Determinative factors in surgical planning of eyebrow cosmetic and reconstructive surgery.

PURPOSE: The purpose of this study was to identify the different factors that an oculoplastic surgeon should consider while practicing cosmetic or reconstructive eyebrow surgery in order to have the final patient's satisfaction. SUBJECTS AND METHODS: In an observational case series study, five photographs were taken from each of 60 females to show ideal eyebrow positioning with fingers. Eyebrow landmarks, including tarsal plate show (TPS) and eyebrow height, were measured in the ideal position. Brow apex position and brow apex angle were evaluated in the desired position of eyebrow. RESULTS: The mean desired apex angle of eyebrow was measured as 135±9 mm. In all, 48.33% of our subjects preferred a wider brow angle, 28.33% a narrower one, and 23.33% a brow angle without any change. The location of brow peak was transferred to the lateral canthus in the desired position. The ideal brow peak in the lateral canthus and between lateral canthus and lateral limbus was assigned to 33.3% and 66.6% of cases, respectively. The desired eyebrow apex angle in two age groups of our subjects (>40 years and ≤40 years) was not statistically different. CONCLUSION: Landmarks of the eyebrow and its desired position are somehow different between different studies, which may be explained by the variation in race, gender, culture, and age. As there is not any uniform rule in planning of cosmetic surgeries of eyebrow, oculoplastic surgeons should consider the difference in culture, race, age, and desire of the patients and have their surgical plans for every individual patient distinctively.

A novel technique for full thickness medial canthal reconstruction; playing with broken lines.

PURPOSE: To introduce a new modification of transposition flap technique for reconstruction of the medial canthal region. METHODS: This prospective study included 58 patients with the full thickness involvement of both upper and lower lid in the medial canthal area. Reconstruction of posterior lamella was performed by utilizing periosteal flaps and tarsoconjunctival grafts, and anterior lamellar reconstruction was performed using transposition of multiple full-thickness skin flaps, a modified form of rhomboid flap technique. Post-surgical outcomes, advantages, and drawbacks of this technique are discussed. RESULTS: Between 2010 and 2014, 58 patients with basal cell carcinoma (BCC), proven by histopathologic study, underwent medial canthal reconstruction. The mean age was 72.8 ± 8.3 years. In 30 patients, the lacrimal apparatus was excised, and periosteal flaps or tarsoconjunctival grafts were prepared to reconstruct the posterior lamella. Anterior lamellar reconstruction was performed in all patients, and the mean number of transposition flaps was 3.63 in addition to the blepharoplasty flap. Patients were followed for 24 months. None of the patients developed flap necrosis or other intraoperative and postoperative complications, with acceptable aesthetic and functional outcomes. CONCLUSION: Full-thickness reconstruction of the medial canthal area by utilizing periosteal flaps and modified transposition flap technique all in one session can be considered an alternative method in medial canthal reconstruction, with acceptable functional and aesthetic outcomes.

Bupivacaine Injection for Management of Lagophthalmos Due to Long-Standing Idiopathic Facial Nerve Palsy.

PURPOSE: To report the results of bupivacaine injection into the orbicularis oculi muscle to treat lagophthalmos in patients with long-standing Bell palsy. METHODS: In this prospective interventional case series, bupivacaine, 5 ml of a 0.750% solution, was injected into the preseptal and pretarsal area of the orbicularis oculi in each of 10 patients with idiopathic peripheral facial nerve palsy. The measures of vertical eyelid apertures during open and closed eyes were made before the procedure and 1, 3, and 6 months after injection. RESULTS: A total of 10 eyes including 2 men and 8 women with an average age of 43 years (26-64 years) were studied. The mean amount of lagophthalmos before injection and after 6 months of follow up were 3.9 mm and 2.3 mm, respectively (p = 0.01)). The mean amount of corneal exposure before injection and after 6 months of follow up was 1.05 mm and 0.25 mm, respectively (p < 0.01). The mean scleral show in open eyes before injection and after 6 months of follow up were 1.20 mm and 0.75 mm, respectively (p = 0.08). The mean scleral show in closed eyes before injection and after 6 months of follow up were 1.95 mm and 1.15 mm, respectively (p = 0.01). All the patients reported significant decrease in epiphora. CONCLUSION: Bupivacaine injection in the paretic orbicularis oculi muscle improves eyelid closure and lagophthalmos and epiphora.

Total lower lid reconstruction: clinical outcomes of utilizing three-layer flap and graft in one session.

AIM: To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid in one session. METHODS: Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap. RESULTS: The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period. CONCLUSION: Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.

