Shubhra Goel

The 18-gauge needle: an innovative simple tool for frontalis sling surgery.

Purpose: The aim of this study was to introduce the use of the 18-gauge hypodermic needle as a simple and cost-effective alternative tool in frontalis silicone suspension ptosis surgery. Methods: A retrospective, interventional, noncomparative case study was performed by reviewing 64 patients (82 eyes) who underwent this technique between February 2010 and January 2011. Patients with simple, severe congenital ptosis with poor levator excursion were included in the study. Patients with prior sling and levator resection surgery were excluded. All patients underwent unilateral or bilateral frontalis sling surgery with a silicone rod placed via a closed-incision pentagonal configuration. All surgeries were performed by a single surgeon at a tertiary referral institute using the 1.5 inch hypodermic 18-gauge needle as an insertion guide for the silicone rod. Intraoperative technique, ease of surgical maneuverability, operative time, and postoperative results and complications were noted. Results: The mean patient age was 10.3 years (range: 1–28 years). Fifty-six of 64 patients (87.5%) were between the ages of 1 and 18 years (mean: 8.5 years), and 8 of 64 (12.5%) between 9 and 28 years (mean: 23 years). Forty-two of 64 (65.7 %) patients were female and 22 of 64 (34.4%) were male. Forty-six of 64 (71.9%) patients underwent unilateral frontalis sling surgery and 18 of 64 (28.1%) patients underwent bilateral surgery. Follow up ranged from 12 to 18 months. In 2 of the 82 eyes (2.4%), the sharp end of the needle cut the silicone rod while introducing the needle from the medial suprabrow stab incision to the eyelid margin end in a closed technique, requiring replacement of the silicone rod. Average surgical time was 15 minutes for unilateral cases and 30 minutes for bilateral cases. The main advantages noted intraoperatively were the small incisions that allowed for less operative time and minimal bleeding, easy maneuverability and control of the needle during tissue passage, and smooth threading of the silicone rod. Blunting of the tip is also eliminated as the needles are disposable. Conclusions: The 18-gauge hypodermic needle is a simple and cost-effective alternative to other needles used in frontalis silicone sling ptosis surgery. Its low cost and easy accessibility make it a particularly quick and useful option in community-based practices, tertiary referral centers, and large medical eye camps globally.

Unusual case of persistent Horner's syndrome following epidural anaesthesia and caesarean section

This is a rare case of persistent Horners syndrome following epidural anesthesia and Caesarean section. A 33-year-old female presented with persistent ptosis and miosis following epidural anesthesia and Caesarian section several months prior. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of head, neck, and chest were unremarkable. Medline search using terms Horner’s, epidural, spinal anesthesia, delivery, childbirth, Caesarian, and pregnancy identified 31 articles describing Horners syndrome in obstetric epidural anesthesia, of which 11 were following Caesarean section. The increased incidence of Horners syndrome in the setting of epidural anesthesia in pregnancy may be related to epidural venous engorgement and cephalic spread of the local anaesthetic, with disruption in the oculosympathetic pathway. It is important to include recent epidural anesthesia within the differential diagnosis of acute Horners syndrome in a postpartum female. Rarely, the ptosis may be permanent and require surgical intervention.

Modified Short-Scar Face-Lift: Technique, Pearls, and Outcomes

Introduction: The modified small-incision face-lift is a safe, effective, minimally invasive way to treat facial rhytidosis in carefully selected patients. The purpose of this study is to describe a modified small-incision face-lift technique. Materials and Methods: Institutional review board– approved retrospective case series. Results: Twenty-six patients underwent a modified small-incision face-lift. The average age of the patients was 62.1 years. Two patients developed hypertrophic scarring requiring surgical revision. There were no other complications, including infection, wound dehiscence, or flap necrosis. Patient satisfaction with the procedure was high. Conclusions: The modified short-scar face-lift is a safe and effective procedure that can be done in the office with or without sedation and requires less recovery time than traditional face-lift techniques.

