M. Douglas Gossman

Prospective Evaluation of the Argon Laser in the Treatment of Trichiasis

We report the results of argon-laser treatment in 60 consecutive eyelids with focal, symptomatic trichiasis. Permanence of eyelash destruction compared favorably with that reported for cryosurgery; complications were limited to minimal contour abnormalities and hypopigmentation.

Experimental Comparison of Laser and Cryosurgical Cilia Destruction

We compared cryosurgery with the argon and carbon dioxide lasers in a rabbit model to evaluate the permanence of eyelash destruction as well as the gross and histologic effects on the eyelid. Each modality was equally effective in preventing eyelash regrowth. Cryosurgery and the carbon dioxide laser produced the greatest acute soft tissue swelling; the carbon dioxide laser produced the most pronounced gross eyelid alterations. The argon laser produced minimal eyelid tissue change. Long-term histologic tissue alterations were not striking and were confined to eyelids treated with cryosurgery and the carbon dioxide laser. We conclude that, of the two lasers, the argon is the best suited to the clinical treatment of trichiasis: it is widely available, more precise in limiting contiguous tissue destruction when delivered through a slit lamp, and is safer for use near the eye.

Expansion of the human microphthalmic orbit

OBJECTIVE To determine the effects of long-term, incremental enlargement of an orbital tissue expander on bone and eyelid growth in microphthalmia. DESIGN A prospective, noncomparative case series. PARTICIPANTS Five consecutive patients with microphthalmos treated with orbital expansion were evaluated. INTERVENTION A tissue expander was placed into the orbits of five children (age, 10 months-6 years) with unilateral microphthalmos and gradually enlarged by saline injections. MAIN OUTCOME MEASURE The midorbital width of each patient was determined from axial computed tomographic scans before insertion of the device. The length of the normal and abnormal eyelid fissures was measured at surgery. The postexpansion dimensions of both the normal and microphthalmic orbits and the eyelids were remeasured when the expanders were removed. The residual deficits between the normal and the microphthalmic sides were expressed in percentages. RESULTS Gradual inflation of the expander to a diameter of 22 mm reduced the average preoperative orbital dimension deficit of the group from 14.6% (range, 8%-25%) to 3.8% after surgery (range, 0.5%-6.3%). The average pre-expansion eyelid length deficit for the group was 17.5% (range, 12%-26%) compared to 2.3% (range, 0.0%-5.3%) after expansion. The average expansion period was 56.8 weeks (range, 20-100 weeks). Two outpatient surgical procedures were required in each patient. CONCLUSION Incremental inflation of a tissue expander placed within the microphthalmic orbit induced sufficient osseous and eyelid growth to ameliorate the major stigmata of this syndrome in all patients treated.

Involutional entropion repair by posterior lamella tightening and myectomy

Summary Involutional entropion is a common eyelid malposition of diverse etiology that may recur after surgical repair. Laxity of the tarsoligamentous complex combined with posteriorly directed rotational force exerted by the orbicularis, in our view, seems to be the most important in the production of entropion. A surgical technique has been developed that is carried out through a standard transcutaneous lower eyelid blepharoplasty incision. It includes tarsoligamentous tightening at the lateral canthus, bolstering of the lateral canthal tendon, and partial orbicularis myectomy. Forty-two procedures in 35 consecutive patients (29% for recurrent entropion) have been performed and evaluated (mean follow-up, 33 months). There have been no recurrences, and the esthetic outcome has been very good.

The use of end-to-side nerve grafts to reinnervate the paralyzed orbicularis oculi muscle.

Facial paralysis is a serious neurologic disorder, particularly when it affects the eye. Loss of the protective blink reflex may lead to corneal ulceration and, possibly, visual loss. The purpose of this study was to compare different nerve-grafting techniques to reanimate the paralyzed eyelid. Sixteen adult dogs (25 kg each) were allocated into four groups. Denervation of the left hemi-face was performed in all cases. One dog served as a control animal (group I). Group II dogs (n = 5) underwent end-to-side coaptation of the nerve graft to the intact palpebral branch and end-to-end coaptation to the denervated palpebral branch. Group III dogs (n = 5) underwent end-to-end coaptation of the nerve graft to the intact palpebral branch and end-to-end coaptation to the denervated palpebral branch. Group IV dogs (n = 5) underwent end-to-side coaptation of the nerve graft to the intact and denervated palpebral branches. The animals were monitored for 9 months after the surgical procedures, to allow adequate time for reinnervation. The dogs were postoperatively monitored with clinical observation, electrophysiologic testing, video motion analysis, and histologic assessments. Clinical observation and electrophysiologic testing demonstrated the production of an eye blink in the denervated hemi-face in all experimental groups. There was a trend toward increased speed of reinnervation for group III animals (end-to-end coaptations). It was concluded that end-to-side coaptation can produce a contralateral synchronous eye blink in a clinically relevant, large-animal model.

