Single-staged Tunneled Forehead Flap for Medial Canthal and Eyelid Reconstruction.

Purpose: The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure. Methods: A retrospective chart review was performed of three surgeons' charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement. Results: A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm2 with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures. Conclusion: The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.

Gastrointestinal stromal tumor metastatic to the orbit.

A 53-year-old woman was referred to the authors with a history of left eyelid swelling and retro-orbital pain. She had a history of a prior stomach gastrointestinal stromal tumor (GIST) with metastasis to the liver and intrahepatic bile duct. Examination showed global motility restriction with no relative afferent pupillary defect, and exophthalmometry confirmed 4 mm of left-sided proptosis. Computed tomography imaging showed a heterogeneous mass involving the left inferior rectus muscle with extension to the optic nerve measuring 32.5 mm anterior to posterior and abnormal thickening of the right inferior rectus muscle. An incisional biopsy was performed through a left inferior orbitotomy. Histopathological examination revealed an orbital mass with epithelioid morphology consistent with a metastatic GIST. Immunohistochemical analysis revealed positivity for CD-117 and Dog-1, and negativity for Myogenin. This represents the fifth biopsy-proven GIST metastatic to the orbit in the literature, only the second case with predominantly epithelioid morphology, and only the second case with bilateral orbital metastasis. The authors detail the relevant clinical history, imaging, and pathology.

Rate of vascularization and exposure of silicone-capped porous polyethylene spherical implants: an animal model.

PURPOSE: This pilot study examines the rates of exposure and fibrovascular ingrowth of silicone-capped, porous, polyethylene orbital implants in the New Zealand white rabbit animal model. METHODS: Unwrapped, silicone-capped, porous, polyethylene orbital spheres were implanted in 16 enucleated rabbit orbits. Four implants were removed at 3, 6, 9, and 12-month intervals and submitted for histopathologic analysis. A board-certified pathologist reviewed and graded vascular ingrowth, inflammation type, and severity for all specimens. RESULTS: Fibrovascular ingrowth in the center of all implants occurred as early as 3 months. No fibrovascular ingrowth occurred at the interface between the silicone cap and the porous polyethylene implant. The overlying Tenon's and conjunctival tissues remained intact without significant host inflammatory response. No implant exposure occurred at any time point. CONCLUSIONS: Silicone-capped porous polyethylene orbital implants appear to offer an inexpensive, easy-to-manufacture implant that resists exposure without the need for a wrapping material and achieves successful biointegration soon after implantation.

Double-blind, bilateral pain comparison with simultaneous injection of 2% lidocaine versus buffered 2% lidocaine for periocular anesthesia.

PURPOSE: Determine if raising the pH of 2% lidocaine with epinephrine 1:100 000 to a physiologic level decreases pain perception during periocular, subcutaneous anesthesia. DESIGN: Double-blind, prospective, randomized study. Simultaneous unilateral injections of buffered and unbuffered lidocaine solutions were given before surgery to patients having bilateral, periocular surgery. PARTICIPANTS: Fifty-four consecutive patients (27 male and 27 female; mean age, 68 years; standard deviation, 11 years). INTERVENTION: Patients were given simultaneous injections of buffered and unbuffered 2% lidocaine with epinephrine 1:100 000. The needles were inserted simultaneously and the anesthesia was injected for a 20-second count for a total volume of 1.0 ml per injected side. MAIN OUTCOME MEASURES: After the simultaneous injections, the patients were asked to rate the pain on each side on a Likert-type visual analog scale of 0 to 10. RESULTS: Sixty-five percent of patients preferred the buffered lidocaine with a scaled pain reduction of 0.9 (P = 0.0005). Additionally, for the patients who believed that the buffered solution was less painful, the mean decrease in scaled pain rating was 2, for a 51% reduction in pain level (P = 0.001). No gender differences were noted. CONCLUSIONS: Buffering 2% lidocaine with epinephrine 1:100 000 with sodium bicarbonate 8.4% offers a clinically and statistically significant reduction in pain experienced by two-thirds of patients receiving periocular subcutaneous anesthesia.

