Thomas C. Naugle

High leg incision fascia lata harvesting

OBJECTIVE The traditional method of harvesting fascia lata has been through an incision above the lateral knee. Problems with this method include a conspicuous scar, herniation of the muscle belly, and hematoma formation. The authors describe a new method of harvesting fascia lata in the region of the hip to minimize these complications. DESIGN Cohort study. PARTICIPANTS Twenty-three patients underwent harvesting of fascia lata by the technique described by the authors. Twenty-one patients had ptosis with poor levator function. In two patients, the fascia lata was used to wrap a hydroxyapatite implant. INTERVENTION The technique for harvesting fascia lata through an incision between the greater trochanter and anterior iliac crest is described. Long-term results were collected from chart reviews and patient interviews after surgery. MAIN OUTCOME MEASURES The patients were evaluated to determine whether any complications resulted from the new incision site. RESULTS No permanent complications were noted at the incision site. CONCLUSIONS Fascia lata can be harvested safely in the region of the iliac crest with an inconspicuous scar and with fewer complications than with the more traditional site slightly above the lateral knee.

Free graft enhancement using orbicularis muscle mobilization.

PURPOSE The purpose of this article is to demonstrate how mobilization of the orbicularis oculi muscle can improve viability, appearance, and function of free skin grafts in the periocular region. By enhancing blood supply with this technique, healing often can be achieved in difficult reconstructive cases. METHODS Seven patients underwent orbicularis muscle mobilization before placement of free skin grafts. Two patients underwent resection of basal cell carcinomas of the lateral eyelids and canthal region requiring complex reconstructive techniques such as lateral canthal tendon reconstruction with auricular cartilage. One patient underwent upper eyelid reconstruction after total resection for sebaceous cell carcinoma with pagetoid spread. Two patients had difficult wound dehiscences that were difficult to repair primarily. In addition, the lower eyelid with recurrent basal cell carcinomas of two patients who initially had undergone reconstruction with a Hughes procedure was reconstructed using tarsal strip grafts and orbicularis muscle mobilization combined with a free skin graft. RESULTS All seven patients have viable free grafts to date, and no further problems occurred in the two patients with wound dehiscences. Follow-up ranges from 1 to 8 years. CONCLUSION Orbicularis oculi muscle mobilization can be combined with a variety of techniques in eyelid and periorbital surgery, including difficult wound repair, reconstruction of the lateral canthal tendon with periosteal flaps or auricular cartilage, tarsal transposition flaps, mucosal grafts, and skin grafts. The addition of this technique can enhance the blood supply to the reconstructed area and allow healing which might not be obtained otherwise.

Surgical technique: use of quilting sutures in ophthalmic plastic surgery.

Goals for a successful skin graft include vascularization of the graft and prevention of fluid accumulation between the graft and recipient bed. Excessive accumulation of serosanguinous fluid between a skin graft and its recipient site can result in excessive pain, edema, and hematoma with or without partial or total graft failure. Full-thickness skin grafts vascularize by anastomoses between vessels of the graft and host at the base of the wound rather than from the wound edges. One of the most important factors to ensure successful vascularization is the maintenance of a firm and constant approximation between the graft and the recipient bed for the first postoperative week and good immobilization of the graft. Mobility or fluid accumulation may predispose patients to infection and contracture, with partial or total loss of the graft. Many immobilization techniques in addition to perimeter sutures have been described, most of which use extrinsic mechanical devices. These techniques include pressure dressings, tie-over bolsters, and adhesives such as glues and Steri-strips. Many of these techniques are problematic and may result in less-than-optimal results in complicated cases. Ocular pain and trauma can prohibit the use of pressure dressings around the globe. Perimeter sutures at the graft/recipient site, tied over a bolster, can create or enhance ectropion in the periocular area, leading to dryness and epiphora. Additionally, an elevated ridge of tissue at the graft/recipient site may result as the edges of the surgical defect are pulled away from the underlying tissue. Glues and Steri-strips may loosen and not provide uniform pressure during the healing process. We propose that quilting sutures placed in the recipient bed with or without Xeroform bolsters can aid in preventing these problems. We performed an extensive literature search involving more than 50 texts and 20 journal articles related to this topic. Only one article addressed this technique in detail and its use in ophthalmic plastic surgery; this article was not in the American literature. This technique anchors the skin graft with a combination of peripheral and central sutures. These can then be passed through a Xeroform gauze pad (Baxter Health Care, McGaw Park, Illinois) or other similar material to provide uniform pressure over the graft (Fig. 1). More direct visualization of the suture entrance can be gained by passing sutures in the recipient bed prior to their passage through the graft, and, if present, a bolster. Figure 2 illustrates a patient immediately after receiving a Xeroform bolster. The imprint covering the entire graft suggests that uniform pressure was imparted by the bolster. Figure 3 illustrates the postoperative result, with no discernible graft scar. We retrospectively studied the charts and photographs of 30 patients who had undergone free skin graft surgery around the eye. The senior author performed 15 surgeries using only the perimeter sutures, and 15 surgeries using the quilting suture technique. One half of the cases receiving quilting sutures used the bolster technique described above in addition. One patient had a total graft failure when no quilting sutures were placed (Fig. 4), whereas one patient with quilting sutures alone had a small area of graft failure. No graft failure occurred in patients receiving quilting sutures with a tied-over bolster. Accepted December 29, 2003. Presented as a poster at the ASOPRS 2001 Fall Scientific Symposium, New Orleans, Louisiana, November 2001. No commercial or financial interests exist in relation to this manuscript and none of the authors have any interest in marketing any product, drug, instrument, or piece of equipment discussed in the manuscript. Address correspondence and reprint requests to Dr. Thomas C. Naugle, Jr., 2633 Napoleon Avenue, Suite 814, New Orleans, LA 70115, U.S.A.

