1. Malignant Lid tumours &
Reconstruction

2. Basal cell carcinoma
• General features
• BCC - most common human malignancy
malignant eyelid tumour - elderly patients.
• Risk factors : fair skin
• inability to tan
• chronic exposure to sunlight
• Site : lower eyelid, followed in relative frequency by the
• medial canthus, upper eyelid and lateral canthus.
• Slow-growing and locally invasive but non-metastasizing.
• Prone to invade the orbit and sinuses
• Greatest risk of recurrence- needs aggressive treatment.
• Histology
• Arises from basal layer of the epidermis - proliferate downwards
palisading at the periphery tumour lobule
• Squamous differentiation - production of keratin - hyperkeratotic type of BCC.
• Sebaceous and adenoid differentiation

4. • Clinical types
• Clues : ulceration, lack of tenderness, induration, irregular
borders and destruction of lid margin
• architecture.
•
• 1 Nodular BCC - shiny, firm, pearly nodule with small
dilated
blood vessels On its surface.
• 2 Noduloulcerative BCC (rodent ulcer)
- central ulceration,
- pearly raised rolled edges
- Dilated and irregular blood vessels (telangiectasis)
3 Sclerosing BCC (morphoeic)
-infiltrates laterally beneath the epidermis as an indurated
plaque .
-simulate a localized area of chronic blepharitis

5. Squamous cell carcinoma
• General features
• SCC is a much less common , more aggressive tumour - metastasis to regional lymph
nodes - elderly individuals
• Careful surveillance of regional lymph nodes is therefore an important aspect of initial
management.
• Perineural spread to the intracranial cavity via the orbit.
• SCC accounts for 5–10% of eyelid malignancies
• arise de novo / pre-existing actinic keratosis / carcinoma in situ
• Immunocompromised patients such as those with AIDS or following renal
transplants are at increased risk.
Site - lower eyelid and the lid margin.
Risk Factors : fair complexion
history of chronic sun exposure.
The diagnosis of SCC may be difficult because
keratoacanthoma and cutaneous horn
may reveal histological evidence of invasive SCC at deeper levels of sectioning.

6. • Histology
• Arise from squamous cell layer of the epidermis.
• Atypical epithelial cells with prominent nuclei and abundant
eosinophilic cytoplasm within the dermis
• Well-differentiated tumours - keratin ‘pearls’ and
intercellular bridges (desmosomes).
• Clinical types
• 1 Nodular SCC - hyperkeratotic nodule develop
crusting erosions and fissures
•
2 Ulcerating SCC - red base and sharply defined,
indurated and everted borders.
•
3 Cutaneous horn with underlying invasive SCC

8. Sebaceous gland carcinoma
• General features
• Very rare slowly-growing tumour - elderly Females
• It usually arises from the meibomian glands, glands of Zeis
or from sebaceous glands in the caruncle.
• Site - upper eyelid [ meibomian glands numerous].
• The clinical diagnosis of SGC is frequently difficult because,
in its early stages, external signs of malignancy may be subtle
so that the tumour may resemble a chalazion or blepharitis.
• A yellowish material within the tumour is highly suggestive of
SGC. There are difficulties in diagnosis and delay in treatment
• Adverse prognostic features
upper lid involvement
tumour size of 10 mm or more
Duration of symptoms of over 6 months.

9. • Histology
• Lobules of cells with pale foamy vacuolated lipid-containing
cytoplasm and large hyperchromatic nuclei
• Clinical types
• 1 Nodular SGC - discrete, hard nodule, most commonly
within the upper tarsal plate, that may exhibit yellow discoloration
due to the presence of lipid .
- may masquerade as a chalazion , unusual consistency should
undergo full-thickness resection and histological examination.
2 Spreading SGC infiltrates into the dermis and causes a
diffuse thickening of the lid margin that may result in loss of lashes
and be mistaken for ‘chronic blepharitis’.
3 Pagetoid spread refers to extension of the tumour within
epithelium including the palpebral forniceal or bulbar conjunctiva.
- mistaken diagnosis of an inflammatory condition.

11. Melanoma
• Pigmentation is a hallmark of melanoma
• Features suggestive of melanoma include recent
onset of a pigmented lesion, change in an
existing pigmented lesion, irregular margins,
asymmetrical shape, colour change or presence
of multiple colours, and diameter greater than
6 mm in diameter.

12. Lentigo maligna
• (melanoma in situ, intraepidermal melanoma /Hutchinson
freckle)
Uncommon condition that develops in sun-damaged skin in
elderly individuals. Malignant change may occur, with
infiltration of the dermis.
• Histology - intraepidermal proliferation of spindle-shaped
atypical melanocytes that replace the basal layer of the
epidermis
• Signs
A slowly expanding pigmented macule with an irregular
border
Nodular thickening and areas of irregular pigmentation are
highly suggestive of malignant transformation
Treatment is usually by excision.

14. Melanoma
Histology shows large atypical melanocytes within the dermis
Signs
• Superficial spreading melanoma is characterized by a
plaque with an irregular outline and variable pigmentation
• Nodular melanoma is typically a blue-black nodule
surrounded by normal skin
3 Treatment is usually by wide excision and may include
local lymph node removal.

