Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab.

PURPOSE: In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen. METHODS: This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events. RESULTS: The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption. CONCLUSIONS: Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

The Management of Lumps, Bumps, and Contour Irregularities of the Lower Eyelid and Cheek After Poor Outcome Fat Transfer.

BACKGROUND: The increasing popularity of fat transfer (FT) to the lower eyelids has led to an increase in unwanted lumps, bumps, and contour irregularities (LBCs). Few studies have addressed the management of LBCs. OBJECTIVES: The aim of this study was to address the management of LBCs. METHODS: In this retrospective review, charts of all patients presenting for evaluation of LBCs following FT procedures to the lower eyelid were reviewed. Clinical characteristics on presentation and surgical findings were evaluated. Patient postoperative clinical course and complications were also documented. RESULTS: Forty-eight patients were included (45 women and 3 men), with an average follow-up of 14 months (range, 5-24 months). In 65%, LBCs manifested above the lower orbital rim (AR) and in 35% they were noted AR and below the rim (AR/BR). The type of contour deficits noted were a solitary nodule (SN) in 54%, a mixed picture (MP) in 23%, diffuse enlargement (DE) in 17%, and multiple nodules (MNs) in 6%. Combining lesion location and type of contour deficit, the most common presentation was an SN-AR in 22 patients (46%), followed by an MP-AR/BR in 8 patients (17%), and a DE-AR/BR in 5 patients (10%). Surgical findings revealed that grafted fat is consistently found separate from native eyelid/orbital fat, and within the orbicularis muscle when AR, and within the orbicularis muscle or the deep suborbicularis oculi fat when BR. CONCLUSIONS: LBCs tend to manifest in characteristic patterns with a predilection for an AR location. Recommendations on the diagnosis and management of these lesions are provided.

Quantitative Analysis of Preoperative and Postoperative Photographs Posted on Social Media by Oculoplastic Surgeons.

PURPOSE: To investigate and quantitatively analyze preoperative and postoperative photographs posted on social media by oculoplastic surgeons. METHODS: Pre- and postoperative blepharoplasty photographs posted by oculoplastic surgeons on the social media platform Instagram were identified over a 4-month period. Photographs demonstrating a frontal pose of the periocular region were selected, and image analysis was performed to compare the preoperative and postoperative photographs. Quantitative image analysis was performed with a semiautomated script using ImageJ (v1.52k) software. Image analysis compared magnification, patient position, luminosity, relative color profiles, and edge detection/sharpness. Three oculoplastic surgeons graded these imaging metrics for the same photoset and the consensus grade was assigned to each category. Finally, the quantitative calculations were then compared with the consensus grades to develop receiver operating characteristic curves for further analysis. RESULTS: The study included 104 posts from 35 members of ASOPRS. Regarding patient positioning, 9 postings were 5%-10% offset from the patients' center, and 6 postings were more than 10% from the patients' center. The majority of photosets demonstrated less than or equal to 2.5% difference in magnification (69/104), with 7 postings demonstrating a greater than 5% difference, and 3 postings exhibiting greater than 10% difference in magnification. In the periocular region, 17.3% (18/104) of postings were found to have a greater than 10% difference in luminosity (>25.5 pixel-value). A more than 5% difference (>12.75 pixel-value) in pre- and postoperative edge-detection measurements was identified in 12 of 104 postings. In 22 of 104 photosets, the mean absolute deviation in color channel ratios was more than 0.01 and 15 of 104 photosets were found to have a mean absolute deviation more than 0.05. CONCLUSIONS: Numerous quantifiable photographic inconsistencies were identified in surgical photographs posted on social media by members of ASOPRS. Adoption of an automated image analysis tool that compares before-and-after surgical photographs could promote standardized oculoplastic surgery photography on social media.

Comparison of non-absorbable silk and absorbable polyglactin sutures for external ptosis repair.

