External Compression Versus Intravascular Injection: A Mechanistic Animal Model of Filler-Induced Tissue Ischemia.

PURPOSE: Soft tissue ischemia is a devastating and unpredictable complication following dermal filler injection. Multiple mechanisms to explain this complication have been proposed, including vascular compression, vessel damage, and intraarterial filler emboli. To elucidate the mechanism of injury, the authors introduce a mouse model, imaged with optical microangiography and laser speckle contrast imaging technologies, to demonstrate in vivo microvascular response to soft tissue and intravascular filler injection. METHODS: To determine the effect of external vascular compression on distal perfusion, the authors attempted to occlude vessels with subcutaneous hyaluronic acid gel (HAG) bolus injections into the pinna of hairless mice. The authors also performed suture ligation of a major vascular bundle. Following these interventions, laser speckle and optical microangiography were performed serially over 1 week follow up. To determine the effect of intravascular HAG injection, the authors devised and validated a novel method of cannulating the mouse external carotid artery for intraarterial access to the pinna vasculature. Using this model, the authors performed intraarterial HAG injections and completed optical microangiography and laser speckle contrast imaging. RESULTS: Despite large HAG bolus injections directly adjacent to vascular bundles, the authors were unable to induce compressive occlusion of the mouse pinna vessels. Vascular occlusion was successfully performed with suture ligation, but optical microangiography and laser speckle contrast imaging confirmed undisturbed distal capillary bed perfusion. With intravascular HAG injection, large segments of pinna showed distinct perfusion reduction along a vascular distribution when compared with preinjection images, most noticeably at the capillary level. CONCLUSIONS: The novel mouse pinna model combining intravascular access and in vivo microvascular perfusion imaging has furthered the understanding of the mechanism of filler-induced tissue ischemia. Distal capillary perfusion was maintained despite external vascular compression. Intraarterial HAG filler injection, however, resulted in large areas of capillary nonperfusion and is the most likely etiology for filler-induced tissue necrosis that is observed clinically.

Learning curve for use of the sonopet ultrasonic aspirator in endoscopic dacryocystorhinostomy.

PURPOSE: The Sonopet Ultrasonic Aspirator is a surgical tool that uses low-frequency ultrasonic vibrations to fragment tissue while simultaneously irrigating and aspirating the surgical field. This technology is becoming more widely used in orbital, lacrimal, neurological, and skull base surgery, but few studies have examined the learning curve associated with adoption of this technology. We present our surgical learning curve, pearls, and pitfalls using the newest generation Sonopet Ultrasonic Aspirator Universal handpiece in endoscopic dacryocystorhinostomy (eDCR) surgery. METHODS: Retrospective chart review of consecutive eDCR surgeries performed by a single surgeon adopting the Sonopet Universal handpiece. Data collected include demographic information, indications for surgery, surgical time, intraoperative findings, anatomic and functional results, and complications. RESULTS: Twenty-six eDCR surgeries in 20 patients were performed from October 2011 - May 2013. Most patients were female (85.7%) with mean age 53.6 years (range 4-84) and mean follow up of 378 days (range 7-761). For routine unilateral and bilateral surgeries, surgery time decreased by 36.4% and 33.9% before reaching a plateau of 67.2 and 80.7 minutes per case, respectively. Mean surgery time for non-sequential unilateral complex cases was 85.1 minutes, which did not vary significantly over the learning curve. We achieved 100% anatomic success and 84.6% functional success. CONCLUSIONS: The Sonopet Ultrasonic Aspirator Universal handpiece can be used safely and effectively for eDCR surgery. A significant learning curve exists for adoption of this technology. Appropriate handpiece tip selection and machine setting adjustments are crucial for successful adoption of this technology and avoidance of complications.

Uveal melanoma: molecular pattern, clinical features, and radiation response.

PURPOSE: To characterize the clinical spectrum of class 1 and class 2 uveal melanomas and their relationship with intraocular proton radiation response. DESIGN: Masked retrospective case series of uveal melanoma patients with fine needle biopsy-based molecular profiles. METHODS: A total of 197 uveal melanoma patients from a single institution were analyzed for pathology, clinical characteristics, and response to radiation therapy. RESULTS: A total of 126 patients (64%) had class 1 tumors and 71 (36%) had class 2 tumors. Patients with class 2 tumors had more advanced age (mean: 64 years vs 57 years; P = .001), had thicker initial mean ultrasound measurements (7.4 mm vs 5.9 mm; P = .0007), and were more likely to have epithelioid or mixed cells on cytopathology (66% vs 38%; P = .0004). Although mean pretreatment and posttreatment ultrasound thicknesses were significantly different between class 1 and class 2 tumors, there was no difference in the mean change in thickness 24 months after radiation therapy (mean difference: class 1 = -1.64 mm, class 2 = -1.47; P = .47) or in the overall rate of thickness change (slope: P = .64). Class 2 tumors were more likely to metastasize and cause death than class 1 tumors (DSS: P < .0001). CONCLUSIONS: At the time of radiation therapy, thicker tumors, epithelioid pathology, and older patient age are significantly related to class 2 tumors, and class 2 tumors result in higher tumor-related mortality. We found no definitive clinical marker for differentiating class 1 and class 2 tumors.

Congenital ectopic cilia of the upper eyelid.

The authors report a 19-year-old woman with a cluster of ectopic cilia located in the temporal aspect of her right upper eyelid associated with symptomatic secretion from the cutaneous ostea of the cilia. Histologic examination revealed subcutaneous connective tissue interspersed with pilosebaceous follicles and apocrine glands. No evidence of lacrimal gland ducts or acini was found.