Donald B. Yoo

Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of transposing fat to the subperiosteal vs supraperiosteal planes.

IMPORTANCE Differences in technique and outcome between fat transposed to the subperiosteal and supraperiosteal planes during transconjunctival lower blepharoplasty remain to be elucidated. OBJECTIVE To provide a single-surgeon comparison of transconjunctival lower blepharoplasty with fat repositioning (TCBFR) to the subperiosteal vs the supraperiosteal plane. DESIGN A retrospective medical record review of patients who underwent TCBFR to the subperiosteal or the supraperiosteal plane by a single surgeon from January 1, 2009, through December 31, 2011. Differences in surgical technique, postoperative course, complications, patient satisfaction, and aesthetic results (by blinded assessment of preoperative and postoperative photographs) are reviewed using a 4-point scale. SETTING An ophthalmic plastic surgical practice. PARTICIPANTS The first 20 consecutive patients who underwent TCBFR to the supraperiosteal plane and the previous 20 who underwent TCBFR to the subperiosteal plane. INTERVENTION Transconjunctival lower blepharoplasty with fat repositioning. MAIN OUTCOME MEASURES Intraoperative findings, postoperative course, complications, and aesthetic results. RESULTS We included 40 patients (27 women and 13 men) with a mean age of 57 years and mean follow-up of 10 months. Subperiosteal TCBFR was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal surgery was faster yet more traumatic, leading to more bruising, swelling, and with more clinically evident temporary postoperative contour irregularities. All patients expressed a high level of satisfaction (100%). Blinded assessment of results demonstrated no statistically significant difference (P = .45) between the 2 surgical approaches with regard to the final aesthetic result. CONCLUSIONS AND RELEVANCE Transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results are comparable between the 2 approaches. LEVEL OF EVIDENCE 4.

Effacing the Orbitoglabellar Groove With Transposed Upper Eyelid Fat

Purpose: An age-related depression can develop over the superonasal orbital rim, which the authors have called the “orbitoglabellar groove (OGG).” It is, in part, related to volume loss over the rim as is seen at the lower eyelid/cheek interface (nasojugal groove). An upper eyelid fat pedicle can be transposed over the OGG during standard upper blepharoplasty surgery to reduce this depression. Methods: The charts of patients who underwent fat transposition to the OGG during upper blepharoplasty over a 20-month period (2010–2012) are retrospectively reviewed. Only primary eyelid surgery patients are included in the study. The procedure, its results, and complications are presented. Results: Seventeen patients are included in this study. Eleven patients (65%) are women and 6 (35%) patients are men. The average patient age is 56 years (range 47–80 years), and the average follow up is 10 months (6–14 months). Two patients (12%) developed a transient induration over the transposed fat pedicle in the postoperative period which resolved with a combination 5-fluorouracil/kenalog injection. There were no cases of postoperative infection, prolonged swelling, motility disturbance, diplopia, or eyelid malposition. Clinical effacement of the OGG was noted in all cases, and physician and patient assessment of surgical results are equally good. Conclusions: The OGG is an involutional periorbital hollow present over the superonasal orbital rim. The depression can be reduced with native eyelid fat transposition during upper blepharoplasty in a similar way that lower blepharoplasty with fat repositioning effaces the nasojugal groove. The learning curve for the procedure is quick, especially for those who have experience with its lower eyelid counterpart.

Microbiology and Antibiotic Prophylaxis in Rhinoplasty: A Review of 363 Consecutive Cases

