Lower Eyelid Full-Thickness Lid Margin Repair for 8-mm Defect Following Mohs Surgery for Basal Cell Carcinoma
Main Text
Table of Contents
Basal cell carcinoma (BCC) represents the most prevalent malignant neoplasm of the human body, accounting for approximately 80% of all non-melanoma skin cancers.1–3 In the United States alone, an estimated 4.3 million cases of BCC are diagnosed annually, with a significant proportion occurring in the head and neck region.4 The periocular area is particularly vulnerable, with studies indicating that 5–10% of all BCCs manifest within the eyelid and surrounding regions.5–7 Risk factors include cumulative ultraviolet radiation exposure, genetic predisposition, immunosuppression, and advanced age.8,9
Surgical management of periocular BCCs presents unique challenges due to the anatomical complexity and functional significance of the eyelid. The delicate structure requires precise reconstruction techniques that maintain aesthetic appearance and critical ocular protective functions. Mohs micrographic surgery has emerged as the gold standard for treatment, offering the highest cure rates while preserving maximal tissue.10–12 However, the procedure invariably results in tissue defects that demand reconstructive approaches.
The lower eyelid, in particular, presents the most challenging reconstructive scenario due to its complex anatomical composition and critical role in ocular protection, tear film distribution, and globe movement.
Reconstruction options range from direct closure to more complex local or regional flaps. Direct closure, as demonstrated in the presented case, is preferred when sufficient tissue laxity exists, typically for defects less than 25–30% of the total lid margin. More extensive defects may necessitate more complex reconstructive strategies, including tarsal strip procedures, Hughes flaps, or free tissue transfer techniques.13,14
In the presented case, an 8-mm, full-thickness lower eyelid defect was encountered following Mohs excision of a basal cell carcinoma. The reconstruction was performed using a comprehensive, layer-specific repair technique.
The repair procedure was methodically executed through multiple critical steps.
First, the defect margins were debrided of nonviable tissue, and the wound edges were carefully modified into a pentagonal configuration to optimize closure and tissue approximation. A vertical mattress suture was initially placed through the tarsal plate to ensure structural integrity and precise alignment of the deeper eyelid layers. Then, the second suture was placed through the orbicularis oculi muscle, providing additional structural support and preventing potential ectropion. A running plain suture was used to close the superficial skin and orbicularis layers, achieving a refined and everted wound margin. Finally, long sutures were strategically positioned to prevent corneal abrasion and were expected to remain in place for approximately two weeks.
This video illustrates the nuanced approach required in periocular reconstructive surgery following skin cancer excision. When choosing the best repair method, surgeons should assess each patient's unique factors, including skin elasticity, defect size, and eye protection needs. This careful approach to lower eyelid reconstruction can deliver good functional results while maintaining appearance and improving patient outcomes and satisfaction.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Urban K, Mehrmal S, Uppal P, Giesey RL, Delost GR. The global burden of skin cancer: a longitudinal analysis from the Global Burden of Disease Study, 1990–2017. JAAD Int. 2021;2. doi:10.1016/j.jdin.2020.10.013.
- Harken EBO, Fazio J. Basal Cell Carcinoma. In: Atlas of Dermatologic Diseases in Solid Organ Transplant Recipients. ; 2022. doi:10.1007/978-3-031-13335-0_13.
- Dika E, Scarfì F, Ferracin M, et al. Basal cell carcinoma: a comprehensive review. Int J Mol Sci. 2020;21(15). doi:10.3390/ijms21155572.
- Naik PP, Desai MB. Basal cell carcinoma: a narrative review on contemporary diagnosis and management. Oncol Ther. 2022;10(2). doi:10.1007/s40487-022-00201-8.
- Donaldson MJ, Sullivan TJ, Whitehead KJ, Williamson RM. Squamous cell carcinoma of the eyelids. Brit J Ophthalmol. 2002;86(10). doi:10.1136/bjo.86.10.1161.
- Erickson TR, Heisel CJ, Bichakjian CK, Kahana A. Eyelid and Periocular Cutaneous Carcinomas. In: Albert and Jakobiec’s Principles and Practice of Ophthalmology: Fourth Edition. ; 2022. doi:10.1007/978-3-030-42634-7_77.
- Sato Y, Takahashi S, Toshiyasu T, Tsuji H, Hanai N, Homma A. Squamous cell carcinoma of the eyelid. Jpn J Clin Oncol. 2024;54(1). doi:10.1093/jjco/hyad127.
- Li W, Wang W. Insights into risk factors for basal cell carcinoma: a mendelian randomization study. Clin Exp Dermatol. 2023;48(6). doi:10.1093/ced/llad046.
- Sánchez G, Nova J, De La Hoz F. Risk factors for basal cell carcinoma: a study from the National Dermatology Center of Colombia. Actas Dermosifiliogr. 2012;103(4). doi:10.1016/j.adengl.2012.05.008.
- Mansouri B, Bicknell LM, Hill D, Walker GD, Fiala K, Housewright C. Mohs micrographic surgery for the management of cutaneous malignancies. Facial Plast Surg Clin North Am. 2017;25(3). doi:10.1016/j.fsc.2017.03.002.
- Wong E, Axibal E, Brown M. Mohs micrographic surgery. Facial Plast Surg Clin North Am. 2019;27(1). doi:10.1016/j.fsc.2018.08.002.
