Updates on periocular post-Mohs reconstructive surgery: a clinical practice review

Introduction

Background

Basal cell carcinoma (BCC) is the most prevalent form of skin cancer globally. Approximately 75% of BCCs occur in the head and neck region (1). Furthermore, 20% of all BCCs arise in the periorbital area. Although BCC is typically not fatal and ocular invasion is rare (occurring in about 2–4% of cases), early diagnosis and treatment are crucial to minimizing the risk of complications such as orbital invasion. These complications can significantly increase the likelihood of requiring radical surgical interventions, which may result in both functional and aesthetic impairments.

About 50% of all cancers in the United States are skin cancers, with BCCs constituting about 80% of all non-melanoma cases (2). About 2 million Americans receive a diagnosis of BCC every year. Among the number of risk factors associated with BCC, the most notable and widely acknowledged one is ultraviolet (UV) ray exposure (3). UV rays can induce deoxyribonucleic acid (DNA) damage to cells, resulting in subsequent mutations in oncogenes, tumor suppressor genes, and other housekeeping genes that ultimately lead to dysregulation of the cell cycle. One study estimates that 75.7% of gene mutations discovered in BCC are a result of UV exposure (4).

BCC is categorized into eight subtypes: superficial, nodular, micronodular, morphea-like, pigmented, infundibulocystic, basosquamous, and fibroepithelioma of Pinkus. Amongst the subtypes, superficial, nodular, and morphea-like BCC are the most clinically recognized (5). Superficial BCC typically presents as a pink-red, scaly, macule that often contains telangiectasia (5). This subtype tends to appear on the shoulders, chest, or back and may resemble inflammatory skin conditions, such as eczema or psoriasis, making it more difficult to differentiate clinically. Nodular BCC is the most common subtype (5). Additionally, it is a tumor prone to ulceration and presents with a shiny pink or flesh-colored nodule with surface telangiectasia. Nodular BCC is commonly found on the nose, cheek, forehead, nasolabial folds, and eyelids, with the majority of cases occurring in the periorbital region. Morphea-like BCC presents as a white- or flesh-colored tumor with hardened areas and undefined boundaries. The lesion usually has a smooth surface and telangiectasis may be present. This subtype is noted for its more aggressive behavior and ability to cause extensive local destruction (5).

Rational and knowledge gap

Eyelid reconstruction following Mohs surgery is a critical aspect of periocular oncology, requiring a balance between functional preservation and aesthetic outcomes. While previous reviews, such as Patel and Itani (6), have provided an overview of reconstructive techniques following Mohs surgery, the evolving landscape of surgical approaches necessitates an updated analysis. Existing literature has primarily focused on individual techniques rather than a comparative evaluation of their clinical efficacy and long-term complications. This review bridges that gap by synthesizing recent evidence and providing practical insights for ophthalmic and plastic surgeons to enhance patient outcomes.

The literature presented spans from foundational studies to the most current findings, ensuring a comprehensive perspective on evolving surgical approaches. Whenever possible, we prioritized resources and studies conducted after 2018. However, in cases where relevant literature post-2018 was unavailable for certain reconstructive techniques, we included the most recent studies, even if they were published before 2018.

Objective

This review seeks to provide a comprehensive analysis of periocular reconstructive techniques following Mohs surgery, comparing their efficacy, functional outcomes, and aesthetic considerations while addressing recent advancements such as synthetic flaps and stabilizing glues to guide clinical decision-making.

Overview of the management of BCC [surgical excision, imiquimod, exenteration, Mohs micrographic surgery (MMS), and radiotherapy]

Treatment options for BCC vary based on the risk of recurrence and the location of the lesion. The ultimate goals of treatment include removing the tumor while preserving the function and cosmesis at the site. Low-risk lesions are frequently managed with electrodesiccation and curettage (ED&C), surgical excision, topical 5-fluorouracil (5-FU), topical imiquimod, cryosurgery, intralesional injection, and photodynamic therapy.

According to Newlands et al., (7) a BCC located on the central portion of the face is considered a high-risk feature and is indicative of a more aggressive tumor behavior. Additionally, BCC in this region presents a unique challenge due to the presence of cartilage and surrounding structures, making complete excision more difficult while achieving both aesthetically and functionally favorable outcomes. Consequently, extensive lesions are more likely to result in positive surgical margins, which, in turn, increase the risk of recurrence. Other high-risk features for BCC include a tumor greater than two centimeters, poorly defined clinical margins, high-risk histologic subtype (morphoeic/infiltrative, micronodular, basosquamous), peri-neural or peri-vascular involvement, previous treatment failure, and immunosuppression (7).

High-risk tumors may be managed with excisions or radiotherapy. ED&C is not recommended in these high-risk tumors due to an increased risk of recurrence (3). Vismodegib is a Food and Drug Administration-approved hedgehog pathway inhibitor that has been seen to decrease tumor size before surgical intervention (8). MMS is another treatment method used for high-risk lesions located in cosmetically sensitive regions, like the periorbital area.

High-risk BCC generally has very low recurrence rates after surgical excision. In a study of 78 eyes completed by Juniat et al. (9), periocular BCC that underwent resection had three cases of recurrence during the average follow-up period of 37.9±17.2 months. Each of the recurrences had at least one of two high-risk features: infiltrative subtype and/or incomplete tumor clearance. In this study, there were no differences between the recurrence rates of patients that received complete tumor clearance with negative margins to those with incomplete tumor clearance (P=0.15). Despite the lack of statistical significance between the two groups, Juniat et al., other studies, and the National Comprehensive Cancer Guidelines still recommend re-excision when incomplete tumor clearance is not achieved (9-11). Rates of recurrence of incomplete tumor excisions of high-risk BCC are estimated to be up to 50% in some studies, further demonstrating the importance of re-excision when there are positive surgical margins (12-17). Recurrence rates are much lower when complete tumor resection has occurred, with studies reporting BCC recurrence rates ranging between 0.39% to 3.96%.