A superior and inferior orbital rim-based orbitometer

In exophthalmometry, alterations in the lateral orbital rim cause inaccuracy in serial readings when this structure is used as a fixation base. The authors have found that, compared with the Hertel-type lateral-rim-based instrument, an exophthalmometer based on the superior and inferior orbital rim areas bilaterally appears to be more accurate and is more comfortable, making it especially useful with pediatric patients. That the new exophthalmometer can be aligned at the mid-pupil horizontally and vertically with a vertical fixation bar enhances accuracy. In addition, the device can measure hypo-ophthalmos and hyperophthalmos by virtue of a vertical bar gradient scale.

Trichiasis and Distichiasis

Trichiasis is a condition of abnormal eyelash growth with misdirection posteriorly. Distichiasis is an abnormality of a second row of lashes emanating from meibomian glands. In both conditions the lid margin is in a normal position. Involutional entropion is an eyelid malposition with secondary trichiasis. These conditions can cause significant keratopathy. This chapter explores treatment modalities.

The Latino Eyelid: Anthropometric Analysis of a Spectrum of Findings

PURPOSE Published anthropometric measurements of the Latino eyelid are limited. This study describes features spanning the morphologic range from non-Latino whites to East Asians in the spectrum of the Latino eyelid. METHODS A cross-sectional study of 68 people (32 Latinos, 18 non-Latino whites, and 18 East Asians, ages 18-39), approved by the Institutional Review Board and HIPAA-compliant, was performed. Saliva samples determined genetic components. Indirect anthropometric measurements were performed with ImageJ software. Eyelid measurements included margin reflex distance, palpebral fissure height, eyelid crease height, orbital height, horizontal fissure length, inner and outer canthal distances, medial and lateral canthal angles, and lateral canthal angle of inclination. Additionally, exophthalmometry and epicanthal folds were recorded. RESULTS Analysis of 184 markers from HumanExome Chip data revealed distinct clustering patterns. Genetically, the Asian participants were in 1 group, the whites in another group, and the Latinos spanned the spectrum between these 2 groups. In Latinos, the inner canthal distance and lateral canthal angle of inclination were similar to Asians, whereas the eyelid crease spanned the range from Asians to whites. Half of the Latinos had epicanthal folds. CONCLUSIONS Latinos possess a spectrum of eyelid features spanning the morphologic characteristics from those of non-Latino whites to those of East Asians. These normative data on Latinos from Texas and Mexico aid in the diagnoses of Latino eyelid disorders and are a reference for optimizing oculofacial surgery outcomes.

Re: "Re: Muscle prolapse after harvesting autogenous fascia lata for frontalis suspension in children," by Fry and Naugle.

To the Editor: We read with interest the letter to the editor by Malhotra et al. regarding Bleyen’s article “Muscle prolapse after harvesting autogenous fascia lata for frontalis suspension in children.” Bleyen et al. had reported bulging of the muscle belly in 50% of patients who had undergone fascia lata retrieval via a low leg incision and 1 patient with chronic discomfort. Concerns regarding the high leg incision for fascia lata retrieval raised by Malhotra et al. were “occasional” poor quality of the fascia lata from the proximal location and difficulty harvesting the tissue in the setting of an obese abdomen. In contrast to Malhotra’s experience, we have found the fascia lata from the high leg incision to be more robust and thicker than tissue harvested from the lower thigh. This has necessitated routinely making the strips for frontalis suspension 1.5 mm wide instead of the 2 mm that is traditional for the fascia harvested in the lower portion of the thigh (Fig.). In only 1 instance have we found the fascia to be of poor quality. This was a patient with fetal alcohol syndrome. In this patient, the fascia was very thin and the muscle was easily visualized through the fascia to at least 15 cm below the high leg

Re: "Muscle prolapse after harvesting autogenous fascia lata used for frontalis suspension in children".