Purpose: The authors compare the outcomes and revision rates for external levator aponeurotic advancement for the treatment of involutional ptosis using non-absorbable silk and absorbable polyglactin sutures.Methods: An IRB-approved retrospective chart review identified 121 patients who underwent external levator advancement for involutional ptosis between 2015 and 2016 by the senior author (JBH).  All patients underwent ptosis repair using either 5-0 polyglactin 910 on a S-14 spatulated needle or 6-0 silk on a G-1 reverse cutting needle for the aponeurotic advancement. Ptosis etiologies other than involutional ptosis were excluded. Patients with >0.5 mm of upper lid height asymmetry post-operatively underwent surgical adjustment. Demographics, clinical findings and revision rates were collected and analyzed from follow-up visits.Results: 116 patients (190 eyelids) met inclusion criteria. Fewer ptosis repairs performed using silk sutures necessitated adjustment when compared to those using polyglactin (1/73 [1.4%] vs. 14/117 [12.0%], p = 0.010). Silk direct connection sutures had no better stability than polyglactin direct connection sutures (p = 0.16), but silk hang-back sutures were significantly superior to polyglactin hang-back sutures (p = 0.035).  Thirteen out of fifteen (86.7%) revisions were advancements to raise the eyelid, while two (13.3%) were recessions.Conclusion: Non-absorbable silk suture may be superior to absorbable polyglactin, necessitating fewer surgical revisions. Silk demonstrated superiority to polyglactin when a hang-back suture was employed. Since the need to place direct or hang-back sutures cannot be made pre-operatively, the authors modified their technique to utilize silk sutures for external aponeurotic ptosis repair.

Laughter-Induced Transient Vision Loss in a Patient With Silent Sinus Syndrome.

BACKGROUND: To report a patient with silent sinus syndrome (SSS) who experienced transient ipsilateral monocular vision loss during intense laughter. METHODS: Case report. RESULTS: Our patient's transient vision loss completely resolved after maxillary sinus decompression and during 7 months of follow-up. CONCLUSIONS: Although the precise mechanism of our patient's vision loss remains undetermined, we suspect that the vascular supply to the eye and/or the optic nerve was compromised as the result of the combination of laughter (causing Valsalva maneuver and increased intrathoracic pressure) and SSS.

Phi, Fat, and the Mathematics of a Beautiful Midface.

PURPOSE: The Golden ratio, or Phi, has been used to explain the substrates of two-dimensional beauty utilizing the faces of models. A "Phi point" has been identified at the apex of the cheek mound that can be targeted in filler injections. The authors report herein how they have applied this algorithm for surgical shaping of the "beautiful" cheek as a routine part of their lower blepharoplasty procedure. The authors present their technique and results with patients undergoing lower blepharoplasty along with the adjunct of liposculpture to areas of volume deficiency in the midface with a particular goal of enhancing the Phi point. METHODS: This study was retrospective, consecutive, nonrandomized, interventional case series. The authors reviewed the medical records of 113 consecutive patients who underwent lower blepharoplasty with autologous fat transfer to the Phi point. The aesthetic outcome, patient satisfaction, and complication/revisions were evaluated. RESULTS: One hundred two out of 113 patients achieved excellent lower lid position and cheek enhancement as assessed by both patient and surgeon. In these 102 patients, there was significant improvement in lower lid appearance, contour, transition to the cheek, and cheek projection as observed by the surgeon. Three patients required revision to achieve sufficient volume. Eight patients were satisfied with the outcome, nevertheless, requested additional filler injection to optimize. CONCLUSIONS: Lower blepharoplasty combined with autologous fat transfer to reshape the Phi point is a safe and reliable technique and another step further in our quest for recreating the beautiful face.

Orbicularis Retaining Ligament Release in Lower Blepharoplasty: Assessing Efficacy and Complications.

PURPOSE: Release of the orbicularis retaining ligament (ORL) has been advocated as a technique to address tear trough deformities. This study sought to compare the effectiveness and morbidity of lower blepharoplasty with and without ORL release. METHODS: Retrospective chart review of 53 lower blepharoplasty patients. Twenty-six patients had ORL release and 27 patients did not. Three independent masked experienced cosmetic surgeons reviewed preoperative and postoperative photographs to assess degree of swelling, ecchymosis, change in steatoblepharon and tear trough deformity, and overall aesthetic result. RESULTS: There were no significant differences in overall aesthetic result, change in steatoblepharon or tear trough deformity, and postoperative ecchymosis in patients who had ORL release compared with those who did not. Patients who had ORL release had postoperative swelling and chemosis of significantly longer duration and a higher likelihood of developing postoperative ectropion. CONCLUSIONS: Orbicularis retaining ligament release does not appear to result in additional aesthetic benefit in lower blepharoplasty patients and may increase morbidity in the form of ectropion and prolonged swelling and chemosis.

