Tammy H. Osaki

Treatment of the Tear Trough Deformity With Hyaluronic Acid

BACKGROUND Volume loss and muscular hyperactivity are two major components of the aging process that contribute to the formation of the folds and wrinkles. Tear trough deformity is one of the most difficult depressions to correct surgically. OBJECTIVE The authors evaluate the results of periorbital filling with hyaluronic acid (HA) in a small series of patients. METHODS Between June 2008 and December 2009, 25 patients were treated with HA to correct tear trough deformities. The HA was administered into the preperiosteal tissues with a serial puncture technique and approximately 0.1 mL was injected at each pass. Each patients before and after photographs were reviewed by three surgeons; to objectively assess the outcomes, a quantitative scale was used to grade the pre- and postinjection results. The significance of subjective aesthetic evaluation of the photographs was evaluated with the Mann-Whitney U-test. Differences were regarded as significant if probabilities were less than 0.05. RESULTS The mean (SD) volume per side needed to achieve correction was 0.54 (0.27) mL on the right and 0.61 (0.30) mL on the left. Complications included some degree of bruising, erythema, and local swelling. Most patients (88%) had cosmetic improvement according to the independent evaluation. CONCLUSIONS All patients were very satisfied with their results. During the course of the study, the authors determined that the ideal candidates for this treatment are young, with thick skin and a definite hollow.

Immunohistochemical investigations of orbital infantile hemangiomas and adult encapsulated cavernous venous lesions (malformation versus hemangioma).

Purpose: Immunohistochemical studies have begun to advance knowledge regarding the pathogenesis of vascular anomalies in many anatomical regions. However, the immunohistochemical features of most orbital tumors have been overlooked. Therefore, a comparative immunohistochemical study of a series of the 2 most common orbital vascular lesions— infantile hemangioma (IH) and encapsulated cavernous venous lesion (ECVL), the latter also termed cavernous hemangioma or venous malformation—was undertaken. Methods: Twenty surgically excised orbital tumors diagnosed clinically and histopathologically as IHs (10 cases) or “cavernous hemangioma” (10 cases) were evaluated pathologically and immunohistochemically using hematoxylin and eosin, Alcian blue, Masson trichrome, GLUT-1, CD31, CD34, D2-40, smooth muscle actin (SMA), desmin, and Ki-67 probes. Results: All cases reacted strongly with the traditional blood vessel endothelial markers CD31 and CD34 and were negative for D2-40, a selective marker for lymphatic endothelium. All IH were positive for GLUT-1, and all ECVL were negative for GLUT-1. In IH, SMA (but not desmin) stained a monolayer of pericytes and in ECVL multilaminar smooth muscle vascular mural cells and intravascular (interstitial) stromal cells. Nuclear Ki-67 immunostaining was strongly positive in IH (average of 16.3%) and close to zero in ECVL. Conclusions: Immunophenotypic results for ECVL and IH demonstrated no overlapping staining patterns. Infantile hemangioma had the classical architecture of capillaries. Because of the constant presence of mural smooth muscle, it was concluded that ECVL is an accurate and descriptive term. However, desmin negativity in ECVL indicates myofibroblastic differentiation rather than full-fledged smooth muscle differentiation. Infantile hemangioma may display ectatic channels as the lesion ages but does not acquire multilaminar smooth muscle walls. Its pericytes lack cytoplasmic filaments and desmin reactivity but are SMA-positive because of the presence of poorly polymerized actin in the cytosol. In IH, Ki-67 positivity was observed in the endothelial cells of the solid and more ectatic regions. In contrast, the virtual absence of Ki-67 positivity in ECVL lends further support for the interpretation that it is more closely related to a malformation than a benign neoplasm.

Comparison of methodologies in volumetric orbitometry.

Purpose: The rate at which the orbit matures is not well-documented. Limiting this pursuit are the difficulties inherent in measuring orbital volumes accurately. This study compared 3 common methods of determining orbital volume and sought to identify an accurate, practical manner for doing so. Methods: The volume of 1 orbit of 8 human cadaver heads was independently measured using 3 different methods: 1) CT was performed, and images were analyzed with 3-dimensional (3D) volumetric software; 2) The same orbits were then exenterated and a silicone cast was taken. The cast volumes were measured by water displacement; 3) The orbits were then filled with 1-mm glass beads that were transferred to a graduated cylinder where their volume was determined. The data were analyzed statistically. Results: Intraobserver agreements were good for both beads and casts. Interobserver agreements were good for both beads and CT (p > 0.05). Values obtained using the bead method were equal to values obtained using the cast method (p > 0.05). However, agreement between direct (orbital fillers and casts) and indirect measurements (radiographic techniques) was not satisfactory (p < 0.05). Conclusions: Independent of method, determining orbital volume is inherently difficult owing to the hyperbolic parabola that is the orbit entrance; all methods require estimation. Glass beads and casts yielded more reproducible values but can only be used in cadavers. CT measurement is prone to error due to the variability of methodologies used but allows access to enormous testing populations. Interstudy comparison is currently not possible. CT volumetric software with strict universal standards for estimating the anterior limit of the orbit appears to be the best method of studying human orbital volumes.

