Sir,

Blepharoplasty is a common cosmetic procedure carried out throughout the world. The skin that is removed during the procedure is usually discarded. We present a case of a routine blepharoplasty performed for bilateral dermatochalasis, in which a high suspicion of index on the part of the surgeon, resulted in the detection of serious histopathological changes in the redundant eyelid skin that would otherwise have been discarded.

Case report

A 68-year-old woman was referred to the oculoplastic surgeons with dermatochalasis with vision obstruction. In clinic the visual acuities were 6/9 OD and 6/9 OS aided and the lids showed bilateral upper lid dermatochalasis worse on the right, with a mechanical ptosis (Figure 1a). The facial and lid skin was generally red and thickened. Thinning of both eyebrows was noted. The patient underwent bilateral blepharoplasties and in view of the clinical observations above, the right upper eyelid specimen (that would have otherwise been discarded) was sent for histopathological diagnosis.

Figure 1
figure 1

(a) Clinical appearance of the eyelids. Note bilateral dermatochalasis, thinned eyebrows, reddish, rugged skin on forehead and slight thickening of the right upper eyelid compared to the left. (b) Haematoxylin and eosin stained section of the right upper lid blepaharoplasty specimen showing a folliculotropic infiltrate. (c) Higher power of the follicular infiltrate showing abnormal lymphocytes with irregular/cerebriform nuclei. (d) CD3 (pan-T-cell antigen) expressed on the folliculotropic lymphocytes, as detected by immunohistochemistry (brown=positive reaction). (e) 186 base pair T-cell clone detected by PCR (tallest peak is the dominant T-cell clone).

Full size image

The haematoxylin and eosin sections revealed a striking folliculotropic, lymphocytic infiltrate. (Figure 1b). The lymphocytes were rather irregular and cerebriform in shape at higher power (Figure 1c). No follicular mucin was identified. Immunohistochemistry showed that the atypical lymphocytes expressed CD3 (Figure 1d), indicating a T-cell phenotype and CD4 with some loss of CD7.

CD30 or CD56 was not expressed. DNA extracted from the paraffin tissue showed the presence of a T-cell clone (Figure 1e). The morphological, immunohistochemical and molecular features were those of folliculotropic mycosis fungoides (MF) (WHO classification). Dermatological review subsequently discovered reddish patches on her anterior chest, with biopsy showing an identical histological diagnosis.

Comment

To the best of our knowledge, this is the first report of folliculotropic MF to affect the peri-ocular skin. Ophthalmic manifestations of mycosis fungoides have shown that late plaque or tumour phase MF affected the eyelids in a significant number of patients.1 MF can present clinically with lower eyelash and eyebrow loss2 as in our case. The significance of folliculotropic MF is that it carries a worse prognosis compared to conventional plaque stage MF and therefore important to distinguish histologically.3 From a practical perspective, oculoplastic surgeons carry out a large number of cosmetic blepharoplasty procedures. Sending every blepharoplasty specimen for routine histological analysis would not constitute wise use of the histopathology service. However, this case serves to illustrate the point that any eyelid skin that is deemed to be even faintly abnormal during examination or during the surgical procedure should be sent for histopathological examination to exclude serious pathology, of the kind identified in this case.

The study was performed in accordance with the declaration of Helsinki. The patient consented to an identifiable photograph of the eyes to be used for publication. The signed consent is in the medical notes.