Basal-Cell Carcinomas on Eyelids: Experience with Cryosurgery LASZLO BIRO, M.D., F.A.C.P., AND ELY PRICE, M.D., F.A.C.P.
An experience o f treating 40 basal-cell carcinomas on eyelids is recounted. Modem technology and technique for such treatment are discussed.
O f a l l b a s a l - c e l l c a r c i n o m a s , the incidence of them on eyelids is of the order of 5 to 10%.1,2 Cures of such lesions are therapeutic challenges because of lo cation and because it is important to retain good func tion of eyelids. It has long been good dermatologie practice, and to a great extent still is, to treat small basal-cell carcinomas on the margins of eyelids by radiotherapy3 and near the margins by curettage and electrodesiccation. We have recently reviewed our ex perience of 29 cases of basal-cell carcinomas on eyelids treated by curettage and electrodesiccation and 33 cases by radiotherapy.4 For larger lesions, still more complex treatments are oculo-plastic surgery and chemosurgery. In this report we describe instrumenta tion and techniques of cryosurgery for management of basal-cell carcinomas on eyelids (Figs. 1A-1D, 2A-2B, 3A-3B, 4, and 5) and discuss our results.
cryosurgery no matter what the size or nature of the lesions. 2. Patients under 50 years of age in whom superfi cial radiotherapy was not advisable for reason of even tual cosmetic end result were accepted for cryo surgery. 3. Patients who rejected hospitalization for surgery or protracted radiotherapy were accepted for cryosurgery if they understood and agreed to suffer the immediate discomforts of cryosurgery. 4. Deeply pigmented patients were accepted for cryosurgery if, forewarned, they agreed to be satisfied if permanent loss of pigment regionally occurred. With these restrictions and criteria, we treated 40 basal-cell carcinomas on eyelids of 38 patients (two patients had two lesions each, the rest one each). Six lesions were situated on upper lids, 19 on lower lids, and 15 on inner canthi. The largest carcinoma was 1.4 cm in largest diameter; four were just over 1 cm; the rest measured between 3-10 mm.
SELECTION OF CASES FOR CRYOSURGERY From the nature of lesions, we chose as follows: 1. Sclerotic and morphea-type lesions were excluded. INSTRUMENTATION 2. Lesions on lids that had extended beyond tarsal The first instrument we used was the CE-8™ cryosur margins onto sulci were excluded. gical system of Frigitronics, Inc., but we found it un 3. Lesions at medial canthi were treated if it was satisfactory for treatment for lesions on or about judged that they had not invaded lacrimal apparatus. eyelids because of poor control of the spray. However, 4. Lesions up to about 1.5 cm on either upper or an improvement in the delivery of liquid nitrogen in lower lids were treated if they had not penetrated to corporated in the CS-76™ unit of Frigitronics made it full thickness of lids. satisfactory for the purpose. Another important new From the nature of patients we chose as follows: feature of this unit that makes it efficient is a means of 1. Elderly patients for whom surgery or protracted measuring in pounds per square inch (psi) force with radiotherapy was not feasible were accepted for which liquid nitrogen is delivered. This force may be Dr. Biro is in private practice (dermatology) in Brooklyn, N ew regulated up to 30 psi by turning the knob of a marked York. dial conveniently situated in the center of the instru Dr. Price is in private practice (dermatology) in Brooklyn, N ew ment. We operated the CS-76 unit at about 10 psi for York. spray delivery of liquid nitrogen, and at 20 psi when we Address reprint requests to Dr. Laszlo Biro, 7502 Ridge used closed-end probes. Spray needles of 20, 22, and Boulevard, Brooklyn, N .Y . 11209.
