Assessing the Effectiveness of Arnica montana and Rhododendron tomentosum (Ledum palustre) in the Reduction of Ecchymosis and Edema After Oculofacial Surgery: Preliminary Results.

PURPOSE: The purpose of this study was to provide preliminary data on the potential effectiveness of the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in reducing postoperative ecchymosis and edema in a select population of healthy volunteers after oculofacial surgery. METHODS: This retrospective review examined the postoperative course of healthy volunteers using topical Arnica and Ledum after undergoing common oculofacial procedures, including blepharoplasty, browpexy, and rhinoplasty, in the hands of 4 surgeons at tertiary referral centers from July 1, 2012 to December 31, 2012 using medical records review. Each patient included had used topical hydrogel pads (OcuMend, Cearna Inc., Chicago, IL) containing Arnica 50 M (10) 50% and Ledum 50 M (10). The pads were applied bilaterally after surgery through postoperative day 6. At each postoperative visit, the patients were evaluated by their respective surgeons and assigned a subjective physician-patient rating score comparing each patient's observed healing compared with expected healing if not using Arnica/Ledum. Photographs of patients undergoing equivalent procedures, but not using Arnica/Ledum were used as controls for comparison. Physician-patient rating scores were categorical: markedly accelerated healing defined as approximately 7 days ahead of expected, accelerated healing, defined as <7 days ahead of expected, and no appreciable difference from expected. The proportion of patients with each physician-patient rating score was calculated for postoperative days 1 to 2, 3 to 5, 6 to 8, and overall. Difference of proportions was calculated with 95% confidence intervals using Newcombe unpaired difference comparison of proportions. Photographs documenting the clinical progression of selected patients are provided. RESULTS: A total of 27 patients (16 females, 11 males) were included in the study. Age range was 18 to 70 years. The majority of patients were white (52.9%), and underwent blepharoplasty (78.9%). The median duration of follow-up was 7 days, range 1 to 14 days. The proportions of patients with markedly accelerated healing were 38.5% (5 of 13), 85.7% (6 of 7), 60.0% (12 of 20), and 51.9% (14 of 27) at POD 1 to 2, 3 to 5, 6 to 8, and overall, respectively. The proportions of patients with accelerated healing at the same time points were 15.4% (2 of 13), 14.3% (1 of 7), 30.0% (6 of 20), and 37.0% (10 of 27), respectively. The proportions of patients with no appreciable difference at the same time points were 46.2% (6 of 13), 0% (0 of 7), 10.0% (2 of 20), and 11.1% (3 of 27) of patients, respectively. The proportion of patients using Arnica/Ledum with markedly accelerated healing was significantly more than the proportion of those demonstrating no appreciable difference from expected at POD 3 to 5 (85.7% vs. 0%, p = 0.05), POD 6 to 8 (60.0% vs. 10.0%), and overall (51.9% vs. 11.1%, p = 0.05). No adverse effects were reported. CONCLUSIONS: The preliminary results from this study demonstrate that the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) may be effective in reducing postoperative ecchymosis and edema after oculofacial surgery.

Xanthelasma-Like Reaction to Filler Injection.

PURPOSE: The purpose of this study is to describe a new complication of a xanthelasma-like reaction which appeared after dermal filler injection in the lower eyelid region. METHODS: A retrospective case analysis was performed on 7 patients presenting with xanthelasma-like reaction after filler injection to the lower eyelids. RESULTS: Seven female subjects with no history of xanthelasma presented with xanthelasma-like reaction in the lower eyelids post filler injection. Fillers included hyaluronic acid (2 patients), synthetic calcium hydroxyapatite (4 patients), and polycaprolactone microspheres (one patient). Average time interval between filler injection and development of xanthelasma-like reaction was 12 months (range: 6-18 months). Treatment included steroid injections, 5FU injections, ablative or fractionated CO2 laser, and direct excision. Pathology confirmed the lesion was a true xanthelasma in one patient. In treated patients, there was subtotal resolution after laser. Xanthelasma-like reaction resolved completely after direct excision. Three patients elected to have no treatment. CONCLUSIONS: Previously there has been one reported case of xanthelasma after filler injection. This case series is the largest to date. Furthermore, this series is notable because xanthelasma-like reactions appeared after injection with 3 different types of fillers. None of the patients had evidence of xanthelasma prefiller injection. The precise mechanism by which filler injection can lead to the formation of xanthelasma-like reaction is unclear. A possible mechanism may be related to binding of low-density lipoprotein and internalization by macrophages. Further investigation is required. Nevertheless, physicians performing filler injections should be aware of this new complication and treatment options.