Efficacy of pulsed electromagnetic energy in postoperative recovery from blepharoplasty.

BACKGROUND: A novel medical device that has been approved by the Food and Drug Administration is available for treatment of postsurgical edema. The device emits a low-level, pulsed electromagnetic energy field, which modulates resting cell membrane potential, allowing a return to physiologic resting membrane potential. OBJECTIVE: To investigate the benefits of electromagnetic energy in eyelid wound healing. METHODS: Fifty-seven individuals participated in this randomized, double-blinded study. All patients underwent upper blepharoplasty. At the postoperative visit, patients rated pain, edema, and ecchymosis, and the physician rated edema, ecchymosis, and erythema. RESULTS: There was no difference (p = .76) in patient pain rating when comparing placebo (1.6) with the patch (1.3). Patients reported 6% less edema (p = .11) and 10% less ecchymosis (p = .17) with the active patch eye than in control eye. The physician-graded edema, ecchymosis, and erythema had a mean Likert-type scale difference between placebo and active eyes of -0.3 (p = .12), -0.3 (p = .17), and -0.2 (p = .004) respectively. CONCLUSION: The use of pulsed electromagnetic energy did not have an effect on postoperative pain, edema, or ecchymosis as rated by patients and physicians. There was a statistically significant reduction in physician-graded erythema for active patch eyes versus placebo.

Comparison of postoperative eyelid position using fibrin sealant versus suture for wound closure in Müller's muscle-conjunctiva resection ptosis repair.

BACKGROUND: The purpose of this study was to compare postoperative eyelid position using fibrin sealant versus suture for wound closure in Müller's muscle-conjunctiva resection ptosis repair. METHODS: One hundred ninety-six patients (367 eyelids) who underwent Müller's muscle-conjunctiva resection ptosis repair were divided into two groups: wounds closed with suture and those closed with fibrin sealant. Preoperative and postoperative eyelid measurements were compared statistically using appropriate t tests. Complications, eyelid symmetry, and revision rates were analyzed using a two-tailed Fisher's exact test. RESULTS: Suture was used for wound closure on 53 eyelids of 39 patients and fibrin sealant was used on 314 eyelids of 157 patients. There was no statistically significant difference (p = 0.49) when comparing the change from preoperative to postoperative margin-to-reflex distance 1 between the two groups. Postoperative symmetry within 0.5 mm was achieved in 87 percent of patients in the suture group and in 96 percent of patients in the fibrin sealant group (p = 0.06). The percentage of patients requiring additional ptosis adjustment was 2 percent in both groups (p = 1.0). Major complications were more common in the suture group (p = 0.0001). CONCLUSIONS: Müller's muscle-conjunctiva resection ptosis repair using fibrin sealant for wound closure offers equivalent lid position and symmetry as compared with suture wound closure. There is also a reduction in major postoperative complications when using fibrin sealant.

Hematic cyst in a barrier-covered porous polyethylene/titanium mesh orbital floor implant.

Hematic cyst formation after placement of nonporous alloplastic orbital floor implants is well described. A benefit of porous polyethylene is fibrovascular ingrowth without capsular formation. This ingrowth inhibits hematic cyst formation. In the case presented here, a hematic cyst developed on a screw-fixated porous polyethylene/titanium mesh implant (Medpor Titan B-T-M, Porex Surgical, Newnan, GA, U.S.A.). The risk factor for this patient was the nonporous barrier surface of the implant and inadequate fracture reduction. Proper surgical technique, including implant sizing, placement, and fixation, are factors reported to prevent hematic cyst formation. This patient's symptoms resolved after removal of the implant and cyst and replacement of the orbital implant.

Ectopic orbital brain diagnosed 20 years after symptomatic presentation.

Ectopic brain in the orbit is a rare entity with only 14 other case reports in the literature. This case is unique in that symptomatic presentation occurred 20 years prior to diagnosis. Symptoms are generally due to mass effect. We report an unusual case of diplopia secondary to ectopic orbital brain and a review of the literature.