IMPORTANCE A practical technique for reducing infectious complications from rhinoplasty would represent an important surgical advance. OBJECTIVES To describe the microbial flora of patients undergoing septorhinoplasty and to evaluate the role of preoperative and postoperative antibiotic prophylaxis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective medical record review of 363 consecutive adult patients who underwent preoperative nasal swab testing and rhinoplasty or septorhinoplasty in a single private practice: 279 women (76.9%) and 84 men (23.1%). The average patient age was 35.9 years (age range, 17-70 years). MAIN OUTCOMES AND MEASURES Identification of endogenous nasal flora and pathogenic bacteria treated with culture-directed antibiotics; evaluation of comorbidities, perioperative infections, and antibiotic treatments. RESULTS A total of 174 patients (47.9%) underwent primary rhinoplasty, and 189 (52%) underwent revision rhinoplasty. On preoperative nasal culture, 78.2% of patients had normal flora; 10.7% had Staphylococcus aureus; and 0.28% had methicillin-resistant S aureus (MRSA). In 7.4% of patients, fecal coliforms including Escherichia coli, Enterobacter species, and Citrobacter species were found. Age, sex, smoking, the use of oral contraceptives, or the presence of seasonal allergies did not significantly change the nasal flora or the postoperative infection rate. Patients with adult acne were found to have an increased incidence of colonization with fecal coliforms (43.8%; P < .001). Patients with diabetes were found to have an increased incidence of colonization with S aureus (66.7%; P = .002). The overall infection rate was 3.0% (11 of 363 patients), with 4.0% (7 of 174 patients) seen in primary septorhinoplasties and 2.1% (4 of 189 patients) seen in revision cases. Coliforms accounted for 5 cases (45.5%) of postoperative infections, while S aureus was responsible for 4 cases (36.4%), including 1 case of MRSA. CONCLUSIONS AND RELEVANCE The results of this study suggest that risk factors alone may not reliably predict the subset of patients in whom antibiotic prophylaxis is indicated. Knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help to further reduce the incidence of infectious complications. LEVEL OF EVIDENCE 3.

The Minimally Invasive, Orbicularis-Sparing, Lower Eyelid Recession for Mild to Moderate Lower Eyelid Retraction With Reduced Orbicularis Strength

IMPORTANCE Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery. OBJECTIVE To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical record review of patients who underwent the minimally invasive, orbicularis-sparing, lower eyelid recession from January 1, 2010, to October 1, 2012, by one of us (G.G.M.) in an ophthalmic plastic surgical practice. We included 29 patients with reduced orbicularis strength and LER resulting from eyelid paresis related to facial nerve disease, surgical trauma (after blepharoplasty), involutional change, or idiopathic causes. INTERVENTIONS Surgical intervention consisting of closed canthal suspension and lower eyelid retractor recession. MAIN OUTCOMES AND MEASURES Surgical results, complications, and patient satisfaction. RESULTS The 29 patients included 18 women and 11 men. The mean patient age was 52 (range, 6-72) years; mean follow-up, 11 (range, 6-21) months; and mean preoperative orbicularis strength, 2.7 (on a scale of 0-4, where 0 indicates no function and 4, normal function). The causes of orbicularis weakness included eyelid paresis related to facial nerve disease (11 patients), surgical trauma (13 patients), involutional change (4 patients), and an isolated idiopathic finding (1 patient). In 12 patients, the eyelid retraction was unilateral; in 17, bilateral. A small tarsorrhaphy was added to the surgery in 6 patients with facial nerve disease. The mean eyelid elevation after surgery was 1.80 mm, with only minor complications. Patient and surgeon satisfaction were high. CONCLUSIONS AND RELEVANCE Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results. LEVEL OF EVIDENCE 4.

Injectable 5-FU with or without added steroid in periorbital skin grafting: initial observations.

Purpose: The authors describe their experience with postoperative injectable 5-fluorouracil (5-FU), with or without added low-dose and concentration steroid, in the particular patient subset undergoing eyelid skin grafting surgery. Methods: A retrospective chart review (2011–2013) of patients who underwent eyelid skin grafting for various etiologies with adjunctive postoperative 5-FU (50 mg/ml) injections (with or without added kenalog 5 mg/ml) was performed. Injections were given 2 to 3 weeks postsurgery and as frequently as every 2 weeks for a total of up to 4 injections. At each visit, patients were evaluated for redness, swelling, wound healing, scar formation, tissue inflammation/atrophy, telangiectasis, and pigmentary disturbances. Patient interpretation of outcome was determined subjectively by asking if they were satisfied and objectively by their separate responses to specific questions graded on a Likert-type scale. Operating surgeon satisfaction was determined only by subjective clinical evaluation of final results. Finally, a graded evaluation of pre- and postoperative digital photographs by an independent facial plastic surgeon was added to quantitatively evaluate the surgical results. Results: Nineteen patients with an average age of 66 years and follow up of 10 months are included. Surgical indications include reconstruction of cancer excision defects, repair of lower eyelid ectropion or retraction, benign eyelid lesion excision, and effacement of a canthal web. On average, patients had a total of 4 separate 0.3 to 0.5 ml 5-FU, or 5-FU/kenalog injections spaced 2 to 3 weeks apart. In 11 of 19 patients, the 5-FU injections were mixed with steroid. There were no cases of skin thinning, color/texture change, atrophy, telangiectasis, or infection after injection, and all patients had uneventful healing of their grafts. Eighty-nine percent of patients were satisfied with their outcome (graded 4.73/5) and the appearance of the skin graft (graded 4.79/5). In 95% of cases, the surgeon was satisfied with the surgical result. Independent surgeon assessment of outcome was graded (4.58/5). Conclusions: A 5-FU or 5-FU/kenalog (75%/25%) mixture can be injected safely after eyelid skin grafting surgery. Surgical results are good with minimal scarring, high patient and surgeon satisfaction, and few complications. Results are equally efficacious and complication-free with or without the addition of a steroid component to the injection mixture.

