Robert M. Schwarcz

Periocular abscesses following brow epilation.

Purpose: The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation. Methods: This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation. Results: Twenty-six female patients with a median age of 20.5 (range, 12–73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis. Conclusions: Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study’s cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

Stop Blaming the Septum

Purpose: To identify if isolated surgical violation of the orbital septum predisposes to “middle lamellar” scarring and subsequent postblepharoplasty lower eyelid retraction. Methods: A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. Results: Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. Conclusions: Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to “isolated” orbital septal scars (middle lamellar scars). Their designation as a “multilamellar scar” is more appropriate.

Upper Eyelid Fractional CO2 Laser Resurfacing With Incisional Blepharoplasty.

Purpose: Laser resurfacing, performed at the same time as blepharoplasty, has most commonly been applied to the lower eyelid skin but can effectively be used on the upper eyelid to reduce rhytidosis and improve skin quality. The authors evaluate the safety and efficacy of this procedure. Methods: Fractional CO2 laser resurfacing was performed in conjunction with incisional upper blepharoplasty. The ultrapulsed laser energy was applied to the sub-brow skin, the upper medial canthal skin, and the pretarsal skin in 30 patients. Photos were obtained preoperatively and at 3 months. Results: All patients demonstrated reduction in upper eyelid rhytidosis without any serious complications. Independent rhytidosis grading (0–4) showed a mean improvement of 42%. One patient experienced wound dehiscence that satisfactorily resolved without intervention. Conclusions: Upper eyelid laser resurfacing is effective and can be safely performed at the same time as upper blepharoplasty. This approach reduces or eliminates the need for medial incisions to address medial canthal skin redundancy and rhytidosis and it directly treats upper eyelid wrinkles on residual eyelid and infra-brow skin during blepharoplasty.

Malar Festoons: Anatomy and Treatment Strategies

Introduction: To describe the anatomic basis for malar festoons and mounds and to review the available options for surgical correction. Materials and Methods: A review of relevant literature was performed to identify previously documented corrective measures for malar festoons and mounds. Results: A wide variety of methods exist for reducing malar festoons. Discussion: Each procedure for minimizing festoons has a rationale that addresses one or more anatomic features, but none represents a method that results in universal correction. A multimodality approach may be favorable based on specific patient findings.

The SOOF Lift in Midface Reconstruction and Rejuvenation

The suborbicularis oculi fat (SOOF) lift, also known as the midface lift, mobilizes the midface structures in a superior fashion and fastens them to the orbital rim The outcome of any cosmetic or reconstructive procedure should center around patient satisfaction Access routes to the SOOF lift can be achieved in a variety of planes and entry points Superiorly the point of entry can be attained transconjunctivally, temporally, or via an infralash incision Inferiorly access can be gained by a sublabial approach, and this can be combined with an eyelid, or temporal, incision for a more robust lift The SOOF or midface lift provides an excellent tool for approaching midface descent

Reply re: "Stop Blaming the Septum".

