Upper eyelid ptosis repair after cataract extraction and the importance of Hering's test.

Blepharoptosis is a well-documented complication of cataract extraction and other ocular procedures. Few authors have described the surgical findings and outcomes of postcataract blepharoptosis repair. The authors present a review of the causes of postcataract blepharoptosis with emphasis on both clinical findings and recommendations for treatment on the basis of their experience with 13 eyelids in eight patients over the past 10 years. They found that all patients had either partial or total disinsertion of the levator muscle from the tarsal plate. Of the eight patients in this series, five had bilateral blepharoptosis after bilateral cataract extraction. Although a multifactorial cause for postcataract blepharoptosis is commonly assumed, the authors propose that the mechanical forces of intraoperative traction on the levator aponeurosis during cataract surgery are the primary cause. This is further supported by their operative findings in the five patients who developed bilateral ptosis after bilateral cataract extraction. All eyelids in this series were repaired by levator muscle advancement and attachment to the tarsal plate with favorable outcomes and no recurrences during a 1-year follow-up. The importance of Hering's phenomenon of equal innervation is also discussed as it applies to bilateral and to apparent unilateral blepharoptosis. The authors propose "Hering's test" as an important indicative study in the preoperative evaluation of all patients with eyelid ptosis.

Closure of palatal fistula with a local mucoperiosteal flap lined with buccal mucosal graft.

OBJECTIVE: Oro-nasal fistula is a common complication of palatoplasty. Current methods for fistula repair utilize mucoperiosteal flaps or pedicled flaps. These procedures are often cumbersome and leave a raw nasal surface, which may increase the incidence of postoperative risks and problems. In addition, the recurrence rate of the fistula is as high as 34%. We propose a simple two-layer method of fistula repair to avoid recurrences. DESIGN: A standard mucoperiosteal flap is raised on the oral side. A buccal mucosal graft is harvested from the cheeks and sutured to the nasal side of the flap that is then inset into the fistula. SETTING: Patients were either referred to the senior author's private practice (four patients) or were patients who had previously been operated on by the senior author himself (three patients). SUBJECTS: Study subjects consisted of seven patients, four males and three females, ages 14 months to 8 years. All patients had previously undergone cleft palate repair, complicated by subsequent oro-nasal fistula formation. INTERVENTIONS: All patients underwent oro-nasal fistula repair under general anesthesia with a local mucoperiosteal flap lined with buccal mucosal grafts placed on the nasal side of the flap. RESULTS: In all cases, the fistula was completely closed at first attempt without complications. Patients were followed for a minimum of 2 years, without evidence of recurrence. CONCLUSIONS: Our proposed surgical procedure for fistula closure using a standard mucoperiosteal flap lined with a buccal mucosal graft is a suitable alternative for the repair of postpalatoplasty oro-nasal fistulas. Further study and long-term follow-up is needed to establish this method as a new standard form of repair.

Lower eyelid hernia repair for palpebral bags: a comparative study.

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.

A case report on spontaneous return of levator function following postcataract blepharoptosis repair.

Blepharoptosis is a recognized complication of cataract extraction and other ocular procedures. A 6-month waiting period is recommended before repairing postcataract ptosis because most cases resolve during this time. We report the course of a patient who developed spontaneous recovery of eyelid function 11 months after cataract surgery. She had previously undergone successful ptosis repair 8 months after cataract extraction, but developed overcorrection 3 months later as her levator function returned to normal. We recommend at least a 1-year waiting period before repair of postcataract ptosis. If corrective surgery is undertaken earlier than 1 year due to visual obstruction or for aesthetic reasons, we suggest two guidelines. The levator should be plicated rather than resected and patients should be forewarned of the possibility for a revisionary procedure if spontaneous return of levator function occurs.

Shave excision of facial tumors in tuberous sclerosis.

Tuberous sclerosis can manifest itself by multiple facial nodules affecting primarily the nose, cheeks, chin, and the nasolabial folds. A simple tangential (shave) excision of these facial tumors is believed to be adequate treatment for some patients.

Extraction of lipomas: a simple technique.

Benign lipomas are among the most common subcutaneous fatty tumors. They are often solitary, more common in women and occur frequently during the fourth and fifth decades. They usually involve the posterior neck, back and thighs, and the great majority are less than 2 cm in diameter. Malignant transformation is extremely rare, and they usually do not require treatment. However if removal is desired, surgical excision is curative. In this article we present a simple method of resecting large lipomas measuring 4 cm to 10 cm in diameter.