Lower lid retraction in thyroid orbitopathy: lamellar shortening or proptosis?

To investigate any correlation between lower lid retraction and proptosis and also between lower lid retraction and lamellar length, as measured by fornix depth, in patients with thyroid eye disease (TED). One hundred and sixty-six eyes of 83 patients with TED were enrolled. The inferior fornix depth, Hertel exophthalmometry measurement, clinical activity score, and lower lid position were the main outcome variables. The correlation between lower lid position measurement and Hertel measurements and also between the lower lid position measurement and inferior fornix depth were evaluated using ANOVA and Pearson's tests. The mean age of subjects in patients with and without lid retraction was 42.8 ± 1.5 and 47.7 ± 1.6 years, respectively (P = 0.4). The inferior fornix depth in patients with and without lower lid retraction was 11.8 ± 1.5 and 11.8 ± 1.3 mm, respectively (P = 0.960). Pearson's analysis showed a significant correlation between the degree of proptosis and lower lid retraction in TED patients (P = 0.01). However, no significant correlation was found between the level of lower lid retraction and the fornix depth (P = 0.87). The main cause of lower lid retraction in TED is proptosis. The beneficial effect of orbital decompression on improvement of lower lid retraction must be considered during a stepwise surgical approach in TED patients.

Randomized study comparing the efficacy of a self-retaining bicanaliculus intubation stent with Crawford intubation in patients with canalicular obstruction.

BACKGROUND: The purpose of this study was to compare the efficacy of self-retaining stent (SRS) bicanalicular intubation with bicanalicular silicone (Crawford) intubation in patients with canalicular and punctal obstruction. METHODS: In this prospective, randomized clinical trial, 38 patients with canalicular or punctal obstruction (25 partial, 13 complete) and epiphora were randomized into two groups. Twenty-one patients (14 with partial and seven with complete obstruction) underwent SRS intubation and 17 patients underwent bicanalicular silicon intubation in a randomized fashion. RESULTS: After a mean follow-up of 6 months following tube removal, 16 (76%, 12 partial, four complete) of the 21 eyes in the SRS intubation group and 13 (76%, 10 partial, three complete) in the bicanalicular silicon intubation group had a successful outcome and remained symptom-free. For partial obstructions, the success rate was 85% and 90% for the SRS and bicanalicular silicon intubation groups, respectively. The corresponding values for complete obstruction were 63% and 50% for the SRS and bicanalicular silicon intubation groups, respectively. CONCLUSION: SRS could effectively substitute for a more extensive procedure such as bicanalicular silicon intubation in patients with canalicular obstruction, particularly those with partial obstruction. The newly developed SRS intubation procedure has the advantages of simple, easy implementation and extubation, low cost, and a lower rate of trauma when compared with bicanalicular silicon intubation.

Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps.

PURPOSE: To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps. METHODS: The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit. RESULTS: The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05). CONCLUSIONS: Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.

Evaluation of efficacy and safety of botulinum toxin type A injection in patients requiring temporary tarsorrhaphy to improve corneal epithelial defects.

AIM: To evaluate the efficacy and safety of botulinum toxin type A (Dysport, (Ipsen Biopharm Ltd, Wrexham, UK)) injection in patients requiring temporary tarsorrhaphy to improve corneal epithelial defects. METHODS: Thirty patients were enrolled into the prospective study between March 2007 and September 2009. Doses of 15 and 30U of Dysport were injected into the levator palpebrae superioris muscle through the eyelid. The patients were followed daily until completion of ptosis and then 1-2 weekly until complete resolution of levator function and improvement of corneal condition. RESULTS: Ptosis took 2.64±1.85 days to be completed (range 1-9 days) and lasted for 12±2.19 weeks. For patients with seventh nerve palsy, 30U Dysport was appropriate to produce sufficient ptosis whereas in other patients 15U of toxin was sufficient. In 83.3% of patients ptosis was sufficient for complete recovery of corneal epithelium and 16.7% required a second procedure (Amniotic membrane transplantation, conjunctival flap). There was a direct correlation between age and duration of ptosis. In patients with seventh nerve palsy, the amount of resultant ptosis was significantly lower than that of other patients. The only adverse effects of injection were superior rectus underaction (33.3%) and diplopia (16.7%) which resolved in all patients without any intervention. CONCLUSION: Dysport injection is a safe and effective substitute for surgical tasorrhaphy with fewer complications.

Assessing amblyogenic factors in 100 patients with congenital ptosis.