MMS has the highest rate of remission and maximal tissue preservation (3). During the procedure, a staged resection is performed, and a frozen section analysis of surgical margins is obtained. With MMS, the 5-year rate of recurrence is 1.4%, and in cases where BCC does recur, the preferred treatment method is repeated MMS (18,19).

Outcomes after MMS vary based on the extent and location of the defect, patient demographics such as age, additional comorbidities, tumor duration, and histopathology. Post-operative medical treatment options are typically re-evaluated within 6–8 weeks, and surgical revisions are recommended after waiting 3–6 months. Medical options include steroid injections, dermabrasion, and laser resurfacing. Surgical scar revision through techniques such as shave excisions, fusiform excisions, M-plasties, serial partial excisions, Z-plasties, W-plasties, and geometric broken line closures may also be performed (20).

The location of the Mohs procedure also impacts reconstructive options. Linear closure with local flaps is the predominant technique for lesions in the forehead, cheek, and perioral region (21).

Radiotherapy is also a viable option for periocular BCC that is capable of providing favorable cosmetic outcomes with adequate tumor control. According to the American Society for Radiation Oncology clinical guidelines in 2020, for patients with non-metastatic BCC who are unable to undergo or decline surgical excision, definitive radiotherapy is strongly recommended as a curative treatment modality (22). Furthermore, the guidelines conditionally recommend definitive radiotherapy in patients with BCC in anatomic locations where surgical intervention may compromise function or cosmesis, like the eyelids. While there is a lack of robust randomized controlled trials evaluating the efficacy of radiotherapy, many retrospective and single-arm prospective studies have demonstrated favorable local control rates (22-24). Few relative contraindications exist in the presented guidelines, including patients with genetic conditions that predispose them to increased sensitivity to radiation (e.g., ataxia telangiectasia, Gorlin syndrome, Li-Fraumeni) and patients with poorly controlled connective tissue disorders (22).

Interventional radiotherapy, or brachytherapy, is also an additional method for reducing tumor burden while maintaining promising cosmetic outcomes in periocular BCC. Brachytherapy is advantageous in that the radiation-induced toxicity to surrounding ocular structures, especially the lens, is reduced while preserving a high dose of radiation within a clinical target volume (25). Many contraindications exist for brachytherapy that overlap with the contraindications of radiotherapy that have been mentioned in the preceding paragraph. Contraindications to brachytherapy include cancers with bony invasion, clinical perineural spread, deep extension beyond subcutaneous fat, and relatively contraindicated in patients with genetic conditions that make them more sensitive to radiation (26).

Brachytherapy also provides a useful tool for skin neoplasms affecting high-risk areas, such as the periocular and periauricular areas (25,27-29). In a study conducted by Cisek et al. (25), 28 patients were treated with interstitial brachytherapy for skin cancers of the upper and lower eyelid, medial and lateral canthus, and the cheek, nose, and temples with infiltration of ocular structures. In their study, only two patients had a recurrence within the mean follow-up period of 22 months with the most common early side effect being conjunctivitis and most common late side effect being dry eye syndrome. Surgical excision followed by brachytherapy also has promising results for tumor control in a 19-patient study done by Fionda et al. (28). In their study, 19 patients with ocular surface neoplasia and eyelid tumors underwent surgical excision and received adjuvant brachytherapy when there were positive surgical margins or negative surgical margins but the cancer had high-risk features, such as poor differentiation, peri-neural invasion, and immunosuppression. Of the 19 patients, only four had local recurrence in the 36-month follow-up period. Similar to the study by Ciesk et al., the most common side effects after treatment of ocular surface neoplasms was dry eye. The most commonly reported side effect after treatment of eyelid tumor in the study was madarosis.

Radiation, either definitive radiation or via brachytherapy, has demonstrated promising results in treating periocular carcinomas with a low recurrence rate. Additionally, radiation can provide desired cosmetic outcomes while maintaining the functionality of surrounding tissues, like the eyelids. However, larger randomized controlled trials need to be conducted to further characterize the role of radiation in periocular BCC.

Pre-surgical preparation

As with most surgeries, it is important to document a patient’s current medications to avoid adverse drug interactions and prevent potential complications. Specifically, it is crucial to note anticoagulants, especially newer generation anticoagulants such as dabigatran, apixaban, and rivaroxaban, given the high vascularity of the eyelids (30).

Before local anesthetic administration, systemic anxiolytics and analgesics can be given to the patient. Lorazepam is commonly administered due to its anxiolytic, sedative, and hypnotic properties (30). However, sedatives like lorazepam can affect intraoperative upper eyelid margins (30). A variety of local anesthetics can be used in oculoplastic surgeries, with the most common ones being amides like lidocaine, prilocaine, and bupivacaine. The pain of local anesthetic injections can be reduced by using topical pre-anesthetics. Topical anesthesia can be advantageous because it decreases the distortion of wound margins. Additionally, pain from a local anesthetic injection in the eyelid can be lessened by slowing the rate of the injection (31).

Prophylactic anti-microbial treatment

Without prophylactic antimicrobial treatment, there is an elevated risk of periocular tissue infection and infection-mediated endophthalmitis, keratitis, and conjunctivitis. While conjunctivitis is the most common eye-related infection, it does not typically warrant concern for vision loss (32-34). Contrarily, keratitis and endophthalmitis are less common but pose a serious risk for vision loss if not treated promptly. Keratitis is most commonly caused by a bacterial infection of S. aureus, coagulase-negative staphylococci, S. pneumoniae, and P. aeruginosa (34). The most common causes of endophthalmitis are the coagulase-negative staphylococci, S. aureus, streptococci, and Gram-negative bacilli (35). Topical povidone-iodine is commonly used to protect against infection caused by intravitreal surgery or injections, as it has a swift kill time and broad-spectrum activity (36).

