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

Abstract

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.

1. INTRODUCTION

Surgical excision remains the cornerstone in the management of periocular tumours (Moran & Phelps, 2020). For smaller defects, primary closure is often sufficient to achieve both functional and aesthetic outcomes. However, larger excisions, particularly those involving more than one‐third of the eyelid's horizontal length, require reconstructive techniques using different flaps, including tarsoconjunctival flaps or free skin grafts (Collin, 1989). In selected cases, an alternative approach is to allow the wound to heal by secondary intention (laissez‐faire).

The laissez‐faire approach was first described for the periocular region in 1957 (Brown & Fryer, 1957). Empirical evidence has since identified suitable candidates for this method, primarily lower eyelid defects involving the central, medial, and lateral regions that encompass the full thickness of the tarsus, including its height and thickness (DaCosta et al., 2009; Lowry et al., 1997). However, central upper eyelid defects pose a significant risk of exposure keratitis (Shankar et al., 2002). Patients with poor Bell's phenomenon, patients using anticoagulants, or those requiring post‐operative radiation therapy are also less ideal candidates.

Several studies have reported the successful application of the laissez‐faire technique (DaCosta et al., 2009; Lowry et al., 1997; Mehta, 1981; Morton, 2010; Morton, 2016; Shafi et al., 2017; Shankar et al., 2002). The medial canthal area, in particular, has gained attention as a site in which surprisingly good results are seen following laissez‐faire, comparable to outcomes expected from formal reconstruction (Morton, 2016; Shafi et al., 2017). In the instances in which adverse outcomes have been reported, the most common issue seems to be cicatricial ectropion, occasionally requiring secondary surgery (Shankar et al., 2002, Mehta, 1981, DaCosta et al., 2009, Zitelli, 1984).

To determine which periocular defects carry a higher risk of complications following laissez‐faire management, it is crucial to understand how the geometry of the defect influences wound contraction during healing. Previous studies have primarily focused on clinical outcomes, such as wound healing and cosmetic results (Shankar et al., 2002, Mehta, 1981, DaCosta et al., 2009, Morton, 2010, Morton, 2016, Shafi et al., 2017, Lowry et al., 1997). However, there is a lack of detailed analysis regarding the impact of defect size, the specific tissue layers involved—such as the anterior and posterior lamellae of the eyelid—and the location within the periocular region, and how these factors influence complications such as ectropion.

The objective of this study was to investigate how the geometry of eyelid defects affects the healing process and to provide a detailed analysis and timeline of healing progression. The study provides an in‐depth examination of different types of defects, including proportional and disproportional lower eyelid defects, as well as medial canthal defects, to better understand how these factors influence the clinical outcome.

2. MATERIALS AND METHODS

2.1. Ethics

The experimental protocol for this study was approved by the Ethics Committee at the Swedish Ethical Review Authority, Sweden (23 January 2023, Ethics approval ID 2022–06240‐01).

The research adhered to the tenets of the Declaration of Helsinki as amended in 2013. All patients included in the study gave their full informed written consent.

2.2. Subjects

A total of 46 patients undergoing laissez‐faire treatment for periocular tumour defects at St. Erik Eye Hospital and the Department of Ophthalmology, Skåne University Hospital, were included in the study. Exclusion criteria included patients with a history of previous surgery, radiotherapy, or trauma to the affected region. Ten of the patients were also included in a previous study with a different aim, namely to evaluate blood perfusion during the healing process using laser speckle contrast imaging (Vennström Berggren et al., 2025).

2.3. Follow‐up

The wounds were photographed during follow‐up visits, scheduled at 1 week, 3 weeks, 6–8 weeks, and at later visits between 5 months and 2 years post‐surgery. However, eight patients missed the 3‐week follow‐up, and only 29 patients attended the late follow‐up visits. At each visit, the wound was photographed, and the healing process was assessed. Complications, including infection, bleeding, and the need for reconstructive surgery, were documented.