Proptosis and Anterior Dislocation as a Late Noninflammatory Complication of Failure of Tissue Integration in the Alphasphere Implant.

A 57-year-old healthy female underwent enucleation for choroidal melanoma with primary implantation of a 2-hydroxyethyl methacrylate sphere (AlphaSphere, Addition Technology, Des Plaines, IL). Her course was uneventful, with successful prosthetic fitting 6 weeks postoperatively. She returned 2 years later, with anterior displacement of the implant, poor implant movement, and poor prosthetic fit. There was no defect in the conjunctiva, Tenon's layer or evidence of inflammation. Successful orbital implant exchange was performed, replacing the AlphaSphere with an eyebank-scleral wrapped acrylic implant. Intraoperative findings revealed dissolution of the scaffolding aspect of the anterior implant, with loss of extraocular muscle attachments and no fibrovascular ingrowth. This case demonstrates late AlphaSphere failure in an otherwise unremarkable course; further review of similar cases or a larger study is warranted to examine the efficacy of this relatively new implant.

The Role of Surgeon Technique in Current Practice Patterns for Combined Ptosis and Dermatochalasis.

PURPOSE: The goal of this study is to identify and describe the role of surgical incision preference, insurance reimbursement, and geographical location on the current ptosis repair practice patterns of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members. METHODS: A 9-question survey was designed with surveymonkey.com and a participation link was emailed to all active ASOPRS members' email addresses in February 2015. After a reminder email, the survey was closed and the results were analyzed. There are 3 major questions the survey data is to be used answer: 1) Surgical approach preference: The first question established preferred surgical technique (internal vs. external approach) for ptosis repair. This result was/is used to stratify the remaining responses into 2 groups. 2) Functional versus cosmetic surgical indication: Three clinical scenarios were presented for a functional versus cosmetic patient for ptosis repair and blepharoplasty. 3) Location: The responses were analyzed based on location to determine any geographic bias for surgical preference. For this analysis, the US was separated into 4 regions (West, Midwest, North, and South), as defined by the United States Census Bureau; all international respondents were grouped together. RESULTS: Three hundred and ten responses were included and analyzed; 61% preferred the internal surgical approach, there was no statistical significance to geographic location (p = 0.17). Surgeons who prefer the external surgical approach (76.1%) were more likely than internal (62.5%) to include a bundled (nonreimbursed) blepharoplasty at no additional charge in the setting of functional ptosis repair (p = 0.015). Treatment plans differed significantly in both groups between functional and cosmetic patients with visually significant ptosis (Margin Reflex Distance < 1.5) and moderate dermatochalasis; with both the internal and external group electing combined surgery at a higher rate in cosmetic patients (p < 0.01 for functional vs. cosmetic within each group, and internal vs. external repair). There was no statistical difference in the timeframe for adjusting external ptosis for functional or cosmetic patients (p = 0.79). More surgeons use nonabsorbable closure for cosmetic blepharoplasty patients (68.7%) than for functional (54.1%) surgery patients (p < 0.01). CONCLUSION: Previous studies have documented the immediate effect of Medicare reimbursement changes on the management of concurrent ptosis and dermatochalasis. This study illustrates current practice patterns for ptosis repair and blepharoplasty. The necessity of creating a separate surgical site for surgeons who prefer the internal approach to ptosis surgery to perform a functional blepharoplasty has a significant influence on surgeon's willingness to perform concurrent blepharoplasty as a nonreimbursed bundled procedure.

Subjective and Objective Measures in the Treatment of Hemifacial Spasm With OnabotulinumtoxinA.

