Cheeklift With and Without Posterior Lamellar Spacer Grafts for Treatment of Lower Eyelid Retraction.

BACKGROUND: To compare outcomes of lower eyelid retraction repair using a subperiosteal midface lifting technique with and without posterior lamellar grafts. METHODS: Charts of patients undergoing a sub-periosteal midface lift for treatment of lower eyelid retraction using 4 techniques for posterior lamellar reconstruction were reviewed. Thirty patients were included in each of the groups: midface with hard palate graft (HPG), midface lift with acellular cadaveric graft (ADG), midface lift with retractor disinsertion (RD) and midface lift alone (NG). Measurements of distance from pupil center to lower lid margin (MRD2) and from lateral limbus to lower lid margin (MRD2limbus) were taken from pre- and postoperative photographs and compared. Secondary outcomes included rates of reoperation, major and minor complications, resolution of symptoms and keratopathy. RESULTS: One hundred twenty operations were assessed (n = 30 for each surgical group). The average follow-up time was 20 weeks. The median MRD2 elevation was 0.95 mm (NG), 0.85 mm (HPG), 1.59 mm (ADG) and 1.02 mm (RD). The median MRD2limbus elevation was 1.06 mm (NG), 0.92 mm (HPG), 1.45 mm (ADG) and 1.12 mm (RD). There were no significant differences in MRD2 or MRD2limbus between the 4 groups (p = 0.06 and 0.29, respectively). Reoperation rates were highest with in the hard palate graft group (33%) compared to other techniques (p = 0.0006). CONCLUSIONS: Similar degrees of lower eyelid elevation were achieved with all the midface lifting techniques, and complication rates did not significantly differ between techniques. However, the higher reoperation rates with the use of spacer grafts suggest that a no-graft technique may be preferable. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reactivation After Teprotumumab Treatment for Active Thyroid Eye Disease.

PURPOSE: To determine the recurrence and reactivation rates after teprotumumab therapy for active thyroid eye disease. DESIGN: Retrospective consecutive case series. METHODS: This was a study of all patients followed for active thyroid eye disease at the Cole Eye Institute, Cleveland Clinic, treated with teprotumumab between May 2020 and May 2021. Patients with less than 6 months follow-up after completion of infusions were excluded. The primary outcome measure was reactivation, defined as a regression in proptosis (increase of ≥2 mm in either eye and to within ≤2 mm of pre-treatment level and Clinical Activity Score [CAS] worsening of 2 points or greater). Secondary outcome was diplopia response. RESULTS: A total of 21 patients were included in the study. The average long-term improvement in proptosis in the eye with more proptosis after teprotumumab was 1.57mm (range, -3 to 4 mm). Of the 17 initial responders, there were 8 reactivations (47%) and 2 isolated proptosis regressions (12%); Overall, 7 of 21 patients (33%) responded throughout the study period. Average time to regression was 12.25 months (range, 2-22.5 months). There was no statistically significant change in diplopia at final visit in any subgroup (P = 0.68 to >.99). CONCLUSIONS: At most, 33% of patients demonstrate continued response 2 years after teprotumumab treatment. The proptosis and CAS regression occurs in the setting of disease reactivation in 80% of regressions. Teprotumumab treatment appears to offer minimal long-term improvement in diplopia.

Metastatic gastric carcinoma to the eyelids masquerading as a chalazion: A case report.

Purpose: To describe an unusual case of metastatic gastric adenocarcinoma involving the eyelids and anterior orbit. Observations: An 82-year-old female with prior diagnosis of locally metastatic gastric adenocarcinoma developed eyelid edema. Initial ophthalmic assessment suggested presence of a chalazion that did not resolve with medical management. A few weeks after initial evaluation, the eyelid and facial edema worsened. Eyelid skin biopsy showed only inflammatory changes, but inflammatory work up was unrevealing and there was poor response to steroid therapy. Orbitotomy with biopsy ultimately revealed involvement of eyelid skin by a signet ring cell metastatic gastric carcinoma. Conclusions and importance: Eyelid and orbital metastasis from gastric adenocarcinoma may present mainly with inflammatory signs and symptoms masquerading as a chalazion. This case highlights the spectrum of presentation of this rare periocular metastasis.

Conjunctival Müllerectomy With or Without Tarsectomy Using Absorbable Versus Nonabsorbable Suture.

