Refining laissez-faire treatment of periocular tumour defects by exploring the impact of defect localization and geometry on the healing process.

Background: Large lower eyelid defects resulting from tumour removal are frequently reconstructed using a tarsoconjunctival flap from the upper eyelid together with an overlying free skin graft, the so-called Hughes procedure. One disadvantage of this technique is that the tarsoconjunctival flap occludes the eye during the revascularization of the graft, which is particularly troublesome for patients with poor vision in the other eye. Another alternative method for reconstructing large lower eyelid defects is the use of a free bilamellar eyelid graft with the advantage that it is a single-stage procedure and that the vision is not occluded during the healing process. However, both these methods require extensive surgery, which is time-consuming and might be too much effort for the frail and elderly. In these specific cases, where one wishes to avoid extensive surgery, laissez-faire treatment, so-called self-healing, might be an alternative.

Methods: 46 patients undergoing laissez-faire treatment for periocular tumour defects were included. Surgical defects were in the medial canthal area (n = 10) and the lower eyelid (n = 28), with the latter classified as proportional (n = 21) or disproportional (n = 7) based on the anterior to posterior lamellae ratio. Cases requiring repeated surgical excisions due to tumour-positive margins (n = 8) were analysed separately. Wound contraction was assessed through serial photography after 1 week, 3 weeks, 6-8 weeks, and 5 months to 2 years. Defect size was standardized using corneal area measurements.

Results: Proportional lower eyelid defects exhibited predictable healing, with rapid wound contraction the first 6-8 weeks and minimal complications. Disproportional defects showed uneven healing, resulting in ectropion or significant tissue loss in 6 of 7 cases. Medial canthal defects generally healed well, but larger defects (>50% of corneal area) took longer to contract and were associated with traction-related complications in isolated cases. Repeated surgical excisions were associated with a higher prevalence of complications, including ectropion, entropion, and residual defects.

Conclusions: Defect geometry is crucial in the healing process and clinical outcomes of periocular defects treated with laissez-faire. Medial canthal defects and proportional lower eyelid defects heal more reliably, while disproportional and large medial canthal defects, as well as cases requiring repeated surgical excisions, pose a higher risk of complications. These findings emphasize the importance of careful patient selection and defect analysis to optimize outcomes.