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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 177-180

Basal and lateral block resection for residual eyelid tumor during second stage reconstruction at 3 weeks


Department of Ophthalmology, IGMC, Shimla, Himachal Pradesh, India

Date of Web Publication19-Oct-2015

Correspondence Address:
Dr. Ram Lal Sharma
Department of Ophthalmology, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.167516

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  Abstract 

There are different techniques for reconstructing the eyelids and canthal area which may need modifications in some situations for proper reconstruction. Three cases of sebaceous gland carcinoma of the lids were done by different techniques, where the extent of the disease required subtotal lid excision. At 3 weeks when healing was noted and the histopathology reports were available, the second stage reconstruction was done along with tissue block excision. The block was excised from the site of graft-host junction showing margin involvement on histopathology. In the first case, the base of the excised margin showed infiltration following tumor excision, and hence a basal block of tissue was excised during second stage surgery. In the second case, the excised margin showed tumor involvement, so a lateral block of tissue was excised in second stage surgery. In the third case the deep basal block of tissue was excised during first stage only. In all the three cases, the excised block was free from tumor, but patient were kept on close follow-up. The technique has worked well in all the cases as no recurrence has occurred in 1-year follow-up. None of these patients received any radiotherapy or chemotherapy postoperatively. The postoperative appearances were normal with adequate functioning lids and earlier rehabilitation.

Keywords: Bridge flap, eyelid reconstruction, sebaceous gland carcinoma


How to cite this article:
Sharma RL, Sharma ML, Mahajan D. Basal and lateral block resection for residual eyelid tumor during second stage reconstruction at 3 weeks. Arch Int Surg 2015;5:177-80

How to cite this URL:
Sharma RL, Sharma ML, Mahajan D. Basal and lateral block resection for residual eyelid tumor during second stage reconstruction at 3 weeks. Arch Int Surg [serial online] 2015 [cited 2024 Mar 28];5:177-80. Available from: https://www.archintsurg.org/text.asp?2015/5/3/177/167516


  Introduction Top


Eyelids are complex structures and pose a challenge for reconstruction to retain their different functions. Sebaceous gland carcinoma (SGC) is best managed by complete excision with adequate normal tissue boundary along with reconstruction. Margin controlled surgery can be performed using a variety of tissue cutting and mounting methods, including slow Mohs surgery, frozen section, cytology preparations, and molecular pathology that combines tumor extirpation along with microscopic examination, could be better option if available. [1] Recurrence rates can be high even in lesions with negative surgical margins. Lang and Maize [2] studied 10 recurrent tumors, six of which had negative margins with the initial excision. In situation, where these facilities do not exist, one can operate by taking adequate margin of tissue while retaining best possible cosmetic and functional lids. One can either go all out to excise the tumor and leave a disfigured face or hampered vision as tissue available is less in the lids.

In infiltrative tumors there is always a possibility of touching the tumor margin along excision line. If the excised tissue still shows tumor margin involvement one can go ahead with tissue block excision of the site (2-3 mm) taking both sides of the suture line. The restoration of lid function is possible despite additional resection and earlier intervention not only allows removal of positive margin but reduces morbidity also. We present three cases of SGC of the eyelids that were excised and reconstructed by different techniques.


  Case Reports Top


Case 1

A 65-year-old male presented with swelling over the right upper eyelid for 1-month which was associated with watering and pain. It was initially small in size and increased progressively. The swelling was irregular, hard and yellowish on the conjunctival side, causing deformation of the lid margin. There was an attempt to curette the swelling 1-month earlier considering it to be a chalazion elsewhere. Thereafter, the swelling increased rapidly to 2 cm × 1.5 cm at presentation. Other ocular examination was normal. There was no evidence of local, regional or systemic metastasis, so it was T 2 N 0 M 0 stage. A wedge biopsy of the tumor showed SGC. Other investigations were normal.

Wide excision of the tumor was followed by lid reconstruction by a Cutler and Beard [3] bridge flap. The first stage involved the excision of tumor [Figure 1]a and construction of the bridge flap [Figure 1]b. Histopathological examination (HPE) of the excised mass showed the involvement of superior margin. In order to ensure the excision of residual tumor during the second stage of the surgery, a 4 mm block of tissue was resected at the junction of superior margin after 3 weeks [Figure 1]c. The resected block on histopathology did not show tumor at the margins. At 1-year follow-up, the patient had mild persisting lid edema but there was no recurrence of the tumor [Figure 1]d.
Figure 1: (a) Upper lid sebaceous gland carcinoma on conjunctival side, (b) upper lid reconstructed by lower lid bridge flap after tumor excision first stage, (c) basal block excision at the suspected margin on histopatholgy during second stage surgery at 3 weeks, (d) early postoperative look following second stage surgery

