Frank A. Nesi

Dermis-Fat Orbital Implantation: 118 Cases

During the previous six years the authors have performed 118 dermis-fat orbital implants. Fifty-one were primary implantations performed at the time of enucleation. Nineteen grafts were implanted after migrated implants were removed, and 19 grafts were used to correct superior sulcus deformities. Nine dermis-fat grafts expanded contracted sockets. It is becoming increasingly clear that these autogenous implants are effective in maintaining orbital volume while preserving the fornicies and conserving the conjunctiva. Although significant atrophy of primary grafts does not occur very frequently, it is more common in cases of secondary implantation, particularly in cases of chemically injured severely contracted sockets (3 of 9 cases). We have noted only one case of significant atrophy following a primary procedure. This occurred two and a half years following an apparently successful primary graft.

Management of paralytic lagophthalmos with a modified gold-weight implantation technique.

Summary: A modified gold‐weight implantation technique was used to treat paralytic lagophthalmos in 15 patients. Three patients had suffered extrusions of previously placed gold‐weight implants, two had other complications necessitating reoperation, and 10 had no previous surgery. The surgical modifications were intended to reduce the incidence of implant extrusion, postoperative ptosis, and implant visibility beneath the skin. The important changes in the surgical technique included (a) advancing the levator aponeurosis over the implant and (b) adjusting the final eyelid height intraoperatively with levator myotomies. Follow‐up ranged from 6 to 11 months. None of the patients in this study had postoperative problems associated with ptosis, implant extrusion, or implant visibility. Mild, prolonged, postoperative edema was noted in several patients. This resolved spontaneously. Mild eyelid retraction and lagophthalmos were seen postoperatively in two patients. This was caused by a failure to perform marginal myotomies at the time of the initial surgeries.

Eyelid sensation after supratarsal lid crease incision.

Purpose To determine the severity and duration of the loss of eyelid sensation after upper eyelid crease incision. Methods This clinic-based case study was performed by analyzing observational measurements of patients undergoing upper blepharoplasty or ptosis surgery. Eighty-three eyelids of 50 patients were studied. A Cochet-Bonnet filament-type aesthesiometer was used to obtain all measurements. Preoperative and postoperative measurements were recorded at 1 week, 1 month, and final (2–6 months) time periods. Statistical analysis evaluated the degree and duration of the sensory loss and the extent of recovery during the evaluation period. Recovery of sensation was defined as a numerical reading within one point of baseline. Results The mean aesthesiometry reading was calculated at the preoperative (3.45), 1-week (1.20), 1-month (1.56), and final postoperative (2.56) periods. Paired t testing showed a decreased but significant difference in sensation measurement at each comparison. Recovery of sensation to within one point occurs at the preoperative to late time period comparison. All but 4 of the 68 eyelids tested at the 1-week postoperative time period had a measured loss of sensation. Of the 44 eyelids tested at the final time period, all but 1 had regained some or all of this sensory loss. Conclusions Loss of skin sensation in the eyelid after upper eyelid crease incision blepharoplasty or blepharoptosis repair occurs in most patients and should be considered an expected outcome of the procedure. Partial to complete recovery of eyelid sensation over 2 to 6 months should also be expected, though in rare instances this does not occur.

Posttraumatic Enophthalmos and Diplopia

Malposition of the globe and failure to fuse visual images are late-developing complications of orbital injury. This article reviews the causes of specific sequelae, such as enophthalmos, hypophthalmos, and diplopia, and describes a procedure of strategic implantation of autogenous bone grafts to correct the condition(s). Using quantifiable methods of assessing globe position and motility, the authors demonstrate improvement in 18 of 19 patients. Vision is reported unchanged or improved in 13 sighted patients. Several cases are presented with analyses of preoperative and postoperative photographs. Indications, contraindications, advantages, and disadvantages of the surgical procedure are described and compared to others.

Trichoadenoma of an eyelid in an adult mimicking sebaceous cell carcinoma.

The purpose of this report is to detail the clinical and histologic findings of a rare trichoadenoma of the eyelid. A 63-year-old male with a recurrent left lower eyelid lesion underwent a shave biopsy with inconclusive results until referred to an oculoplastic surgeon. The patient presented with a lesion suspicious for sebaceous cell carcinoma of the eyelid. An excisional biopsy was performed, and the specimen was sent for permanent section histologic analysis. The results revealed the lesion to be a trichoadenoma of the eyelid. The remaining lesion was excised, and the lower eyelid was reconstructed.

Basic Principles of Ophthalmic Plastic Surgery

Ophthalmic plastic and reconstructive surgery combines the precision of ophthalmic microsurgery with plastic and reconstructive surgical principles, allowing for subspecialized care of the eyelid, orbital, and lacrimal system. A foundation in ophthalmology allows the oculoplastic surgeon the knowledge and skills to safely and successfully protect the globe while achieving functional and aesthetic results. Certain basic ophthalmic and plastic surgical considerations form the necessary framework for the successful practice of oculoplastic surgery.

Primary orbital angiosarcoma: a case report.

PURPOSE The pathogenesis, natural history, histopathology, and recommended treatment for orbital angiosarcoma are illustrated and reviewed. METHODS Case report. RESULTS A 71-year-old white male presented with bluish discoloration and swelling of the left medial canthal area. A fine needle aspiration and excisional biopsy with histopathologic examination was performed, which showed angiosarcoma. Pattern of growth was demonstrated radiographically and histopathologically, confirming primary orbital angiosarcoma. Subsequent wide surgical resection was carried out, with substantial reconstruction of the left orbital and periorbital area. The patient responded well to the surgery, and was free of tumor after six years of follow-up. CONCLUSION Angiosarcoma is a rare and highly malignant tumor of epithelial origin. The aggressive nature of this tumor usually results in a high mortality rate despite treatment. However, early diagnosis and wide surgical excision has resulted in successful treatment of these tumors.

Eyelid Laceration and Lid Defects

Eyelid reconstruction is a common challenge that ophthalmic and plastic surgeons encounter. Facial trauma, tumors, and congenital colobomas are examples of instances when such procedures are required. Knowledge of the anatomy of the periorbital tissues is crucial for the precise repair of the involved structures to ensure proper lid function and to prevent excessive cicatrix formation. The surgeon should be able to choose the appropriate technique and should be familiar with the step-by-step plan in order to prevent loss of excessive tissue. Different approaches will be discussed with emphasis on eyelid trauma. However, all these can be applied to periocular tumor excision and reconstruction as well.

Upper Eyelid Blepharoplasty: The Evaluation

Avoiding complications in performing a lower eyelid blepharoplasty may be based on the evaluation of the patient. By combining a thorough evaluation with proper history taking, many complications that result from this surgical procedure can be avoided.

Lower Eyelid Blepharoplasty

Lower eyelid blepharoplasty has evolved from subtractive, excisional procedures to the current modern approaches which utilize tissue reposition and augmentation to achieve ideal rejuvenation of the region. The following factors are important considerations when performing lower eyelid surgery