Skin cancers on the eye lid

Skin tumours: a brief introduction

A tumour or cancer is a term normally used to described any type of cells which are growing abnormally out of control of the body. Benign tumours usually grow but do not invade the surrounding tissues and are not normally harmful unless they develop in specific locations in the body. Malignant tumours (sometimes referred to as cancers) invade the surrounding tissues as they grow and therefore can be dangerous and even fatal. There are many types of benign and malignant skin tumours . This information sheet discusses malignant tumours.

Malignant skin tumours commonly occur in the eyelid. The most common types of malignant eyelid skin tumours in Caucasians are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but other rarer types include sebaceous gland carcinoma and melanoma. These cancers can all grow and invade surrounding tissues, which can be very damaging to the eye and eye socket. Very occasionally, some of them can also spread around the body (metastasise), which can be fatal.

BCCs hardly ever spread to other parts of the body, and only ever do so when they are left to get very large. SCCs may spread if they are left too long before treatment. Sebaceous gland carcinomas and melanomas have a higher chance of spreading if they are not treated when they are small.

Skin cancers should be removed. This is normally done surgically (excised), although occasionally other treatments like radiotherapy and chemotherapy are also used. The whole tumour and a surrounding ring of healthy tissue (a margin) should be excised. The excised sample is sent to the pathology laboratory to be examined under a microscope to confirm exactly what type of tumour it is and if the whole tumour has been removed.

Treatment options will be discussed with you, depending on the site, size and tumour type and your age I may suggest that you consider Mohs excision surgery to remove the cancer in a layer by layer approach to ensure full excision is confirmed before a reconstruction is planned. Mohs surgery would be offered after discussion of your skin tumour and location etc at the Skin cancer MDT meeting at the Norfolk and Norwich University Hospital. Mohs surgery is performed by a specially trained Mohs surgeon and the reconstruction of the delicate and complex eye structures is then done by myself.

 

What type of anaesthetic is used?

The options for anaesthesia include:

  • Local anaesthetic without sedation

  • Local anaesthetic with sedation

  • General anaesthetic

For more detailed information on the anaesthetic options, please refer to the “Anaesthesia for Eye Surgery” Information sheet

 

What happens during the operation?

You will be brought into the operating theatre and will lie down on a bed. You will have anaesthetic eye drops put in both eyes. These can sting for a short time. The tumour and planned margin of excision will be marked. You will then have local anaesthetic injections into the eyelid skin. If you are awake (not sedated or general anaesthetic), this will sting, rather like a dentist’s injections. The tumour and surrounding area is thoroughly cleaned with an antiseptic. Sterile drapes are placed around the head and surgery will commence.

The extent of the area that needs to be excised will depend on the type of tumour and its size. Generally larger or more aggressive tumours will require a larger area to be excised. There are then several possibilities:

Immediate reconstruction: the tumour is removed and the eyelid is reconstructed immediately afterwards during the same operation.

Delayed reconstruction: the tumour is excised and sent to the pathologist who makes a thorough assessment of the specimen over the next 1- 3 days. The eyelid is reconstructed in a separate operation after the pathologist has given a full report on the tumour and its margins.

Mohs micrographic surgery: where a specially trained Mohs surgeon removes the tumour in a layer by layer approach to try and conserve tissue and limit the collateral damage to adjacent structures whilst ensuring complete removal of the tumour. This requires MDT discussion and planning with the Mohs surgery team who remove the tumour following which I will repair the complex and delicate structures around the eye and in the eye lids.

 

What are the reconstructive options once the tumour is removed ?

The main priority is to remove the entire tumour and a clear margin around it. It is also important to try and reconstruct the tumour excision site in such a way that the eyelids and the eye can still function normally and the cosmetic appearance is as close to normal as possible. The exact type of reconstruction depends on how much tissue/eyelid is removed.

For smaller excisions, the excision site can usually be closed directly, i.e. by stretching or moving nearby tissues into the gap.

Sometimes depending on the site a small defect may be left to granulate or heal on its own. 