/ . Dermatol. Surg. Oncol. 5:5 May 1979
397
BASAL-CELL CARCINOMAS ON EYELIDS
24 gauges permitted precise delivery of liquid nitrogen and two thermocouple needles supplied with the unit permitted measurement of temperature in tissue at two different sites. Recently we have begun to use two small, hand-held instruments, the Cry-Op® and the Cry-Ac™. The Cry-Op is self-pressurized for delivering liquid nitro gen at 10 psi and is equipped with a Luer-Lock fitting for the needles. Its one defect was a tendency to form crystals at the needle tip that resulted in impaired re lease of liquid nitrogen when large lesions had to be sprayed for a minute or longer. A 22-gauge needle was found to afford best control for treating lesions on eyelids. The Cry-Ac is also self-pressurized. Its release han dle is in a somewhat awkward position; we found it difficult to hold for treatment of lesions on eyelids. This instrument comes with three attachments that are not Luer-Locked needles. None of them afforded the type of pinpoint spray one likes to have when treating le sions on eyelids. Still other instruments currently in use have been well described by Torre.5 C R Y O SU R G IC A L T E C H N IQ U E
Following are the steps of procedure as we practiced it: 1. The margins of lesions were marked and diame ters measured and recorded. 2. Anesthesia was induced with 1% lidocaine. If a Jaeger retractor was to be used, the conjunctiva was anesthetized with 0.5% proparacaine hydrochloride. 3. One or two thermocouples were implanted, de pending on the sizes of lesions. Exact depths of place ment of thermocouples into tissue can be made by needle-depth templates,5 but this method was found to be impractical for lesions on eyelids. Instead, we ap proximated 3 mm of depth by pre-marking ther mocouple needles. 4. If cryoprobes were used, sizes were selected to correspond with the sizes of lesions and the probes were applied at ambient temperatures. Pre-chilling prevents good contact. When activated, probes freeze to lesions and must not be tom away. Thawing causes separation spontaneously. 5. When the open-spray method was selected, pa tients were placed in supine positions to avoid run-off of liquid nitrogen in undesirable directions. Conespray technique6 was used when treating lesions on lower lids at a distance from the tarsal margins. It was necessary to use a Jaeger retractor when treating le sions near or on tarsal margins in order to protect globes. Insertion of thermocouples was also important in these sites. 6. With both methods, freeze times, complete398
J. Dermatol. Surg. Oncol. 5:5 May 1979
thaw times, halo thaw-times, and minimum tempera tures recorded by thermocouples, as defined by Torre7, were measured. 7. Two freeze-thaw cycles were always run through. 8. Patients were informed by written instruction sheets of postoperative effects to be expected. Those instructions stressed particularly that cryosurgery re sults in instant frostbite; that treated areas generally swell considerably and that occasionally blisters form; that it is best to leave treated areas open to air, but if there is constant oozing, dressings may be made. For cleansing, either hydrogen peroxide or soap and water are advised. Once dry scabs have formed, dressings and cleansing are no longer necessary. For pain simple analgesics like acetyl salicylic acid are recommended. Patients are required to return for examination in 48 hours and are advised not to drive cars. RESULTS
We have been able to follow our cases for two years in five, for between one and two years in fifteen, and for one year in twenty. One basal-cell carcinoma on a lower lid recurred in three months. It had involved two-thirds of the margin of the lid and the medial canthus. There is reason to think there was technical inadequacy in the double freeze-thaw cycles of this case. The patient refused cryosurgery again and was referred for oculo-plastic surgery. In another patient, what appeared to be a possible recurrence proved on biopsy to be an actinic keratosis as a new lesion. In a third patient, a recurrence at six months was re-treated and at follow-up three months later, the site on a lower lid seemed free of malignancy. Complications encountered with cryosurgery on eyelids may be divided into early and late. The early complications were severe edema of treated lids, some edema of contralateral, uninvolved lids, pain, con junctivitis and subconjunctival hemorrhage and insuf flation of eyelids. Late complications were localized depigmentation, especially in dark-skinned patients, postinflammatory hyperpigmentation, milia in centers or peripheries of treated areas, scaphoid depression of margins of lids, stellate scars, papules, or erythema tous macules that persisted for several weeks or months, and loss of eyelashes. COMMENTS
The advent of cryosurgery some 15 years ago was wel comed by all engaged in the management of tumors on the eyelid, particularly since none of the older meth ods, however complicated and difficult, promised a 100% cure rate.
