Authors’ Response: “Posterior lamellar wedge resection of lower eyelid margin lesions”

Dear Editor, We thank the authors for their insightful commentary on our study, “Posterior Lamellar Wedge Resection of Lower Eyelid Margin Lesions.”[1] Their contribution adds value to the ongoing discussion on the optimal management of benign eyelid margin lesions. Shave excision biopsy is indeed a practical and widely used method, particularly for superficial lesions confined to the anterior eyelid margin. However, it is important to emphasize that all lesions in our series were located at the eyelid margin, with a significant number extending beyond the anterior lamella into the posterior lid margin and palpebral conjunctiva—not solely isolated anteriorlamellar lesions. In fact, 66.7% of lesions demonstrated posterior extension, which heavily influenced our choice of surgical technique. In contrast to the authors’ series, where most lesions were anteriorly situated and predominantly involved the upper eyelid, our study focused exclusively on lower eyelid lesions. Lower lid marginal lesions tend to be more conspicuous than upper lid lesions. All patients in our cohort sought treatment primarily for cosmetic reasons. In such cases, the goals of preservation of natural eyelid contour, an invisible scar, and complete lesion excision are critical. Our approach—using an infraciliary incision combined with posterior lamellar wedge resection—was designed to achieve these objectives, resulting in high patient satisfaction (mean VAS 96/100) and excellent Strasser scores in the majority of cases. Importantly, no recurrences or surgical revisions were observed over long-term follow-up. On the other hand, shave excision lacks depth control and is unsuitable for lesions with posterior or deep margin extension, where it risks notching, lash loss, incomplete excision, residual visible pigmentation,[2] and recurrence.[3,4] Regarding the peripunctal region, we clarify that such lesions were excluded from our study. In clinical practice, we manage them with horizontal circular shave excision and temporary silicone punctal plug placement to preserve lacrimal drainage function. However, a risk of recurrence persists, as highlighted in the series by Custer and Council,[2] where eight of 13 peripunctal lesions recurred after treatment. We recognize that posterior lamellar wedge resection imposes a greater surgical burden than shave excision, including longer operative time, suturing, and technical demand. Nevertheless, when performed by a trained oculoplastic surgeon in an outpatient setting, the procedure is efficient and well-tolerated. Our patients had high cosmetic expectations, and the technique was carefully tailored to meet these. Notably, no patient required reoperation, and no intraoperative or postoperative complications occurred. Thus, despite its complexity, this method provides a reliable, single-stage solution with excellent functional and aesthetic outcomes. For objectivity, Strasser scoring was performed independently by an oculoplastic fellow using standardized postoperative photographs. In conclusion, while shave excision remains appropriate for superficial anterior lamellar or upper eyelid lesions, posterior lamellar wedge resection offers distinct advantages in lower eyelid margin lesions with posterior or deeper extension, where both cosmetic and anatomical restoration are paramount. We thank the authors again for their valuable feedback and look forward to continued collaboration in refining eyelid lesion management. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.