Observations on the Tear Trough.

BACKGROUND: The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature. OBJECTIVES: The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance. METHODS: We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients. RESULTS: The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures. CONCLUSIONS: A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways.

Periorbital Injection of Hyaluronic Acid Gel in Patients With Deep Superior Sulcus.

PURPOSE: Hyaluronic acid gel (HAG) fillers provide a versatile and safe correction method for a sunken superior sulcus (SS) resulting from soft tissue volume loss occurring with aging, previous surgery, or enophthalmos related to trauma or phthisis bulbi. The purpose of this study was to report the long-term clinical outcomes of filler injection for soft-tissue augmentation in patients with a deep SS. DESIGN: Retrospective, interventional case series METHODS:: The medical records of 27 patients (32 eyes) with deep superior sulci were reviewed. Twenty injections of hyaluronic acid fillers (Restylane; Q-med AB, Uppsala, Sweden) were performed in the retrobulbar (RB) area, and 15 injections were performed in the SS. Pre- and post-treatment photographs were taken. MAIN OUTCOMES MEASURES: Visual acuity for seeing eyes, intraocular pressure, exophthalmos measurement, marginal reflex distance 1, interpalpebral fissure, tarsal platform show, and SS hollowing depth grade RESULTS:: Enophthalmos corrections were 1.3 ±â€Š0.8 mm (P < 0.001) and the SS hollowing grade decrease was 1.2 ±â€Š0.9 (P < 0.01) after 1 month of RB injection. Enophthalmos corrections were 0.1 ±â€Š0.4 mm (P = 0.317) and the SS sunkeness grade decrease was 1.7 ±â€Š0.8 (P < 0.001) after 1 month of SS injection. The amount of filler to correct enophthalmos of 1 mm was 0.83 ±â€Š0.53 mL using the RB injection. Using Kaplan-Meier survival analysis, the mean period of maintenance for deep SS correction was 9.1 months for RB injections and 8.5 months for SS injections. CONCLUSION: Retrobulbar (RB) hyaluronic acid gel (HAG) injections corrected enophthalmos and a deep SS, while SS injections corrected only a deep SS. These 2 techniques of RB and direct sulcus injection are safe and effective methods for the correction of a deep SS.

Orbital Expansion in Cranial Vault After Minimally Invasive Extradural Transorbital Decompression for Thyroid Orbitopathy.

PURPOSE: To test the hypothesis that the orbit expands in the cranial vault after wide dural exposure after minimally invasive extradural transorbital decompression for thyroid eye disease. METHODS: A cross-sectional cohort study of 36 patients (60 orbits). Preoperative and postoperative (6 months) orbital CT following extradural transorbital decompression was analyzed. Primary outcome measure was the percentage area of the cranial vault occupied by orbital and brain tissue in a predefined window before and after surgery. Secondary outcome measures were displacement of the anteriormost aspect of the temporal lobe, reduction in clinical proptosis, change in clinical activity score, and change in diplopia. RESULTS: The mean percentage of the selected area of the cranial vault preoperatively was 0% orbital and 44% ± 15% brain tissue, compared with 70% ± 16% orbital and 28% ± 14% brain tissue postoperatively (p < 0.001). Posterior movement of the brain was demonstrated in 59 of 60 orbits, with a mean displacement of 2.0 mm ± 1.3 mm (p < 0.001). Mean proptosis reduction was 11.2 mm ± 3.6 mm (p < 0.001). The proportion of patients with clinical activity score <3 compared with clinical activity score ≥3 was not significantly different after surgery (p = 0.163). Improved diplopia was noted in 5 patients (14%), and worsening diplopia was noted in 3 patients (8%), although these changes were not significant (p = 0.772). Intraoperative dural tear with cerebrospinal fluid leak was reported in 2 orbits (3%), which was successfully managed with fibrin glue, with no sequelae. No other complications were noted, including infection, spontaneous orbital pulsations, postoperative hemorrhage (intracranial or intraorbital), or reactivation of disease. CONCLUSION: With wide exposure of the middle cranial fossa dura following extradural transorbital decompression, orbital tissue typically expands in the cranial vault.

Use of Botulinum Toxin for the Correction of Mild Ptosis.

Background: Lid margin asymmetry and its associated compensatory mechanisms might cause patients to seek treatment to improve aesthetics. Surgery might not be indicated and can potentially worsen the asymmetry in these cases. Methods: A case series of three patients was organized to illustrate the use of botulinum toxin administered to the pre-tarsal orbicularis for the correction of micro-ptosis and improved symmetry. The marginal reflex distance and tarsal platform show were measured on both sides. Measurements were made using ImageJ software on standardized frontal photographs taken pre- and post-injection. Results: The average increase in the marginal reflex distance was 0.914mm, with an average pre-tarsal botulinum toxin dose of three units. The average change in tarsal platform show between the two eyes was 0.89mm. Conclusion: Botulinum toxin application to the pre-tarsal orbicularis oculi muscle might be a suitable option for the management of small eyelid margin asymmetries.