BIRO AND PRICE
F I G U R E 1 A . Clinical appearance in close-up o f a basal-cell carcinoma on an upper lid o f a 75-year-old man. (From Biro, L., and Price. E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Or bit. St. Louis, C.V. Moshy, 1979.)
F I G U R E I B . Appearance o f the lesion pictured in Fig. IA one week after cryosurgery by use o f a closed-end probe. (From Biro, L., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
F I G U R E 1C. Appearance o f the lesion pictured in Fig. IA six weeks after cryosurgery. N ote the loss o f eyelashes and devel opment o f milia. (From Biro, L ., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
F I G U R E I D . Appearance o f the lesion pictured in Fig. IA three months after cryosurgery. (From Biro, L., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
./, Dermatol. Surg. Oncol. 5:5 May 1979
399
B A S A L -C E L L CA RCIN O M A S ON E Y E L ID S
F I G U R E 2 A . Clinical appearance o f a cystic basal-cell car cinoma below the lower lid o f a 72-year-old woman.
F I G U R E 2 B . Appearance o f the treated site o f the lesion pictured in Fig. 2A three months after cryosurgery by use o f a closed-end probe.
F I G U R E 3 A . Clinical appearance o f a basal-cell carcinoma at the junction o f a lower lid and cheek o f a 69-year-old woman.
F I G U R E 3 B . Appearance o f the treated site o f the lesion pictured in Fig. 3A four months after cryosurgery by conespray technique.
Cryosurgery in the management o f cancer o f the eyelid has obvious advantages over excisional surgery. The method is office oriented; the procedure is rapid; and because it is performed under local anesthesia, the risk is slight for the older age group in whom most of these tumors are encountered. Cosmetic results com pare favorably with all other methods em ployed. Both Beard” and Fraunfelder9 claim that, unlike with other methods, re-treatment by cryosurgery is feasible and effective.
Among the disadvantages o f cryosurgery is the necessity on the part o f the operator to estimate the borders and depths o f tumors just as one has to in curettage and electrodesiccation and radiation therapy. In addition, one must have special equipment and constant delivery o f liquid nitrogen. Som e patients object to the prolonged healing time and unsightly ap pearance postoperative!y. Finally, there is a wide range o f individual responses to freezing. The major difficulty that confronted us was the lack
400
J . Dermatol. Surg. Oncol. 5:5 May 1979
BIRO AND PRICE
F I G U R E 4 . Clinical appearance o f insufflation o f the right lower lid o f a young woman treated for basal-cell carcinoma after cryosurgery by open-spray technique. (From Biro. L.. and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass. A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis. C.V. Moshy. 1979.)
o f standardized technique such as exists in curettage and electrodesiccation, radiation therapy, and chemosurgery. N ot until one can measure temperature properly and judge the depth o f freeze accurately will a standard be had. Inexperienced cryosurgeons do better by use o f the closed-end cryoprobe technique, especially on the eyelid, where liquid nitrogen run-off makes treatment difficult with spray. H ow ever, we intend to continue wherever possible to treat tumors o f eyelids by the open-spray or cone-spray technique because the cosm etic results seem to be somewhat better than the ones achieved by the closed-end probe technique. In addition, a number o f variables that are introduced when treatment is performed by closed probe"’ are not operative when the spray technique is practiced. N o matter which method is selected, it is wise to take liberal borders o f between 3 to 4 mm and freeze ade quately to - 2 5 ° to - 3 0 ° C with a freezing time o f 60 seconds at maximum and halo thaw-time o f 60 seconds at minimum. This series as well as a recent series by Kuflik" report satisfactory experience o f three dermatologists in private practice who use this new modality in the routine management o f basal-cell carcinomas on eyelids.
F I G U R E 5. Clinical appearance o f a recurrence o f a basal cell carcinoma on the free margin o f a lower eyelid five months after treatment.
