Use of Hyaluronic Acid Gel in the Treatment of Lagophthalmos in Sunken Superior Sulcus Syndrome

Modern blepharoplasty: From bench to bedside

The demand for procedures aiming to rejuvenate the upper third part of the face and the periocular region has increased in the past several years. Blepharoplasty is one of the most frequently performed procedures worldwide to date. Surgery is currently the first choice in order to achieve permanent and effective results; however, it is burdened by potential surgical complications feared by patients. There is an increasing trend in individuals to request less invasive, non-surgical, effective, and safe procedures for eyelid treatment. The aim of this minireview is to present a brief overview of non-surgical blepharoplasty techniques that have been reported in the literature in the past 10 years. Numerous modern techniques that provide a rejuvenation of the entire area have been described. Numerous less invasive methods have been proposed in the current literature and in modern-day routine clinical settings. Dermal fillers are a commonly chosen option for providing enhanced aesthetic results, especially considering that volume loss can be one of the main underlying causes of facial and periorbital aging. Deoxycholic acid use may be considered when the problem is represented by periorbital excess fat deposits. The simultaneous excess and loss of elasticity of the skin can be assessed with techniques such as lasers and plasma exeresis. Furthermore, techniques such as platelet-rich plasma injections and the insertion of twisted polydioxanone threads are emerging as viable methods to rejuvenate the periorbital region.

Management of post enucleation socket syndrome patients - A retrospective study

The aim of this retrospective monocentric study was to report the outcomes following the correction of post enucleation socket syndrome (PESS) as well as the factors predicting for a multistep management. Patients were included, if they had received surgery to manage PESS. Demographics and patient history were collected. The symptoms of PESS were clinically rated by the same surgeon and ocularist, preoperatively and after each procedure. The surgery was considered as successful when no PESS clinical symptoms were observed. A prognostic study was performed to investigate the surgical outcomes. RESULTS: Thirty-six patients were included and eight of them had their PESS corrected after the first surgery. In the multivariate analysis (MVA), the deep upper lid sulcus symptom remained the main significant factor associated with an incomplete correction after the first surgery (OR 45.5, IC 95% (3.481-594.6), p = 0.004). For further corrections, the ptosis was the only significant prognostic factor requiring several surgeries (p = 0.005). At the end of the management, 94.4% of the patients had satisfying outcomes. CONCLUSIONS: The management of a PESS involves the correction of both the orbital cavity and the soft tissues. Although its correction is complex and time consuming in the majority of cases, the patients should be informed that the final cosmetic outcomes remain good at the expense of several surgeries.

Hyaluronic acid injections in post-enucleation or evisceration socket syndrome: a case series

Background

One of the primary goals of enucleation and evisceration surgery is the restoration of an adequate orbital volume through the use of appropriately sized alloplastic or autogenous tissues. In patients inadequately treated, post-enucleation or evisceration socket syndrome occurs. Fillers are an ideal alternative for eyelid and eyebrow arcade volume enhancement since their injection is easily performed in an outpatient setting avoiding several complications. The aim of this study is to report the use of hyaluronic acid (HA) fillers to treat volume deficits of the upper and lower eyelids, projecting the brow arcade and reducing the asymmetry.

Methods

Thirteen patients (2 male, 11 female, mean age 32.7 years) were treated from June 2012 to May 2020. Non-surgical treatment by HA filler injection for aesthetic rehabilitation of deep superior sulcus, inferior tear trough deformity, and scleral show was performed.

Results

No complications as orbital-ache and/or vasovagal response were reported during the injections. Minor complications such as light swelling at the site of injection, self-resolved within 2 days, were recorded. Stable results were observed at follow-ups. In two cases, two successive treatments were required at 3 and 6 years from the first injection.

Conclusions

Hyaluronic acid fillers offer a versatile and safe method for replacing soft tissue lost from the upper eyelid/brow complex in cases of post-enucleation or evisceration socket syndrome.

Level of evidence: Level IV, therapeutic study.

Periorbital Injection of Hyaluronic Acid Gel in Patients With Deep Superior Sulcus

PURPOSE

Hyaluronic acid gel (HAG) fillers provide a versatile and safe correction method for a sunken superior sulcus (SS) resulting from soft tissue volume loss occurring with aging, previous surgery, or enophthalmos related to trauma or phthisis bulbi. The purpose of this study was to report the long-term clinical outcomes of filler injection for soft-tissue augmentation in patients with a deep SS.

DESIGN

Retrospective, interventional case series METHODS:: The medical records of 27 patients (32 eyes) with deep superior sulci were reviewed. Twenty injections of hyaluronic acid fillers (Restylane; Q-med AB, Uppsala, Sweden) were performed in the retrobulbar (RB) area, and 15 injections were performed in the SS. Pre- and post-treatment photographs were taken.

MAIN OUTCOMES MEASURES

Visual acuity for seeing eyes, intraocular pressure, exophthalmos measurement, marginal reflex distance 1, interpalpebral fissure, tarsal platform show, and SS hollowing depth grade RESULTS:: Enophthalmos corrections were 1.3 ± 0.8 mm (P < 0.001) and the SS hollowing grade decrease was 1.2 ± 0.9 (P < 0.01) after 1 month of RB injection. Enophthalmos corrections were 0.1 ± 0.4 mm (P = 0.317) and the SS sunkeness grade decrease was 1.7 ± 0.8 (P < 0.001) after 1 month of SS injection. The amount of filler to correct enophthalmos of 1 mm was 0.83 ± 0.53 mL using the RB injection. Using Kaplan-Meier survival analysis, the mean period of maintenance for deep SS correction was 9.1 months for RB injections and 8.5 months for SS injections.

