Anatomical position of hyaluronic Acid gel following injection to the infraorbital hollows.

PURPOSE: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. METHODS: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. RESULTS: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. CONCLUSIONS: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Surgical microanatomy of the müller muscle-conjunctival resection ptosis procedure.

PURPOSE: To assess for alterations in the microscopic anatomy that occur as a result of the Müller muscle-conjunctival resection (MMCR) ptosis procedure and to better understand the mechanisms by which MMCR elevates the eyelid. METHODS: Sixteen orbits from 8 fresh frozen Caucasian cadaver heads, ranging from 38 to 100 years of age were used. For each head, MMCR was performed on one side. The contralateral, unoperated orbit served as an anatomic control. Each exenterated orbital contents and excised MMCR specimen was evaluated. The histopathology of the eyelids and MMCR specimens were studied microscopically by staining with hematoxylin-eosin, elastic, and Verhoeff-Masson trichrome. RESULTS: Müller muscle and conjunctiva were present in all 8 of the excised MMCR specimens. Elastic fibers consistent with Müller muscle tendon or among the smooth muscle fibers were seen within all excised MMCR specimens. The levator aponeurosis was intact in 8 of 8 operated eyelids; however, the aponeurosis was plicated in all. The accessory lacrimal gland tissues were intact in all of the operated and unoperated eyelids. CONCLUSIONS: MMCR works by shortening the posterior lamella, which results in advancement of the levator palpebrae superioris muscle and plication of the levator aponeurosis. Plication of the levator aponeurosis likely contributes to the increased volumetric effect seen clinically after MMCR. Phenylephrine testing can help in fine-tuning the amount of resection, but given the mechanism of action of MMCR, adequate levator muscle function remains a critical factor in the success of the surgery. Moreover, MMCR preserves accessory lacrimal gland tissues.

Tarsal dermoid cyst: clinical presentation and treatment.

The authors present 2 cases of eyelid dermoid cyst attached to tarsus in pediatric patients. Both patients were infants who presented with a firm, nontender upper eyelid mass firmly adherent to tarsus. In both cases, the lesion was excised en bloc, and histopathology revealed a dermoid cyst. To the authors' knowledge, there are no previously reported cases of tarsal dermoid cyst. These cases demonstrate the importance of including dermoid cyst in the differential diagnosis of a tarsus-based eyelid mass. Misdiagnosis may lead to incision and curettage, resulting in spillage of cyst contents and the risk of severe inflammation and scarring.

Eyelid eversion for visualisation of the upper eyelid lamellae: an anatomical cadaver study.

Controversy persists in surgical eyelid anatomy despite the routine use of microanatomical examination in modern eyelid research. The aim of our study was to facilitate visualisation of upper eyelid anatomy by optimising the orientation of cadaveric specimens. We studied the anatomy of everted eyelids, providing an excellent histological view of the posterior approach to the eyelid commonly used in surgery. Non-traumatic separation of the eyelid lamellae provides a new view of the eyelid's lamellar nature. Further application of this model may enhance understanding of the multilayered aspect of the levator aponeurosis. The technique may improve intraoperative understanding of critical eyelid anatomy and promote safer and more effective eyelid surgery.

Histologic comparison of autologous fat processing methods.

PURPOSE: To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation. METHODS: An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff-stained specimens was then performed. RESULTS: Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing. CONCLUSIONS: Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.

Acquired lax eyelid syndrome: an unrecognized cause of the chronically irritated eye.

PURPOSE: To describe the demographics, symptoms, and findings of acquired lax eyelid syndrome and to assess the efficacy of the 4-eyelid tarsal strip-periosteal flap technique to treat horizontally lax upper and lower eyelids. METHODS: A retrospective, case-series review of 80 patients (320 eyelids) evaluated from January 2000 to April 2004 for lax upper and lower eyelids causing chronic irritation was performed. Ten patients with diagnosed floppy eyelid syndrome or obstructive sleep apnea were excluded. Height and weight of all patients were recorded to calculate body mass index. Lateral tarsal strip fixation of all 4 eyelids to periosteal flaps based inside the orbital rim was performed to achieve horizontal tightening. Postoperative follow-up ranged up to 52 months. Preoperative/postoperative symptoms and examination findings of upper and lower eyelid distraction, keratopathy, and conjunctival inflammation were compared. RESULTS: The most common presenting symptoms were epiphora (85.7%) and irritation (80%). The most common examination findings were upper and lower eyelid horizontal laxity and palpebral conjunctival injection (100% patients). Thirteen of 70 patients (18.6%) were obese, based on body mass index; 26 of 70 patients (37.1%) were mildly overweight; 29 of 70 patients (41.4%) were normal weight; and 2 of 70 patients (2.9%) were underweight. After surgery, 91% of patients had improved or resolved symptoms and signs; 2.5% of dehiscences occurred with the use of the 4-eyelid technique. Gradual continued improvement was observed for up to 1 year. CONCLUSIONS: Evaluation of patients presenting with chronically irritated eyes should include distraction of both the upper and lower eyelids and examination for conjunctival inflammation. Acquired lax eyelid syndrome is similar to floppy eyelid syndrome; however, 43.3% of patients were normal weight or underweight. The 4-eyelid tarsal strip-periosteal flap fixation is a rapid and effective technique for correction of this syndrome.

