Alessandro Innocenti, Dario Melita
We read with great interest the article titled “Infraorbital groove correction by microfat injection after lower blepharoplasty” by Won Lee et al.
The authors described a new interesting technique, involving the use of autologous fat from periorbital compartments, for infraorbital groove correction after lower blepharoplasty, with the main advantage of correction the deep infraorbital groove and subsequently rejuvenating the lower eyelid area without the need for further fat tissue donor area.
Won Lee, Jin-Kwon Cho, Eun-Jung Yang
We thank Dr. Wen-Tsao Ho for an astute description of our study. As we described in our article, fat transposition and grafting are useful for filling the infraorbital groove. Fat pad sliding involves shifting the medial orbital fat normally excised in lower blepharoplasty, and naturally, central fat pad sliding can also be performed at the centre of the infraorbital groove. However, as we described in our article, fat pad sliding sometimes results in undercorrection. Infraorbital grooves are not always due to volume loss. They are also caused by different factors, such as skin thickness differences and orbicularis oculi muscle changes. Thus, fat pad sliding can only compensate for the volume of the layers below the muscles of the infraorbital groove, which can sometimes lead to insufficient results. Our method can fill the subcutaneous volume loss with fat; hence, it can be more effective than performing deep volumisation alone.
Kasturi Bhattacharjee, Divakant Misra, Manpreet Singh, Nilutparna Deori
Purpose: The aim of this study was to analyze the long-term changes in visual parameters, that is, contrast sensitivity (CS) and higher-order aberrations (HOAs), and corneal topography in the patients undergoing upper eyelid blepharoplasty (UEB) for dermatochalasis. Methods: This was a prospective, single surgeon, intervention study including patients (≥40 years age) having severe dermatochalasis with a minimum post-UEB follow-up of 12 months. The preoperative readings of CS (using Pelli–Robson chart), HOAs (using WaveLight ALLEGRO analyzer), and corneal topography (using topographic modeling system-4, Tomey corporation) were noted and compared at 3, 6, and 12 postoperative months. Results: We studied 30 patients (60 eyes) who underwent bilateral UEB. The majority of patients were females (n = 21,70%), and the mean age of patients was 56.53 ± 9.06 years. The preoperative and postoperative values of LogMAR visual acuity, log CS value, corneal topography measurements (K1, K2, cylinder value, and the axis), optical aberrations (total HOAs; third-order––trefoil & coma; four-order––spherical aberrations and secondary astigmatism, and tetrafoil) were compared. At 12 months, the mean CS value, the majority of HOAs, and corneal topography (only cylinder values) showed a stable, statistically significant difference in the postoperative period. Conclusion: The UEB may produce long-term, visually-beneficial, optical, and corneal changes. The patients undergoing cataract surgery aiming for spectacle independence may gain additional visual benefits with UEB.
Varajini Joganathan & Sabrina Shah-Desai
Visual loss from aesthetic hyaluronic acid filler injections is an under-reported complication. Our study surveyed British Oculoplastic consultants and Consultant members of the British Eye Emergency Care Society, on their awareness of visual vascular complications of dermal fillers and its emergency management.
A prospective survey of the members of the British Oculoplastic Society and the British Eye Emergency Society, using the Survey Monkey platform.
There were 53 responses. Eighty five percent of responders were aware of ophthalmic artery occlusion and visual loss as a recognised complication of hyaluronic acid based fillers. Six respondents had encountered at least one case of visual loss associated with HA fillers. Approximately 27% of the respondents had some experience of the recommended appropriate management of this complication. Majority of these practitioners did not have local management guidelines for this complication (88%) nor were they aware of guidance to manage the complication (75%).
This survey captures the current experience of British Ophthalmologists and Oculoplastic Surgeons in the management of visual vascular complication with dermal fillers. This may relate to the rarity of this complication. Although there is an awareness of visual loss as a complication from aesthetic dermal fillers, there appears to be a lack of knowledge of current management guidelines across Eye Specialists in UK. It is important for practitioners to be able to recognise and manage vascular compromise and further study recommendations are made.
Zhi Hong Toh,John Tsia-Chuen Kan,Chee Chew Yip
A young female patient developed left-sided headache, periorbital pain, and acute loss of vision within a few minutes after receiving left-sided nasal hyaluronic acid dermal fillers. Visual acuity of her left eye was no light perception, with a grade 4 relative afferent pupillary defect. Posterior segment examination revealed marked edema of the posterior pole with absence of cherry-red spot, suggestive of an iatrogenic ophthalmic artery occlusion. Multiple emboli (A, arrows) were seen within the central retina artery and branching arterioles. Fundus fluorescein angiography (B) showed delayed arm-retina time, absence of choroidal flush, and nonperfusion of central retina artery.
William Young, Stacy M Scofield-Kaplan, R Evan Levy, Zachary Keenum, Ronald Mancini
To evaluate the change in lateral canthal angle (LCA), inferior ocular surface exposed (IOSE), lower eyelid curvature, and margin-to-reflex distance 2 in those undergoing lower eyelid ectropion repair using a lateral tarsal strip technique.