REFERENCES 1. Brodkin, R. H ., Kopf, A. W., and A ndrade, R. Basal-cell epitheliom a and elastosis: a com parison o f distribution. In: Ur bach, F., ed. The Biologic Effects o f Ultraviolet Radiation (with E m phasis on the Skin). Oxford, Pergamon, 1969, p. 581. 2. Biro, L ., Price, E .. and MacWilliams, P. Basal-cell carcinom a in office practice. N.Y. State J. Med. 75:1427-1433, 1975. 3. Dom onkos, A. N. Treatm ent o f eyelid carcinom a. Arch. Der matol. 91:364-371, 1965. 4. Biro, L ., and Price, E. Dermatologic management o f eyelid tum ors. In: Hornblass, A ., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. M osby, 1979 (in press). 5. Torre, D. Cryosurgical instrumentation. In: Zacarian, S., ed. Cryosurgical Advances in Dermatology and Tumors o f the H ead and N eck. Springfield, 111., Charles C Thomas, 1977, p. 38. 6. T orre, D. Cryosurgical treatm ent o f epitheliom as using the cone-spray technique. J. Dermatol. Surg. Oncol. 3:432-436, 1977. 7. Torre, D ., L ubritz, R. R., and G raham , G. F. Cryosurgical treatm ent o f basal cell carcinom as. Prog, in Dermatol. 12:1116, 1978. 8. Beard, C., and Sullivan, J. H. C ryosurgery o f eyelid disorders including malignant tum ors. In: Z acarian, S., ed. Cryosurgical A dvances in Derm atology and Tumors o f the Head and N eck. Springfield, 111., Charles C T hom as, 1977, p. 188. 9. Fraunfelder, F. T., Farris, H. E ., Jr., and Wallace, T. R. C ryosurgery for ocular and periocular lesions. J. Dermatol. Surg. Oncol. 3:422-427, 1977. 10. Rothenborg, H. W., and Fraser, J. “ T hird generation” cryotherapy. J. Derm atol. Surg. Oncol. 3:408-413, 1977. 11. Kuflik, E. G. Cryosurgery for basal-cell carcinom as on and around eyelids. J. Dermatol. Surg. Oncol. 4:911-913, 1978.
J. Dermatol. Surg. Oncol. 5:5 May 1979
401
An experience o f treating 40 basal-cell carcinomas on eyelids is recounted. Modem technology and technique for such treatment are discussed.
O f a l l b a s a l - c e l l c a r c i n o m a s , the incidence of them on eyelids is of the order of 5 to 10%.1,2 Cures of such lesions are therapeutic challenges because of lo cation and because it is important to retain good func tion of eyelids. It has long been good dermatologie practice, and to a great extent still is, to treat small basal-cell carcinomas on the margins of eyelids by radiotherapy3 and near the margins by curettage and electrodesiccation. We have recently reviewed our ex perience of 29 cases of basal-cell carcinomas on eyelids treated by curettage and electrodesiccation and 33 cases by radiotherapy.4 For larger lesions, still more complex treatments are oculo-plastic surgery and chemosurgery. In this report we describe instrumenta tion and techniques of cryosurgery for management of basal-cell carcinomas on eyelids (Figs. 1A-1D, 2A-2B, 3A-3B, 4, and 5) and discuss our results.
cryosurgery no matter what the size or nature of the lesions. 2. Patients under 50 years of age in whom superfi cial radiotherapy was not advisable for reason of even tual cosmetic end result were accepted for cryo surgery. 3. Patients who rejected hospitalization for surgery or protracted radiotherapy were accepted for cryosurgery if they understood and agreed to suffer the immediate discomforts of cryosurgery. 4. Deeply pigmented patients were accepted for cryosurgery if, forewarned, they agreed to be satisfied if permanent loss of pigment regionally occurred. With these restrictions and criteria, we treated 40 basal-cell carcinomas on eyelids of 38 patients (two patients had two lesions each, the rest one each). Six lesions were situated on upper lids, 19 on lower lids, and 15 on inner canthi. The largest carcinoma was 1.4 cm in largest diameter; four were just over 1 cm; the rest measured between 3-10 mm.
