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Kreis AJ, Gower EW, Kropp M, Kello AB, Nouhoum G, Resnikoff S, Talero SL, Solomon AW. The prevention and management of postoperative trachomatous trichiasis: A systematic review. Surv Ophthalmol 2024; 69:93-102. [PMID: 36878359 DOI: 10.1016/j.survophthal.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
Among ocular infections, trachoma is the main cause of blindness. Repeated conjunctival Chlamydia trachomatis infections lead to trichiasis, corneal opacification, and visual impairment. Surgery is often needed to relieve discomfort and preserve vision; however, a high postoperative trachomatous trichiasis (PTT) rate has been observed in various settings. We wanted to know why, whether PTT rates could be reduced, and how to manage the PTT that occurs. We performed a search of the literature. Of 217 papers screened, 59 studies were identified for inclusion as potentially relevant, the majority having been excluded for not directly concerning PTT in humans. Preventing PTT is a major challenge. Only one published trial, the STAR trial in Ethiopia, has reported a cumulative PTT rate <10% one year after surgery. The literature on the management of PTT is sparse. Though no PTT management guidelines are available, high-quality surgery with a low rate of unfavorable outcomes for PTT patients is likely to require enhanced training of a smaller group of highly-skilled surgeons. Based on the surgical complexity and the authors' own experience, the pathway for patients suffering from PTT should be studied further for improvement.
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Affiliation(s)
- Andreas J Kreis
- Experimental Ophthalmology, University of Geneva, Geneva, Switzerland; Department of Ophthalmology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Emily W Gower
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Martina Kropp
- Experimental Ophthalmology, University of Geneva, Geneva, Switzerland; Department of Ophthalmology, University Hospitals of Geneva, Geneva, Switzerland
| | - Amir B Kello
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Guirou Nouhoum
- Techniques and Technologies of Bamako, Institut d'Ophtalmologie Tropicale d'Afrique, University of the Sciences, Bamako, Mali
| | - Serge Resnikoff
- Organisation pour la Prévention de la Cécité, Paris, France; School of Optometry & Vision Science (SOVS), University of New South Wales, Sydney, Australia
| | - Sandra L Talero
- Research Department of Development and Innovation, Superior School of Ophthalmology, Barraquer Institute of America, Bogotá, Colombia
| | - Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Balouch B, Ranjbar PA, Barna A, Marshall C, Eichorn D, Martha V, Tong J, Hawkshaw MJ, Sataloff RT. 5-Fluorouracil for Treatment of Vocal Fold Scar. J Voice 2023:S0892-1997(23)00127-3. [PMID: 37270334 DOI: 10.1016/j.jvoice.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Vocal fold (VF) scar can result from trauma, neoplasm, inflammatory processes, congenital causes, surgery and other etiologies. In general, once the vibratory margin of the VF has been scarred, it has not been possible to return VF function to normal; but often it can be improved. The drug 5-fluorouracil (5-FU) is a pyrimidine antimetabolic that has many clinical applications ranging from systemic chemotherapy to topical treatment of actinic keratosis and basal cell carcinoma of the skin. Local injection with 5-FU also has been used for hypertrophic scar and keloids. 5-FU was shown to have benefit in animal models of VF scar and subglottic stenosis. OBJECTIVES The present study aimed to evaluate the effect of 5-FU injection on VF vibratory function in patients with VF scar. Outcomes of 5-FU injection were compared to controls injected with dexamethasone. METHODS Adult voice center patients who had undergone VF injection with dexamethasone or a series of three 5-FU injections for treatment of VF scar were included in the study. Postoperative outcomes included percentage of subjects demonstrating improvement after injection, change in scar size, glottic closure, and VF stiffness, as well as digital image analysis measurements of mucosal wave. Outcomes were compared between subjects who received 5-FU and those who received dexamethasone. RESULTS There were 58 VFs injected with 5-FU and 58 historical controls injected with dexamethasone. Baseline subject characteristics and etiology of scar did not differ significantly between the 5-FU and dexamethasone cohorts, except that scar size was greater in the 5-FU group and mucosal wave was worse at baseline. After a series of three 5-FU injections, 61.22% improved, 8.16% demonstrated no change, and 30.61% worsened. In the dexamethasone cohort, 51.06% improved, 0.00% demonstrated no change, and 48.94% worsened. The response differed significantly between the 5-FU and dexamethasone cohorts, with a greater proportion of subjects who underwent 5-FU injection demonstrating improvement postoperatively. In the 5-FU cohort, 32.76% of subjects previously had undergone and failed dexamethasone injection for VF scar: and within that group 84.21% improved, 5.26% demonstrated no change, and 10.53% worsened following 5-FU injection. On digital image analysis, the percent improvement in postoperative mucosal wave was significantly greater in the 5-FU cohort compared to the dexamethasone group, which demonstrated a worsening of mucosal wave. CONCLUSIONS A series of three intralesional injections with 5-FU outperformed dexamethasone for improving mucosal wave in patients with VF scar. A prior failed trial of dexamethasone injection predicted a favorable response to 5-FU. Further research is encouraged to confirm or refute these findings.