Long-Term Follow-Up of Lateral Canthal Resuspension.

PURPOSE: To evaluate the long-term results of lateral canthal resuspension over time. DESIGN: A cohort study of adults (n = 25, 45 eyelids) undergoing lateral canthal resuspension. METHODS: Marginal reflex distance 2 (MRD2), inferior scleral show, lateral canthal height, lateral canthal angle, horizontal palpebral aperture, and lateral scleral triangle area were measured preoperatively and at postoperative week 1, month 3, and the final follow-up visit. RESULTS: Minimum follow-up time was 6 months (mean, 15.1 months). At the final follow-up visit, MRD2 decreased by 0.41 ± 0.14 mm, inferior scleral show decreased by 0.27 ± 0.05 mm, and lateral canthal height increased by 0.81 ± 0.15 mm. The overall function of time was found to be significant for change in MRD2 (P < 0.01). In multiple comparisons, all time point values were significantly different from one another (Bonferroni corrected, P < 0.05), except for 3 months and the final position, which were not. Similarly, the overall effect of time on lateral canthus position was also significant (P < 0.01). All time points were significantly different from one another (Bonferroni corrected, P < 0.05). The overall effect of time on inferior scleral show was also significant (P < 0.01). Differences were significant from preoperative to final postoperative position, although the other time points were not significant (Bonferroni corrected, P < 0.05). No complications were noted. CONCLUSIONS: Minimally invasive lateral canthal resuspension provides durable, albeit modest, improvements in MRD2, inferior scleral show, and lateral canthal height without significantly changing lateral canthal angle, horizontal palpebral aperture, or lateral scleral triangle area.

Filling the periorbital hollows with hyaluronic acid gel: Long-term review of outcomes and complications.

INTRODUCTION: Hyaluronic acid gel has been used for rejuvenation of the periorbital tissues since 2004. The in-office, nonsurgical procedural nature has resulted in the growing popularity of the use of fillers. The periorbital region poses unique challenges to the cosmetic surgeon. Malar edema, blue-gray dyschromia, and contour irregularities are well reported short-term complications. We present a long-term follow-up review of complications associated with periocular injection of hyaluronic acid gel fillers. METHODS: Retrospective review of 147 patients with at least a 5-year follow-up period since the first injection. Five senior masked reviewers were asked to grade photographs of patients in comparison with preinjection photographs. Grading was based on a reference photographic key looking specifically at the presence and severity of malar edema, blue-gray dyschromia, and contour irregularity. RESULTS: Malar edema (11%), blue-gray dyschromia (31.3%), and contour irregularities (30.5%) continue to be problems in longer term follow-up of patients. The vast majority (90%) of these complications were mild and required no intervention. There is no statistically significant difference in the mean volumes injected by severity grading of each measured complication. CONCLUSION: Hyaluronic acid gel fillers of the periorbital region are well tolerated in our long-term follow-up experience. The vast majority of cases of malar edema, blue-gray dyschromia, and contour irregularities are mild and do not require intervention. Conservative treatment and tailored treatment approaches, in terms of volume and frequency of injections, may decrease the tendency of these adverse effects to occur.

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases.

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.

Spontaneous Resolution of Optic Neuropathy in Sphenoid Wing Meningioma.

The authors describe herein a case of optic neuropathy in progesterone receptor positive sphenoid wing meningioma of the greater wing which demonstrated spontaneous recovery with conservative management.

Maximizing Symmetry in Upper Blepharoplasty: The Role of Microptosis Surgery.

BACKGROUND: Traditional descriptions of blepharoplasty and ptosis surgery focus on the incision and eyelid crease. However, it may be more useful to consider the tarsal platform show as the important construct in analyzing and planning aesthetic eyelid surgery. METHODS: In order to measure and characterize the key contours of the eyelid, the authors find it helpful to consider the brow fat span, tarsal platform show, and margin reflex distance. RESULTS: Subtle eyelid ptosis can result in asymmetry by lengthening the tarsal platform show, and it is exacerbated by the tendency for the eyebrow to compensate. When ptosis is asymmetric, the plan should usually include asymmetric ptosis surgery. There are two general patterns that can be recognized and used for planning to address preoperative tarsal platform show asymmetry. If the tarsal platform show is longer on the side with worse blepharoptosis, then asymmetric or unilateral ptosis surgery will improve symmetry. In the cases of symmetric show despite asymmetric blepharoptosis, there may be bony and soft-tissue asymmetry, which leads to crowding of the orbit on the more ptotic side. Surgical planning should include consideration to increase the tarsal platform show on the more crowded side. It is not necessary to cut the eyelid skin in order to alter the tarsal show and brow fat span; ptosis surgery alone, by altering the eyelid position and eyebrow compensation, can reset the tarsal platform show/brow fat span relationship. CONCLUSIONS: It is important to recognize preoperative asymmetry, to predict the resetting of compensatory mechanisms, and to design asymmetric surgery, in order to maximize postoperative symmetry.

