Intraoperative Margin Control in Eyelid Tumor Surgery: Current Standards, Imaging Advances, and Emerging Techniques

Background: Eyelid malignancies require accurate intraoperative margin control to achieve complete tumor excision while preserving the functional and aesthetic integrity of the periocular region. Mohs micrographic surgery (MMS) is widely regarded as the reference standard for margin-controlled excision, whereas frozen section-controlled excision (FSC) represents a reliable and widely used alternative in oculoplastic practice. In parallel, several emerging imaging technologies are being investigated to improve real-time tumor detection and surgical precision. Methods: A narrative review of the literature was conducted to summarize current evidence on intraoperative margin control in eyelid tumor surgery. The review focused on established surgical techniques, including MMS and FSC, as well as emerging imaging modalities such as fluorescence confocal microscopy, reflectance confocal microscopy, optical coherence tomography, line-field confocal optical coherence tomography, photoacoustic imaging, and artificial intelligence (AI)-assisted analysis. Results: MMS provides complete circumferential peripheral and deep margin assessment and remains the benchmark for high-risk, recurrent, and poorly defined periocular tumors, particularly basal cell carcinoma. FSC offers favorable oncologic outcomes, allows immediate reconstruction, and remains an effective option when MMS is not available. Emerging imaging modalities have shown promising diagnostic performance for tumor detection, presurgical mapping, and intraoperative support, particularly in basal cell carcinoma, although evidence in periocular tumors remains limited for most techniques. AI-assisted approaches have also demonstrated high accuracy in the interpretation of frozen sections and optical imaging data, suggesting potential to improve workflow efficiency and diagnostic consistency. Conclusions: MMS and FSC remain the current standards for intraoperative margin control in eyelid tumor surgery. Emerging imaging technologies and AI-based tools may further enhance surgical precision and tissue preservation, but most remain investigational in the periocular setting. Further prospective studies are needed to validate their clinical utility, define standardized workflows, and clarify their role alongside established histopathologic techniques.