Lower Eyelid Full-Thickness Lid Margin Repair for 8-mm Defect Following Mohs Surgery for Basal Cell Carcinoma

Case Overview

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.

Statement of Consent

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.