Faculty Bibliography

Floppy eyelids are usually asymmetrical, and more severe on the side the patient sleeps on. This has been related to the mechanical basis of this entity"™s pathophysiology. Patients who exhibit floppy eyelid syndrome (FES) tend to suffer from obstructive sleep apnea and other sleeping disorder such as snoring; therefore, their spouses are likely to be found sleeping facing away from them. In this study, we aim to assess this correlation between FES laterality and the spouse"™s sleeping side. 185 patients with floppy eyelid were assessed. Upper lids were pulled cephalad towards the orbital rim to assess which side everted and was more floppy. Based on the upper lid distraction test, a prediction was made to which side of the bed the spouse slept on. 185 patients with floppy eyelid syndrome were assessed, 160 male patients and 25 females, at an average age of 68. All 25 female patients, and 117 of the male patients, had spouses that slept in the same bed. Their side of sleep was predicted correctly in 87% of cases. The physician extrapolated the spouse slept on the opposite side facing away from the snoring spouse and was correct in 91% of cases. There is a high correlation between FES laterality and the patient"™s spouse"™s sleeping side. These data strengthen the mechanical etiology, and can also be used to confirm the worse-affected side in FES patients.

Non-invasive procedures targeting the submental fat or “double chin” have undergone a surge in popularity. Injections of deoxycholic acid, a secondary bile acid, have recently received FDA-approval for fat reduction in this area. With appropriate patient selection, this preparation of 10 mg/mL of sodium deoxycholate (Kybella®, Kythera Biopharmaceuticals, Westlake Village, CA) leads to aesthetic improvement of moderate-to-severe convexity or fullness associated with submental fat in adults.

BACKGROUND:Hyaluronic acid (HA) fillers have increased in popularity. Although complications are rare, knowledge regarding their prevention and management are crucial. The utility of preinjection aspiration has become controversial. OBJECTIVE:Our study investigated the utility of preinjection aspiration as a safety checkpoint for HA fillers through comparison of physiochemical and rheological properties in an in vitro model. MATERIALS AND METHODS:Whole blood was drawn from vacutainers using syringes containing 10 commonly used HA fillers. Each HA filler was examined with the plunger pulled back at volumes of 0.2 and 0.5 cc. The time required to visualize a flash was recorded. Data were compared using physiochemical and rheological properties, pullback volumes, and needle gauges. RESULTS:Using a multivariable regression model, HA concentration, elastic modulus (G'), viscous modulus (G″), and complex modulus (G*) had significant relationships with time to flash, whereas needle gauge and pullback volume did not. However, when comparing pullback volume using an appropriate paired analysis, 0.5 cc pullback volume had a significantly decreased mean time to flash than 0.2 cc. CONCLUSION:Preinjection aspiration may have utility as a safety checkpoint for HA fillers. Practitioners may have to adjust pullback volume and waiting time to visualize the flash based on physiochemical and rheological properties.

PURPOSE/OBJECTIVE:To report on the presentation, radiography, histology, and treatment of 8 cases of extranodal Rosai-Dorfman disease involving the orbit. METHODS:Multicenter retrospective case series. RESULTS:Five males and 3 females had a median age of 10 years (range 2-78 years). Presenting signs and symptoms included proptosis, periorbital pain, palpable mass, blepharoptosis, decreased vision, diplopia, impaired extraocular motility, and afferent pupillary defect. Four patients had bilateral orbital disease, while 4 had unilateral disease. Six cases were extraconal, 1 was intraconal, and 1 was both intra- and extra-conal. Four cases had only extranodal disease without lymphadenopathy (3 of which had localized orbital disease). Diagnosis was confirmed by exam, orbital, and/or systemic radiography, and biopsy in all cases. Treatment strategies included excision or debulking, systemic corticosteroids, chemotherapy, radiotherapy, observation or a combination thereof. At last follow up, 4 patients were disease free, while 4 had residual improved disease. CONCLUSIONS:Rosai-Dorfman disease of the orbit is a rare clinical entity. Purely extranodal disease is rare, with isolated orbital disease being exceedingly rare. This study is unique in that 4 of 8 patients had strictly isolated extranodal disease of the orbit. A large majority of the cases had disease in the extraconal space, contrasting with previous reports. In addition, lacrimal gland disease, particularly bilateral involvement, was prominent in the current study. Although there is no consensus on treatment, surgical excision should be attempted if plausible in symptomatic patients especially if the orbit represents a localized site of disease.

PURPOSE/OBJECTIVE:Laser resurfacing, performed at the same time as blepharoplasty, has most commonly been applied to the lower eyelid skin but can effectively be used on the upper eyelid to reduce rhytidosis and improve skin quality. The authors evaluate the safety and efficacy of this procedure. METHODS:Fractional CO2 laser resurfacing was performed in conjunction with incisional upper blepharoplasty. The ultrapulsed laser energy was applied to the sub-brow skin, the upper medial canthal skin, and the pretarsal skin in 30 patients. Photos were obtained preoperatively and at 3 months. RESULTS:All patients demonstrated reduction in upper eyelid rhytidosis without any serious complications. Independent rhytidosis grading (0-4) showed a mean improvement of 42%. One patient experienced wound dehiscence that satisfactorily resolved without intervention. CONCLUSIONS:Upper eyelid laser resurfacing is effective and can be safely performed at the same time as upper blepharoplasty. This approach reduces or eliminates the need for medial incisions to address medial canthal skin redundancy and rhytidosis and it directly treats upper eyelid wrinkles on residual eyelid and infra-brow skin during blepharoplasty.

PURPOSE/OBJECTIVE:To identify if isolated surgical violation of the orbital septum predisposes to "middle lamellar" scarring and subsequent postblepharoplasty lower eyelid retraction. METHODS:A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. RESULTS:Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. CONCLUSIONS:Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to "isolated" orbital septal scars (middle lamellar scars). Their designation as a "multilamellar scar" is more appropriate.

PURPOSE/OBJECTIVE:The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation. METHODS:This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation. RESULTS:Twenty-six female patients with a median age of 20.5 (range, 12-73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis. CONCLUSIONS:Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study's cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

PURPOSE OF REVIEW/OBJECTIVE:With any operation, the surgeon should be aware of predisposing factors that may lead to postoperative complications. Here we review the major factors due for consideration in both eyelid and refractive eye surgery, preoperatively and postoperatively, and consider the importance of timing to lessen the inherent risks of each procedure. RECENT FINDINGS/RESULTS:Refractive surgery can affect corneal sensation by ablating the corneal nerves and can cause serious corneal complications if followed by eyelid surgery. Studies find that patients undergoing eyelid surgery have a change in astigmatic error of as much as 1.0 D during the first 3 postoperative months. The longest reported follow-up period of astigmatic changes in adult patients following eyelid ptosis surgery is 1 year and a considerable number of patients had a change in cylinder of up to 0.3 D postoperatively. Blepharoplastic surgery is also reported to cause astigmatic changes postoperatively, significantly more if entire fat pads are removed. SUMMARY/CONCLUSIONS:To prevent corneal exposure, postrefractive eyelid surgery should be performed at least 6 months after lamellar ablative procedures and at least 3 months after surface ablative procedures. Refractive surgery revision may be necessary when astigmatic error occurs and should be carried out no earlier than 6 months postoperatively to allow for stabilization. Cosmetic blepharoplasty with fat pad debulking should be performed at least 6 months prior to refractive surgery to allow for any potential corneal astigmatic change to stabilize, for regained strength in the orbicularis, and for improved tear film distribution.