AND FASCIAL FLAPS (12.79- 12.84)
The layers of well-vascularized fascia and muscle in the temporal
region provide a useful source of reconstructive material for complex defects of the eyelids, orbit, and periorbital region.
The presence of two independent vascular territories in the temporal region permits separate utilization of muscle or fascia in the
elevation of regional flaps. The temporoparietal fascia and overlying skin are supplied by the superficial temporal artery, which provides thin axial-pattern fascial and fasciocutaneous flaps. T he
temporalis muscle and its distal pericranial extension is supplied by
deep temporal vessels and is a particularly useful source of tissue
where bulk or dynamic function are required in reconstruction.
12.79 Temporal is muscle. The blood supply to the t emporalis m uscle is
completely independent of th at of the overlying temporoparietal
fascia. Two vascular pedicles, the anterior and posterior deep temporal
arteries, supply the anterior and posterior portions of the muscle,
respectively. Both arise from the internal maxillary artery. These
vascular pedicles enter the muscle in its deep surface, anterior and
posterior to the coronoid, respectively. Both vesse ls enter the muscle
inferior to the superior edge of the zygomatic arch . Using th ese
landmarks, the temporalis muscle can be safely bisect ed into a bilobed
f lap, providing vascularized anterior and posterior segments.
2!0
PALPEBRAL TUMOURS
12.82 A 70-year-old woman with recurrent sec of the right lateral canthal region. a Excisional defect includes the lateral t wo-thirds of both upper and
lower eyelids, adjacent temporal skin, and the underlying zygoma and orbital floor. The planned forehead flap, incorporating a hair-bearing segment in
its upper margin, which will reconstruct the lateral portion of the eyebrow, is seen. bAn axial fasciocutaneous forehead flap is first elevated,
incorporating t he superficial temporal vessels and temporoparietal fascia. The temporalis muscle is then exposed. c The temporalis muscle f lap is
transposed and fixed to the bony margin of the orbital defect to provide support to the globe. Two fascial slings are developed by dissecting the deep
temporal fascia from the surface of the muscle and maintaining its distal attachment only. d The fascia slings are fixed to the med ial canthus, providing
dynamic orbicularis function. The lower sling is shown draped over a chondromucosa l graft, w hich provides lining and support for the low er eyelid. e
The forehead f lap provides continuous cover for both eyelids. f Result 9 months postoperatively shows dynamic functioning of the eyelids and
reconstruction of the eyebrow with a hair-bearing forehead flap.
12.83 A 90-year-old man w ith r ecurrent BCC of the left
cheek invading the lateral orbit, zygoma, and maxilla. a
The excisional defect measures 8 em x 10 em and includes
the anterior wall of the maxilla, the zygoma, the orbital
floor, and overlying soft tissues, including the lateral half
of the upper and lower eyelids. b The temporal is muscle is
elevated on its neurovascu lar pedicle and divided in ha lf. c
Complete mobility of the temporal is muscle on its deep
vascular pedicle after division of its origin to the coronoid
process of the mandible. d The t wo halves of the muscle
are used in the reconstruction. The temporal segment fi lls
the maxillary cavity and resurfaces the cheek. The
posterior segment is fixed to the medial bony margin of
the maxilla to support t he orbital contents and also serves
to obliterate the hollow of the temporal fossa. e The
completed reconstruction at 1 year.
---:==========:;:>---------- - 2!2
REcoNSTRUCTION OF MAJOR DEFECTS
12.84 Patient with extensive multifocal recurrent BCC following
multiple surgical procedures and a full course of radiotherapy.
a Extensive mult ifocal carcinoma involvi ng the orbit almost
circumferentially. b After resection w ith carefu l frozen section
monitoring of edges and depth, a total resection of both t he upper and
lower eyelids and surround ing frontal, temporal, and cheek skin has
been performed . Only a small portion of conjunctiva in both the upper
and lower fornix is preserved. The planned midline forehead flap and
cheek-neck rotation flap can be seen. c The lining of the upper eyelid is
reconstructed by extensive mobilization of the remaining conjunctiva.
Th e lower eyelid lining and support is reconstructed by a large
chondromucosa l graft from the nasal septum, wh ich is anchored to the
remaining inferior orbital margin. d The entire temporal is muscle is
raised in combination w ith a midline forehead flap and a large
cheek-neck rotation flap. e The temporal is muscle is rotated med ially
to allow a total reconstruction of both the upper and lower eyelids.
