Download - Eyelid Cancer and Reconstruction
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Eyelid Cancer and Reconstruction
Laurence Z. Rosenberg,M.D.Southeastern Plastic Surgery
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Benign Lesions
Chalazion
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Benign Lesions
Chalazion
Caused by a blocked duct from a meibomian gland
This is not a sty (glands of Zeis)
Initial treatment warm compresses
May require surgical excision
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Benign Lesions
Chalazion
Cautious observation for a limited time.
If the lesion is not getting better, refer or do a biopsy.
If you excise the lesion, always send the specimen to pathology
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Benign Lesions
Trichoepithelioma
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Benign Lesions
Trichoepithelioma
Benign lesion, often develop after puberty
May be numerous
Obsevation is indicated
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Benign Lesions
Trichoepithelioma
Desmoplastic trichoepithelioma may resemble a basal cell carcinoma
If there is change, never hesitate to biopsy
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Benign Lesions
Verruca
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Benign Lesions
Verruca
Caused by Human Papilloma Virus. Over 150 strains
Filliform warts: long thin lesions on the face
Different from genital warts
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Benign Lesions
Verruca
Usually clear up in children without treatment
May be more persistent in adults
Multiple treatments, but on eyelid, careful excision o cauterization
20% recurrence
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Benign Lesions
Inclusion Cyst
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Benign Lesions
Inclusion Cyst
Often called a sebaceous cyst, this is a misnomer
May resemble a basal cell carcinoma
May become inflamed or infected
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Benign Lesions
Inclusion Cyst
Usually no treatment is required
Often removed for appearance or because of infection
Remove entire cyst and punctum if possible.
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Benign Lesions
Nevus
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Benign Lesions
Nevus
Atypical Nevus
Size >5 mm diameter
Ill-defined or blurred borders
Irregular margin resulting in an unusual shape
Varying shades of color (mostly pink, tan, brown, black)
Flat and bumpy components
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Benign Lesions
Nevus
Dysplastic Nevi –pathologic diagnosis
The lesion may be a junctional naevus or more frequently a compound naevus (the cells are found at the epidermodermal junction and within the dermis).
The nevus cells form a row along the dermoepidermal junction (called lentiginous proliferation), with or without nevus cells in nests
(called theques).
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Benign Lesions
NevusDysplastic Nevi –pathologic diagnosis
These theques are often irregular in size and shape and may 'bridge' or join together.
The cells may be odd-looking i.e. they have cytologic atypia, and they may be spindle-shaped (elongated) or epithelioid (resembling epidermal keratinocytes i.e., broad).
There may be fibrosis or scarring in the dermis.
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Benign Lesions
Nevus
Dysplastic Nevi –pathologic diagnosis
Inflammatory cells may infiltrate the lesion.
Associated blood vessels may be increased in number or enlarged.
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Benign Lesions
Nevus
Treatment
May be for cosmetic purposes
Excision dependent on the degree of atypia (moderate or severe)
not an exact science
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Malignant Lesions
Basal Cell Carcinoma
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Malignant Lesions
Basal Cell Carcinoma
Most common human cancer
More common in fair skinned people
May be heritable: Basal Cell Nevus Syndrome
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Malignant Lesions
Basal Cell Carcinoma
Nodular BCC
Most common type on the face
Small, shiny, skin colored or pinkish lump
Blood vessels cross its surface
May have a central ulcer so its edges appear rolled
Often bleeds spontaneously then seem to heal over
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Malignant Lesions
Basal Cell Carcinoma
Superficial BCC
Often multiple
Anywhere
Pink or red scaly irregular plaques
Slowly grow over months or years
Bleed or ulcerate easily
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Malignant Lesions
Basal Cell Carcinoma
Morpheaform BCC
Also known as sclerosing BCC
Usually found in mid-facial sites
Prone to recur after treatment
May infiltrate cutaneous nerves (perineural spread)
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Malignant Lesions
Basal Cell Carcinoma
Pigmented BCC
Brown, blue or greyish lesion
Nodular or superficial histology
May resemble melanoma
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Malignant Lesions
Basal Cell Carcinoma
Basisquamous BCC
Mixed BCC and Squamous Cell Carcinoma
More Aggressive
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Malignant Lesions
Basal Cell Carcinoma
Treatment
Currettage and cautery: Margins unknown
Excision: Margins known, but not circumferential
Mohs: Best for high risk lesions, most definitive margin assessment
Photodynamic Therapy: superficial BCC. Lower Cure Rate
Imiquimod: Immune modulator
Radiation: May be used in elderly or as adjuvant therapy
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Malignant Lesions
Squamous Cell Carcinoma
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Malignant Lesions
Squamous Cell Carcinoma
Directly related to UV exposure
Smoking
Chronic wounds
Human Papiloma Virus
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Malignant Lesions
Squamous Cell Carcinoma
Treatment:
Surgery
Excision
Mohs
Patient may require assessment of the lymph nodes
Large tumors may require pre-operative radiographic imaging
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Malignant Lesions
Squamous Cell Carcinoma
5% metastasize to other sites
more likely in transplant patients, old age, alcoholics etc.
May require adjuvant radiation therapy
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Malignant Lesions
Melanoma
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Malignant Lesions
MelanomaCancer of the melanocytes
Prognosis dependent of tumor thickness
Stage IA: Melanoma <1.0mm
Stage IB: Melanoma is <1.0mm with ulceration or Mitoses >1
or > 1.0mm and ≤ 2.0mm
Stage IIC: Melanoma > 4.0mm, with Ulceration
Stage IIIC: Nodal Involvement or Intransit spread
Stage IV: Spread to distant organs
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Malignant Lesions
Melanoma
Stage IA: The 5-year survival rate is around 97%. The 10-year survival is around 95%.
Stage IB: The 5-year survival rate is around 92%. The 10-year survival is around 86%.
Stage IIC: The 5-year survival rate is around 53%. The 10-year survival is around 40%.
Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.
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Malignant Lesions
Melanoma
Stage IV: The 5-year survival rate for stage IV melanoma is about 15% to 20%.
The 10-year survival is about 10% to 15%.
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Malignant Lesions
MelanomaTreatment:
Dependent on tumor thickness
in-situ 0.5cm
< 1.0mm 1cm
1.0 – 2.0mm 1 – 2cm
>2.0mm 2cm
If the tumor is > 1.0mm thick, or ulcerated or mitotic index ≥ 1
Perform sentinel lymph node biopsy
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Reconstruction
Mohs defect45 by 55mm
50% lower Lid30% Upper lidResection of lateral canthusLoss of temporal skin
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Reconstruction
Repair of the eyelid, like all reconstruction:
Knowledge of the anatomy
Function of the part to be reconstructed
Application of technique
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
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Reconstruction
1. Lower Lid Posterior LamellaTemporalis fascial flap
2. Lower Lid anterior Lamella1.Cervical facial flap
3. Reconstruct upper lid1.Primary attachment to New lower lid
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Reconstruction