To the Editor: The authors have reviewed Dr. Steinsapir’s letter and have identified 3 areas with which he takes issue. First, and what appears to be the foremost of Dr. Steinsapir’s concerns, is that he believes the journal, OPRS, failed the authors and its readership by not mandating institutional review board oversight prior to publication of this manuscript. The authors cannot directly speak for the Journal or its Editor, but believe the issue of institutional review board approval and its attainment by private practioners who care for patients outside of a formal institution, has been raised previously, and then addressed with policy defined by its Editor, Dr. Jonathan Dutton, in a commentary on this subject in OPRS in 2013. In this publication, Dr. Dutton defines “OPRS RESEARCH PUBLICATION POLICY.” Dr. Dutton states: “If an author is in private practice and all clinical and surgical procedures are performed in that private practice, and there is no federal funding for the research, then institutional review board oversight is “not required” for the use of patient medical information for the research study. If no institutional review board is required or none is available at your institution, then a statement to that effect and a statement that the research adhered to the tenets of the Declaration of Helsinki as amended in 2008 should be included in the Methods section of the article.” Dr. Steinspair also expresses concern regarding the authors performing forced traction tests in the study. Dr. Steinsapir states that this is “inconsistent with routine oculoplastic practice, and not a routine part of clinical eyelid assessment in postblepharoplasty patients.” While the authors respect Dr. Steinsapir’s viewpoint, they know each other, are colleagues, routinely discuss clinical situations and controversies, and have independently, or as a group, discussed their concern with the long standing perception that an isolated middle lamellar or “septal” scar is a core cause of eyelid retraction after blepharoplasty. As a result, they have performed forced traction tests in postsurgical patients in this setting to assess their belief. After discussing that anecdotal clinical experience supported their supposition, they embarked on the study. Finally, Dr. Steinsapir states “the authors withheld important details concerning how the forced traction test was performed.” The authors referenced this general maneuver in the body of the manuscript,2 which the authors felt was sufficient for a test most experienced eyelid surgeons are familiar with. In this reference, the maneuver is illustrated (although not described). There are space limits in journals and if readers cannot rely on references to known information, then journal articles would swell in volume when repeating such information. In addition, the Journal review process agreed with the authors in this instance, as it did not feel as strongly as Dr. Steinsapir regarding this omission. For this reason, the authors do not feel this is a transgression on their part, but understand others may have the same concern as Dr. Steinsapir. As such, for those who are not familiar with the forced traction test, it is simply a forced upwards distraction of the lower eyelid to assess its superior mobility. Dr. Steinsapir is correct in stating that an elaboration of when the last postoperative forced traction test was performed by each author is lacking. This was not standardized by the authors and they accept this oversight. However, it does not change the main study finding (which is all the report suggests) that isolated septal violation during transconjunctival blepharoplasty (i.e., preseptal approach surgery) did not lead to healing from the surgery should have taken place. I think performing such a test immediately after surgery would have little value. The timing of this test is a critical issue. For that reason, a 70% participation in this test postsurgery stands out. The authors withheld important details concerning how the forced traction test was performed. The authors state that this was a retrospective study, and not, therefore a clinical trial. That requires the reader to believe that forced traction testing of the eyelid is a routine part of the postoperative assessments by all the authors of this study. This is inconsistent with routine oculoplastic practice. Performing a so-called finger on cotton applicator pushup of a lower eyelid is not a routine part of clinical eyelid assessment and generally is only performed when there is lower eyelid malposition. It is hard to believe that such a manipulation was routinely performed for patients with completely normal eyelids postoperatively in 202 cases. Even in the setting of prospective studies, it is exceptionally common to have incomplete datasets for 1 reason or another. Collecting this information in anticipation of a study implies a prospective study design and would be in conflict with how the authors state their study was performed. It is asking a lot of the readers to believe that such a complete dataset from 4 different surgeons regarding a nonroutine eyelid measurement was available without advanced coordination. The authors did not address if they routinely performed assessment on 100% of patients prior to surgery. Presumably they would have wanted to exclude from study patients with abnormal “forced traction tests” found preoperatively so as to not falsely attribute the eyelid tethering to surgery. Either way, I think reasonable readers should have questions about the validity of this data. While I respect the ultimate clinical conclusion of these authors regarding septal scaring, I do have questions about the data they relied on to reach this conclusion. Ultimately the authors have to be accountable for these questions. However, The Journal and its peer review process have failed them by not more closely scrutinizing this study prior to publication. The Journal should explain to readers why this article does not follow the published standards regarding institutional review. I think there are sufficient and material questions concerning the study that publication should be suspended pending careful editorial reassessment of this article to protect the integrity of The Journal. The authors should have an opportunity to defend their article and conform it to the published standards regarding human subject investigation, or voluntarily withdraw the article from publication. It is ethically incumbent of the authors to disclose to their potential IRB the details of this controversy so it can be addressed in a formal posthoc review of the study. Journal policy regarding human subject protection is there to protect all the stakeholders in this process: study subjects, investigators, The Journal, the medical community, and the public.

A New Paradigm of Surgical Management of the Atonic Face

Introduction: Consequences of facial paralysis are functionally and cosmetically debilitating. Surgical facial suspension in patients with facial nerve palsy is characterized by inexorable recurrent descent of the atonic tissues. Despite numerous variations on techniques that have been attempted over the years, including muscle and fascia flaps, deep plane or periosteal dissection, and multiple vector fixation, we have been disappointed to note substantial or complete loss of improvement effect over 1–2 years. This experience has allowed us to reassess the basic philosophy of rehabilitation for patients with facial paralysis. If the most robust and invasive surgeries are not adequately permanent to avoid the need for frequent reoperation, then perhaps a rational approach is to accept and anticipate the need for repeat procedures and use minimally invasive procedures that are designed for maintenance reoperations. Materials and Methods/Results: We report our experience with a layered multivector cable suture suspension technique to address the atonic descent of the eyebrow, eyelid, midface, and lower face in patients with facial palsy. We describe 2 approaches, a Keith needle with either Gortex or a nylon suture passed from nasolabial fold to deep temporalis fascia and a procedure involving multivector cables. To address the ocular complications in the atonic face, we review upper and lower eyelid adjunctive techniques. For facial paralysis, solutions to address ocular issues include placement of gold weight to upper eyelid, skin graft to upper eyelid, midface-lift, and lower eyelid slings. Finally, to address the lateral oral commissure droop, we discuss a localized technique involving upward positioning of the area by removal of an ellipse of tissue down to the level of the orbicularis oris muscle. Discussion: We discuss our experiences in addressing the upper face, midface, and lower face regarding static reanimation surgery of the atonic face with multivector cables and other modalities to provide a systematic approach. Many of these techniques can be used on the cosmetic patient as well.