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Long-term efficacy and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm.

To evaluate efficacy and safety of botulinum toxin A injections after more than 10 consecutive years of treatment for benign essential blepharospasm and hemifacial spasm.

Ptosis repair options and algorithm.

Purpose of review The treatment options for ptosis are strictly surgical. Each patient needs to be individually assessed and treated. A surgeon needs to be familiar with all types of surgical repair to choose the best possible option for his/her particular patient. Recent findings There are certain established surgeries in ptosis repair; however, there is no ideal surgical technique to treat every patient without any drawbacks. Several modifications of known techniques have been described to address the weaknesses of original applications. Also, new techniques such as orbicularis plication, levator readaptation, and new approaches in frontalis suspension surgery were presented. An algorithm showing the appropriate/most preferred ptosis surgery techniques is prepared based on the traditional knowledge and the latest publications. Summary There have been many modifications and new proposals in the management of ptosis. The surgeon needs to be familiar with an algorithm for the appropriate surgical method.

Treatment of unilateral congenital ptosis: putting the debate to rest.

Purpose of review Frontalis suspension for the surgical correction of poor levator function congenital ptosis has been a matter of debate in the last decade, but recently progress has been made. This study highlights the relevant keystones regarding sling material, surgical steps, and approach that can improve functional and esthetic results, while minimizing risk to the eye. Recent findings The incidence and demographics of ptosis in children have been reported by two recent studies confirming that unilateral, poor levator function congenital ptosis is the most common form, the left eye is most commonly affected, and frontalis suspension is the most commonly performed technique. Significant progress has been made concerning the sling material and the surgical technique of frontalis suspension. Although different surgical designs for sling suspension have proven to have no effect on the final result, a recent study has shown the importance of direct fixation with sutures of the sling material to the tarsal plate to increase the success rate Autologous fascia lata has been found to be an excellent sling material with the lowest complication rate and should be considered the preferred material for long-term correction. A review of the recent literature suggests that unilateral surgery is the preferred approach. Summary Although the surgical treatment of simple congenital ptosis has not radically changed through the years, recent reports have established some keystones that can positively affect the esthetic outcomes and safety of frontalis suspension.

Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags.

Purpose: To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. Methods: The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as “worsened,” “unchanged,” or “improved.” Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). Results: Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18–57 years). Chief complaints were “hollows” in 94% of patients, “dark circles” in 33%, lower eyelid “bags” in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. Conclusions: Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

Surgical Outcomes in Patients with Bilateral Ptosis and Hering's Dependence

PURPOSE To assess whether sequential or simultaneous ptosis repair yields a better postoperative outcome in patients with documented preoperative Herings dependency. DESIGN Retrospective, case-control study. PARTICIPANTS AND CONTROLS Of the 216 patients who underwent bilateral ptosis surgery, 109 patients with documented Herings dependency constituted the study group and the 107 patients with no Herings dependency constituted the control group. METHODS The charts of patients who underwent levator advancement ptosis surgery between April 2002 and December 2004 by the same surgeon (R.C.K.) were reviewed retrospectively. Data regarding patient demographics, preoperative and postoperative margin-reflex distance values, levator function, presence of Herings dependency, side of the initial operation, and reoperation status were collected from the charts. Patients demonstrating preoperative Herings dependency of eyelid position operated simultaneously and sequentially were compared for postoperative symmetry and reoperation rates. Postoperative asymmetry was defined as a more than 1-mm difference between upper eyelid heights. MAIN OUTCOME MEASURES Postoperative asymmetry and reoperation rates. RESULTS In the Herings dependency group (n = 109), 64 sequential surgeries that yielded 15 asymmetric results (23.4%) and 7 reoperations (10.9%) compared with the 45 simultaneous operations, which revealed 1 case of asymmetry (2.2%; P = 0.002) and 1 case of reoperation (2.2%; P = 0.137). Compared with the control group, sequentially operated Herings dependency patients still showed higher postoperative asymmetry (P = 0.011), and the reoperation rate was similar (P = 0.134). Herings dependency patients who had the initial operation on the left side demonstrated a significantly higher rate of postoperative asymmetry (42.3% vs. 10.5%; P = 0.006). CONCLUSIONS Bilateral ptosis cases with documented Herings dependency yield better results when both eyes are operated in the same session, rather than delaying surgery for the second eyelid. Ocular dominance probably has a significant impact on Herings dependency and postoperative outcome after unilateral operations.

What is new in the era of focal dystonia treatment? Botulinum injections and more.

Purpose of review The treatment options for the management of dystonias continue to evolve and improve. Clinical outcomes, however, are not predictably consistent using a single treatment regimen in all patients. Recent findings Botulinum toxin is still considered the best treatment option for the treatment of focal dystonias: blepharospasm, hemifacial spasm, and apraxia of eyelid opening. New findings indicate that physicians may be a little more aggressive with the dosage when the disease progresses. A new formulation of botulinum toxin has been produced that includes no proteins and may address the immunoresistance that can occur with prolonged use. Additional systemic medications may be helpful as adjuncts only in selected cases. Improved surgical techniques are now more successful and cause fewer complications. Therefore, many refractory cases are now offered a surgical approach alone or in combination with botulinum toxin. Summary There have been recent therapeutic developments in the treatment of ocular dystonias.

