Blepharoplasty: laser or cold steel?

Blepharoplasty of the upper and/or lower eyelids can restore a youthful appearance to the aging face. This is a minimally invasive procedure that can be accomplished with little bleeding and a small incision. Laser-assisted blepharoplasty was pioneered in 1980, with the technique simplified after the subsequent introduction of the pulsed carbon dioxide laser. Laser-assistance helps mitigate bleeding during blepharoplasty. In ideal circumstances, the laser can be used as a multipurpose device that simultaneously offers cutting, cautery and blunt dissection capabilities. However, there is little experimental evidence confirming the superiority of laser-assisted blepharoplasty over more traditional scalpel surgery. For some procedures cold-steel may be preferable, and some surgeons prefer to use a knife for initial incisions and then laser for its coagulative properties. Patient factors and physician skill should guide the selection of the ideal blepharoplasty technique.

Histopathologic evaluation of a new dermal allograft following explantation.

BACKGROUND: Numerous materials have been used to accomplish soft tissue augmentation, but the ideal implant remains elusive. Dermaplant is a recently introduced soft tissue matrix derived from human cadaveric dermis and intended for use in soft tissue reconstruction. This product is U.S. Food and Drug Administration (FDA) approved, but there is a paucity of data regarding its clinical performance. OBJECTIVE: To report histopathologic findings of an explanted Dermaplant specimen. METHODS: A healthy 52-year-old man underwent repair of postblepharoplasty eyelid retraction and a prominent tear trough defect. At the patient's request the tear trough implant was removed in the seventh postoperative week. Gross and microscopic evaluations were performed. RESULTS: Fibroblastic infiltration and new collagen production were demonstrated within the implant and at its periphery. Occasional macrophages and giant cells were also noted around the implant. CONCLUSION: In this patient the Dermaplant was well tolerated and supported ingrowth of host tissues. The behavior of this material over the long-term cannot be extrapolated from this study.

Carbon dioxide laser skin resurfacing with a cooled handpiece.

BACKGROUND AND OBJECTIVE: Carbon dioxide (CO(2)) laser skin resurfacing has become an accepted procedure for the rejuvenation of aged and wrinkled facial skin. The benefits of this technique have been limited by the prolonged postoperative erythema, delayed re-epithelialization, and potential changes in pigmentation. We investigated the effects of coupling a pulsed CO(2) laser to a zinc selenide handpiece at various temperatures to cool and conduct heat from the skin surface. We compared the heat conducting handpiece to standard techniques used to determine the effects on epithelial preservation, depth of thermal damage, and new collagen growth. STUDY DESIGN/MATERIALS AND METHODS: The dorsal aspect of piglets was treated with four handpiece arrangements: no thermally conducting window; a zinc selenide thermally conducting window at room temperature; and the zinc selenide thermally conducting window cooled to 10 and 5 degrees C. Intensities were measured to account for reflections from the surface of the handpiece. With the CO(2) laser in scanning mode and a spot size of 1 mm, each handpiece was used at intensities ranging from 8-30 W in one pass. Biopsies for histopathologic analysis and determination of the degree of epithelial damage and the depth of thermal damage were taken on days 0, 2, and 16. RESULTS: All specimens revealed complete re-epithelialization by day 16. The addition of a cooled handpiece did not affect either the amount of epithelial preservation or the depth of thermal damage. CONCLUSIONS: There is no significant advantage in using a cooled or room temperature zinc selenide handpiece for epithelial preservation or decreasing the inflammatory response in CO(2) laser resurfacing.

Topical application of mitomycin-C in endoscopic dacryocystorhinostomy.

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external DCR for treatment of obstruction of the lacrimal pathway and has a success rate of up to 95% in primary cases. Despite the benefits of using an endoscopic approach, including enhanced intranasal access to the lacrimal drainage system, there still exists a significant failure rate, particularly in revision procedures. As these failures are mainly due to obstructive postoperative adhesions, intraoperative adjuncts that prevent or minimize scarring should enhance the success rate. Endoscopic DCR was performed with intraoperative topical application of mitomycin-C, an antimetabolite often used in ophthalmologic procedures to reduce scarring and formation of adhesions following surgery. The procedure was successful in 7 of 8 instances, with a follow-up of 3 to 27 months. In one procedure, obstruction recurred 10 weeks after surgery. We feel that the results of this small series are encouraging and that further studies are warranted to determine the effectiveness of mitomycin-C as an adjunct to endoscopic DCR.

Laser incisional surgery.

Soft tissue surgery is more efficient, and sometimes more effective, using laser incisional surgery as opposed to standard techniques. The modern generation of lasers produces soft tissue incisions with a minimum amount of thermal damage at wound edges. The transition to laser incisional surgery requires a knowledge of methods, maneuvers, and safety information.

Blepharoplasty.