Avoiding and Managing Complications in the Periorbital Area and Midface

The eyes play a central role in the perception of facial beauty. The goal of periorbital rejuvenation surgery is to restore youthful proportions and focus attention on the eyes. Blepharoplasty is the third most common cosmetic procedure performed today. Because of the attention placed on the periorbital region, preventing and managing complications is important. Obtaining a thorough preoperative history and physical examination can significantly reduce the incidence of many of the complications. This article focuses on the preoperative evaluation as it relates to preventable complications, followed by common intraoperative and postoperative complications and their management.

Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members.

PURPOSE To assess current practice patterns for management of upper and lower eyelid blepharoplasty by active American Society of Ophthalmic Plastic and Reconstructive Surgery members. METHODS An invitation to participate in a web-based anonymous survey was sent to the active American Society of Ophthalmic Plastic and Reconstructive Surgery membership via email. The survey consists of 34 questions, both multiple choice and free response, regarding upper and lower eyelid blepharoplasty surgery. Practice patterns for both aesthetic and functional blepharoplasty are assessed. RESULTS Thirty-four percent (161/472) of American Society of Ophthalmic Plastic and Reconstructive Surgery members polled responded to the survey. Members perform an average of 196 upper eyelid, 46 lower eyelid, and 53 four-eyelid blepharoplasty procedures per year, with 70% of cases being functional and 30% purely aesthetic. Most members prefer monitored care (71%) to local (21%) or general (8%) anesthesia. Eighty-nine percent of surgeons use topical antibiotics after surgery, erythromycin being the most common (51%). Fourteen percent of members use postoperative oral antibiotics, with cephalexin (81%) being most common. In upper eyelid blepharoplasty, orbicularis muscle is excised by 86% of respondents. Orbital fat is excised, when deemed appropriate, in 97% of cases, with nasal fat excised most commonly (88%). Less commonly, fat repositioning (36%) and adjunctive fat grafting (33%) are performed. In lower eyelid blepharoplasty, surgeons report using one or more of the following approaches: transconjunctival (96%), transcutaneous (82%), and both transconjunctival and transcutaneous (51%). Common adjunctive procedures include orbital fat excision (99%), fat repositioning (80%), and lateral canthal suspension (96%). Less common adjunctive procedures include laser skin resurfacing (36%) and chemical peels (29%). CONCLUSIONS This report outlines contemporary practice patterns among active American Society of Ophthalmic Plastic and Reconstructive Surgery members in the management of upper and lower eyelid blepharoplasty. It is important to quantify such data periodically to update the membership as to how this common surgical procedure is approached. This also allows eyelid surgeons to compare their practice patterns with a national group specializing in such surgery.

True Lower Eyelid Retractor Recession as an Adjunct to Lower Lid Recession Surgery

True lower eyelid retractor recession is a useful tool in lid recession surgery. The lower lid retractors are accessed through a transconjunctival incision, dissected fee of the conjunctiva and allowed to hang back. There is no manipulation of the orbicularis muscle. This is a safe adjunct for lower lid recession.

The “GRED (Globe Retropulsion and Eyelid Depression)” Maneuver to Access Postseptal Fat in Transconjunctival Lower Blepharoplasty

The globe retropulsion and eyelid depression (GRED) technique is described. This involves simultaneous unimanual lower lid depression and globe retropulsion (over the closed upper lid) with two fingers of one hand. The maneuver reliably promotes direct entry to the clearly delineated post-septal fat compartment, obviates the need for an assistant to create this exposure, and does not obscure the globe or lower lid from view.

Upper Eyelid Fat Repositioning

Redistribution of the more prominent nasal fat in upper blepharoplasty can be performed in two ways. The nasal fat can be repositioned to the central preaponeurotic area. The nasal fat can also be repositioned to a periorbital hollow known as the orbitoglabellar groove over the superior nasal orbital rim. These procedures are analogous to fat repositioning in the lower lid.