This is an Institutional Review Board-approved retrospective analysis of patients undergoing lower eyelid ectropion repair. This study included all patients from 2012 to 2018 operated on by a single surgeon at the University of Texas Southwestern Medical Center. For each patient, LCA, IOSE, and eyelid curvature were measured on preoperative and postoperative photographs using NIH Image J photographic analysis. These measurements were compared using paired 1-tail t-tests for LCA and IOSE and paired 2-tail t-tests for eyelid curvature. This study was Health Insurance Portability and Accountability Act-compliant with protection of individually identifiable information.
Fifty-one patients with lower eyelid ectropion underwent lower eyelid ectropion repair using a lateral tarsal strip technique. Forty-three of the patients underwent a bilateral lower eyelid ectropion repair. There was no statistically significant difference in the LCA. There was a reduction in IOSE among both cohorts. The fourth degree polynomial trendlines generated to assess eyelid curvature demonstrated statistical significance, suggesting a flattening of eyelid curvature. margin-to-reflex distance 2 also had a statistically significant decrease postoperatively.
Lower eyelid ectropion repair using a lateral tarsal strip approach causes a reduction in IOSE, a more gradual lower eyelid curvature, and a decrease in margin-to-reflex distance 2 without causing a statistically significant change in LCA.
Ali Modarressi, Christophe Nizet, Tommaso Lombardi
Dermal fillers are widely used for facial rejuvenation and reconstruction and present fewer risks than surgical approaches. Nevertheless, several complications may occur, including nodule formation. A nodule is a clinical sign corresponding to different etiologies, such as overcorrection, infection, allergic reaction, or granuloma. However, their treatment represents a diagnostic challenge.
We present a retrospective review of 26 consecutive patients who underwent a biopsy for facial nodule formation more than 3 months after filler injections, to determine the diagnosis of the nodule and type of filler used. All patients were women (mean age, 57.8 years). Some patients suffered from different localizations: lip, 14 cases; nasolabial folds, 6; cheeks, 5; infraorbital region, 5; the glabella, 2; the temporal region, 1; and chin, 1 case. Only 5 (19.2%) patients knew the type of filler used, and in another 4 cases, the injector was able to provide some information. In 65.4% of cases, the filler type was unknown. Histopathological analysis revealed a “granulomatous” nodule in 30 sites and a “non-granulomatous” nodule in 4 cases. Concerning the type of filler, 5 different histopathological patterns were found.
Our results demonstrate that a clinical history and histopathological analysis whether to confirm or not to confirm the diagnosis of granuloma and to identify the type of filler are essential tools to achieve an accurate diagnosis of the problem-oriented treatment of nodules after dermal filler injections. We propose an algorithm for the management of nodules after filler injection.
Hyun-Hae Cho, Dae Joong Ma, Min Seong Kim, In Hwan Cho
A 51-year-old healthy woman who received facial hyaluronic acid filler injections in the glabellar region presented with no light perception (NLP) in her left eye the following week. The patient noted immediate loss of vision after several injections. At initial presentation, she had skin necrosis on the bridge of her nose and forehead. The intraocular pressure was 17 mmHg and a positive relative afferent pupillary defect was observed, with an otherwise unremarkable anterior segment. Fundoscopic examination revealed whitening of the retina, pale edematous disc, marked attenuation, and boxcarring of the retinal vessels, without a cherry-red spot. These findings were consistent with ophthalmic artery occlusion [Figure 1]a. Optical coherence tomography (OCT) showed profound loss of inner and outer retinal layers [Figure 1]b……….
Mohsen Bahmani Kashkouli, Behzad Khademi, Reza Erfanian-Salim, Bahram Eshraghi, Nasser Karimi & Meysam Maleki
To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.
Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.
Forehead and eyebrow PUs were observed on the first follow-up visit (16–72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2–14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.
Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.
Kasturi Bhattacharjee, Sripurna Ghosh, Shoaib Ugradar, Ariel M Azhdam
Of the two common techniques of lower blepharoplasty, the transconjunctival approach is limited to young patients with prominent herniation of lower fat pad without skin excess and the transcutaneous approach to patients requiring skin excision. However, the current trends not only highlight the traditional sculpting of the three orbital fat pads in lower lid blepharoplasty but also additional relocation of the intraorbital fats for correcting the inferior orbital hollowing. The purpose of this review is to analyze the published literature on common types, techniques, indications, and outcomes of the multiple surgical variants of lower lid blepharoplasty often aimed at treating the redundant skin, steatoblepharon, tear trough deformity, lid laxity, and dermatochalasis, thereby to correct the negative vector and inferior orbital hollowing along with effacement of the lid cheek junction. An extensive survey of peer-reviewed literature published in English in electronic databases, as well as bibliographies from cited articles, was conducted. Databases such as MEDLINE PubMed, the Cochrane Library, and Embase were scanned using relevant medical subject heading (MeSH) terms. Clinical studies with a minimum of five study cases were included. Level III evidence, case reports, letters, editorials, and case series with fewer than five eyes were excluded. This article provides a concise overview of available literature and as such no meta-analysis was done due to the narrowed scope of the involved studies and the variety in surgical approaches and techniques of lower lid blepharoplasty.