Advanced adenoid cystic carcinoma of the conjunctiva: total
upper eyelid and medial canthal region reconstruction
with three local flaps plus auricular cartilage graft
Maria Rosa Bertonati
Received: 12 December 2010 / Accepted: 22 June 2011 / Published online: 26 July 2011
Adenoid cystic carcinoma (ACC) of the eyelid is a rare
malignant tumor which originates primarily from the con-
junctiva or from the skin . We report an advanced case of
ACC involving the entire upper eyelid and the medial
canthal region. This condition was treated by radical surgical
resection and reconstruction using three local flaps plus an
auricular cartilage graft. This obtained satisfactory functional
and aesthetical results. To our knowledge only five cases of
primary conjunctival ACC  and four cases of primary
cutaneous ACC  of the eyelids have been described to
date, and the case herein reported is the first involving the
entire upper eyelid together with the medial canthal region.
A 73-year-old woman underwent ophthalmological evalu-
ation elsewhere for an indolent nodule at the medial third of
the left upper eyelid. A diagnosis of Meibomian gland
chalazion was made, and the patient was treated first with
topical antibiotics and steroids without resolution, then with
surgical incision and curettage of the nodule. No micro-
scopic analysis was performed on the pathological tissue.
The patient was referred to our institute 5 years later; she
had a slow growing mass of the left upper eyelid.
On the left upper eyelid, there was an infiltrating,
multilobulated mass involving the entire thickness of the
lid. The mass was slightly elevated and palpation of the
eyelid skin overlying the lesion revealed multiple nodules
(Fig. 1a). The upper tarsus was entirely infiltrated by the
mass which appeared thickened and irregular (Fig. 1b).
There was no loss of cilia or any macroscopic alteration of
the eyelid skin and conjunctiva. The main lacrimal gland
was not involved.
An incisional biopsy of the conjunctiva revealed adenoid
cystic carcinoma. Preoperative imaging (head and neck CT,
chest radiography, abdominal ultrasound) failed to reveal
lymph node or other metastatic disseminations.
The surgical excision of the mass and the first step of
reconstruction were performed under general anaesthesia.
The entire upper tarsus and eyelid body were removed en
bloc, and the margins were checked using intraoperative
frozen section analysis. There was involvement by the
neoplasm at the medial margin of the excised tissue, and
resection was extended to the medial canthal region until a
clear margin was achieved (Fig. 2a).
A bridging flap from the inferior eyelid (Cutler–Beard
technique) was used for the reconstruction of the central
portion of the upper eyelid (Fig. 2b). The flap was split
into a cutaneous and a conjunctival lamella, these were then
sutured to the corresponding planes of the upper eyelid
A. Neri (*)
Ophthalmology, University of Parma,
Via Gramsci 14,
43100 Parma, Parma, Italy
M. R. Bertonati
Ophthalmology, La Spezia Hospital,
La Spezia, Italy
Anatomical Pathology and Cytopathology, La Spezia Hospital,
La Spezia, Italy
Eur J Plast Surg (2012) 35:693–696