Eyelid Skin Cancer Reconstruction Techniques: A How-To Guide for Patients undergoing MOHS surgery and reconstruction

I treat a large number of eyelid cancer patients in my practice. Doing so, I work with many Mohs surgeons in Denver. Patients often ask me “What is the reconstruction that you will do on my eyelid after the MOHS surgeon removes the cancer?” The answer is really “It depends”. What exactly does it depend on? There are several factors that affect the reconstruction technique used for eyelid cancer defects. For me they include:

1. How big the defect or hole is after the cancer is removed. – Obviously if the hole or defect after cancer is removed is 1mm in size that will be different than if the defect or hole after is the entire lower eyelid

1. Where the defect or hole is – Different parts of the eyelid, the upper or lower eyelid or involvement of the tear duct will all affect the reconstruction technique. There are different techiques in the upper eyelid versus the lower eyelid namely because the eyelid function in the upper eyelid and lower eyelid is different.

So what are general guidelines I use for eyelid cancer reconstruction? The reconstruction techniques I use are based on a hierarchy of needs for the patient. The first and foremost thing of importance for me in reconstructing an eyelid is protection of the eye or sight. There is no purpose of trying to have the best cosmetic outcome that somehow sacrifices the eyeball. At the end of the day, the eyelids protect the eye and vision. That is their primary purpose and that is my primary purpose as the surgeon to make sure the eye is protected in the reconstruction.

There are three basic techniques that are used for eyelid reconstruction.

1. Primary Closure

2. Sliding flaps

3. Tissue Grafts

Primary Closures involve directly closing a hole. In the most simplest terms if there is a hole I close that hole with sutures. If that happens to be in the edge of the eyelid, I suture the eyelid so the lashes are continuous and the eyelid is reconstructed as back to normal as possible.

Sliding flaps involve moving tissue adjacent to a hole or rotating adjacent tissue to close a hole. This is often if a hole or defect is too big for primary closure. If one could imagine if there a large hole in the lower eyelid, closing the defect primarily would result in the eyelid being pulled down. Thus I would have to rotate tissue around into the defect.

Tissue Grafts involve taking skin or other tissues and transferring them in from the upper eyelid, behind the ear, in front of the ear or elsewhere into the defect. The eyelid has two main components important in reconstruction. The first is the inside of the eyelid that is the pink tissue that rubs against the eye. The second is the skin on the outside of the eyelid. As one can imagine if there is complete loss of a large portion of the eyelid, the outside and inside parts of the eyelid have to be replaced. This is often taken from the other eyelids where there is no cancer to be transferred into the eyelid with the defect.

In general, Primary closure is done with there is less that 50% of the eyelid. Sliding flaps may be done between 40% and 70%. Greater than 60% may require grafts. As one can imagine there is a large amount of crossover where several techniques will be used at the same time. Also depending on the individual patient’s eyelid anatomy a different technique may be employed for eyelid reconstruction. There is no simple formula for each patient. That is critical to know. Each patient is an individual.

As an oculoplastic surgeon, my goal is to give you the best reconstruction possible in my hands. This is important to me. Also important is preserving your vision and sight. These are the two facts I hold dear in eyelid reconstruction for patients. Hope that helps.