Allan E. Wulc

Botulinum toxin type a for dysthyroid upper eyelid retraction.

Purpose:To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition.Methods:In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction cau

Computed Tomography in Lacrimal Outflow Obstruction

BACKGROUNDnAcquired nasolacrimal duct obstruction is a common ophthalmologic problem. Despite widespread understanding of treatments available for nasolacrimal duct obstruction, few authors have commented on its etiology. Because the nasolacrimal system is anatomically related to important nasal and sinus structures, the authors postulated that acquired nasolacrimal duct obstruction and its complications might occur simultaneous to, and possibly as a consequence of, rhinologic or sinus disease.nnnMATERIALS AND METHODSnTwenty-three patients with acquired nasolacrimal duct obstruction and 100 control patients were evaluated by coronal computed tomography for evidence of sinus disease or nasal abnormalities. Specifically, five findings were noted: ostiomeatal complex disease, ethmoidal opacification, agger nasi cell opacification, concha bullosa, and nasal septal deviation.nnnRESULTSnOverall, 20 (87%) patients with acquired nasolacrimal duct obstruction demonstrated one or more radiologic finding of sinus disease or rhinologic abnormality whereas 63 (63%) control subjects exhibited these findings. This difference was determined to be statistically significant (P < 0.05). A statistically significant higher incidence of ethmoidal opacification, agger nasi cell opacification, and nasal septal deviation was observed in patients with nasolacrimal outflow obstruction than in controls. Differences in the incidence of ostiomeatal complex disease and concha bullosa were not found to be statistically significant.nnnCONCLUSIONnThese data demonstrate a correlation between computed tomography findings of sinus disease or nasal abnormality and the presence of acquired nasolacrimal outflow obstruction. This association between radiologic evidence of sinorhinologic disorders and lacrimal outflow obstruction may imply that dacryocystitis, like sinus disease, may be produced by disease of the lateral nasal wall. When evaluating a patient with acquired nasolacrimal duct obstruction, the physician should consider evaluation for concomitant nasal and sinus disease.

Lateral Wall Advancement in Orbital Decompression

Treatment of dysthyroid orbitopathy can be enhanced with a modified craniofacial approach using a lateral wall osteotomy, and anterolateral advancement and osteosynthesis in conjunction with medial and inferior wall orbital decompression. The technique of lateral wall advancement is described, and the results are discussed. While the authors advocate orbital decompression for dysthyroid optic neuropathy, advancement of the lateral orbital wall can easily be performed as an adjunct to the two- or three-wall decompression procedure. Advancement appears to increase the overall decompressive effect by providing a potential space where lateral expansion can occur and by enlarging the bony orbital volume. It also appears to lessen lid retraction and facilitates (and in some cases, obviates) the need for further lid retraction surgery.

Fibrin sealant for Müller muscle-conjunctiva resection ptosis repair.

Purpose: To determine the safety and efficacy of fibrin sealant for use in Müller muscle–conjunctiva resection ptosis repair. Methods: This was a retrospective review of a consecutive case series. All patients underwent Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure. Surgery was performed in a manner similar to a previously described technique, using fibrin tissue sealant rather that suture for wound closure. Postoperative symmetry was defined as MRD1 of each eyelid within 0.5 mm. Results: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure was performed on 53 eyelids of 33 patients. There were 27 female patients and 6 male patients. Twenty patients underwent bilateral ptosis repair and 13 patients underwent unilateral ptosis repair. Average follow-up was 17 weeks (range, 3 to 45 weeks). Mean preoperative MRD1 was 1.22 mm (range, –1.5 to 2.5 mm) in the right upper eyelid and 1.50 mm (range, 0 to 2 mm) in the left upper eyelid. Mean postoperative MRD1 was 3.11 mm (range, 2 to 4.5 mm) in the right upper eyelid and 3.12 mm (range, 1 to 4.5 mm) in the left upper eyelid. Postoperative symmetry was found in 32 of 33 patients (97%). We found no evidence of keratopathy or other complications attributable to the fibrin sealant. Conclusions: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.

Cosmetic Microdroplet Botulinum Toxin A Forehead Lift: A New Treatment Paradigm.

Purpose:To investigate the safety and efficacy of a microdroplet, cosmetic, periocular botulinum toxin A method that extensively treats the eyebrow depressors but leaves the brow elevators untreated. Methods:This is a 5-year retrospective, consecutive, nonrandomized series of botulinum toxin treatments. The study was reviewed by an institutional review board and complied with the Health Insurance Portability and Accountability Act (HIPAA). Patients were treated with 33u2009U onabotulinum toxin (BOTOX, Allergan, Inc., Irvine, CA, U.S.A.) injected in microdroplets of 10 to 20 &mgr;l. Sixty to 100 injections of microdroplets were needed to complete a treatment pattern concentrated at the brow, glabella, and crows feet area. The forehead was not treated. Patients who returned between 10 and 45 days were studied with image analysis. Results:There were 563 consecutive microdroplet treatments on 227 unique patients (female, n = 175, mean age 46u2009±u20094 years; male, n = 52, mean age 44u2009±u20098 years). The incidence of ptosis was 0.2% and transient. Forty-nine patients returned for a follow-up visit between 10 and 45 days and were included for image analysis to compare the before and after results of treatment. The average brow height was 24.6u2009mm before and 25u2009mm after treatment (p = 0.02). Photonumeric scales for forehead lines, brow ptosis, and brow furrow all showed statistically significant improvements (p < 0.0001). Conclusions:The microdroplet brow lift method safely concentrates cosmetic botulinum toxin treatment along the eyebrow, crows feet, and glabellar area, resulting in a brow lift effect that reduces forehead lines, elevates the eyebrow, and reduces the furrow along the brow. This new treatment paradigm results in an aesthetic improvement to the face and periocular area without the forehead paralysis associated with conventional treatment.

