Xanthelasma Excision Suturing Technique
For xanthelasma excision, perform simple excision with primary closure using fine absorbable sutures (6-0) for deep dermal layers and non-absorbable monofilament sutures (6-0 or 7-0) for skin closure, extending excision to the superficial dermis or orbicularis muscle if involved, with marker sutures for orientation if needed for complex cases. 1, 2
Surgical Approach and Depth
Simple excision is the primary technique for most xanthelasma cases, particularly for lesions confined to the dermis (grades I and II). 2
Extend excision to the superficial dermis as xanthelasma results from perivascular infiltration of foam cells within the superficial reticular dermis. 3
Include orbicularis oculi muscle if involved, which occurs in approximately 25% of cases—failure to excise involved muscle increases recurrence risk. 2
Avoid excessive depth beyond what is necessary to clear the lesion, as xanthelasma is a benign disorder and aggressive excision increases morbidity without improving outcomes. 1, 4
Suturing Technique Specifics
Use 6-0 absorbable sutures (such as polyglactin or poliglecaprone) for deep dermal layer closure if needed to reduce tension. 5, 6
Use 6-0 or 7-0 non-absorbable monofilament sutures (such as nylon or polypropylene) for skin closure to minimize scarring in this cosmetically sensitive periorbital area. 5
Place marker/orienting sutures if the excision involves multiple eyelids or complex anatomy to facilitate accurate assessment of any residual tissue. 7, 5
Ensure meticulous hemostasis before closure to prevent hematoma formation in the thin periorbital tissues. 2
Closure Options Based on Defect Size
Primary linear closure is appropriate for 70% of cases (grades I-II) where simple excision creates a defect that can be closed without tension. 2
Local flaps are required in 25% of cases (grade III) where larger defects or multiple eyelid involvement prevents primary closure. 2
Skin grafts are needed in 5% of cases (grade IV) with extensive involvement where local tissue is insufficient. 2
Secondary intention healing is an alternative option that provides good cosmetic results despite increased early morbidity, particularly useful when primary closure would create excessive tension. 4
Critical Technical Considerations
Complete excision of all visible xanthelasma tissue is essential, as incomplete removal is the primary cause of the 3-17% recurrence rate. 1, 2, 8
Avoid complex reconstruction before confirming complete excision, particularly in cases involving all four eyelids or patients with underlying hyperlipidemia, as these have higher recurrence rates. 1
Photograph the specimen if dealing with extensive or recurrent disease to document the extent of excision. 7
Common Pitfalls to Avoid
Underestimating depth of involvement: Failing to excise involved orbicularis muscle leads to recurrence—inspect the muscle layer intraoperatively. 2
Excessive tension on closure: This increases the 4.2% risk of scar contracture requiring secondary procedures—use local flaps or grafts when primary closure creates tension. 2
Ignoring lipid disorders: 50% of xanthelasma patients have dyslipidemia, and uncontrolled hyperlipidemia increases recurrence risk—coordinate with internal medicine for lipid management. 8, 3
Inadequate patient counseling: Patients with all four eyelids involved or underlying hyperlipidemia syndromes should be counseled about higher recurrence rates (>50%) even with complete excision. 1