Primary closure with and without secondary intention among those with minor defects

Healing by secondary intention, also termed the laissez-faire method, is often utilized when the medial canthus of the eye is affected (37-39). Additionally, the laissez-faire method has been successful in the recovery of full-thickness lower eyelid wounds affecting up to 75% of the lower eyelid (38). The laissez-faire method for periocular defects may apply to patients with primary precancerous conditions, patients with poor general health, and those unfit for prolonged surgery. This approach involves simple wound management and may be utilized for small parts of large defects that are partially closed through flaps or grafts (37). Due to the simplicity of wound management, this may be the treatment of choice in certain cases within the elderly population (38). Disadvantages and other possible complications of the laissez-faire method include prolonged healing time, lower lid cicatricial ectropion, watery eyes, and large upper eyelid defects due to an increased risk of exposure to keratitis (37). This method is contraindicated in patients with poor compliance with follow-up visits as possible wound infections and poor wound healing must be assessed.

Direct margin repair

Direct closure is usually indicated for small defects affecting the anterior and posterior lamella with a length of less than one-third of the eyelid (40). A pentagonal wedge resection is executed and the wound is closed using a vertical mattress suture (41). When repaired, a small portion of the tarsus may also be required for resection (40). Additionally, the pre-tarsal and pre-septal sections of the eyelid should be treated separately for favorable cosmetic outcomes (40,41). This is usually achieved by creating a skin crease incision between the planned tarsal and septal sections of the eyelid and not crossing their boundaries. Additionally, lateral canthotomy and superior cantholysis can be performed to assist in direct closures to increase the mobility of the eyelid (42).

Local flap closure and advance flap for superficial and anterior lamellar defects

There are a variety of myocutaneous flaps that can be used to repair defects in the anterior lamella (Table 1). The flaps can be categorized into five subtypes: a sliding flap, advancement flap, rotation flap, transpositional flap, and special transpositional flap (43).

A sliding flap involves undermining myocutaneous tissue in an elliptical shape, thereby allowing tissue movement to the defective site (44). While the sliding flap is relatively noninvasive, prolonged flap swelling and keratoconjunctivitis can arise as potential complications (45).

Advancement flaps, such as an H-plasty and bipedicle advancement skin flap, consist of making incisions in the shape of an H and undermining the surrounding tissue to allow flap movement (46). H-plasty has many benefits compared to skin grafts and secondary intention healing. The flaps have their own blood perfusion, provide a good match of skin color/texture, and have less contraction in the healing process (46). A recent study has found that revascularization of H-plasty procedure flaps has occurred as soon as one week post-operatively (46).

Rotational flaps are oriented curvilinearly and pivoted in the direction of the defect (47). A secondary defect arises depending on the size of the flap, with larger rotation flaps causing a narrower and longer secondary defect and vice versa (47). Burow’s triangles are often used to assist in closing the secondary defects that are created when using rotational flaps (48). A rotational flap that is employed in periocular anterior lamella repair is a Mustarde cheek rotational flap (49). The Mustarde cheek rotational flap provides a good match in skin color and texture (50). Additionally, because the flap is very wide and necrosis is uncommon, as it has good access to blood supply, making the Mustarde flap a good choice for inferior eyelid anterior lamella repair (50).

Transpositional flaps are linear flaps that pivot towards a defect over an incomplete bridge of tissue (47). The skin in transpositional flaps is not immediately adjacent to the defect and is lifted and fitted into the defect. The rotational angle is kept as small as possible to avoid blood supply comptonization to the skin flap (49). Special transpositional flaps involving a rotational element include the Limberg rhomboid flap and the bilobed flap (43). Limberg flaps are generally indicated when neither direct closure nor elliptical closures are practical (51). The Limberg flap requires very precise measurements, as it is based around a defect with 60-degree and 120-degree angles with limbs of equal length (47). The main disadvantage to the Limberg flap is that it occasionally requires the unnecessary discarding of normal tissue to convert the defect into the typical Limberg flap shape (47).

The bilobed flap has been found to produce satisfactory results in medial canthal reconstruction and anterior lamella defects of the inferior eyelid (52). The flap is made of two lobes with the same base and is subsequently transposed to cover the defective area (52). The bilobed flap evenly distributes the load of the flap by transferring tension over a greater rotation angle and is often implemented when primary skin closure is difficult (47,53). However, because the base of the flap is narrower than the two flaps combined, lymphedema or trapdoor deformities can arise (51).

Tenzel flap and a tarso-conjunctival flap for full-thickness defects of the eyelid

The Tenzel flap is a reconstructive technique commonly used when there is a full-thickness defect that affects one to two-thirds of the eyelid (54). Although the Tenzel flap has been used for upper and lower eyelid reconstruction, a higher success rate was found in upper eyelid reconstruction (55). The Tenzel flap, also known as a semicircular rotational flap, involves a semicircular musculocutaneous flap that begins at the lateral canthus and curves superiorly or inferiorly depending on the affected eyelid (56). In addition to the Tenzel flap, a lateral canthotomy and inferior cantholysis are performed (57). Once complete, the flap is medially advanced and the defect in the eyelid is directly closed (Figure 1). Finally, the lateral canthus is reconstructed by suturing the deep surface of the orbicularis oculi to the part of the periosteum superficial to the Whitnall tubercle (58). The Tenzel flap method is advantageous, as it has low donor site morbidity and it is a single-step procedure that can reconstruct a moderate-size defect. On the other hand, cicatricial entropion, usually affecting the lower eyelid, may arise as a complication in some cases involving a Tenzel flap (56).

