PERIORBITAL MELANOCYTIC LESIONS - EXCISION AND RECONSTRUCTION IN 40 PATIENTS

The treatment of melanoma arising in the periorbital region is a diffi cult reconstructive problem. The abundance of vital structures in clos e proximity to one another makes the resection and subsequent reconstr uctive procedures extremely challenging. Reported here is experience w ith periorbital melanocytic lesions in 40 patients with the emphasis o n the types of reconstruction performed.Forty patients with periorbita l melanocytic lesions were treated between 1984 and 1995. The periorbi tal region was subdivided into five zones. These zones are the followi ng: zone I, upper eyelid; zone II, lower eyelid; zone III, medial cant hus; zone IV, lateral canthus; and zone V, contiguous structures. Ocul ar melanomas were not included ill this study. The distribution of the lesions in our 40 patients was zone I (n = 1), zone II (n = 14), zone III (n = 1), zone IV (n = 9), and zone V (n = 31) The ages of the pat ients ranged from 3 to 84 years at the time of reconstruction, with an average age of 57 years. Resection and reconstruction were performed simultaneously in all patients. Thirty-six of the patients were recons tructed with one procedure, three patients required two procedures, an d one patient required five procedures. The tumor type was superficial spreading melanoma in 15 patients, melanoma in situ in 17 patients, m alignant spindle cell neoplasm in 2 patients, desmoplastic melanoma in 2 patients, amelanocytic melanoma in 1 patient, epithelioid melanoma in 1 patient, and atypical melanocytic nevus in 2 patients in which an early, evolving melanoma could not be excluded. Elective lymph node d issection was performed in four patients for intermediate thickness le sions (1.5 to 4.0 mm). The types of reconstructions performed included full-thickness skin grafts, upper lid myocutaneous flaps, check advan cement flaps, cervicofacial flaps, inferiorly based nasolabial flaps, tarsoconjunctival flaps, frontalis muscle flaps, medial transposition Z-plasty, and primary closure. The resection of periorbital melanomas carl be difficult because of the number of important anatomic structur es in the region. The challenge to the surgeon in handling head and ne ck melanomas in general lies in the need to provide the best functiona l and aesthetic result while still resecting the primary lesion with t he intent of effecting a cure. We present our series to demonstrate th at the adequacy of margins of resection need not be compromised to fac ilitate reconstruction and that excellent results are obtainable with reconstructive procedures performed after adequate resections. Several different types of flaps and grafts can be used, with the indications varying depending on the location of the lesion and the extent of res ection.The major reconstructive options will be reviewed in detail.