Question
Asked 18th Dec, 2014

What is your diagnosis and the treatment algoritm for this patient's cheek-infraorbital lesion?

An elderly woman who complained of progressive ulcero-nodular lesion eroding the lower palpebra and the palpebral conjunctiva.. Duration 5 years. No lymph nodes were palpable, hearing was good, no vertigo, no diabetes, mild hypertension was told.

Most recent answer

5th Jan, 2015
Thabit Ali Mustafa Odat
Jordanian Royal Medical Services
As you don't have Mohs in your medical faculty frozen section control excision is mandatory after doing CT scan to assess the depth and rule out bone and orbital invasion.
The reconstruction depends on the defect and in this case it will be big, so I might do Hughes flap for the posterior lamella (if the vision in the other eye is good and the patient dosen't have glaucoma) and Mustarde cheeck rotation flap for the anterior lamella. You may need to do periosteal flaps medially and laterally too. Although there will be lagophthalmos after the surgery but the results are usually functionally and cosmetically acceptable.
1 Recommendation

Popular answers (1)

29th Dec, 2014
Ciaran O'Boyle
Nottingham University Hospitals NHS Trust & The University of Nottingham
For a biopsy-proven basal cell carcinoma like this, Mohs excision would also be an option.  It can have the advantage that all of the margin can be evaluated, whereas a standard frozen section, or "wax" histology, will only bread slice the specimen and therefore its results will only be based upon a sample of the margin. 
The other advisable thing to do, of course would be a pre-operative CT scan to rule out intra-orbital involvement, which might require orbital exenteration.
  For reconstruction, personally, I would use a temporal skin flap for the outer lamella.  For the inner lamella and uspport, a mucoperiosteal graft from hard palate is also excellent.
3 Recommendations

All Answers (16)

19th Dec, 2014
Zorica Gajinov
University of Novi Sad
Basal cell cancer
surgical treatment (excision and reconstructive surgery)
20th Dec, 2014
Victor C. Kok
Asia University
Biopsy followed by pathological review.
21st Dec, 2014
Anthony Rowsell
University of Oxford
Basal Cell Carcinoma (BCC)
Wide Surgical Excision
Delay reconstruction until pathology confirms:
(1) That the tumour is a BCC
(2) That the excision margins are clear of tumour
1 Recommendation
21st Dec, 2014
Atilla Coruh
Erciyes Üniversitesi
Biopsy 
21st Dec, 2014
Thomas Schleussinger
Hautarztpraxis Schleussinger Dr.Krebs Dr.Hofmann Schongau
BCC, if histology a solid form, you should discuss radiotherapy too, but in every therapy the eye could be damaged. The extension of the tumor into the depth could be very wide
radiotherapy, wide surgigal excision and controll of the margins should be prferred.
2 Recommendations
21st Dec, 2014
Gheorghe Solcan
Ion Ionescu de la Brad University of Life Sciences from Iasi
I agree with dr Schleussinger  solutions
22nd Dec, 2014
Mansour M Al-Nozha
Taibah University
 1-skin cancer         2- cutaneous leishmaniasis , biobsy will help to establish diognosis
24th Dec, 2014
Bharat B Dogra
Dr. D. Y. Patil Vidyapeeth
My diagnosis: Basal cell carcinoma lower eyelid.
Treatment option: wide excision including full thickness excision of lower eyelid and reconstruction using nasal septal cartilage and mucosal lining and skin cover by cheek rotation flap in same sitting
1 Recommendation
25th Dec, 2014
Mahmoud Omranifard
Isfahan University of Medical Sciences
My treatment is two way !-biopsy and after its result  i deceid  2-forezen  section or mohos surgery
27th Dec, 2014
Atilla Coruh
Erciyes Üniversitesi
Chondro-mucosal graft from the septum for the inner lamelle and bi-lobed flap for the outer lamella of the lower palpebra with safe surgical margins (frozen section). Ulcerated palpebral conjunctiva and infiltrated infra-orbital rim with BCC..
29th Dec, 2014
Ciaran O'Boyle
Nottingham University Hospitals NHS Trust & The University of Nottingham
For a biopsy-proven basal cell carcinoma like this, Mohs excision would also be an option.  It can have the advantage that all of the margin can be evaluated, whereas a standard frozen section, or "wax" histology, will only bread slice the specimen and therefore its results will only be based upon a sample of the margin. 
The other advisable thing to do, of course would be a pre-operative CT scan to rule out intra-orbital involvement, which might require orbital exenteration.
  For reconstruction, personally, I would use a temporal skin flap for the outer lamella.  For the inner lamella and uspport, a mucoperiosteal graft from hard palate is also excellent.
3 Recommendations
29th Dec, 2014
Atilla Coruh
Erciyes Üniversitesi
I reserved the temporoparietal fascial flap for the recurrence if it occurs. I do not have Moh's Micrographic Surgery Infrastructue at my medical faculty. 
30th Dec, 2014
Peet van Deventer
Stellenbosch University
I would advise excision of lesions and histological confirmation that adequate clear margins are obtained followed by a transverse forehead flap for reconstructing the cheek and eyelid in stages. A muco-chondral nasal septal graft can be used for  lining of the reconstructed eyelid.
1 Recommendation
30th Dec, 2014
Peet van Deventer
Stellenbosch University
Judged on the photo probably dual pathology namely basal cell carcinomas of the  lower eyelid and cheek and a seborhoeic keratosis paranasal. Biopsies will give the answer but with a history of 5 years and infiltration of lower eyelid and conjunctiva, complete excision is indicated any way.  Frozen section to my experience is to difficult to determine completeness of excision and I prefer the pathologist to do paraffin sections . Once that is done and confirmation obtained of adequate clear margins of excision proceed with the reconstruction.
To obtain adequate resection on the deep aspect,  bone may be exposed and therefore a flap would be necessary. Either a pedicle flap or free flap like a radial forearm flap. To my opinion a transverse forehead flap would be large enough and cosmetically acceptable.
30th Dec, 2014
Antonio Stanizzi
Azienda Ospedaliero Universitaria Ancona
Wide excision is mandatory but the most difficult part is the reconstruction of the lower eyelid in its 3 layers, avoiding the ectropion. I’d like to  raccomend you to have a look to this article:
Full-thickness lower eyelid reconstruction: an easy and reliable method of reinforcing the forehead flap with fascia lata.
Stanizzi A, Grassetti L.
Plast Reconstr Surg. 2012 Feb;129(2):376e-377e. doi: 10.1097/PRS.0b013e31823af045. No abstract available.
5th Jan, 2015
Thabit Ali Mustafa Odat
Jordanian Royal Medical Services
As you don't have Mohs in your medical faculty frozen section control excision is mandatory after doing CT scan to assess the depth and rule out bone and orbital invasion.
The reconstruction depends on the defect and in this case it will be big, so I might do Hughes flap for the posterior lamella (if the vision in the other eye is good and the patient dosen't have glaucoma) and Mustarde cheeck rotation flap for the anterior lamella. You may need to do periosteal flaps medially and laterally too. Although there will be lagophthalmos after the surgery but the results are usually functionally and cosmetically acceptable.
1 Recommendation

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