Incidental Finding of Mucosa-Associated Lymphoid Tissue Lymphoma during Lower Blepharoplasty

Recently, the public has developed a growing interest in aesthetic surgery. Middle-aged individuals in Northeastern Asia have have shown particular interest in undergoing blepharoplasty to reduce bulging eyelid fat. However, those who present for aesthetic surgery usually have not considered the possibility of an eyelid tumor, and thus, have not taken time to undergo evaluation for this possibility. Here, the authors describe a case of mucosaassociated lymphoid tissue (MALT) lymphoma that was diagnosed by a thorough physical examination in a man requesting lower blepharoplasty. A 58-year-old man visited out aesthetic center to alleviate bulging of both lower eyelids, which had begun approximately 5 years previously. The patient had no underlying disease at presentation, and chest X-ray and electrocardiography findings were normal. Physical examination confirmed bulging of both lower eyelids to a similar extent, and the unidentified tumor was palpated on the left side (Fig. 1). A biopsy was recommended for evaluation purposes, but the patient requested cosmetic surgery only, and thus, we began lower blepharoplasty after informing the patient that a biopsy might be needed during surgery and that if so, additional treatment might be required. Initially, we elevated a musculocutaneous flap by subciliary incision, and then began dissection to the extent of the inferior orbital rim. After exposing the preseptal space, an incision was performed on the orbital septum to expose the orbital fat for removal and transposition. However, we encountered a pinkish, hard, highly vascularized mass-like lesion between the orbital septum and orbital fat, which is not normally found during lower blepharoplasty. After resecting the 1.8 cm × 1.5 cm × 1.2 cm mass, lower blepharoplasty was performed in the usual manner (Fig. 2). The pathologic examination result indicated MALT lymphoma with an immunoprofile of CD20 (+), bcl-2 (+), CD3 (–), CD10 (–), CD38 (–), and CD138 (–) (Fig. 3). The patient was sent to another hospital for a systematic workup, and subsequent orbital computed tomography (CT) and positron emission tomography (PET)-CT indicated a possibility of residual lymphoma localized in the extraocular area (Fig. 4). As a result, he was treated using involved-field radiation therapy at the origin of the lymphoma at 2 Gy for 20 days based on a 1AE Ann Arbor staging. Orbital CT and PET-CT at 6 months postoperatively revealed no evidence of lymphoma and a good cosmetic outcome was achieved at 6 months after surgery (Fig. 5). The patient was very satisfied with the discovery of the mass at an early stage and the sufficient biopsy.