2.4. Wounds

Four fundamentally distinct types of wounds were identified. Defects located in the medial canthal area (n = 10) differed significantly in terms of anatomical structures compared to tissue defects in the lower eyelid (n = 28). Lower eyelid defects were further categorized based on the composition of the excised tissue. These included proportional defects, where the anterior and posterior lamellae were proportionally excised (n = 21), and disproportional defects, where more tissue was excised from the anterior lamella than the posterior (n = 7). Cases where the healing process was disrupted due to repeated surgical excisions following resections with tumour‐positive margins were classified into a separate subgroup: repeated surgical excision (n = 8), containing both defects from the medial canthal area (n = 2) and the lower eyelid (n = 6). There was a large variation in the timespan between the first and second excision, from 1 week up to 7 weeks. In two cases, a third excision had to be made.

2.5. Would contraction

The tumour defect was outlined in the photograph to measure wound contraction over time, as illustrated in Figure 1. To account for variations in image magnification, the size of the defect was standardized as a percentage of the corneal area. In 3 photos, patients had their eyes closed during photography at follow‐up visits, making it impossible to standardize the defect size using the corneal area. In these cases, care was taken to approximate the size of the cornea as much as possible based on the size of the upper eyelid. An additional nine images presented greater challenges regarding outlining the tumour defects due to factors such as eversion of the remaining eyelid stump or issues with the quality or angle of the photograph. No measurements were made in cases involving guiding sutures or repeated surgical excisions. The tumour defect was outlined by two physicians (authors J.N.O. and A.O.). Furthermore, the images from each patient were reviewed by a group of four oculoplastic surgeons involved in the study (authors M.M., E.B., J.B.E., and K.T.). The group assessed the healing process and the clinical outcome.

FIGURE 1.

Illustration of proportional, disproportional, and medial canthal defects with standardized measurements. The tumour defect (blue dashed area) was outlined and measured in photographs to assess wound contraction over time. To account for variations in image magnification, defect size was standardized as a percentage of the corneal area (red dashed area).

2.6. Calculations and statistics

The photos were analysed using MatLab (The MathWorks Inc. MATLAB version: R2024b, MA, USA). Data are shown as median values. Statistical analysis was performed using the Kruskal–Wallis test with Dunn's post‐hoc test for multiple comparisons. Significance was defined as p < 0.05. Further calculations and statistical analysis were performed using GraphPad Prism 7.0a (GraphPad Software Inc., San Diego, CA, USA).

3. RESULTS

The periocular tumours were primarily basal cell carcinoma (n = 44), along with a smaller number of squamous cell carcinoma cases (n = 2). Directing sutures were employed in three cases to reduce wound size. The decision to use guiding sutures was not based on the size of the defects but on the position of the remaining eyelid and the risk of the sutures damaging the corneal surface.

The median age of the patients was 77 years (range 49–103), and the cohort included 26 women and 20 men. Among these, 29 patients were on antihypertensive medication, and 10 patients had diabetes. 17 patients had other cardiovascular conditions and were receiving anticoagulant treatment that was not discontinued. All cases healed, and there were no cases of postoperative infections. A total of five patients underwent later reconstructive surgery due to complications such as ectropion, entropion, and cicatricial traction.

3.1. Proportional lower eyelid defects

In 21 cases, the tumour excision involved equal portions of the anterior and posterior lamellae, resulting in a proportional defect. Most importantly, these proportional defects exhibited a higher rate of healing without any ectropion‐related complications, in contrast to the disproportional defects.

The healing process observed in this study closely adhered to the expected phases of wound healing. By the 1‐week follow‐up, defects ranged in size from 24% to 141% of the corneal area (Figure 2), with a median of 46% (hereafter referred to as the initial wound area). At this stage, active inflammation was evident, reflecting the exudative phase, characterized by the initial inflammatory response and tissue debridement. Signs of the epithelialization phase were also observed, with new epithelial tissue beginning to form over the wound.

FIGURE 2.