SELECTION OF CASES FOR CRYOSURGERY From the nature of lesions, we chose as follows: 1. Sclerotic and morphea-type lesions were excluded. INSTRUMENTATION 2. Lesions on lids that had extended beyond tarsal The first instrument we used was the CE-8™ cryosur margins onto sulci were excluded. gical system of Frigitronics, Inc., but we found it un 3. Lesions at medial canthi were treated if it was satisfactory for treatment for lesions on or about judged that they had not invaded lacrimal apparatus. eyelids because of poor control of the spray. However, 4. Lesions up to about 1.5 cm on either upper or an improvement in the delivery of liquid nitrogen in lower lids were treated if they had not penetrated to corporated in the CS-76™ unit of Frigitronics made it full thickness of lids. satisfactory for the purpose. Another important new From the nature of patients we chose as follows: feature of this unit that makes it efficient is a means of 1. Elderly patients for whom surgery or protracted measuring in pounds per square inch (psi) force with radiotherapy was not feasible were accepted for which liquid nitrogen is delivered. This force may be Dr. Biro is in private practice (dermatology) in Brooklyn, N ew regulated up to 30 psi by turning the knob of a marked York. dial conveniently situated in the center of the instru Dr. Price is in private practice (dermatology) in Brooklyn, N ew ment. We operated the CS-76 unit at about 10 psi for York. spray delivery of liquid nitrogen, and at 20 psi when we Address reprint requests to Dr. Laszlo Biro, 7502 Ridge used closed-end probes. Spray needles of 20, 22, and Boulevard, Brooklyn, N .Y . 11209.
/ . Dermatol. Surg. Oncol. 5:5 May 1979
397
BASAL-CELL CARCINOMAS ON EYELIDS
24 gauges permitted precise delivery of liquid nitrogen and two thermocouple needles supplied with the unit permitted measurement of temperature in tissue at two different sites. Recently we have begun to use two small, hand-held instruments, the Cry-Op® and the Cry-Ac™. The Cry-Op is self-pressurized for delivering liquid nitro gen at 10 psi and is equipped with a Luer-Lock fitting for the needles. Its one defect was a tendency to form crystals at the needle tip that resulted in impaired re lease of liquid nitrogen when large lesions had to be sprayed for a minute or longer. A 22-gauge needle was found to afford best control for treating lesions on eyelids. The Cry-Ac is also self-pressurized. Its release han dle is in a somewhat awkward position; we found it difficult to hold for treatment of lesions on eyelids. This instrument comes with three attachments that are not Luer-Locked needles. None of them afforded the type of pinpoint spray one likes to have when treating le sions on eyelids. Still other instruments currently in use have been well described by Torre.5 C R Y O SU R G IC A L T E C H N IQ U E
Following are the steps of procedure as we practiced it: 1. The margins of lesions were marked and diame ters measured and recorded. 2. Anesthesia was induced with 1% lidocaine. If a Jaeger retractor was to be used, the conjunctiva was anesthetized with 0.5% proparacaine hydrochloride. 3. One or two thermocouples were implanted, de pending on the sizes of lesions. Exact depths of place ment of thermocouples into tissue can be made by needle-depth templates,5 but this method was found to be impractical for lesions on eyelids. Instead, we ap proximated 3 mm of depth by pre-marking ther mocouple needles. 4. If cryoprobes were used, sizes were selected to correspond with the sizes of lesions and the probes were applied at ambient temperatures. Pre-chilling prevents good contact. When activated, probes freeze to lesions and must not be tom away. Thawing causes separation spontaneously. 5. When the open-spray method was selected, pa tients were placed in supine positions to avoid run-off of liquid nitrogen in undesirable directions. Conespray technique6 was used when treating lesions on lower lids at a distance from the tarsal margins. It was necessary to use a Jaeger retractor when treating le sions near or on tarsal margins in order to protect globes. Insertion of thermocouples was also important in these sites. 6. With both methods, freeze times, complete398
J. Dermatol. Surg. Oncol. 5:5 May 1979
