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ABSTRACT: To present a new technique using the recently introduced Enduragen(®) material (Tissue Science Laboratories) as a patch graft for exposed ocular implants.
A retrospective, interventional, non-comparative case series of 3 patients who had Enduragen patch grafts for the closure of Tenon's capsule and conjunctiva over exposed ocular implants. Medical records were reviewed and the following parameters were collected: age, gender, indication for surgery, type of surgery, laterality, type of orbital implant, complications after repair and length of follow-up.
Three patients were identified, 2 males and 1 female. One patient had a secondary quad-motility implant with supertemporal exposure. The second patient had a secondary implant with a fistula at the lateral aspect of the socket. The third patient had a centrally exposed primary hydroxyapatite implant. All patients received Enduragen patch grafts to cover the implant. Follow up ranged from 40 to 43 months (mean, 41.3 months; SD, ± 1.5). None of the 3 patients had any signs of implant re-exposure at the time of the last post-operative visit. There were no intra-operative or early complications observed.
This consecutive case series suggests that Enduragen could be used as a safe and effective patch graft for exposed ocular implants. However, a larger prospective study with longer follow-up would be useful in further defining the indications and limitations of the Enduragen patch graft for the treatment of exposed orbital implants.
Orbit (Amsterdam, Netherlands) 03/2011; 30(2):92-5.
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ABSTRACT: A half-inch 32-gauge needle (Air-Tite Products) minimizes injection discomfort. In the periorbital areas we inject in an oblique
manner to the skin to lessen the chance of deep injections or even injury should a patient suddenly move. Pinching upward
or gently rubbing the adjacent skin during injection minimizes patient discomfort by distracting the patient during the injection
and “confusing” the sensory sensation of the injection (Figure 95.1). We recommend premarking the areas to be injected, and utilizing bright lighting and wearing magnification to avoid injury
to eyelid vessels. We seldom use topical anesthetics, and some suggest a reduced duration of effect in patients treated with
topical anesthetic prior to injection.1 We inject into the subcutaneous tissue planes to avoid the underlying muscle and neurovascular structures. This reduces patient
discomfort and lessens the risks of bruising and deep dissemination. In general the injections can be given obliquely or perpendicular
to the skin, but in the orbicularis areas it is critical to inject at as flat an angle as possible because of the thinness
of the eyelid skin and to point away from the eye. It is also helpful when injecting the lower orbicularis areas to put the
skin on stretch, which helps with placing the Botox in the subcutaneous plane. Botox must be avoided in the central upper
eyelid to prevent ptosis and over the inferior oblique in the lower eyelid to avoid diplopia.
Figure 95.1Pinch technique during oblique injection of corrugator. This descreases discomfort and avoids neurovascular structures and
bleeding.
12/2007: pages 303-304;
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ABSTRACT: For deep glabellar and nasolabial folds, our preferred filler is Radiesse®. Radiesse is calcium hydroxyapatite gel. Radiesse
is an excellent dermal filler for severe folds, wrinkles that require large volumes and respond well to deep placement, which
is critical with Radiesse. It is recommended to inject Radiesse below the dermis to avoid visibly noticeable lumps and irregularities.
For the nasolabial folds, inject slightly medial to each nasolabial fold as the natural muscular action of the facial muscles
will tend to lateralize the effect and can worsen the appearance of the folds if not placed medially (Figure 117.1).
Figure 117.1Injection of Radiesse into the left nasolabial fold. Note the slight medial placement to the premarked nasolabial fold.
12/2007: pages 354-355;
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ABSTRACT: Botulinum toxin type A (Botox®) interferes with acetylcholine release from nerve terminals causing temporary paralysis of
the injected muscles. The pioneering work of Scott1 over 25 years ago was for strabismus. In 1989 it was approved for blepharospasm, hemifacial spasm, torticollis, and strabismus.
Since then it has been approved for cosmetic treatment of the glabellar furrows and axillary hyperhydrosis. Botox has become
the number one cosmetic procedure and is widely used to treat rhytids of the glabella, forehead, eyelids; nasal; cervical;
and perioral areas. Offlabel oculofacial uses include: hyperkinetic wrinkles of the face; hyperlacrimation; eyelid retraction;
spastic entropion; blepharoptosis; migraine/stress headaches; and improving symmetry for facial palsy.