Scatter plots showing wound size in laissez‐faire treatment, calculated as a percentage of the corneal area. Time points include early follow‐up (weeks 1–8) and late follow‐up (weeks 48–52). No measurements were made in cases involving repeated surgical excision. Additionally, a few cases yielded results that only differed by 1–2%, which explains why they are not visible in the figure, as the data points are overlapping in the graph. Proportional and disproportional eyelid defects (a, b): The proportional and disproportional eyelid defects followed the same phases of wound healing and contraction. Wound size decreases rapidly during the first 6–8 weeks, followed by a plateau phase. The curves do not reach zero, indicating a residual defect of approximately 5% of the corneal area. Clinically, this corresponds to a slight reduction in vertical lid height, observed as scleral show in all eyelids. Medial canthal defects (c): Wounds show faster contraction, particularly within the first 3 weeks, achieving complete closure during early follow‐up. The curves reach zero, indicating complete healing, in contrast to the eyelid defects.

At the 3‐week follow‐up, the contraction phase was prominent, and the wound had reduced to an average of 36% of the initial wound area (20% of the corneal area). This period was marked by rapid wound contraction and partial closure. By the 6‐ to 8‐week follow‐up, the wound had almost completely contracted (11% of initial size; equivalent to 6% of the corneal area), leaving only a small notch of space between the wound edges (Figure 3).

FIGURE 3.

Clinical progression of proportional and disproportional eyelid defects treated with laissez‐faire. Proportional eyelid defects involving equal portions of the anterior and posterior lamellae. These defects exhibited predictable healing with rapid contraction between the 1‐week and 6–8‐week follow‐ups, forming a small notch (arrow) that resolved during the remodelling phase. A slight reduction in lid height, seen as increased scleral show (arrow), was observed in all cases. Disproportional eyelid defects involving a larger portion of the anterior lamella. These defects showed suboptimal outcomes, including residual tissue loss at the late follow‐up (arrow).

During the remodelling phase (evaluated at the 5 months to 2 years follow‐up), the notch gradually smoothed as the tissue matured and reorganized. Nearly all eyelids healed with a slight reduction in vertical lid height, evident as scleral show. The final outcome was a slight decrease in eyelid area, leaving a residual defect measuring an average of 10% of initial size (5% of the corneal area).

Two patients initially exhibited more moderate wound contraction but achieved satisfactory outcomes. Additionally, one entropion was found at the one‐year follow‐up, requiring surgical intervention. In this case, the initial wound was a central proportional defect that had healed, leaving a good contour and a 3–4 mm central soft part without tarsal plate support. The patient had developed entropion in the lateral half of the eyelid, with the soft part acting as a hinge. The medial eyelid remained in a normal position against the globe. Some degree of eyelid retraction or ‘scleral show’ developed in all lower lid defects.

3.2. Disproportional lower eyelid defects

In seven cases, the tumour excision involved a larger portion of the anterior lamella compared to the posterior lamella, resulting in disproportional defects. These defects followed the same phases of wound healing as proportional defects, with an initial rapid contraction phase followed by a slower remodelling phase (Figure 2). No measurements were made in two cases due to the use of guiding sutures.

The overall outcomes were less satisfactory compared to those of proportional lower eyelid defects. One eyelid healed with a good result, while the remaining six showed varying degrees of residual tissue loss or discreet ectropion.

3.3. Medial canthal defects

In 10 cases, the tumour excision involved the medial canthal area. These defects followed the same wound healing phases as lower eyelid defects but achieved complete healing more quickly (Figure 2).

At the 1‐week follow‐up, defects ranged in size from 21% to 210% of the corneal area, with a median of 43% (hereafter referred to as the initial wound area). By the 3‐week follow‐up, the wounds showed significant contraction and had reduced to an average of 16% of the initial wound area (13% of the corneal area). One patient did not attend the 3‐week follow‐up. See Figure 2 and Figure 4 for further details. At the 6‐ to 8‐week follow‐up, all cases were completely healed, which was significantly different from disproportional defects (p = 0.0022) and proportional defects (p = 0.0013). No complications were observed, and no additional surgeries were required.

FIGURE 4.