The temporal is muscle covers the conjunctiva of the upper lid and the
chondromucosa l graft of the lower lid. The temporal is muscle itself has
been divided dow n the middle to reconstruct the t wo eyelids
separately. f The upper eyelid is reconstructed by a split skin graft
placed over the tempora lis muscle. The low er eyelid aesthetic unit is
reconstructed by a free full-thickness skin graft. The midline forehead
flap is brought onto the supraorbital margin in an attempt to separate
the fronta l and temporal region from the eyelids. The cheek neck
rotation flap reconstructs the remainder of the cheek and temporal
defect. g The reconstruction at 6 weeks, w ith separated upper and
lower eyelid. However, owing to inadequate movement, there is
inadequate protection of the ocular globe and cornea, resulting in
exposure keratitis. The reconstructed upper and lower eyelids were
then sutured together to provide adequate coverage. h The patient at
6 months with upper and lower eyel ids sutured together before
division. Note the acceptable aesthetic reconstruction of extensive
defect with flaps and skin grafts placed in aesthetic units. i After
division of upper and lowe r eyelids, active movement of both the
upper and lower eyelids can be seen w it h adequate protection of the
ocular globe and contents. In retrospect, it was a mistake to separate
the upper and lower eyelids at the initial reconstruction. The
temporalis muscle should have been left intact and t hen separated at a
second procedure.
213
PALPEBRAL TUMOURS
TEMPOROPARIETAL FASCIAL FLAP
Anatomy
The temporoparietal fascia is a thin layer of moderately dense connective tissue that lies immediately deep to the hair follicles and subdermal fibrofatty tissue. It is separated from the underlying deep
temporal fascia and temporalis muscle by a loose avascular plane.
Throughout the temporoparietal region, this fascia forms a distinct
layer that is part of the subcutaneous musculoaponeurotic system
and is continuous with the galea superiorly and the superficial musculoaponeurotic system inferiorly. The temporoparietal fascia is
richly vascularized by the superficial temporal artery and vein. A terminal branch of the external carotid artery, the superficial temporal artery crosses the zygomatic arch in front of the ear and courses
superiorly within the substance of the fascia. It is accompanied by
its corresponding vein, which lies more superficial in the immediate subfollicular plane. Superior to the ear, the superficial temporal
artery divides into anterior and posterior branches. These anastomose freely with supraorbital and supratrochlear vessels anteriorly
and with the posterior auricular and occipital vessels posteriorly.
Distal branches of the superficial temporal artery leave the fascial layer and become contiguous with the subdermal vascular
plexus. This occurs about two-thirds of the way between the zygomatic arch and the sagittal midline of the cranium. The intimate
relationship between fascial and cutaneous vascular systems forms
the anatomical basis of regional fasciocutaneous flaps.
Surgical technique
After first mapping out the course of the vessels with a Doppler, a
pre-auricular incision is made and extended superiorly into the scalp.
Elevation of scalp flaps in the immediate subfollicular plane exposes the temporoparietal fascia. The course of the superficial temporal
artery is then clearly apparent and an axial flap can be designed
accordingly. The flap pivots about the entry point of the vascular
pedicle into the fascia, just above the zygomatic arch. The distal limit
of the flap lies approximately 11 em cephalad, where the artery leaves
the fascia to become contiguous with the subdermal plexus.
The temporoparietal fascia is incised and easily dissected off the
underlying deep temporal fascia. Further mobilization requires division of the fascial attachments to the zygomatic arch and isolation
of the flap on its vascular pedicle. The limit of anterior transposition is the medial canthus of the eye or the ipsilateral commissure
of the lip. Sufficient tissue is provided for resurfacing the cheek or
orbital region.
of the paralysed face. Subsequently, refinements in surgical techniques and more radical mobilization of the temporalis muscle have
facilitated its use in augmenting contour after major maxillofacial
resections in eyelid reconstruction and in intraoral reconstruction.
In particular, the temporalis muscle has considerable application in
complex orbital and eyelid reconstruction.
Anatomy
The temporalis muscle lies deep to the temporoparietal fascia and
is separated from it by a distinct, avascular subaponeurotic plane.
It is a bipennate muscle with two broad opposing origins. The deep
origin is from the surface of the calvarium, extending from the inferior temporal line above to the inferior temporal crest below. The
superficial origin is from the deep temporal fascia. This is a dense
fascial layer, which completely invests the outer surface of the muscle
from the upper edge of the zygoma and is peripherally fused with
pericranium at the superior temporal line of the skull. The muscle
inserts into the coronoid process and anterior aspect of the vertical ramus of the mandible. The blood supply to the temporalis
muscle is completely independent of that of the overlying temporoparietal fascia.
