Generation of Filler Emboli as a Mechanism for Filler-Related Blindness.

BACKGROUND: Intra-arterial injection of fillers can lead to occlusion of the ophthalmic artery or its branches supplying the retina or the optic nerve. The mechanism through which this occurs is incompletely understood. We investigated the possibility of generating microparticles after injecting commercially available fillers into a flowing system in vitro. METHODS: Three hyaluronic acid fillers and one calcium hydroxylapatite filler were injected into an artificial saline flow system mimicking arterial systolic blood pressure and corresponding to the diameter of the facial artery. All the saline at the end of the tube was collected, centrifuged, and inspected for filler particles. RESULTS: After injection into the system, all fillers immediately disintegrated into small particles that were carried downstream with the flow of the saline. The saline at the end of the tube contained collections of filler. CONCLUSION: Hyaluronic acid and hydroxylapatite fillers break up into small particles immediately after injection into a flowing system, generating emboli rather than a column of filler. The results of this study lead us to hypothesize another potential mechanism leading to filler-related blindness.

Measurement of the Force Required by Blunt-Tipped Microcannulas to Perforate the Facial Artery.

PURPOSE: To measure the force required by blunt-tipped microcannulas of various sizes to penetrate the wall of the facial artery. METHODS: Twenty hemifaces of 10 fresh frozen cadavers were dissected to reveal the facial artery from its origin at the external carotid artery until the angular artery was found. On the right side of each cadaver, the facial artery was removed at the nasolabial fold, while arteries on the left were kept in situ, preserved with their fascial attachments. A force-sensitive resistor (Tekscan, Boston, MA, U.S.A.) was used to measure the force required by a syringe attached to 18G, 22G, 23G, 25G, and 27G blunt-tipped microcannulas, to pierce the proximal wall of the facial arteries on the left hemiface at the nasolabial fold. The facial arteries from each right hemiface were pierced by cannulas that were attached to a horizontally mounted microtensile load cell, which included a linear motor (Ibex Engineering, Newbury Park, CA). The force required to perforate the proximal wall of the facial arteries was calculated for each cannula. A 2-tailed t test was used to compare the forces measured by the force-sensitive resistor and the microtensile load cell. RESULTS: On force testing, the 18G and 22G cannulas were unable to penetrate the vessel wall in facial arteries that were both: removed from the cadavers and maintained in the cadavers. There was no statistically significant difference between the values obtained by the load motor and the force-sensitive resistor (p = 0.33). The force required to penetrate the proximal wall of the facial artery was: 0.72 kg to 0.81 kg for 23G, 0.43 kg to 0.54 kg for 25G, and 0.23 kg to 0.32 kg for 27G blunt-tipped microcannulas. There was a significant correlation between the gauge of the cannulas and the force required to penetrate the vessel walls (r = -0.970; p = <0.01). CONCLUSIONS: Blunt-tipped microcannulas smaller than 22G penetrate the facial artery with a low amount of force.

Minimally invasive periorbital rejuvenation.

Minimally invasive procedures have become increasingly popular over the last decade. In many cases, the use of neuromodulators and fillers has replaced surgical procedures. This article reviews the analysis and evaluation of the aesthetic patient presenting for periorbital rejuvenation. A layered approach is used, evaluating the skin, fat, muscle, and bone to determine which procedure is best suited for each patient. Volume enhancement with the use of fat and fillers and muscle manipulation with the use of neuromodulators are discussed. A brief summary of currently available skin-resurfacing techniques is also discussed.

Aesthetic lateral canthoplasty.

INTRODUCTION: To report our technique and experience in using a minimally invasive approach for aesthetic lateral canthoplasty. METHODS: Retrospective analysis of patients undergoing lateral canthoplasty through a minimally invasive, upper eyelid crease incision approach at Jules Stein Eye Institute by one surgeon (R.A.G.) between 2005 and 2008. Concomitant surgical procedures were recorded. Preoperative and postoperative photographs at the longest follow-up visit were analyzed and graded for functional and cosmetic outcomes. RESULTS: A total of 600 patients (1,050 eyelids) underwent successful lateral canthoplasty through a small incision in the upper eyelid crease to correct lower eyelid malposition (laxity, ectropion, entropion, retraction) and/or lateral canthal dystopia, encompassing 806 reconstructive and 244 cosmetic lateral canthoplasties. There were 260 males and 340 females, with mean age of 55 years old (range, 4-92 years old). Minimum follow-up time was 3 months (mean, 6 months; maximum, 6 years). Complications were rare and minor, including transient postoperative chemosis. Eighteen patients underwent reoperation in the following 2 years for recurrent lower eyelid malposition and/or lateral canthal deformity. CONCLUSIONS: Lateral canthoplasty through a minimally invasive upper eyelid crease incision and resuspension technique can effectively address lower eyelid laxity and/or dystopia, resulting in an aesthetic lateral canthus.

Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty.

Patients who have undergone upper blepharoplasty occasionally develop anterior lamellar insufficiency, which can result in lagophthalmos, corneal decompensation, and even blindness. Historically, skin grafts in the upper eyelid have been considered a last-resort procedure because of poor cosmetic outcomes. Poor cosmetic outcomes result from the traditional practice of placing the skin graft above the eyelid crease. This article describes a surgical technique for upper eyelid skin grafting in which the graft is placed in a supraciliary position. Presented are results of a retrospective study of 20 patients (31 eyelids) who underwent supraciliary upper eyelid skin grafting. The postoperative results were evaluated by examining the improvement in lagophthalmos, the improvement of keratopathy and comfort of the patient, and the cosmetic appearance of the graft. Upper eyelid skin grafting using this surgical technique is an effective and cosmetically acceptable method to improve corneal integrity and comfort in patients who have corneal exposure from insufficient anterior lamella after upper eyelid or eyebrow surgery.