PURPOSE: To compare the outcomes of blepharoptosis repair using conjunctival Müllerectomy with or without tarsectomy (CM±T) using absorbable suture versus nonabsorbable suture. METHODS: Retrospective case-series of all consecutive cases of CM±T ptosis repair between January 1, 2019, and August 31, 2021. Patients were placed in groups based on whether they had absorbable or nonabsorbable suture used during their procedure. Preoperative and postoperative measurements of MRD1 were gathered in both groups, and information on patient satisfaction, symmetry, complications, and reoperations. RESULTS: Ninety-two patients had surgery using nonabsorbable suture and 96 patients had surgery using absorbable suture, with average age of 72.0 and 70.9 years, respectively ( p = 0.488). When comparing nonabsorbable to absorbable suture, the groups did not differ on average preoperative MRD1 (1.11 mm [±0.96] vs. 0.96 mm [±0.86]; p = 0.161), average postoperative MRD1 (3.18 mm [±0.54] vs. 3.20 mm (±0.51); p = 0.736) or average MRD1 improvement (2.09 mm (±0.86) vs. 2.25 mm (±0.79); p = 0.089). Goal MRD1 was achieved in 85.3% of nonabsorbable cases and 82.8% of absorbable cases ( p = 0.562) and the rate of reoperation between groups was not significant ( p = 0.63). Good postoperative symmetry was noted in 91.6% of nonabsorbable and 91.0% absorbable suture cases ( p = 0.83). No difference in the number of complications was noted between groups ( p = 0.88), including need for contact lens placement (2.7% nonabsorbable, 1.3% absorbable; p = 0.37). CONCLUSIONS: The use of absorbable suture was found to have predictable and effective outcomes similar to cases using nonabsorbable suture for CM±T without an increase in complications or rate or reoperation.

Direct Browlift.

Direct browlifting comprises various techniques to lift the brows using incisions on or around the brows. The classic direct browlift involves removing an ellipse of skin and subcutaneous tissue within or just above the brow cilia. However, the technique can be modified to address only lateral brow ptosis, to place the incision in the midforehead or the eyelid crease, and to place the incisions in different areas during bilateral surgery to attempt to improve symmetry. Careful attention to incision location, closure technique, and use of postoperative therapies can allow for nearly invisible scars in some cases.

Biplanar-pivoted V-Y Flap for Reconstruction of Medial Canthal Defects.

PURPOSE: To determine the safety and effectiveness of a biplanar-pivoted V-Y flap design in reconstructing medial canthal defects of all sizes. METHODS: Retrospective review of patients who underwent repair of medial canthal region defects with the biplanar-pivoted V-Y flap from January 2016 to May 2021. Variables collected included age, gender, surgical indication, defect sizes and location, flap(s) and/or graft(s) used, and follow-up time. Outcome measures included complications, patient satisfaction with cosmesis, ability to close the defect with minimal wound tension, and additional surgeries. RESULTS: Eighteen cases of medial canthal, nasal sidewall, and nasojugal fold area reconstruction were performed using a biplanar-pivoted V-Y flap in 18 patients. The cohort included 7 males and 11 females with a mean age of 72.4 years (range, 52-92 years) and mean follow-up time of 4.4 months (range, 1-14 months). Mean defect size was 2.0 × 1.4 cm (range, 0.5-5.5 cm). Eight patients received concomitant full-thickness skin grafts, five patients underwent simultaneous rotational flap repair, one patient underwent simultaneous nasoglabellar myocutaneous flap repair, and one patient received a simultaneous traditional, nonbiplanar V-Y plasty of the upper eyelid. All defects were closed with no wound tension. No cases of infection, hemorrhage, or wound dehiscence occurred during follow-up. Complications included mild ectropion (2 patients) and mild tip necrosis (1 patient). No patients elected for reoperation. No trapdoor deformity was observed. No patients underwent reoperation for local tumor recurrence. CONCLUSIONS: The extended mobility of the biplanar-pivoted V-Y flap provides excellent closure of defects involving the medial canthal region with minimal surgical complications.

Bilateral dysthyroid compressive optic neuropathy responsive to teprotumumab.

