1 . he had a history of bilateral brow suspension surgery 10 years ago at another institution .
the patient had a 30 cm  20 cm pelvic mass located in the presacral area with boundaries between both parailiac regions displacing the rectum and bladder .
it was completely excised with a pathology report of myelolipoma . in physical examination , he had hypertrichosis , finger clubbing , and radiologically cortical thickening of the bones fig .
the patient presented with bilateral blepharoptosis with coarse skin folds the patient had cortical thickening of the bones and clubbing his best - corrected visual acuity was 7/10 in the right eye ( re ) and 5/10 in the left eye ( le ) .
horizontal length of the upper lids of re and le was 46 mm and 41 mm , respectively .
vertical fissure heights were 6 mm and 4 mm with margin - reflex distances of 0.5 mm and 0.5 mm , respectively .
vertical eyelid contour of the re showed an inverse  v  shape for the re and a smooth curve for the le .
the eyelids were floppy and easily everted . to correct these clinical findings , a surgery which combines vertical tarsal shortening accompanied with horizontal whole eyelid wedge resection and brown suspension
10 mg/0.25 ml triamcinolone acetate was injected into each supratarsal space to decrease the thickness of the tarsus .
horizontal wedge resection which is not a part of routine ptosis surgery was performed in this operation with the aim of normalizing the obvious horizontal length of the lids .
pathological evaluation revealed epidermal hyperplasia , severe inflammatory changes in subepidermal level , hyperplastic sebaceous glands , and collagen tissue derangement fig .
reconstruction of each eyelid was achieved by vertical tarsectomy , horizontal full thickness lid resection , and supratarsal steroid injection .
ptosis was assessed with silicone rod frontalis suspension , and resection of excessive skin was performed as in blepharoplasty skin biopsy showing thickening of the dermis with increased collagen content and lymphocytic infiltration ( h and e , 10 ) the postoperative course was uneventful and patient satisfaction is good within the 1 year of follow - up fig .
it is characterized by skin thickening , clubbing , hyperhidrosis , and periosteal reaction in the long bones .
primary hoa is predominantly a male disease that at least 90% of patients are men .
although symptoms may be seen in childhood , it manifests mostly during the fifth decade of life .
described the largest number of primary hoa series in the literature that the authors reported that family history was positive in all studied patients .
the pathogenesis of hoa is unclear and some studies explained the role of several growth factors in the evolution of the disease .
although clinical findings are similar , secondary hoa differs from primary hoa with absence of family history .
secondary hoa is an acquired form that is associated with usually lung disease but also heart , liver , and intestines .
the presented patient had a huge pelvic mass which was completely excised with a pathology report of myelolipoma .
hence , our diagnosis was secondary hoa due to the paraneoplastic manifestations of pelvic malignancy which causes secretion of many growth factors .
blepharoptosis may develop secondary to sebaceous gland hyperplasia , thickening of the dermis with increased collagen content , mucin deposition , and lymphocytic infiltration or due to additionally marked scarring .
our patient was a 52-years - old man with negative family history which let us exclude the diagnosis of primary hoa .
the differential diagnosis includes several diseases as acromegaly , syphilitic periostitis , and thyroid acropachy .
acromegaly is characterized by enlargement of facial bones that are not present in our case .
serology , radiology , and clinical findings did not support a diagnosis of syphilis or thyroid disease .
hoa may develop secondary to pulmonary or congenital cyanotic cardiac diseases those were not present in our patient .
the remaining possible etiological factor for secondary hoa in our case was the huge pelvic malignancy which was excised previously .
the surgery for these kinds of pathologies may be planned as single or staged procedures .
blepharoplasty with excessive skin excision is usually required both for better cosmesis and to reduce the tissue bulk .
no complications were encountered during surgery , but bleeding was more than any other lid surgery .
the profound inflammatory reaction in the tissue might be the cause of this excessive bleeding .
hoa may not be always primary , particularly in patients with negative family history . in cases of findings with abnormal fibroproliferative and inflammatory changes , detailed systemic examination and investigations both using serologic and imaging modalities
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has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
 a 52-year - old male patient presented to our hospital with a history of secondary hypertrophic osteoarthropathy ( hoa ) associated with an abdominal neoplasia and blepharoptosis . 
 he had finger clubbing , hyperhidrosis , and hypertrichosis . 
 he also had a recent history of extensive abdominal surgery with a pathology report of myelolipoma . 
 routine blood work was unremarkable . 
 upper eyelid reconstruction with blepharoplasty , upper eyelid wedge resection , and brow suspension was performed to address his eyelid concerns . by this case report 
 , we would like to attract notice that the eyelid involvement may be a part of hoa and to emphasize the importance of systemic and pathologic evaluation in failed blepharoptosis surgery . 
Case Report
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