Skin cancer on and around the eyelid
You might find it useful to read this article in the Daily Mail
by one of Mr Malhotra's patients about her cancer journey.
Mr. Malhotra is a genius, I have no idea how he has done what he has done,
but it is the work of a genius!
Best wishes, A
Following Mohs excision (courtesy of Dr Habib Kurwa)
A week after reconstruction
A month after reconstruction (the eye is dyed green with fluorescein to help evaluate the condition of the cornea and surface of the eye)
Basal cell carcinoma (the most common skin cancer) of the lower eyelid before operation
Immediately after the cancer has been removed with frozen-section examination
Reconstruction of the rigid back surface of the lower eyelid (with moist-lining) by borrowing tissue from the upper lid, known as a Hughes tarsoconjunctival flap, with a skin graft for the lower eyelid surface
A month after surgery
How grateful I am for the magnificent job you have done repairing my eyelid. I realise how lucky I have been to have your attention and to have achieved such a very good result. My family are all amazed and delighted with the outcome.
To prevent a recurrence, the tumour should be removed completely, while as much healthy tissue as possible is preserved. Removal may be followed by reconstructive surgery, which could involve a skin graft.
The general approach to removing skin cancer is known as margin-controlled excision, where the edge of the cancer is identified and the growth within this area is removed. It normally takes place under a local anaesthetic.
Several methods are available:
- Mohs surgery – see below.
- Frozen section – cancerous skin is removed, frozen, sliced thinly and examined under a microscope by a pathologist before the wound is closed to make sure that all the cancerous cells have been removed. The aim is to find a clear margin — the edge of an area to which the cancer has not spread. If a clear margin is found, the wound is then reconstructed. If a clear margin is not seen, the surgeon removes more tissue until the entire area has a clear margin. This technique is very similar to Mohs but may result in loss of a few millimetres more more eyelid tissue.
- Paraffin section — this is similar to frozen section but the pieces are fixed in paraffin gel and dyed and then examined. This provides greater clarity — the equivalent of high definition on a television set against a film on YouTube — but is much slower to process. In most cases, low definition images are perfectly adequate.
What to expect
- Your surgery will generally take place under local anaesthesia, as a day surgery case.
- Examination of frozen skin slices can take up to an hour. You will be sent to a waiting room, so bring a book.
- Preparation of slices in paraffin can take a few days, so you will be sent home and asked to return.
- Occasionally, skin cancer wounds will heal on their own. This is known as granulation, or "Laissez-faire".
- After surgery, you will have a pad on your eye overnight. If a skin graft has been used in reconstruction, you may need to wear a pad for up to a week.
- In some cases, the eyelid will remain closed for up to two weeks.
- If you have concerns about this, such as poor sight in your other eye, talk to Mr Malhotra.
- The healing process can take between six months and a year. Once healing is complete, you will need a follow-up consultation with your doctor to make sure that the cancer has not recurred. This ensures that any recurrent problem is detected and treated early.
Skin cancers are often found on or around the eyelid skin, most usually on the lower eyelid. They can also be found on the margins of the eyelid, corners, eyebrows or rarely near the eye on the conjunctiva (the inner lining of the eyelid).They appear as lumps or elevations of the skin or as small swellings or nodules. In some cases, eyelashes are distorted or missing. The cancerous area may be ulcerated, may bleed or crust and the skin shape may be distorted. These cancers are painless.
Diagnosis may need to be confirmed by taking a sample of skin (a biopsy). Skin cancers are normally caused by excessive exposure to UV light – the sun or sun beds. The face, eyelids and arms are the main areas to be affected and fair-skinned people are much more likely to develop skin cancer than those with darker skin. Rarely, skin cancer can be an inherited condition.Basal cell carcinoma (BCC) is the most common form of UK skin cancer, also known as rodent ulcer.
Early signs can include small lumps, scar-like or eczema-like changes on the skin. You may also see a small sore with raised borders.The second most common type is squamous cell carcinoma (SCC). The first sign of this can be a patch of scaly eczema. It is generally located near an orifice, such as the eye, mouth or ear.
