Square Procedure in Managing Eyelid Margin Involving Melanoma-In-Situ

Abstract

Purpose : The management of eyelid margin involving melanoma in situ (MIS) presents a unique challenge to oculoplastic surgeons due to the delicate anatomy and critical function of the eyelids. We performed a retrospective, observational clinical study evaluating the effectiveness of the square procedure, a staged excision with permanent section, with concurrent double freeze-thaw cryotherapy for treating MIS cases involving the eyelid margin.

Methods : Retrospective chart review of 16 adult patients with MIS involving the eyelid margin from 2012 to 2018. Patients with Breslow depth of greater than 1 millimeter (mm) were excluded. Demographic and clinical data were abstracted. Logistic regression and Fisher’s exact test were performed to evaluate predictors of the primary outcome, recurrence rate, and the secondary outcome, post-operative complications.

Results : A total of 16 patients were involved with median age of 67 years old (range: 44-86). All patients had lentigo maligna MIS. Tumor free margins were reached after a median of 2 (1-6) stage of excision with a median margin distance of 12.5 mm (5-40). Upon square excision, concurrent double freeze-thaw cryotherapy was performed in 8 eyelids (50%) to spare the eyelid margin excision. After a median follow-up time of 72.5 months (0-274), recurrences were observed in 1 patient (6.2%) who had recurrent MIS on the skin graft. None of the eight patients with lid margin preserving cryotherapy demosntrated local recurrence. Cryotherapy was not associated with melanoma recurrence (p=1.00). Most common complication after reconstruction was eyelid retraction or ectropion (18.75%). Implementing cryotherapy to the eyelid margin was not associated with complication after reconstruction (p=1.00).

Conclusions : The square procedure offers an effective and reliable technique for managing eyelid margin involving MIS. Concurrent use of double freeze-thaw cryotherapy to prevent the eyelid margin excision further enhances the technique without an increased risk of recurrence or post-reconstruction complication. Future studies will be necessary to determine whether this procedure is equal or superior to other approaches to this challenging clinical problem.

This abstract was presented at the 2024 ARVO Annual Meeting, held in Seattle, WA, May 5-9, 2024.