Two stage lid reconstruction: when the whole eyelid is lost from cancer

Occasionally, a skin cancer turns out to be significantly larger than is thought at first glance. As a matter of course, for eyelid tumors, a dermatologist trained in the “Mohs technique” (in which tumors are removed layer by layer and evaluated to ensure complete removal, while leaving the maximal amount of normal tissue behind) removes the tumor prior to oculoplastic reconstruction.  Even a dermatologist trained in this specialized technique can be fooled sometimes, as the “true” extent of the tumor can be significantly larger than presumed extent based on the clinical appearance.  This occasionally leads to a Friday afternoon phone call, in which a dermatologist has ended up with a much larger eyelid problem to fix after removing a tumor, and needs a little oculoplastic help.

The patient below was seen preoperatively by both Dr. Walrath and by the referring dermatologist.  It was clear that this tumor was going to involve half of the lower lid, as indicated by the blue dotted line.

This was the clinical extent of the tumor, but the microscopic extent of the tumor was only figured out during the Mohs surgical process.  Unfortunately, the tumor  was determined to take up almost the entire lower lid, involving all three layers. An oculoplastic surgeon is able to adapt to this eventuality and shift seamlessly to a better suited reconstructive technique.*   A photo of the immediate post-Mohs state is presented below.

The reconstruction was initially planned to be a “rotational” flap, using nearby tissue to fix the defect.  However, the plan was altered on the fly to allow for repair of a complete lower lid defect.  The back part of the eyelid was reconstructed by using the inner layers of the upper lid.  To make this work, the lids were left attached (sewn shut) for one month, so that the new lower lid would have time to develop its own blood supply.  The outer part of the lower eyelid was taken as a skin graft from the patients clavicle area.

After 5 months, the patient is quite pleased.  He has a functioning eyelid, looks good, and has no discomfort.  Apart from the “Stage I” and “Stage 2” procedures initially, he has had no further surgical procedures. His final postoperative photo is below.

* Interestingly enough, the opposite can be true as well.  Dr. Walrath recently took care of a patient who was upset with his appearance after an out-of-state reconstruction of the lower lid, in fact the exact same procedure as the patient described above in this post.  For this other patient, Dr. Walrath determined that in fact a larger tissue rotation could have been performed, avoiding the challenges of the “lid-sharing” procedure.   He did perform this revision, effectively replacing the reconstructed eyelid with yet another new eyelid!