Haideh Hirmand

Anatomy and nonsurgical correction of the tear trough deformity.

Summary: The development of dark circles under the eyes is one of the early signs of periorbital aging, lending a fatigued and aged appearance to the face. Loeb, in 1961, used the term “nasojugal groove” to describe the concavity at the border of the eyelid and the cheek medially. Flowers, in 1969, first named this groove the “tear trough.” In the present article, the author presents a detailed description of the anatomy and nonsurgical correction of this deformity. Nonsurgical correction of the tear trough deformity with hyaluronic acid is effective and safe and is associated with high patient satisfaction. The procedure offers both an adjunct to surgery and an alternative to it in some patients. It also provides an opportunity for global midfacial volume correction. Careful patient selection and attention to technique will minimize side effects.

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.

The role of lacrimal intubation in the management of facial trauma and tumor resection

BACKGROUND Lacrimal drainage dysfunction is a common and problematic consequence of any pathologic process that interferes with the physiology or continuity of the lacrimal drainage apparatus. The literature widely documents several reliable, safe, and consistently well-tolerated techniques of nasolacrimal intubation for the repair of lacrimal system dysfunction; however, the role and the timing of such intubation in primary surgery involving the regional anatomy of the lacrimal system remain controversial. The authors evaluated the role of lacrimal intubation as a therapeutic and prophylactic procedure in complex primary surgery for trauma, tumor, and chronic infection of the lacrimal drainage system. METHODS Sixty-one cases of either unilateral or bilateral silicone intubation of the lacrimal drainage system in 54 patients were analyzed retrospectively with respect to diagnosis, indication for intubation (therapeutic or prophylactic), and clinical outcome. Final long-term patency of the system after tube removal was assessed by the absence of epiphora and positive Jones primary dye test. RESULTS Lacrimal intubation as part of the primary repair of facial trauma, tumor resection, and relief of lacrimal system obstruction resulted in a patent, functional lacrimal drainage system in all 61 cases, with no associated morbidity. The risks of diagnostic manipulation at the time of surgery were avoided. CONCLUSIONS This series demonstrates that prophylactic intubation of the lacrimal system in any trauma or tumor resection near or around the region in addition to those that directly involve these systems should be considered, as the risks of silicone intubation in such cases are relatively negligible compared with the morbidity and nuisance associated with postoperative epiphora and/or recurrent dacryocystitis. Concomitant nasolacrimal intubation in conjunction with the repair of complex midfacial fractures or tumor extirpation is a safe and effective means of ensuring the establishment of a patent, functional drainage system in the absence of direct lacrimal system involvement.

Silicone migration to the pleural space associated with silicone-gel augmentation mammaplasty.

We present a case report of silicone particles found in the pleural fluid of a patient 20 years after bilateral augmentation mammaplasty with silicone-gel implants. The patients history is notable for bilateral replacements of implants and multiple closed capsulotomies several years subsequent to the original augmentation procedure. A ruptured left implant was found in 1991 when she first experienced pain in the upper back. A left pleural effusion developed subsequently. Analysis of the pleural effusion fluid by scanning electron microscopy suggested the presence of silicone. All laboratory results were normal, and the effusion did not recur after thoracentesis. The patient has been under close follow-up, and further pulmonary complications or other symptoms have not developed. This case report demonstrates the potential for silicone migration to the pleura and the possibility of subsequent pulmonary complications, such as pleural effusion.

Dendritic Cell-T Cell Conjugates that Migrate from Normal Human Skin are an Explosive Site of Infection for HIV-1

Distinctive features of dendritic cells include their potent antigen presenting capabilities and their migratory properties. Stimulation of the skin using contact sensitzing agents1,2, or following transplantation3, “activates” dendritic cells to migrate into the afferent lymphatics and on to the draining lymph node. Movement of dendritic cells via the lymph1,4–6 to the lymph node provides an explanation for the dependence on intact, cutaneous afferent lymphatics for effective primary immune responses to contact allergens7 and transplants8 in situ. Furthermore, injection of ex vivo antigen-pulsed dendritic cells back into mice results in migration of the dendritic cells to the draining lymphoid tissue9, where CD4+ T cells are primed10–12.

Consensus panel's assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics.

In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.

A review of onabotulinumtoxinA (Botox).

OnabotulinumtoxinA was introduced to the US market in 2002 as the first botulinum toxin type A (BoNTA) approved for facial aesthetics. This article provides an overview of onabotulinumtoxinAs uses and indications as well as safety and efficacy data. As with other BoNTA products, onabotulinumtoxinA is generally well tolerated. Consideration is also given to clinical applications of the product. Information on handling, storage, and dosing is provided.

IncobotulinumtoxinA (Xeomin): background, mechanism of action, and manufacturing.

IncobotulinumtoxinA is the third botulinum neurotoxin type A (BoNTA) to be approved for aesthetic use in the United States. This article introduces the new product with an overview of clinical applications and a discussion of the neurotoxins molecular structure. The role and clinical relevance of complexing proteins in BoNTA products are discussed. Finally, incobotulinumtoxinAs mechanism of action is described.

Optimizing blepharoplasty outcomes in patients with previous laser vision correction.

Background: Dry eye syndrome, often referred to as dysfunctional tear syndrome, can occur following laser vision correction surgery and routine blepharoplasty. Identifying patients prone to developing or worsening of dysfunctional tear syndrome following blepharoplasty can help optimize surgical outcomes. Methods: The authors highlight the salient features of the dysfunctional tear syndrome including key steps in identifying at-risk patients. The authors discuss changes in the cornea that occur with keratorefractive surgery and their significance in patients seeking blepharoplasty. The authors suggest guidelines for blepharoplasty in these patients and discuss the timing of surgery. Results: After blepharoplasty, lagophthalmos of the upper lid is a common temporary finding. This change in eyelid function may unmask underlying deficiencies in the tear film or corneal sensation. Coexisting lower lid malposition can displace the existing tear meniscus and increase exposure of the cornea. Whether in combination or alone, these findings can create a dry eye problem. Dysfunctional tear syndrome should be considered in all patients with a history of laser vision correction during the preoperative evaluation for blepharoplasty. Surgeons should rely on preoperative history and physical examination, including assessment of preoperative eyelid anatomy and the status of the ocular surface. Patients with prior laser vision correction should wait at least 6 months before undergoing blepharoplasty because of the effects on corneal sensation, tear production, and tear film alteration. Conclusions: Identification and appropriate treatment of dysfunctional tear syndrome together with intraoperative modifications will optimize postoperative outcomes and avoid a potentially disabling condition after blepharoplasty in patients with previous laser vision correction surgery.

A review of AbobotulinumtoxinA (Dysport).

AbobotulinumtoxinA was approved by the US Food and Drug Administration in 2009 as the second botulinum neurotoxin type A (BoNTA) for use in facial aesthetics. This article provides an overview of abobotulinumtoxinAs applications and indications as well as safety and efficacy data. AbobotulinumtoxinA is generally well tolerated. Adverse events from abobotulinumtoxinA are similar to those reported with other BoNTA products. Clinical applications of the product are also discussed in this article. Information on handling, storage, and dosing is provided.