Aesth Plast Surg (2024) 48:4828–4832

https://doi.org/10.1007/s00266-024-04435-x

ORIGINAL ARTICLES EYELID SURGERY

Aesthetic Surgical Treatment of Large Xanthelasma palpebrarum

Yuan Lin1 • Liangliang Wu1

Received: 13 May 2024 / Accepted: 17 September 2024 / Published online: 14 October 2024
Ó The Author(s) 2024

Abstract offers a satisfactory approach for managing large xanthe-

Background Xanthelasma palpebrarum (XP) is a common lasma palpebrarum.
eyelid condition. Various treatment modalities exist, each Level of Evidence IV This journal requires that authors
with its own merits and drawbacks. Managing larger assign a level of evidence to each article. For a full
lesions poses increased challenges. This study aims to description of these Evidence-Based Medicine ratings,
explore the aesthetic surgical management of large xan- please refer to Table of Contents or the online Instructions
thelasma palpebrarum. to Authors www.springer.com/00266.
Methods Patients with xanthelasma palpebrarum present-
ing to our department underwent partial excision of the Keywords Xanthelasma palpebrarum
Aesthetic surgical
lesion and debridement of the medullary nucleus under treatment
Eyelid
local anesthesia for lesions with a diameter of 6 mm or
more. Microsurgical scissors were utilized to remove
residual subcutaneous lesions. Postoperatively, tie-over Introduction
bolster dressings were applied. Patients with lipid and
glucose abnormalities received corresponding therapy. Xanthelasma palpebrarum (XP) is the most prevalent form
Bolster dressings were removed on the third postoperative of xanthoma, predominantly manifesting on the eyelids.
day, with suture removal seven days later. These lesions typically present as plaque-like, yellow for-
Results All flaps subjected to subcutaneous medullary mations, most frequently occurring near the inner canthus.
debridement exhibited complete viability, with minimal Xanthelasma is considered an idiopathic condition, often
localized eyelid depression early postoperatively and showing no significant correlation with hypercholes-
inconspicuous scarring three months post-surgery. No terolemia [1]. Nonetheless, an increased risk of
instances of lid ectropion were observed. The eyelid atherosclerosis can be inferred in hyperlipidemic patients
maintained a natural appearance, with a low recurrence rate with xanthelasma, attributed to associated abnormalities in
of xanthelasma palpebrarum. lipoprotein or apolipoprotein levels. Various studies have
Conclusion Surgical intervention involving partial exci- attempted to differentiate between normolipidemic and
sion of the lesion and medullary nucleus debridement hyperlipidemic patients exhibiting xanthelasma. Despite
these efforts, xanthelasma may not develop in many indi-
viduals with hypercholesterolemia, and similarly, these
Yuan Lin and Liangliang Wu have contributed to the work equally
and regarded as co-first authors.
lesions can occur in normolipidemic subjects. Conse-
quently, it has been suggested that xanthelasma may not
& Yuan Lin necessarily be linked to hyperlipidemic conditions. Histo-
[email protected] logically, XP is characterized by the accumulation of lipid-
1 laden histiocytes within the superficial dermis, predomi-
Department of Plastic and Reconstructive Surgery, The First
Affiliated Hospital of Wannan Medical College, Wuhu, nantly surrounding blood vessels and adnexal structures
Anhui Province, People’s Republic of China [2]. While generally benign, XPs can lead to significant

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cosmetic and functional disfigurement. The medical liter- used to incise the skin directly down to the orbicularis oculi
ature reports various treatment modalities, including laser muscle, following the upper border of the lesion, then
ablation, TCA (trichloroacetic acid) ablation, and surgical proceeding with the lower incision. The skin pad above the
resection. In this context, we introduce a novel approach orbicularis oculi was excised, presenting an un-capping
for the treatment of large XPs, employing a technique of procedure (Fig. 2).Subsequently, the lesion was dissected
partial lesion removal combined with un-capping micro- off through the lower incision, underlying the epidermis to
surgery and inverse peeling. the margin of the lesion. The xanthelasma nucleus pulposus
was excised from the surface of the orbicularis oculi
muscle. Under surgical magnification, foam cells adherent
Patients to the flap were meticulously removed with microscissors
until normal skin tissue was exposed. Any lipomatous
From July 2019 to July 2024, our department treated forty infiltration of the orbicularis muscle was also excised until
patients diagnosed with xanthelasma palpebrarum. The normal muscle architecture was restored. Due to the
cohort comprised 7 males and 33 females, ranging in age removal of cholesterol deposits in the lower aspect of the
from 26 to 58 years. Among these patients, 10 had dys- XP during un-capping, closure of the incision was achieved
lipidemia, 3 were diagnosed with diabetes mellitus; while, without tension (Fig. 3).Closure of the incision was per-
the remaining individuals exhibited normal lipid profiles. formed using 7/0 synthetic nylon sutures. 2 or 3 sutures
were placed beneath the orbicularis oculi muscle, and
vaseline gauze was applied to secure the skin back to the
Methods muscle, resembling a tie-over bolster dressing (Fig. 4).

