Fatty nodules of the dermis of the upper eyelids: a new entity

Dear Editor,Acquiredyellowishlesionsofvarioushuesinvolvingonlytheskin of the eyelids are generally caused by lipidized histio-cytes (xanthelasma, xanthoma) [1, 2] or lipidized epithelialcells (sebaceous tumors) [ 3, 4]. We report an extraordinarycase of a late middle aged woman with bilateral nasal uppereyelid, yellow–orange, mildly elevated nodules due to acomplete focal replacement of an involved segment of thedermis by mature adipocytes.A62-year-oldwomanfirstnotedpainless,yellowish,upperinner eyelid discolorations in 2008. They slowly enlarged tobecome mildly elevated, and focally marginated nodules.They were soft and compressible. On ophthalmic examina-tion, performed on March 5, 2013, each lesion was oval andsoft with irregular borders (Fig. 1a). Visual acuity was 20/40in each eye. There was no ptosis. The eye examination wasremarkable for bilateral posterior chamber intraocular lenseswith Descemet’s stripping endothelial keratoplasties (DSEK)for Fuchs’ dystrophy. The patient denied using makeup(exceptforaneyebrowpencil),anyinjectionsaroundtheeyes,skin conditions including similar lesions elsewhere, systemicmedicines or diseases, and a diet with excessive fruit orvegetable intake. A recent complete blood count and lipidprofile obtained as part of a thorough clinical checkup werewithinnormallimits.Becauseofslowenlargement,thepatientwantedthelesionsexcised.Atbilateralsurgery,theorbicularismuscle was clearly observed and noted to be free of dehis-cences; the medial fat pads were not encountered. After5 months of follow-up, the lesions have not recurred.Thegrossspecimensmeasured0.9×0.4cmand0.7×0.5cm,with 0.2 cm of thickness. Microscopically, the dermis of botheyelid specimens was dominated by well-developed, large,univacuolar lipocytes that extended throughout its full thick-ness, sparing only a thin lamina of collagen beneath a non-disturbed epidermis. Hair structures and sweat glands werepreserved (Fig. 1b, top and bottom panels). The fat cells wereS-100 positive (Fig. 1c) and there were many thin trichrome-positive strands of surviving dermal collagen (Fig. 1d). Alcianblue staining was negative. Rare multinucleated histiocytescontainingeither delicate granules or fine lipidic vacuoles wereobserved (Fig. 1e). CD68 confirmed the presence of a lightdispersion of small, non-activated histiocytes (Fig. 1f).Thecurrentpatient’soval,palpable,yellow-orange,elevat-edlesionswithfocallywell-definedmargins(“puddlesoffat”)differ from the flat or placoid, creamy-yellow appearance ofxanthelasma with ill-defined edges [1]. Abundant ectopicdermal lipocytes constituted the main pathologic feature, andprobably arose from metaplasia of dermalfibroblast-like stro-mal cells. Lipocytes can occur among dermal nevus cells;osteomas of the dermis [5] and osteolipomas are additionalexamples of metaplastic phenomena [6]. An intramuscularlipoma of the orbicularis has been described [7], but eyeliddermal involvement by a solitary lipoma or polypoidal nevuslipomatosus has not been reported [6]. The underlyingorbicularis muscle in the current case did not display a dehis-cence that might have permitted prolapse of more deeplylocatedfat.Injectionsoffat,paraffin,orsiliconeandentrappedointment create multiloculated, extracellular lipogranulomashistopathologicallythatarerimmedbymononucleatedepithe-lioid cells and multinucleated giant cells [8, 9].There is one relevant report in the dermatology literature[10] of a group of 27 French patients with flat, superonasal