12/2007: pages 293-293;
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ABSTRACT: Potential causes of increased postoperative swelling include rough tissue handling, excessive cauterization, and lymphatic
disruption. Other contributing factors are poor patient compliance with cool compresses, head elevation, and rest. Progressive
postoperative periorbital and orbital inflammation is usually considered to be infectious or toxoallergic in etiology. Clinical
onset, signs, symptoms, and response to empiric therapy often help distinguish the diagnosis.
12/2007: pages 112-113;
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ABSTRACT: Our preferred hyaluronic acid dermal fillers are Restylane, Perlane, and Juvederm. Each of these has a very high safety profile
and are easier to inject than Radiesse. They are outstanding for lip enhancement, including the vermillion border, perioral
rhytids, and for less severe glabellar and nasolabial folds or as a superficial fine tuning to deeper filling with Radiesse.
The newer, higher viscosity hyaluronic acids, however, are excellent for deep lip augmentation, nasolabial folds, and deep
rhytid filling. We have found excellent success treating nasojugal (“tear trough”) deformities with hyaluronic acids, which
offers a nonsurgical option to cosmetic lower eyelid blepharoplasty (Figure 116.1). Patients require variable amounts depending on the desired outcome and severity of the folds. Injections deep (periosteally)
or just below the orbicularis tend to cause less swelling and bruising below the eyes. The effects are potentiated by the
concomitant application of Botox. We generally use the provided needle and find that direct injection with withdrawal of the
needle as well as the described “feathering” technique both work well. We routinely perform the infraorbital and mental nerve
blocks as previously prescribed, as lip injections are quite painful. Premark the perioral rhytids prior to the nerve blocks
to ensure optimal filling.
Figure 116.1(A) Preinjection of Restylane in a patient with pronounced lower eyelid hollowness “tear trough deformities.” (B) Immediately
following the injections, showing the marked improvement.
12/2007: pages 352-353;
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ABSTRACT: Cosmetic applications of Botox continue to expand beyond the FDA-approved use for glabellar furrows. Patients should sign
informed consent for off-label cosmetic uses. Treatment of eyelid and facial rhytids is gratifying for the patients and physicians.
Not only do the eyelid injections improve current rhytids, but the future development of mimetic rhytids is prevented. It
is paramount to understand the anatomy of the eyelid and facial muscles and that the rhytid-inducing musculature is the injection
site rather than the actual wrinkles. Patient desires and expectations must be clearly defined as some patients may want to
be smooth and adynamic, whereas others prefer a natural youthful appearance. We strongly encourage the latter. Aesthetic appreciation
and training is essential in obtaining excellent cosmetic results.
12/2007: pages 305-306;
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ABSTRACT: To yield optimal results, we strongly encourage our patients to undergo adjunctive transblepharoplasty procedures to the standard
upper blepharoplasty.
12/2007: pages 95-98;
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ABSTRACT: Fillers are an outstanding adjunct to Botox and, in some situations, are superior to surgery. In our practice, we prefer the
nonanimal-based synthetic fillers (Restylane, Juvederm, Perlane, and Radiess). This is because skin and allergy testing is
not required and there is no risk of animal-based disease transmission. In our practice, we have found that patients have
a higher acceptance for the synthetic than for animal-based products. Patient acceptance is quite high, and both the physician
and patient can immediately enjoy the rejuvenative effect just following injection. We recommend patients avoid any blood-thinning
agents for approximately 2 weeks prior to injections.
12/2007: pages 344-344;
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ABSTRACT: Botox is extremely safe, with an LD50 of 3500 units in humans. Despite a high safety profile, non-life-threatening complications can be frequent and frustrating
to both the patient and the physician. Proper understanding of oculofacial anatomy is paramount to correctly understanding
the indications and proper administration of Botox. Botox will not address skin pigmentation/quality, excess skin, contour
deformities, volume loss/deformities, or tissue drop. Botox therapy is ideal for initiating cosmetic surgery to patients into
practice.
12/2007: pages 307-308;
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ABSTRACT: In patients who would like a longer-lasting effect and are undergoing a blepharoplasty surgery, we have used the removed fat
and orbicularis as an autogenous graft to the nasolabial folds, lips, and glabellar folds.
12/2007: pages 386-386;
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ABSTRACT: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised.
A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications.
Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site.
This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.