Arnica Ointment 10% Does Not Improve Upper Blepharoplasty Outcome: A Randomized, Placebo-Controlled Trial.

BACKGROUND: It has been suggested that arnica can reduce postoperative edema and ecchymosis associated with cosmetic surgical procedures and improve outcome. Despite a high incidence of arnica use among upper blepharoplasty patients, evidence to support its treatment effect is lacking. The authors performed a randomized, double-blind, placebo-controlled trial to investigate the efficacy of arnica ointment after upper blepharoplasty. METHODS: One hundred thirty-six bilateral upper blepharoplasty patients were randomized between arnica ointment 10% and placebo ointment. In both study arms, one periorbital area was designated as the treatment side (either arnica or placebo ointment), and the contralateral side served as an untreated (no ointment) internal control. As the primary endpoint, the overall periorbital appearance as based on light photography and judged by a medical and nonmedical panel, was assessed after 3 days, 7 days, and 6 weeks. Secondary endpoints were swelling, ecchymosis, erythema, pain, and patient satisfaction with recovery and outcome. RESULTS: There was no significant difference between arnica and placebo in overall judgment of periorbital appearance 3 days, 7 days, and 6 weeks after surgery. Furthermore, swelling, ecchymosis, erythema, pain, and patient satisfaction with recovery and outcome did not differ between arnica and placebo. Postoperative outcome in untreated eyelids was not different from eyelids treated with either arnica or placebo on any of the studied outcome measures. CONCLUSION: The authors' study demonstrates that topical arnica ointment after upper blepharoplasty does not improve postoperative outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A randomised double-blinded crossover study comparing pain during anaesthetising the eyelids in upper blepharoplasty: First versus second eyelid and lidocaine versus prilocaine.

AIM: The aim of this study was to investigate whether infiltration of the upper eyelid skin is less painful with prilocaine than with lidocaine. METHODS: In 40 consecutive patients scheduled for bilateral upper blepharoplasty, one upper eyelid was anaesthetised with lidocaine with epinephrine and the other with prilocaine with felypressin. After injection of each upper eyelid, the patient scored the pain experienced on infiltration using a visual analogue scale (0-10). In addition, the surgeon scored the need for reinjection during the operation; differences in perioperative bleeding; and degree of oedema, erythema and haematoma before discharge on a four-point rating scale (no, minimal, moderate or severe). RESULTS: Pain scores were significantly lower in upper eyelids injected with lidocaine than in those injected with prilocaine (p = 0.036). In addition, scores for oedema, erythema and haematoma were significantly lower in upper eyelids anaesthetised with lidocaine than in those anaesthetised with prilocaine (respectively, p = 0.001, p = 0.004 and p = 0.000). CONCLUSIONS: Compared with prilocaine with felypressin, lidocaine with epinephrine is significantly less painful in anaesthetising the upper eyelids; gives significantly less postoperative oedema, erythema and haematoma; and provides better haemostasis during upper blepharoplasty. LEVEL OF EVIDENCE: This was a level II, randomised double-blinded crossover study.

Calcium hydroxylapatite nodule resolution after fractional carbon dioxide laser therapy.

BACKGROUND: Injection of calcium hydroxylapatite filler may result in nodule formation owing to superficial placement of the filler. Calcium hydroxylapatite nodules are difficult to reverse. Previously reported therapeutic options are limited and include intralesional triamcinolone, massage, needling, and excision, each with inconsistent results or potential for scarring. OBSERVATION: We have observed complete resolution of calcium hydroxylapatite nodules after a single treatment with fractional carbon dioxide laser. CONCLUSIONS: A single session of fractional carbon dioxide laser treatment may resolve selected cases of calcium hydroxylapatite nodules. The mechanism of action may involve conversion of the product into tricalcium phosphates which dissolve readily. This novel therapeutic technique may enhance treatment options for a difficult clinical problem.

Vision loss after inadvertent corneal perforation during lid anesthesia.

