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Abstract

A 66-year old woman presented with a four year history of slowly enlarging, irregular yellow plaques on the medial-central aspect of the lower eyelids and infraorbital cheeks bilaterally, measuring 8 mm on the right and 16 mm on the left. A clinical diagnosis of xanthelasma palpebrarum was made, and the patient requested excision. During the excision procedure, lesional tissue was noted to be extending deep into the orbicularis oculi muscle layer. Upon dissection into deeper tissue, a hard foreign material was encountered; samples were obtained for histopathologic examination, along with the excised xanthelasma tissue. Histopathology revealed foamy histiocytes within the papillary and reticular dermis. Examination of the deeper dermis and subcutis revealed uniform vacuoles surrounded by giant cells. The vacuoles contained small, regular, nonbirefringent beads, which were also observed in fragments obtained from the deeper muscular tissue. When questioned, the patient confirmed she had received Belafill® filler (polymethylmethacrylate microspheres suspended in degradable bovine collagen) in the lower eyelid area approximately 10 years prior. Xanthelasma-like reactions to polymethylmethacrylate microsphere-bovine collagen filler are rare, with five cases reported in the literature. Histopathology was obtained in two of these cases; both revealed foamy histiocytes consistent with xanthelasma, and one revealed granulomas containing filler material in the deep dermis/subcutis. The mechanism of development of the xanthelasma-like component is unclear but may be related to inflammation or binding of filler material to lipids which are subsequently phagocytosed by macrophages. Excision provided satisfactory results in our cases and in prior reports.