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Eyelid Trichoadenoma: Surgical Treatment Associated with Aesthetic Blepharoplasty Tricoadenoma Palpebral: Tratamento Cirúrgico Associado À Blefaroplastia Estética

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Eyelid Trichoadenoma: Surgical Treatment Associated with Aesthetic Blepharoplasty Tricoadenoma Palpebral: Tratamento Cirúrgico Associado À Blefaroplastia Estética CASE REPORT VendraminFriedhoferFranco T FSetH etal. al. Eyelid trichoadenoma: surgical treatment associated with aesthetic blepharoplasty Tricoadenoma palpebral: tratamento cirúrgico associado à blefaroplastia estética HENRI FRIEDHOFER1 ABSTRACT ÁLVARO JÚLIO DE ANDRADE SÁ2 Trichoadenoma is a benign cutaneous tumor that is asymptomatic, rare, and slow growing. MARIA CRISTINA DE PAULA There are few cases reported in the literature, and we could only identify one description MESQUITA3 of trichoadenoma occurring in the eyelid area. We describe the case of a patient with tri- GILLES LANDMAN4 choadenoma in the outer corner of the lower eyelid that we treated with surgical excision ARTHUR DE PAULA AMORIM associated with blepharoplasty. MESQUITA5 Keywords: Neoplasms, basal cell/surgery. Skin neoplasms/surgery. Blepharoplasty. Eyelids/ surgery. Study conducted at the Hospital Israelita Albert Einstein, originating from private clinic’s first author, RESUMO located in São Paulo, SP, Brazil. O tricoadenoma é um tumor cutâneo benigno, assintomático, raro e de crescimento Submitted to SGP (Sistema de Gestão len­­­to. Existem poucos casos relatados na literatura e identificamos apenas um descrito de Publicações/Manager Publications na região palpebral. Apresentamos o caso de uma paciente portadora de tricoadenoma System) of RBCP (Revista Brasileira de no canto externo da pálpebra inferior direita, tratada com excisão cirúrgica associada a Cirurgia Plástica/Brazilian Journal of blefaroplastia. Plastic Surgery). Article received: November 21, 2011 Descritores: Neoplasia de células basais/cirurgia. Neoplasias cutâneas/cirurgia. Blefaro- Article accepted: January 18, 2011 plastia. Pálpebras/cirurgia. INTRODUCTION in confluent minuscule papules of similar coloration to the adjo­­­ining skin (usually yellowish or grayish), covered by te­­­ Trichoadenoma, first described by Nikolowski in 1958, la n­­­­­­giectasias and measuring from a few millimeters to 1.5 cm. is a rare, asymptomatic, slow-growing, benign cutaneous On dermatoscopic examination, it may appear to be a baso- tu­­­mor. It originates in the cells of the pilous follicle and cellular carcinoma. most commonly presents on the face, trunk, or buttocks, On histopathologic examination, the trichoadenoma pre­­­ ty­­­pically during the fourth decade of life. It presents with sents with multiple cysts containing keratin, surrounded by more maturation than trichoepithelioma and with less diffe- squamous dermal cells. Although trichoadenomas usually rentiation than trichofolliculoma1 and desmoplastic trichoe- appear in isolation, association with other cutaneous lesions pithelioma1-4. Some authors2,5-10 believe that it is intermediate like sebaceous nevus11 and melanocytic nevus12 has been between trichoepithelioma and trichofolliculoma in terms described. Despite the fact that the diagnosis of trichoade- of its differentiation towards the infundibular portion of the noma is made histologically, some authors doubt its existence pilosebaceous canal. Trichoadenoma mainly affects adults and consider it a form of trichoepithelioma or keratinizing of both genders, and has no malignant potential1. Clinically, basalioma2, for which histological characteristics and evolu- it presents with a single, well-delimited nodular lesion or tion are needed for a correct diagnosis. 1. Associate professor at the Faculty of Medicine of São Paulo (FMUSP), responsible for the orbitopalpebral surgery group of the Division of Plastic Surgery of the Hospital das Clínicas da FMUSP, São Paulo, SP, Brazil. 2. Assistant physician at the Hospital Municipal Infantil Menino Jesus, formerly a resident physician at Hospital das Clínicas da FMUSP, São Paulo, SP, Brazil. 3. Full member of the Brazilian Society for Dermatology, director of Clínica Dermac de Dermatologia, Uberlândia, MG, Brazil. 4. Assistant Professor at Universidade Federal de São Paulo (Unifesp), associate professor in the Department of Pathology of Unifesp, São Paulo, SP, Brazil. 5. Medical student at Universidade de Uberaba, Uberaba, MG, Brazil. 160 Rev Bras Cir Plást. 