EYELID, PERIOCULAR, AND FACIAL SKIN CANCERS

GENERAL CONSIDERATIONS

The outer layer of skin is called the epidermis. Epidermal cells include the squamous cells, round basal cells, and pigment producing melanocytes. The dermis is the deeper layer of skin and contains the hair follicles, oil and sweat glands, and blood vessels. Skin cancers can arise from any of these skin cells. A biopsy is usually required to comfirm the diagnosis of skin cancer.

Excessive exposure to sun is the single most important factor associated with skin cancers of the face and eyelids. Fair-skinned people develop skin cancers far more frequently than darker-skinned people. Skin cancers may occasionally be hereditary.

The most common type of periocular (eye area) and facial skin cancer is basal cell carcinoma . It may appear as a painless nodule, or as a sore that won't heal. The skin may become ulcerated, or the lesion may show bleeding, crusting, or deformation of the adjacent eyelid or facial structures. When they develop along the eyelid margin, lash loss may also be evident. 96% of all eyelid and facial malignancies represent basal cell carcinomas. While basal cell carcinoma cannot physically spread to lymph notes or distant sites (i.e. no metastatic potential), they can cause significant problems from appreciable growth and invasion in the tissues from which they arise. Left untreated, they will continue to grow and invade surrounding structures. When detected early and treated appropriately with surgical excision, there is greater than 99% chance of permanent tumor eradication. The earlier the surgery, the less tissue will be required for removal - thereby the smaller will be the required reconstruction.

Squamous cell carcinoma presents in a similar manner as basal cell carcinoma. Squamous cell malignancies are much less frequent, representing 1% of eyelid and facial malignancies, but are more serious as they can spread to lymph nodes and more distant sites. When detected early and treated appropriately with surgical excision, there is greater than 99% chance of permanent tumor eradication. The earlier the surgery, the less tissue will be required for removal - thereby the smaller will be the required reconstruction

Sebaceous cell carcinoma arises from the oil glands in the skin. They represent 1% of eyelid and facial malignancies. It may appear as a thickening of the eyelid or facial skin, or a persistent eyelid inflammation. At times it can be confused with a chalazion (the chronic sequelae of a stye). This is a more serious form of skin cancer with an even greater metastatic potential through the bloodstream or lymphatic system. Prompt surgery is required.

Malignant melanoma arises from the pigment-producing melanocytes. Although this makes up only 1% of eyelid or facial malignancies, it is one of the most aggressive and potentially life-threatening skin cancers owing to its significant metastatic potential through the bloodstream or lymphatic system. A "mole" or pigmented area that bleeds or becomes tender, or one that changes its size, shape, or color, should be evaluated to rule-out melanoma. Prompt surgery is required.

SURGICAL TREATMENT

Non-surgical treatment modalities are not recommended for these malignancies for the following reasons: Cryotherapy (freezing the tumor) yields an unacceptable 20% recurrence rate. Radiation therapy yields an unacceptable 10% recurrence rate and causes much damage to normal tissue.

The correct surgical method involves excisional biopsy of the tumor with frozen and paraffin section control - followed by immediate reconstructive surgery - all performed during 1 surgical procedure. A frozen section involves immediate evaluation of the tumor specimen during the surgery. In this regard the pathologist confirms the diagnosis and, if malignant, evaluates the margin to ensure that the surgical margin is completely free of tumor. Frozen section diagnosis is 99% accurate. The paraffin section is a confirmatory step performed by the pathologist over the subsequent 1 - 2 days to confirm whether the margins are definitively free of tumor and the frozen section diagnosis was accurate. Paraffin sections are practically 100% accurate. During surgery, Dr. Kohn does not move from the tumor excision stage of the procedure to the reconstruction stage until he has frozen section corroboration that the surgical margins are completely free of tumor.

The surgical reconstruction procedure is dictated by the location and size of the tumor excision site. Reconstructions can vary in scope ranging from direct tissue closure to advancement flap reconstructions or free grafts of varying size Reconstruction of the resulting defect is tailored to preserve eyelid function, protect the eye, and provide excellent cosmetic appearance.

Dr. Kohn is quite familiar with the Moh's procedure and does not recommended it for the following reasons: (1) It offers no benefit in terms of guaranteed tumor eradication (2) It offers no benefit in terms of minimizing the amount of tissue required for excision, (3) It involves much longer surgical time and sometimes multiple surgical procedures, (4) It often leads to adverse cosmetic and/or functional results.

AFTER SURGERY

Pain is negligible after surgery and no patch is required. Patients simply use antibiotic ointment at bedtime for 7 - 10 days. Sutures are removed 7 to 10 days later in the office

RISKS AND COMPLICATIONS

Bleeding and infection, which are potential risks with any surgrey, are very uncommon. As with any medical procedure, there may be other inherent risks that should be discussed with Dr. Kohn. In eyelid margin tumors, notch formation can rarely occur. Tumors in contiguity with the tear drainage system can occasionally result in tearing from obstruction of the tear drainage system. This may require either immediate or later reconstruction of the tear drainage system.

National statistics reflect a 3% incidence of tumor recurrence (or incomplete excision) associated with surgical excision of eyelid or facial malignancies. Dr. Kohn has performed over 3000 surgeries for eyelid and facial malignancies with 2 recurrences - less than a 0.1% recurrence rate.

CONCLUSIONS

Eyelid and facial malignancies can be a serious threat to their tissues of origin, and in the case of squamous cell carcinoma, sebaceous cell carcinoma, or malignant melanoma, can represent a serious life-threatening problem. When treated with correct surgery, they can be definitively excised with resultant normal appearance and function.

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