Xanthelasma palpebrarum is the most common form of xanthoma, often bilaterally involving the medial aspect of the upper eyelids [1]. The incidence rate is higher in women (1.1%) compared to men (0.3%) with occurrences highest at 30–50 years of age [1,2]. Lesions present as yellow plaques or papules due to lipid deposition in macrophages [1,2]. Although no pathophysiology can be deduced, 50% of patients with xanthelasma palpebrarum demonstrate dyslipidemia and have increased risk of ischemic heart disease. Causes of lipid dysregulation have been attributed to primary and secondary hyperlipidemia, diabetes mellitus, and thyroid dysfunction [1].

Various treatment modalities for xanthelasma palpebrarum have been documented. Topical trichloroacetic acid injection, systemic drug therapy, and laser therapy [2-4] are less invasive but give rise to mixed outcomes depending on mass size and the duration and option of treatment. Surgical excision has produced good outcomes, although reconstruction techniques, such as direct closure, skin graft, and flap, can lead to complications, including ectropion, scarring, eyelid retraction, graft necrosis, and skin color mismatch [1,2,5-7].

The laissez-faire technique is a treatment approach that comprises healing by secondary intention without other treatment modalities [8]. Previously, this treatment has been found to result in naturally reformed eyelid position, contour, and volume [8,9]. This approach also avoids skin color mismatch and hypertrophy [8-10]. However, there is some controversy regarding the longer healing time and possibly less cosmetic results of this process [8]. This report evaluates the results of the laissez-faire technique by presenting a case of simple surgical excision for xanthelasma palpebrarum.

This study protocol was reviewed and the need for approval was waived by the institutional review board of Aichi Medical University Hospital. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

A 76-year-old female presented with multiple gradually progressive yellow plaques on both upper and lower eyelids. The onset and initial location of the lesions could not be recalled by the patient. She did not complain of pain, erythema, swelling, or heaviness of the eyelids. Upon physical examination, the lesions were found to be located above the medial canthus on both upper eyelids and in the central third of both lower eyelids (Fig. 1A). The plaques were elastic-hard in consistency, non-tender, and with well-defined borders. Surgical and medical intervention had not been performed prior to this consultation. The patient had no previous history of dyslipidemia, hypertension, diabetes mellitus, or thyroid dysfunction. A clinical diagnosis of xanthelasma palpebrarum was made and surgical excision was planned.

Figure 1. Seventy-six year-old female with multiple xanthelasma palpebrarum. (A) Clinical presentation on initial examination. The xanthelasma palpebrarum lesions are noted on both upper and lower eyelids. (B) Post-operative areas 1 day after the operation. (C) Thirteen days after the operation. (D) Three months after the operation. Surgical areas show good cosmesis with no eyelid deformities.

Full-thickness excision of the eyelid lesions was performed utilizing a surgical blade under local anesthesia. Meticulous cautery was performed throughout the surgery. Since the excision areas were extensive, a simple closure would have caused eyelid retraction or ectropion. As the eyelid skin redundancy was not sufficient, particularly in the upper eyelid, and a mixed graft or flap for eyelid reconstruction would not have yielded good cosmetic results, we choose neither graft nor flap for reconstruction. The decision was made, therefore, to allow the surgical areas to heal via the laissez-faire technique (Fig. 1B).

The application of an anti-bacterial ointment every day was prescribed to keep the wound wet until the wet lesions disappeared. The patient presented with acceptable tissue healing at the 13th post-operative day (Fig. 1C). Three months post-operatively, good cosmesis was achieved (Fig. 1D). Although the medial upper eyelid crease became somewhat obscured, the patient presented with minimal scar formation, good eyelid function, and little eyelid contour irregularities.

The application of the laissez-faire technique after removing xanthelasma palpebrarum produced good outcomes, both cosmetically and functionally, without serious complications.

The laissez-faire technique illustrated good results, irrespective of the simultaneous treatment of the four eyelids. Although the skin defects of the patient were large enough, especially in the upper eyelids, the flap reconstruction or skin grafting approach was not applied due to the risk of poor cosmetic results. Flap reconstruction can cause irregular scarring and traction, while skin grafts can result in a patchy appearance. In this case, the cosmetic outcomes having chosen a different reconstruction technique would have risked being worse than those achieved by using the laissez-faire technique.

More generally, the laissez-faire technique is able to overcome several of the disadvantages associated with other surgical techniques. Direct closure has several postoperative complications, including ectropion, scarring, eyelid retraction, superior sulcus deepening, and eyelid margin deformities [2,5-7]. Although flaps or skin grafts have been often used to lessen these complications [5-7], these techniques can give rise to skin color mismatch, necrosis, and differences in skin thickness [5-7,10].

In conclusion, the laissez-faire technique is an acceptable treatment option for surgical site closure post-excision of xanthelasma palperarum, especially in cases with multiple lesions. The method results in good cosmesis and retention of eyelid function and avoids the sequelae of other common treatment modalities.

None.

The authors have nothing to disclose.