Is it safe to remove a nevus from the lower eyelid?

Is It Safe to Remove a Nevus from the Lower Eyelid?

Yes, it is safe to remove a nevus (mole) from the lower eyelid when performed by an appropriately trained surgeon using proper surgical techniques, though specific clinical features must be evaluated to rule out malignancy before proceeding. 1

Key Safety Considerations Before Removal

Warning Signs Requiring Immediate Evaluation

Before any removal procedure, you must assess for features suggesting malignancy rather than a benign nevus:

• Gradual enlargement over time - this is a red flag for potential melanoma 2
• Central ulceration or induration 2
• Irregular borders 2
• Eyelid margin destruction or loss of lashes (madarosis) 3, 2
• Telangiectasia 2
• Recurrence in the same location - raises suspicion for sebaceous carcinoma, especially in elderly patients 3

If any of these features are present, refer to an ophthalmologist or oculoplastic surgeon for evaluation before attempting removal. 2

Surgical Safety Profile

Evidence for Safety

The lower eyelid is actually the most common site for periocular melanoma (when malignant lesions do occur), making proper evaluation critical 4. However, when appropriate surgical techniques are used:

• Periocular repairs performed by trained surgeons have excellent safety profiles 5
• Complication rates for lower eyelid procedures are relatively low - in one study, lower eyelid complications occurred in 37% of cases but most were minor (hypertrophic scarring, pincushioning) 5
• Major complications like ectropion occur in only 1.9% of cases 5

Appropriate Surgical Approach

For benign nevus removal from the lower eyelid:

• Excisional biopsy with 2-5mm margins is the standard approach for suspected benign lesions 1
• Full-thickness skin biopsy including subcutaneous fat should be performed to allow proper histopathological evaluation 1
• Shave biopsies are NOT recommended as they prevent accurate pathological staging if the lesion proves to be malignant 1

Who Should Perform the Procedure

The procedure should be performed by:

• An ophthalmologist with surgical training 3
• An oculoplastic surgeon 4, 5
• A Mohs surgeon experienced in periocular reconstruction 5

General practitioners should refer rather than attempt removal if there are any atypical features or if the lesion is symptomatic 2

Critical Pitfalls to Avoid

Do Not Proceed If:

1. Multiple previous excisions at the same site - this pattern suggests possible sebaceous carcinoma masquerading as a benign lesion 3
2. The lesion is causing moderate to severe pain - this warrants immediate ophthalmologic evaluation as it may indicate malignancy or infection 3
3. Visual symptoms are present - requires ophthalmologic evaluation before any intervention 3

Technical Considerations

• Avoid aggressive manipulation in patients with neurotrophic corneas to prevent corneal epithelial injury 6
• Ensure proper pathological evaluation - all excised tissue must be sent for histopathology with proper orientation marking 1
• Plan for reconstruction - the lower eyelid requires specific reconstructive techniques to maintain function and prevent ectropion 7, 8

Post-Removal Monitoring

• Histopathological confirmation is mandatory - even clinically benign-appearing lesions must be evaluated microscopically 1
• If melanoma is diagnosed, initial wide excision margins of 10mm from the macroscopic tumor edge are recommended 4
• Median follow-up of 3 years is appropriate for excised pigmented lesions 4

Bottom Line

Removal is safe when performed by appropriately trained surgeons using proper excisional techniques with histopathological confirmation. 1, 5 The key to safety is thorough pre-operative evaluation to identify any features suggesting malignancy, proper surgical technique with adequate margins, and mandatory pathological examination of all excised tissue. 4, 2