Patients are often referred to the surgeons at Face & Eye with eyelid and facial lesions (tumours, growths and lumps). The main goal in the evaluation of these lesions is to differentiate malignant from benign lesions. In general, the majority of malignant tumours affecting the eyelids and surrounding areas are slowly enlarging, destructive lesions that distort or destroy the normal shape of the eyelid.
Helpfully there are a number of subtle features that can help to differentiate malignant from benign eyelid tumours, but in some cases it can be extremely difficult to make the correct diagnosis of an eyelid lesion without a biopsy (the removal of a sample of tissue which is examined by a pathologist with a microscope). Some malignant lesions may appear to be harmless whilst, conversely, some benign lesions may appear to be sinister. The majority of malignant tumours in this area are basal cell carcinomas (rodent ulcers). Rarer tumours include squamous cell carcinomas, sebaceous gland carcinomas, Merkel cell tumours and melanomas.
A typical lower lid nodular basal cell carcinoma (BCC or rodent ulcer) and an adjacent smaller one
An early diagnosis is vital and can significantly reduce morbidity associated with malignant eyelid tumours. However, malignant eyelid tumours are diagnosed early only if a high degree of clinical suspicion is applied when examining all eyelid lesions. The appropriate management of malignant eyelid tumours requires a thorough understanding of their clinical characteristics and their pathologic behaviour. This is what the highly qualified oculoplastic surgeons at Face & Eye are trained to do.
Many basal cell carcinomas of the eyelids and surrounding areas are treated with Mohs micrographic surgery.
A lower lid Mohs surgery defect
The appearance following oculoplastic reconstruction
Mohs surgery is a highly specialised surgical technique to remove certain skin tumours. It offers a number of advantages over other possible treatments, having a uniquely high cure rate and the benefit of ensuring that only the minimal amount of normal tissue is sacrificed. It will be appreciated that this feature is of immense importance around the eyes. This also ensures that the reconstructive surgery required to deal with the ensuing defect is less extensive.
The Mohs surgeons for this region are Dr Nick Telfer and Dr Vindy Ghura, Consultant Dermatologists based at the Dermatology Department of Hope Hospital, Salford. They are amongst the very few doctors in the United Kingdom who have received specialist training in Mohs surgery. Their role in your management is to remove the tumour. This is done under local anaesthesia.
Once this has been done you will transfer to Face & Eye, where you will undergo surgery for the reconstruction of the defect left by the Mohs surgery. This will normally take place the same day. The precise details of the surgery will be decided on the day after it is clear what the size and extent of the defect is. This may involve the use of local tissue flaps (skin that is advanced or rotated) and/or a skin graft which is usually taken from behind or in front of the ear, from the upper inner arm area, or from the area just above the collar bone.
A typical upper lid basal cell carcinoma (BCC)
The appearance of the upper lid defect following a Mohs micrographic excision of the BCC
The appearance a few weeks after a skin graft reconstruction (the skin graft was taken from behind the ear)
The appearance a few weeks after a skin graft reconstruction (the skin graft was taken from behind the ear)
The reconstructive procedures can be performed under local anaesthesia on a day case basis. Most patients, however, prefer “twilight anaesthesia”. (Please note that the Mohs micrographic surgery itself is undertaken under local anaesthesia only).
You will visit the clinic to have a preoperative consultation. This usually lasts 30 minutes. You will be asked to complete a healthcare questionnaire, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery. We need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. We need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke. You will have your blood pressure checked by the nurses at the clinic.
Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
If you are unsure of the names of any medications, bring them with you.
You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
Your vision in each eye will be measured. Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
Some insurance companies request copies of preoperative photographs.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of eyelid reconstructive surgery following a tumour excision?
Most complications of eyelid reconstructive surgery are amenable to successful treatment.
Complications from eyelid reconstructive surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. A haematoma usually needs to be drained in the operating theatre
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this.
- Scarring or thickening of a skin graft if this is required. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
After surgery, the eye is initially covered with pressure dressings for 1-2 days. The dressing is then removed. If a skin graft has been used the dressing is usually left in place for approximately 3-4 days. Activity is restricted for 2 weeks to prevent bleeding.
After the dressing has been removed you will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are often dissolvable but are usually removed in clinic after 2 weeks.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Contact lenses should not be worn for a few weeks following this type of surgery.
Please note that although eyelid reconstructive surgery can be performed under local anaesthesia alone, local anaesthesia with safe, conscious intravenous sedation given by a very experienced and skilled consultant anaesthetist (commonly referred to as “twilight anaesthesia”) is also available where requested. This form of anaesthesia is extremely popular with our patients and the effects are reversed very quickly. It enables local anaesthetic injections to be given painlessly with little recollection of the surgery, and helps to keep patients calm, relaxed and comfortable. It also helps to prevent rises in blood pressure thereby minimizing bleeding and postoperative bruising.
Any patients requiring general anaesthesia or who are unsuitable for surgery at our day case facility, the Face & Eye Clinic, will be treated by our surgeons in a local private hospital e.g. the new Manchester Spire Hospital or the Private Wing of Manchester Royal Eye Hospital (The Manchester Centre for Vision).