Thyroid eye disease is an auto-immune mediated orbitopathy which can cause dysthyroid compressive optic neuropathy. Traditional management of active thyroid eye disease includes temporizing high-dose steroids, orbital radiation and surgical decompression, which each possess significant limitations and/or side effects. Teprotumumab is an IGF-IR inhibitor recently FDA-approved for active thyroid eye disease. The authors report reversal of bilateral dysthyroid compressive optic neuropathy managed medically utilizing teprotumumab.

Treatment Options for Lower Eyelid Festoons.

Festoons represent a combination of fluid accumulation and soft tissue laxity in the superolateral cheek. They remain a difficult entity to treat. The ideal treatment for festoons would possess minimal invasiveness and recovery time, and predictably improve the condition. No nonsurgical treatment currently meets these criteria, and surgical treatments have significant limitations. Fortunately, a variety of treatment options exist that can benefit each patient and be tailored to their specific needs. Knowledge of the underlying anatomy, clinical characteristics, and clinical evaluation will better equip the treating physician to manage festoons.

Blindness After Filler Injection: Mechanism and Treatment.

Dermal fillers remain popular for facial rejuvenation but with its increasing use, the potential for more complications including blindness is present. This article focuses on the mechanism of filler-associated blindness, possible treatments, and future directions. Unfortunately, to date there is no proven treatment to reverse filler-induced blindness or visual compromise. It is essential for all injectors to discuss the potential ocular risks including blindness with their patients and obtain informed consent before filler injection.

Dimensions, Function and Applications of the Auricular Muscle in Facial Plastic Surgery.

PURPOSE: To determine the dimensions and function of the auricular muscle and to consider applications of this muscle in facial plastic surgery. METHODS: Nonpreserved fresh frozen human cadaver dissections from the (HOSPITAL-Blinded) Body Donation program were dissected. The length and width of the superior auricular muscle were measured. One surgeon performed all dissections and measurements. RESULTS: A total of seven left and five right hemifaces were studied. The average central height of the superior auricular muscle was 4.7 cm, and an average width was 5.0 cm. There was no significant difference between the average values of the left versus the right hemiface measurements. The muscle originated in the fibers of the galea and temporal fascia and inserted into the conchal cartilage in each specimen. Engaging the muscle in its line of action yielded slight elevation of the forehead and prevented movement of the galea along the vertex of the scalp. CONCLUSIONS: The auricular muscle acts as an occipitofrontalis stabilizer and a weak brow elevator. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .

Unilateral Ptosis, Proptosis, and Orbital Myositis After Shingles Vaccination.

Vaccinations for shingles are recommended for most adults over 60 years of age and are typically well tolerated. The present case describes acute onset of unilateral ptosis, proptosis, and orbital myositis developing within days after administration of shingles vaccination. The episode resolved to baseline after 1 week of treatment with steroids. To the authors' knowledge, this is first reported case of orbital inflammation following shingles vaccination. Given the temporal relationship and rapid response to treatment, this may represent an autoimmune reaction to the shingles vaccine.

Long-Term Patient Experience with Tetracycline Injections for Festoons.

BACKGROUND: The purpose of this study was to evaluate the long-term patient experience with tetracycline injections for treatment of festoons. METHODS: Charts of all patients undergoing tetracycline injection for treatment of lower eyelid festoons at the Cole Eye Institute, Cleveland Clinic, between 2008 and 2018 were identified using billing records. Patients were invited to participate in a questionnaire based on the FACE-Q checklist, a previously validated questionnaire for studying cosmetic procedure outcomes. Data from the questionnaire were summarized with size, mean, and frequency. RESULTS: One hundred two patients who received tetracycline injection during the study period were identified and 61 responses were obtained. The average follow-up time after injection was 3.6 years. Of 61 respondents, 36 (59 percent) noted improvement in their festoons after treatment, and 27 of 33 (82 percent) noted that improvement occurred within 2 months of treatment. Overall, 40 of 60 respondents (67 percent) would consider repeating tetracycline treatment. The most common adverse effects included discomfort (18 percent), swelling (15 percent), and bruising (13 percent). There was no statistically significant difference in questionnaire responses between men and women, except that men were more likely to consider repeated injection (92 percent versus 58 percent; p = 0.005). CONCLUSION: Tetracycline injection appears to improve festoons in a majority of patients, with an acceptable side-effect profile, although more data are needed to determine the optimal dose and frequency and to identify possible rare and/or significant side effects.