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Affiliation(s)
- Bailey Balouch
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Alex Barna
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Camryn Marshall
- Florida Atlantic University College of Medicine, Boca Raton, Florida
| | - Daniel Eichorn
- Department of Otolaryngology - Facial Plastic Surgery and Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Vishnu Martha
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane Tong
- Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical Center, Baltimore Maryland
| | - Mary J Hawkshaw
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
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Wu W, Zhao Y, Chen Y, Zhong A. Comparing the Efficacy of Multiple Drugs Injection for the Treatment of Hypertrophic Scars and Keloid: A Network Meta-Analysis. Aesthetic Plast Surg 2023; 47:465-472. [PMID: 36536095 PMCID: PMC9945066 DOI: 10.1007/s00266-022-03163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is no consensus regarding the choice of injected drugs for pathological scars. Although the clinical efficacy of different drug treatments was shown in many randomized controlled trials, the efficacies of many drugs are inconsistent. Therefore, this study aimed to determine how different effective drugs are for treating pathological scars. It is anticipated that the study findings may serve as guidelines for plastic surgeons. METHODS Relevant literature was extracted from the following databases Cochrane Library, Embase, PubMed, Web of Science, CNKI, Weipu, and Wanfang until June 2022, such as randomized clinical trials (RCTs) evaluating different injected drugs for the treatment of pathological scars, including BTA, TAC, 5-Fu, VER, and BLE. RESULTS This network meta-analysis of 1539 patients from 23 articles revealed that the most effective treatment for a pathological scar was TAC + BTA. The effective rate of TAC + BTA combination therapy was significantly different from that of the BTA, TAC, 5-Fu, VER, and BLM monotherapies. TAC+5-FU was more effective than TAC, 5-FU, VER, or BLM alone, and BTA was more effective than both TAC and 5-Fu. The effectiveness of VER and BLM was the same, but both were better than TAC and 5-Fu. No big differences were found between any of the other local injection therapies. CONCLUSIONS According to this network meta-analysis, a combination of keloid and hypertrophic scar injection treatment is recommended, especially BTA+TAC. However, this network meta-analysis has some limitations and must be further verified by larger samples and higher quality RCTs. 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.
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Affiliation(s)
- Wenhao Wu
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 PR China
| | - Yang Zhao
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 PR China
| | - Yuxuan Chen
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 PR China
| | - Aimei Zhong
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 PR China
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Aoki M, Matsumoto NM, Dohi T, Kuwahawa H, Akaishi S, Okubo Y, Ogawa R, Yamamoto H, Takabe K. Direct Delivery of Apatite Nanoparticle-Encapsulated siRNA Targeting TIMP-1 for Intractable Abnormal Scars. MOLECULAR THERAPY. NUCLEIC ACIDS 2020; 22:50-61. [PMID: 32911344 PMCID: PMC7486579 DOI: 10.1016/j.omtn.2020.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/24/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022]
Abstract
Hypertrophic scars (HSs) and keloids are histologically characterized by excessive extracellular matrix (ECM) deposition. ECM deposition depends on the balance between matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteases (TIMPs). TIMP-1 has been linked to ECM degradation and is therefore a promising therapeutic strategy. In this study, we generated super carbonate apatite (sCA) nanoparticle-encapsulated TIMP-1 small interfering RNA (siRNA) (siTIMP1) preparations and examined the effect of local injections on mouse HSs and on ex vivo-cultured keloids. The sCA-siTIMP1 injections significantly reduced scar formation, scar cross-sectional areas, collagen densities, and collagen types I and III levels in the lesions. None of the mice died or exhibited abnormal endpoints. Apatite accumulation was not detected in the other organs. In an ex vivo keloid tissue culture system, sCA-siTIMP1 injections reduced the thickness and complexity of collagen bundles. Our results showed that topical sCA-siTIMP1 injections during mechanical stress-induced HS development reduced scar size. When keloids were injected three times with sCA-siTIMP1 during 6 days, keloidal collagen levels decreased substantially. Accordingly, sCA-siRNA delivery may be an effective approach for keloid treatment, and further investigations are needed to enable its practical use.