thaw times, halo thaw-times, and minimum tempera tures recorded by thermocouples, as defined by Torre7, were measured. 7. Two freeze-thaw cycles were always run through. 8. Patients were informed by written instruction sheets of postoperative effects to be expected. Those instructions stressed particularly that cryosurgery re sults in instant frostbite; that treated areas generally swell considerably and that occasionally blisters form; that it is best to leave treated areas open to air, but if there is constant oozing, dressings may be made. For cleansing, either hydrogen peroxide or soap and water are advised. Once dry scabs have formed, dressings and cleansing are no longer necessary. For pain simple analgesics like acetyl salicylic acid are recommended. Patients are required to return for examination in 48 hours and are advised not to drive cars. RESULTS
We have been able to follow our cases for two years in five, for between one and two years in fifteen, and for one year in twenty. One basal-cell carcinoma on a lower lid recurred in three months. It had involved two-thirds of the margin of the lid and the medial canthus. There is reason to think there was technical inadequacy in the double freeze-thaw cycles of this case. The patient refused cryosurgery again and was referred for oculo-plastic surgery. In another patient, what appeared to be a possible recurrence proved on biopsy to be an actinic keratosis as a new lesion. In a third patient, a recurrence at six months was re-treated and at follow-up three months later, the site on a lower lid seemed free of malignancy. Complications encountered with cryosurgery on eyelids may be divided into early and late. The early complications were severe edema of treated lids, some edema of contralateral, uninvolved lids, pain, con junctivitis and subconjunctival hemorrhage and insuf flation of eyelids. Late complications were localized depigmentation, especially in dark-skinned patients, postinflammatory hyperpigmentation, milia in centers or peripheries of treated areas, scaphoid depression of margins of lids, stellate scars, papules, or erythema tous macules that persisted for several weeks or months, and loss of eyelashes. COMMENTS
The advent of cryosurgery some 15 years ago was wel comed by all engaged in the management of tumors on the eyelid, particularly since none of the older meth ods, however complicated and difficult, promised a 100% cure rate.
BIRO AND PRICE
F I G U R E 1 A . Clinical appearance in close-up o f a basal-cell carcinoma on an upper lid o f a 75-year-old man. (From Biro, L., and Price. E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Or bit. St. Louis, C.V. Moshy, 1979.)
F I G U R E I B . Appearance o f the lesion pictured in Fig. IA one week after cryosurgery by use o f a closed-end probe. (From Biro, L., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
F I G U R E 1C. Appearance o f the lesion pictured in Fig. IA six weeks after cryosurgery. N ote the loss o f eyelashes and devel opment o f milia. (From Biro, L ., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
F I G U R E I D . Appearance o f the lesion pictured in Fig. IA three months after cryosurgery. (From Biro, L., and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass, A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. Mosby, 1979.)
./, Dermatol. Surg. Oncol. 5:5 May 1979
399
B A S A L -C E L L CA RCIN O M A S ON E Y E L ID S
F I G U R E 2 A . Clinical appearance o f a cystic basal-cell car cinoma below the lower lid o f a 72-year-old woman.
F I G U R E 2 B . Appearance o f the treated site o f the lesion pictured in Fig. 2A three months after cryosurgery by use o f a closed-end probe.
F I G U R E 3 A . Clinical appearance o f a basal-cell carcinoma at the junction o f a lower lid and cheek o f a 69-year-old woman.
F I G U R E 3 B . Appearance o f the treated site o f the lesion pictured in Fig. 3A four months after cryosurgery by conespray technique.
Cryosurgery in the management o f cancer o f the eyelid has obvious advantages over excisional surgery. The method is office oriented; the procedure is rapid; and because it is performed under local anesthesia, the risk is slight for the older age group in whom most of these tumors are encountered. Cosmetic results com pare favorably with all other methods em ployed. Both Beard” and Fraunfelder9 claim that, unlike with other methods, re-treatment by cryosurgery is feasible and effective.