Figure 1 Illustration of the Tenzel flap used in lower lid reconstruction. (A) A lower lid defect is identified following Mohs-surgery. (B) A superiorly curved semicircular flap beginning at the lateral canthus is made and (C) the lower lid defect margins can be approximated. (D) The lower lid wound margins are sutured for direct approximation. (E) The surgically created semicircular flap is directly closed using sutures.

A tarso-conjunctival flap, also called a Hughes flap, is recommended when a defect involves more than three-quarters of the lower eyelid (59). A tarso-conjunctival flap is created by everting the upper eyelid and incising the tarsal and conjunctiva from the anterior lamella of the upper eyelid in a U-shaped fashion (60). The flap is then brought down to the defective area of the lower eyelid and a suture is made between the lower lid and the tarso-conjunctival flap (61). The anterior lamella can be reconstructed by suturing a full-thickness skin graft to the exposed tarso-conjunctival flap (Figure 2) (56). Flap division takes place within two weeks or less to minimize the risk of flap ischemia and necrosis, while allowing time for sufficient flap revascularization. In a study, the use of a tarso-conjunctival flap yielded relatively successful functional and cosmetic outcomes in 39 of 45 cases (60). While complications were noted to be low, some adverse effects included lower lid margin erythema, ectropion, trichiasis, and pyogenic granulomas (60,62).

Figure 2 Illustration of the Hughes flap used in lower lid reconstruction. (A) A lower lid defect is identified following Mohs-surgery. (B) The upper eyelid is everted and the tarsal and conjunctiva are separated from the anterior lamella in a U-shaped fashion. (C) The surgically created flap is brought down to the lower lid defect and (D) sutured to the lower lid defect margins. (E) The anterior lamella is reconstructed using a full-thickness skin graft. (F) The flap is left in place and a delayed flap division takes place to reduce the risk of flap ischemia.

Periocular skin grafting

Skin grafts can be categorized into full-thickness or split-thickness skin grafts. Full-thickness grafts comprise of the entire epidermis and dermis, are usually used for small areas, and have a lower risk of contracture (63). Although full-thickness skin grafts are an important tool for periocular reconstruction, complications reported in a prospective case series study included hypertrophy, contracture, contracture-ectropion, trapdoor contracture, web contracture, infection, and hematoma formation (64). Conversely, split-thickness skin grafts are composed of the epidermis and superficial layers of the dermis, are usually indicated for larger areas, and have a higher risk for contracture than full-thickness skin grafts (63). Contracture may lead to ectropion, lid retraction, or webbing, suggesting the need for additional corrections in the future (65). While flaps are generally preferred to resolve defects affecting the anterior lamella, other procedures like full-thickness grafts from the contralateral upper eyelid, inner arm, retroauricular space, or supraclavicular areas may be utilized if there are insufficient neighboring tissues for a periocular flap (66,67). Defects of the posterior lamella can be repaired using grafts from the contralateral upper eyelid, hard palate mucosa, mucochondrial tissue from the ala of the nose, or ear cartilage (66,68). Hard palate grafts are routinely used for lower lid reconstruction and seldom used for upper eyelid reconstruction, as there is a higher risk for corneal damage (69). However, a retrospective case series study reported successful hard palate grafting for upper eyelid reconstruction, with most cases of ocular irritation (3 of 15 patients) and keratopathies (2 of 15 patients) being transient and resolving in several weeks (69).

Although a skin graft from the contralateral eyelid will give the best match cosmetically and functionally, it is more practical to use a graft from the retroauricular space (65). Additionally, when using grafts for periocular defects, a vascular source must be provided by the anterior or posterior lamella (66). Therefore, a graft that replaces the anterior lamella cannot be placed on a graft that replaces the posterior lamella, and vice versa, as this would cause the tissue to lack an adequate blood supply.

Structural grafting

The pericranial galeal flap utilizes structural grafting for total upper eyelid reconstruction and provides sufficient vascular supply to successive grafts (70). The procedure begins with creating a horizontal incision through the skin, subcutaneous tissue, and the frontalis muscle. After the galeal-pericranial flap is detached from the frontalis muscle and the frontal bone, two vertical releasing incisions are made (71). Subsequently, a tunnel is created through the soft tissue of the eyebrow, allowing the flap to be inverted and passed through the newly made tunnel to reach the area intended for reconstruction (72). To further achieve satisfactory aesthetic results, an overlying free skin graft can be placed on the mucosal graft (70). Chang et al. (70) reported this technique was sufficient to avoid postoperative lid retraction and exposure keratopathy. Additionally, the surgical scar is created on the forehead and may be concealed by the natural creases in the area, adding to more favorable cosmetic outcomes (70-72). As previously mentioned, overlying full-thickness skin grafts are commonly obtained from retroauricular skin. However, Brusati et al. (71) reported a preference for skin grafts harvested from the oral cheek mucosa, citing its ideal thickness and color match to the skin in the periocular region.

Reconstruction involving the nasolacrimal system

The lacrimal system involves many small dimensions vital for proper tear drainage and prevention of epiphora (73). The lacrimal system consists of the lacrimal secretory system, which comprises the lacrimal gland and goblet cells—structures responsible for basal tear secretion (74). The excretory portion of the lacrimal system consists of the puncta, ampulla, valve of Rosenmuller, canaliculi, the lacrimal sac, and the nasolacrimal duct (74). Due to its possibility of invasion, neoplasms like BCC may lead to the development of a secondary acquired nasolacrimal duct obstruction. In 2018, Sweeney et al. (75) reported successful resolution of secondary acquired nasolacrimal duct obstructions via endoscopic dacryocystorhinostomy (DCR). In endoscopic DCR, an initial mucosal incision is performed by combining two parallel cuts on the lateral nasal wall (73). Following the incision, a relieving cut is created and the mucosal flap is elevated (73). After the lacrimal sac is adequately exposed, lacrimal sac flaps are created and either mono-canalicular or bi-canalicular tubes are inserted into the puncta (73). The type of tube inserted depends on the site of obstruction. Once the tubes have been inserted, the nasal mucosa flap is repositioned and a triamcinolone-soaked alginate hemostat is placed in the nose to minimize post-operative epistaxis (73).

