What is eyelid skin cancer?

Eyelid skin is the thinnest on the body and as such is particularly vulnerable to  damage from ultraviolet light. This in turn increases the chance of skin cancers developing.

There are many different types of skin cancer but 3 together are the commonest: Basal cell carcinoma; Squamous cell carcinoma; Melanoma.


What is Basal Cell Carcinoma?

Basal cell carcinoma (also known as a rodent ulcer) is a malignant growth of the
skin.
Unlike many other types of cancer it tends not to spread to the rest of the body. 

It has the best prognosis of all of the skin cancers, as long as it is completely
removed.
It usually presents as a slow growing lump on the skin. This lump may have an ulcer or non healing centre. It may be itchy or recurrently bleed. If it is in the line of eyelashes, these lashes may be lost.

What is Squamous Cell Carcinoma?

Squamous cell carcinoma is a malignant growth of the skin. 

There is a spectrum of disease with milder forms confined to the visible lump and more severe types that have the potential to spread to the rest of the body. 

If it is completely removed it has a good prognosis. 

It usually presents as a lump or ulcer on the skin. It may be itchy or recurrently bleed. If it is in the line of eyelashes, these lashes may be lost. It may have a     prominent crust or scale associated with it.


What is Melanoma?

A melanoma is a malignant cancer of melanocyte cells in the skin. Melanocytes    are the cells in the skin that carry the pigment melanin and give skin its brown colour. Most melanomas are brown but some are amelanotic or flesh coloured.

It is a rare cancer and has the worst prognosis of all skin cancers.

Wide excisions are necessary and if caught early enough this may be curative. Unfortunately in some cases the tumour has already spread (metastatic) by the time it is removed.

It usually presents as a small brown lump in the skin. There may be different shades of brown and the border may be irregular. It will get bigger with time. It may itch or bleed.

If you have a new area of brown skin or an old one that has changed you should see your general practitioner or a dermatologist


What is eyelid skin cancer excision and reconstruction surgery?

These are operations to completely remove skin cancer and then to reconstruct / rebuild the defect left after the excision. 

The aim of excision is to remove all of the cancer. The aim of the reconstruction is to provide a good functional outcome e.g. an eyelid that can protect the surface of the eye and a good cosmetic outcome e.g. a good appearance.  


What are the benefits of surgery?

Surgical excision of skin cancer gives the best chance that a tumor will not come back. 

It allows examination of the specimen by a pathologist in the laboratory under a microscope. This enables us to determine if we have removed all of the cancer. This can be very reassuring to people with this condition. 


Excision of skin cancer

What is Excision with Direct Closure?
For small tumours it may be possible to excise and reconstruct at one operation, by simply stitching the two edges of the wound together. This is excision with direct closure.

If the pathology report 1 week after this shows that the tumour has not been completely removed it is possible to go back to theatre and remove further tissue at a later date. If the defect is too big to close directly and requires a skin flap or graft, the reconstruction must wait until the pathology report is received. This is known as excision with delayed reconstruction.


What is Excision with Delayed Reconstruction?

The skin cancer is removed in theatre and a dressing is applied and secured with surgical tape. You will go home the same day and the dressing stays in place for a week.

1 week later you will come back to theatre and have the surgery to reconstruct the defect.

During the week between operations the pathologist will be able to examine the excised tumour and tell if it has been completely removed. We need this ‘all clear’ pathology report before we can carry out the reconstruction. If it is not ‘all clear’ instead of reconstructing, further excision will be necessary and the reconstruction will be delayed a further week. 

It is very unusual for the first excision to be incomplete and most people have their reconstruction 1 week later.


What is Excision with Frozen Section Control?

In rare cases a tumour may be excised at the beginning of the operating list and reconstructed at the end of the same operating list. 

The excised tumour is sent urgently to the pathologist who freezes it and examines it immediately. He then tells the surgeon if he can reconstruct or excise further. This method is usually reserved for tumours where multiple excisions may be necessary.


What is Mohs Excision Surgery?

Mohs surgery is carried out by a dermatologist who has been specially trained in this technique.

This is usually at a clinic in another hospital.

The skin cancer is removed in thin slices. Each slice is looked at immediately by the Mohs surgeon.