AIM: To study the frequency of amblyogenic factors in patients with congenital ptosis. METHODS: In this cross-sectional study, 114 eyes of 100 patients with congenital ptosis more than 1 year old were included. Amblyopia was defined as best-corrected visual acuity (BCVA) less than 10/10 or a difference between the two eyes of at least 2/10. In patients too young to be measured by the linear Snellen E test, fixation behavior was observed. Different types of amblyopia were assessed for each patient as: 1) anisometropic amblyopia: astigmatic anisometropia ≥1 dpt, hyperopic spherical anisometropia ≥1 dpt, myopic spherical anisometropia ≥-3 dpt (with cycloplegia); 2) strabismic amblyopia, and 3) stimulus deprivation amblyopia (SDA). Then the total incidence of amblyopia and each type of it were obtained. Patients with uni- and bi-lateral ptosis were also compared. RESULTS: The incidence of amblyopia in ptotic eyes was 39/114 (34.2 %), and for each specific cause was: refractive amblyopia in 29.8%, SDA in 10.5%, strabismic amblyopia in 4.3%. Amblyopia was more frequent in severe ptosis, 76% in patients with covered optical axes (OA), compared to non-covered OA (22.5%). In unilateral ptosis with covered OA, astigmatic anisometropic amblyopia was more frequent, and in bilateral ptosis with at least one eye covered OA, spherical anisometropic amblyopia was more frequent. In both unilateral and bilateral ptosis, SDA was more common if the OA was covered. CONCLUSION: As refractive anisometropic amblyopia is more prevalent than SDA, paying attention to all causes of amblyopia may be important in preventing amblyopia in a child with a ptotic eye.

Enucleation with hydroxyapatite implantation versus evisceration plus scleral quadrisection and alloplastic implantation.

PURPOSE: To compare the motility and complications of enucleation with evisceration plus scleral quadrisection. METHODS: In a prospective study between January 2006 and June 2007, 50 patients underwent evisceration with scleral quadrisection and alloplastic implantation (group 1) and 50 patients underwent enucleation and hydroxyapatite implantation (group 2). Horizontal and vertical excursions of implants and complications such as exposure or extrusion and deep superior sulcus deformity were evaluated postoperatively. RESULTS: After a mean follow-up interval of 11.5 months for group 1 and 13.2 months for group 2, vertical measurements were approximately 20% less than horizontal measurements in both groups. The mean horizontal and vertical movements in group 2 were significantly less than in group 1 (p < 0.001). There was 1 case of small hydroxyapatite exposure in group 2 (1 in 50; 2%) and 2 cases of implant extrusion in group 1 (4%) (p = 0.50). Deep superior sulcus deformity was noted in 10 patients in group 1 (20%) and 7 patients in group 2 (14%) (p = 0.43). Analysis of covariance in both groups showed that age, gender, and follow-up interval were not predictors of movement in either direction (all p-values >0.05). CONCLUSIONS: Evisceration with scleral quadrisection and alloplatic sphere implantation can effectively substitute for a more extensive procedure such as enucleation in patients with painful blind eyes, cosmetically unacceptable blind eyes, and medically uncontrolled endophthalmitis. It provides rapidity, ease, and better implant excursion and lower cost of the implants compared with their porous counterparts.

Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: a prospective, randomized, double-masked study.

PURPOSE: To assess the efficacy of intraoperative mitomycin C (MMC) during silicone intubation (SI) as a substitute for dacryocystorhinostomy (DCR) in nasolacrimal duct obstruction (NLDO). METHODS: In this prospective, double-masked study, 88 patients with complete NLD obstruction who were candidates for DCR were randomized in 2 groups. All study patients underwent SI with application of MMC or placebo in a randomized, double-masked fashion, with the former receiving 0.2 mg/mL for 2 minutes before SI. RESULTS: After a mean follow-up interval of 8 months, 25 of the 43 eyes in the MMC group and 21 of the 44 eyes in the placebo group had a successful outcome and were free of tearing and discharge. No significant difference was noted between the 2 groups (p = 0.331). In patients with simple epiphora and less than 6 months of duration, SI alone was effective in 83% of patients; however, in the same group, MMC application during SI did not show beneficial effect over SI alone. But in patients with simple epiphora of 6-months duration or longer, the application of MMC during SI resulted in better efficacy compared with SI alone. The success rates in the patients that had chronic dacryocystitis was lower (23%) compared with patients that had only epiphora (63.7%). CONCLUSIONS: SI alone could effectively substitute for a more extensive procedure such as DCR in patients with simple epiphora, particularly those with newly developed symptoms. In cases with longer duration of symptoms of epiphora, application of MMC would increase the success rate significantly.