Self-irrigating piezoelectric device in orbital surgery.

Purpose: Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral and maxillofacial surgery, piezoelectric technology offers a greater margin of safety than traditional bone cutting instruments. The authors describe the novel use of this system in a variety of orbital surgeries. Methods: This interventional case series was performed in accordance with institutional review board regulations. The medical records of all patients who had undergone orbital surgery using the piezoelectric blade at 3 institutions were reviewed. Indication for surgery, gender, age, duration of follow up, intraoperative complications, surgical result, and postoperative course was recorded. Results: Sixteen patients underwent surgery on 18 orbits using the piezoelectric system between August 2011 and June 2012. Surgeries performed included orbital decompression (8), lateral orbitotomy (5), cranio-orbitotomy (4), and external dacryocystorhinostomy (1). Eight were female and 8 were male patients. Mean age was 55 years old (standard deviation 15 years). Mean follow up was 82 days. The osteotomy created by the blade was narrow and smooth in every case. The surgeons uniformly appreciated the precision and safety of the instrument compared with traditional electric saw blades. There were no soft tissue lacerations or intraoperative complications and reconstructions were uniformly uneventful. Postoperative healing was rapid with no unexpected inflammation, and no palpable bony defects were appreciated in the reconstructed cases. Conclusions: Because it does not cut soft tissue and cuts a narrow trough, the self-irrigating piezoelectric saw blade appears safer and more precise than traditional electric saw blades in and around the orbit.

Orbital development as a function of age in indigenous North American skeletons.

Purpose: Infants with orbital hemangiomas and vascular malformations often develop expanded orbits or regional hyperostosis. Treatment in these cases depends, in part, on the stage of orbital development at the time of intervention; yet, orbital development with respect to age is not well-known. The authors sought to determine the rate of orbital development and the age of orbital maturation in a single ethnic population. Methods: Skeletons recovered in North America and housed at the Peabody Museum of Archaeology and Ethnology, Harvard University, were inspected. The age of specimen was determined by dentition. Orbital volume was measured using 1-mm glass beads and a graduated cylinder. Linear measurements were taken with calipers and paper rulers. The measurements were plotted against age, and statistical analysis was performed. Relevant literature was reviewed. Results: Of the hundreds of skeletons examined, 42 were sufficiently intact for orbital measurement. The specimens represented a period of up to 1000 years. Thirty-two were pediatric (defined prenatal to 18 years) and 10 were adults. Mean adult orbital volume was 26.2 ml. Based on the regression analysis, 60% of adult orbital volume was achieved at 4.35 years, 75% at 9.36 years, and 90% at 17.13 years of age. Linear dimensions progressively increased with age. Conclusions: This largest direct-measure study of pediatric orbital volume suggests that orbital growth continually decelerates from birth until maturity at 22 years. With 50% of orbital growth occurring by 16 months of age, surgeons removing periocular vascular anomalies after that age should consider concurrent skeletal management.

Management of progressive myopathic blepharoptosis with daily application of octyl-2-cyanoacrylate liquid bandage.

Purpose: To describe the results of a conservative and reversible technique for the treatment of progressive myopathic blepharoptosis in cases when surgery is not indicated, using octyl-2-cyanoacrylate liquid bandage. Methods: Ten consecutive patients with progressive myopathic blepharoptosis were studied. Octyl-2-cyanoacrylate liquid bandage was applied to the upper eyelid to create a deeper eyelid crease. Margin reflex distance, photographs, and visual fields were obtained prior to and after treatment. Results: All patients described a better appearance after application of the product, and none had an allergic response. All cases had an increase in the margin reflex distance and improvement in visual fields. Conclusion: Octyl-2-cyanoacrylate liquid bandage is an alternative method that is simple, safe, and effective in the management of severe blepharoptosis. Moreover, it can be used in patients without systemic conditions or those who are unwilling to undergo a surgical procedure.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

