Post-Operative Endonasal Debridement May Improve Outcomes of Endoscopic Dacryocystorhinostomy.

Background: Endoscopic dacryocystorhinostomy (endoDCR) has proven to be an effective minimally invasive surgical procedure for treatment of nasolacrimal duct obstruction. Post-surgical endonasal debridement has not yet been independently assessed for its impact on functional success. Methods: A retrospective review was performed of all patients who underwent endoDCR by an experienced oculofacial plastic surgeon over 7 years (2012-2019). Post-operative intranasal debridement was not routinely performed from March 2012 to February 2016. From March 2016 to June 2019, all patients underwent routine ipsilateral intranasal debridement at post-operative week 2. Surgical success was determined based upon subjective assessment of epiphora resolution at the patient's final post-operative visit. Results: A total of 69 patients (88 surgeries) were included. Thirty-five patients had standard post-operative follow-up without debridement, whereas 34 underwent endonasal debridement at post-operative week 2. Demographics and follow-up were similar between the 2 groups. Functional success was achieved in 84.1% of patients without debridement, and in 97.7% with debridement (P = .058). Conclusion: This review demonstrates a trend toward improvement in the rate of surgical success of endoDCR when routine endonasal debridement was instituted 2 weeks following surgery. We believe that removal of nasal crusts, clots, and residual absorbable gelatin sponge at the osteotomy site improves tear outflow and reduces cicatricial healing enhancing patency of the surgically derived lacrimal-nasal fistula. We advocate for postoperative debridement in the perioperative management of endoDCR patients to optimize successful outcomes.

Adnexal squamous cell carcinoma: incidence of eyelid margin involvement.

PURPOSE: We aimed to perform a review of facial and periorbital squamous cell carcinoma (SCC) cases to assess the relative incidence of eyelid margin involvement. METHODS: This is a retrospective review of all patients with biopsy-proven SCC who were evaluated at a single oculoplastic surgery practice from 2007 to 2019. The charts were reviewed for the anatomical location of the malignancy, and those involving the eyelid were further divided into marginal and non-marginal lesions. Statistical analysis was performed using a one proportion z-test. RESULTS: A total of 76 patients with a diagnosis of biopsy-proven periorbital and facial SCC were identified, 67 involved the ocular adnexa. Thirty-nine (58.2%) patients had lesions located on the eyelid. Of these, 33 (84.6% p < 0.0001, 95% CI 69.45-94.13) had lesions located at the margin, six of the 39 lesions were non-marginal. The remaining lesions were present within the brow (n = 10, 14.9%), medial canthus (n = 10, 14.9%), palpebral conjunctiva (n = 1, 1.5%), or orbit (n = 1, 1.5%). In six patients (8.9%) lesions involved multiple anatomic subunits. CONCLUSION: We present our investigation of the incidence of SCC of the marginal vs. non-marginal eyelid, revealing a statistically significant increased involvement of the eyelid margin. Future investigations are necessary to further elucidate the vulnerability of the eyelid margin to the development of SCC in particular in regards to the role of the unique genetic expression profile of eyelash follicular stem cells.

Potent Periorbital Fractionated CO 2 Laser Resurfacing.

BACKGROUND: The aged face results from a culmination of skin changes, gravitational descent, and volume loss. Surgical interventions in the periorbital region are beneficial for addressing these 3 factors. Despite this, studies describing CO2 laser safety settings are lacking. OBJECTIVE: There is no present consensus on ideal periorbital CO2 laser; therefore, this study evaluates the safety of periorbital laser resurfacing as an adjunct to lower blepharoplasty using robust settings. MATERIALS AND METHODS: A retrospective review was performed of all patients who underwent bilateral lower blepharoplasty with adjunctive periorbital (upper and lower eyelid) fractionated CO2 laser resurfacing from 2013 to 2018 performed by a single oculoplastic surgeon. RESULTS: Fifty-nine patients were included. Six patients experienced side effects including postinflammatory hyperpigmentation, (3/59, 5.1%), prolonged superficial excoriations (1/59, 1.7%), prolonged hyperemia (1/59, 1.7%), and lower eyelid retraction requiring lower eyelid recession (1/59, 1.7%). None of the patients developed postoperative infection. All patient expressed satisfaction at their final postoperative visit. CONCLUSION: CO2 laser resurfacing, even with robust settings, is a safe and effective adjunct to lower blepharoplasty.

5-Fluorouracil With Microneedling Modulates Wound Healing in a Murine Model: An Immunohistochemical Analysis of Mechanism and Dose Efficacy.