PURPOSE: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation (FaCE) Scale Instrument outcomes when treating hemifacial spasm (HFS) with onabotulinumtoxinA. METHODS: An Institutional Review Board-approved retrospective review of records of 66 HFS patients treated with onabotulinumtoxinA. SFGS and FaCE surveys were completed prior to onabotulinumtoxinA therapy and at 1 month follow up. Surveys were analyzed for differences using paired Student t tests, with statistical significance set at p < 0.05. Correlations were determined using Spearman correlation (rs), with coefficients of ≥0.40 or ≤-0.40 considered significant. RESULTS: There were 22 complete data sets. SFGS composite score improved from mean, 56.9 (SD, 12.3) to 63.6 (SD, 12.3), p < 0.01. SFGS subdomain synkinesis score significantly improved (p < 0.01). The FaCE scale subdomain oral function significantly worsened (p = 0.05). The Δ pre-/post-SFGS composite score did not correlate with the Δ pre-/post-FaCE composite score (rs = 0.24). There was a significant positive correlation between SFGS composite score and FaCE social function score (rs = 0.462, p = 0.03) and between SFGS voluntary movement score and FaCE social function score (rs = 0.477, p = 0.03). Subgroup analysis of single FaCE questions demonstrated no statistical change in subjective dry eye (p = 0.30). CONCLUSIONS: There was an improvement in social functioning in treated HFS patients, which positively correlated with improvement in overall objective voluntary facial movement. There was no statistical difference in subjective dry eye symptoms. The overall SFGS composite score improved following treatment of HFS with botulinum toxin. This information can be used when counseling expected outcomes in HFS patients treated with onabotulinumtoxinA.

Effect of upper eyelid myectomy on subsequent chemodenervation in the management of benign essential blepharospasm.

PURPOSE: Some patients with severe benign essential blepharospasm (BEB) become clinically refractory to chemodenervation with botulinum toxin. In these patients, surgical myectomy is an effective additive treatment for the management of this disabling condition. The purpose of this study is to determine how myectomy for BEB alters subsequent botulinum toxin administration. METHODS: A retrospective chart review of 27 patients undergoing surgical myectomy for the treatment of refractory BEB was conducted. The frequency and dosage of botulinum toxin were compared between preoperative and postoperative treatments. Paired Student t tests were used to determine significance (α = 0.05). RESULTS: The mean interval between botulinum treatments was 10.1 weeks preoperatively and 15.7 weeks postoperatively (p < 0.001). The mean quantity of botulinum toxin administered was 68 units prior to myectomy and 64.9 units postoperatively (p = 0.227). When comparing the quantity of botulinum toxin injected into the upper eyelid region only (site of myectomy), there was a significant decrease in the dose administered preoperatively and postoperatively (46.8 units vs. 39.9 units, p = 0.00310). CONCLUSIONS: Upper eyelid myectomy is an effective treatment modality for BEB in those patients who are refractory to botulinum toxin injections. Myectomy for BEB decreases the morbidity, botulinum toxin treatment frequency, and long-term expense associated with this disabling condition.

Subjective and objective outcome measures in the treatment of facial nerve synkinesis with onabotulinumtoxinA (Botox).

PURPOSE: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation Scale (FaCE Scale) instrument outcome measures pre- and 30-day posttreatment of facial nerve synkinesis with botulinum toxin with attempts to correlate the 2 scales. METHODS: An IRB approved retrospective review of 22 patients with facial nerve synkinesis where the surgeon completed the SFGS and the patient completed the FaCE prior to receiving onabotulinumtoxinA therapy, the SFGS, and FaCE scales were completed again 1 month later. RESULTS: Of the 22 patients, 9 complete datasets were analyzed. Mean patient age was 59.8; 8 (89%) women and 1 (11%) men. Overall SFGS composite score decreased from 57.6 ± 20.9 to 45.2 ± 13.5, (p = 0.001). SFGS subdomain synkinesis significantly improved (p < 0.001), while voluntary movement significantly decreased (p = 0.002). A difference in the resting symmetry was not statistically significant (p = 0.08). The FaCE scale composite score significantly improved from 40.9 ± 9.5 to 47.6 ± 11.9, (p = 0.03). FaCE subdomains facial comfort (p = 0.005) and social function (p = 0.009) significantly improved, while oral function, eye comfort, facial movement, and lacrimal control did not. The Δ pre/post-SFGS composite score did not correlate with the Δ pre/post-FaCE composite score (rs= -0.318). Subdomain analysis demonstrated significant negative correlation between Δ pre/post-SFGS synkinesis score and Δ pre/post-FaCE eye comfort score (rs = -0.826, p < 0.01). CONCLUSIONS: Significant improvement was seen in objectively reported synkinesis following botulinum toxin therapy. An improvement was noted in the overall subjective facial nerve functioning following therapy along with improvement in social functioning and facial comfort. A meaningful negative correlation was noted when comparing the SFGS "synkinesis" subdomain with the FaCE scale subdomain "eye comfort", implying improvement in eye comfort with control of synkinesis.

