Sang-Rog Oh

Analysis of eyelid fat pad changes with aging.

Purpose: Few studies have focused on the aging changes in the upper eyelid. This study evaluated the differential changes in the nasal and central fat pads of the upper eyelid associated with aging. Methods: In this retrospective, consecutive series, the medical records and photographs of 77 patients were reviewed. The patients were grouped in 7 categories according to decade of life. Using a standardized scale, the volume grade of the nasal and central fat pads was graded from 0 to 3. Statistical evaluation correlating age with central and nasal fat pad change was performed. Results: With aging, the central fat pad volume appeared to diminish, with relative sparing of the nasal fat pad. There was a positive correlation of the volume grade of the nasal fat pad with age and a negative correlation of the central fat pad with age. In addition, there was a statistically significant difference between the volume grades of the nasal and central fat pads in the groups 70 years and older. Conclusions: With aging, there appears to be a pattern of differential fat pad alteration. This study shows that in the upper eyelids of patients >70 years of age, the medial fat pad becomes prominent whereas the central fat pad atrophies. Teleologically, the relative preservation of nasal fat may be due to its higher abundance of neural-crest progenitor cells. Clinically, this finding has implications in esthetic and functional upper eyelid blepharoplasty.

Spontaneous superior ophthalmic vein thrombosis: a rare entity with potentially devastating consequences.

PurposeSpontaneous superior ophthalmic vein thrombosis (SOVT) is a rare entity. We describe three patients with spontaneous ophthalmic vein thrombosis, each with various risk factors.Patients and MethodsA retrospective review of three patients with a diagnosis of superior ophthalmic vein thrombosis. Clinical characteristics, radiographic features, management techniques and outcomes are described.ResultsAll patients presented with unilateral painful proptosis. Two patients had intact light perception, whereas one patient presented with absent light perception. All patients had identifiable risk factors for thrombosis, which included sickle cell trait, hereditary hemorrhagic telangectasia and colon cancer with recurrent deep vein thrombosis. Anticoagulation was initiated in two patients. Resolution of proptosis was seen in all patients, with no recovery of vision in one patient.ConclusionsRisk factors for spontaneous superior ophthalmic vein thrombosis are multifactorial. MRI and MRV confirm the diagnosis of SOVT. Despite urgent intervention devastating visual loss may occur.

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

Background: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising. Methods: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient. Results: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months. Conclusions: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.

Reduction of Orbital Inflammation following Decompression for Thyroid-Related Orbitopathy

Purpose. Thyroid-related orbitopathy (TRO) is associated with inflammation, expansion of orbital fat, enlargement of extraocular muscles, and optic neuropathy (ON). We examined the effects of orbital decompression on the inflammatory and congestive signs of TRO in patients who underwent emergent orbital decompression. Methods. This retrospective, consecutive study included patients with ON from TRO who underwent orbital decompression. Pre- and postoperative orbital inflammatory signs in the operated and nonoperated, contralateral eyes were graded with the 10-item clinical activity score (CAS). Results. Thirty-one orbits were included. Postoperatively, 22 patients and 29 orbits had resolution of ON while the remaining 2 patients had improvement in visual acuity. Mean preoperative CAS was 9.5 ± 0.4. At 12 months, postoperative CAS was 2.1 ± 0.6 (P < 0.01) in the operated eye and 3.2 ± 0.5 (P < 0.05) in the nonoperated, contralateral eye. Conclusion. In our series, 94% of orbits had resolution of ON. There was also a statistically significant postoperative reduction in the CAS in both the operated and nonoperated, contralateral eyes. This phenomenon may be due to lowered venous congestion, decreased intraorbital pressure, and diminution in inflammatory factors.

Surgical Approaches to the Orbit and Optic Nerve

In 1888, Kronlein introduced the concept of lateral orbital rim removal to access deep orbital lesions. While this approach is still employed to this day, today’s aesthetically oriented orbital surgeon has a myriad of new minimally invasive techniques in their armamentarium. Orbital imaging continues to improve with more sensitive and higher resolution computed tomography (CT) and magnetic resonance imaging (MRI) scanning technologies. Multidisciplinary collaborations have facilitated newer surgical approaches through the sinuses and transcranial routes. Technological advancements in the instrumentation of today’s orbital surgeon have also improved in the 15 years since the last edition of this chapter. Finally, advances in anesthesia techniques have allowed more cases to be performed in an outpatient setting with less sedation.

Anatomy of the Midface

Sound working knowledge of the bones, muscles, vasculature, innervation, fat depots, and retaining ligaments of the face is the cornerstone to precise, reproducible, and aesthetic surgical results.

The man who could not see what he could not eat.

A 55-year-old Hispanic man born in New Mexico presented with progressively worsening bilateral upper eyelid ptosis and dysphagia. External levator advancement 5 years before did not improve his ptosis. A thorough systemic workup for myasthenia gravis was negative, but electromyography suggested a myopathic process. Molecular genetic testing was positive for oculopharyngeal muscular dystrophy.

Thyroid-related orbitopathy: a multidisciplinary perspective

Advances in immunologic and genetic research have revealed a newer understanding of the pathophysiology of thyroid-related orbitopathy. In addition, oxidative stress and its deleterious effects may contribute to the progression of thyroid-related orbitopathy. Yet clear perception of its risk factors and exact etiology have not been fully appreciated. Targeted medical and surgical therapies have allowed for better treatment and rehabilitation from this unremitting disease. However, a universal clinical assessment tool and protocol would greatly improve referral patterns to specialists and aid in clinical study outcome measures. Like other systemic disease processes, a multidisciplinary approach allows optimal care for patients in all stages of thyroid-related orbitopathy.

The trans-septal approach to the orbital apex via the contralateral exenterated orbit.

Purpose: To report a unique approach to the orbital apex through the contralateral orbit. Methods: A 65-year-old male presented with right compressive optic neuropathy due to nasopharyngeal carcinoma spread. Clinical evaluation and imaging showed a right orbital apex mass. Surgery included apical orbital tumor debulking, and orbital decompression performed via the contralateral exenterated side. Postoperatively, symptoms were relieved. Conclusions: Orbitotomy via the contralateral exenterated orbit should be considered as a surgical option in these unique patients requiring direct access to the orbital apex.

Applied anatomy for the aesthetic surgeon.

Purpose of review With the expanding view of the oculofacial surgeon as experts in the realm of aesthetic surgery, familiarity with facial anatomy is essential. The purpose of this review is to present an update on the relevant facial anatomy and its application on rejuvenation. Recent findings Numerous studies have redefined facial morphology and variations in facial features, which are important when treating all aesthetic patients. This particularly becomes valuable when patients of differing ethnic origins present for evaluation. Enhanced surgical options are now available that have expounded on previous work on skeletal and fascial attachments of the face that occur with aging. Additionally, an improved understanding of facial anatomy has led to safer and more effective surgical procedures to anatomically restore youth to the aging face. Conclusion Anatomic and anthropomorphic knowledge is constantly improving in the realm of oculofacial plastic surgery. Newer insights into the treatment of facial aging have resulted from the application of an ever-expanding understanding of facial anatomy.