Two vascular pedicles, the anterior and posterior deep temporal arteries, supply the anterior and posterior portions of the muscle,
respectively. Both arise from the internal maxillary artery. In a previous cadaver study, the vascular pedicles have been dissected and
their points of entry into muscle have been related to skeletal landmarks. The anterior and posterior vascular pedicles enter the muscle
on its deep surface, anterior and posterior to the coronoid, respectively. Both vessels enter the muscle inferior to the superior edge
of the zygomatic arch. Using these landmarks, the temporalis muscle
can be safely bisected into a bilobed flap, providing vascularized
anterior and posterior segments.
At the periphery of the temporalis muscle origin, the periosteum
and deep temporal fascia fuse and continue cephalad as the pericranium. Vascular communications between pericranial vessels and
branches of the deep temporal arteries have been noted. This permits elevation of the temporalis muscle in continuity with a distal
pericranial extension.
Surgical technique
Through a coronal incision, the galea and temporoparietal fascia
are divided and retracted to expose the underlying pericranium and
temporalis muscle. The pericranium is then incised along the entire
length of the muscle origin and the flap is completely elevated from
the calvarium by subperiosteal dissection. On its superficial surface,
the muscle is anchored to the zygomatic arch by the attachment of
the deep temporal fascia. Division of these fascial attachments facilitates transposition of the flap as far anteriorly as the orbital region.
However, further anterior transposition is obstructed by the zygomatic arch.
Maximal mobilization of the flap is obtained by excising a segment of the zygomatic arch and transecting the coronoid process.
The temporalis muscle is thus isolated on its neurovascular pedicle,
significantly increasing the arc of rotation. The flap reliably resurfaces the ipsilateral half of the maxilla, and, when tunnelled intraorally, it reaches the ipsilateral canine of the mandible.
Clinical applications
The distinguishing features of the temporoparietal fascial flap are
its excellent blood supply, its lack of bulk, and its pliability. It has
been most commonly employed in ear reconstruction, where it provides protective cover for the auricular framework without obscuring contour details. These same qualities make it a particularly
useful reconstructive option for a variety of regional defects, particularly in the orbit and periorbital region.
TEMPORALIS MUSCLE FLAP
The temporalis muscle flap was first described by Golovine in 1898.
The bulkiness of the temporalis muscle and its proximity to the orbit
promoted its initial employment in the obliteration of dead space
following orbital exenteration. Preservation of the neurovascular
pedicle permitted the transfer of functioning muscle for animation
Clinical applications
Rich vascularity, dynamic muscle function and soft tissue bulk are
the distinguishing features of the temporalis muscle that make it an
excellent flap for reconstruction of regional defects. It has particu-
214
RECONSTRUCTION OF MAJOR DEFECTS
lar application for the reconstruction of orbital, eyelid, and periorbital defects.
Obliteration of the orbital cavity following exenteration (see
12.81)
The deformity produced by exenteration of the orbit is extreme. All
orbital contents (and often the periosteum) are resected in the procedure. The goals of reconstruction are to resurface the orbital cavity
and furnish a socket that will easily accommodate a prosthesis.
Whenever possible, the orbit should be resurfaced by the regional
skin flaps in order to maintain maximal orbital depth. The temporalis muscle has the disadvantage of partially obliterating the orbital
cavity depth, thus making the fitting of a prosthesis more difficult.
However, the well-vascularized temporalis muscle is useful in
extreme defects, particularly after radiation, or if postsurgical radi-
ation therapy is planned.
Reconstruction of massive defects involving upper and lower
eyelids and adjacent periorbital tissues (see 12.82-12.84)
Full-thickness defects of both the upper and lower eyelids pose a significant reconstructive problem. Where such defects extend to the
adjacent cheek or temporal area, the use of cheek rotation flaps or
lid-sharing procedures is precluded. The complexity of repair is further compounded if there is a concomitant bony defect of the orbital
floor, with loss of support to the globe.
The temporalis muscle flap can fulfil multiple tissue requirements
simultaneously and is particularly useful in the reconstruction of
such complex defects. Large cutaneous deficits of the periorbital
region can be resurfaced adequately with well-vascularized tissue.
Functioning striated muscle and deep fascia can be transferred and
secured to the medial canthus, restoring dynamic function to the
eyelids. Fixation of a segment of the flap to the bony margins of the
defect provides a supportive sling under the orbital contents.
Resurfacing extensive lateral facial and periorbital defects
(see 12.83, 12.84)
The unique colour, texture, and hair-bearing characteristics of the
cheek can be matched accurately only by the use of local flaps that
have similar qualities. Cutaneous defects of the lateral face are therefore optimally reconstructed by cheek and neck rotation and
advancement flaps or Washio-type retro-auricular flaps. Where the
use of these options is precluded by the location or extent of the
defect, or scarring at the donor site, the temporalis muscle flap provides a reasonable alternative.
215
PALPEBRAL TUMOURS
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