Medical Care
Dietary restriction and pharmacologic reduction of serum lipids, although important in the overall care of a patient with abnormal lipids, yield only limited response in the treatment of xanthelasma.
Surgical Care
Numerous options are available for the removal of xanthelasma palpebrarum, including surgical excision, argon and carbon dioxide laser ablation, chemical cauterization, electrodesiccation, and cryotherapy.
Surgical excision
For small linear lesions, excision is recommended, as scarring should blend in with the surrounding eyelid tissue. Smaller bulging lesions can be "uncapped" and removed; then, the flap can be replaced and sutured.
Doi recommends using a surgical microscope, undermining between the tumor and the orbicularis oculi with an 11 blade, raising the flap and carefully removing the tumor piece by piece with microscissors from the reverse side, and then suturing the flap with 7-0 nylon. [4]
In full-thickness excisions, the lower lid is more prone to prominent scarring, as the tissue tends to be thicker. Simple excision of larger lesions risks eyelid retraction, ectropion, or the need for more complicated reconstructive procedures. When xanthelasma removal has been incorporated into routine blepharoplasty, extending the incisional limits increases the risk for ectropion or webbing.
Case presentation of excision of recurrent xanthelasma. Recurrent xanthelasma bilateral upper lids; previous excision combined with blepharoplasty; patient insistent on repeat excision and blepharoplasty; advised of lagophthalmos risk due to medial position and lack of medial dermatochalasis.
Close-up view of recurrent xanthelasma right upper lid. Note the scar from previous excision by a plastic surgeon. Careful examination reveals subtle infiltration in the lateral aspect of scar.
Xanthelasma. External view, 1 week after surgery. Sliding and rotational flaps from residual lateral dermatochalasis used for medial excisional gap.
Laser ablation
Carbon dioxide, yttrium aluminum garnet, pulsed dye, argon, and 1450 nm diode laser have been laser modalities used in treatment of xanthelesma. [5] The carbon dioxide laser was the most commonly reported modality. Enhanced hemostasis, better visualization, lack of suturing, and speed have been cited as reasons to use these techniques. Scarring and pigmentary changes can occur. In a retrospective study involving the use of a 1064-nm, Q-switched Nd:YAG laser, 46 patients had significant clearing of lesions after 4 laser sessions. [6]
Chemical cauterization
The use of chlorinated acetic acids has been found to be effective in the removal of xanthelasma. These agents precipitate and coagulate proteins and dissolve lipids. Monochloroacetic acid, dichloroacetic acid, and trichloroacetic acid (TCA) have been used with good results. Haygood used less than 0.01 mL of 100% dichloroacetic acid with excellent results and minimal scarring. [7] TCA treatment has been advocated prior to surgical excision to cause initial shrinkage of the lesions. [8] Intralesional heparin sodium [9] and pingyangmycin [10] have been described for xanthelasma but are not yet conventional treatments.
Electrodesiccation and cryotherapy
Electrodesiccation and cryotherapy can destroy xanthelasmas when they are superficial but may require repeated treatments. Cryotherapy may cause scarring and hypopigmentation.
Complications
Ectropion and cutaneous nasal webbing may occur after excision of xanthelasma lesions.
Hypopigmentation may occur after trichloroacetic acid application.
If xanthelasma extend deep into the orbicularis muscle, the lesions may not respond to surface ablation techniques.
Further Outpatient Care
Patients should receive follow-up care for medical and surgical treatment.
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Case presentation of excision of recurrent xanthelasma. Recurrent xanthelasma bilateral upper lids; previous excision combined with blepharoplasty; patient insistent on repeat excision and blepharoplasty; advised of lagophthalmos risk due to medial position and lack of medial dermatochalasis.
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Close-up view of recurrent xanthelasma right upper lid. Note the scar from previous excision by a plastic surgeon. Careful examination reveals subtle infiltration in the lateral aspect of scar.
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Xanthelasma. External view, 1 week after surgery. Sliding and rotational flaps from residual lateral dermatochalasis used for medial excisional gap.
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Xanthelasma. Top image, 4 weeks after surgery; lower image, before surgery.
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Xanthelesma of four eyelids in patient with hyperlipidemia.
