Skin subdermal adhesion technique for upper blepharoplasty treatment for dermatochalasis

Aim

We developed a simple bipolar skin and subdermal hemostasis technique called the "Skin Subdermal Adhesion Technique" (SAT), which prevents postoperative complications and provides good cosmetic results.

Patients and Methods

We performed 40 ptosis surgeries in 20 patients using SAT. All patients underwent bilateral excision of the excess skin due to age-related upper eyelid skin laxity; patients with facial nerve palsy and those who underwent manipulation of the levator muscle were excluded. The maximum wound width of the defect after skin resection and diameter after SAT were measured. Additionally, the presence or absence of postoperative complications requiring additional surgeries or procedures was investigated.

Results

The mean (range) age was 76.0 (55-86) years. Among the bilateral resection widths, the diameter of the wider side was 11-20 mm (mean, 14.85±2.67 mm). In contrast, the defect width after SAT was 8-13 mm (mean, 9.75±1.84 mm). SAT reduced the maximum width by 34.3%. There were no cases of postoperative complications, such as wound hematoma formation or infection.

Conclusion

SAT is useful for treating upper eyelid skin defects because it does not require any special equipment, is quick to perform, reduces the risk of postoperative complications such as hematoma, and provides good cosmetic results.

Deciphering the Refined Musculature of the Brow Area in Asians by Micro-Computed Tomography

BACKGROUND

The brow area is an important aesthetic unit. Accurate anatomical understanding of the brow is important for clinical treatments related to this region. Due to the complexity of the brow area and limitations of methods, there are still some controversies regarding description of its musculature.

OBJECTIVES

In this article, we aimed to reveal the detailed brow musculature with micro-computed tomography (micro-CT) combined with histological staining.

METHODS

Eight fresh cadavers (16 hemifaces) were obtained. Eight hemifaces were processed with phosphotungstic acid contrast staining for micro-CT scanning and reconstruction. The corresponding other 8 hemifaces were prepared with Masson staining.

RESULTS

The orbicularis oculi muscle, frontalis muscle (FM), depressor supercilii, and procerus muscle were situated superficially. The FM terminated and connected with its antagonistic muscles at 2 to 5 mm above the brow but the fusion line descended in the lateral third. The corrugator supercilii muscle (CSM) originated from the periosteum, extending laterally and superficially. During its course, it mainly penetrated the FM. The CSM had broad subcutaneous insertion, covering about 77.9% ± 7.5% of the hairy brow. CSM fibers connected to the subcutaneous fiber septa to directly transmit contraction force. The soft tissue on the lateral side of the brow was looser than that on the medial side.

CONCLUSIONS

Our study deepens the understanding of the precise anatomy of the brow area and helps guide clinical practice.

Modified orbitofrontal approach for optic nerve sheath hemangioma: Illustrative case and literature review

Background

Optic nerve sheath hemangiomas (ONSHs) are rare vascular tumors from the blood vessels surrounding the optic nerve, accounting for <1% of optic tumors and 0.5% of vascular malformations. Although benign, their location near the optic nerve poses a risk of significant nerve damage and vision loss. Symptoms often include visual disturbances, eye pain, and strabismus, making it difficult to make a diagnosis. Advances in imaging, especially magnetic resonance imaging (MRI), have improved early detection and diagnosis. In addition, insights into the molecular mechanisms, including endothelial signaling and angiogenesis, have facilitated the development of more effective treatments, such as targeted therapies and minimally invasive surgical options.

Case Description

We present the case of a 57-year-old woman who experienced progressive left-eye swelling, increased tearing, and declining visual acuity. Imaging studies, including MRI and computed tomography scans, revealed a left intraconal mass suggestive of ONSH. A transcranial-modified orbitofrontal approach was employed for tumor resection due to its proximity to vital structures. Postoperative histopathology confirmed hemangioma. At 1-year follow-up, the patient exhibited significant improvement in visual function and resolution of orbital swelling.