The cynomolgus monkey eyelid as an anatomic model for oculoplastic surgery.

PURPOSE: To investigate the Cynomolgus monkey eyelid as an experimental model for oculoplastic surgery METHODS: Eyelid and periocular tissue were removed from Cynomolgus monkeys being euthanized. After fixation, the macroscopic and microscopic characteristics of the Cynomolgus monkey eyelid were studied. RESULTS: Macroscopic and microscopic characteristics of the Cynomolgus monkey eyelids were described. The Cynomolgus monkey eyelid bears resemblance to the human eyelid in its compartmentalization and complexity. CONCLUSIONS: The Cynomolgus monkey eyelid is a suitable experimental research model. Its compartmentalization resembles that of the human eyelid both microscopically and macroscopically.

Sebaceous carcinoma of the eyelids treated by mohs micrographic surgery: report of nine cases with review of the literature.

BACKGROUND: Ocular sebaceous carcinoma (SC) is a rare tumor of the eyelids. Clinically it frequently involves the upper lid in older women. Microscopically it tends to extend far beyond its assessed clinical margins. SC is characterized by a variety of tissue invasion mechanisms. It may spread by direct extension, be multifocal in advanced cases, and develop "skip areas" after trauma. Despite its ability to develop discontinuity, over the past two decades there have been several favorable case reports of SC treated by Mohs micrographic surgery (MMS). OBJECTIVE: To illustrate by case report the clinical presentation and management of patients with SC and to document our series of SC patients treated by MMS over the last 14 years. METHODS: A retrospective study was conducted of all cases of sebaceous carcinoma involving the ocular adnexa treated at the University of Wisconsin Mohs Surgery Clinic from 1987 to 2001. We also reviewed the accumulated medical literature of SC treated by MMS. RESULTS: In our series, there were nine cases of periocular SC. Five cases originated on the upper lid and four on the lower lid. Five of nine patients (55%) showed epithelial invasion. One patient developed a local recurrence 1.5 years later and was treated by orbital exenteration. This patient has had no evidence of disease for 5 years. Eight of nine patients (88%) had no evidence of local recurrence with a follow-up of 1-14 years. In our literature review we found 40 additional cases of orbital SC treated by MMS. Intraepithelial spread of SC was found in 50% of patients (24 of 48). Six patients developed local recurrence. The overall local cure rate following MMS is 87.8% (43 of 49), with a mean follow-up of 3.1 years. The regional metastatic rate was 8% (4 of 49). There were no deaths reported. CONCLUSION: We present nine new cases of SC. The age, sex, and site distribution are compatible with other SC cases reported in the literature. We reviewed the medical literature and compiled 49 cases of SC treated by Mohs surgery. Intraepithelial spread was discovered in 50% of the cases. Multifocal disease or discontinuity was present in 6% (3 of 49). Mohs surgery appears to be an effective method for excising the microscopic ramifications of primary SC. When feasible, we recommend in SC cases where intraepithelial pagetoid spread has been observed, that removal of another Mohs layer should be considered in order to provide an additional assurance layer against local tumor recurrence.

Eyelid lymphatics I: histochemical comparisons between the monkey and human.

PURPOSE: To study the lymphatic drainage of the cynomolgus monkey and human eyelid and periocular tissue by means of histochemistry. METHODS: Eyelid and periocular tissue from three cynomolgus monkeys undergoing sacrifice for glaucoma and retina research purposes and discarded tissue from a wedge resection of one human eyelid were used for histochemical analysis. Lymphatic capillaries were distinguished histochemically in monkey and human eyelids by light microscopy with a 5'-nucleotidase (5'-Nase) staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining. RESULTS: Histochemical analysis with 5'-nucleotidase revealed a subcutaneous and pretarsal lymphatic plexus in both the human and monkey. CONCLUSIONS: Histochemical results demonstrate similar lymphatic plexi in the monkey and human. Future studies will help to clarify the lymphatic drainage pathways of monkey and human eyelids.

Eyelid lymphatics II: a search for drainage patterns in the monkey and correlations with human lymphatics.

PURPOSE: To study the lymphatic drainage of the cynomolgus monkey through the use of lymphoscintigraphy. METHODS: Lymphoscintigraphy with 500 microCi of 99mTechnetium sulfur colloid injected at specific sites around the eyelids was performed with five cynomolgus monkeys in lateral and ventral positions. RESULTS: Lymphoscintigraphy of the monkey eyelid and periocular tissue revealed lymphatic drainage to the parotid lymph nodes from the entire upper eyelid, medial canthus, and lateral lower eyelid and drainage to the submandibular lymph nodes from the medial and central lower eyelid. In addition to draining to the parotid lymph nodes, the central upper eyelid was also seen to drain to the submandibular lymph nodes. CONCLUSIONS: Lymphoscintigraphy of the cynomolgus monkey eyelids reveals discrete lymphatic drainage pathways for the upper and lower eyelids and a dual pathway for the central upper eyelid. Future studies will help to clarify the lymphatic drainage pathways of human eyelids.