Simple Incisionless Temporary Stabilization: An Adjunct to Lower Blepharoplasty.

Background: Lateral canthal tightening is indicated for patients undergoing lower eyelid blepharoplasty who have preexisting lower eyelid laxity or ectropion. A canthoplasty or canthopexy is indicated at the time of lower blepharoplasty to avoid postoperative complications, such as eyelid retraction or ectropion. Various surgical techniques are described to accomplish this goal, including canthopexy procedures, which usually access the lateral canthal tendon through an upper eyelid blepharoplasty or lateral canthal incision. Objectives: To describe an incisionless technique adjunctive to lower blepharoplasty, which stabilizes the lower eyelid in the week following blepharoplasty. Methods: This operative technique description and retrospective case series includes 15 patients who underwent a simple incisionless temporary stabilization (SITS) during lower eyelid blepharoplasty. The procedures were performed at the same outpatient office-based surgery center and were performed by the author surgeons. Patients were followed from 3 to 6 months postoperatively. Results: The SITS procedure during lower eyelid blepharoplasty successfully maintained a desirable functional and aesthetic eyelid position with minimal complications. One patient reported tearing postoperatively which was determined to be unrelated to the SITS and resolved by the 1-month follow-up visit. No patient had any other complications during the follow-up period. Conclusions: The SITS procedure was successfully utilized in patients with mild-to-moderate lower eyelid laxity and/or a negative vector to prevent postoperative ectropion and eyelid retraction. It is a more favorable alternative to temporary tarsorrhaphy, as it does not obstruct vision during healing and better secures the eyelid. It should not be used in patients with significant lower eyelid laxity that would place the patient at significant risk of ectropion and lower eyelid retraction related to swelling and inappropriate eyelid position during the early postoperative course.

Divided nevus of the eyelid: review of embryology, pathology and treatment.

Divided nevus, which is also known as "kissing nevus," "split ocular nevus" and "panda nevus" is a rare congenital dermatological abnormality that occurs on opposing margins of upper and lower eyelids. There is a paucity of literature on this rare anomaly, with most knowledge from this disease process derived from isolated case reports and series. The purpose of this study is to report a new case of divided nevus of the eyelid and to discuss the unique embryology, pathology, and potential treatment options for this rare entity. A systematic review of literature was performed of the English literature on PubMed and Medline with just under 150 cases reported in the literature. The vast majority of the divided nevi seen in this review were medium sized and of the melanocytic intradermal type. There were no described cases of malignant transformation in any of the documented cases. Numerous methods for reconstruction were described including the entire reconstructive ladder with both one and two staged approaches. In this review, we present basic guidelines to the reconstruction of these complicated defects, although ultimate treatment should be individualized and dependent on surgeon comfort.

Medial conjunctival resection for tearing associated with conjunctivochalasis.

PURPOSE: Conjunctivochalasis is an age-dependent redundancy or laxity of the conjunctiva. It may result in epiphora (tearing) through mechanical disruption of the normal tear flow or exacerbate dry eye symptoms by disruption of an already unstable tear film. In this study, the authors performed a retrospective analysis of the benefits of a simple medial conjunctival resection for tearing associated with conjunctivochalasis. METHODS: A review of medical records identified 18 patients (25 eyes) who underwent a medial conjunctivoplasty for tearing between 2000 and 2012. The degree of epiphora was graded for each patient from 0 (no tearing) to 3 (persistent tearing requiring surgical correction). All patients were given an initial preoperative score of 3. Patients were excluded from the study if more than 1 eyelid procedure that would affect the lacrimal pump function was performed at the time of conjunctivoplasty or if clinically significant entropion, ectropion, or nasolacrimal duct obstruction was present at the time of conjunctivoplasty. RESULTS: At an average of 2.7 months post-conjunctivoplasty (range 4 weeks to 12 months), 80% of patients improved to a score of 2 or better and 60% improved to 1 or better. Six patients ultimately needed an additional surgical procedure for unresolved or recurrent tearing. CONCLUSIONS: The data suggest that conjunctivoplasty using a simple medial conjunctival resection is an effective treatment for patients with epiphora secondary to conjunctivochalasis.