Among the disadvantages o f cryosurgery is the necessity on the part o f the operator to estimate the borders and depths o f tumors just as one has to in curettage and electrodesiccation and radiation therapy. In addition, one must have special equipment and constant delivery o f liquid nitrogen. Som e patients object to the prolonged healing time and unsightly ap pearance postoperative!y. Finally, there is a wide range o f individual responses to freezing. The major difficulty that confronted us was the lack
400
J . Dermatol. Surg. Oncol. 5:5 May 1979
BIRO AND PRICE
F I G U R E 4 . Clinical appearance o f insufflation o f the right lower lid o f a young woman treated for basal-cell carcinoma after cryosurgery by open-spray technique. (From Biro. L.. and Price, E. Dermatologic management o f eyelid tumors. In: Hornblass. A., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis. C.V. Moshy. 1979.)
o f standardized technique such as exists in curettage and electrodesiccation, radiation therapy, and chemosurgery. N ot until one can measure temperature properly and judge the depth o f freeze accurately will a standard be had. Inexperienced cryosurgeons do better by use o f the closed-end cryoprobe technique, especially on the eyelid, where liquid nitrogen run-off makes treatment difficult with spray. H ow ever, we intend to continue wherever possible to treat tumors o f eyelids by the open-spray or cone-spray technique because the cosm etic results seem to be somewhat better than the ones achieved by the closed-end probe technique. In addition, a number o f variables that are introduced when treatment is performed by closed probe"’ are not operative when the spray technique is practiced. N o matter which method is selected, it is wise to take liberal borders o f between 3 to 4 mm and freeze ade quately to - 2 5 ° to - 3 0 ° C with a freezing time o f 60 seconds at maximum and halo thaw-time o f 60 seconds at minimum. This series as well as a recent series by Kuflik" report satisfactory experience o f three dermatologists in private practice who use this new modality in the routine management o f basal-cell carcinomas on eyelids.
F I G U R E 5. Clinical appearance o f a recurrence o f a basal cell carcinoma on the free margin o f a lower eyelid five months after treatment.
REFERENCES 1. Brodkin, R. H ., Kopf, A. W., and A ndrade, R. Basal-cell epitheliom a and elastosis: a com parison o f distribution. In: Ur bach, F., ed. The Biologic Effects o f Ultraviolet Radiation (with E m phasis on the Skin). Oxford, Pergamon, 1969, p. 581. 2. Biro, L ., Price, E .. and MacWilliams, P. Basal-cell carcinom a in office practice. N.Y. State J. Med. 75:1427-1433, 1975. 3. Dom onkos, A. N. Treatm ent o f eyelid carcinom a. Arch. Der matol. 91:364-371, 1965. 4. Biro, L ., and Price, E. Dermatologic management o f eyelid tum ors. In: Hornblass, A ., ed. Tumors o f the Ocular Adnexa and Orbit. St. Louis, C.V. M osby, 1979 (in press). 5. Torre, D. Cryosurgical instrumentation. In: Zacarian, S., ed. Cryosurgical Advances in Dermatology and Tumors o f the H ead and N eck. Springfield, 111., Charles C Thomas, 1977, p. 38. 6. T orre, D. Cryosurgical treatm ent o f epitheliom as using the cone-spray technique. J. Dermatol. Surg. Oncol. 3:432-436, 1977. 7. Torre, D ., L ubritz, R. R., and G raham , G. F. Cryosurgical treatm ent o f basal cell carcinom as. Prog, in Dermatol. 12:1116, 1978. 8. Beard, C., and Sullivan, J. H. C ryosurgery o f eyelid disorders including malignant tum ors. In: Z acarian, S., ed. Cryosurgical A dvances in Derm atology and Tumors o f the Head and N eck. Springfield, 111., Charles C T hom as, 1977, p. 188. 9. Fraunfelder, F. T., Farris, H. E ., Jr., and Wallace, T. R. C ryosurgery for ocular and periocular lesions. J. Dermatol. Surg. Oncol. 3:422-427, 1977. 10. Rothenborg, H. W., and Fraser, J. “ T hird generation” cryotherapy. J. Derm atol. Surg. Oncol. 3:408-413, 1977. 11. Kuflik, E. G. Cryosurgery for basal-cell carcinom as on and around eyelids. J. Dermatol. Surg. Oncol. 4:911-913, 1978.
J. Dermatol. Surg. Oncol. 5:5 May 1979
401