Practical Anatomy of the Face and Eyelids: Cosmetic Applications

The evolving shift towards less invasive procedures for aesthetic facial rejuvenation naturally demands a more sophisticated understanding of facial anatomy. The outcome of any surgical or nonsurgical procedure can be optimized with a detailed understanding of the anatomical framework. An artistic and logical appreciation of the anatomical facial structures and their morphological variations is important in choosing and performing any procedure. This chapter highlights the practical anatomy of the upper and midface relevant to oculofacial cosmetic surgery.

Reply Re: "The 18-gauge needle: an innovative simple tool for frontalis sling surgery".

To the Editor: We read with interest the article titled “The 18-Gauge Needle: An Innovative Simple Tool for Frontalis Sling Surgery” that was published in the Ophthalmic Plastic and Reconstructive Surgery journal. We would like to congratulate the authors for introducing yet another useful version of using an 18-gauge needle for silicone sling surgery among others. The authors have used the silicone rod provided by BD Visitec that comes with a preswaged needle at either end. The main disadvantage of this preswaged 20-gauge needle is its excess malleability, which makes the passage difficult. The authors have detached the silicone rod from the needle to feed it through a disposable 18-gauge needle into a pentagon fashion and report a reduced intraoperative time. We believe that the time taken to detach the silicone sling from the needle and thread the much flexible silicone rod into the 18-gauge needle is more likely to slow down the procedure. We have been following the alternative technique of retaining the preswaged needle, and “railroading” it with a disposable 18-gauge needle passed from the opposite stab incision (Fig.). This technique has worked well for us, while retaining all the advantages of using an 18-gauge needle. Since the BD Visitec silicone rod is available with preswaged needle at either end, and a length sufficient for a bilateral surgery, it may not be necessary to detach the silicone from the needle unless one is using an indigenous cost-effective spool of silicone rod for multiple cases. Such situations of a surgical “camp” are certainly on the decline, even in developing countries. The only situation where one might want to use the technique described by the authors is during a revision surgery, where the same silicone rod is being reused to make a fresh pass along the incisions. We have experienced that using the 18-gauge needle to enter from a smaller incision (lateral/medial brow stab) to a larger one (central brow stab) certainly reduces the chances of “dimpling” due to dermal entrapment that can occur in the conventional technique. Finally, we would like to mention an additional use of 18-gauge needle in performing a transnasal wiring for medial canthal dystopia (Fig.). The sharp tip of the needle helps penetrate the bone easily, without the need for mechanized drilling across the nasal bridge. It allows controlled and easy passage of 26-gauge stainless steel wire or 4-0 polypropylene suture for canthal fixation. We commend the authors for sharing their experience and propose that railroading might be a quicker option. We hope that this correspondence reaches BD Visitec, and we have a less malleable preswaged needle in the near future! re: “The 18-Gauge Needle: An innovative simple Tool for Frontalis sling surgery”

Subcaruncular Approach for Medial Eyelid Repair: A Simplified Technique

Introduction: Laxity of the medial canthal tendon (MCT) is commonly encountered in clinical practice. The techniques described in the literature to correct MCT laxity often involve extensive dissection, with potential risk to the lacrimal system. We describe a simple and minimally invasive MCT repair in which the medial eyelid is secured to the anterior central portion of the MCT via a subcaruncular approach without disturbing the normal eyelid position or the lacrimal system. Materials and Methods: A retrospective analysis of 30 patients undergoing MCT repair in all 4 eyelids was performed. Eyelids with moderate to severe MCL laxity were treated by this technique. Results: Patient age ranged between 55 and 90 years, with a mean of 74.2 years. Upper lid distraction ranged from 8–20 mm (mean 13 mm). Lower lid distraction ranged from 14–30 mm (mean 23.4 mm). In 87% of patients, eyelid laxity diminished postoperatively, and 13% had incomplete correction of the laxity with recurrence of symptoms. Recurrence w...