A 58-year-old man was followed up in our Department due to small bilateral nodular lesions in the upper and lower eyelids of 5-6 mm in size, subcutaneous, cartilage-like consistency, slow growing and coloring.
After an initial evaluation by anamnesis and physical examination, the presumptive clinical diagnosis was xanthelasmas.
Under local anesthesia, the nodular lesions described in both lower eyelids were resected conservatively to the muscular plane on the first occasion, performing a direct closure.
Posterior histopathological diagnosis was Xgranuloma with muscular inversion.
During the 6 months following surgery, the progress continued, both in extension and in size of the lesions, occupying the entire correct classification process, including areas of previous extirpation, and preventing one.
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Taking into account the pathological anatomy and the patient's decision, a second more radical excision of the lesions was performed, including the entire skin pemphigus vulgaris unit, as well as the orbicularis muscle involved.
The lesions of the upper eyelids were asymptomatic and without functional impact, so the patient refused removal.
The defect created was repaired using a subcutaneous extended cutaneous flap described by Heywood (7) based on the rich vascularization of the lateral area of the corner.
This region is irrigated by the branches of the terminal zygomatic acid derivative, which anastomose with the periorbital vessels.
In a cheek not previously intervened, we can design an external subcutaneous tissue flap at 1 or 2 cm from the external corner, with width and length to repair the entire area of relief with a lateral orbital rim angle, which allows a vertical axis.
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In order to obtain the flap, an adrenaline solution 1/100,000 was applied prior to the dissection and removal of the lesion.
The design is carried out on a zygomatic area with a pivot point at 1-2 cm from the lateral corner and whose major axis is located laterally between a horizontal line at pupil level and an oblique line at 60-70.
The length and width of the skin island will depend on the defect.
In this way we get a scar that will follow the skin lines of minimum tension and allow us to primary closure of the donor area.
Dissection begins from the distal margin to the external corner.
The thickness of the flap should be equivalent to the thickness of the defect, without risk for distal viability.
A precise and careful dissection 1 cm around the base of the flap, point pivot, is necessary to avoid damage to the vessels that guarantee flap survival.
Subcutaneous isolation allows us to rotate the skin island from 100o to 120o from the cheek to the neck defect, without bulging effect.
The most distal portion is anchored in the inner corner as a belt and simple stitches are given.
Special care should be taken to ensure that the size of the flap is similar to the defect, to avoid complications.
Finally, we adapt the flap by suturing only the skin with irreabsorbable monofilament of 4/0 or 5/0.
The pathology report of the resection specimen (3.9) reported that it occupied not only the thickness of the dermis, but also the tended towards central retinal lesions with multiple cellular clusters in which the lesion was located.
These stems are made up of abundant multinucleated giant cells, some with arrangement of nuclei in peripheral corona, whose cytoplasm is wide, eosinophilic or indentified vaccillary (lipid contours).
These cells intermingle with foamy mononucleated histiocytes and lymphoplasmacytic inflammatory cells.
Mononucleated and multinucleated histiocytic cells are stained positively for CD68, lyme and alpha 1-antichemotrypsin.
No necrobiosis areas were observed.
In our case, we highlight the unusual absence of Touton cells and muscle involvement.
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The clinical outcome 8 weeks after surgery was excellent from both aesthetic and functional points of view.
The color and texture of the eyelid were achieved without presenting the patch or retraction effect of the skin grafts.
In addition, the procedure allowed us to solve the skin defect quickly, in a single surgical time and with few sequelae, avoiding the use of skin grafts or procedures using more complex flaps.
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The donor site scar, visible at first, improved over time and was hidden in a natural fold. In addition, postoperative thickening of the flap, secondary to initial lymphedema, disappeared within 3-4 months after surgery.