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Case 2

A 49-year-old female presented with swelling in the left lower lid for 2 years. It was initially solitary and small, but gradually increased to become multi-lobulated and yellowish in color. Swelling involved the 3/4 th of the lateral lower lid sparing the canthi. There were dull pain and watering from the eye. Visual acuity of the patient was 6/12 in the left eye with early cataractous changes and rest of the anterior, and posterior segments were normal. Left lower eyelid margin was thickened, and eyelashes were lost [Figure 2]a. There was no regional metastasis to the lymph nodes. Investigations were normal. The edge biopsy of tumor showed undifferentiated SGC of the lid. The stage was IC (T 2 N 0 M 0 ) according to the American Joint Committee on Cancer [4] cancer staging manual.
Figure 2: (a) Lower lid sebaceous gland carcinoma, (b) lateral block resection during second stage surgery at the suspected margin on histopathology, (c) reconstruction of lower lid defect by lateral rotation flap, (d) normal look and function of lids at 6 months follow-up

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In the first stage, wide excision of the growth was done taking 3 mm tumor free margins, creating a defect of 20 mm in the lower lid, which was filled by a full-thickness bridge flap from the upper eyelid. This flap was sutured in two layers-posterior tarso-conjunctival and anterior musculo-cutaneous with the remaining free edges of the lower lid [Figure 2]b. The lower lid was excised along with the tumor in V-shaped manner, and the lower sharp edge of the V was sutured by approximating the two edges. The upper defect was sutured with the rectangular flap raised from the upper lid after creating suitable edges of the lower lid defect.

HPE of the excised mass showed the involvement of lateral margin with tumor. So, a 4 mm block of tissue was resected at lateral margin after 3 weeks, followed by division of the bridge flap covering the globe [Figure 2]c. The new lower lid was made with concavity downward by suturing the skin and conjunctiva over the divided tarsal plate edge. The insertion of the levator was identified and sutured over the remaining upper lid tarsal plate while conjunctiva and skin were stitched back. The resected block showed tumor free margins. At 2 years follow-up there was no recurrence of tumor [Figure 2]d.

Case 3

A 58-year-old female presented with swelling and pain in the left upper eyelid for 3 months. There were occasional bleeding and discharge from the swelling. The rest of the ocular examination and vision was normal. The edge biopsy of the lesion showed SGC. Orbital scanning showed the cauliflower mass of 2.5 cm × 1.5 cm in size, involving lateral half of the left upper eyelid with 1 cm base on the conjunctival side adherent to the lateral rectus and lateral canthus. The radiotherapy opinion was taken but they advised primary tumor excision despite deeper involvement.

The surgery was planned by assessing the extent of the tumor on all visible sides [Figure 3]a. The tumor base was approached from the conjunctival side by doing lateral cantholysis. The tumor was excised along with 6 mm of lateral rectus muscle. A 5 mm basal block of tissue was excised from the base of the tumor [Figure 3]b. Three samples were sent for HPE - tumor mass, lateral rectus muscle and surrounding tissue and the basal block. A full-thickness lower lid rotation flap was fashioned for reconstruction of upper lateral lid by Mustarde's flap. [5] The histopathology of the main mass showed the nests of tumor cells toward the base of the left lid with basal resection line showing infiltration. The second sample (lateral rectus and conjunctival tissue) was free from tumor infiltration and the third sample (base of the tumor) revealed lacrimal glands tissue without any infiltration.
Figure 3: (a) Upper lid protruding sebaceous tumor, (b) primary tumor excision with tissue block excision at base of the tumor, (c) upper lid reconstructed from lower lid switch flap during first stage surgery, (d) postoperative look after 6 weeks following second stage surgery

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Second stage surgery was planned by division of lower lid flap for reconstruction of the upper lid, followed by lateral canthus reconstruction by joining new free upper and lower lid lateral margins along with lateral rectus restoration after 3 weeks [Figure 3]c. The new horizontal palpebral fissure measured 28 mm by constructing the new lower lid margin from the cheek rotation flap. The conjunctiva was mobilized from the lower fornix to create the inner margins. 1-year follow-up of the patient revealed no complications [Figure 3]d.


  Discussion Top


SGC is a rare aggressive malignant tumor derived from the adnexal epithelium of sebaceous glands. It is sometimes associated with internal malignancy, the Muir-Torre syndrome. During surgical excision the delineation of tumor margin are difficult and can have a multi-centric origin, so recurrence is 6-29% after resection. [6] Local excision, orbital exenteration, radiotherapy, and chemotherapy are various methods used to manage patients with SGC based on tumor stage at presentation. Wide excision with at least 4 mm margin and radical neck dissection is necessary in patients with regional metastases. In this case series, patients were followed up at short intervals, to detect early recurrence as the tumor has a fast growth potential. The margins of excised tissue were marked while submitting a specimen to the pathologist. These diagnostic difficulties must be accepted and emphasize the importance of biopsies in suspicious inflammation. [7] As a rule all chalazia occurring 1 st time in the elderly individual should be considered suspicious.

