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Indian J Ophthalmol. 2016 Mar;64(3):177-90. doi: 10.4103/0301-4738.181752.

Pathology of eyelid tumors.

Pe'er J1.

Author information

Abstract

The eyelids are composed of four layers: skin and subcutaneous tissue including its adnexa,
striated muscle, tarsus with the meibomian glands, and the palpebral conjunctiva. Benign and
malignant tumors can arise from each of the eyelid layers. Most eyelid tumors are of
cutaneous origin, mostly epidermal, which can be divided into epithelial and melanocytic
tumors. Benign epithelial lesions, cystic lesions, and benign melanocytic lesions are very
common. The most common malignant eyelid tumors are basal cell carcinoma in Caucasians
and sebaceous gland carcinoma in Asians. Adnexal and stromal tumors are less frequent. The
present review describes the more important eyelid tumors according to the following groups:
Benign and malignant epithelial tumors, benign and malignant melanocytic tumors, benign
and malignant adnexal tumors, stromal eyelid tumors, lymphoproliferative and metastatic
tumors, other rare eyelid tumors, and inflammatory and infections lesions that simulate
neoplasms.

PMID:
27146927
PMCID:
PMC4869455
DOI:
10.4103/0301-4738.181752
[Indexed for MEDLINE]
Free PMC Article

Images from this publication.See all images (17)Free text

Squamous papilloma presenting as a papillary lesion in the upper lid margin

 Basal cell carcinoma of the lower eyelid presenting as an elevated ulcerated
nodule

Clinical picture of a split nevus, also known as kissing nevus

Oculodermal melanocytosis, known as nevus of Ota, showing unilateral bluish

discoloration of the eyelid and periorbital skin and blue scleral discoloration

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Periocular Reconstruction
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Chapter 12 Periocular Reconstruction

Paul Bowman, Scott W. Fosko, Morris E. Hartstein

INTRODUCTION
Cutaneous neoplasms are commonly encountered in the periocular region. Dermatologic
surgeons should feel comfortable performing excisions and closing the resultant defects. In
regards to surgical reconstruction, the periorbital area is unique in several ways. It is a
complex region with free margins and anatomic landmarks that can easily be distorted. Most
importantly, the function of the eyelidsprotecting the globe and maintaining a moist
environment for the corneamust be assured. With experience, dermatologic surgeons can
become adept at repairing most periocular defects. This chapter will address reconstruction of
small to medium-sized defects of the periocular area, and some partial-thickness, non-
marginal defects of the eyelids. Collaboration with an oculoplastic surgeon is prudent when
periocular defects require reconstruction of the lacrimal apparatus or canthi, or when defects
involve a significant portion of the eyelid margin.

PERIOCULAR ANATOMY
Surface Anatomy

It is useful to conceptually divide the face into aesthetic units when discussing reconstructive
techniques.1,2 Recognizing the junction lines between neighboring units is important as they
conceal surgical scars well. Most authors use the eyebrow as the superior limit of the
periocular aesthetic unit; however, the suprabrow area can also be considered to be part of the
periocular area, as closures in this area can affect the eyebrow and upper eyelid (Figure 12.1).
The infraorbital and nasojugal creases define the inferior border of the periocular unit. The
nasofacial sulcus marks the medial border in the medial canthal area, while the frontal
process of the zygomatic bone defines the lateral margin. Anatomically, it is also useful to
distinguish the palpebral portions of the upper and lower eyelids, which overlie the globe
when the lids are closed, from the orbital portions, which continue over the bony orbital
margin to the edge of the periocular aesthetic unit.
Figure 12.1 Surface anatomy of the periocular area.

Other naturally occurring skin folds and creases within aesthetic units can similarly be used
to hide surgical scars, as these lines appear normal and do not attract attention. The upper
eyelid crease, for example, hides upper blepharoplasty incisions. Other aspects of periocular
aesthetics should also be considered when moving tissue for reconstruction. The concavity of
the medial canthus, the symmetry of the eyelids, and the orientation of eyebrow hairs are
some of the more subtle features that can become conspicuous if undesirably altered.
Attention to these surface characteristics will help avoid distortion of periocular structures
and promote aesthetically proper surgical closures.

Surgical Anatomy

A thorough knowledge of the anatomy of the periocular region is paramount to successful

surgery in this area (Figure 12.2). Understanding tissue planes and functional relationships
between anatomic structures serve the surgeon well in this complex area. Familiarity with the
location of nerves, blood vessels, and danger zones is critical to achieving optimal surgical
results and avoiding bad outcomes.
Figure 12.2 Surgical anatomy of the periocular area. Note the superficial location of the
temporal branch of the facial nerve as it approaches the periocular area. It lies between the
thin superficial muscular aponeurotic system (SMAS) layer and the temporalis fascia for
most of its course here. Only as it crosses the edge of the frontal bone does it dive under the
frontalis muscle and become more protected. Not pictured in this diagram are the superior
and inferior palpebral arteries, which arch across the eyelids parallel to the lid margins,
piercing the orbital septum above and below the medial and lateral canthal tendons.

