Large particle hyaluronic Acid gel for the treatment of lower eyelid retraction associated with radiation-induced lipoatrophy.

A 42-year-old female with a remote history of a left maxillary sinus tumor treated with excision and radiation therapy was referred for dry eye symptoms. Ophthalmic examination revealed left-sided exposure keratopathy, lagophthalmos, lower eyelid retraction, and fat atrophy of inferior periorbital tissue with associated hollowing. Large particle hyaluronic acid gel was injected to expand and reinforce the lower eyelid. After treatment, there was significant improvement in lagophthalmos, inferior scleral show, and periorbital hollowing. Excellent symmetry with the fellow eye was achieved. The patient reported markedly reduced dry eye symptoms. No adverse side effects were observed. The use of large particle hyaluronic acid gel shows promise as a novel nonsurgical therapy in the management of lower eyelid retraction associated with radiation-induced lipoatrophy. Additionally, large particle hyaluronic acid gel may provide better soft tissue expansion and retention than small particle hyaluronic acid gel, increasing the longevity of treatment.

Perspectives on periocular asymmetry.

Eyelid, orbit, and eye position asymmetry may adversely affect overall facial aesthetics. Armed with the knowledge of important periocular measures and landmarks, asymmetries can be easily identified and consideration may be given to correction or camouflage.

Eyelid edema.

Facial aesthetic surgeons are sometimes challenged by the predicament of diagnosing and managing patients with chronic eyelid edema. Herein we provide a brief review of some of the more common causes of pre- and postoperative eyelid edema, many of which have important systemic implications, and offer management suggestions.

Periocular anesthesia in aesthetic surgery.

This article focuses on the administration of anesthesia for periocular aesthetic procedures. Special emphasis is given to office-based procedures, most often without any systemic sedation, highlighting the importance of open communication with patients. Finally, attention is given to potential pitfalls including anesthetic systemic toxicity, ocular injuries, and orbicularis myotoxicity.

Frosted jones pyrex tubes.

PURPOSE: To describe the use of a new, frosted Jones Pyrex tube in the treatment of obstructed canaliculi of the upper lacrimal system. The frosted Jones tube retains the advantages of the traditional smooth Pyrex tube yet appears to improve the positional stability in the surgically created fistula. METHODS: Ten patients of a single surgeon who had previously undergone external conjunctivodacryocystorhinostomy and placement of a Jones Pyrex tube, with subsequent Pyrex tube extrusion, were included in the study. All had previous success with Pyrex tubes, with follow-up ranging from 1 month to 14 years. In each case, when the patient presented with an extruded tube, it was replaced with a frosted Jones tube (Weiss Scientific Glass Blowing Company, Portland, OR, U.S.A.). RESULTS: In this preliminary study, none of the 10 patients fitted with a frosted Jones Pyrex tube had a recurrence of extrusion. All patients reported proper functioning of the tubes, with no complaints of epiphora or discomfort. CONCLUSIONS: Compared with a standard Jones Pyrex tube, a frosted tube functions equally well and reduces the possibility of extrusion, which is the main complication of traditional conjunctivodacryocystorhinostomy. We have exchanged smooth tubes for frosted tubes in patients who have had extrusion of the original tube, and we are currently investigating primary placement of the frosted Jones Pyrex tube.

Treatment of multiple apocrine hidrocystomas with trichloroacetic acid.

The apocrine hidrocystoma is a benign adenomatous cystic proliferation derived from apocrine glands, which frequently occurs in periocular tissues. These cystadenomas may occur bilaterally, in multiple disfiguring confluent groups on both the upper and lower lids. Although these lesions have been treated successfully with meticulous surgical extirpation and electrosurgery, this report describes the successful treatment of two patients, each with multiple large (>7 mm) periocular apocrine hidrocystomas by either chemical ablation of the cystic epithelium with trichloroacetic acid (TCA) or surgical excision. Examination of the cysts at 1, 3, and 6 months after TCA treatment revealed well-healed lesions without cyst recurrence. Most of the TCA-treated cysts resolved completely, without leaving any trace to clinical examination. Treatment of cysts with TCA was technically simpler and much less time-consuming than surgical excision. The treatment of large apocrine hidrocystomas with TCA is an effective and expeditious method of treating these disfiguring and recalcitrant lesions.