Clinical progression of medial canthal defects treated with laissez‐faire. Medial canthal defects achieved complete healing more quickly compared to lower eyelid defects. There was significant contraction by 3 weeks and full closure after 6–8 weeks after surgery. In small to intermediate‐sized defects (<100% of corneal area), healing occurred with minimal complications. Larger defects (>200% of corneal area) exhibited residual scarring, causing significant tissue traction in the medial canthal region (arrow).

There were two cases of large defects, one measuring approximately twice the area of the cornea, and the second case involving the medial parts of the upper and lower eyelids and extending into the entire medial canthal region up to the bridge of the nose. In the latter case, perioperative sutures were used to reduce the wound size (preventing accurate measurement of the defect), but a large tissue defect remained and was left to heal via laissez‐faire. Despite the extent of the defects, both wounds achieved closure by the 6‐ to 8‐week follow‐up. However, residual scarring caused significant traction on the eyelids in both cases, and one case later underwent reconstruction.

A comprehensive graphical representation of wound contraction over time in medial canthal defects as well as lower eyelid defects, proportional and disproportional can be found in Figure  5 .

FIGURE 5.

Healing progression and contraction forces in proportional, disproportional, and medial canthal defects at 1 week, 3 weeks, and late follow‐up. Proportional defects: Balanced contraction forces between the anterior and posterior lamellae pull uniformly, resulting in predictable healing and maintaining the eyelid margin's position. Disproportional defects: Imbalanced contraction forces due to greater anterior lamella excision create a net downward pull, leading to eversion of the eyelid margin and increased risk of residual tissue loss or ectropion. Medial canthal defects: Faster healing is observed compared to lower eyelid defects, with contraction occurring evenly from all directions, facilitating efficient wound closure.

3.4. Repeated surgical excisions

Eight patients required a repeated surgical excision due to tumour positive margins, with outcomes generally less favourable compared to defects that did not require additional surgery. The interval between the primary and secondary surgeries ranged from 1 to 7 weeks. Two of the defects involved the medial canthal area. Of these, one healed successfully, while the other resulted in an enlargement of the caruncular area due to cicatricial traction, requiring reconstructive surgery at the 1‐year follow‐up.

The remaining six cases involved the lower eyelid, comprising five proportional and one disproportional defect. The disproportional defect healed with a residual ectropion, necessitating surgery at the 1‐year follow‐up. Among the five proportional defects, two had suboptimal outcomes due to insufficient wound contraction, leaving a noticeable residual tissue defect. A third defect healed with ectropion; the patient was offered surgery but declined. The fourth case, involving the complete lower eyelid except the puncta, healed with a significant tissue deficiency, leading to an entropion‐like condition where the skin and orbicularis muscle rolled upwards, causing keratinized skin to irritate the ocular surface. This required reconstructive surgery with a tarsoconjunctival graft. The remaining defect achieved a satisfactory outcome, likely due to the use of directed sutures, which helped minimize the tissue defect.

4. DISCUSSION

Traditionally, laissez‐faire healing in the periocular region has been reserved for patients where formal reconstruction is considered unsuitable, either due to compromised general health or unfavourable skin conditions for flap or graft survival. However, existing literature challenges this approach, presenting a more positive perspective on laissez‐faire outcomes (Shankar et al., 2002, Mehta, 1981, DaCosta et al., 2009, Morton, 2010, Morton, 2016, Shafi et al., 2017, Lowry et al., 1997, Zitelli, 1984). Despite this, the limited evidence may contribute to hesitation among oculoplastic surgeons in clinical practice. This study aims to offer clearer guidelines on the use of laissez‐faire following periocular tumour excision, providing a foundation for informed decision‐making.

We found that proportional lower eyelid defects, involving equal proportions of the anterior and posterior lamellae, healed predictably with laissez‐faire treatment. Regardless of wound size, rapid contraction occurred between the 1‐week and 6‐ to 8‐week follow‐ups, leaving a small notch that gradually resolved during the slower remodelling phase, consistent with the established phases of wound healing. All patients experienced a slight loss of lid height, evident as increased scleral show, but only 1 of 21 patients developed entropion, which later required surgical correction. In contrast, disproportional defects involving a larger portion of the anterior lamella were more prone to suboptimal outcomes, including residual tissue loss or varying degrees of ectropion.