Comparison of fibrin sealant versus suture for wound closure in Müller muscle-conjunctiva resection ptosis repair.

PURPOSE: To compare fibrin sealant (Tisseel) versus suture for wound closure in Müller muscle-conjunctiva resection ptosis repair. METHODS: The charts of 114 patients (211 eyelids) who had undergone Müller muscle-conjunctiva resection were retrospectively reviewed. Suture versus Tisseel were used for wound closure. Preoperative and postoperative eyelid measurements, postoperative symmetry within 0.5 mm, and complications were compared. RESULTS: Müller muscle-conjunctiva resection ptosis repair was performed on 211 eyelids of 114 patients. Seventeen cases were unilateral and 97 cases were bilateral. Method of wound closure included suture (45 eyelids of 31 patients) versus Tisseel (166 eyelids of 83 patients). For the suture group, the mean preoperative MRD1 was 1.2 mm and the postoperative MRD1 was 3.0 mm; the difference was 1.9. For the Tisseel group, the mean preoperative MRD1 was 1.2 mm and the postoperative MRD1 was 3.0 mm; the difference was 1.8. The 2 groups did not differ statistically in preoperative (p = 0.97) or postoperative MRD1 values (p = 0.53), the difference (p = 0.63), or postoperative symmetry within 0.5 mm (p = 0.39). In the suture group, complications included moderate to severe pain (10%), suture granuloma (6%), corneal abrasion (3%), loose suture (3%), and persistent keratopathy (3%). We found no evidence of keratopathy attributable to the Tisseel (p = 0.0001). This difference in the prevalence of complications was statistically significant (p = 0.0001). Four patients in the suture group (13%) underwent subsequent procedures including suture granuloma removal (2) and suture removal (1); 1 patient (3%) required levator resection. Three patients in the Tisseel group (4%) subsequently underwent levator resection. CONCLUSIONS: Müller muscle-conjunctiva resection ptosis repair using fibrin sealant for wound closure offers comparable eyelid position results compared with suture. Use of Tisseel showed fewer postoperative complications and was associated with fewer subsequent surgical procedures.

Periocular autologous fat transfer.

Autologous fat transfer is a useful adjunct to augment facial soft tissue deflation in the periocular region. With meticulous technique, small aliquot placement, and reinjection at appropriate intervals, fat makes an excellent adjunct to the management of the aging face, and compliments other facial rejuvenation techniques. Appropriate counseling, realistic expectations, and meticulous technique make fat transfer an effective method of soft tissue augmentation.

Infraorbital nerve surgical decompression for chronic infraorbital nerve hyperesthesia.

PURPOSE: To present three cases of chronic infraorbital nerve hyperesthesia relieved by surgical decompression of the infraorbital nerve. METHODS: Retrospective chart review. RESULTS: We identified three cases of chronic hyperesthesia of the infraorbital nerve. Two cases were related to previous blunt orbital trauma, whereas the third was associated with a long-standing anophthalmic socket with numerous previous surgeries. In each case, patients had dramatic relief of infraorbital nerve hyperesthesia and pain after surgical decompression of the infraorbital nerve. CONCLUSIONS: Surgical decompression of the infraorbital nerve can provide significant symptomatic improvement in patients with chronic infraorbital nerve hyperesthesia secondary to nerve compression.

Fibrin sealant for Müller muscle-conjunctiva resection ptosis repair.

PURPOSE: To determine the safety and efficacy of fibrin sealant for use in Müller muscle-conjunctiva resection ptosis repair. METHODS: This was a retrospective review of a consecutive case series. All patients underwent Müller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure. Surgery was performed in a manner similar to a previously described technique, using fibrin tissue sealant rather that suture for wound closure. Postoperative symmetry was defined as MRD1 of each eyelid within 0.5 mm. RESULTS: Müller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure was performed on 53 eyelids of 33 patients. There were 27 female patients and 6 male patients. Twenty patients underwent bilateral ptosis repair and 13 patients underwent unilateral ptosis repair. Average follow-up was 17 weeks (range, 3 to 45 weeks). Mean preoperative MRD1 was 1.22 mm (range, -1.5 to 2.5 mm) in the right upper eyelid and 1.50 mm (range, 0 to 2 mm) in the left upper eyelid. Mean postoperative MRD1 was 3.11 mm (range, 2 to 4.5 mm) in the right upper eyelid and 3.12 mm (range, 1 to 4.5 mm) in the left upper eyelid. Postoperative symmetry was found in 32 of 33 patients (97%). We found no evidence of keratopathy or other complications attributable to the fibrin sealant. CONCLUSIONS: Müller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.