Gap-junctional protein connexin 43 is expressed in dermis and epidermis of human skin: differential modulation by retinoids.

Retinoids are effective modulators of proliferation and differentiation of keratinocytes in vivo and in vitro. In mouse 10T1/2 cells, retinoid action on proliferation and neoplastic transformation is correlated with the upregulation of gap-junctional communication and expression of connexin 43 (Cx43). In the present study we have determined if retinoids induce similar effects on gene expression in human skin. Studies were conducted in intact skin and on cultured keratinocytes and dermal fibroblasts. In a clinical study, 2 weeks of treatment with 0.05% all-trans retinoic acid resulted in increased expression of Cx43 mRNA and protein in epidermis. Expression occurred predominantly in the suprabasal layer. Cultured cells exhibited a differential response to retinoic acid. In keratinocytes, increased expression of Cx43 occurred at low (10(-11) M) concentrations, whereas inhibition occurred at high (10(-7) M) concentrations; however, junctional communication, measured by dye transfer, was not altered over this concentration range. Dermal fibroblasts, in contrast, exhibited a dose-dependent increased expression of Cx43 at concentrations up to 10(-7) M retinoic acid and proportionately increased their junctional communication over this dose range. These data indicate that control of Cx43 gene expression by retinoids in human skin cells is complex. The production of gradients of junctional channels could play a role in the control of growth and differentiation in epidermis.

Nasal augmentation with split calvarial grafts in Orientals.

This study reports on my experience with autogenous split calvarial grafts in nasal augmentation in 62 Orientals. In 78 percent of patients, the procedure was performed under local anesthesia in an outpatient setting. Total operating time for harvesting of split calvarial grafts ranged from 20 to 55 minutes, with a mean of 32 minutes. Patients ranged in age from 16 to 48 years, with a mean of 27 years. Follow-up was from 6 months to 8 years, with an average of 3.1 years. Intraoperative discomfort was uniformly low and well tolerated when local anesthesia was used. The complication rate was 8.0 percent, with three cases of minor seroma-hematoma formation at the bone-graft donor site. These were treated with aspiration. There were two recipient-site complications, with one case of complete bone resorption that occurred in a densely fibrotic nose with preexisting septal perforation and a case of overcorrection that was successfully rasped 1 year later. Because of their easy accessibility beneath the scalp, split calvarial grafts to the nose are useful in various types of nasal augmentation, and the technique is offered as a practical alternative to the use of alloplastic materials.

Breast capsulopexy for capsular ptosis after augmentation mammaplasty.

A simple and reliable technique of capsulopexy is presented. A total of six inferiorly displaced inframammary folds were thus corrected during the past 8 years with good results and with an average of 3.2 years of follow-up. It is felt that this method is simple, reliable, and easier than other techniques previously reported in the literature.

Lymphedema of the face.

Lymphedema of the extremities is well documented in the literature. We present a case of lymphedema involving the face of a 27-year-old man and discuss the clinical presentation, microscopic findings, and surgical treatment. To our knowledge, this is the first such case report in the literature.

Sebaceous gland carcinoma of the eyelids in Hawaii.

Sebaceous gland carcinomas of the eyelids are rare neoplasms accounting for less than 1% of all eyelid tumors. They usually mimic chalazia and undergo repeated curettage before a definitive diagnosis is made. Although they are relatively slow-growing tumors, they behave in an aggressive manner, frequently metastasizing to regional lymph nodes. Approximately 50% of the patients who develop metastasis to lymph nodes of the neck will survive five years. A case report and the review of similar cases in Hawaii in the past 10 years demonstrates the need for early detection and treatment of sebaceous adenocarcinoma of the eyelids.

An experimental flap model for the evaluation of intraarterial effects of drugs on skin viability.

An experimental flap model is presented utilizing the common laboratory rat. This flap allows the study of intraarterial infusion of pharmacological agents and their effect on the skin.

Compression neuropathy from muscle fibrosis induced by repeated meperidine injections.

The combination of myopathy and neuropathy with fibrosis and contractures has apparently not yet been reported from the use of meperidine. We describe a patient addicted to meperidine in whom bilateral hand numbness and weakness developed and electrodiagnostic studies revealed moderate slowing of motor nerve conduction velocities. Neurolysis of the median and ulnar nerves resulted in markedly improved symptoms.