Customized, single-incision, three-wall orbital decompression.

PURPOSE: To present the clinical outcome in 55 consecutive patients by using a customized, single-incision, 3-wall orbital decompression. METHODS: A retrospective chart review was performed of 97 customized, single-incision, 3-wall decompressions in 55 consecutive patients within one surgeon's practice. A standardized surgical technique featuring lateral small-incision, 3-wall decompression with specific "strut" preservation was used in all patients. Success of the procedure was assessed on the basis of the amount of proptosis reduction achieved, as measured by the difference in Hertel exophthalmometry measurements, and by improvement in or preservation of preoperative visual acuity and color vision in the setting of compressive optic neuropathy. Subjective diplopia was recorded before and after surgery, as was the presence of extraocular muscle restriction. RESULTS: A total of 97 orbital decompressions in 55 consecutive patients were reviewed. The majority of surgeries were performed for disfiguring proptosis with some degree of exposure-related symptoms (81%), with other indications including compressive optic neuropathy (17%), and pain (2%). The average amount of proptosis reduction achieved at 3 months was 5 mm (range, 1 to 11 mm). Visual acuity in patients with compressive optic neuropathy improved an average of 2 lines on the standard Snellen chart testing (range, 1 to 5). Color vision improved an average of 5 Ishihara plates (range, 0 to 13). Seventy-one percent of patients had subjective diplopia before surgery; 21% of these patients reported improvement or complete resolution of diplopia after surgery. Of the 29% of patients without preoperative subjective diplopia, all but one (1.8 of total patients) remained symptom free. CONCLUSIONS: We find that a customized, single-incision, 3-wall orbital decompression provides adequate decompression and proptosis reduction while minimizing postoperative strabismus and providing an aesthetically desirable result.

Endoscopic pretrichial brow lift: surgical indications, technique and outcomes.

PURPOSE: To present an alternative technique for rejuvenating the upper face of patients with high hairlines. METHODS: A chart review was performed to ascertain the longevity and aesthetic quality of endoscopically assisted pretrichial brow lifts. The charts of a single surgeon were reviewed (2000 to 2003). The technique was noted to be consistent, and in the majority of cases, additive to other concurrent procedures. Morbidity was defined as asymmetry, poor longevity, and patient dissatisfaction. All patients were included who had the procedure performed. No exclusions were recognized for race, age, gender, medical history, or any other patient demographic. RESULTS: Results for the clinical outcome were graded as excellent, good, fair, or poor. Subjective and objective assessments were made by using history, examination, and photos. A rating of excellent incorporates symmetry, longevity, smoothness of the brow skin, and patient satisfaction both with the recovery process and with the results. CONCLUSIONS: In properly selected cosmetic patients, the endoscopic pretrichial brow lift is an effective method for rejuvenating the upper face. A more youthful appearance is achieved with the procedure, and it is easily combined with eyelid rejuvenation. We believe that this technique is the procedure of choice for addressing brow ptosis in patients with high hairlines.

Gold weight implantation: a better way?

PURPOSE: To introduce an alternative surgical technique for gold weight implantation for the treatment of lagophthalmos. We suggest that unwrapped intraorbital gold weight implantation provides adequate function, better cosmetic appearance, and lower morbidity than conventional implantation with wrapped or unwrapped pretarsal gold weights. METHODS: The charts of a single surgeon were reviewed (1994 to 2003). All patients who underwent intraorbital gold weight implantation were included in the study. The technique was noted to be consistent with intraorbital fixation of a custom 2.2-gm gold weight (MedDev Corporation, Sunnyvale, California). Implants were not wrapped. Efficacy was defined as elimination of exposure keratopathy with preservation of the visual axis. Morbidity was defined as extrusion of the weight, shift of positioning requiring intervention, inflammation/infection of the eyelid, or poor cosmetic appearance. RESULTS: Of 59 patient charts reviewed, 2 patients had morbidity as defined by our study: One had shifting of the gold weight, necessitating repositioning of the weight; the other had extrusion of the gold weight, requiring its removal. The remaining patients had no complaints or cosmetic concerns. Follow-up examinations found no incidence of exposure keratopathy. CONCLUSIONS: We found intraorbital gold weight implantation, without the use of a wrap, to be simple and effective, with adequate function, an acceptably low postoperative morbidity rate, and an excellent cosmetic outcome.