Periocular fat grafting: indications and techniques.

Purpose of review Autologous fat transfer (AFT) is gaining popularity in periorbital and facial rejuvenation as well as structural reconstruction because of the advantages of fat over other fillers and implants. Recent findings As the technique and instruments were refined over the years, the incidence of AFT morbidity decreased; however, there is still no consensus on the standardization of the procedure. Several studies have failed to demonstrate superiority of any routine technique; however, various suggestions provided by these investigations have had significant impact on the outcome of surgery. New insights are mainly focused on improving the survival of the grafted tissue, mainly through enhancing cell differentiation and angiogenesis. Clinical applications of adipose-derived stem cell (ADSC) transfer with or without other enhancers were proven to be successful; however, there is not enough human research on this topic yet. Experts made a clear distinction between AFT and ADSC transfer, and the details can be found in this report. Management of hard-to-treat maxillofacial conditions including orbital disorders evolved from AFT techniques, the so-called structural fat grafting. Summary Harvesting methods to obtain stem cells have proven helpful in many studies. The future of fat grafting relies on the basic research that includes using additive agents, enhancers, or scaffolds to fat for increased survival of the graft.

Bilobed flap in the reconstruction of inferior and/or lateral periorbital defects.

Purpose: To report the outcome of bilobed flap (BF) reconstruction of inferior and/or lateral periorbital defects following tumor excision. Methods: Records of 20 patients who underwent inferior and/or lateral periorbital reconstruction with the BF were reviewed. The surgery was performed with local anesthesia in 18 patients and with general anesthesia in 2. Malignant tumors were excised together with a 4- to 5-mm margin of surrounding skin. Superolaterally based BFs were created from the malar or zygomatic region to cover the defects. Results: Patients ranged in age from 48 to 86 years (mean, 67 years). Nineteen patients had epithelial carcinoma and 1 had pilomatrixoma. Mean tumor diameter was 16mm (range, 7–42mm). Skin defects were located in the inferior (n = 14), lateral (n = 4), or inferolateral (n = 2) periorbital region. The BF was used in combination with the posterior lamella and/or canthus reconstruction techniques in 9 patients. For skin defects, BF was used alone in 17 patients, together with other flaps in 3. Primary closure of the skin defect with the flaps was achieved in 19 patients (95%). Three patients (15%) developed major complications requiring revision surgery (2 canthal webbings, 1 permanent pin-cushion deformity, and 1 ptosis) and 6 patients developed minor temporary complications. Mean follow-up duration was 34 months (range, 9–75 months). Conclusions: The BF is a valuable alternative for reconstruction of inferior and/or lateral periorbital defects alone or in combination with other eyelid reconstruction methods to achieve good functional and aesthetic outcome.

Intraoperative predictability of temporal artery biopsy results.

Purpose: To determine whether inflammatory/granulomatous changes of giant cell arteritis can be grossly identified by the surgeon during temporal artery biopsy to allow institution or discontinuation of steroid therapy without delay. Methods: The records of 113 consecutive patients operated on by the same surgeon (R.C.K.) between November 2002 and June 2007 were reviewed. Demographic characteristics, date and site of the surgeries, surgical complications, surgeon’s intraoperative presumption about the outcome (based on his assessment of the thickness, nodularity, tortuosity, and color/pallor of the arterial wall, blood flow, and the lumen size), and histopathologic biopsy results were collected from the chart review. The main outcome measure was the correspondence of the surgeon’s intraoperative impression expressed in the operative note to the ultimate histopathologic diagnosis. Results: After exclusion of 5 cases with incomplete data, the study consisted of 108 patients (78 females and 30 males) with an average age of 72.4 ± 11.4 years (range, 45–93 years). There were no complications during or after surgery. The surgeon’s comment was “grossly positive” in 17 cases, and 15 of these cases were pathologically positive. For all of the cases that the surgeon’s impression was negative, the pathology was negative as well (100% negative predictive value). Overall, the surgeon’s intraoperative comments had a 100% sensitivity to detect giant cell arteritis. The specificity and accuracy values were 97.9% and 98.2%, respectively. Conclusion: The surgeon’s intraoperative evaluation of the temporal artery may be extremely valuable in predicting the biopsy result and may allow the surgeon to determine whether steroids could be discontinued in patients in whom the clinical history is not highly suggestive of giant cell arteritis.

Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management.

Orbital and periorbital extension of congenital dacryocystoceles is rarely observed in neonatal infants. The authors describe 4 cases of congenital dacryocystocele that presented with extension to the orbital and periorbital regions. The first 3 newborns underwent marsupialization of the orbital and periorbital dacryocystoceles with aspiration of the purulent material followed by nasolacrimal duct probing after radiographic evidence of diffuse orbital or periorbital expansion. The fourth patient was successfully treated with an external dacryocystorhinostomy with excision of the enlarged cystic walls. Transconjunctival orbitotomy with sac marsupialization followed by nasolacrimal intubation can provide immediate and permanent resolutions of this unusual complication in most instances. External dacryocystorhinostomy may be required, however, when the orbital or periorbital dacryocystocele is complicated by acute or recurrent dacryocystitis.