Treatment of prominent eyes with orbital rim onlay implants: four-year experience

3-D cephalometry of the the orbit regarding endocrine orbitopathy, exophthalmos, and sex

Purpose

This study aimed at evaluating the orbital anatomy of patients concerning the relevance of orbital anatomy in the etiology of EO (endocrine orbitopathy) and exophthalmos utilizing a novel approach regarding three-dimensional measurements. Furthermore, sexual dimorphism in orbital anatomy was analyzed.

Methods

Orbital anatomy of 123 Caucasian patients (52 with EO, 71 without EO) was examined using computed tomographic data and FAT software for 3-D cephalometry. Using 56 anatomical landmarks, 20 angles and 155 distances were measured. MEDAS software was used for performing connected and unconnected t-tests and Spearman´s rank correlation test to evaluate interrelations and differences.

Results

Orbital anatomy was highly symmetrical with a mean side difference of 0.3 mm for distances and 0.6° for angles. There was a small albeit statistically significant difference in 13 out of 155 distances in women and 1 in men concerning patients with and without EO. Two out of 12 angles showed a statistically significant difference between female patients with and without EO. Regarding sex, statistically significant differences occurred in 39 distances, orbit volume, orbit surface, and 2 angles. On average, measurements were larger in men. Concerning globe position within the orbit, larger distances to the orbital apex correlated with larger orbital dimensions whereas the sagittal position of the orbital rim defined Hertel values.

Conclusion

In this study, little difference in orbital anatomy between patients with and without EO was found. Concerning sex, orbital anatomy differed significantly with men presenting larger orbital dimensions. Regarding clinically measured exophthalmos, orbital aperture anatomy is an important factor which has to be considered in distinguishing between true exophthalmos with a larger distance between globe and orbital apex and pseudoexophthalmos were only the orbital rim is retruded. Thus, orbital anatomy may influence therapy regarding timing and surgical procedures as it affects exophthalmos.

Eyelid Reconstruction: An Algorithm Based on Defect Location

ABSTRACT

Eyelid reconstruction is a complex topic. This review looks at articles from 1990 to 2018 on eyelid reconstruction that had at least 10 patients and a mean 6 month follow-up. The authors present the results of our findings and propose an algorithm to guide the surgeon in choosing the best technique based on location, size, and lamella. Defects less than 1/3rd of the upper or lower eyelid may be closed primarily. Anterior and posterior lamella defects of the lower eyelid greater than 1/3rd in size should be reconstructed with a double mucosal and myocutaneous island flap. Those greater than 50% in size should be recreated with a Tripier flap for the anterior lamella and conchal chondroperichondral graft for the posterior lamella. For total lid reconstruction, a Fricke flap is best for the anterior lamella and the tarsoconjunctival free graft/lateral orbital rim periosteal flap is best for the posterior lamella. Full-thickness defects between 1/3rd and 2/3rd in size of the upper eyelid should be reconstructed with a myotarsocutaneous flap and those greater than 2/3rd should be reconstructed with a Cutler-Beard flap for the anterior lamella and auricular cartilage for the posterior lamella. For the medial canthal region, the island pedicle and horizontal cheek advancement flap is recommended for the anterior lamella and a composite upper lid graft for the posterior lamella. For the lateral canthal region, a bilobed flap is recommended for the anterior lamella and a periosteal flap for the posterior lamella.

The Prominent Eye-What to Watch Out For

Globe prominence (proptosis) may be caused by a variety of congenital or acquired conditions and poses unique challenges to aesthetic and reconstructive surgery. Once the underlying cause of proptosis is determined, a treatment plan consisting of surgical and medical procedures can be formed. Thyroid eye disease is the most common cause of proptosis and helps guide treatment options for proptosis. Although common eyelid and orbital procedures are used for proptosis correction, special care must be taken due to the unique difficulties of the distorted anatomy. Various surgical procedures and less invasive treatments can be combined to provide optimal aesthetic and functional results.

Expanding Role of Orbital Decompression in Aesthetic Surgery

Background

Eye prominence is a source of cosmetic "deformity" for many patients not afflicted by Graves.

Objectives

To report our experience in using customized orbital decompression for purely aesthetic reason to reduce eye prominence in non-thyroid patients.

Methods

Retrospective analysis of patients undergoing cosmetic orbital decompression by one surgeon. Surgical technique included customized graded orbital bony-wall decompression (lateral-wall, basin, medial-wall, posterior-strut) and intraconal fat removal using eyelid crease and/or caruncle incisions. Inclusion criteria included any patient with relative prominent eye due to non-thyroid etiology. Preoperative and postoperative photographs at longest follow-up were used for analysis. Outcome measures included patient satisfaction (via a written questionnaire) and complication rates.

