Ahmed S. Sufyan

Dry Eye Symptoms and Chemosis Following Blepharoplasty: A 10-Year Retrospective Review of 892 Cases in a Single-Surgeon Series

OBJECTIVES To determine the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis following upper or lower blepharoplasty. To examine the outcomes among long-term blepharoplasty data to better understand the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis, to evaluate the known risk factors for DES in the general population, and to analyze intraoperative procedures (such as forehead-lift, midface-lift, canthopexy, and canthoplasty) to determine their effects on DES and chemosis. METHODS A retrospective medical record review was performed among all the cases of upper or lower blepharoplasty performed by the senior author during a 10-year period (January 1999 through December 2009). A self-reported dry eye questionnaire was used to collect baseline and follow-up data. Patients with incomplete medical records, multiple (>1) revision procedures, less than 3 weeks of postoperative follow-up data, or a history of Sjögren syndrome, severe thyroid eye disease, histoplasmosis ocular infection, periocular trauma causing eyelid malposition, or radiotherapy for nasopharyngeal cancer were excluded from the study. Binary logistic regression analyses were performed to analyze the relationship between 13 preoperative and anatomical variables and DES or chemosis. χ2 Tests were performed to analyze the relationship between intraoperative risk factors and DES or chemosis. RESULTS In total, 892 cases met the study inclusion criteria. Dry eye symptoms and chemosis following blepharoplasty were reported in 26.5% and 26.3% of patients, respectively. The incidences of DES and chemosis were significantly higher in patients who underwent concurrent upper and lower blepharoplasty (P < .001) and in patients who underwent skin-muscle flap blepharoplasty (P = .001). Hormone therapy use and preoperative scleral show were associated with DES after blepharoplasty (P < .05). Male sex, preoperative eyelid laxity, and preoperative DES were associated with an increased incidence of chemosis following blepharoplasty (P < .05). Intraoperative canthopexy significantly increased the risk for developing chemosis (P = .009), and postoperative lagophthalmos significantly increased the risk for DES following blepharoplasty (P < .001). CONCLUSIONS Dry eye symptoms and chemosis are common following blepharoplasty, and the risk for developing these conditions may increase with intraoperative canthopexy, postoperative temporary lagophthalmos, concurrent upper and lower blepharoplasty, and transcutaneous approaches violating the orbicularis oculi muscle. Patients with a preoperative history of DES, eyelid laxity, scleral show, or hormone therapy use may be at greater risk for developing dry eyes or chemosis following surgery.

Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures

PURPOSE To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures. METHODS A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6-10 days, decision for surgical repair, and presence of diplopia were recorded. RESULTS Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07). CONCLUSION Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia.

Optimization of autologous muscle stem cell survival in the denervated hemilarynx.

Objective: Current treatments for vocal fold paralysis are suboptimal in that they fail to restore dynamic function. Autologous muscle stem cell (MSC) therapy is a promising potential therapy for vocal fold paralysis in that it can attenuate denervation‐induced muscle atrophy and provide a vehicle for delivery of neurotrophic factors, thereby potentially selectively guiding reinnervation. The goal of this project was to characterize optimal conditions for injected autologous MSC survival in the thyroarytenoid (TA) muscle following recurrent laryngeal nerve (RLN) injury by local administration of adjuvant factors.

Long-term analysis of surgical correction of the senile upper lip.

OBJECTIVE A quantitative comparison of immediate and long-term results of surgical correction of the senile upper lip using lip advancement and lip lift. METHODS Retrospective review of 30 patients who underwent senile upper lip repair, including lip advancement or lip lift. Digital image analysis was used to standardize each patients preoperative and postoperative photographs for accurate, objective comparison. RESULTS Lip lift and lip advancement achieve significant improvement in the appearance of the senile upper lip (P < .001). This improvement is sustained during many years (mean, 5 y; P < .001). Using repeated measures analysis of variance, no significant difference was found in the operative group compared with the control group when examining age-related change. CONCLUSION Lip advancement and lip lift can restore the senile upper lip to a more youthful and natural appearance with sustained long-term benefits.

The Effects of Alar Batten Grafts on Nasal Airway Obstruction and Nasal Steroid Use in Patients With Nasal Valve Collapse and Nasal Allergic Symptoms: A Prospective Study

IMPORTANCE Clinical management of nasal airway obstruction (NAO) in patients with and without nasal allergic symptoms and nasal valve collapse (NVC). OBJECTIVE To examine the impact that autologous alar batten grafts have on patients with NAO owing to NVC and their affect on nasal steroid use and allergic symptoms. DESIGN A prospective study. SETTING Indiana University Medical Center, Indianapolis. PARTICIPANTS Patients with NAO due to NVC with or without symptoms of nasal allergic symptoms. INTERVENTIONS All of the patients had placement of autologous batten grafts during the study period. STUDY SELECTION Prospective study of patients with dynamic NVC undergoing alar batten graft treatment. DATA EXTRACTION Nasal Obstruction Symptom Evaluation survey preoperatively and postoperatively, prospective outpatient questionnaire to determine use of nasal steroids and presence of nasal allergic symptoms preoperatively and postoperatively. RESULTS A total of 126 patients underwent surgical intervention for the treatment of NAO due to NVC. All of these patients were using nasal steroid sprays, and 78 patients (62%) also reported nasal allergic symptoms at their initial presentation. At 6-month and 1-year postoperative evaluations, 118 (94%) and 122 (97%), respectively, reported significant improvement of their NAO, regardless if they had presented with or without allergic nasal symptoms. Sixty-two of the 78 patients (79%) who initially presented with NAO owing to NVC and nasal allergic symptoms preoperatively reported significant improvement in their NAO and nasal allergic symptoms postoperatively. Eight of 126 (6%) restarted their use of nasal steroids postoperatively. All 8 of these patients reported nasal allergic symptoms preoperatively. No patients in the nonallergic group continued the use of nasal steroids postoperatively. There was no increase in nasal steroid use at the 12-month follow-up visit. CONCLUSIONS AND RELEVANCE Nasal airway obstruction due to NVC in patients can be surgically treated with autologous alar batten grafts. In addition, the use of alar batten grafts may improve NAO in patients with nasal allergic symptoms and reduces their use of nasal steroids. These results support the idea of potential surgical repair of the nasal valve to treat patients with NAO due to nasal allergic symptoms and NVC. LEVEL OF EVIDENCE 4.