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Affiliation(s)
- Masayo Aoki
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo 113-8603, Japan; Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan.
| | - Noriko M Matsumoto
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | - Hiroaki Kuwahawa
- Department of Plastic and Reconstructive Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Satoshi Akaishi
- Department of Plastic and Reconstructive Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Yuri Okubo
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | - Rei Ogawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | | | - Kazuaki Takabe
- Division of Breast Surgery, Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA; Department of Surgery, University at Buffalo Jacob School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY, USA
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Oh BH, Oh Y, Nam KA, Roh MR, Chung KY. Application of secondary intention for the restoration of the apical triangle after Mohs micrographic surgery. J DERMATOL TREAT 2019; 32:418-423. [PMID: 31533495 DOI: 10.1080/09546634.2019.1666967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Restoring the apical triangle (AT) to maintain the symmetry of the face after Mohs micrographic surgery can be challenging. We have applied secondary intention (SI) after partial closure in cases with large defects. OBJECTIVE To compare the cosmetic results between immediate closure (IC) and SI. METHODS & MATERIALS We retrospectively reviewed 24 patients (IC group: n = 15, SI group: n = 9). To evaluate the symmetry, the comparative ratio (CR; area of the AT of the involved side/area of the normal contralateral side) was calculated. RESULTS The defects were significantly larger in the SI group than in the IC group (588.89 ± 346.53 mm2 vs. 252.87 ± 196.52 mm2, p < .01). While there was no statistically significant difference in average CR, the standard deviation was higher in the SI group (0.95 ± 0.08 vs. 0.93 ± 0.31, p = .3359), indicating the difficulty in predicting the results of SI healing. The average visual analog scale score evaluated by two dermatologists was higher in the IC group, albeit without a significant difference (8.23 ± 0.96 vs. 7.78 ± 1.52, p = .5267). CONCLUSION SI after partial closure can be an option for large defects in the AT area.
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Affiliation(s)
- Byung Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yeongjoo Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Ae Nam
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Ryung Roh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kee Yang Chung
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Peake M, Pan K, Rotatori RM, Powell H, Fowler L, James L, Dale E. Incorporation of 3D stereophotogrammetry as a reliable method for assessing scar volume in standard clinical practice. Burns 2019; 45:1614-1620. [PMID: 31208769 DOI: 10.1016/j.burns.2019.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 05/02/2019] [Accepted: 05/15/2019] [Indexed: 01/21/2023]
Abstract
Significant disfigurement and dysfunction is caused by hypertrophic scarring, a prevalent complication of burn wounds. A lack of objective tools in the assessment of scar parameters makes evaluation of scar treatment modalities difficult. 3D stereophotogrammetry, obtaining measurements from 3D photographs, represents a method to quantitate scar volume, and a 3D camera may have use in clinical practice. To validate this method, scar models were created and photographed with a 3D camera. Measurements from 3D image analysis of these scar models were compared to physical measurements of scar model volume. Reliability of 3D image analysis was assessed with both scar models and burn patient scars. Measurements of scar models by two independent observers were compared to determine inter-rater reliability, and measurements from 3D images of burn patient hypertrophic scars were compared to determine the consistency of the method between observers. The time taken for patient photography was recorded. No significant differences were found between the two methods of volume calculation (p = 0.89), and a plot of the differences showed agreement between the methods. The correlation coefficient between the two observers' measurements of scar model volume was 0.92, and the intra-class correlation coefficient for patient scar volume was 0.998, showing good reliability. The time required to capture 3D photographs ranged from 2 to 6 min per patient, showing the potential for this tool to be efficiently incorporated into clinical practice. 3D stereophotogrammetry is a valid method to reliably measure scar volume and may be used to objectively measure efficacy of scar treatment modalities to track scar development and resolution.
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Affiliation(s)
- Mitchell Peake
- Shriners Hospitals for Children, Cincinnati, United States; University of Cincinnati College of Medicine, United States
| | - Kristen Pan
- Shriners Hospitals for Children, Cincinnati, United States; University of Cincinnati College of Medicine, United States
| | - R Maxwell Rotatori
- Shriners Hospitals for Children, Cincinnati, United States; University of Cincinnati College of Medicine, United States
| | - Heather Powell
- The Ohio State University Wexner College of Medicine, United States
| | - Laura Fowler
- Shriners Hospitals for Children, Cincinnati, United States
| | - Laura James
- Shriners Hospitals for Children, Cincinnati, United States
| | - Elizabeth Dale
- Shriners Hospitals for Children, Cincinnati, United States; University of Cincinnati College of Medicine, United States; University of Cincinnati, Department of Plastic, Reconstructive, and Burn Surgery, United States.