Preoperative Preparation and Planning Postoperative Precautions and Care

With the patient in the supine position, the surgeon posi- Patients were instructed to maintain cleanliness and dry-
tioned themselves at the head of the operating table. A ness of the area postoperatively. Tie-over stitches were
crescent-shaped or elliptical excision was delineated removed 2 days after the operation; while, the incision
around the xanthelasma palpebrarum (XP) lesion (Fig. 1). stitches were removed on the 7th postoperative day.
We implemented a modified incision technique, initiating
with an upper incision along the margin of the XP and a
lower incision line positioned within the lesion. The Results
excised skin’s vertical width ranged from 4 to 6 mm,
adjusted based on skin laxity. In all cases, the incisions exhibited robust healing without
any occurrence of hematoma beneath the flaps. Patients
Surgical Procedure underwent follow-up examinations for a period ranging
from 0.5 to 5 years postoperatively. However, within the
Local anesthesia consisting of 1% xylocaine with epi- first year, recurrence was observed in 5 cases; while, scar
nephrine (1:100,000) was sublesionally administered using formation at the wound site was noted in 6 cases.
a 30-gauge needle. After approximately 5 min for the
anesthesia to take effect, a scalpel (number 11 blade) was

Fig. 1 Prior to surgery, an elliptical excision was meticulously Fig. 2 During the un-capping surgery, it was observed that the foam
planned for the upper segment of the lesion cell tissue (a) was located beneath the epidermis

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cryotherapy, ablation, non-ablation laser therapy, tri-

chloroacetic acid ablation therapy, and Pingyangmycin
injection, among others [3–7].
Each modality carries its unique set of advantages and
drawbacks. Non-surgical approaches, while diverse, may
elicit local pigmentation or superficial scarring upon
treatment. For smaller lesion areas, various treatment
modalities often yield optimal outcomes. However, larger
skin lesions pose a challenge, lacking efficacious treatment
options devoid of complications. Some researchers have
reported favorable outcomes with step-by-step resection,
Fig. 3 Foam cell tissue in the lower portion was meticulously excised
skin grafting, flap transplantation, and similar techniques
using microscissors subsequent to the removal of the upper segment
of the lesion [8–14]. Additionally, certain scholars advocate for ‘‘un-
capping’’ nucleus pulposus removal coupled with flip Nd-
YAG laser treatment, citing its simplicity, ease, and low
recurrence rates; even in cases of recurrence, this method
remains viable for subsequent treatment [14].The pathol-
ogy of xanthelasma palpebrarum is marked by the accu-
mulation of lipid-containing phagocytes, known as foam
cells, within the dermis [15] (Fig. 7). While some foam
cells may penetrate into the superficial layer of muscle, the
epidermis remains intact. This histological characteristic
underscores the efficacy of nucleus pulposus removal in
eliminating eyelid xanthoma foam cells situated beneath
Fig. 4 Pressure was meticulously applied using packed Vaseline
the basal layer of the epidermis. In the ‘‘un-capping’’
gauze within the surgical site
procedure, the upper pole of the lesion is incised to the
Remarkably, no complications such as pigmentation muscle surface to excise the foam cells beneath the skin
abnormalities or ectropion were encountered (Figs. 5, 6, flap within the lesion area. Subsequently, the flap is
and Table 1). inverted, and the nucleus pulposus is meticulously removed
using microsurgical scissors, followed by suturing the skin
on the lesion surface in situ [16]. Our method represents an
Discussion advancement in un-capping nucleus pulposus removal. We
have devised an elliptical or crescent-shaped excision area
Xanthelasma palpebrarum stands as the most prevalent for the upper pole of the lesion, enabling the simultaneous
form of xanthoma, typically manifesting on the medial removal of the entire skin layer, subcutaneous layer, and
aspect of the upper eyelid, with occasional involvement of superficially infiltrated muscle by foam cells in a single
the adjacent skin near the lower eyelid or the lateral can- stage. The extent of resection typically ranges from 4 to
thus. Characterized by protruding, semi-solid yellow pla- 6 mm, tailored to the degree of skin laxity. Subsequently,
ques, xanthelasma palpebrarum exhibits rare malignant the lower part of lesions that could not be resected in one
transformations. An array of treatments exists for this stage undergoes foam cell removal beneath the epidermis
condition, encompassing both non-surgical and surgical using an operating microscope or magnifying glass to
modalities. Non-surgical interventions comprise preserve epidermal integrity. This approach effectively
minimizes the extent of subcutaneous peeling, thereby

