Surgical Management of Malignant Eyelid Tumors: Reconstruction Outcomes and Location-Specific Thresholds for Preoperative Planning

Objective: To evaluate surgical outcomes of malignant eyelid tumor reconstruction and to develop location-specific tumor size thresholds and a preoperative nomogram for individualized reconstruction planning. Methods: A retrospective case series of 107 patients who underwent surgical excision and reconstruction for malignant eyelid tumors was conducted. Reconstruction techniques were classified as primary closure, local flap, free graft only, or combined reconstruction. Receiver operating characteristic (ROC) curve analysis was performed separately for upper and lower eyelid tumors to identify optimal tumor size thresholds. A logistic regression-based nomogram was developed and internally validated using 5-fold cross-validation. Results: Basal cell carcinoma was the most common diagnosis (79.4%), with a significant predilection for the lower eyelid compared with other tumor types ( P =0.002). Tumor size differed significantly across reconstruction groups ( P <0.001). Canthal involvement was present in 38.3% of patients and was associated with larger tumor size and more complex reconstruction ( P <0.001), without adversely affecting complication or recurrence rates. ROC analysis demonstrated excellent discriminatory performance for upper eyelid tumors (AUC =0.953, 95% CI 0.870–1.000), with an optimal cutoff of ≥0.9 cm. In contrast, tumor size showed only fair performance for lower eyelid tumors (AUC =0.679, 95% CI 0.547–0.799). The nomogram demonstrated acceptable internal validity (AUC =0.754). Conclusion: Reconstruction complexity following malignant eyelid tumor excision is strongly influenced by tumor size and anatomical location. The predictive value of tumor size differed substantially between upper and lower eyelid tumors, highlighting the importance of individualized and anatomy-based surgical planning in periocular reconstruction.