The margins of the bony orbit are defined by the frontal bone superiorly, the zygomatic bone
inferolaterally, and the maxilla inferomedially. Within the orbit sits the globe with its
associated vessels, muscles, nerves, fat, and most of the lacrimal apparatus. The orbital
septum, a membranous sheet of connective tissue that arises from the periosteum of the
orbital rim and spans across the lids, separates the globe and deeper orbital structures from
the more superficial muscles and skin. Within each eyelid is a crescent-shaped tarsal plate,
the fibroblastic lamina that provides the semirigid structure of the lid. The medial and lateral
ends of these plates are stabilized by the medial and lateral canthal tendons, respectively,
which attach to the adjacent bony orbit.

The orbicularis oculi muscle lies superficial to the orbital septum. The sphincter muscle of
the eyelids, it controls blinking and forceful eyelid closure. It can be divided into palpebral
and orbital portions. The palpebral part, confined to the eyelids, arises from the medial
canthal tendon and arches across both lids (anterior to the tarsal plates) to insert into the
lateral canthal tendon. In oculoplastic surgery it is useful to further subdivide this part into the
pretarsal and preseptal portions. The orbital portion of the muscle, located more peripherally,
lies flat on the surface of the orbital margin, bordering the forehead and cheek. Its fibers arise
from the medial end of the medial canthal tendon and adjoining bone to extend laterally in a
series of uninterrupted concentric loops around the orbit. The elevator of the upper lid is the
levator palpebrae superioris, a long, flat muscle above the globe. Its aponeurosis fuses with
the orbital septum superiorly to insert into the superior tarsus and skin of the upper eyelid.
The upper eyelid is larger and more mobile than the lower eyelid, and it completely covers
the cornea when the lids are closed. The skin of the eyelids is less than 1 mm thick with
minimal subcutaneous tissue, and it is tightly adherent to the underlying muscle in the
pretarsal region. Over the preseptal and orbital regions, the skin is more mobile. The posterior
surface of the eyelids is lined by the palpebral conjunctiva, a thin mucous membrane that
reflects in the superior and inferior fornices of the conjunctival sac onto the anterior surface
of the globe (the bulbar conjunctiva). Coronally, the eyelids can be divided into two lamellae.
The anterior lamella includes the superficial skin and orbicularis oculi muscle, whereas the
posterior lamella consists of the tarsal plates, lid retractor muscles, and palpebral conjunctiva.

The lids meet each other at the medial and lateral canthal angles, while the palpebral fissure
between them opens into the conjunctival sac and underlying globe. The lateral canthal angle
is more acute than the medial, and it lies in direct contact with the globe. The more rounded
medial canthus is separated from the globe by a small space, the lacrimal lake, which
contains a small mound of tissue, the lacrimal caruncle. The lacrimal gland, situated in the
superolateral part of the orbit, lies posterior to the orbital septum and the frontal bone. It
secretes tears into the superior fornix of the conjunctiva that wash across the cornea to collect
in the lacrimal lake in the medial canthus. Near the medial canthus, both upper and lower
eyelids have small lacrimal papules on their margins that contain lacrimal punctor, through
which tears drain into the lacrimal canaliculi and to the lacrimal sac. The sac then drains
through the nasolacrimal duct to empty into the inferior meatus of the nose. The lacrimal sac
lies in a protected position, behind the medial canthal tendon. It is enveloped by fibers of the
orbicularis oculi muscle, such that each blink of the eyelids serves to pump tears through the
sac and into the nose.

The temporal branch of the facial nerve is the most superficially located (and thus most
susceptible) motor nerve in the periocular area. From its emergence beneath the parotid gland
in the preauricular region, its course is roughly delineated by drawing one line from 0.5 cm
below the tragus to a point 2 cm above the lateral end of the eyebrow and a second along the
zygomatic arch.3,4 The nerve is most superficial in the area of the zygomatic arch, and it is
therefore most at risk to damage during a surgical procedure at this site. Anatomically, the
four tissue layers of importance in the area of the lateral canthus are the skin and
subcutaneous fat, the superficial muscular aponeurotic system (SMAS), the temporalis fascia,
and the temporalis muscle. The SMAS is a thin layer of connective tissue that is continuous
with the galea superiorly, the frontalis anteriorly, the occipitalis posteriorly, and the muscles
of facial expression inferiorly. In the area of the temple, the temporal branch of the facial
nerve runs just below the SMAS, within a layer of loose areolar tissue superficial to the
temporalis fascia.4 At the lateral forehead the nerve dives under the frontalis muscle,
becoming less vulnerable to surgical injury. The temporal nerve innervates the ipsilateral
frontalis muscle and, to a lesser extent, the orbicularis oculi muscle, and nerve transection
leads to weakness of the ipsilateral forehead with droop of the eyebrow and decreased ability
to close the eye tightly. The importance of understanding the course of the facial nerve
branches and their anatomic relationship to these tissue planes cannot be overstated.