The principle of total eyelid reconstruction is to have a movable lid that protects the cornea, looks aesthetically good, and have acceptable loss at the donor site. There are different techniques for reconstruction of the total eyelid defects most of them are by two-stage surgery. The first stage is the covering of the lid defect by creating a tarso-conjunctival flap followed by a temporal skin graft and second stage is carried out after 6-9 weeks. One of the drawbacks of two staged surgeries is the occlusion of the visual axis for 1-2 months, increasing recovery time. We were able to reduce this interval to 2-3 weeks. This duration is not only suitable for biopsy report to come but early enough to intervene in cases of marginal involvement by the tumor. The other options for reconstruction are cheek advancement flap with chondro-mucosal graft or free mucosalized tarsal graft with, bipedicled skin-muscle flap, with or without a full-thickness skin graft to repair the skin-muscle donor site [8] in single stage. The techniques are challenging to perform and being a single stage surgery, the opportunity to intervene is lost if histology reveals residual tumour at the margin. On the other hand, two stage surgeries have big advantage of tissue block excision of involved margin, particularly following lid tumor reconstruction.

In standard Cutler and Beard [3] procedure, a full-thickness cutaneo-conjunctival inferior eyelid advancement flap is made for reconstruction of the total or partial upper eyelid defects [3] and second stage is carried out by division of the flap at 6-8 weeks to allow stretching of the tissues. If one can avoid destabilization of the donor site or retraction of the recipient site the inverse construction is equally successful and less complicated, [9] the method that was used successfully in our case 2 with second stage done at 3 weeks. Hughes's tarso-conjunctival [10] flap is the other lower lid reconstruction technique in which the flap is raised 4 mm above the upper lid margin. The division of the flap is done during second stage preferably after 6 weeks. The defect in the upper eyelid can be transferred to the lower eyelid, the Mustarde's lid switch. [11] The switch flap was swung into the defect and sutured in layers in our case 3. The bridge flap was divided after 3 weeks as soon as the histopathology report of the primary block excision was negative for tumor. The switch flap is the only method of reconstruction which gives natural-looking lashes to the upper eyelid. The drawbacks are persistent lid edema and total loss of flap. This patient did not have any such problem but palpebral fissure was slightly narrow but acceptable, as excessive tissue has to be excised due to the muscle involvement.

The surgical technique must be individualized for each patient and for each type of tumor. Reconstructive techniques with free grafts and flaps yield excellent esthetic and functional results in the orbital region. The two modifications which have been done in this case series were the block dissection of the involved margin at second stage surgery at 3 weeks. These modifications work well in these locally advanced cases, where one can eliminate the tumor from the site with reasonable resection and retain good and acceptable cosmetic and functional results.


  Conclusion Top


Excision of malignant neoplasms represents the leading cause of plastic reconstruction in the orbital region. Reconstruction in two stages provides a chance to excise the tissue block for residual tumor during second stage and can still retain good functional and aesthetic results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dhingra N, Gajdasty A, Neal JW, Mukherjee AN, Lane CM. Confident complete excision of lid-margin BCCs using a marginal strip: An alternative to Mohs′ surgery. Br J Ophthalmol 2007;91:794-6.  Back to cited text no. 1
    
2.
Lang PG Jr, Maize JC. Histologic evolution of recurrent basal cell carcinoma and treatment implications. J Am Acad Dermatol 1986;14:186-96.  Back to cited text no. 2
[PUBMED]    
3.
Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1-7.  Back to cited text no. 3
[PUBMED]    
4.
Edge SB, American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7 th ed. New York: Springer; 2010.  Back to cited text no. 4
    
5.
Mustarde JC. Repair and Reconstruction in the Orbital Region. New York, NY, USA: Churchill Livingstone; 1980.  Back to cited text no. 5
    
6.
Fischer T, Noever G, Langer M, Kammer E. Experience in upper eyelid reconstruction with the Cutler-Beard technique. Ann Plast Surg 2001;47:338-42.  Back to cited text no. 6
    
7.
Wolfe JT 3 rd , Yeatts RP, Wick MR, Campbell RJ, Waller RR. Sebaceous carcinoma of the eyelid. Errors in clinical and pathologic diagnosis. Am J Surg Pathol 1984;8:597-606.  Back to cited text no. 7
    
8.
Patrinely JR, O′Neal KD, Kersten RC, Soparkar CN. Total upper eyelid reconstruction with mucosalized tarsal graft and overlying bipedicle flap. Arch Ophthalmol 1999;117:1655-61.  Back to cited text no. 8
    
9.
Betharia SM, Kumar S. Reconstruction of the lower lid using the upper lid. Indian J Ophthalmol 1988;36:113-5.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Hughes WL. Total lower lid reconstruction: Technical details. Trans Am Ophthalmol Soc 1976;74:321-9.  Back to cited text no. 10
[PUBMED]    
11.
Mustardé JC. Major reconstruction of the eyelids: Functional and aesthetic considerations. Clin Plast Surg 1981;8:227-36.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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