Blepharoplasty is a popular technique for eyelid rejuvenation. Safe and successful blepharoplasty surgery requires a complete understanding of eyelid anatomy, careful preoperative evaluation, and meticulous attention to intraoperative detail. This article discusses the role of blepharoplasty in periorbital rejuvenation, provides the reader with an overview of the anatomy, patient selection, preoperative evaluation, surgical technique, and complications of blepharoplasty surgery. An overview of the educational process through which surgeons can learn to perform blepharoplasty is also presented.

Carbon dioxide laser skin resurfacing.

Numerous modalities have been used to achieve facial rejuvenation. The carbon dioxide laser is an instrument long familiar to the soft tissue surgeon that has recently been adapted for use in facial rejuvenation. The laser achieves this goal by ablating the epidermis and superficial dermis, while producing a limited amount of thermal damage in the underlying dermis. Actinic damage and certain forms of dyspigmentation and scarring may be improved or eliminated, and skin tone is improved. Although portions of the face may be treated in certain situations, the best aesthetic results are generally achieved with full-face treatment. Clinical results are excellent, but both patient and physician must anticipate a 12 to 16 week period of erythema in the treated region. Early complications including infection, hyperpigmentation, and scarring have been recognized for several years, but late complications such as significant hypopigmentation have been recognized more recently.

Sinus surgery: does mitomycin C reduce stenosis?

This experimental study investigates the effect of mitomycin C (MMC) on sinus mucosal healing. MMC has an antiproliferative action on fibroblasts. It is used in glaucoma surgery to prevent restenosis of fistulas. Antrostomies were drilled in rabbit maxillary sinuses. One side was used as a control and the other treated with MMC at a concentration of 0.04, 0.4, or 1 mg/mL. Two animals from each group were sacrificed at 1, 2, 4, and 12 weeks. The antrostomies in the control and 0.04-mg/mL groups had closed by 1 week; in the 0.4-mg/mL group by 4 weeks, and in the 1.0-mg/mL group by 12 weeks. Ciliary function was initially impaired but normalized within 1 week. Both light and scanning electron microscopy showed no permanent damage to the cilia. These results suggest that MMC can be used to delay closure of antrostomies in sinus surgery.

Diplopia after surgical repair of orbital floor fractures.

Blowout fractures of the orbit are common sequelae to blunt facial trauma. Many aspects of this injury have been studied, in particular, the timing of and indications for surgical intervention. Although diplopia is often an indication for surgery and is presented to patients as a potential postoperative complication, the incidence of diplopia after surgical repair of orbital blowout fractures has not been well studied. We retrospectively studied 54 patients who underwent repair of an orbital blowout fracture. A minimum of 6 months follow-up was available for all patients included in the study. A total of 47 of 54 (86%) patients had clinically significant diplopia preoperatively, and 20 of 54 (37%) remained diplopic. A total of 17 of 54 (31%) fractures involved the medial wall and orbital floor, and 13 of these 17 patients (86%) had postoperative diplopia. Patients with combined orbital floor and medial wall fractures appear to be at higher risk for clinically significant diplopia postoperatively than those with fractures of the orbital floor only. The explanation for this observation may be related to a greater difficulty in restoring the preoperative contour of orbits with combined fractures.

Surgical management of lesions affecting the anterior optic pathways.

Although benign neoplasms are the most common lesions of the anterior visual pathways that lend themselves to a combined neurosurgical and ophthalmic surgical treatment, malignant neoplasms, infections (especially fungal), and vascular lesions are also sometimes treated via a combined approach. Recent advances in the field of skull base surgery have made it possible to treat complicated lesions in precarious locations with increasing margins of safety and decreasing morbidity. The role of the neurosurgeon in managing selected patients with lesions of the anterior a visual pathway should not be underestimated.

Current techniques of enucleation: a survey of 5,439 intraorbital implants and a review of the literature.

Enucleation is a commonly performed procedure. A multitude of intraorbital implants are available for use following enucleation. Each has advantages and disadvantages. This survey report represents the most comprehensive evaluation yet of the current trends in the rehabilitation of the anophthalmic socket. The membership of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) was surveyed. Information was requested regarding preferred intraorbital implants, complications associated with each implant, and some details of current surgical techniques. Hydroxyapatite (HA) was used in 56% of primary enucleations by this group as compared to 1% in 1989. In comparison to other leading implants, HA was found to have equally low or lower complication rates when poor motility, infection, extrusion, migration, superior sulcus deformity, enophthalmos, lower lid malposition, and contracted fornices were assessed. A detailed discussion of these various complications is presented. The majority (59%) of ophthalmic plastic surgeons use donor sclera when placing an intraorbital implant. HA was clearly the implant material most used by ophthalmic plastic surgeons in 1992, and may be the material of choice for enucleation. To date it has achieved better postoperative results and a favorable side effect profile. Because it has been available for only 5 years, more time is necessary to determine its long-term success rate. Despite theoretical concerns of the transmission of infectious agents with the use of donor sclera, the majority of surgeons use this material when placing an intraorbital implant.