Guy G. Massry

Evisceration with scleral modification

Purpose To describe an evisceration technique that combines scleral modification with optic nerve release for coverage of any sized orbital implant. Methods The medical records of 70 patients who underwent the described evisceration procedure were reviewed. Results The average implant was 20 mm in diameter, with 50 patients (71%) receiving a solid polymethylmethacrylate sphere. Fifty-eight patients (83%) had a history of at least one previous ocular surgery, and 12 patients (17%) had phthisical eyes preoperatively with moderate to severe scleral cicatrization. Postoperatively, there were two cases of new or worsened ptosis, no cases of worsened motility, and no cases of implant extrusion. Conclusion Evisceration with scleral modification is a simple and effective procedure that allows placement of any size orbital implant. Surgical results are excellent with few complications.

Tarsal strip procedure for the correction of tearing

Purpose To evaluate the tarsal strip procedure in the treatment of tearing related to lacrimal pump failure. Methods A retrospective chart review of all tearing patients undergoing the tarsal strip procedure was done. Patients with ectropion, nasolacrimal duct obstruction, and punctal eversion and stenosis were excluded. Data collected included patient age, sex, procedures performed, follow-up, and resolution of tearing. The main outcome measure is resolution of tearing. Results Thirty-four eyelids of 21 patients underwent a tarsal strip procedure for the correction of tearing. Complete resolution of tearing was noted in 14 eyes. Seventeen eyes were partially improved and required no further intervention. Three eyes were unimproved over the follow-up period. Two eyes eventually required another procedure. Conclusions Patients undergoing tarsal strip for tearing caused by presumed lacrimal pump failure showed a significant rate of improvement in their tearing symptom after the procedure. The tarsal strip procedure appears to be effective in the surgical treatment of tearing secondary to laxity of the lower eyelid.

Nasal Fat Preservation in Upper Eyelid Blepharoplasty

Introduction: Traditional upper blepharoplasty is a subtractive form of surgery that involves the excision of variable amounts of skin, muscle, and fat from the eyelid. The goal of surgery is to improve field of vision and/or appearance. While surgical debulking of the eyelid may improve appearance early on, the volume loss inherent to this process (especially fat excision) can contribute to a hollowed appearance with an associated deep and sunken superior sulcus. This skeletonized look may be mitigated by repositioning a prominent nasal fat pad, if present, to the central upper eyelid. Methods: The charts of patients who underwent upper blepharoplasty with repositioning of the nasal fat pad (as described in this manuscript) to the central arcus marginalis of the superior orbital rim during surgery were reviewed. Patients with a history of previous eyelid surgery or trauma or who had concurrent ptosis or other eyelid malpositions were excluded from the study. Also excluded were patients who did not manifest prominent nasal fat pads at surgery. Postoperative interval follow up was consistent until 6 months after surgery and more sporadic thereafter, as patients more frequently missed appointments. Postoperative healing issues, patient complaints, complications, and subjective physician and patient satisfaction assessments were noted. Final results were gauged on each patients final visit after surgery. Results: Seventy-six patients were included in the study. Forty-eight patients (63%) were women, and 28 patients (37%) were men. The surgical procedure was uneventful in all patients. The average patient age was 66 years and the mean follow up was 11 months (range 6–22 months). There was one case of postoperative pseudo-Brown syndrome, which resolved with steroid injections. There were 2 cases of postoperative presumed mechanical ptosis, early in the series, lasting for 2 weeks, which in both cases responded to oral steroids. Subjectively, there was no new or worsening superior sulcus hollowness observed by patient or surgeon at last follow up in all cases. Conclusions: Volume loss and the value of fat preservation in lower blepharoplasty are well-documented and accepted among eyelid surgeons. The affect of iatrogenic volume depletion in upper eyelid blepharoplasty, while understood, has gained less attention. Repositioning the prominent nasal fat pad of the upper eyelid to the central sulcus adds little time to surgery, allows preservation of upper eyelid fat during surgery, and may be a useful adjunct to the upper blepharoplasty surgeon. While further studies are needed to more critically assess eyelid volumetric changes, this technique holds promise as a preventative measure for superior sulcus hollowing after surgery.