The supraorbital and infraorbital nerves exit the skull via the supraorbital notch and
infraorbital foramen, respectively, both located on a vertical line drawn from the medial
corneal limbus. Moving clockwise from the supraorbital notch, the supratrochlear and
infratrochlear nerves penetrate the orbital septum at the orbital rim. While localizing these
can be useful in performing nerve blocks to anesthetize the eyelids and periorbital area, the
nerves lie at such a depth that they are relatively protected from inadvertent transection
during surgery.

The periorbital area has a rich vascular supply derived from both the internal and external
carotid arteries. The ophthalmic artery arising from the internal carotid artery supplies the
supraorbital, supratrochlear, dorsal nasal, and palpebral arteries. The superior and inferior
palpebral arteries arch across the eyelids parallel to the lid margins, piercing the orbital
septum above and below the medial and lateral canthal tendons. The external carotid artery
contributes the remainder of the blood supply, including the superficial temporal artery,
which emerges from beneath the parotid gland in the preauricular area. The superficial
temporal arterys frontal branch arcs across the temporalis muscle to supply the lateral
eyebrow region as it anastomoses with the supraorbital artery, while the transverse facial
artery courses over the zygoma to join the infraorbital artery in the lower eyelid. The facial
artery ascends along the nasofacial sulcus to anastomose with the infraorbital and transverse
facial arteries, above which the facial artery continues superiorly along the medial orbit as the
angular artery, merging with the dorsal nasal artery superior to the medial canthus. Although
such excellent vascular supply easily supports flaps and grafts in the periorbital region, the
thin, distensible tissues can also predispose to significant postoperative ecchymoses.
Meticulous intraoperative hemostasis is important in avoiding hematoma development.

PREPARATION
The periorbital area is a unique region, and in preparing for surgery, the surgeon should have
several special considerations. Protection of the eye is of utmost importance, and this should
be kept in mind at each step of the surgical process. When cleansing the periorbital skin,
Hibiclens (chlorhexidine) (Zeneca Pharmaceuticals, Wilmington, DE) should not be used as
it can be toxic to the cornea. Betadine (povidone-iodine) (Purdue Frederick Company,
Norwalk, CT), which is less irritating, can be used as an alternative cleanser. When injecting
local anesthetic into periocular tissues, the injecting hand should be firmly stabilized against
the patient, and the needle directed parallel to or away from the globe whenever possible to
avoid accidental injury to the eye should the patient moves unexpectedly.

Consideration should be given to using protective corneal shields to prevent inadvertent

surgical trauma,5 especially if the procedure will involve the palpebral portion of the eyelids
(Figure 12.3). These shields are inexpensive and easily inserted under the lids after instilling
several drops of tetracaine 0.5% or a similar anesthetic into the palpebral fissure. The shields
are generally well tolerated. To minimize migration and inadvertent corneal exposure during
surgery, the largest size corneal shields that can comfortably be inserted should be used.
Besides protecting the globe, the shields also block the patients view of the bright surgical
lights. Both plastic and metal shields are available; the same metal shields used for laser
resurfacing (Jedmed, St Louis) can be used for general reconstructive surgery.
Figure 12.3 Insertion of corneal shields. (a) Instillation of topical anesthetic (tetracaine,
proparacaine, etc.). (b) Plastic eyeshield about to be introduced. Note the size of the shield
the largest possible size should be used to fully protect the cornea (if too small the shield may
shift during surgery). (c) As the patient is asked to gaze inferiorly, the upper eyelid is lifted
up and over the superior edge of the shield. (d) The patient is asked to gaze upwards, which
helps to carry the superior edge of the shield under the upper eyelid. The lower eyelid is then
lifted up and over the inferior edge of the shield. (e) The patient is asked to resume normal
forward gaze (or look down slightly) to carry the inferior edge of the shield under the lower
eyelid. Placing a finger just below the eyebrow, slight manual retraction of the upper eyelid
can help to release eyelashes or remaining portions of the upper lid still below the superior
edge of the shield. (f) Corneal shield in place.

