Treatment for LM and LMM can be divided into surgical and non surgical options. It is widely accepted that surgical resection of these lesions, with adequate margins, offers the best local control. However, currently there is some controversy on the optimal surgical margin for removal of eyelid lentigo maligna. In an evidenced based meta analysis of eyelid lesions, Cook and Bartley found conflicting papers, opinions, and consensus statements on margin recommendations for melanocytic lesions [7]. Historically a recommended surgical margin of 5 mm for LM and 10 mm for LMM has been advised. However, many reports have found these recommendations to fall short in recurrence control and have recommended various distances ranging from 5 to 12 mm for LM/LMM [8, 9]. One must also take in to account that many of these recommendations were derived from studies that excluded periocular lesions or contained a small portion of representative eyelid cases. In an eyelid melanoma-specific study, Esmaeli et al. found no correlation between margins and local recurrence [10]. It has also been observed that up to 16 % of histopathologically diagnosed LM on further examination harbored portions of LMM [11]. For LM and LMM, surgical control may be obtained with currently recommended or smaller margins by better identifying the actual margin of the lesion. Techniques for identifying melanoma in vivo include dermatoscopy and confocal laser microscopy [11–14]. These techniques in experienced hands have led to better identification of the extent of lesions resulting in enhanced care. However, if mismanaged, recurrence of these lesions can be significant and lead to metastatic disease (Fig. 9.4).

The surgical removal can be done primarily with standard wide margins, with Mohs micrographic surgery with frozen sections, or staged excision with rush permanent sections, interpreted by a pathologist rather than the surgeon interpreting frozen sections. The latter and variations of the technique are now preferred, offering more reliable control and tissue sparing [2, 15, 16].

The goal in working with lesions around the eyelid is to offer the best procedure to provide a cure while preserving the function and aesthetics of the eye. For lesions not involving the eyelid margin, a full thickness skin excision is recommended by the techniques previously explained. If the lesion involves the eyelid margin and/or the conjunctiva, a full thickness eyelid resection is recommended. If the lesion extends into the orbit, then an exenteration must be considered. Periocular LM is found most commonly extending from the cheek or forehead onto the eyelid area, followed by the lower lid, lateral canthus, medial canthus, and least commonly on the upper eyelid [17].

The procedure used for reconstruction of the lower eyelid is determined by the size of the defect; lesions involving under 25 % of the eyelid can usually be closed primarily including both full thickness defects and anterior lamellar defects. Defects involving 25–50 % will require a sliding skin flap for skin defects, and canthotomy with canthal lysis and advancement of adjacent lateral skin for full thickness defects. Defects greater than 50 % will require a vascularized tarsal conjunctival flap with free skin graft for full thickness lesions (Hughes procedure) (Fig. 9.5), or a rotational cheek flap with or without a free mucosal graft (Fig. 9.6). A similar approach is taken for the upper eyelid with the exception that the cheek flap cannot be used for the upper eyelid. In large, full thickness upper eyelid defects, the lower eyelid is rotated to replace the upper eyelid and later divided. Medial canthal lesions require evaluation of the nasolacrimal system. It is important to closely inspect the punctum for pigment as the disease can track down the canalicular system. Defects in this area all require probing and irrigation of the nasal lacrimal ducts to access patency of the system. If a defect is found, it can be repaired with use a bi cannular or mono cannular stent to maintain patency through the healing process.

Defects for LM/LMM can be large, and skin grafts may be necessary, although they can have a significant affect on eyelid function and aesthetics (Fig. 9.7). In attempts to avoid some of the side effects from surgery on the eye and eyelid and for patients unable to undergo surgery, nonsurgical methods have been explored.