Post-surgical antibiotic prophylaxis

Rates of periocular postoperative infections are relatively low due to the region’s high vascularity and short duration of surgery (76). As a precaution and in efforts to prevent surgical site infections, most oculoplastic surgeons provide patients with topical antibiotics, such as bacitracin or tobramycin ointment (77). Oral antibiotics are sometimes administered; however, usage varies by geographic region (78).

Post reconstructive surgery complications

Eyelid infections following oculoplastic procedures were found to be relatively uncommon due to the high vascularity of eyelids (79). In a retrospective nonrandomized case series, it was reported that infection only occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and in 0.4% of patients with laser resurfacing (80). Broad-spectrum antibiotic therapy and drainage contribute to the successful treatment of postoperative infections (79).

Eyelid retraction may affect both the upper and lower eyelid. Upper lid retraction may occur if there is excessive trauma to the levator muscle, levator aponeurosis, and the pre-aponeurotic fat pad. Upper eyelid retraction may also arise from cicatricial changes and tissue loss after periocular reconstruction, loss of anterior lamella, middle lamellar injury, and middle lamellar scarring (81,82). Upper eyelid retraction is more commonly observed than upper eyelid ectropion due to the effects of gravity (82). Patients will often present with a superior scleral show with the eyelid positioned above the superior corneal limbus or with exposure keratitis secondary to the upper eyelid retraction. In efforts to avoid upper eyelid retraction, oculoplastic surgeons preserve a minimum of 10 mm of skin under the brows above the upper lid crease incision, with 20 mm of skin being ideal (81,82).

Lower eyelid retraction may result from cicatricial postsurgical alterations, especially if the wound has notable vertical tension (82). Vertical tension is due to several factors and can involve scarring between the orbital septum, lateral canthal laxity, midface descent, and malar hypoplasia (83). Additionally, patients with a postoperative lower lid retraction may present with secondary tearing, irritation, and lagophthalmos. The transconjunctival method significantly reduces the incidence of lower eyelid retraction, as it avoids scarring of the lower eyelid skin and anterior lamella (84).

Synthetic flaps

Sheridan and Tompkins described the ideal skin substitute as one that: (I) is inexpensive; (II) has a long shelf life; (III) is used off the shelf; (IV) is non-antigenic; (V) durable; (VI) flexible; (VII) prevents water loss; (VIII) provides a bacterial barrier; (IX) drapes well; (X) is easy to secure; (XI) grows with child; (XII) is applied in one operation; (XIII) does not become hypertrophic (85). While it currently remains impossible to adhere to all these ideals, research in this field is rapidly evolving. Although synthetic flaps may be used when there is not enough skin for proper closure after BCC resection, such methods have not been studied extensively in the periocular region (86). This may be due to the relatively small resections that typically take place around the eye, making the need for synthetic skin flaps unnecessary. However, in the event of rapidly enlarging BCC in the periocular region that requires resection, it would be beneficial to have access to synthetic skin.

Glues in stabilization of periocular skin grafts

The use of glue as means of stabilization of periocular skin grafts requires further analysis. A retrospective study demonstrated some effectiveness with the use of cyanoacrylate glue as a way to stabilize periocular grafts (87). However, this study was relatively small (n=9) and 2 patients experienced complications such as mild residual ectropion and mild punctual ectropion (77). Even though most patients did not suffer from major complications such as graft necrosis, longer and larger studies must be performed to evaluate the long-term efficacy of cyanoacrylate glue as a means of graft stabilization.

Strengths and limitations

This review provides a comprehensive analysis of periocular reconstructive techniques following Mohs surgery, offering valuable insights into their indications, efficacy, and potential complications. By incorporating recent advancements, such as synthetic flaps and stabilizing glues, the paper highlights emerging innovations in the field. While the authors have tried to find data that is recent and published after 2018, some were unable to be adequately identified. Thus, the “updates” presented may not signify large differences from previously published reviews. Additionally, while the discussion covers various techniques, direct comparisons of long-term outcomes, and patient-reported satisfaction are limited. Future studies incorporating quantitative analysis could further strengthen the clinical applicability of these findings.