Comparison of preferences between onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin) in the treatment of benign essential blepharospasm.

PURPOSE: To evaluate subjective outcomes and preferences in patients with benign essential blepharospasm (BEB) treated with both onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin). METHODS: An institutional review board approved retrospective review of 128 patients treated with onabotulinumtoxinA for BEB by 1 author (J.B.H.). Fifty of these patients were switched to incobotulinumtoxinA as an alternate drug. At scheduled follow up, patients decided to continue with incobotulinumtoxinA or switch to onabotulinumtoxinA. Patient preferences regarding treatment with onabotulinumtoxinA versus incobotulinumtoxinA were recorded. The preference groups were analyzed using unpaired Student t test, with statistical significance set at p < 0.05. RESULTS: Of the 50 incobotulinumtoxinA patients, the mean age was 64.9 years; 39 (78%) were women and 11 (22%) were men. In all, 26 (52%) preferred incobotulinumtoxinA and 24 (48%) preferred onabotulinumtoxinA. Most frequently, those who preferred incobotulinumtoxinA believed that it was "more effective" (N = 10, 29%), whereas those who preferred onabotulinumtoxinA concluded that it had a "longer duration" (N = 11, 37%). The mean treatment interval was 13.0 weeks (standard deviation [SD] = 6.39) in those who preferred onabotulinumtoxinA, whereas it was 10.2 weeks (SD = 2.15) in those who preferred incobotulinumtoxinA (p = 0.017). There was no statistical difference when comparing mean disease duration, number of total treatments, and number of units/treatment between the 2 preference groups. CONCLUSIONS: This study demonstrates that patients who prefer incobotulinumtoxinA over onabotulinumtoxinA had a statistically significant shorter treatment interval. In addition, those who preferred incobotulinumtoxinA thought it was more effective, whereas those patients who preferred onabotulinumtoxinA thought it had a longer duration. This information can be used when counseling both newly diagnosed and long-standing BEB patients regarding their therapeutic options.

Volumetric rejuvenation of the tear trough with repo and Ristow.

PURPOSE: The authors report the results of their approach for the treatment of the tear trough deformity, by lower eyelid blepharoplasty with fat repositioning and fat transfer to Ristow's space and the deep medial fat compartment. METHODS: One hundred fourteen eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer between 2010 and 2012. RESULTS: No major complications were observed in any of the patients in this series. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid-cheek junction noted by both patients and physicians. CONCLUSIONS: Despite the availability of multiple procedures, effacement of the tear trough region remains a challenge. The addition of fat transfer to Ristow's space and the deep medial fat compartment to traditional fat repositioning lower blepharoplasty are effective methods for volumizing the tear trough and may synergistically improve outcomes.

Anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic orbital volume augmentation.

OBJECTIVE: To describe the complication of anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic enophthalmos correction. METHODS: Retrospective case series of patients who experienced anterior filler displacement following orbital injection of calcium hydroxylapatite. Data includes patient demographics, indication for injection, route and volume of injection, description of postinjection complications, and final outcome. RESULTS: Four cases of anterior filler displacement and expansion following injection of calcium hydroxylapatite were identified. The patients' ages ranged from 33 to 64 years old. All 4 patients underwent multiple prior orbital surgeries and suffered from anophthalmic enophthalmos. Injectable calcium hydroxylapatite was delivered transcutaneously, to the deep extraconal orbital space, via 27-gauge, 1.25-inch retrobulbar needles. Each patient received an initial 1.3 ml of filler, with 1 patient receiving an additional 0.8 ml. Within 1 week, all patients experienced prominent, edematous lower eyelids. A CT scan of 1 patient radiographically documented anterior migration of the filler material. Two patients required transconjunctival excision of the filler and infiltrated orbital fat. Histopathologic examination of 1 specimen revealed chronic foreign body granulomatous inflammation. Two patients were treated medically, with resolution of clinical findings over 6 to 9 months. CONCLUSIONS: Anterior filler displacement is a potential complication of orbital volume augmentation with injectable calcium hydroxylapatite. Patients should be counseled regarding this possibility when considering options for the treatment of anophthalmic enophthalmos. A history of multiple prior orbital surgeries, with associated tissue disruption and scarring, may be a risk factor for filler displacement.