Refinements of the Tarsal Strip Procedure

We present several refinements in technique that simplify the tarsal strip procedure and enhance its results. Among these refinements are: electrosurgical deepithelialization of conjunctiva and lid margin, use of a V-shaped needle, direct needle passage about the lateral orbital tubercle, and the parallel placement of a buried absorbable suture to unite the upper and lower lid margins and to maintain a long-lasting sharp canthal angle. We have used these maneuvers in 45 patients with few complications; patient acceptance has been high. Also, we have found that using these maneuvers is helpful in teaching the procedure to residents.

Electrosurgical modification of orbicularis oculi hypertrophy.

Purpose To assess two electrosurgical approaches for the modification of orbicularis hypertrophy that may be used in conjunction with, or separate from, lower lid blepharoplasty. The hypothesis to be tested is that purely electrosurgical nonexcisional techniques may be used to modify orbicularis oculi muscle. Methods Electrosurgical techniques to treat orbicularis hypertrophy with an “open” and a “closed” technique are described. The open technique is performed in conjunction with transconjunctival blepharoplasty. The closed technique requires a 1-mm to 2-mm dermal incision, 2 minutes of surgical time per eyelid, and a specially insulated and formed electrosurgical needle. A review and case series are presented to illustrate and describe the techniques and results. Results Results for both techniques were rated by both patients and surgeons using the categories of poor, fair, good, or excellent. The open technique was performed in conjunction with transconjunctival blepharoplasty on 23 patients during 2 years with a minimum follow-up of 6 months. Results for the open technique were considered “excellent” by 14 patients and “good” by 9 patients. The operating surgeons evaluated the improvement as “excellent” in 4, “good” in 11, and “fair” in 8 patients. The closed technique was performed on eight patients. Results for patient satisfaction for the closed technique were considered “good” by 4, “excellent” by 2, “fair” by 1, and the final patient abstained from categorization. Operating surgeon evaluation of the closed technique revealed “excellent” outcomes in 3, “good” in 3, and “fair” for 2 patients. Conclusion Electrosurgical techniques may be used to modify orbicularis hypertrophy. Drawbacks include a significant learning curve, potential cutaneous ulceration, and occasional temporary anatomic distortion as manifested by scleral show. Complications are minimal, and the technique was safe in all patients studied.

Vector-running subcuticular sutures in high-tension and high-mobility areas

Routine cuticular sutures pierce the epidermis, and if left in place long enough, will noticeably scarify, a process called tracking. Alternatively, the running subcuticular suture has the advantage of minimizing suture tracking, especially following a prolonged usage, because it does not pierce the epidermis along most of its course. A hybrid modification of these two sutures, described herein, allows for prolonged tight closure under high tension in high-movement areas, avoidance of tracking, and rapidity of placement. This innovation is called the vector-running subcuticular suture.

Modifying brow position with botulinum toxin.

Botulinum toxin, produced by the bacteria Clostridium botulinum, acts at the neuromuscular junction. Through inhibition of acetylcholine release at the presynaptic terminal, this neurotoxin is able to induce muscular weakness or paralysis. Although various strains exist, botulinum toxin type A (BOTOX , Allergan, Inc., Irvine, CA) is the one most often used in medical procedures today. Beginning in the 1970s, botulinum toxin was used to treat strabismus by weakening the extraocular muscles. Soon after, its success in treating facial spastic disorders was recognized. Carruthers and Carruthers noted that in blepharospasm patients treated with C. botulinum, there was a significant decrease in periorbital rhytides and glabellar frown lines. The efficacy of botulinum toxin in ameliorating facial wrinkles caused by repeated muscle contractions has been convincingly demonstrated with millions of cosmetic treatments. As experience with such treatments has expanded, physicians and patients have noticed other aesthetic benefits, such as the alteration in facial muscle balance. For example, in a 1996 paper describing the efficacy of botulinum for treating glabellar folds and then again by Frankel and Kamer in 1998, it was noted that when patients were treated for glabellar lines, there was a simultaneous elevation of the medial brow. Subsequently, Huang et al showed that it was possible to produce elevation of the medial, central, and temporal portions of the brow with the use of botulinum toxin. Therefore, although initially

Volumetric rejuvenation of the tear trough with repo and Ristow.

Purpose: The authors report the results of their approach for the treatment of the tear trough deformity, by lower eyelid blepharoplasty with fat repositioning and fat transfer to Ristow’s space and the deep medial fat compartment. Methods: One hundred fourteen eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer between 2010 and 2012. Results: No major complications were observed in any of the patients in this series. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid–cheek junction noted by both patients and physicians. Conclusions: Despite the availability of multiple procedures, effacement of the tear trough region remains a challenge. The addition of fat transfer to Ristow’s space and the deep medial fat compartment to traditional fat repositioning lower blepharoplasty are effective methods for volumizing the tear trough and may synergistically improve outcomes.