Upper Eyelid Blepharoplasty: A Novel Method to Predict and Improve Outcomes.

BACKGROUND: In some upper eyelid blepharoplasties, maximal skin removal may not result in desired outcomes; raising crease height can therefore be considered. Currently, there is no method to determine the amount of skin to be excised and/or crease elevation required to achieve a specific outcome. OBJECTIVE: This study extrapolated an equation to determine amount of skin excision and/or lid crease elevation needed to achieve a specific eyelid margin to fold distance (MFD). METHODS: This institutional review board-approved, HIPAA-compliant study was a prospective, nonrandomized clinical trial. Patients were included if aged 30 to 100 years old and underwent upper eyelid blepharoplasty with one surgeon between 2012 and 2014. Exclusion criteria were thyroid eye disease, myasthenia gravis, myotonic dystrophy, pregnancy, blepharoptosis, prior eyelid surgery or trauma, concurrent brow surgery, and topical alpha-agonists. The following data were collected preoperatively and at postoperative months 1 and 6: age, gender, BMI, brow position, MFD, margin to crease distance (distance between eyelid margin and crease, MCD), and vertical skin distance (distance between eyelid margin and brow, VSD). RESULTS: A total 322 eyelids of 164 patients underwent 208 skin excisions, 26 crease elevations, and 88 combined skin excision and crease elevation. Age, gender, and BMI category were all nonsignificant and excluded from the final model. This equation was extrapolated with regression analysis: Change in MFD = -0.40 + (-0.28 × Change VSD) + (0.53 × Change MCD) with |R| = 0.28. CONCLUSION: To better predict and obtain desired upper eyelid blepharoplasty outcomes, the authors created an equation.

Necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma: Necrotizing dacyocystometaplasia.

INTRODUCTION: Necrotizing sialometaplasia is thought to represent an inflammatory reaction directed against an ischemic insult or local trauma within a glandular tissue and is most commonly observed in the minor salivary glands of the oral mucosa. The importance of this condition arises from the fact that its clinical and histological aspects may raise issues of differential diagnosis with malignant neoplasms. The authors present a case of necrotizing sialometaplasia involving the lacrimal sac simulating a well-differentiated squamous cell carcinoma. CASE: A 52-year-old man presented with epiphora in the left eye after having sustained an orbital blowout fracture during a motor vehicle accident. During subsequent external dacryocystorhinostomy, an abnormal lacrimal sac mucosa was observed and analyzed histologically revealing a well-differentiated squamous cell carcinoma. However, the subsequent biopsies of the lacrimal sac were negative for malignancy; in view of these findings, two pathologists reviewed the first specimen and immunohistochemical staining was performed allowing us to arrive at a diagnosis of necrotizing sialometaplasia. We suggest the term necrotizing dacryocystometaplasia for the involvement at this site. CONCLUSION: Although exceedingly unusual, necrotizing dacryocystomeplasia should be considered in patients presenting with epiphora in the appropriate clinical context. Notably, this condition can be mistaken for a malignant disease, presenting a diagnostic challenge both clinically and histopathologically.

Aggressive glabellar angiomyxoma with orbital extension.

A 62-year-old male presented with a large non-tender mass in the glabella, extending into the right orbit that had been steadily growing for 6 months. Imaging revealed a 2.5 x 1.8 cm cystic mass with extension into the right anterior orbit. Biopsy with microscopic examination revealed a predominantly myxoid stroma containing spindle-shaped cells with bipolar cigar-shaped nuclei and small caliber capillary-type vascular proliferations. These findings are consistent with an angiomyxoma. Although angiomyxomas typically present in the pelvic region or peritoneum in female patients, there have been rare examples of angiomyxomas with orbital involvement.

A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma?

A 49-year-old woman, who had previously undergone bilateral Jones tube placement, began nasal continuous positive airway pressure for obstructive sleep apnea. The patient's use of continuous positive airway pressure was limited by intolerance of the transfer of air through the Jones tube to her ocular surface resulting in irritation and discomfort. A change from nasal continuous positive airway pressure to a full face mask, including both Jones tubes in the pressure circuit, resolved the problem.

A simplified marking technique for eyebrow reconstruction using composite grafts.

Eyebrows can be damaged in facial burns, trauma, skin cancer, herpes zoster and other conditions. Some of these patients will demand eyebrow reconstruction surgery. This can be done using free composite grafts from the scalp or flaps from the temporal area. Both techniques require time-consuming planning, marking and shaping of the graft or flap in order to achieve a good cosmetic result. In an attempt to make free graft reconstructions faster and easier, we modified the technique. We describe an easy way of obtaining a template that simplifies the procedure and enhances symmetry.

Fundamentals of facelift surgery.

A multitude of techniques exists for facelift surgery (rhytidectomy). These techniques range from simple skin undermining to complex procedures involving superficial musculoaponeurotic system (SMAS) manipulation and subperiosteal dissection. Most surgeons agree that some type of modification of the SMAS is necessary to achieve an acceptable result. The technique presented herein involves developing a relatively large skin flap, tightening the SMAS, and redraping the skin.

Eyelid sensation after supratarsal lid crease incision.

PURPOSE: To determine the severity and duration of the loss of eyelid sensation after upper eyelid crease incision. METHODS: This clinic-based case study was performed by analyzing observational measurements of patients undergoing upper blepharoplasty or ptosis surgery. Eighty-three eyelids of 50 patients were studied. A Cochet-Bonnet filament-type aesthesiometer was used to obtain all measurements. Preoperative and postoperative measurements were recorded at 1 week, 1 month, and final (2-6 months) time periods. Statistical analysis evaluated the degree and duration of the sensory loss and the extent of recovery during the evaluation period. Recovery of sensation was defined as a numerical reading within one point of baseline. RESULTS: The mean aesthesiometry reading was calculated at the preoperative (3.45), 1-week (1.20), 1-month (1.56), and final postoperative (2.56) periods. Paired t testing showed a decreased but significant difference in sensation measurement at each comparison. Recovery of sensation to within one point occurs at the preoperative to late time period comparison. All but 4 of the 68 eyelids tested at the 1-week postoperative time period had a measured loss of sensation. Of the 44 eyelids tested at the final time period, all but 1 had regained some or all of this sensory loss. CONCLUSIONS: Loss of skin sensation in the eyelid after upper eyelid crease incision blepharoplasty or blepharoptosis repair occurs in most patients and should be considered an expected outcome of the procedure. Partial to complete recovery of eyelid sensation over 2 to 6 months should also be expected, though in rare instances this does not occur.