These two cancers spread locally, are slow-growing but can invade neighbouring parts of the body. They do not spread (metastasise) into non-adjacent areas. When detected early, there is a good chance of removing the tumour completely and minimising the amount of tissue that needs to be removed.
Sebaceous gland carcinoma is a cancer of the glands that produce our natural skin oils and in 75 per cent of cases affects the glands around the eye. Causes vary and include triggers ranging from benign lumps to exposure to radiation and, rarely, a genetic condition called Muir Torre' syndrome.
Malignant melanoma is cancer of the melanin-forming cells that give you a tan. The more moles you have on your skin, the higher the risk of developing a melanoma. This usually looks like a large mole, which becomes itchy and painful, grows or becomes irregular. It may get darker, become mottled or bleed for no apparent reason. Again, excessive UV exposure is the major cause of melanoma. Fairer-skinned people are more likely to develop it and there may be a genetic link in some cases. These are more serious forms of skin cancer because they may metastasise to other parts of the body. They need prompt, aggressive treatment because of the threat of early spreading.
For full information about what to do before and after surgery, see Patient information, which you can download as a pdf.
One of the most advanced treatments for skin cancer is named after the man who invented it in the 1930s, Dr Frederick Mohs. In Mohs' surgery, the tumour is removed piece by piece. Each piece is immediately frozen and examined under a microscope. If some cancer might still be present, more tissue is removed and examined. This goes on until there are no signs of any cancer cells. Reconstruction is then carried out.
Mohs Micrographic Surgery (MMS) relies on the surgeon also being a pathologist and identifying cancer cells. The surgery is very precise and means that the maximum amount of healthy tissue is retained, while removing cells that could cause a recurrence of the cancer.
The cure rate for MMS is up to 99 per cent for skin cancers that have not been treated by other methods and more than 90 per cent where other forms of treatment have failed.
Some tumours do not respond to common treatments, including those greater than 2cm in diameter, those in difficult locations, such as the eyelid, and tumours complicated by previous treatment. Removing a recurring skin cancer is more complicated because scar tissue makes it difficult to differentiate between cancerous and healthy tissue. Again, the Mohs approach makes effective treatment possible.
Mr Malhotra recommends MMS to treat difficult basal cell carcinomas (BCC), and squamous cell carcinomas (SCC). Both are most often caused by excessive exposure to UV light from the sun or sun beds.
It can also be used to treat less common tumours, including melanoma, sebaceous carcinoma (SG) or microcystic adnexal carcinoma (MAC) — a tumour of a facial sweat gland. These may require more than one visit as often the skin pieces need to be processed as paraffin sections, which takes considerably longer, in order to provide greater clarity.
MMS is particularly useful when:
- A cancer has been treated previously and recurred.
- Scar tissue exists in the area of the cancer.
- The cancer is in an area where it is important to preserve healthy tissue for a most functional and cosmetic result, such as eyelids, nose, ears, lips.
- The cancer is large.
- The edges of the cancer cannot be clearly defined.
- The cancer grows rapidly or uncontrollably.
What to expect
- You will generally be under local anaesthesia as a day surgery case.
- The surgeon removes the first layers of skin cancer and you return to the waiting area with a pad over your eye. You may need to wait an hour or so and may want to bring something to read.
- The surgeon traces the path of the tumour using his map of the surgical site (a drawing of the removed tissue that is used as a guide to the precise location of any remaining cancer cells) and a microscope.
- If any of the sections of skin contain cancer cells, you will return to the treatment room. Another thin layer of tissue is removed and examined for cancerous cells while you return to the waiting area.
- Occasionally, top-up anaesthetic injections are needed before the repeat excisions.
- The process continues layer by layer until the cancer is completely gone.
- In most cases, complete excision is achieved within two excisions (often called levels), although three or four levels may be needed in difficult cases. As much healthy tissue is kept as possible.
- Mr Malhotra will decide on the best method of reconstruction once the cancer is completely removed.
- Reconstruction is carried out either immediately after MMS or within a week.
All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information.
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