To the Editor: Bleyen et al. are to be congratulated for broaching the complication of muscle prolapse after harvesting fascia lata via an incision slightly above the lateral aspect of the knee. On evaluating 30 patients in whom this technique was used, they noted 50% had some form of muscle prolapse; 2 patients had invisible but palpable bulging, 5 patients had mildly visible bulging, and 8 patients had obvious, visible bulging. While 90% of patients had no functional discomfort, 2 patients (6.7%) had occasional discomfort, and one patient (3.3%) had frequent discomfort on exercising. The authors noted that no herniation of the muscle has been reported with harvesting fascia lata superiorly on the thigh, halfway between the greater trochanter and the anterior iliac crest, as described by Naugle et al. Since the time of our original report in 1997, there have been no reports of muscle herniation. Malhotra et al. have used the Naugle high leg incision via an endoscope with good results. We postulate that the absence of muscle herniation with our incision is primarily due to the deeper position of the fascia lata in the upper leg. Additionally, high in the leg there appears to be less gravitational force exerted by the quadriceps femoris than that exerted at the traditional lower leg harvesting site. The tensile strength of the homologue of Scarpa fascia aids in preventing herniation of the muscle belly. Also, there is less muscle mass directly beneath the incision with this technique, and if herniation were to occur, which it has not, it ostensibly would be less noticeable. Moreover, our technique includes a 2-layered closure with polygalactin suture of the deep subcutaneous tissue, including the homologue of Scarpa fascia, which is not present lower in the leg, thus improving the tensile strength of the wound. Another benefit of the high incision technique using a fiberoptic retractor is that one may reflect above and below the incision to allow for good visualization of the entire dissection and can usually obviate the use of a fascia lata stripper. This capability enables the surgeon to control bleeders during the harvesting process and postoperatively should bleeding occur. Another advantage of this technique is that there is a less conspicuous scar. The high leg scar may be hidden by short pants, undergarments, or bathing apparel. Unsightly scars have been reported in 11% to 38% of patients undergoing fascia lata harvesting. This issue is particularly important in those patients with a history of forming hypertrophic or keloid scars. We concur with the authors that the risk of muscle herniation should be discussed with patients and their families preoperatively and commend the authors on their review.

Oliver H. Dabezies, Jr, MD (1930-2001)

O liver H. Dabezies, Jr, MD, an internationally known leader in the field of ophthalmology and long-time clinical professor of ophthalmology at Tulane Medical School, died June 23, 2001, in New Orleans, La. He was 71 years old. Dr Dabezies was a New Orleans native and received his medical degree from Tulane. He continued his medical training in New Orleans, completing an internship at Charity Hospital of Louisiana and a residency at the Eye, Ear, Nose and Throat Hospital. From 1958 to 1960, as a captain in the army, Dr Dabezies was director of the residency program of Walter Reed Memorial Hospital in Washington, DC. Early in his career, he headed the American National Standards Institute Committee, which wrote regulations adopted by the Food and Drug Administration to prevent contamination and resulting blindness from the use of contaminated contact lens care products. Dr Dabezies continued to teach after retiring from private practice in 1999. He received Tulane Medical School’s Distinguished Service Award in 1994 and was named the Tulane Alumni Association’s outstanding alumnus in 1995. Dr Dabezies served on the board of the Southern Eye Bank in New Orleans for more than 42 years and was its president at the time of his death. He was the first recipient of the Eye Bank’s Distinguished Service Award. He was former president of the New Orleans Academy of Ophthalmology and organized the academy’s quarterly educational meetings. Dr Dabezies treasured ophthalmic heritage and was an avid historian. He authored comprehensive histories of the Southern Eye Bank, the Tulane University Department of Ophthalmology, and the New Orleans Academy of Ophthalmology as well as The History of Ophthalmology in the American Medical Association. He was a founder of the Contact Lens Association of Ophthalmologists, served as its executive vice president for 11 years, and authored its textbook on contact lenses. More recently, he created the International Contact Lens Society of Ophthalmologists. Dr Dabezies earned both the Honor and Senior Honor Awards from the American Academy of Ophthalmology and served on its board. The academy also named him the guest of honor at its 1995 annual meeting. A former secretary of the American Medical Association’s Ophthalmology Section, Dr Dabezies was to receive the section’s highest award, the Howe Medal in Ophthalmology, at the American Medical Association’s annual meeting this year. Thomas C. Naugle, Jr, MD New Orleans, La Barrett G. Haik, MD Memphis, Tenn Oliver H. Dabezies, Jr, MD OBITUARY