Blepharoplasty for eyelid herniation in Crohn's disease.

The experience of plastic surgery in Crohn’s disease is very limited and seems to have a clear therapeutic role so far: repairing of scars and muscle or skin defects and improving body image in multi-operated patients or patients with stomas. Cosmetic surgery in Crohn’s disease is always debatable, as the surgeon and the gastroenterologist have to balance between a patient’s desire for an attractive appearance and the risk for potential complications. Prolonged therapy with systemic corticosteroids in patients with Crohn’s disease may result in various complications and side effects including poor cosmesis. In fact, many patients and especially the younger ones frequently complain of problems related to poor body and facial appearance.

We present herein a female patient with long-term corticosteroid therapy for Crohn’s disease who underwent successful cosmetic blepharoplasty.

A 53-year-old woman with ileocolonic Crohn’s disease for the last ten years came to our hospital because of a pronounced bilateral lower eyelid edema. According to the patient, the eyelid edema presented eight years ago and gradually became pronounced. Since Crohn’s disease diagnosis, the patient was treated initially with systemic corticosteroids and then was switched firstly to azathioprine and then to methotrexate in the hope that corticosteroids could be tapered. However, the patient proved to be corticosteroid dependent and relapsed with any dose lower than that of 8 mg/day of methylprednisolone.

Physical examination and blood tests were unremarkable and the patient was in disease remission. Any local or systemic diseases that could possibly relate to this bilateral eyelid edema were excluded. Ophthalmologic examination showed lower eyelid herniation of orbital fat. Other ophthalmologic co-morbidities or extraintestinal manifestations were excluded. A bilateral blepharoplasty was successfully performed and the patient was discharged two days afterwards in excellent condition (Fig. 1). On follow up the patient showed complete wound healing and had a perfect cosmetic result.

Figure 1

Bilateral blepharoplasty for eyelid herniation complicating corticosteroid therapy in Crohn’s disease

The experience of treating Crohn’s disease complications with plastic surgery is extremely limited mainly due to the relapsing nature of this systemic disease. An interesting retrospective study in fourteen patients suggested that gracilis muscle transposition for complex fistula and persistent non-healing sinus in perianal Crohn’s disease is a safe and viable option [1]. Another study using a local fasciocutaneous infragluteal flap demonstrated good wound healing [2]. In general, during facial operations doses of 30 mg or less of perioperative glucocorticosteroids can safely be administered without a major impact on wound healing. In animal models, the addition of steroids during surgery resulted in delayed wound healing, particularly in animals receiving high-doses of steroids. Two cases with Crohn’s disease and hidradenitis suppurativa successfully treated with intramuscular grafting of buried skin chip [3] and a case of an intractable enterocutaneous fistula treated with an island pedicled anterolateral thigh have been reported [4].

Data on cosmetic surgery in Crohn’s disease is lacking. There is only one report on three non-Crohn’s disease patients with non-infectious inflammatory reactions to gold weight eyelid implants, successfully treated with local corticosteroids [5].

Perhaps plastic surgery for reconstruction or cosmesis could be of help in carefully selected patients with Crohn’s disease.