A 68-year-old woman was referred for glaucoma management after inadvertent corneal perforation during eyelid anesthesia for upper eyelid blepharoplasty. A mixture of 50:50 2% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine buffered with sodium bicarbonate was injected intracamerally. Decreased vision and uncontrollable intraocular pressure resulted, despite prompt anterior chamber washout. Examination showed corneal edema, inflammation, and secondary angle closure. Intraocular pressure control with seton placement led to an improvement in vision; however, mild corneal haze remained, and specular microscopy showed endothelial cell loss, presumably secondary to local anesthetic toxicity. Inadvertent ocular penetration is a rare but serious complication of local eyelid anesthesia. Prompt recognition is essential to institute appropriate management and minimize subsequent vision loss.

Lower blepharoplasty with direct excision of skin excess: a five-year experience.

BACKGROUND: Many patients present for aesthetic treatment of their lower eyelid region. Although traditional lower blepharopasty can successfully correct prominent lower eyelid bags, tissue excesses in the lower periorbital region (such as crepe-like skin and festoons) can cause distress for patients both aesthetically and physically, as they may cause discomfort. The skin that can be removed from this area (below the eyelashes) with a traditional incision is limited since tension on the lower eyelid must be avoided. OBJECTIVE: The authors report the results of their five-year experience performing lower blepharoplasty with a direct skin excision in the lower periorbital region. METHODS: Fifty-five patients were treated with the authors' method of blepharoplasty between Ferbruary 2004 and February 2009. After precise preoperative marking, each patient was placed under local anesthesia and the excess of tissue in the lower periorbital region was removed. When necessary, removal of fat bags was performed. When the tissue in excess was significant, this kind of direct incision allowed the removal of more skin than the traditional method, without tension on the lower eyelid. RESULTS: No major complications-or even temporary scleral show-was observed in any of the patients in this series. In addition, no patients complained of any exaggerated visibility of postoperative scarring. The high rate of patient satisfaction with this procedure has led the authors to apply this type of incision with increasing frequency in their blepharoplasty patients. CONCLUSIONS: The authors' direct incision technique for lower blepharoplasty, when selected with the appropriate indications, can provide a successful and safe alternative to traditional methods. Options for treatment of the lower lid are few since the area is a very challenging one to treat and the authors believe that this additional alternative will be helpful to both surgeons and patients alike.

Hypotony maculopathy after eyelid massage for overcorrected blepharoptosis.

A 57-year-old woman with a history of left eye trabeculectomy was evaluated for gradual ipsilateral visual loss. Several months prior, she had undergone levator advancement of the left upper eyelid. For management of resulting retraction, she was instructed to "massage" her eyelid. Examination was notable for left eye visual acuity of 20/200 and an intraocular pressure of 5 mm Hg. On fundoscopic examination, the macula was edematous with multiple folds, consistent with hypotony maculopathy. Two years later, after obliteration of the bleb and placement of a Seton valve, the intraocular pressure has increased to 8 mm Hg with an acuity correctable to 20/50. Ocular hypotony may result from digital eyelid massage in patients with filtering blebs. Clinicians should bear this in mind when managing patients with eyelid retraction after blepharoptosis repair.

Isolated Muller's muscle resection for the correction of blepharoptosis.

PURPOSE: To assess the outcome of isolated Muller's muscle resection with preservation of conjunctiva in patients with blepharoptosis and good to moderate levator function. METHODS: This study was designed as a prospective, nonrandomised case series. Thirty-four eyes of 27 blepharoptosis patients were operated on, who were phenylephrine test-negative as well as positive. Open-sky Muller's muscle resection was performed with preservation of the conjunctiva. Main outcome measures were increase in margin reflex distance (MRD1), eyelid contour, and symptoms and signs of dry eye. RESULTS: The mean increase in MRD1 was 2.75 mm. All but one patient (96%) had upper lid margins resting at or up to 1 mm below the limbus and obtained symmetry to within 0.5 mm of the fellow eye. No patients had symptoms or signs of dry eye. CONCLUSION: Isolated Muller's muscle resection is effective for the correction of ptosis in patients with moderate to good levator function. This is irrespective of the lid's response to phenylephrine. Preservation of conjunctival tissue eliminates concerns about dry eye, and also preserves the full height of the fornix.

Perilimbal needle manipulation of conjunctival chemosis after cosmetic lower eyelid blepharoplasty.

