This 70 year old lady presented in the clinic with an ulcerated ring shaped pigmented lesion in the lateral canthus (outer corner of the eyes) of the left eye. A provisional diagnosis of Basal cell carcinoma was made due to the typical appearance of the lesion. Basal Cell Carcinoma (BCC) also known as the “rodent ulcer” because the lesion appears as if a rodent burrowed a hole in to the skin. Excision Biopsy of the lesion with frozen section margin control was done along with reconstruction of the resultant defect in the same sitting. If surgery is done early in this disease, BCC is curable and can have an aesthetically pleasing outcome as in this case.
Pic 1: Picture at presentation with the planned margins marked in Red (Above)and Picture after 1 year after surgery (Below) showing excellent outcome of the reconstruction. The patient had no recurrence of the malignancy till the last visit- 3 years after surgery. A regular follow up with a physician is important in these patients as those with BCC are more prone to have BCC elsewhere in the body.
Pic 2: Swipe on the instagram post to see the steps of the surgery including the reconstruction of the lateral canthus. The defect involved 1/2 and 1/4th of the lateral lower and upper lid respectively. The upper lid defect was closed by direct closure fixing it to the periosteum of the lateral orbital rim. A wide periosteal flap was raised from the outer side of the lateral orbital rim and fixed it to the residual tarsus of the lower lid to reconstruct the posterior lamellae of the lower lid. An advancement skin flap was fashioned from the temple area and divided unequally to cover the anterior lamellar skin defect. The flap was fixed to the lateral canthus with a non-absorbable suture to fix it to the lateral canthus form a new lateral canthal angle.
Basal Cell Carcinoma
BCC is one of the commonest eyelid malignancies in India. While in the west, BCC accounts for nearly 90% of the eyelid malignancies, in the Indian subcontinent, BCC cedes it’s top position to Sebaceous cell carcinoma in India. BCC is a non-melanocytic cancer of the skin arising from basal cells of the epidermis. It is mostly seen on sun exposed areas, particularly in the head and neck region. BCC is caused by skin damage caused by prolonged exposure to ultraviolet light thus explaining the preponderance of this cancer in Caucasian skin which does not have the protective effect of melanin.
Frozen Section Margin Control
Frozen section is a pathology technique which assists the surgeon to obtain clean surgical margins during excision. After excising the mass, the mass is immediately sent to the pathology laboratory for frozen section examination. In the pathology lab, the mass is frozen fast and the margins of the excised mass is cut into thin wafer like slices and examined under microscope. If cancer cells are found at the surgical margins, the excision margins are further increased and frozen section control is repeated. This same process is repeated until all the surgical margins are clear of malignant cells.