These findings align with previous studies that have documented complications associated with laissez‐faire. For example, Shankar et al. (2002), in a study of 24 patients, reported a small proportion of cases with cicatricial ectropion, underscoring the challenges with asymmetry in healing outcomes (Shankar et al., 2002). Similarly, DaCosta et al. examined 10 patients and found that suboptimal results, such as ectropion or residual tissue loss, were more frequent in large defects (DaCosta et al., 2009). Morton (2016) reviewed 34 cases and noted that proportional defects healed predictably, emphasizing the higher risk of complications in disproportional defects (Morton, 2016), consistent with our findings. Lowry et al. (1997), in a cohort of 59 patients, observed that lid malposition due to disproportional healing was the most common complication (Lowry et al., 1997). Collectively, these studies highlight the importance of geometric symmetry in achieving favourable outcomes with laissez‐faire, supporting our observation that disproportional defects are more prone to complications such as ectropion and residual tissue loss.

One might speculate how the forces generated during wound contraction contribute to the differing outcomes in proportional versus disproportional eyelid defects. In proportional defects, the contraction forces in the anterior and posterior lamellae are typically balanced. This balance creates a ‘force cancellation’ effect, where the opposing forces pull uniformly to contract the wound. This equilibrium allows for predictable healing, maintaining the anatomical position of the eyelid margin and preventing complications. In contrast, disproportional defects, where a larger portion of the anterior lamella is excised, result in an imbalance of contraction forces. Without adequate counteracting support from the posterior lamella, the imbalance creates a net downward pull. This leads to eversion of the eyelid margin, ultimately causing cicatricial ectropion. See Figure 5 for further explanation.

To reduce the risk of ectropion, surgical techniques that restore balance between the lamellae—such as the use of grafts, directing sutures, or targeted tension reduction—can help counteract unbalanced contraction forces and preserve eyelid function and aesthetics. Ensuring full‐thickness excisions or addressing disproportion with small skin grafts may further minimize postoperative complications, offering a more stable and predictable healing process.

Entropion as a complication following laissez‐faire has not previously been described. In our series, we encountered one true entropion and one entropion‐like situation. In the case of the true entropion, where the central soft part of the lower eyelid acted as a hinge causing the lateral part to turn inwards, it was easily resolved. The soft central part was excised, and the remaining medial and lateral tarsal plates were sutured together. Direct closure had not been possible for the initial defect due to its size but was enabled by the tissue expansion of the remaining eyelid caused by the wound contraction. In the other case, the whole lower eyelid had been excised, and skin and orbicularis rolled upwards causing ocular irritation. This was managed by a secondary eyelid reconstruction with a tarsoconjunctival flap and skin graft yielding a good result.

Medial canthal defects in our study typically healed within a few weeks and with minimal complications, supporting previous findings that this region is particularly well‐suited for secondary intention healing. Shafi et al. (2017) analysed 36 patients with medial canthal defects following tumour excision and reported excellent functional and cosmetic outcomes, comparable to those achieved with surgical reconstruction (Shafi et al., 2017). Similarly, Zitelli (1984) emphasized the unique healing properties of concave facial surfaces, such as the medial canthal area, which often heal more effectively than convex or flat surfaces due to their favourable geometry and mechanical stability (Zitelli, 1984).

Two factors may explain the superior healing observed in medial canthal defects compared to lower eyelid defects. First, contraction in the medial canthal region occurs proportionally from all directions, unlike in lower eyelid defects where contraction follows a linear path along the eyelid margin. Second, the medial canthal area benefits from a robust vascular supply, with contributions from both the ophthalmic and facial arteries, which likely facilitate more efficient revascularization and tissue repair. However, the anatomical structures involved in wound healing of medial canthal defects and full‐thickness eyelid defects are different, which makes comparisons difficult.

