Multiple soft fibromas of the lid.

Fibromas are benign tumors that are composed of fibrous or connective tissue. They can grow in all organs, arising from mesenchymal tissue (a type of loose connective tissue). The term "fibroblastic" or "fibromatous" is used to describe tumors like the fibroma. This 69-year-old male presented to us with giant, multiple, very slowly progressive, painless, noninflammatory, soft, trans-illuminant, pedunculated lid swellings with a two decade history. There were no other swellings on the body. He was clinically normal on systemic examination except for the immature cataracts in both eyes. The diagnosis was confirmed on histopathology. Simple excision removed all the soft fibromas virtually leaving no scar. A review of literature world-wide using Medline Plus/PubMed revealed this to be the only reported case of multiple giant soft fibromas of the lid.

Few reports have described similar lesions elsewhere. In one of the studies reviewing 855 cases of primary lid tumors, fibro-epithelial polyps (FEP) (n = 56) represented 8.6% of all benign lesions.[1] There was a slight preference for the right eyelid, and most cases were diagnosed in males in this report. This lesion was evenly distributed on both the upper and lower eyelids. Other studies have shown higher prevalence with an incidence of 46%, and an equal presence was observed in either sex.[2] FEP are also known as acrochordons and skin tags. The exact etiological cause still remains unknown.

Case Report

A 69-year-old male presented to us with a history of droopy skin over the eyelids since the past 2 decades. Being advised to seek medical opinion from elsewhere over a decade ago, he did not undergo any clinical examination because he was neither motivated nor did the lid mass cause him any difficulty except for abnormal cosmesis [Fig. 1]. The lesions developed initially as small folds in the skin of the lid [Fig. 2 – left upper lid] and over two decades assumed the current proportions. The fibromas were multiple in number (one on each lid), very slowly progressive, soft and trans-illuminant [Fig. 3]. The larger of the masses encompassed the lid fold [Fig. 4] and was pedunculated.

Figure 1

Solitary lid masses

Figure 2

Close up of small fibro-epithelial polyps developing on the left upper lid

Figure 3

Trans illumination of fibro-epithelial polyps

Figure 4

Base encompassing lid

There were no episodes of pain or inflammation. There were no associated findings suggestive of neurofibromatosis. The patient's daughter was getting married in the coming month. It was at her advice and suggestion that the father finally decided to undertake the surgical removal of the lesions. He underwent simple excision [Fig. 5] of the lesions on December 7, 2011 and had an uneventful recovery. The base of lesions was clamped with a small artery forceps and crushed. Surgical scissors were used to excise the crushed area thereby removing the lesion from its base. The availability of loose skin led to overlap of tissue thereby requiring no suturing in layers. Histopathologic examination using hemotoxylin eosin staining revealed stratified squamous epithelium lining a connective tissue stalk showing loose fibro-collagenous tissue containing congested blood vessels and chronic inflammatory infiltrate. No adnexal structures were seen. This confirmed the diagnosis [Fig. 6].

Figure 5

Simple excision of lesions

Figure 6

Histopathologic examination at ×100 revealing details

Discussion

Fibromas are benign tumors that are composed of fibrous or connective tissue. The term fibrosarcoma is reserved for malignant tumors. There are two common fibroma types seen on the skin. They are the hard fibromas (dermatofibroma) and the soft fibroma (skin tag). The hard fibroma (fibroma durum) consists of many fibers and few cells. If seen on the skin it is known as a dermatofibroma, a special form of which is the keloid. A dermatofibroma is a round, brownish to purple growth commonly found on the legs and arms. Dermatofibromas contain scar tissue and feel like hard lumps in the skin.

Soft fibromas also called “FEP,” “acrochordons,” or “cutaneous tags” occur as three types: (a) Multiple small, furrowed papules, especially on the neck and in the axillae, generally only 1–2 mm long; (b) single or multiple filiform, smooth growths in varying locations, about 2 mm wide and 5 mm long; and (c) solitary bag-like, pedunculated growths, usually about 1 cm in diameter but occasionally much larger, seen most commonly on the lower trunk.[3] The soft fibroma consists of many loosely connected cells and less fibroid tissue then the hard dermatofibroma. Most FEP vary in size from 2 to 5 mm in diameter, although larger FEP up to 5 cm in diameter are sometimes evident. The most frequent localizations are the neck and the axilla, but any skin fold, including the groin, may be affected.[4]

These tumors are usually asymptomatic, and they do not become painful unless inflamed or irritated. Pedunculated lesions may become twisted, infarcted, and fall off spontaneously.[5] Only on rare occasions, histological examination of a clinically diagnosed FEP reveals a basal or squamous cell carcinoma.[6]

Various methods of removal include cryotherapy for smaller lesions and ligation with a suture or a copper wire have been described; however, freezing of the surrounding skin during liquid nitrogen cryotherapy may result in dyschromic lesions. Taking hold of the acrochordon with forceps and applying cryotherapy to the forceps may provide superior results when the lesions are multiple and smaller in size.[78] In our case, simple excision gave excellent cosmesis leaving virtually no scar [Figs. 7–9]. An online search using Medline Plus/PubMed and other medical search engines revealed this to be the only published case with photographs in detail. These lesions can easily be treated at any center using simple techniques.

Figure 7

Postoperative photograph right eye close up

Figure 9

Postoperative photograph overview of scar and appearance of face

Postoperative photograph left eye close up