The Mohs surgeon keeps excising until he is certain all of the tumour is removed.

This is most suitable for squamous cell carcinoma and basal cell carcinoma, particularly when the margin of the tumour is difficult to see with the naked eye or when tumour is recurrent after previous reconstruction

The reconstruction takes place usually within 2 days 


Reconstruction

When a skin cancer is removed it leaves a defect or ‘hole’ in the skin

Reconstruction is surgery to repair this defect

There are many different reparative techniques

Each person and each defect are different and the appropriate techniques and options will be discussed with you by your consultant

Some reconstructions involve some or all of the techniques described below


What is Direct Closure?

Direct closure of a wound is simply bringing the two edges of a wound together with buried, deep, absorbable sutures and skin sutures which may be absorbable or non-absorbable

It is appropriate in smaller defects where there is enough skin laxity to allow closure of the wound


What is a skin graft?

A full thickness skin graft involves the transfer of a piece of skin from a donor site where there is relative excess of skin, to the defect (excision site) also known as the host site. 

The donor site is closed directly. The skin graft is sutured into place with either absorbable or non-absorbable sutures.

There are various donor sites (where skin can be taken from for use in reconstruction) commonly used for reconstruction around the eyes. They include: upper eyelid; in front of the ear; behind the ear; behind the collar bone; upper inner arm.


What is a skin flap?

A skin flap is similar to a skin graft except that the donor skin is not completely detached. This means that it retains some of its own blood supply, which usually produces superior results.

A skin flap donor site is usually immediately adjacent to the defect, allowing the skin flap to be mobilised and rotated or slid into place in the defect.


What is a Hughes flap?

For large reconstructions of the lower lid it may be necessary to use a Hughes flap reconstruction.

Part of the inside of the upper eyelid is mobilised and pulled down over the eye like a ‘roller blind’ into the defect in the lower eyelid. This is the Hughes flap.

A skin graft is then placed on top of the Hughes flap

The tissue covering the eye will stay in place for 4 weeks. During this time you will not be able to see out of the eye because it will be covered by the Hughes flap

4 weeks after the reconstruction a short second stage operation will be carried out in theatre to divide the tissue coming down from the upper eyelid. The eyelids will immediately open and vision will return.


What are the alternatives to surgery for eyelid skin cancer?

Alternatives to surgery depend on the type of skin cancer. Basal cell carcinomas are suitable in some cases to non-surgical treatments however others such as melanoma are not. Your consultant will discuss this with you.

Radiotherapy. Small basal cell carcinomas on the eyelid margin may be well treated by this method. It is also used for larger lesions when the risks of surgery are too great for that individual, when a person declines surgery or when total excision is not possible. 

Cryotherapy. Small basal cell carcinomas that have not invaded deeply may be treated with cryotherapy. This is particularly suitable for people who are not fit for surgery or those who have conditions that predispose them to multiple skin cancers. It is applied using a cryoprobe that looks like a pen with a cold tip or with a liquid nitrogen spray.


What will happen if I decide not to have surgery?

Skin cancer does not spontaneously get better. Over time it will gradually grow. It will start to destroy normal tissue, grow deeply and may ulcerate and bleed. 

Eventually eyelid skin cancer may grow into the orbit. In this situation the only surgical option for curative excision is an exenteration or complete removal of the eyelids, eye and orbital tissue.

Basal cell carcinoma does not spread to the rest of the body. It grows and invades tissue directly.

Squamous cell carcinoma and Melanoma can spread to the rest of the body. Declining surgery for any of these or other types of skin cancer may result more extensive surgery at a later date or even allow the spread of the cancer to other parts of the body.

Surgical removal of these lesions does not prevent distant spread (this may have already occurred at the time of surgery) but it is your best chance of reducing the risk of it happening. 


What will happen before surgery?

Before the operation you will be seen in the clinic by Mr McCormick. You may also be seen by another doctor who is a member of the team.

Mr McCormick will ask you about your problem. He/she will also ask about other medical problems you have medications you take and any allergies (bring a list or the tablets themselves with you). 

Mr McCormick will examine your eyes and will determine if you are suitable for surgery. He will explain exactly what type of surgery he will be carrying out

If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. 

You will be asked to read and sign a consent form after having the opportunity to ask any questions. 