Results

Etiologies of prominent eyes included congenital shallow orbits (14), congenital hypoplasia of malar-eminence (5), enlarged globe from high myopia (5), buphthalmos (1), and relative proptosis from contralateral enophthalmos (1). Concurrent procedures included lower eyelid-retractors lysis (5), periocular fat injection (3), tear-trough implant (3), canthoplasty (3), and periocular filler injection (3). Mean patient age was 33.8 years (range, 19-60 years). The average follow-up was 9 months (range, 6 months-4 years). All 26 patients (11 males, 15 females) had reduction in globe prominence. The mean reduction in axial globe position was 3.1 mm (range, 1.5-6.2 mm). Twenty-four of 26 patients were satisfied with the surgical outcome, with 2 patients complaining of sunken eyes. No case of permanent diplopia occurred.

Conclusions

Orbital decompression may be done for cosmetic purpose, effectively and safely, to reduce eye prominence in non-thyroid patients by an experienced orbital surgeon.

Level of Evidence

4.

Infraorbital Dark Circles: A Review of the Pathogenesis, Evaluation and Treatment

Infraorbital dark circles represent a common and multifactorial challenge in the world of aesthetic medicine and are the result of a variety of factors including deep facial anatomy, soft tissue changes, as well as contributions from the skin. A variety of treatment options exist, and a customised management strategy can be developed for the particular anatomic changes present. A literature search using MEDLINE and non-MEDLINE sources was performed utilising keywords including: ‘Dark circles’ ‘infraorbital dark circles’, ‘infraorbital pigment’, ‘under-eye circles’ and ‘lower eyelid bags’. A comprehensive review of the literature was performed and the data were assimilated with evidence from our practice. This review provides a detailed discussion of the aetiology, pathogenesis, evaluation and management of infraorbital dark circles. An understanding of the deep and superficial anatomy is crucial to the management of this complex entity. The armamentarium for treatment includes minimally invasive interventions such as makeup and cosmeceuticals, a variety of laser and chemical treatments, fillers and fat transfer, as well as more invasive surgical manoeuvres.

The transeyelid midface lift

The transeyelid approach to midface lift is an elegant approach for mild descent of malar soft tissue. The subciliary approach is the most commonly used and technically less challenging for surgeons experienced in facelift techniques. This technique in midface rejuvenation also has the advantage of ease of combining with other periocular and mid and upper face rejuvenation, such as blepharoplasty and forehead lift. Complication is rare with lid malposition, scaring, and temporary nerve function impairment being the most common.

Orbital decompression in thyroid eye disease

Though enlargement of the bony orbit by orbital decompression surgery has been known for about a century, surgical techniques vary all around the world mostly depending on the patient's clinical presentation but also on the institutional habits or the surgeon's skills. Ideally every surgical intervention should be tailored to the patient's specific needs. Therefore the aim of this paper is to review outcomes, hints, trends, and perspectives in orbital decompression surgery in thyroid eye disease regarding different surgical techniques.

Volumetric considerations for lower eyelid and midface rejuvenation

PURPOSE OF REVIEW

With the accepted understanding of volume loss as one of the main factors in facial aging, oculofacial surgeons are embracing the concept of 'removing' less and 'filling' more. The purpose of this review is to present an update of the different alternatives and techniques for lower eyelid and midface restoration/rejuvenation using filler agents.

RECENT FINDINGS

When a filler agent is chosen, the aim is to provide some lift, support and sculpting to the treated area. Nonpermanent or semi-permanent fillers are most widely accepted by physicians mainly because there is a lower possibility of complications. The involutional changes in the facial structures are a continuous process; this requires reassessment and variation in techniques in addition to choosing different products at different ages. Safety, support capability, ease of injection and cost are the factors to consider when choosing an injectable implant. But, physicochemical structure or rheological properties, such as viscosity and elasticity, enable the clinician to objectively select the most appropriate injectable implant depending on the specific anatomical area. An injectable with low viscosity may be ideal for lip enhancement wherein softness is required, whereas a higher viscosity filler or a harder filler may be better indicated for structure and support in the midface.

SUMMARY

Given the wide variety of filler materials available, clinicians and surgeons must be able to select products based on safety, lifting or sculpting capability and rheological properties, such as viscosity and elasticity. These factors provide an objective parameter of how the filler agent will perform in a specific area.

Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review

PURPOSE OF REVIEW

To review the literature related to thyroid-associated orbitopathy and to emphasize recent developments in its pathophysiology, diagnosis, and therapy. Current therapeutic trends and controversies are discussed.

RECENT FINDINGS

Expression of thyroid stimulating hormone receptor is highest in the fat and connective tissue of patients with thyroid-associated orbitopathy, where fibroblasts have the potential for adipogenesis. Electrophysiology can now detect subclinical optic neuropathy, and somatostatin-receptor scintigraphy can help justify immunomodulation. Other than steroids, radiotherapy can control inflammation, but its use is controversial. Current trends in orbital decompression are to camouflage incisions and to limit strabismus with balanced decompression, deep lateral wall techniques, fat removal, and onlay implants. Proptosis reductions of 0.9 to 12.5mm are possible by the use of various algorithms. Before or after decompression, botulinum toxin can correct strabismus, intraocular pressure elevation, and retraction. The latter is now also treated with full-thickness blepharotomy.

SUMMARY

As knowledge of the pathophysiology of thyroid-associated orbitopathy grows, there is a slow movement from nonspecific and invasive measures to more directed treatments causing less morbidity.