- Bittner GC, Cerci FB, Kubo EM, Tolkachjov SN. Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations. An Bras Dermatol. 2021;96(3). doi:10.1016/j.abd.2020.10.004.
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Cite this article
Lee J. Lower eyelid full-thickness lid margin repair for 8-mm defect following Mohs surgery for basal cell carcinoma. J Med Insight. 2025;2025(513). doi:10.24296/jomi/513.
Procedure Outline
Table of Contents
- Vertical Mattress Through Tarsus
- Vertical Mattress Through Orbicularis Muscle
- Tie Sutures Leaving Long Ends
- Incorporate and Secure Long Mersilene Ends
Transcription
CHAPTER 1
Hi, I'm John Lee, the oculoplastic surgeon at Boston Vision. You're gonna see me perform a lower eyelid, full-thickness lid margin repair. In this case, the patient had a Mohs excision for a basal cell carcinoma, leaving him with a sizable lower eyelid defect. And we're gonna close that with full-thickness margin repair. A full-thickness margin repair is a very common way to repair Moh's excisions. In this case, it was approximately an eight-millimeter full-thickness lower eyelid defect. Tarsus was reapproximated without having to resort to a lower eyelid lengthening procedure, such as a Tenzel flap.
CHAPTER 2
So we have here a full-thickness lower eyelid defect. This is a result of a Mohs excision for basal cell carcinoma of the lower eyelid. He underwent one round of Mohs, and had clear margins, and ended up with this lower lid defect, which we're gonna close today. So things I've noticed, full-thickness, you can see all the way to the globe, through the lid, meaning the conjunctiva, tarsus, orbicularis, and skin all involved. So we're going to attempt to just pull the lower edges together. I've made a vertical mark extending from the incision down to below where the tarsus would be. And I've connected these vertical lines in a pentagonal shape so that the edges will close better. These black marks are chars from the cautery during the Mohs excision. If I'm unable to get these two edges opposed, I have prepped and numbed an area on the lateral temple, which we can use as a Tenzel flap if we don't have enough laxity to get across. Do you feel me pinching you at all? No. Good. So first thing we'll do is see how much laxity there is in that lower lid. And the edges come together pretty easily, that's good news. So it looks like we'll be able to get the edges just to come across, which is exactly what we wanted. Sounds great. So we're gonna remove some of this char here just with abrasion. Okay. And I'll take that clamp. We're gonna use a large chalazian clamp to isolate that lower lid, 15-blade.
CHAPTER 3
And we're actually gonna extend the vertical aspect of this wound so that we get across the entire vertical aspect of the lower tarsus. Likewise, on the lateral side. And then it'll connect the inferior aspect in a pentagonal shape. These incisions are going through skin and orbicularis inferiorly. Okay.
CHAPTER 4
And we're gonna complete the wound with a pair of Westcott scissors. So we do a little bleeding control here. So vertically we're through skin, orbicularis, and tarsus medially and laterally. And inferiorly we're gonna complete the pentagon. So now, we have a lower eyelid defect architecture that we want. We want vertical edges and a pentagon shape on the bottom. Okay, I'll take Mersilene.
CHAPTER 5
We're gonna close this wound in a vertical mattress fashion. I'll pass the first suture through the tarsus. And we're gonna span the wound. And exit on this side, again, through the tarsus. And complete the suture in a vertical mattress fashion, again, through the tarsus, but further from the wound edge. And deeper into the wound edge. We are gonna span the wound. I need a little dab on this side. Dab this one? Dab. Yeah. Okay, and likewise, we're gonna go deep, staying within the tarsus, and ending up lateral to the original entrance point of the suture. Needle off. Load that up again. Dab or Mersilene? Mersilene. So we now pass the Mersilene suture across the tarsus on both ends of the defect. The next step is we're gonna pass a very similar suture through the orbicularis, again, in a vertical mattress fashion. Through orbicularis, close to the wound. Exiting the wound edge in a shallow location. And orbicularis starting wide. I'm passing through deep. Dab over here. Mm-hmm. Again, deep in the orbicularis. Okay. Needle off. Now, we have two sets of Mersilene sutures: one closing the tarsus and one closing the orbicularis. So we'll secure those. And we will leave these ends long. Dab. Mm-hmm.
CHAPTER 6
Now we're gonna work on closing the skin and orbicularis vertically. So we're just gonna take relatively shallow bites of skin and orbicularis and have a running plain gut suture. Short. Follow. Mm-hmm. Dab. Mm-hmm. And with this last pass of the plain gut, we'll put our first knot down, and we're gonna take advantage of the fact that we have this loop because these Mersilene ends will be incorporated into that knot. Adie, hold, press... Hold? Hold that down there. So continue to tie off that plain gut around those long Mersilene ends. Scissors to me. So the plain gut suture can be cut short. And these Mersilene will stay here for about two weeks. We tie them down inferiorly here so that they don't reflect posteriorly and abrade the cornea. You can see here, instead of a full-thickness defect, we have a nicely-everted wound edge on the lid margin, and a nicely-closed superficial layer. And these long Mersilenes are tucked away nicely.
CHAPTER 7
In this case, we were presented with a full-thickness lower eyelid defect of approximately eight millimeters. When we approach this, we have to decide whether there's enough laxity in the lower eyelid to approximate the vertical edges of the wound. For this gentleman, he had enough laxity where we were able to directly close that wound, but we had prepared for an eyelid-lengthening procedure with a Tenzel flap, which would've extended his skin and muscles from the temple and moved it into position in the lower eyelid.