Fig. 5 Case1: A patient with

large xanthelasma palpebrarum
near inner canthus. a (pre-
operative) and b (postoperative
view one and a half of year
later)

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Fig. 6 Case2: A patient with large xanthelasma palpebrarum on the medial side of the upper and lower eyelids. a (pre-operative) and b (one year
after surgery, there was a slight recurrence below the left upper eyelid)

Table 1 Complications and

Complications Number of patients Proportion (%)
number of patients
Scar 6 15
Hyperpigmentation 0 0
Ectropion 0 0
Relapse 5 12.5
Local depression in the early stage 10 25

and averting complications such as eyelid ectropion and

scar hyperplasia. Therefore, our surgical method can be
used as another option besides skin grafting and skin flaps
in the surgical treatment of large-area xanthelasma. How-
ever, limitations include the potential for residual foam
cells beneath the epidermis post-operation, posing a chal-
lenge in recurrence control. Moreover, surgery necessitates
microscopic or magnifying glass assistance, and entails a
recovery period, with early postoperative activities mildly
affected.
As of now, the etiology of xanthelasma remains unclear,
and a standardized treatment protocol is lacking. The issue
of postoperative recurrence persists as a significant chal-
lenge, with no definitive method ensuring a zero recurrence
Fig. 7 Foam cells were aggregated within the dermis (HE,9100) rate [11, 18]. Mendelson and Masson reported a recurrence
rate of 40% after primary excision of xanthelasma palpe-
reducing operative duration. Due to the epidermis’ lack of brarum (XP), escalating to 60% after secondary excision
inherent blood supply, in situ replantation carries the risk [19]. In two separate studies, the combination of local flaps
of poor survival. Certain scholars have explored the use of and skin grafts derived from blepharoplasty for large-area
skin grafts obtained during blepharoplasty for treating XP resection yielded recurrence rates of 3% and 8% at
extensive eyelid xanthoma surgically. Despite local pres- 6–12 months post-surgery, respectively [8, 17].
sure management, six cases reported subcutaneous hema- During our follow-up of patients after surgery, 5 patients
toma or effusion, leading to complications such as skin with recurrence of xanthelasma were found. We observed
necrosis [17]. Following nucleus pulposus foam cell one recurrence case where the lesion noticeably thickened,
removal, we employed 7/0 nylon for incision closure, with causing the epidermis to become extremely thin and diffi-
additional sutures (2–3 stitches) placed beneath the orbic- cult to separate. During the process of peeling and trim-
ularis oculi muscle within the dissection range. A Vaseline ming the foam cells beneath the epidermis, the epidermis
gauze roll, akin to a tie-over bolster dressing, was then was perforated in efforts to preserve its integrity, poten-
ligated, to be removed after 48 h. This approach effectively tially leaving behind a small amount of foam cells that
mitigates subepidermal effusion or hematoma, fostering contributed to recurrence. Another patient, presenting with
skin survival while minimizing inconveniences like eye large xanthelasma on the upper and lower eyelids, expe-
bandaging. Our surgical method offers several advantages, rienced recurrence manifesting as new lesions around the
notably shortened operation times through partial lesion original site, rather than in situ. Additionally, a patient with
removal in a single stage. Additionally, we effectively congenital cleft lip and palate experienced recurrence
prevent subepidermal effusion, thus reducing surgical scars approximately one year post-surgery, suggesting a

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potential link to congenital conditions that warrants further References

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if changes were made. The images or other third party material in this strategies for xanthelasma palpebrarum: a comprehensive liter-
article are included in the article’s Creative Commons licence, unless ature review of contemporary modalities. Arch Dermatol Res
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included in the article’s Creative Commons licence and your intended 19. Mendelson BC, Masson JK (1976) Xanthelasma: follow-up on
use is not permitted by statutory regulation or exceeds the permitted results after surgical excision. Plast Reconstr Surg 58(5):535–538
use, you will need to obtain permission directly from the copyright
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