We report an effective treatment procedure for postoperative conjunctival chemosis following cosmetic lower eyelid blepharoplasty. A minimally invasive procedure was used to treat three patients who presented with chronic conjunctival chemosis following lower eyelid blepharoplasty. This procedure utilizes local anesthesia and perilimbal manipulation with a 27-gauge needle. Two months following the procedure, reduction of the chemosis was observed in all three patients. Our cases indicate that perilimbal manipulation with a 27-gauge needle is a viable treatment for this surgical complication.

Transient impaired vision, external ophthalmoplegia, and internal ophthalmoplegia after blepharoplasty under local anesthesia.

PURPOSE: To report a case of transient bilateral vision impairment with external ophthalmoplegia and internal ophthalmoplegia after blepharoplasty under local anesthesia. DESIGN: Interventional case report. METHODS: A 70-year-old man underwent bilateral upper blepharoplasty under local anesthesia. During orbital fat removal additional anesthetic was injected into both medial fat pads for pain control. RESULTS: Immediate postoperative examination revealed bilateral decreased visual acuity and internal ophthalmoplegia in the right eye. An exotropia was present with marked limitation of right eye adduction. These findings resolved completely 3 hours postoperatively. CONCLUSIONS: Local anesthesia during blepharoplasty can enervate the optic nerve, ciliary ganglion, and extraocular muscle nerves. Local anesthesia should be injected judiciously during orbital fat removal to avoid this reversible but alarming event.

Postoperative infection with group A beta-hemolytic Streptococcus after blepharoplasty.

PURPOSE: To report a case of group A beta-hemolytic streptococcal infection with signs of early necrotizing fasciitis after cosmetic blepharoplasty in a healthy patient. DESIGN: Interventional case report. METHODS: A healthy 59-year-old woman underwent outpatient bilateral upper and lower blepharoplasty with midface lifting. Thirty hours postoperatively she developed marked pain and edema of the left eyelids and face, and a violaceous eyelid bulla, which heralded early necrotizing fasciitis. Culture of the serosanguinous exudates from the left eyelid revealed group A beta-hemolytic Streptococcus organisms. RESULTS: The patient was treated with intravenous antibiotics, intravenous corticosteroids, hyperbaric oxygen therapy, and wound debridement. The infection resolved with mild cicatrization of the left upper eyelid. CONCLUSIONS: Group A beta-hemolytic Streptococcus is an increasingly recognized cause of infection that occurs after trauma or surgery, even in highly vascularized areas such as the eyelids and face. It is a potentially devastating infection, particularly in vascularly compromised patients, and requires immediate and aggressive treatment.

Necrotizing fasciitis after cosmetic blepharoplasty.

PURPOSE: To report a case of necrotizing fasciitis after cosmetic blepharoplasty. METHOD: Case report. A 74-year-old woman with history of type II diabetes mellitus underwent bilateral upper eyelid blepharoplasty. Postoperatively she developed fever, grayish discoloration of the skin, violaceous bullae, and a right facial nerve palsy. Necrotizing fasciitis was diagnosed and treated with intravenous antibiotics, debridement of necrotic tissue, and hyperbaric oxygen therapy. RESULTS: The infection resolved, but the patient required reconstruction for correction of cicatricial ectropion. CONCLUSION: Necrotizing fasciitis is a potentially fatal infection that typically occurs in the setting of trauma. Early recognition of its pathognomonic signs and aggressive management are paramount.

Necrotizing fasciitis caused by group A streptococcus infection after laser blepharoplasty.

PURPOSE: To describe a patient who developed early signs of necrotizing fasciitis after undergoing laser blepharoplasty. METHODS: A 36-year-old woman developed wound discharge, wound dehiscence, and facial swelling 66 hours postblepharoplasty. Cloxacillin was administered but changed to high-dose intravenous penicillin G and clindamycin when the eyelid cultures grew group A streptococcus (an organism capable of causing necrotizing fasciitis organism). RESULTS: The patient was treated with intravenous antibiotics for 10 days followed by 3 weeks of oral medications. The wounds healed spontaneously with an excellent result. CONCLUSIONS: Infection postblepharoplasty is rare. When it occurs, tissue destruction can be potentially devastating. Prompt diagnosis, intravenous antibiotics, and close follow-up are essential.