PURPOSE: The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model. METHODS: A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density. RESULTS: Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed. CONCLUSIONS: Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk.

Consideration of Nasal Contour in Endoscopic Forehead Rejuvenation.

Purpose: Preliminary studies have suggested an improvement in nasal aesthetics after endoscopic forehead lifting. We aimed to assess subjective and objective changes in nasal contour after minimally invasive forehead rejuvenation. Methods: We performed a retrospective review of patients who underwent endoscopic forehead lifting by four surgeons at a single surgery center from 2004 to 2018. All patients had subperiosteal blunt release of soft tissues overlying the radix. Changes in nasal contour were assessed on pre- and postoperative patient photos by four independent judges using the Global Aesthetic Improvement Scale. Objective changes in nasal length and length-to-base ratio were measured on patient photographs using ImageJ software. Measurements were further compared by demographic variables of age and gender. Results: In total, 326 patients met inclusion criteria. Summative judging results revealed 79.4% of patients with clinical improvement in nasal contour (11.1% very much improved, 25.6% much improved, and 42.6% improved), 20.1% with no change and 0.6% with worsening. There was a statistically significant increase in average nasal length (2.17 mm, p < 0.0001) and length-to-base ratio (0.03, p < 0.0001) postoperatively. Stratification of patients by age and gender did not reveal a significant difference in degree of nasal proportion change. Conclusions: There is a noteworthy subjective and quantitative improvement in nasal contour and length after endoscopic forehead lifting. This change restores ideal facial proportions and may serve as a useful counseling point when offering this surgery to patients.

Wound Dehiscence Following Upper Blepharoplasty: A Review of 2,376 Cases.

PURPOSE: There have been limited studies evaluating specifically the incidence of wound dehiscence following isolated upper blepharoplasty. This is a large-scale upper blepharoplasty review to evaluate the rate of wound dehiscence, to assess risk factors, and to analyze management outcomes. METHODS: A retrospective review was performed of all patients who underwent upper blepharoplasty at a single surgery center. All incisions were closed using either 6-0 fast-absorbing plain gut or polypropylene suture in a running fashion, with an additional interrupted suture near the lateral wound edge. Incidence of wound dehiscence was determined and further assessed by patient age (≤67 or >67 years), gender, preexisting medical conditions, smoking history, and suture type. RESULTS: A total of 1,190 patients (2,376 eyelids) met inclusion criteria. In total, there were 34 instances (1.4%) of wound dehiscence in 32 patients at an average 9 days (range, 0-30 days) following surgery. Evaluation of wound dehiscence rates by demographic factors revealed male gender to be a significant predictor of wound dehiscence (p = 0.0062). Age, hypertension, heart disease, and diabetes were not predictors of wound dehiscence. Lifetime smoking history increased risk for wound dehiscence (p < 0.0001). Use of fast-absorbing plain gut suture was also significantly associated with dehiscence, when compared with polypropylene (p = 0.0025). Multivariate analysis revealed male gender and fast-absorbing plain gut suture to be independent risk factors for wound dehiscence. Seventeen eyelids with wound separation were observed for second-intention healing, 1 underwent delayed scar revision. Fourteen eyelids were repaired primarily using suture and 3 with cyanoacrylate surgical skin adhesive. All patients reported satisfaction with their final outcome, and objective final healing was deemed satisfactory. CONCLUSIONS: Wound dehiscence following isolated upper blepharoplasty is rare and associated with male gender and fast-absorbing plain gut suture. Patients with wound separation may be successfully managed with individualized care.

Pedicled Buccal Fat Flap: An Underutilized Source of Vascularized Periorbital Volume.

Pedicled buccal fat flaps have demonstrated great utility for oral reconstructions. We present a retrospective case description detailing the utility of the buccal fat pad (BFP) as an anterior maxillary flap for midfacial and lower eyelid volumization and reconstruction. A 64-year-old healthy female had undergone bilateral lower blepharoplasty with silicone tear tough implantation, complicated by infection of the right tear trough implant. Delayed implant removal resulted in chronic infection and inflammation producing significant right lower eyelid retraction, and full-thickness scarring to the orbital rim. Reconstruction was performed, featuring the creation of a midfacial subperiosteal pocket and to access the BFP, which was mobilized and secured to the inferior orbital rim. Long-term follow-up confirms ongoing viability of the surgical intervention. Herein, the BFP is shown to be a source of vascularized volume in reconstructive periorbital surgery.