Processed human pericardium barrier for gold weight implantation.

PURPOSE: To determine the safety and efficacy of processed human pericardium as a barrier material for gold weight implantation. METHODS: In this retrospective, noncomparative case series, all patients undergoing gold weight implantation with human pericardium barrier between November 2000 and May 2002 were studied. Charts were reviewed for surgical indications, gold weight size, follow-up interval, and complications. RESULTS: Twenty-three eyelids of 23 patients underwent gold weight implantation with processed human pericardium barrier material. There were 15 female and 8 male patients. Mean patient age was 53 years (range, 22 to 78 years). Indications for surgery included extruded implant (4 eyelids), thin tissues overlying existing implant (3 eyelids), thin anterior lamellar eyelid tissues (6 eyelids), radiotherapy (1 eyelid), and requirement for long-term gold weight therapy (9 eyelids). Mean follow-up was 11 months (range, 3 to 36 months). Acceptable tissue coverage was found in 23 of 23 eyelids. There were no complications of infection, extrusion, or thinning of overlying tissues. One patient had prolonged eyelid edema and erythema that resolved spontaneously 3 months after surgery. CONCLUSIONS: Human pericardium appears to be well tolerated on at least a short-term basis within the eyelid when used as a barrier material for gold weight implantation.

Orbital trauma caused by bicycle hand brakes.

PURPOSE: This report aims to increase awareness of an unusual mechanism of orbital injury sustained by bicycle riders. METHODS: In this retrospective small case series, we describe two cases of orbital injury caused by upper eyelid penetration. A 5-year-old boy (patient 1) and a 6-year-old boy (patient 2) presented to our service within a 2-week period. Both had been injured by similarly styled, handlebar-mounted bicycle hand brake levers. Patient 1 had an orbital roof fracture and penetrating brain injury and underwent repair of a left upper eyelid laceration, craniotomy for pseudoencephalocele, and ptosis repair. Patient 2 had orbital hemorrhage and underwent repair of left upper eyelid laceration. RESULTS: In both cases, a handlebar-mounted bicycle hand brake lever perforated the left eyelid when the rider fell onto it. Neither patient was wearing protective headwear or eyewear. Two months after surgery, patient 1 had 20/25 visual acuity OU and excellent cosmetic appearance. Patient 2 had baseline amblyopic vision 2 days after surgery but moved from town and was lost to follow-up. CONCLUSIONS: Orbit injuries from bicycle brake levers are rare, and helmets or protective eyewear probably would not have prevented these injuries. However, a change in the design and/or mounting location of handlebar-mounted brake levers might help prevent further injuries of this type.

Use of bioglass for orbital volume augmentation in enophthalmos: a rabbit model (oryctolagus cuniculus).

PURPOSE: To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules. METHODS: Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration. RESULTS: There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2). CONCLUSIONS: Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.

Positron emission tomography scanning in essential blepharospasm.