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.

Frontal periosteum as an exposed orbital implant cover.

PURPOSE To describe the surgical technique of harvesting frontal bone periosteum, through an eyelid-crease incision, for coverage of orbital implants. METHODS A retrospective review of the medical records of 15 patients who underwent the procedure. RESULTS Eleven patients had surgery to cover exposed orbital implants, whereas in 4 patients the periosteal graft was used as an implant cover during enucleation. Periosteal grafts as large as 25 mm in diameter can be harvested. Recurrent exposure developed in 2 patients who had complicated histories of local trauma. One of these patients required a secondary dermis-fat graft, and the other experienced spontaneous granulation. The remaining 13 patients had excellent results without complications. CONCLUSION Harvesting frontal bone periosteum, through an eyelid-crease incision, for orbital implant coverage is a relatively straightforward surgical technique. The procedure can be performed in the office under local anesthesia and yields excellent results. Recurrent exposure occurred only in 2 patients with histories of significant local trauma.

Prevalence of lacrimal gland prolapse in the functional blepharoplasty population.

Traditional functional blepharoplasty has focused on the excision of variable amounts of skin, muscle, and fat, with little attention given to the finding of the lacrimal gland prolapse (LGP). The reported incidence of LGP found on clinical examination, on patients of all ages presenting for blepharoplasty, is 15%. The authors experience with the procedure in the older age group (older than 60), is that this percentage is much lower than that found at surgery. To verify whether this is correct, the author evaluated lacrimal gland position intraoperatively in a group of patients undergoing functional upper blepharoplasty. In those patients who had LGP, the author routinely repositioned the gland and evaluated surgical outcomes. Methods: The author evaluated the presence of an intraoperatively displaced lacrimal gland in his functional blepharoplasty population over a 2.5-year period (2008–2010). Patients with a history of previous eyelid surgery, trauma, or who had concurrent ptosis or other eyelid malpositions were excluded from the study. When present, the degree of prolapse was graded as mild (0–2 mm), moderate (3–5 mm), or severe (6 mm or more). The author arbitrarily suture-repositioned the gland in all patients with 4 mm or more of prolapse. In cases with less prolapse, light cautery to the tip of the gland capsule and surrounding soft tissue allowed adequate repositioning without suture fixation. Pertinent patient demographics and postoperative complications were documented. Patients were seen consistently to 6 months after surgery with an average follow up of 12 months. Results: Fifty-seven patients were included in the study. Thirty-four patients (60%) had some degree of LGP. Of these, 8 patients (24%) had mild prolapse, 23 patients (67%) had moderate prolapse, and 3 patients (9%) had severe prolapse. Nineteen patients (56%) with LGP had the gland suture-repositioned, and 15 patients (44%) received cautery to retro-place the gland. In one patient (3%), transient dry-eye symptoms developed after surgery. Otherwise, there were few benign and self-limiting postoperative complications, consisting of prolonged upper eyelid swelling and transient mild pain. Conclusion: Lacrimal gland prolapse is a common finding during functional upper blepharoplasty surgery and appears to be a normal involutional periorbital aging change. Most cases are moderate in degree (as defined in the article), and not associated with specific preoperative symptoms or complaints, except lateral hooding with concomitant visual field deficit. Repositioning the gland intraoperatively is generally complication free and typically not associated with increased morbidity or healing time. The clinical significance of LGP in the elderly undergoing blepharoplasty surgery is unknown and requires further study.

The lift and fill lower blepharoplasty.

