Procedure: Left medial canthal reconstruction:

Patient required forehead flap, skin grafting and medial canthal tendon reconstruction.

Procedure: Right Lower Lid Reconstruction

Procedure: Left Upper Lid Reconstruction

Procedure: Reconstruction of Right Lower Eyelid

Procedure: Reconstruction of Right Medial Canthus

Procedure: Reconstruction of Right Medial Canthus:

Procedure: Reconstruction of Left Medial Canthus:

Procedure: Reconstruction of Right Lower Lid

Periocular Skin Cancer(Skin cancers around eyelid area)

The most common skin cancers in the eyelid area are basal cell carcinoma, squamous cell carcinoma, melanoma and sebaceous cell carcinoma. Each of these have different biology and growth patterns that require individualized treatment. Basal cell carcinoma is the most common of all of these.

Basal Cell Carcinoma

Basal cell carcinoma is more common in people with fair skin and history of sun exposure. The most common subtype is a nodular basal cell which usually grows slowly as a pearly white bump. In the eyelid area the lower eyelid and inner corner of the lid is the most common area of growth.

If Dr. Ahmad suspects you have a skin cancer he will proceed with a biopsy of the suspicious area. A biopsy removes a small piece of tissue for the pathologist to examine. A pathologist is a specialized doctor that looks at tissue under a microscope to make a diagnosis. If the diagnosis is a basal cell Dr. Ahmad will give you options for removal and reconstruction of the area.

Mohs Surgery is a specialized excision technique used by dermatologists to remove skin cancers around delicate areas like the eyelids. Patients with recurrent skin cancers or extensive lesions may benefit from Mohs surgery. The dermatologist would remove the skin cancer in their office using the Mohs technique and then Dr. Ahmad would repair the hole usually within several days of the initial removal. It is not possible to close the hole the same day of excision of the eyelid cancer.

Goals of Eyelid Reconstruction

The most important goal of eyelid reconstruction after skin cancer removal is making sure all the cancer cells has been removed. This is why Dr. Ahmad works closely with the dermatoligist (Mohs surgeon) in making sure the best plan for excision of the skin cancer has been created!

On this same issue, every patient who has had an eyelid cancer removed should always remember that in a small percentage of patients, there can be recurrence of the cancer. In other words even with Mohs surgery or any other technique of removal of skin cancers, they can return. Why would a skin cancer return if it has been completely removed? It only takes one cancer cell to remain for a cancer to recur. Sometimes all the cancer has been removed but a new cancer pops up in the same geographic location as the previous skin cancer. For example if you have had a skin cancer on the lower eyelid you could get another cancer in the same lower eyelid because the whole eyelid may have the same predilection to cancer. Any patient with an eyelid cancer should be seen by a dermatologist every year for a full body screening especially of the head and neck area.

The second goal of reconstruction of the eyelid is to make an eyelid that covers the eye. An eye without an upper or lower eyelid will be an irritated eye!!! An irritated eye will have blurry vision, pain, tearing and ultimately will have scarring of the cornea which can cause permanent vision loss. Loss of eyelid tissue can cause poor function of the eyelids which is usually seen as a poor blink function or loss of the natural blink. Reconstruction of the eyelid can also exacerbate or make this worse because we have to move tissue or use skin grafts that are not exactly like the tissue that was removed. Lack of a blink or a poor blink can cause eye irritation and even blurry vision.

The third goal of reconstruction is aimed at making the eyelid as cosmetically pleasing as possible. This is usually the first item that patients are worried about!!! Dr. Ahmad am I going to look like a freak or abnormal?, is what most patients ask. Dr. Ahmad understands how important the aesthetic beauty of the eyelids are for each individual. He will do his best to give you the best outcome possible. Sometimes even the smallest holes may be the hardest to repair, for example the medial canthal angle. It is always important to remember that we are dealing with cancer remova. Although Dr. Ahmad will do his best to give you the best aesthetic outcome, ultimately it is the biology and extent of your initial cancer that will determine your final outcome.

Techniques

The eyelid is extremely complex, it is made up of different layers, each important in the function and beauty of the lids. The outside of the eyelid is made up very thin skin, which has minimal subcutaneous fat. The middle of the eyelid is made up of the Tarsal Plate which is a thick tissue near the lash line. The tarsal plate gives the eyelid margin(near the lash line) stability. If you don’t have tarsal plate your eyelid skin may turn inwards and scrape your eye!!!!! The tarsal plate is much larger in the upper eyelid than in the lower eyelid. In fact one of the most common procedures that Dr. Ahmad performs is a Hughes flap. Dr. Ahmad takes part of the upper eyelid tarsal plate and moves it into the lower eyelid to reform the lower eyelid margin. The upper and lower eyelid stay connected for 2-4 weeks. One of the downsides of this flap is that the eye is closed for this period. Dr. Ahmad would not do this procedure on a one eyed patient.

The inner eyelid is made up of conjunctiva which is smooth and helps lubricate the eye and its surface. Skin and skin elements like lashes can not be against the eye.

Patients who have a skin cancer removed around the eyelids with only skin missing have several options for reconstruction. The two main options for repair are a eyelid flap or skin graft. Dr.Ahmad prefers flaps for most people as they heal beautifully and skin that is in the vicinity of the hole is being used for reconstruction. The downside of the flap is that initially the eyelid may appear very tight and new incisions are required to obtain tissue. Any flap or incision in the eyelid area can potentially cause the eyelid not to work as it did before. Usually the function of the eyelids improve over time as wounds stretch and swelling resolves.

Skin Grafts are skin removed from another location and placed onto the eyelid defect or hole. Full thickness skin grafts are most commonly used in eyelid reconstruction. The most common area where the skin graft is harvested is from behind the ears. This skin is very thin like the eyelid and usually has no hair elements so the skin graft will not have hair growing from it!!! Other areas where skin grafts can be harvested from is from in front of the ear, above the clavicle, the upper arm and of course from the upper eyelid. One of the issues of skin grafts is that during the healing process the graft may not take completely(more common in smokers) or may become elevated or bulky during the healing process. Sometimes the skin grafts may need to be trimmed or injected with steroids.

Skin Graft Cleaning Techniques

After the placement of a skin graft a dressing is usually sutured onto the graft. After the dressing is removed, dilute hydrogen peroxide is used to gently clean the graft. This is usually done with a Q-tip taking great care not to rub the graft but just roll the Q-tip over the graft. Antibiotic ointment is then applied to the sutures around the graft. Patients should be very gentle with the skin grafts as the blood supply comes from the tissue underneath the skin graft. Rubbing of the graft or sleeping on the graft during the first few weeks may injure the blood supply and make the skin graft not take completely.

After eyelid reconstruction the eyelids may need to be sutured closed for several days. Dr. Ahmad closes the eyelids to optimize healing of the reconstructed area. If the patient only has one eye or only good vision from the eye which needs reconstruction, Dr. Ahmad will take this into consideration. Each patient is different as is their underlying visual status. Dr. Ahmad will taylor the surgical plan as needed to give you the best chance for success!!