PURPOSE: To localize in the brain using positron emission tomography neuroimaging with (18)fluorodeoxyglucose [PET ((18)FDG)] differences in glucose metabolism between patients with essential blepharospasm (EB) and controls. DESIGN: Prospective case-control study. METHODS: Positron emission tomography neuroimaging with (18)fluorodeoxyglucose was performed in 11 patients with EB and 11 controls matched for age and gender. Global analysis of images was used to localize differences in glucose metabolism between groups. RESULTS: Multiple cortical and subcortical abnormalities were observed in EB patients in comparison with controls. Cortical areas with the largest and most significant clusters of increased glucose uptake were the inferior frontal gyri, right posterior cingulate gyrus, left middle occipital gyrus, fusiform gyrus of the right temporal lobe, and left anterior cingulate gyrus. Cortical areas with the largest and most significant clusters of decreased glucose uptake were the inferior frontal gyri, ventral to the area of increased glucose metabolism. Subcortical abnormalities, consisting of increased glucose uptake, involved the right caudate and consisting of decreased glucose uptake, involved the left inferior cerebellar hemisphere and thalamus. CONCLUSIONS: Global analysis of positron emission tomography neuroimaging with (18)fluorodeoxyglucose neuroimaging in EB patients in comparison with controls demonstrates a pattern of abnormalities involving several cortical and subcortical areas that control blinking, including the inferior frontal lobe, caudate, thalamus, and cerebellum.

Facial skin rejuvenation.

PURPOSE OF REVIEW: In recent years, many new products and techniques have arisen that are useful in the rejuvenation of facial skin. Most of the therapies are directed at improving the results of photoaging. These cutaneous changes occur from chronic exposure to ultraviolet B light (290 to 320 nm) associated with sunburn, and ultraviolet AII light (320 to 340 nm), and ultraviolet AI light (340 to 400 nm) associated with photoaging. Clinically chronic photoaging may result in fine wrinkles, texture abnormalities, pigment dyschromias, and actinic keratoses. RECENT FINDINGS: Many methods of patient assessment are available, but the most useful include the Fitzpatrick skin type classification and the Glogau photoaging scale. Although many therapies are available to reduce or even reverse many of these aging changes, patient education regarding lifestyle changes (especially smoking cessation) and sun avoidance need to be a critical foundation of treatment. Indeed, patient participation in their own skin care regimen is important for any program to be effective. Topical therapy including tretinoins, hydroxy acids, bleaching agents, and sunscreens are discussed herein. SUMMARY: The physician has an important role in understanding which treatment options are appropriate for mild, moderate, and severe photoaging, and in educating patients on the risks and benefits of each. This includes resurfacing modalities with microdermabrasion, chemical peels, and laser skin resurfacing.

Periocular dog bite injuries and responsible care.

PURPOSE: To report patients who received dog bite injuries to the periocular area and the incidence of repeat attacks by the biting dog and its disposition. To discuss the demographics of bite attacks, occult injuries, steps to avoid medicolegal problems, and the appropriate options for animal disposition. METHODS: Single-practice prospective case series of dog attacks on 18 victims. Patients were followed and questioned about any repeat attacks by the offending dog. RESULTS: Of 18 individuals who received dog bites to the perio-ocular area, only 2 were >12 years old. Of the 16 cases available for follow-up (4 months to 3 years; mean, 16 months), 7 of the dogs were euthanized and 1 was sent away from the family. Of the 8 remaining animals, 5 (63%) bit again. All the dogs bit family members or family friends. CONCLUSIONS: Although most dogs make wonderful pets, canine bites pose a significant public health concern, and some simple steps may be taken to protect against personal injury and legal fallout from repeat attacks.

Zoon's balanitis treated with Erbium:YAG laser ablation.

BACKGROUND AND OBJECTIVE: Zoon's balanitis (ZB) is an uncommon, benign, idiopathic inflammatory condition affecting uncircumcised males. Definitive treatments include circumcision and carbon dioxide (CO2) laser ablation. We describe an alternative laser modality showing efficacy in the treatment of ZB. STUDY DESIGN/MATERIALS AND METHODS: We report the first case of ZB effectively treated with Erbium:YAG (Er:YAG) laser ablation. We review the pathogenesis and medical, surgical, and laser management of ZB. RESULTS: Our patient demonstrated a long-term clinical and histologic cure after Er:YAG laser ablation of ZB. CONCLUSIONS: As an alternative to circumcision or continuous wave CO2 laser, we propose a trial of Er:YAG laser ablation as a low risk, first line treatment of ZB.