16. Merkel cell carcinoma
• Rare Fast-growing tumour which typically affects the elderly.
Although Merkel cells lie within the epidermis, the tumour
appears to arise from the dermis.
-Difficulty in diagnosis and delay in treatment.
• The tumour is highly malignant and 50% of patients have
metastatic spread at presentation.
• 1 Histology - sheets of cells with scanty cytoplasm,
round or oval nuclei and numerous mitotic figures
2 Signs. A violaceous, well-demarcated nodule - intact
overlying skin, - upper eyelid
3 Treatment is by excision, frequently combined with
chemotherapy.

18. Kaposi sarcoma
• Kaposi sarcoma is a vascular tumour which typically
affects patients with the acquired immune deficiency
syndrome (AIDS). Many patients have advanced
systemic disease although in some instances the tumour
may be the only clinical manifestation of HIV infection.
• 1 Histology shows proliferating spindle cells,
vascular channels and inflammatory cells within the
dermis .
2 Signs. A pink, red-violet to brown lesion which
may be mistaken for a haematoma or a naevus.
3 Treatment is by radiotherapy or excision.

20. Rare predisposing conditions :
Xeroderma pigmentosum AR disease
- skin damage on exposure to sunlight,progressive cutaneous
pigmentation abnormalities
- bird-like facies
- development of (BCC), (SCC) and melanoma, which may be multiple.
-Conjunctival malignancies have also been reported.
Gorlin–Goltz syndrome (naevoid basal cell carcinoma syndrome) AD
- Extensive congenital deformities of the eye, face, bone and CNS.
- multiple small BCC during the 2nd decade of life and are
- predisposed to medulloblastoma, breast carcinoma and Hodgkin
lymphoma.
Muir–Torre syndrome AD
- Cutaneous tumours include BCC, sebaceous gland carcinoma (SGC) and
keratoacanthoma.
- Colorectal & genitourinary carcinoma is the most common systemic
tumour.

21. Treatment
• (a) Incisional - using a blade or a biopsy punch,
in which only part of the lesion is removed to
allow histological diagnosis.
• (b) Excisional, in which the entire lesion is
removed and a histological diagnosis made; the
latter may be:
1 Shave excision using a blade to remove
shallow epithelial tumours, such as papillomas
and seborrhoeic keratosis.
2 Full-thickness skin excision for
tumours that are not confined to the epidermis.

22. Surgical excision
• Aim to remove the entire tumour with preservation of as
much normal tissue as possible.
• Smaller tumours can be removed via an excision biopsy
and the defect closed directly, whilst awaiting
histological confirmation of complete clearance.
• More radical surgical excision is required for large BCC
and aggressive tumours such as SCC, SGC and
melanoma.
• It is necessary to ensure complete clearance of tumour
prior to undertaking any reconstruction.
• Faster confirmation can be achieved using either frozen-
section control or micrographic surgery, and
reconstruction can then take place on the same day.

23. • 1 Standard frozen section :
Histological examination of the margins of the excised specimen at the
time of surgery to ensure that they are tumour-free.
No tumour cells - eyelid is reconstructed;
Tumour cells present , further excision is performed until the tumour-
free.
2 MOHS micrographic surgery
- Layered excision of the tumour.
Processing of each layer enables a map of the edges of the tumour to
be developed.
- Further tissue is taken in any area where tumour is still present until
clearance is achieved.
-Time-consuming, maximizes the chances of total tumour excision
minimizing sacrifice of normal tissue.
- Useful technique for tumours that grow diffusely and have indefinite
margins with finger-like extensions, such as sclerosing BCC, SCC,
recurrent tumours and those involving the medial or lateral canthi.

26. Reconstruction
• Depends on the extent of tissue removed &
whether this is full- or partial-thickness.
If one of the lamellae has been sacrificed during
excision of the tumour, it must be reconstructed
with similar tissue.
• 1 Small defects involving less than one-third
of the eyelid closed directly - surrounding tissue
is sufficiently elastic - approximation of the cut
edges .
• If necessary, a lateral cantholysis - to mobilize
additional tissue - defect cannot be
reapproximated.

27. • 2 Moderate size defects involving up to
half of the eyelid may require a flap (e.g. Tenzel
semicircular) for closure
3 Large defects involving over half of the
eyelid
• a Posterior lamellar reconstruction
- an upper lid free tarsal graft, buccal mucous
membrane or hard palate graft.
b Anterior lamellar reconstruction
- skin advancement, a local skin flap or a free
skin graft (At least one reconstructed lamella
requires its own blood supply to maximize the
viability of any free graft.

30. CUTLER- BEARD PROCEDURE

33. Hughes tarsoconjuntival flap:

34. Laissez-faire [Let it do]
• Full reconstruction of the defect created by
tumour removal may not always be required. In
the laissez-faire approach the wound edges are
approximated as far as possible and the defect is
allowed to granulate and heal by secondary
intention. Even large defects can often achieve a
satisfactory outcome with time.

35. • THANK YOU.