Conclusions

MMS is a mainstay surgical treatment of BCC that involves the periocular region and other sensitive regions. While MMS leaves a maximal amount of tissue compared to other surgical procedures aimed at treating BCC, a certain degree of resection is unavoidable. Surgical repair of the eyelid following MMS presents unique challenges as eyelid reconstruction must take into account the eyelid’s highly specific function while also preserving aesthetic outcome. There is a repertoire of reconstructive methods including primary closure with and without secondary intentions, direct margin repair, local flap closure and advance flap, Tenzel flap and tarso-conjunctiva flap, periocular skin grafting, and structural grafting. Various flap methods corresponding to the lesion it is used to repair, their advantages, and their disadvantages are shown in Table 1. Skin flaps can be employed in conjunction with reconstructive flaps when the flap does not have sufficient surrounding tissues while larger defects may require galeal-pericranial flaps. The nasolacrimal system can also be reconstructed if it is resected during Mohs surgery using mono-canicular or bi-canalicular tube insertion. As more studies that use synthetic flaps and stabilizing glue are conducted, they may also prove useful as an additional or alternative means to reconstruct the eyelid following periorbital Mohs surgery.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-24-34/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-24-34/coif). S.J. serves as an unpaid editorial board member of Annals of Eye Science from August 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Furdova A, Kapitanova K, Kollarova A, et al. Periocular basal cell carcinoma - clinical perspectives. Oncol Rev 2020;14:420. [PubMed]
2. Rubin AI, Chen EH, Ratner D. Basal-cell carcinoma. N Engl J Med 2005;353:2262-9. [PubMed]
3. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med 2015;88:167-79. [PubMed]
4. Jayaraman SS, Rayhan DJ, Hazany S, et al. Mutational landscape of basal cell carcinomas by whole-exome sequencing. J Invest Dermatol 2014;134:213-20. [Crossref] [PubMed]
5. McDaniel B, Badri T, Steele RB. Basal Cell Carcinoma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Apr 21]. Available online: http://www.ncbi.nlm.nih.gov/books/NBK482439/
6. Patel SY, Itani K. Review of Eyelid Reconstruction Techniques after Mohs Surgery. Semin Plast Surg 2018;32:95-102. [Crossref] [PubMed]
7. Newlands C, Currie R, Memon A, et al. Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S125-32. [Crossref] [PubMed]
8. Jabbehdari S, Veluvolu M, Kornhauser T, et al. Vismodegib as an adjuvant treatment for periorbital basal cell carcinoma: a case report and review of literature. Ann Transl Med 2024;12:54. [Crossref] [PubMed]
9. Juniat V, Shah P, Vonica O, et al. Periocular basal cell carcinoma recurrence following surgical treatment: Safe surveillance time. Eye (Lond) 2023;37:971-6. [Crossref] [PubMed]
10. Schmults CD, Blitzblau R, Aasi SZ, et al. Basal Cell Skin Cancer, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2023;21:1181-203. [Crossref] [PubMed]
11. Ho SF, Brown L, Bamford M, et al. 5 years review of periocular basal cell carcinoma and proposed follow-up protocol. Eye (Lond) 2013;27:78-83. [Crossref] [PubMed]
12. Poignet B, Gardrat S, Dendale R, et al. Basal cell carcinomas of the eyelid: Results of an initial surgical management. J Fr Ophtalmol 2019;42:1094-9. [PubMed]
13. Gulleth Y, Goldberg N, Silverman RP, et al. What is the best surgical margin for a Basal cell carcinoma: a meta-analysis of the literature. Plast Reconstr Surg 2010;126:1222-31. [PubMed]
14. Smeets NW, Krekels GA, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004;364:1766-72. [PubMed]
15. Malhotra R, Huilgol SC, Huynh NT, et al. The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology 2004;111:631-6. [PubMed]
16. Mohs FE. Micrographic surgery for the microscopically controlled excision of eyelid cancers. Arch Ophthalmol 1986;104:901-9. [PubMed]
17. Glatt HJ, Olson JJ, Putterman AM. Conventional frozen sections in periocular basal-cell carcinoma: a review of 236 cases. Ophthalmic Surg 1992;23:6-8; discussion 9. [PubMed]
18. Bharath AK, Turner RJ. Impact of climate change on skin cancer. J R Soc Med 2009;102:215-8. [Crossref] [PubMed]
19. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years’ follow-up. Lancet Oncol 2008;9:1149-56. [Crossref] [PubMed]
20. Cerrati EW, Thomas JR. Scar Revision and Recontouring Post-Mohs Surgery. Facial Plast Surg Clin North Am 2017;25:463-71. [Crossref] [PubMed]
21. Johnson AR, Egeler SA, Wu WW, et al. Facial Reconstruction After Mohs Surgery: A Critical Review of Defects Involving the Cheek, Forehead, and Perioral Region. J Craniofac Surg 2019;30:400-7. [Crossref] [PubMed]
22. Likhacheva A, Awan M, Barker CA, et al. Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol 2020;10:8-20. [Crossref] [PubMed]
23. Kim SK, Barker CA. Outcomes of radiation therapy for advanced T3/T4 nonmelanoma cutaneous squamous cell and basal cell carcinoma. Br J Dermatol 2018;178:e30-2. [Crossref] [PubMed]
24. Brantsch KD, Meisner C, Schönfisch B, et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008;9:713-20. [Crossref] [PubMed]
