Eyelid basal cell carcinoma Patient information

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1 Eyelid basal cell carcinoma Patient information Your procedure relates to the face, eyelids, orbit or tear drainage system that together are treated by specialist surgeons in the field of oculoplastic surgery. Miss Kimia Ziahosseini is the consultant ophthalmic and oculoplastic surgeons and works closely with her team in oculoplastic surgery at Spire Norwich Hospital and Norfolk and Norwich University Hospitals. All surgery carries risks and benefits. It is for you to weigh up the risks and benefits before deciding to proceed. What is eyelid skin cancer? Skin cancers can affect the eyelids and adjacent face (peri-ocular skin). Usually they appear as painless lumps often with a pearly appearance. They may become ulcerated and often go through cycles of bleeding then crusting but never fully healing. They may distort the normal eyelid appearance. These findings need to be checked out and may need a biopsy to find out if the lump is a skin cancer. What are the common eyelid skin cancers? Basal cell carcinoma (BCC) or rodent ulcer is by far the commonest skin cancer. 19 out of 20 eyelid skin cancers will be BCCs. They are slow growing so get bigger slowly, but they do destroy the normal eyelid in the area and so need to be treated. It is extremely rare for them to spread to distant parts of the body (metastasise). Squamous cell carcinoma (SCC) is the next commonest eyelid skin cancer. They grow faster than BCCs and 1 in 20 may spread to lymph nodes in the neck and rarely to distant parts of the body. These lumps need to be spotted early and treated adequately to prevent further growth or spread. Early detection and treatment in an appropriate manner is required. What is a Basal Cell Carcinoma? Basal Cell Carcinoma is generally abbreviated to BCC. A BCC is also known as a rodent ulcer. It is a very slow growing cancer of the skin that often affects the eyelids. Its growth is so slow that it virtually never spreads elsewhere in the body. However, if it is not treated it will continue to grow slowly and eventually destroy the surrounding tissue causing ulceration. BCC s are caused by exposure to UV light and will occur on sun-exposed areas such as the face, scalp, ears, hands, shoulders and back. Fair skinned adults are most at risk of developing BCC s, especially if they have been outdoor workers, lived in very sunny areas or are very pale skinned. BCC s are commoner in people over 50 years, but a greater number of younger adults are developing BCCs because of prolonged sun exposure or sun beds. What are the early warning signs? If you develop a skin lesion, or soreness, that fails to heal within 4 to 6 weeks and has two or more of the following features, you should seek medical advice: A painless lump that can appear smooth or even shiny. An open sore or ulcer which bleeds or crusts, and does not heal.

2 A red patch on the skin, which may be itchy, painful, crusty or fail to heal. A flat or slightly raised scarred area on the skin, which is paler than the surrounding skin, making the affected skin look taut and shiny. Will a biopsy be taken? Sometimes a biopsy is needed to confirm the diagnosis and allow more detailed planning of the treatment. The biopsy is done in the minor operating room under local anaesthetic and will only take about minutes. A follow up appointment will be arranged to discuss the result with you. How are BCC s treated? There are several ways of treating BCCs. The choice of treatment will depend on many factors such as the size, position and type of the BCC. Surgery - This is the commonest form of treatment for eyelid tumours and gives the best chance of the BCC not recurring. Cryotherapy (freeze treatment) - Freezing which is a fairly simple treatment can treat smaller BCCs. The recurrence rate is higher than with surgery. Radiotherapy - This can be used for bigger BCCs but once again gives higher recurrence rates than surgery. What are the aims of surgery? The aim of surgery is to completely remove the BCC. A small margin of normal looking skin is also cut out to ensure that any microscopic extensions of the BCC are also removed. The next aim is to repair the eyelid in a way that allows it to function as normally as possible so that the eye remains healthy. Finally the surgeon will try to repair the lid so that it looks as normal as possible. How is this done? The skin containing the lump is cut out with some normal surrounding skin (normally about 3mm). If the BCC is very close to the edge of the eyelid it will be necessary to remove a full thickness piece of the eyelid in order to completely remove the BCC.