Purpose: To evaluate a series of patients who underwent combined lower transconjunctival blepharoplasty with fat repositioning and orbicularis muscle suspension, “The Lift and Fill Lower Blepharoplasty,” as a means of improving lower eyelid, and eyelid/cheek interface aesthetics after surgery. Methods: The authors retrospectively reviewed the charts of patients who underwent both transconjunctival lower blepharoplasty with fat repositioning and orbicularis muscle suspension over a 4-year period (2007–2010) from the 2 authors’ practices. All patients with a history of previous eyelid surgery or trauma, eyelid or orbital inflammatory disease, and those with frank eyelid malposition are excluded. Additional procedures are noted and results and complications are reviewed. Results: The study consists of 54 patients, of whom 42 are women, with an average age of 56 years and an average follow up of 19 months. Thirty patients had fat repositioning performed subperiosteally, and in 24 patients the dissection plane was preperiosteal. A skin excision was added in most patients and canthal suspension in approximately half of the patients. There were no cases of postoperative eyelid malposition or other significant complications. There were no appreciable differences in outcomes between the sub- or preperiosteal fat repositioning approaches. All patients were happy with their surgical outcome. Conclusion: The combination of transconjunctival lower blepharoplasty with fat repositioning, and orbicularis muscle suspension, “The Lift and Fill Lower Blepharoplasty,” provides a reliable and reproducible aesthetic rejuvenation of the lower eyelid and its transition to the cheek.

New insights into physical findings associated with postblepharoplasty lower eyelid retraction.

BACKGROUND Postblepharoplasty lower eyelid retraction (PBLER) has been linked to anterior lamellar shortage, unaddressed eyelid laxity, and middle lamellar scarring. The authors believe there are other, less-appreciated physical findings (orbicularis weakness, negative-vector eyelid, and inferior eyelid/orbit volume deficit) that also influence the development and potentially the management of this complex type of eyelid malposition. OBJECTIVES To better understand PBLER, potentially prevent its development, and improve treatment options, the authors determined the incidence of various physical findings present on initial examination of patients referred for PBLER revision. METHODS The medical charts of patients referred for PBLER revision over a 21-month period were reviewed. The presence of anterior lamellar shortage, lower eyelid laxity, and a middle lamellar (internal eyelid) scar was documented. Orbicularis weakness, negative-vector eyelid topography, and volume deficiency of the lower eyelid/inferior orbit also were noted. The incidence of each finding was calculated. RESULTS Forty-six patients (35 women, 11 men) were included. All patients had undergone primary transcutaneous surgery, which led to the eyelid retraction. Orbicularis weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, negative-vector eyelid topography, and eyelid laxity were common. A middle lamellar scar of significance was found in only 17% of eyelids. CONCLUSIONS The data suggest that the aforementioned underappreciated findings are common in patients with PBLER. Evaluating these factors when planning primary blepharoplasty may reduce the incidence of PBLER. Awareness of these findings when planning revisional procedures may improve surgical outcomes. LEVEL OF EVIDENCE 4.

The external browpexy.

Purpose: To introduce and describe the author’s experience with the external browpexy, a minimally invasive transcutaneous variant of the trans-blepharoplasty temporal brow suspension (internal browpexy). Methods: The charts of patients who underwent an external browpexy over a 2-year period by the author are reviewed. Excluded from the study are patients with a history of previous forehead/eyebrow or eyelid surgery. The surgical procedure is described in depth, representative patient photographs are presented to assess outcome, and results and complications are reviewed. Results: Twenty-eight patients are included in the study. The average age is 62 years (range 51–76), and the average follow-up is 6 months (range 2–12). Eighteen patients are men, 5 patients had unilateral surgery, and only 1 patient noted a subtle postoperative scar. All patients (including the one with the mild scar) were pleased with their surgical results. Conclusions: The external browpexy is a straightforward procedure, easily mastered and has subjectively yielded excellent outcomes with high patient satisfaction over a 6-month average follow-up. In the author’s experience, the brow incision has consistently healed without perceptible scar, and over this timeframe, the procedure has subjectively been shown to be a reliable temporal brow elevator/stabilizer. The procedure is presented as an alternative to the internal browpexy to aid in enhancing upper blepharoplasty outcomes.

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.