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Eyelid and perio-cular skin cancer

What is eyelid and peri-ocular skin cancer?

Skin cancers can affect the eyelids or adjacent face (peri-ocular region).  Eyelid skin cancers are most often on the lower eyelid, but may be found anywhere on the eyelid margins, corner of eye, eyebrow skin or adjacent areas of the face.  Usually they appear as painless elevations or nodules, often with a pearly appearance, with either loss or distortion of the eyelashes, or fine hairs of the skin.  There may be ulceration of the involved area, with bleeding, crusting, redness and/or distortion of the normal skin appearance.  These findings need to be evaluated and will require a biopsy to confirm the diagnosis as skin cancer.

What are the common eyelid and peri-ocular skin cancers?

The most common type of skin cancer is the basal cell carcinoma or rodent ulcer, followed less commonly by squamous cell carcinoma.  There are other rarer cancers which may also occur, affecting different parts of the skin micro-structure.  Basal carcinoma, or BCC, and squamous cell carcinoma., or SCC, both enlarge locally and usually do not spread or metastasise to distant parts of the body.  However, with time, if these tumours are not completely removed, either type will invade adjacent structures and a squamous cell carcinoma may spread to lymph nodes in the head and neck.

It is important to know that BCC and SCC are relatively slow growing, but do require treatment to eradicate them.  Therefore early detection and treatment in an appropriate manner, in an oculoplastic clinic, is required.  The tumour must be removed completely and at the same time minimise the amount of normal tissue around the tumour being removed, in order to do the best surgical reconstruction of the area using oculoplastic techniques. 

Other tumours:

Sebaceous gland carcinoma and malignant melanoma are more serious forms of skin cancer because these may spread or metastasise to other parts of the body.  These are rare forms of skin cancers and require prompt, aggressive treatment because of a threat of early spread.

What is Mohs' micrographic surgery?

This is a specialised technique for excising BCC's and SCC's, in which the oculoplastic surgeon works closely with a surgical dermatologist.  The dermatological surgeon removes the tumour, using a special Mohs' micrographic technique, which ensures that the tumour is completely removed and then the oculoplastic surgeon carries out the delicate eyelid and peri-ocular reconstruction, using oculoplastic techniques, such as flaps and skin grafts.

What is a basal cell carcinoma?

Basal cell carcinoma (BCC) or rodent ulcer is the most common form of skin cancer.  Over 30,000 new cases of BCC's are reported each year in the UK.  It is more common in patients who have pale skin and have had exposure to sunlight, for instance, brought up, lived or worked, or taken long holidays in sunny climates, such as Australia.  Fortunately, it is a very slow growing form of skin cancer and rarely spreads to other areas of the body.  It does spread locally and, if left untreated, BCC's can disfigure, especially on the face, can ulcerate and become unpleasant and can invade the orbit and even grow towards the brain.  If the BCC invades the orbit, it may not be possible to save the eye and an exenteration operation is required, with loss of the eye.  

BCC's are caused by exposure to sunlight and will occur on sun exposed areas, such as the face, scalp, ears, hands, shoulders and back.  The Caucasian adult population is most at risk of developing BCC's, especially if they have been outdoor workers, sailors or are very fair skinned.  BCC's are more frequently seen in persons aged over 50 years, but a greater number of younger adults are developing this form of skin cancer because of prolonged sun exposure.

What are the early warning signs?

If you develop a skin lesion, or soreness, that fails to heal within 4 to 6 weeks and has two or more of the following features, you should seek medical advice:

  1. Painless lump in skin which can appear smooth or have an open sore or ulcer on it, bleed or crust, and does not heal.
  2. Red patch on the skin which is itchy, painful or crusty, or may have no symptoms, but the lesion fails to heal or fade.
  3. Smooth raised growth with an ulcer in the centre, which can be flesh coloured, pink, shiny, red or pigmented like a mole.
  4. Firm nodule on the skin which can be flesh coloured, pink, shiny, red or pigmented like a mole.
  5. Small elevation that looks like a flat scarred area on the skin, which is pale, or white, compared to the surrounding skin, and may have an ulcer or an indentation in the centre.  This form of BCC can grow more quickly, making the affected skin look taught and shiny.  
NB  Remember that basal cell carcinomas are curable and recognise the early warning signs.  

How are BCC's treated?

There are two very important principles in the management of eyelid and peri-ocular skin cancers: (1) complete removal and (2) delicate peri-ocular and eyelid reconstruction.  Complete removal of the tumour is critical to minimise the possibility of recurrence.  The tumour should be removed with as little normal tissue surround as possible, but enough to ensure safe and complete removal of the tumour, to minimise the possibility of recurrence.  Recurrences can be very difficult to manage.  

The surgeon removes the tumour and asks a pathologist to check the tissue microscopically to ensure that the margins have been completely removed.  This can either be done immediately as a frozen section, or take 2 or 3 days if the tissue is first fixed.  The gold standard is to ask a dermatological surgeon, specialising in Mohs' micrographic surgery, to excise the tumour in a special way to ensure its total removal, after which the oculoplastic surgeon will do the reconstruction on the same day, or within 48 hours.  

Once the tumour has been completely removed and there is microscopic confirmation that no tumour cells remain, reconstructive surgery is usually necessary.  Occasionally the wound can be left to heal on its own by a process called granulation, or laissez-faire.  Most commonly, reconstructive surgery is performed to make a new eyelid or repair the defect. 

What types of reconstructive surgery are there?

There are many excellent oculoplastic techniques available to reconstruct almost any surgical defect around the eyelids and peri-ocular region.  Each operation will be specifically tailored to the defect that is present, following removal of the tumour.  The goals remain the same, which is to reconstruct the eyelid so that it functions properly and protects the eye, preserves the vision and has a satisfactory aesthetic or cosmetic appearance, matching the rest of the face as well as possible.  Any surgical treatment for eyelid and peri-ocular skin cancer will leave a fine scar, but every effort is made to minimise visible scarring and to obtain an optimum cosmetic result.  If surgery involves flaps, it may require a two stage procedure.  After surgery the healing process can take up to 6 months or a year to complete. 

What precautions do we need to protect ourselves in the future from eyelid and peri-ocular skin cancers?

If you have had one BCC, it is likely that you will develop others over the ensuing years, on parts of your face, neck, shoulders and hands which are sun exposed.

  • Examine your skin every 6 to 12 months for early warning signs and look and feel for any changes in your skin. 
  • Ask your partner to examine your back, neck, ears and scalp.  Alternatively, use a mirror to examine these areas. 
  • If you are concerned about a lump, seek advice from your GP. 
  • Wear protective clothing and wide-brimmed hats when outdoors, which will protect the skin most at risk. 
  • Wear 100% UV protective sunglasses, as the skin surrounding the eyes is vulnerable. 
  • Avoid sunshine during midday hours if possible.
  • Use high factor sunscreen (SPF 15 or 30), this is vital.  Apply sunscreen before going out in the sun and re-apply every 2 to 3 hours, or more frequently if perspiring or swimming. 
  • Advise others, especially family and friends, to protect themselves from the sun.