Faculty Bibliography

Blowout fractures of the orbit are common sequelae to blunt facial trauma. Many aspects of this injury have been studied, in particular, the timing of and indications for surgical intervention. Although diplopia is often an indication for surgery and is presented to patients as a potential postoperative complication, the incidence of diplopia after surgical repair of orbital blowout fractures has not been well studied. We retrospectively studied 54 patients who underwent repair of an orbital blowout fracture. A minimum of 6 months follow-up was available for all patients included in the study. A total of 47 of 54 (86%) patients had clinically significant diplopia preoperatively, and 20 of 54 (37%) remained diplopic. A total of 17 of 54 (31%) fractures involved the medial wall and orbital floor, and 13 of these 17 patients (86%) had postoperative diplopia. Patients with combined orbital floor and medial wall fractures appear to be at higher risk for clinically significant diplopia postoperatively than those with fractures of the orbital floor only. The explanation for this observation may be related to a greater difficulty in restoring the preoperative contour of orbits with combined fractures

The Fasanella-Servat procedure was initially used as a shortened, simplified operation for 2 to 3 mm of ptosis correction. Both then and now, this procedure is indicated in involutional ptosis and in patients with a good tear film function. Its main advantage over traditional ptosis surgery is that it is a truly adjustable procedure, allowing eyelid recontouring or lowering at 5 to 7 days after operating at the time of suture removal. In addition, no patient cooperation is required and surgery can be performed under general anesthesia or can be combined with more extensive surgical procedures that require deep sedation. The Fasanella-Servat procedure has been shown to use both a tarsectomy and advancement and reattachment of the levator aponeurosis. The ptosis correction achieved is independent of the amount of smooth muscle removed in the surgical specimen. During the postoperative interval, the surgeon has the advantage of waiting for edema to clear before readjustment and final contouring of the eyelid height is achieved at the first postoperative visit. This allows the surgeon to lower an eyelid if Hering's Law has created a contralateral ptosis or if the operated eyelid has less than a pleasing contour

This is the first known report of a relatively large postoperative pyogenic granuloma developing after a nonsutured transconjunctival blepharoplasty. Inflammation and separation or malapposition of the conjunctival wound edges probably permitted the lesion to proliferate in the inferior fornix. No foreign material could be implicated because no suture was used to close this incision. Additionally, Polydek suture material (braided polyester fiber) was associated with the complication of a suture tract and granuloma when used for a tarsal suspension procedure for ectropion repair in this patient

Cosmetic blepharoplasty is performed in various subspecialties, therefore articles appear in the ophthalmic, plastic surgical, otolaryngologic, and dermatologic literature. We review the past year's articles regarding evaluation, technique, adjunctive procedures, and complications. As the various techniques of upper-eyelid and lower-eyelid blepharoplasty have taken their place in the armamentarium of the aesthetic surgeon, attention has turned toward adjunctive procedures to enhance the surgical result

In an attempt to elucidate the mechanism whereby the Fasanella-Servat operation corrects ptosis, the authors examined the histopathologic features of 40 consecutive surgical specimens from 37 patients. Because all specimens contained tarsus, this tissue was graded into two groups according to vertical height: (1) minimal (30%) and (2) moderate (70%). Muller's smooth muscle was graded into four groups: (1) absent to negligible (42.5%); (2) minimal (45%); (3) moderate (10%); and (4) large (2.5%). Levator aponeurosis was absent, and conjunctive was present, in all resections. Accessory lacrimal gland tissue was present in 42.5% of cases and did not cause decreased tear production. Although 87.5% of cases had absent to minimal smooth muscle resections, these patients had equally successful results in comparison to patients with moderate to large amounts of smooth muscle resections. Based on these data, the authors have concluded that the effectiveness of the Fasanella-Servat operation does not depend on a Mullerectomy, but instead is probably due to a combination of other factors: (1) a vertical posterior lamellar shortening; (2) secondary contractile cicatrization of the wound; and (3) plication or advancement of the Muller's smooth muscle-levator aponeurosis complex on the tarsus

Various involutional eyelid changes, such as fine rhytids, dynamic laugh lines in the lateral canthal area, secondary malar bags, and dermal pigmentation are not effectively treated by a blepharoplasty. Preoperative discussions are important to ensure that adequate expectations are held. Too often, a patient is informed that fine rhytids and dermal pigmentation can be successfully treated with lid surgery alone. The importance of the preoperative interview in determining patient expectations cannot be minimized. Preoperative ophthalmic and periocular examination is essential to identify any pre-existing pathology. Even though the surgical approach is adapted to the individual needs of each patient, the most meticulous of surgeons is predetermined to encounter his or her share of complications. There is a fine line between a 'complication' and a common, but unwanted, sequela of surgery. Patients, overwhelmingly, do have some widening of their palpebral fissures, even following conservative surgery. Unfortunately, this occasionally creates ocular irritation or gross discomfort in allergic or borderline dry eyed patients. Lower eyelid bowing is so common even in the face of minimal skin resection that we do not consider it a 'complication' if it does not produce a functional problem. It is humbling for all surgeons to review their blepharoplasty problems and helpful to recognize that, statistically, we are all due to face these events eventually

The bowed lower eyelid, with scleral show, is a common but untoward result following blepharoplasty with even minimal skin excision. A number of conditions, unrecognized preoperatively, can predispose a patient to scleral show. These include eyelid laxity with or without atrophic orbicularis muscle tone, lax canthal tendons, hypoplastic malar eminences, unrecognized Graves' ophthalmopathy, unilateral high myopia, or the secondary blepharoplasty. Suspension of the tarsus of the lower eyelid, concomitant with or following blepharoplasty, can straighten bowed lids and provide 2 to 3 mm of elevation, if desired. A classification of patients likely to develop scleral show is presented along with a revised technique of tarsal suspension

Paralytic ectropion can be corrected with numerous procedures. Advocates of particular procedures have previously been unable to quote statistical rates of success for each procedure over significant lengths of time. This study reviews over 200 cases of paralytic ectropion, representing the spectrum of seventh nerve disease seen at an eye and ear specialty hospital and a general medical facility. Of all eyelid implantation devices 93 to 95% failed to work or needed reoperation by 3 years postoperatively. Soft tissue surgery without prosthetic implants or exoplants provided 60% success after a 3-year follow-up. Eyelid elevation or tightening coupled with surgery for facial reanimation produced a higher rate of success at 3 years (83%). An overwhelming number of patients (62%) complained of some degree of epiphora after any or all procedures. Based on these findings, soft tissue surgery without prosthetic implants or exoplants has a higher rate of success

Volkmann's ischemic contractures have long been recognized by orthopedic surgeons as a sequela of increased pressure within osseofascial muscle compartments. We present evidence that the same mechanism is a cause of fibrosis and contracture of extraocular muscles following orbital blowout fractures. Surgical treatment of a specific, recognizable type of blowout fracture is proposed