Future of cosmetic surgery.

Changes in cosmetic surgery will be driven by several key forces. The patient's self-image, and perceived place in society, will continue to drive patients to the cosmetic surgeon as well as to demand newer and better treatments. Technological advances, especially those based on an enhanced understanding of cellular and tissue physiology, promise enhanced tools other than the scalpel for the surgeon. Conceptual advances in our understanding of beauty and patient psychology will lead to a more integrative approach to cosmetic surgery.

Ultrasonographic visualization of lower eyelid structures and dynamic motion analysis.

AIM: To define the ultrasonographic structure of normal lower eyelid anatomic compartments and their spacial relationship in dynamic motion. METHODS: High resolution ultrasound (15MHz) was performed on the lower eyelids of 7 normal subjects. Movements of the lower eyelid and its compartments were visualized with ultrasound. In addition, the maximal excursion area of the lower eyelid fat compartments and retractor motions was measured before and after motion. RESULTS: The orbicularis muscle could be seen as an echolucent structure between the dermis and the echodence fat pads. Lower eyelid fat pad seems to be divided into 2 compartments as range of motion and direction of movement of each of them varies. It seems that these compartments have also different behavior. The measured profile area of the visible normal lower eyelid fat pads during movement of globe from up-gaze to down-gaze decreased by 50%. Order of movement of lower eyelid structures seems to be as follows: after globe movement fist we see retractor movement, anterior orbital fat pad, then skin and septum, and finally movement of inferior fat pad. CONCLUSION: Ultrasound represents a noninvasive tool for the visualization of lower eyelid morphology. Expanding its application could help us understand the compartmental changes in physiological eyelid movement, in aging and diseased study populations, as well as assess operative outcomes.

Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler.

PURPOSE: To evaluate the efficacy of hyaluronic acid gel fillers as a nonsurgical alternative for the management of upper eyelid margin asymmetry in cases of relative retraction. METHODS: This is a retrospective study of 8 patients with upper eyelid margin asymmetry relating to relative upper eyelid retraction treated with hyaluronic acid gel injection to affect upper eyelid lowering. Digital photographs were used to quantitatively assess outcomes by comparing pretreatment and posttreatment differences between marginal reflex distance (MRD1) in the right and left eyelids. Image J was used for photographic analysis, and Student paired t test was performed. RESULTS: Eight patients (2 male; mean age, 50.9 years; range, 30-69 years) were injected with hylauronic acid gel in the upper eyelid. The etiology of upper eyelid margin asymmetry included Graves eyelid retraction (n = 3), asymmetry following reconstructive surgery (n = 1) and aesthetic surgery (n = 1), contralateral Horner syndrome (n = 1), Bell palsy (n = 1), and contralateral involutional ptosis (n = 1). The average volume injected in the upper eyelid was 0.2 ml (range, 0.1-0.4 ml). One of 8 patients was injected bilaterally. Average follow-up was 5.7 months (range, 2-12 months). Two of 8 patients requested repeat injection within a 6-month period for undercorrection. No overcorrections were noted, and no patient requested reversal with hyaluronidase. There was a statistically significant improvement in symmetry with mean pretreatment MRD1 difference of 1.53 mm (range, 0.78-3.36 mm) and mean posttreatment MRD1 difference of 0.70 mm (range, 0.02-2.03 mm), p = 0.007. At 4 to 8 months' follow-up, 8 of 8 demonstrated persistent improvement in asymmetry with statistically significant reduction in MRD1 difference when compared with pretreatment with average follow-up MRD1 difference of 0.74 mm (range, 0.11-1.65 mm), p = 0.018. CONCLUSION: This pilot study suggests that upper eyelid injection with hylauronic acid gel filler may be an effective nonsurgical alternative to improve upper eyelid margin asymmetry in cases of relative upper eyelid retraction.

A case of acute reversible Charles Bonnet syndrome following postsurgical unilateral eye patch placement.