However, more complex procedures are usually required for larger excisions. These may include the following:

A skin graft taken from elsewhere in the body. Common places that grafts can come from are another eyelid, in front or behind the ear and the shoulder. Occasionally other graft materials such as the ear cartilage, the roof of the mouth (hard palate) and abdominal fat are used.

Skin from an area where there is some skin redundancy near to the excision site is freed up and rotated or moved in to fill the defect. This is called a skin flap

For large lower lid tumours, a procedure may be used that stretches tissue across from the upper lid of the same side. If this procedure is used, the eye will remain closed for 1-4 weeks and then a small second procedure is done to open the eyelids.

Some larger reconstructions may require more than one operation.

 

What to expect immediately after the operation

A pad is normally put on the eyelid. We will advise you when to remove this. If both eyelids are padded, one or both will be removed before you go home. If a skin graft is performed the eye pad and dressing is usually left in place for 2 to 3 days. Swelling and bruising is usual after surgery but can vary considerably. Factors associated with greater swelling and bruising include increasing age, the use of aspirin, warfarin or other blood thinners and a history of previous surgery on the same lid.

The eyelid can be gently bathed with saline or cooled boiled water once or twice a day. Antibiotic ointment should then applied to the suture line and/or graft with a cotton-tipped bud. It can also be applied to the eyelid before showering or bathing to “waterproof” the suture line/graft. The wound area should be kept relatively dry for about three weeks, i.e. it should not be soaked or submerged in water but it is fine for it to get splashed with water for example whilst in the shower. If it does get wet, gently dab it dry, but do not rub the wounds when drying them.

Ice (crushed ice or frozen peas), cold packs, or cool gel face masks (available from most chemists) can be applied to the eyelid for 15 minutes at least 4 times daily for the first 5-7 days . This reduces lid swelling and bruising and can be continued for as long and as often as it seems to provide some benefit. About two-thirds of the bruising and swelling will have subsided by the first post-operative visit at one week. The remainder gradually subsides over the next several weeks and is usually invisible to others by six weeks. Your vision may be slightly blurred in the first couple of weeks while the lids are swollen: this will improve once the swelling settles.

You may have some pain or discomfort following your surgery, this is usually mild to moderate and normally relieved by simple painkillers such as paracetomol. Severe pain is very rare after eyelid surgery – you should notify me immediately if you experience more than mild to moderate pain. Some eyes may feel dry or gritty for the first few days to weeks after surgery. This can usually be relieved with the use of artificial tear drops that you can buy from the chemist.

You can use make-up the day after surgery, but avoid the areas with incisions or stitches. You can drive once you are happy with the vision and comfort in the eye(s), usually the next day. You should not drive if one eye is padded. 

It is sensible to avoid heavy physical activity (bending and lifting, digging, strenuous exercise) for the first week. Walking, reading, watching TV and light domestic duties can be performed when you feel able.

Do not use aspirin or blood-thinning medications for the first 5 days after surgery unless you are already on them or we have discussed this prior to surgery.

You will usually need about one week off work.

 

Should I contact my medical team after the operation?

Most patients do not have any significant problems or complications after surgery, but there are some things to look out for. If any of the following occur, you should contact the clinic or me.

  • Reduced vision that is not just from the eye cream, i.e. if you blink a few times, the vision is still reduced.

  • A very sore or light sensitive eye

  • The eyelids do not close properly

  • Infection: the eyelids become more red, sore, swollen and sticky

  • Persistent bleeding that does not settle with an eyepad/pressure for a few hours.

 

Follow up and the multi-disciplinary team

We will arrange a follow-up appointment 1-2 weeks after the surgery. Further follow-up will depend on the type of tumour, the risk of recurrence and if any further treatment (e.g. chemotherapy, radiotherapy or additional surgery) is required. Some patients with less aggressive cancers will be discharged soon after the surgery, while others may be followed up for years after the surgery. For larger tumours we may also involve other specialists such as medical oncologists, radiation oncologists, radiologists. This all depends on the MDT discussion with other medical experts from other departments who regularly look after patients with cancers.

 

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