Conclusion

This case highlights the critical role of surgical intervention in managing ONSHs that threaten visual function and cause mass effects. The transcranial-modified orbitofrontal approach proved effective in providing optimal access for safe tumor resection and improving visual outcomes. Integrating advanced imaging techniques and intraoperative monitoring contributes significantly to enhancing prognosis in ONSH cases.

Spontaneous Blinking Kinematics After Frontalis Muscle Flap Advancement

PURPOSE

To measure the spontaneous blinking metrics after blepharoptosis correction with frontalis muscle flap advancement.

METHODS

A video system was employed to measure the amplitude and velocity of spontaneous blinking of 24 eyelids after the frontalis muscle flap surgery for blepharoptosis correction. A control group with no eyelid disorders was also measured. The data of 13 eyelids who had frontalis slings with autogenous fascia, which were previously collected with the same method in another study, were used for comparison. Digital images were used to measure the superior margin reflex distance and the presence of lagophthalmos during a gentle closure of the palpebral fissure. Superficial keratitis was assessed by corneal biomicroscopy.

RESULTS

The mean amplitude of spontaneous blinking was 6.3 mm in controls, 2.6 mm in the frontalis flap patients, and 2.1 mm in the fascia sling group. The mean blink velocity was 133.8 mm/second in controls, 39.0 mm/second (3.7 standard error) after the frontalis flap, and 36.3 mm/second in patients with frontalis sling with fascia. For these 2 parameters, there was no statistical difference between the surgical groups, but a significant reduction when compared with the control group. No significant association was found between lagophthalmos and keratitis and the surgical procedure.

CONCLUSIONS

There is no difference between the blinking metrics of eyelids operated using the frontalis muscle flap advancement technique or frontalis sling with autogenous fascia. The presence of lagophthalmos and keratitis also does not differ between the 2 procedures.

Surgical treatment of orbital tumors in a single center: Analysis and results

BACKGROUND

Orbital tumors, arising within the bony orbit and its contents, present diverse challenges due to their varied origins and complex anatomical context. These tumors, classified as primary, secondary, or metastatic, are further subdivided into intraconal and extraconal based on their relationship with the muscle cone. This classification significantly influences surgical approach and management. This study highlights surgical experiences with orbital tumors, underscoring the importance of tailored surgical approaches based on the lesion's site and its proximity to the optic nerve.

METHODS

This retrospective study at the National Institute of Cancer's Head and Neck Department (2005-2014) analyzed 29 patients with orbital tumors treated with surgery, radiotherapy, chemotherapy, or combinations of them. Patient demographics, tumor characteristics, and treatment responses were evaluated using computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT imaging. Malignant tumors often required orbital exenteration and reconstruction, highlighting the study's commitment to advancing orbital tumor treatment.

RESULTS

29 patients (18 females and 11 males, age 18-88 years, mean 53.5 years) with orbital tumors exhibited symptoms such as decreased vision and exophthalmos. Tumors included primary lesions like choroidal melanoma and secondary types like epidermoid carcinoma. Treatments varied, involving a multidisciplinary team for surgical approaches like exenteration, with follow-up from 1 to 9 years. Radiotherapy and chemotherapy were used for specific cases.

CONCLUSION

Our study underscores the need for a multidisciplinary approach in treating orbital tumors, involving various surgical specialists and advanced technologies like neuronavigation for tailored treatment. The integration of surgery with radiotherapy and chemotherapy highlights the effectiveness of multidimensional treatment strategies.

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon

BACKGROUND

Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos.

METHODS

We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes.

RESULTS

Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment.

CONCLUSION

We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Isolated cavernous venous malformation of the eyelid

Cavernous hemangioma, currently known as "cavernous venous malformation," is a common, benign, non-infiltrative, slowly progressive vascular malformation of the orbit presenting in adults. We report the case of a 9-year-old girl who presented with a painless palpable mass over the right upper eyelid of 7 years' duration. A computed tomography scan of the orbits revealed a heterogeneously enhancing, well-circumscribed mass in the right upper eyelid with no orbital extension. A transcutaneous excisional biopsy with histopathology disclosed cavernous venous malformation. The majority of cavernous venous malformations are intraconal and present in the fourth to fifth decade of life.

Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis

BACKGROUND

The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and undercorrection. This article describes the authors' extended frontalis muscle advancement technique, which takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis.

METHODS

A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1, levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, and cosmetic result was performed at the last follow-up.

RESULTS

From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative margin reflex distance 1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0%) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7%) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2%) had an excellent or good cosmetic result.

CONCLUSIONS

Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, and minimizes undercorrection, residual lagophthalmos, eyelid contour abnormality, and eyebrow ptosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Clinicopathological Features and Management of Orbital Cholesterol Granuloma

PURPOSE

To investigate the clinical features, radiographic features, treatment strategies, pathological features, and prognosis of orbital cholesterol granuloma (CG).

METHODS

Twelve patients with orbital CG who were referred to Tianjin Eye Hospital between January 2002 and December 2020 were included in this retrospective case series study. Data collected including patient ophthalmic manifestations, imaging findings, treatment strategies, pathological features, and prognosis were retrospectively reviewed.

RESULTS

The patients comprised 10 males and 2 females. The mean age was 34.5 years (standard deviation [SD] = 8.9, median: 36 and range: 16-45 years). Four patients had a history of orbital trauma. The clinical manifestations at the first visit were proptosis (7/12, 58.3%), periorbital or eyelid swelling (6/12, 50%), limitation of eye movement (4/12, 33.3%), ptosis (2/12, 16.7%), and decreased visual acuity (1/12, 8.3%). Computed tomography (CT) showed a nonenhancing, well-circumscribed lesion in the orbit with extensive erosion of the adjacent frontal bone and temporal bone. Magnetic resonance imaging (MRI) showed a nonenhancing mass with intermediate-to-high signal intensity on T1- and T2-weighted images. Ten patients underwent lateral orbitotomy, and two patients underwent supraorbital orbitotomy. All patients had aggressive bone erosion. Histopathologic evaluation of the cyst contents and wall revealed cholesterol clefts, multinucleated giant cells, histiocytes, foamy macrophages, and altered blood pigments. The mean follow-up time of 79.6 months (SD = 49.8, range: 19-193 months). Three patients were lost to follow-up. No postoperative diminution of vision was noted, and no recurrence was observed.

CONCLUSIONS

CGs can present as superotemporal or temporal orbital lesions. The diagnosis can be established based on CT and MRI. Most of the patients can have no history of orbital trauma.

Commentary on "Primary orbital monophasic synovial sarcoma with calcification: A case report"

The present letter to the editor is related to the study titled "Primary orbital monophasic synovial sarcoma with calcification: A case report''. Orbital synovial sarcoma is one of the rare intraorbital masses seen in adult and pediatric populations. Some case reports in the literature revealed that synovial sarcoma may contain calcifications. Therefore, it is important to make differential diagnosis among calcified orbital masses in childhood.

Ptosis Correction: Our Modification and Experience

Background

Congenital ptosis not only results in an asymmetric facial appearance but can lead to permanent visual disturbances if not addressed at an appropriate time. Crawford used fascia lata for suspension of the eyelid to frontalis muscle, which remains a standard procedure for congenital ptosis correction to date, with an acceptable recurrence rate due to graft slippage. There are many modifications in this technique to reduce this complication; hence, in this study, we share our experience of a modification to improve the outcomes.

Methodology

This retrospective study was conducted at a private tertiary care hospital in Karachi for 10 years. In total, 26 patients fulfilled our inclusion criteria. All patients underwent a modified Crawford’s procedure under general anesthesia.

Results

In this study, the male-to-female ratio was 1:1.5. In total, 17 (65%) patients had unilateral ptosis. The mean age of presentation was 7 ± 3 years. All of our patients had poor levator function (<5 mm excursion) with a mean of 3 mm and mean grade of ptosis of 4 ± 1.6 mm. The mean preoperative marginal reflex distance (MRD) was +1.8 ± 0.6 mm. In this study, the patients had a mean postoperative MRD of 4.2 ± 0.7 mm at the four-week follow-up.

Conclusions

Although Crawford’s procedure gives promising results for ptosis correction, suturing the fascial sling to the tarsal plate ensures good anchorage and prevents relapse.