The Alar-Spanning Suture: A Useful Tool in Rhinoplasty to Refine the Nasal Tip

The alar-spanning suture is a surgical technique used by an experienced rhinoplastic surgeon to address certain nasal tip deformities. Wide nasal tip deformities with strong, convex lower lateral cartilages are best indicated for treatment with this technique. The alar-spanning suture can improve lateral crural position and eliminate dead space by refining and narrowing the supratip, often without requiring extensive dissection or additional strut grafting. We use operative photographs and an intraoperative video to demonstrate the alar-spanning suture technique, which is a useful addition to the armamentarium of any rhinoplastic surgeon.

Single-Stage Repair of Paralytic Ectropion Using a Novel Modification of the Tarsoconjunctival Flap

Patients with facial paralysis present with a constellation of ocular manifestations. Ectropion resulting from downward displacement of the lower eyelid appears after loss of orbicularis tone and function.1 In addition, upper eyelid retraction, resulting in lagophthalmos and a decrease in tear production and/or proper tear distribution and channeling,may result in dry eyes and epiphora. Tear flow is impairedbecause of a dysfunctional orbicularis oculimuscle and a decrease in transportation of tears.2 Thegoalsof surgery forparalytic lowereyelidectropionand lagophthalmos are to preserve visual acuity, improve corneal exposure, reduce ocular complaints, and restore facial symmetry. Initial management would include the application of an ocular lubricant, use of a moisture chamber, or possibly temporary tarsorrhaphy.Whenparalysis is expected to persist, a more permanent procedure is needed. The use of a laterally based tarsoconjunctival flap combinedwith a standard lower eyelid ectropion repair allows for correction of the constellations of symptoms observed in patients with paralytic ectropion in a single-stage surgical procedure. The technique can be viewed in the Video.

Triangulation applied to facial nerve localization during parotidectomy--is math the answer?

OBJECTIVES To offer a novel framework that provides residents and practitioners with a reliable and surgically relevant method for identifying the facial nerve trunk (CNVII) after exiting the skull base during parotidectomy. METHODS The currently available literature and textbooks do not completely address the challenges trainees encounter in learning how to identify CNVII during parotidectomy. In response to this gap in the literature and potential associated deficits in surgical training, we developed an approach that integrates multiplanar intersections (based on mathematical principles) with surgical anatomy to create a reliable method for CNVII identification during parotidectomy. RESULTS The multiplanar intersections shown via our medical illustrations and surgical photography demonstrate the application of the triangulation concept to improve the accuracy and efficiency in surgical localization of CNVII. CONCLUSIONS The integration of multiplanar localization with surgical anatomy provides a reliable method for a surgeon to consistently and rapidly identify the CNVII, which inherently reduces the risk for inadvertent injury to the CNVII.

Posterior conjunctival plication to correct secondary ptosis after eyelid retraction repair in Graves disease.

PURPOSE To describe the results of posterior conjunctival plication for the treatment of secondary eyelid ptosis after eyelid retraction repair in Graves disease. METHODS Case series. All patients were evaluated preoperatively by routine eye examination and eyelid measurements including Margin Reflex Distance 1 and levator function. Two eyes of 2 patients who presented with ptosis following eyelid retraction repair were corrected with posterior conjunctival plication. RESULTS Posterior conjunctival plication for secondary ptosis following eyelid retraction repair was successful in 2 eyelids of 2 patients with Graves disease. Follow up period ranged from 6-10 months over which no sign of recurrent ptosis was observed. CONCLUSIONS Posterior conjunctival plication is an effective surgical technique for the correction of secondary ptosis following eyelid retraction repair in patients with Graves disease.

Nasal Batten Grafts: Are Patients Satisfied?

nNO and eNO between healthy individuals (34) and allergic rhinitis patients (35), and compared it with a variety of clinical features of allergic rhinitis. RESULTS: In healthy individuals, mean nNO was 27688 ppb, mean eNO was 33.024.0 ppb. In allergic rhinitis patients, both nNO(389119 ppb) and eNO(64.855.9 ppb) was statistically significantly higher than healthy individuals. Especially, eNO was statistically meaningfully related to rhinorrhea(p 0.038), sneezing (p 0.019), and sum of allergic symptom score (p 0.028), but nNO showed no statistical relationship. CONCLUSION: Allergic rhinitis patients had higher nNO and eNO than healthy individuals and particularly, eNO showed proportional change to severity of allergic symptoms. Clinical application of this method is believed to help diagnose allergic rhinitis and estimate the severity of allergic rhinitis.