You will also see a preoperative assessment nurse. He/She will carry out blood tests and an ECG (heart tracing) if required. He/She will also advise you if you need to starve before the operation. 


What should I do about my medication?

Mr McCormick will want to know all the medication that you take and about any allergies you have. 

In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery.

Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.


What are the risks and possible complications of surgery?

Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from a wound. Infection is treated with antibiotics.

Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on a skin wound is usually enough to control minor bleeding. In rare cases, a deeper haematoma may require a return to theatre to prevent loss of vision.

Loss of vision: Total loss of vision in an eye due to this surgery is extremely rare ( less than 0.1% or 1 in 1000 operations ). A blood haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball and is an emergency. If not treated quickly it can lead to permanent loss of vision.

Scar: Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible.

Further surgery: Your surgeon will take great care to correct the eyelid abnormality by exactly the correct amount. No operation has a 100% success rate and in very small numbers of cases, further surgery is required. This is less than 1 in 100 cases. Emergency return to theatre due to bleeding is extremely rare.

Skin puckering: If deep sutures are placed, there is a risk of puckering of the skin above them or discomfort. This is usually temporary but may necessitate further surgery to remove the suture if persistent.

Loss of sensation: After surgery there may be numbness of some of the skin around the incision. This is usually temporary returning gradually over months. Rarely it is permanent and may involve larger areas like the forehead.

Inflammation: Swelling and bruising of the skin after surgery always occurs but in varying degrees. A big improvement will be noticed after 2 weeks, with most resolved 3 months later. Rarely inflammation may cause small lumps to form called granulomas. Most resolve spontaneously but some require further surgery.

Altered appearance: One of the goals of surgery may be to positively improve appearance. Some people may be unhappy with the appearance after surgery due to: asymmetry of facial features; eyelid contour or eyelid position changes.

What type of anaesthesia will I have?

Three types of anaesthesia are used for these procedures: local anaesthetic alone; local anaesthetic with intravenous sedation; general anaesthesia.
You will choose one of them based on the advice of your surgeon.
Local anaesthetic involves an injection just under the skin with a tiny needle. It is similar to dental anaesthesia. Initially the injection is painful but after 10 – 15 seconds the area becomes numb.
Local anaesthesia with Intravenous Sedation means that you are breathing for yourself and don’t have a breathing tube inserted but you are very relaxed and sleepy and often don’t remember the operation or the local anaesthetic injection.
General anaesthetic means you are completely asleep with a breathing tube inserted.

What are the risks of anaesthesia?

You will have the opportunity to discuss the risks of anaesthesia with your surgeon and anaesthetist prior to surgery. It is worth noting that modern anaesthesia in all its forms is extremely safe.
Local anaesthetic may cause bruising, bleeding and swelling. There is a theoretical risk of the needle penetrating the eye and causing loss of vision.
Intravenous sedation should be carried out by an anaesthetist in a controlled environment. In this way it is very safe. There is a risk of loss of airway, which theoretically could lead to brain injury or death.
General anaesthetic has an extremely low risk of heart attack, stroke and death. The risk very much depends upon your general health and will be assessed prior to surgery.
Anaesthetic risks can usually be greatly reduced by thorough pre operative assessment, which you will receive.

What should I expect after surgery?

After surgery you may experience some pain. Simple paracetamol is usually enough to control this.

The eyelids will be bruised which may take up to 2 weeks to settle.

Swelling of the skin will take up to 3 months to resolve but some changes to the eyelids as scar tissue matures may still be seen up to a year later.

Post operative Instructions

After Excision – awaiting reconstruction 1 week later
Pad and bandage to remain in place until returning for reconstructive surgery

If the pad becomes loose, chloramphenicol should be applied to the wound and eye four times a day.

After Reconstruction

Pad for 24 hours if simple direct closure of skin or skin flap

Pad and bandage remains in place for 3 days if skin graft

Apply chloramphenicol ointment to the skin wound 3 times a day for 2 weeks

Clinic review 1 week when any non-dissolvable sutures may be removed

Above: Top Left - Lower eyelid basal cell carcinoma. Top Right - Following excision of tumour. Bottom Left - After a Hughes flap and skin graft. Bottom Right - The reconstructed eyelid.