25. Cisek P, Kieszko D, Bilski M, et al. Interstitial HDR Brachytherapy in the Treatment of Non-Melanocytic Skin Cancers around the Eye. Cancers (Basel) 2021;13:1425. [Crossref] [PubMed]
26. Shah C, Ouhib Z, Kamrava M, et al. The American Brachytherapy society consensus statement for skin brachytherapy. Brachytherapy 2020;19:415-26. [Crossref] [PubMed]
27. Bilski M, Cisek P, Baranowska I, et al. Brachytherapy in the Treatment of Non-Melanoma Skin Peri-Auricular Cancers-A Retrospective Analysis of a Single Institution Experience. Cancers (Basel) 2022;14:5614. [Crossref] [PubMed]
28. Fionda B, Pagliara MM, Sammarco MG, et al. New combined treatments, surgery and high-dose-rate interventional radiotherapy (brachytherapy), in advanced ocular surface and eyelid cancers. Transl Oncol 2025;51:102160. [Crossref] [PubMed]
29. Fionda B, Pagliara MM, Chyrek AJ, et al. Ocular Brachytherapy (Interventional Radiotherapy): Preserving the Vision. Clin Oncol (R Coll Radiol) 2023;35:e445-52. [Crossref] [PubMed]
30. Ing EB, Philteos J, Sholohov G, et al. Local anesthesia and anxiolytic techniques for oculoplastic surgery. Clin Ophthalmol 2019;13:153-60. [Crossref] [PubMed]
31. Gupta A, Tomlins PJ. Alleviating Pain in Oculoplastic Procedures by Reducing the Rate of Injection of Local Anaesthetic. Open Ophthalmol J 2015;9:156-8. [Crossref] [PubMed]
32. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA 2013;310:1721-9. [Crossref] [PubMed]
33. Gower EW, Lindsley K, Tulenko SE, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev 2017;2:CD006364. [Crossref] [PubMed]
34. Thomas PA, Geraldine P. Infectious keratitis. Curr Opin Infect Dis 2007;20:129-41. [Crossref] [PubMed]
35. Watson S, Cabrera-Aguas M, Khoo P. Common eye infections. Aust Prescr 2018;41:67-72. [Crossref] [PubMed]
36. Berkelman RL, Holland BW, Anderson RL. Increased bactericidal activity of dilute preparations of povidone-iodine solutions. J Clin Microbiol 1982;15:635-9. [Crossref] [PubMed]
37. Bernardini F, Skippen B. Principles and Techniques of Eyelid Reconstruction. In: Chaugule SS, Honavar SG, Finger PT. editors. Surgical Ophthalmic Oncology: A Collaborative Open Access Reference. Cham: Springer International Publishing; 2019:33-57.
38. Morton J. Secondary intention healing in lower eyelid reconstruction--a valuable treatment option. J Plast Reconstr Aesthet Surg 2010;63:1921-5. [Crossref] [PubMed]
39. Shafi F, Rathore D, Johnson A, et al. Medial canthal defects following tumour excision: To reconstruct or not to reconstruct? Orbit 2017;36:64-8. [Crossref] [PubMed]
40. Morley AM, deSousa JL, Selva D, et al. Techniques of upper eyelid reconstruction. Surv Ophthalmol 2010;55:256-71. [Crossref] [PubMed]
41. Omari A, Shaheen KW. Upper Eyelid Reconstruction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Jun 6]. Available online: http://www.ncbi.nlm.nih.gov/books/NBK551694/
42. Lize F, Leyder P, Quilichini J. Horizontal V-Y advancement flap for lower eyelid reconstruction in young patients. J Fr Ophtalmol 2015;38:7-12. [Crossref] [PubMed]
43. Patrinely JR, Marines HM, Anderson RL. Skin flaps in periorbital reconstruction. Surv Ophthalmol 1987;31:249-61. [Crossref] [PubMed]
44. Tang W, Zhang L, Li Z, et al. Myocutaneous sliding flap for reconstruction of divided eyelid nevus. Can J Ophthalmol 2023;58:47-51. [Crossref] [PubMed]
45. Mizobuchi R, Nojiri G, Uchiyama M, et al. Sliding Flap for the Wide Upper Eyelid Margin Defect After Cancer Removal. J Craniofac Surg 2022;33:2593-7. [Crossref] [PubMed]
46. Berggren J, Castelo N, Tenland K, et al. Revascularization After H-plasty Reconstructive Surgery in the Periorbital Region Monitored With Laser Speckle Contrast Imaging. Ophthalmic Plast Reconstr Surg 2021;37:269-73. [Crossref] [PubMed]
47. Starkman SJ, Williams CT, Sherris DA. Flap Basics I: Rotation and Transposition Flaps. Facial Plast Surg Clin North Am 2017;25:313-21. [Crossref] [PubMed]
48. Volz A, Häusermann P. Optimal placement of Burow’s triangles for aesthetically pleasing repair of multiple defects using local flaps after tumor excision. JDDG J Dtsch Dermatol Ges 2018;16:1166-9. [Crossref] [PubMed]
49. Yan Y, Fu R, Ji Q, et al. Surgical Strategies for Eyelid Defect Reconstruction: A Review on Principles and Techniques. Ophthalmol Ther 2022;11:1383-408. [Crossref] [PubMed]
50. Ibáñez-Flores N, Bruzual-Lezama C, Castellar-Cerpa JJ, et al. Lower eyelid reconstruction with pericranium graft and Mustarde flap. Arch Soc Esp Oftalmol (Engl Ed) 2019;94:514-7. [Crossref] [PubMed]
51. Seyhan T, Caglar B. “Reading man flap” design for reconstruction of circular infraorbital and malar skin defects. Dermatol Surg 2008;34:1536-43. [PubMed]
52. Sullivan TJ, Bray LC. The bilobed flap in medial canthal reconstruction. Aust N Z J Ophthalmol 1995;23:42-8. [Crossref] [PubMed]
53. Iida N, Ohsumi N, Tonegawa M, et al. Simple method of designing a bilobed flap. Plast Reconstr Surg 1999;104:495-9. [Crossref] [PubMed]
54. Cha JA, Lee KA. Reconstruction of periorbital defects using a modified Tenzel flap. Arch Craniofac Surg 2020;21:35-40. [Crossref] [PubMed]
55. Abbasi S, Kamil Z, Faisal SM, et al. Upper Eyelid Reconstruction Surgeries; Comparison Of Outcomes Between Reverse Tenzel Flap Versus Cutler Beard Flap Procedure. J Ayub Med Coll Abbottabad 2022;34:36-40. [Crossref] [PubMed]