Purpose: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). Methods: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. Results: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96–28.90 mm) right and 21.22 mm (15.87–28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948–0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92–30.88 mm) right and 20.30 mm (8.61–28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991–0.989). All exophthalmometers’ mean differences from CT ranged between −0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. Conclusions: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Infrabrow Skin Excision Associated With Upper Blepharoplasty to Address Significant Dermatochalasis With Lateral Hooding in Select Asian Patients

PURPOSE In Asian patients, lateral hooding in the aging upper eyelid is prominent and frequently seen. Removal of the redundant skin of this region during classic blepharoplasty tends to produce a resultant prolonged scar. Furthermore, as the height of the eyelid skin excision increases, suturing of the thick upper skin to the thin pretarsal skin can result in upper lid fullness. This study documents the combination of infrabrow skin excision and upper blepharoplasty to address lateral hooding in select patients of Asian ancestry. METHODS This study is a retrospective chart review of patients who underwent infrabrow skin excision associated with upper blepharoplasty. The inclusion criteria were moderate and severe upper eyelid dermatochalasis in patients with high eyebrows and lateral hooding; residual lateral hooding following previous blepharoplasty. RESULTS Thirty-two eyelids of 16 female patients of Japanese ancestry underwent infrabrow skin excision associated with upper blepharoplasty. The mean age of patients was 68.87 ± 7.88 years (57-82 years). Mean follow up was 37.25 ± 18.96 months (9-72 months). Patients were evaluated at 1, 3, 6, and 9 months at least. The Strasser system for evaluation of surgical results was applied at 3 months. All patients had scores indicating good results and were satisfied with the cosmetic outcome and improvement of visual field after surgery. No complications related to wound dehiscence, lagophthalmos, hypertrophic scars, or sensory changes were observed. CONCLUSION The combination of infrabrow skin excision and upper blepharoplasty was effective to address moderate and severe dermatochalasis with lateral hooding in select patients of Japanese ancestry.

Influence of involuntary eyelid spasms on corneal topographic and eyelid morphometric changes in patients with hemifacial spasm

Background/aims In patients with hemifacial spasm (HFS), treatment relieves eyelid spasms on the affected side, thus changes in corneal topography and eyelid morphometry may be observed after treatment. We aimed to evaluate these parameters during a 4-month period in patients with HFS treated with botulinum toxin A (BTX-A). Methods This prospective study evaluated eyelid morphometric and corneal topographic changes in patients with HFS before onabotulinum toxin A application, and after 15 days and 2, 3 and 4 months. Results 24 patients were treated with BTX-A. On the normal side, the mean palpebral fissure height (PF), interpalpebral surface area (ISA), steep K and astigmatism values were 8.7±1.98 mm, 122.09±39.37 mm2, 44.99±1.45 D and 0.9±0.64 D, respectively, before treatment. A statistically significant difference was not observed in these parameters after treatment (p>0.05). On the affected side, the mean PF, ISA, steep K and astigmatism were 5.5±1.77 mm, 67.68±28.49 mm2, 46.91±3.57 D and 2.63±2.46 D, respectively, before treatment. We observed a statistically significant (p<0.05) increase in the mean PF and ISA on the affected side 15 days (8.36±1.91 mm and 115.92±34.44 mm2, respectively), 2 months (8.18±1.80 mm and 112.22±33.57 mm2, respectively) and 3 months (7.27±1.65 mm and 95.48±27.80 mm2, respectively) after treatment. A statistically significant decrease in steep K and astigmatism was observed at 2 months (45.14±1.20 D and 1.01±0.58 D, respectively) and 3 months (45.64±1.77 D and 1.36±1.31 D, respectively) after treatment. Conclusions The results suggest that treatment with BTX-A in patients with HFS leads to eyelid and corneal changes on the affected eye that are significant during the known period of action of the toxin. Thus, caution should be taken when performing ophthalmological examination in patients with HFS, since it may vary according to BTX-A period of action.

Absence of Bacterial or Fungal Growth in Vials of Reconstituted Botulinum Toxin Type A After Storage

BACKGROUND Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. OBJECTIVES The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. METHODS A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion medium, and thioglycolate broth) and assessed for bacterial and/or fungal growth by standard methods. RESULTS None of the BTX-A vials contained detectable bacterial or fungal contamination after 4 weeks of storage. CONCLUSIONS Storing vials of reconstituted BTX-A for 4 weeks after administration to patients was not associated with detectable growth of bacteria or fungi.