A fully alert 70-year-old male with no significant medical or psychiatric history presented for surgical follow-up after uncomplicated right lower eyelid cicatricial ectropion surgery with postoperative unilateral, eye patch placement complaining of visual hallucinations. Preoperative unaided visual acuity was 20/20 in each eye. The patient described simple, nonformed and complex, formed images that were both static and animated. The images included crystal-like formations that appeared to bubble, green leaves against a vivid magenta backdrop, and an isolated hallucination of a lifelike plant with trembling leaves. These hallucinations began 2 days postoperatively and persisted 2 days following eye patch removal. The patient perceived the hallucinations multiple times a day over the 7-day period, without a stereotyped pattern. The images occurred when the eyes were open and ceased when they were closed. They were prompted by looking at a blank wall or white surface. The patient consistently recognized these images as unreal. They typically persisted for 1 to 2 minutes and could be extinguished by looking away. There were no associated auditory hallucinations, psychosis, or delirium and no history of visual, cognitive, or neurological deficit. The patient denied the use of hallucinogenic medications, including analgesics, or the initiation of any new medications. To the authors' knowledge, this is the first reported case of acute reversible CBS following unilateral eye patch placement. CBS may be a frightening postsurgical consequence of eye patch placement. It is important that the ophthalmic surgeon be aware of the potential for development of CBS and offer appropriate referral and reassurance should it occur.

Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate, and buccal mucosal grafts.

PURPOSE: To histologically evaluate the outcome of mucous membrane grafts to the eyelid. METHODS: Case series of 31 eyes from 24 patients who underwent transplantation of hard palate (25 eyes), buccal (1 eye), or nasal turbinate (5 eyes) mucosa to the posterior eyelid surface. These grafts were biopsied at 0.5 months to 84 months (mean, 20 months) postoperatively. They were examined with light microscopy and compared with either the donor mucosa from the same patient (2 patients) or the typical donor site histology (22 patients). RESULTS: Graft biopsies revealed general epithelial morphology that was quite similar to the respective donor sites in virtually all cases. Six (25%) of 24 hard palate graft biopsies, which were obtained at 8 months to 49 months (mean, 22 months) postoperatively, displayed orthokeratosis alternating with parakeratosis, while 12 (50%) demonstrated parakeratosis alone, and another 6 (25%) showed adjacent regions of parakeratotic and nonkeratinized epithelium. No hard palate grafts showed complete absence of keratinization after transplantation. Other significant findings included loss of goblet cells in nasal turbinate grafts and few submucosal glands remaining in any specimen. CONCLUSIONS: Full-thickness mucosal grafts typically maintain their native epithelial morphology following transplantation to the ocular surface. Submucosal glands usually do not survive transplantation, which could be the result of intentional thinning of the graft at the time of transplantation. Contrary to the opinion that hard palate graft epithelium usually undergoes metaplasia from keratinized to nonkeratinized within 6 months following transplantation to the eye, all hard palate grafts in this study remained orthokeratotic and/or parakeratotic.

Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections.

PURPOSE: To review our initial experience using hyaluronic acid gel (Restylane) as a filler to treat the periorbital hollows. METHODS: This is a retrospective, anecdotal case review of 244 cosmetic hyaluronic acid gel injections in 155 patients. An average volume of 0.9 ml per injection session was used in an individualized pattern that variably included the orbital rim hollow, zygomatic hollow, septal confluence hollow, and eyebrow and cheek fat pad. To achieve smooth contours, a layered, feathered threading technique was used, placing the filler deep to the orbicularis. Hyaluronidase injections were used in 11% of patients at follow-up visits to "dissolve" some of the filler to reduce contour irregularities. RESULTS: One hundred eight of 121 (89%) patients with follow-up visits were satisfied with the cosmetic improvement after hyaluronic acid gel injections. For maintenance, the interval to second injection averaged 6.5 months. Side effects included lumps or contour irregularities (11%), bruising (10%), color change (7%), and fluid (15%). Twelve patients were unsatisfied and were not interested in additional injections: 5 with malar fluid, 3 with lumpy irregularity, and 3 with color change. CONCLUSIONS: Complex 3-dimensional contours and thin skin over bone render periorbital filling difficult. However, with individualized planning and with care taken to create smooth, feathered contours, it is possible to achieve acceptable improvement. We found that most patients considered themselves improved cosmetically, despite occasional side effects including contour irregularity or lumps, bruising, color change, and fluid accumulation. Patients with very thin skin, preexisting color problems, or preexisting eyelid fluid may not be good candidates for periorbital filling with hyaluronic acid gel. The effect of the filler is temporary, of course, and we counsel patients to anticipate maintenance injections at 6- to 12-month intervals.

Nonsurgical filling of the periorbital hollows.

Soft tissue fillers such as hyaluronic acid gel (Restylane) provide significant improvement of volume loss in the periorbital region when used correctly. The temporary nature of these fillers is often an advantage. They appeal to surgeons because of their relative ease of use and minimal complications, and patients appreciate the benefits of a noninvasive treatment with virtually no downtime.