56. Ahmad J, Mathes DW, Itani KM. Reconstruction of the eyelids after mohs surgery. Semin Plast Surg 2008;22:306-18. [Crossref] [PubMed]
57. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle flap technique. Ophthalmology 1978;85:1164-9. [Crossref] [PubMed]
58. Levine MR, Buckman G. Semicircular flap revisited. Arch Ophthalmol 1986;104:915-7. [Crossref] [PubMed]
59. Bouazza M, Elbelhadji M, Cherkaoui S, et al. Role of Köllner-Hughes tarsoconjunctival flap in the reconstruction of large eyelid defects. J Fr Ophtalmol 2017;40:363-70. [Crossref] [PubMed]
60. Hishmi AM, Koch KR, Matthaei M, et al. Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection. Eur J Med Res 2016;21:27. [PubMed]
61. Jordan DR, Anderson RL, Nowinski TS. Tarsoconjunctival flap for upper eyelid reconstruction. Arch Ophthalmol 1989;107:599-603. [Crossref] [PubMed]
62. Rohrich RJ, Zbar RI. The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction. Plast Reconstr Surg 1999;104:518-22; quiz 523; discussion 524-6.
63. Khan AA, Khan IM, Nguyen PP, et al. Skin Graft Techniques. Clin Podiatr Med Surg 2020;37:821-35. [PubMed]
64. Leibovitch I, Huilgol SC, Hsuan JD, et al. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol 2005;89:219-22. [Crossref] [PubMed]
65. Madge SN, Malhotra R, Thaller VT, et al. A systematic approach to the oculoplastic reconstruction of the eyelid medial canthal region after cancer excision. Int Ophthalmol Clin 2009;49:173-94. [PubMed]
66. Hayano SM, Whipple KM, Korn BS, et al. Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy. J Skin Cancer 2012;2012:438502. [PubMed]
67. Rathore DS, Chickadasarahilli S, Crossman R, et al. Full thickness skin grafts in periocular reconstructions: long-term outcomes. Ophthalmic Plast Reconstr Surg 2014;30:517-20. [PubMed]
68. Inchingolo F, Tatullo M, Abenavoli FM, et al. Upper eyelid reconstruction: a short report of an eyelid defect following a thermal burn. Head Face Med 2009;5:26. [PubMed]
69. Leibovitch I, Malhotra R, Selva D. Hard palate and free tarsal grafts as posterior lamella substitutes in upper lid surgery. Ophthalmology 2006;113:489-96. [PubMed]
70. Chang HH, Suh E, Fortes BH, et al. Forehead galeal pericranial flap for single-staged total upper eyelid reconstruction in sebaceous gland carcinoma excision. Int Med Case Rep J 2017;10:309-12. [PubMed]
71. Brusati R, Colletti G, Redaelli V. Upper eyelid reconstruction with forehead galeal flap. J Plast Reconstr Aesthet Surg 2009;62:901-5. [PubMed]
72. Yüce S, Demir Z, Selçuk CT, et al. Reconstruction of periorbital region defects: A retrospective study. Ann Maxillofac Surg 2014;4:45-50. [Crossref] [PubMed]
73. Ullrich K, Malhotra R, Patel BC. Dacryocystorhinostomy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Jul 14]. Available online: http://www.ncbi.nlm.nih.gov/books/NBK557851/
74. Hwang CJ, Chon BH, Perry JD. 7-Ophthalmologic Evaluation in Orbital and Lacrimal Disease. In: Sindwani R. editor. Endoscopic Surgery of the Orbit. Philadelphia: Elsevier; 2021:41-8. Available online: https://www.sciencedirect.com/science/article/pii/B978032361329300007X
75. Sweeney AR, Davis GE, Chang SH, et al. Outcomes of Endoscopic Dacryocystorhinostomy in Secondary Acquired Nasolacrimal Duct Obstruction: A Case-Control Study. Ophthalmic Plast Reconstr Surg 2018;34:20-5. [Crossref] [PubMed]
76. Kaoutzanis C, Gupta V, Winocour J, et al. Incidence and Risk Factors for Major Surgical Site Infections in Aesthetic Surgery: Analysis of 129,007 Patients. Aesthet Surg J 2017;37:89-99. [Crossref] [PubMed]
77. Ashraf DC, Idowu OO, Wang Q, et al. The Role of Topical Antibiotic Prophylaxis in Oculofacial Plastic Surgery. Ophthalmology 2020;127:1747-54. [Crossref] [PubMed]
78. Fay A, Nallasamy N, Bernardini F, et al. Multinational Comparison of Prophylactic Antibiotic Use for Eyelid Surgery. JAMA Ophthalmol 2015;133:778-84. [Crossref] [PubMed]
79. Klapper SR, Patrinely JR. Management of cosmetic eyelid surgery complications. Semin Plast Surg 2007;21:80-93. [Crossref] [PubMed]
80. Carter SR, Stewart JM, Khan J, et al. Infection after blepharoplasty with and without carbon dioxide laser resurfacing. Ophthalmology 2003;110:1430-2. [Crossref] [PubMed]
81. Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int 2012;2012:252368. [Crossref] [PubMed]
82. Carniciu AL, Jovanovic N, Kahana A. Eyelid Complications Associated with Surgery for Periocular Cutaneous Malignancies. Facial Plast Surg 2020;36:166-75. [Crossref] [PubMed]
83. Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg 2000;106:438-53; discussion 454-9. [Crossref] [PubMed]
84. Goldberg RA, Lessner AM, Shorr N, et al. The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthalmic Plast Reconstr Surg 1990;6:241-6. [Crossref] [PubMed]
85. Sheridan RL, Tompkins RG. Skin substitutes in burns. Burns 1999;25:97-103. [Crossref] [PubMed]
86. Kopecký A, Němčanský J, Kratky V, et al. Bioengineered dermal substitutes for periocular defects. Ann Eye Sci 2021;6:16. [Crossref]
87. Jackson CM, Nguyen M, Mancini R. Use of Cyanoacrylate Glue Casting for Stabilization of Periocular Skin Grafts and Flaps. Ophthalmic Plast Reconstr Surg 2017;33:218-20. [Crossref] [PubMed]