Wounds requiring repeated surgical excisions had a high prevalence of unsatisfactory outcomes. This may be attributed to both the timing and size of the excisions. Larger wounds from repeated surgical excisions increase the risk of scar formation and unbalanced traction on the eyelids. Additionally, delayed excisions disrupt the natural healing process, suggesting that performing repeated surgical excisions within days rather than weeks after the primary surgery could improve outcomes. However, the small number of repeated surgical excision cases limits conclusions, emphasizing the need for further research on timing and wound size in healing outcomes.

Laissez‐faire offers several advantages, including the preservation of natural anatomy and avoiding the distortion commonly associated with reconstruction. This approach facilitates better orientation in cases where a repeated surgical excision is needed due to tumour‐positive margins during the initial procedure. Additionally, it may be beneficial for patients in poor general health, for whom general anaesthesia or prolonged surgery may pose significant risks. Despite these benefits, laissez‐faire often remains underutilized (Shafi et al., 2017).

Cryosurgery is a simple, time‐saving, inexpensive, and effective treatment for low‐level aggressive pattern basal cell carcinoma. It has also been shown to be an effective treatment option for well‐defined basal cell carcinomas with an intermediate growth pattern (Finskas et al., 2020). Cosmetic results are often excellent, and there is no tissue loss.

The choice of surgical procedure should be based on factors such as patient wishes, comorbidities, and ability to tolerate repeated surgery. The availability of different surgical procedures makes it possible for the surgeon to adapt to the specific needs of the patient. The Hughes transconjunctival flap procedure is, in many cases, the first choice of reconstructive procedure, but in selected cases, cryosurgery, lamellar grafting, and laissez‐faire might be appealing options. However, studies are needed to compare the functional and cosmetic outcomes of different methods, as well as patient satisfaction. Discomfort and dry eyes are frequently reported in patients after reconstructive surgery procedures. Forms such as the dry eye questionnaire (DEQ‐5) (Chalmers et al., 2010) might be useful to compare the outcome after different procedures in future studies. It can be speculated whether patients that choose laissez‐faire after discussion with their surgeon might have lower expectations or demands and prioritize minimal surgery.

A limitation of the present study is the limited number of patients, which did not allow for subgroup analysis with regard to background characteristics. Future research should investigate the effects of factors such as age, smoking, and impaired microcirculation (e.g., diabetes and cardiovascular disease) on treatment outcomes. Morton (2016) highlighted the increase in eyelid laxity with age, which can significantly influence both the selection of laissez‐faire as a treatment approach and its outcomes (Morton, 2016). Studies involving larger patient populations could provide valuable insights into how these variables impact the healing process and further optimize patient selection for laissez‐faire treatment. Finally, comparing patient experiences between laissez‐faire and formal reconstruction could yield important information about patient satisfaction and quality of life, further guiding the choice of treatment.

When planning reconstructive surgery, it is more reasonable/correct to approximate wound edges perioperatively rather than assess the defect in its entirety with retracted wound edges. These measurements then guide the size of the transplant and/or flap that is used to cover the defect. However, since the aim of the study was to follow the natural healing process, which involves retraction of the wound edges, we chose to measure the defect in its entirety as seen 1 week postoperatively. Ideally, we would have done both measurements, and this is an aspect we will certainly take into consideration in future research on laissez‐faire.

The level of disproportionality is hard to calculate, and eyelid defects were classified as ‘proportional’ or ‘disproportionate’. It could be speculated whether larger defects are more often disproportionate, as they result from more invasive carcinomas. In this study, there was a large span regarding the size of the defect in cases deemed ‘proportional’ as well as those deemed ‘disproportional’, but no clear connection can be discerned. This study was too limited to find out if there is a relationship between the defect area and postoperative outcomes, such as lid retraction.

In conclusion, laissez‐faire proved to be an effective treatment option for selected periocular defects, particularly for medial canthal and proportional lower eyelid defects. Disproportional lower eyelid defects and repeated surgical excisions were associated with higher risks of complications such as ectropion and residual tissue loss. These findings emphasize the importance of careful patient selection and defect geometry in achieving optimal results. Future research should include larger patient cohorts to explore the impact of factors such as comorbidities, defect size, and timing of interventions.