Doc, what is this in my lower eyelid?

This 70 year-old woman presented with a rapidly enlarging lesion in her right lower lid. The lesion bled easily whenever she rubbed her eye. Examination revealed an ulcerated lesion involving almost half of her right lower eyelid and there was out-turning of the eyelid (ectropion) due to scarring. 

Figure 1. Right lower eyelid basal cell carcinoma with ectropion. 

The appearance was consistent with basal cell carcinoma, a type of skin lesion that typically occurred in sun-exposed skin such as the face and hands. Although cancerous, this type of skin cancer does not spread to distant part of the body. However, if left untreated, it will slowly destroy the surrounding tissues. 

Figure 2. A patient with extensive basal cell carcinoma destroying 

most of the right eyelid, the tumour also invaded deeply. Exenteration 

in which all the ocular tissue were removed leaving behind the 

bony orbit had to be performed. 

The best treatment option is excision with some clear margin to ensure complete excision. Because the lesion in this patient was large, the excision required extensive reconstruction. In this patient, the reconstruction was done using rotation flaps as shown in the photos below.

Figure 3. a. Marking of the lesion with 3mm clear margin; 

b and c. Complete excision of the lesion; 

d. the posterior lamellar was replaced with tarsal plate from the upper lid; 

e and f; the tarsal plate of the upper lid was rotated to the lower lid; 

g. the tarsal plate was sutured to the cut edge of the lower lid; 

h. the anterior lamellar was replaced with upper lid myocutaneous graft; 

i. the upper myocutaneous flap was rotated to the lower lid defect; 

j. to avoid flap retraction the cheek was elevated and sutured to the lateral orbital rim; 

k. the rotation flap was sutured in placed and the harvested area was closed as in upper blepharoplasty; 

l. the right eye was tightly packed for 24 hours to prevent haematoma beneath the flap.