CONCLUSION

Retrobulbar (RB) hyaluronic acid gel (HAG) injections corrected enophthalmos and a deep SS, while SS injections corrected only a deep SS. These 2 techniques of RB and direct sulcus injection are safe and effective methods for the correction of a deep SS.

Free Orbital Fat Grafting During Upper Blepharoplasty in Asians to Prevent Multiple Upper Eyelid Folds and Sunken Upper Eyelids

BACKGROUND

Nowadays, a sharp, well-defined supratarsal fold and appropriate fullness of the upper eyelid tissue are considered important features of beautiful and youthful eyes. Individuals with thin upper eyelid tissue are at high risk of developing multiple upper eyelid folds and/or sunken appearance after upper blepharoplasty. Innovatively, the authors propose the application of free orbital fat grafting to the postorbicularis oculi space during upper blepharoplasty in order to achieve better aesthetic results.

METHODS

Fifty Chinese patients with congenital single eyelids combined with mildly sunken upper eyelid tissue were operated on between June 2017 and October 2018. During blepharoplasty, the lateral portion of the orbital septum was dissected, and appropriate lateral orbital fat was harvested. When the double-eyelid fold was formed and skin was interruptedly sutured, the harvested fat was divided into several pieces each side according to the sunken depth, and they were used to replace a layer on two-thirds of the central region of the supraseptal skin-muscle flap through the zipping gaps.

RESULTS

Forty-five patients underwent the follow-up interview for 6 to 18 months with a mean period of 10 months. The satisfaction rate was 82%. No significant asymmetry, irregularities, and sunken upper eyelid and multiple upper eyelid folds occurred.

CONCLUSION

The lateral orbital fat grafting to the central region of the supraseptal skin-muscle flap during upper blepharoplasty is an effective and simple method to correct or prevent multiple upper eyelid folds and/or sunken upper eyelid in Asians.

Anatomical and ultrasound-based injections for sunken upper eyelid correction

BACKGROUND

A needle or a cannula can be safely used during filler injection procedures to correct a sunken upper eyelid. To date, there are no precise injection points recommended that are based on an anatomical study.

OBJECTIVE

This study systematically investigated the vascular pattern and depth of forehead arteries at the periorbital area of upper eyelid.

METHODS

Twenty cadavers were dissected in this study. Additional data were obtained from 30 healthy volunteers using Doppler ultrasound imaging with high-frequency probe.

RESULTS

The ophthalmic artery divided into two opposite primary branches: the superior and inferior orbitoglabellar arteries running along the orbital rim. After the supratrochlear artery arose from the superior orbitoglabellar artery at the medial eyebrow, the supraorbital artery either divided from this artery near the supraorbital foramen or emerged as an individual artery from the supraorbital notch. The inferior orbitoglabellar artery gave off the radix artery superior to the medial canthal tendon. The radix artery divided into two opposite branches: the dorsal nasal artery going to the nose and the paracentral artery going to the glabella. Ultrasound imaging revealed a subcorrugator space that a cannula can safely pass through. At the supraorbital foramen/notch, the supraorbital artery traveled very close to the bone. Based on the anatomical data collected, the following injection points for a needle and a cannula technique are recommended.

CONCLUSION

Correction of a sunken upper eyelid is a dangerous procedure which should be performed only by experienced physicians. However, with precise anatomical knowledge and correct techniques, optimal outcomes can be safely achieved.

Use of hyaluronic acid gel filler to improve contact lens wear in patients with deep sunken superior sulcus

Purpose

Deep sunken superior sulcus of the upper eyelid can result from aging, genetic, prostaglandin use, and prior aggressive upper blepharoplasty. If severe, it can cause exposure keratopathy, lagophthalmos, and giant fornix syndrome. We herein report on another milder manifestation of deep superior sulcus and its treatments.

Methods

Case report.

Results

Deep sunken superior sulcus syndrome caused to soft contact lens displacement and wear intolerance and was treated with upper eyelid suclus hyaluronic acid gel injection.

Conclusions

Contact lens wear intolerance is likely more common in patients with deep sunken superior sulcus syndrome and can potentially be treated with superior sulcus hyaluronic acid gel injection.

Non-aesthetic indications for periocular hyaluronic acid filler treatment: a review

Dermal fillers have been in use for many years for aesthetic rejuvenation of the face. More recently, however, fillers have been increasingly used as an alternative to traditional surgical procedures for non-aesthetic indications. These indications include lagophthalmos, eyelid malpositions and orbital volume deficiency. The advantages of these filler injections are multiple: minimally invasive, repeatable, titratable and even reversible (depending on the product used). We review the current literature of functional uses of filler injections as mentioned above and evaluate the safety profile and efficacy of filler injections for this purpose.

Non-surgical treatment for eyelid retraction in thyroid eye disease (TED)

Thyroid eye disease (TED) is an autoimmune condition with an unpredictable course that may lead to permanent facial disfigurement. Eyelid retraction is one of the most common findings, and frequently demands attention due to ocular exposure and impaired cosmesis. Surgical treatment remains the most effective option, but there is a role for temporary corrections during the active phase of the disease, as well as in patients who are poor surgical candidates. The aim of this review is to describe the non-surgical modalities currently available for treatment of eyelid malposition in TED. The authors have focused on the use of hyaluronic acid, triamcinolone injections and botulinum toxin type A as non-surgical treatment alternatives, paying special attention to dosing, technique, efficacy and duration of effect. Non-surgical treatment modalities may represent viable in cases where surgical correction is not an option. Although temporary, these modalities appear to be beneficial for ocular exposure remediation, improving quality of life and broadening our therapeutic arsenal.