3 The eyelid is then repaired generally using stitches that dissolve and do not require removal. Where possible, a small gap will be closed by stitching the wound edges together. However, if the gap is large, it may be necessary to rearrange some of the surrounding looser skin to close the gap or to use a skin graft from another area such as the upper eyelid(s) or from near the ear. You will be told before surgery if this may be necessary. Sometimes the moist inner lining of the eyelid needs to be replaced and a graft or flap of this can be taken from another eyelid or from the inside of the mouth or nose and used to repair the eyelid. How can you tell if the BCC has been completely removed? The surgeon removes the BCC and sends it to a pathologist who checks the tissue microscopically to see if the BCC has been completely removed. This can either be done within an hour if the tissue is frozen or within a few days with the more standard method. Sometimes a skin surgeon who specialises in Mohs micrographic surgery will remove the BCC in a special way to try to ensure its total removal. What is Mohs micrographic surgery? This is a specialised method for excising BCCs where a skin surgeon removes the BCC in layers, which are carefully examined under a microscope at the time of surgery to ensure that it is completely removed. An oculoplastic surgeon then repairs the eyelid. What type of anaesthetic will I have? Most operations are done under local anaesthetic (LA). Numbing drops are put in the eye and local anaesthetic is injected into the affected area of the eyelid. This causes stinging for 10 to 20 seconds and the lid will then be numb. The patient remains awake through out the procedure. Occasionally sedation can be given by an anaesthetist, which will calm and relax the patient. This helps patients who are nervous about having local anaesthetic or if the surgery will take a long time. Occasionally the surgery is performed under a general anaesthetic (GA) when the patient is asleep throughout the operation. What will happen on the day of surgery? Before the operation, the surgeon will want to check that your lump is still present. You will be asked to sign a consent form, which will include your permission for the lump to be tested in the pathology laboratory. The lab will keep the tissue; it will not be returned to you. If you are going to have the lump removed by Mohs micrographic surgery, then a Mohs surgeon will remove the lesion for you under local anaesthesia a few days before. You will have a dressing over your eye or affected area in the meanwhile until you attend Nelson Day Unit for the reconstruction where you will meet your oculoplastics surgeon. At the end of the operation, antibiotic ointment will be put in the eye and on the stitches. You will usually be given antibiotic drops or ointment to use until your next appointment. An eye pad will be put on your eye (unless you have no sight in the other eye). You will be told when you can remove the pad. After it is put it in the eye, the ointment may blur your vision a little for a short while.

4 What are the risks? The risks of this surgery include, but are not limited to: Bruising Infection Early swelling Asymmetry of eyelid position Asymmetry of eyelid contour (curvature) and height The need for another operation in the future Suture related inflammations Scarring Loss of lashes Graft site complications (depending on the graft donor site - skin scarring, mouth scarring - either lip, cheek or hard palate or nose scarring - midline septum or outer wall) Complications may be permanent. Further procedures may be necessary Recurrence of skin tumour In addition to the risks specific to the individual procedure, there are also general risks, such as blood loss, infection, cardiac arrest, airway problems and blood clots, which are associated with any surgical procedure. Local anaesthetic may cause bruising or possible allergic responses. If your operation is to be carried out under general anaesthetic, the anaesthetist will discuss this with you. Although we have discussed with you the purpose and likely outcome of the proposed procedure it is not possible for us to guarantee a successful outcome in every case. Those treating you will do their best to ensure success but unfortunately complications can and do occur. You should only agree to surgery if you fully understand the risks. What are the benefits? Removal of skin tumour Correction or repair of eyelid defect Improve cosmetic appearance Improve eyelid closure and protect eye Improve symptoms of eye discomfort If you have any specific concerns, you should discuss them with your surgeon before the operation.

5 What precautions do we need to protect ourselves in the future from eyelid and peri-ocular skin cancers? If you have had one BCC, it is likely that you will develop others over the ensuing years, on parts of your face, neck, shoulders and hands which are sun exposed. Examine your skin every 6 to 12 months for early warning signs and look and feel for any changes in your skin. Ask your partner to examine your back, neck, ears and scalp. Alternatively use a mirror to examine these areas. If you are concerned about a lump seek advice from your GP.

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