During the discussion of the procedure and expected postoperative course, the surgeon should
prepare the patient for the possibility of swelling and bruising, which are not uncommon in
the thin, distensible tissues of the eyelids (Figure 12.4). This is an expected part of periorbital
surgery. Having the patient sleep with the head in an elevated position for the first few days
after surgery may minimize postoperative bruising. Although short-lived and usually
painless, the bruising can at times be quite dramatic and alarming to the patient. Because of
gravitational forces, periorbital ecchymoses can occasionally extend as inferior as the jaw
line.

Figure 12.4 (a) Postoperative bruising and swelling often collects in the thin, distensible
tissues of the eyelids, even if the surgery was not performed on the lids themselves. Because
of gravity, patients with surgical sites of the suprabrow or temple often develop ecchymoses
of the lower eyelid. (b) In this patient, swelling and bruising from a surgical site on the lower
lid extended superiorly to involve the upper lid. Failing to elevate the head overnight can also
partially contribute to this scenario.

GENERAL PRINCIPLES OF
PERIOCULAR RECONSTRUCTION
The main goals of reconstruction are to restore function, optimize wound healing, and create
the best possible cosmetic result. For small to medium-sized superficial defects of the
periocular area, the first two issues are rarely a problem, and the focus then shifts to
optimizing cosmesis.

How well a surgical scar is hidden is a function of three factors: the tension on the wound, the
quality of the tissue used to close the defect, and the placement of skin incisions. Wounds
closed with minimal tension heal better and form less prominent scars. Fortunately, there is
minimal intrinsic tension in the periocular region when compared to other body areas such as
the back or chest, where hypertrophic and spread scars are common. To minimize tension
across a wound, it is also important to consider the relaxed skin tension lines (RSTLs) (Figure
12.5). These lines indicate the direction of least tension in relaxed skin (incisions parallel to
them experience less tension while healing). Perpendicular to the RSTLs are the lines of
maximum extensibility (LME). Placing a fusiform excision parallel to the RSTLs will thus
simultaneously provide maximal tissue extensibility to close the wound and minimal tension
while healing, resulting in an optimal scar.
Figure 12.5 The relaxed skin tension lines (RSTLs) of the upper face and periocular area.

Another critical factor in camouflaging a surgical recon-struction is the quality of skin used to
close the defect. Repairs are most effectively hidden when the texture and thickness of the
skin closing the defect closely matches the surrounding skin, thus de-emphasizing any border
between the two. For this reason, simple, side-to-side closures, where the tissue that slides
over the defect is the neighboring skin, are often aesthetically ideal. In contrast, skin grafts,
which are taken from distant, often poorly matching tissues, often demonstrate conspicuous
patch appearances with obvious borders. Flaps are best designed using skin from the same
aesthetic unit, which is most similar in thickness and texture; this also avoids crossing
junction lines into neighboring units.

Finally, surgical incisions are best concealed in wrinkles or aesthetic unit junctions, as these
are normal lines that even casual observers expect to see. When placing incisions outside
these natural lines, short, curved, or turning incisions may be less obvious than straight ones.
Crossing aesthetic unit junction lines with long, straight incisions should be avoided if
possible. Curving the ends of incisions to parallel the RSTLs will also minimize tension and
leave the least conspicuous scar. When designing a periocular repair, it is best to highlight
natural wrinkles, RSTLs, and aesthetic unit boundary lines on the skin with a surgical marker
before incision. Asking the patient to animate muscles around the area (smile, frown, etc.) is
especially useful in younger patients in whom rhytids are not obvious at rest.

When it is not possible to hide incisions within contour lines and wrinkles, moving the repair
away from the easily visualized central face may make it less noticeable. As the lateral
surfaces of the temple and cheek curve around the head they become parallel to the line of
sight and are not as visible. So, for a surgical defect of the lateral face, shifting the repair
peripherally to the temple will conceal it in the frontal view, whereas extending incisions
medially onto the cheek may accentuate it. This could be a consideration in choosing a
laterally based flap over a simpler side-to-side elliptical closure that would require extending
incisions further into the central face.

METHODS OF CLOSURE
In general, periocular skin defects can be allowed to heal by one of four methods: granulation
(second intent healing), side-to-side closure (conversion into a fusiform ellipse), flaps, and
grafts. Since every wound has multiple repair options, it is important to understand the
relative strengths and weaknesses of each in order to choose the one reconstructive procedure
most appropriate for any particular surgical wound.

Granulation (Second Intent Healing)

Some defects of the periocular area can be allowed to granulate with good functional and
cosmetic results. In general, smaller wounds on concave surfaces can achieve excellent
cosmetic results through granulation.6

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