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Riccio M, Marchesini A, Senesi L, Skrami E, Gesuita R, De Francesco F. Managing Pathologic Scars by Injecting Auto-Cross-linked Hyaluronic Acid: A Preliminary Prospective Clinical Study. Aesthetic Plast Surg 2019; 43:480-489. [PMID: 30627811 DOI: 10.1007/s00266-018-01303-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pathological scars are unattractive and may significantly impair the patient's quality of life. Current treatments provide inconsistent results, and none may be regarded as definitive. Recently, an auto-cross-linked hyaluronic acid (HA) formulation, IAL-SYSTEM ACP, featuring a long residence time and an enhanced safety profile, has been successfully used to prevent surgical adhesions, treat tendon lesions and rejuvenate the face and the décolletage. This study aims to preliminarily investigate whether IAL-SYSTEM ACP may also be effective in treating pathological scars resulting from burns, trauma or iatrogenic causes. METHODS Patients presenting one pathological scar were prospectively recruited and treated with two IAL-SYSTEM ACP injections carried out two weeks apart. Scar improvement was measured comparing the patient and observer scar assessment scale (POSAS) scores collected before treatment (T0) and 90 days after the second injection (T90) using nonparametric tests. The effect of age and scar type over score variation was investigated through quantile regression analysis. RESULTS Forty-one patients, 10 women and 31 men (median age, 34 years) were recruited. No patient dropped out, and no significant adverse event was observed. At T90, the median observer total score decreased by 11 units (- 77.5%) and the median patient total score decreased by 15 units (- 73.7%). The difference was significant (p < 0.001) in both cases. Traumatic injuries and young patient's age were the most significant predictors of a positive treatment outcome. CONCLUSIONS Treatment of pathological scars by two IAL-SYSTEM ACP injections, carried out two weeks apart, may provide significant clinical benefits. These findings should be the subject of further investigations. 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 .
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Affiliation(s)
- Michele Riccio
- SOD Chirurgia Ricostruttiva e Chirurgia della Mano (Department of Reconstructive Surgery and Hand Surgery), AOU "Ospedali Riuniti", Via Conca, 71, 60126, Ancona, Italy
| | - Andrea Marchesini
- SOD Chirurgia Ricostruttiva e Chirurgia della Mano (Department of Reconstructive Surgery and Hand Surgery), AOU "Ospedali Riuniti", Via Conca, 71, 60126, Ancona, Italy
| | - Letizia Senesi
- SOD Chirurgia Ricostruttiva e Chirurgia della Mano (Department of Reconstructive Surgery and Hand Surgery), AOU "Ospedali Riuniti", Via Conca, 71, 60126, Ancona, Italy
| | - Edlira Skrami
- Centre of Epidemiology, Biostatistics and Medical Information Technology, "Politecnica delle Marche" University, Ancona, Italy
| | - Rosaria Gesuita
- Centre of Epidemiology, Biostatistics and Medical Information Technology, "Politecnica delle Marche" University, Ancona, Italy
| | - Francesco De Francesco
- SOD Chirurgia Ricostruttiva e Chirurgia della Mano (Department of Reconstructive Surgery and Hand Surgery), AOU "Ospedali Riuniti", Via Conca, 71, 60126, Ancona, Italy.
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Funaro MG, King AN, Stern JN, Moldwin RM, Bahlani S. Endoscopic Injection of Low Dose Triamcinolone: A Simple, Minimally Invasive, and Effective Therapy for Interstitial Cystitis With Hunner Lesions. Urology 2018; 118:25-29. [DOI: 10.1016/j.urology.2018.03.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 11/29/2022]
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An Aesthetic Orbicularis Oculi Myectomy Technique for Blepharospasm: Use of Topical 5-Fluorouracil and Fibrin Sealant. Ophthalmic Plast Reconstr Surg 2017; 34:342-345. [PMID: 28863116 DOI: 10.1097/iop.0000000000000992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe a modified technique of orbicularis oculi myectomy for refractory blepharospasm. This technique includes removal of orbicularis muscle, reformation of the eyelid crease and pretarsal platform using fibrin sealant (Tisseel), and topical 5-fluorouracil to reduce scar formation and improve aesthetic outcome. METHODS Retrospective chart review of 7 patients who underwent bilateral orbicularis oculi myectomy with our technique from 2013 to 2016. Outcome measures were postoperative botulinum toxin dose, frequency, duration between treatments, the amount of lagophthalmos, severity of dry eye, and patient satisfaction with aesthetic and functional outcome. RESULTS Patients who underwent the aesthetic myectomy technique had significantly decreased botulinum toxin use with relief of symptoms postoperatively. Only 1 of 7 patients experienced mild dry eye symptoms postoperatively, managed with artificial tears. All patients were satisfied with the aesthetic and functional outcome. CONCLUSIONS The aesthetic myectomy technique provides effective treatment for blepharospasm with good functional and aesthetic outcome.
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