2012;27(1):160-4 Eyelid trichoadenoma: surgical treatment associated with aesthetic blepharoplasty There are only a few cases described in the literature and After a conclusive diagnosis was obtained, the treatment only one case in the eyelid area has been identified to date13. strategy consisted of surgical resection of the lesion with In view of the rarity of this tumor, there is no defined algo- narrow margins, followed by cryomicroscopy in the opera- rithm for its treatment. However, to date, all published cases ting room. Before treatment, the patient had also expressed have been treated by surgical excision, either for aesthetic her wish to correct the aging-related changes in her eyelids reasons, due to lack of knowledge concerning the tumor’s (Figure 2). Therefore, it was proposed that aesthetic blepha- behavior if left untreated, or because of tumor enlargement. roplasty would be performed during the same surgical proce- There are no reports of relapse after resection of these lesions. dure as tumor excision and reconstruction. This article describes the case of a patient with trichoade- noma in the external corner of the bottom right eyelid, treated Surgical Procedure with surgical excision associated with blepharoplasty. The surgical procedure was performed under local anes- thesia with bupivacaine hydrochloride 0.5%, using a vaso- constrictor, along with intravenous sedation. The lesion was CASE REPORT totally resected with narrow margins, keeping the integrity of the underlying plane of the orbicular muscle. During the The patient, a 48-year old woman, observed a small, hard, operation, the resected piece was forwarded for pathological pink tumor on her right lower eyelid 3 years ago. Excision of cryoanalysis, which showed clean, tumor-free margins. the lesion was performed on that occasion and histological The resection created an irregular defect with a horizontal analysis led to the diagnosis of hemangioma. diameter of approximately 15 mm and a vertical diameter of Six months ago, the patient noticed a small acne-type 12 mm (Figure 3). le­­sion in the same place as the excision; topical administra- Next, a myocutaneous graft of the orbicular muscle of tion of fusidic acid and betamethasone valerate did not re­­­ the upper eyelid was performed, laterally pedunculated in its solve the lesion. preseptal portion (Figure 4). The size of the graft was planned After 2 months, the lesion was still asymptomatic but to be not much larger than the defect caused by the resection pro­­­­gressing; a new biopsy resulted in a diagnosis of tri­­ of the trichoadenoma in the lower eyelid. Canthopexy was choepithelioma. Afterward, worried about the appearance of subsequently performed, slightly elevating the lateral corner the lesion and fearing malignancy, the patient sought advice using “U” stitches with multifilament polyester 4-0 thread from another service. Detailed dermatological examination (Ethibond – Ethicon, São José dos Campos, SP, Brazil) revealed a slightly erythematous plaque of approximately bet­­­ween the periosteum of the orbital margin/rim and the 1.3 cm in diameter in the same place, with multiple cys­­­­tic- lateral retinaculum. The donor area was sutured in planes: ap pearing, often translucent, white-yellowish papules. The the muscle portion was sutured using interrupted sutures with papules were not itchy; they were hard, appeared shiny with 6-0 monofilament nylon thread, and the cutaneous portion, small, thin vessels on the surface of the grouped cysts, and with the same thread but using a continuous suture. Next, had a scabby surface (Figure 1). On the same occasion and the myocutaneous graft was transposed and sutured to the upon request, the specimen was reanalyzed by an indepen- surgical area in the lower eyelid with 6-0 monofilament nylon dent pathologist who confirmed, as suspected, the diagnosis thread (Mononylon – Ethicon) using interrupted sutures in of trichoadenoma with extensive squamous metaplasia of the sudoriferous epithelium. Figure 2 – Preoperative appearance showing Figure 1 – Preoperative appearance of the trichoadenoma. aging of the eyelid. Rev Bras Cir Plást. 2012;27(1):160-4 161 Friedhofer H et al. its lower portion (Figures 5 and 6). During the same surgical procedure, a small amount of excess skin in the middle two-thir­­­­ds of the lower eyelid was resected; after hemostasis was achieved, a continuous suture was placed, using the same thread used in the infraciliary area, in a similar manner as in the blepharoplasty with cutaneous graft. The same suture also attached the ciliary margin of the lower eyelid to the higher part of the myocutaneous graft. On the contralateral side, blepharoplasty was performed using the same technique, and a segment of the preseptal orbicular muscle was also resected together with the skin in the upper eyelid, associated with the canthopexy (Figure 7). Palpebral bags of all four eyelids were treated with conser- vative resection, followed by hemostasis. Cefazolin (2 g) was administered 60 minutes before sur­­ gery for antibiotic prophylaxis. Saline compresses and the Figure 5 – Transposition of the myocutaneous graft. Figure 6 – Suture in the area of the upper eyelid defect. Figure 3 – Defect after tumoral resection. Figure 4 – Myocutaneous graft in the upper eyelid Figure 7 – Immediate postoperative image after with lateral peduncle. contralateral symmetry achieved. 162 Rev Bras Cir Plást. 2012;27(1):160-4 Eyelid trichoadenoma:
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