British Journal of Ophthalmology 12/2007; 91(11):1528-31. · 2.90 Impact Factor
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ABSTRACT: We present a patient with a facial movement disorder that has characteristics of both blepharospasm and bilateral asynchronous hemifacial spasm. Because of the increased incidence of blepharospasm in patients with hemifacial spasm, our patient's clinical presentation is probably not a chance occurrence, but rather a manifestation of some predisposition for these two movement disorders. This unusual constellation of signs and symptoms challenges the current diagnostic criteria and suggests that some of these facial movement disorders may lie on a spectrum, rather than represent distinct entities.
Movement Disorders 02/2007; 22(2):231-4. · 4.51 Impact Factor
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ABSTRACT: Proper preoperative assessment of the eye and periocular region is essential to verify ocular health and vision and to obtain an optimal surgical result. A systematic approach to reviewing the ocular history, review of systems, and pertinent physical exam will be discussed. This is important to identify not only underlying ocular conditions but also potentially serious systemic conditions with ocular manifestations that can impact the patient's overall health. A thorough exam by a qualified provider is needed if there are any management issues regarding the presence of a condition(s) that can impact the surgical outcome.
Seminars in Plastic Surgery 02/2007; 21(1):5-17.
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ABSTRACT: To describe a technique for performing a bolsterless temporary tarsorrhaphy.
Retrospective analysis and surgical technique description.
Temporary suture tarsorrhaphy (TST), which consists of a suture through the upper and lower eyelid posterior lamella, was performed after eyelid or socket surgery.
Over 15 years, >1000 patients in the practice of one of the authors (R.L.A.) had TST that successfully maintained corneal coverage without complications in all but four eyes. In two patients, replacement was required because of tissue erosion; in two patients, the suture was placed too posteriorly and caused corneal irritation that required replacement.
The TST is functionally equivalent to, or superior to, traditional bolster temporary tarsorrhaphy. The TST is faster and simpler, requires fewer materials, and avoids the risks of bolsters, which include eyelid margin necrosis, irregularities, and lash loss from vascular compromise.
American Journal of Ophthalmology 08/2006; 142(2):344-6. · 4.22 Impact Factor
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American Journal of Ophthalmology 06/2006; 141(5):916-7. · 4.22 Impact Factor
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ABSTRACT: To report cold urticaria as an under-recognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery.
Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases.
Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae.
Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.
Ophthalmic Plastic and Reconstructive Surgery 10/2005; 21(5):327-30. · 0.69 Impact Factor
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ABSTRACT: Purpose: To report cold urticaria as an underrecognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery.
Methods: Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases.
Results: Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae.
Conclusions: Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.
Ophthalmic Plastic and Reconstructive Surgery 08/2005; 21(5):327-330. · 0.69 Impact Factor
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ABSTRACT: To review cases of spontaneous enophthalmos erroneously diagnosed as silent sinus syndrome to identify other inflammatory disorders with a similar clinical presentation.
Retrospective observational case series. Chart reviews were performed covering encounters over a 5-year period, searching for patients referred to two physicians with an incorrect diagnosis of silent sinus syndrome. Only cases of acquired enophthalmos of reported nontraumatic or nonneoplastic cause were included. Particular attention was directed toward noting clinical features of upper eyelid position and periocular atrophy.
Nineteen cases of erroneous referral for silent sinus syndrome were identified. Fourteen of these cases were due to tumor, trauma, congenital facial asymmetry, or diffuse facial lipodystrophy. Among the remaining cases, four were diagnosed as Parry-Romberg syndrome and one as linear scleroderma.
Parry-Romberg syndrome and linear scleroderma must be distinguished from silent sinus syndrome as causes of inflammatory-mediated, spontaneous enophthalmos.
Ophthalmic Plastic and Reconstructive Surgery 12/2003; 19(6):449-54. · 0.69 Impact Factor
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ABSTRACT: We describe an effective adjunctive suture technique for severe forms of both tarsal and marginal ectropion in a case series of 28 patients undergoing the rotation mattress suture technique for ectropion repair. Forty eyelids, followed for 1 to 5 years (average, 2.5 years), underwent tarsal or marginal ectropion repair, using the rotation mattress suture technique. Transient notching was noted in 31 eyelids (78%) but persisted in only 1 case (3%). Twenty-five eyelids (63%) had 0.5 to 1.0 mm of eyelid retraction. There were only 2 cases (5%) of recurrent ectropion. We found that excluding transient changes and predictable, mild lower eyelid retraction, the rotation mattress suture provides a powerful adjunctive reparative option for difficult cases of ectropion with low complication and failure rates.
Ophthalmic Plastic and Reconstructive Surgery 10/2003; 19(5):404-6. · 0.69 Impact Factor