Restoration of blink in facial paralysis patients using FES

Six subjects with profound facial paralysis were tested to determine the feasibility of restoring functional blink via electrical stimulation of the orbicularis oculi muscle (OOM) without also evoking painful sensations. Stimulation of the paretic eyelid was triggered by EMG detection of blink in contralateral healthy OOM to deliver charge during inhibition of the levator palpebrae antagonist. Transcutaneous and percutaneous stimulation electrode placements were tested during multiple stimulation trials in subjects. Stimulation was delivered via two constant voltage computer controlled channels. Sensory activation thresholds were approximately an order of magnitude lower for percutaneous stimulation (0.4 V) vs. transcutaneous stimulation (3 V). Exploration of multiple possible stimulation paradigms yielded a means by which sufficient muscle activation could be recruited to evoke complete eyelid closure without producing prohibitively painful sensation. Stimulation efficacy across subjects correlated with degree of patient neuromuscular recovery following initial paresis.

Facial transplantation: an anatomic and surgical analysis of the periorbital functional unit.

Background: Complete loss of eyelid pair is associated with chronic discomfort, corneal ulceration, and visual impairment. Contemporary reconstructive techniques rarely provide functionally acceptable results. Composite tissue allotransplantation may provide a viable alternative. This study reports on neurovascular anatomy and technical details of harvesting an isolated periorbital unit and discusses its functional potential. Methods: Twenty-four hemifaces (12 fresh cadavers) were dissected to study surgically relevant neurovascular structures and to develop an efficient harvest method. Angiographic analysis was performed in seven hemifaces following harvest. Results: The superficial temporal and facial vessels demonstrated consistent location and diameters. Anatomic variability was characterized by the absence of the frontal branch of the superficial temporal artery or facial-to-angular artery continuation, but never of both vessels in the same hemiface. Angiographic analysis demonstrated filling of the eyelid arcades, provided the anastomoses between the internal and external carotid branches were preserved. The facial nerve exhibited consistent planar arrangement and diameters in the intraparotid and proximal extraparotid regions, but less so in the distal nerve course. The inferior zygomatic and buccal branches frequently coinnervated the orbicularis oculi and lower facial muscles with an unpredictable intermuscular course. Based on the foregoing, an effective surgical harvest of the periorbital composite was developed. Conclusions: Surgical harvest of a functional periorbital allotransplant is technically feasible. Revascularization of the isolated periorbital unit is influenced by variations in regional anatomy and cannot be guaranteed by a single vascular pedicle. The orbicularis oculi muscle and its innervation can be preserved, and recovery, albeit without the certainty of reflexive blinking, is expected.

Restoration of orbicularis oculi function by contralateral orbicularis oculi innervated muscle flap vs neuromuscular pedicle technique

In preliminary experiments with dogs and cats, unilateral paralysis of the orbicularis oculi muscle group was produced by a section of the seventh nerve that included the posterior auricular branch. Either one of two procedures was then employed in attempts to reinnervate the paralyzed eyelid. In one group of animals, a neuromuscular pedicle was employed and in another, a contralateral orbicularis innervated muscle flap was used. Both methods restored synchronous, reflex blinking to the denervated eyelid. Of the two procedures, neurotization appears to offer the greater promise because the use of a neuromuscular pedicle requires an expendable nerve that is functional, and no such suitable substitute is available in humans.

Pedicle Flaps Contribute to Endoscopic Skull-Base Surgery and Facial Soft-Tissue Repair: The Diuturnity of Johannes Fredericus Samuel Esser (1877–1946)

Pedicle flaps based on the external maxillary (facial) artery were introduced during the World War I, precisely a century ago. Today they remain effective tools in facial soft-tissue repair. Recently, pedicle flaps based on the internal maxillary (sphenopalatine) artery have been chosen to reliably close dural defects after endoscopic skull-base surgery. Pedicle flaps, “biologic” to the extent they are based on a defined arterial blood supply, are the lasting contributions—the diuturnity”of Johannes (“Jan”) Fredericus Samuel Esser (1877–1946) of Leiden, Holland, and Chicago (IL).