Foundational Papers in Oculoplastics 3030927938, 9783030927936

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Table of contents :
Foreword
Preface
Acknowledgments
Contents
Part I: Facial Aesthetics
Chapter 1: Midfacial Aging – Deflation or Descent?
Author(s)
Abstract: The Role of Gravity in Periorbital and Midfacial Aging
Summary
Abstract: Observations on Periorbital and Midface Aging
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 2: The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 3: Lower Eyelid Blepharoplasty
Author(s)
Abstract: Avoidance of Complications in Lower Lid Blepharoplasty
Summary
Abstract: Transconjunctival Lower Eyelid Blepharoplasty: Technique and Complications
Summary
Abstract: Arcus Marginalis Release and Orbital Fat Preservation in Midface Rejuvenation
Summary
Abstract: The Five-Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comments
References
Chapter 4: Endoscopic Brow Lift: A Personal Review of 538 Patients and Comparison of Fixation Techniques
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 5: The Deep-Plane Rhytidectomy
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 6: Tumescent Technique for Local Anesthesia Improves Safety in Large-Volume Liposuction
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 7: Structural Fat Grafting: More Than a Permanent Filler
Author(s)
Abstract
Summary
Relevance
Author Comment
Strengths
Weaknesses
One-Sentence Summary
References
Chapter 8: Pulsed Carbon Dioxide Laser Resurfacing of Photoaged Facial Skin
Author(s)
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 9: Treatment of Glabellar Frown Lines with C. Botulinum-A Exotoxin
Author(s)
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 10: Aesthetic and Restorative Midface Lifting with Hand-Carved, Expanded Polytetrafluoroethylene Orbital Rim Implants
Author
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 11: Dermal Fillers for the Oculofacial Plastic Surgeon
Author(s)
Abstract: Filling the Periorbital Hollows with Hyaluronic Acid Gel: Initial Experience with 244 Injections
Summary
Abstract: Avoiding and Treating Blindness from Fillers: A Review of the World Literature
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part II: Facial Anatomy
Chapter 12: Orbital Anatomy
Author(s)
Summary: Surgical Anatomy of the Orbit
Abstract: Orbital Septa: Anatomy and Function
Summary
Abstract: The Transconjunctival Approach to the Orbital Floor and Orbital Fat
Summary
Abstract: Transcaruncular Approach to the Medial Orbit and Orbital Apex
Summary
Abstract: Superomedial Lid Crease Approach to the Medial Intraconal Space
Summary
Abstract: The Inferomedial Orbital Strut: An Anatomic and Radiographic Study
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 13: Eyelid Anatomy
Author(s)
Summary: The Levator Aponeurosis
Summary: Oriental Eyelids: An Anatomic Study
Summary: The Microscopic Anatomy of the Lower Eyelid Retractors
Summary: The Anatomy of the Lateral Canthal Tendon
Summary: Horner’s Muscle and the Lacrimal System
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comments
References
Chapter 14: Facial Anatomy
Author(s)
Abstract: The Retaining Ligaments of the Cheek
Summary
Abstract: The Tear Trough Ligament: Anatomical Basis for the Tear Trough Deformity
Summary
Abstract: Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions
Summary
Abstract: Facial Soft-Tissue Spaces and Retaining Ligaments of the Midcheek: Defining the Premaxillary Space
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part III: Facial Dystonia
Chapter 15: Blepharospasm and Facial Dystonia
Author(s)
Summary: Blepharospasm-oromandibular Dystonia Syndrome (Brueghel’s Syndrome). A Variant of Adult-onset Torsion Dystonia?
Summary: Apraxia of Lid Opening
Relevance
Strengths
Weaknesses
One-Sentence Summary
References
Chapter 16: Treatment of Blepharospasm with Botulinum Toxin
Author(s)
Summary: Treatment of Blepharospasm with Botulinum Toxin
Abstract: Long-Term Botulinum Toxin Treatment of Benign Essential Blepharospasm, Hemifacial Spasm, and Meige Syndrome
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 17: Blepharospasm Surgery
Author(s)
Summary: Treatment of Blepharospasm with Botulinum Toxin
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part IV: Eyelid Disorders
Chapter 18: Ptosis
Author(s)
Summary: The Cure of Ptosis By Aponeurotic Repair
Summary: Levator Resection for Minimal Ptosis: Another Simplified Operation
Summary: Müller Muscle-Conjunctiva Resection: Technique for Treatment of Blepharoptosis
Abstract: Treatment of Congenital Ptosis with Frontalis Suspension
Summary
Abstract: Blepharoptosis Induced by Prolonged Hard Contact Lens Wear
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comments
References
Chapter 19: Lagophthalmos
Author(s)
Summary: A Technique for Lid Loading in the Management of Lagophthalmos of Facial Palsy
Abstract: Use of Hyaluronic Acid Gel in the Management of Paralytic Lagophthalmos: The Hyaluronic Acid Gel “Gold Weight”
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 20: Entropion/Ectropion
Author(s)
Summary: The Tarsal Strip Procedure
Summary: Transconjunctival Entropion Repair
Abstract: Tarsal Margin Rotation with Posterior Lamella Superadvancement for the Management of Cicatricial Entropion of the Upper Eyelid
Summary
Abstract: Results of Buccal Mucosal Grafting for Patients with Medically Controlled Ocular Cicatricial Pemphigoid
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 21: Lower Eyelid Retraction
Author(s)
Abstract: “Madame Butterfly” Procedure: Combined Cheek and Lateral Canthal Suspension Procedure for Post-Blepharoplasty, “Round Eye,” and Lower Eyelid Retraction
Summary
Abstract: Treatment of Lower Eyelid Retraction by Expansion of the Lower Eyelid with Hyaluronic Acid Gel
Summary
Abstract: Stop Blaming the Septum
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 22: The Floppy Eyelid Syndrome
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 23: Corneal Neurotization
Author(s)
Abstract: Corneal Neurotization: A Novel Solution to Neurotrophic Keratopathy
Summary
Abstract: Clinical and Morphologic Outcomes of Minimally Invasive Direct Corneal Neurotization
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part V: Infectious Disease
Chapter 24: Bacterial Infectious Disease
Author(s)
Abstract: Bacterial Periorbital and Orbital Cellulitis in Childhood
Summary
Abstract: Subperiosteal Abscess of the Orbit: Age as a Factor in the Bacteriology and Response to Treatment
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 25: Fungal Infectious Disease
Author(s)
Abstract: Diagnosis and Management of Rhino-OrbitocerebralMucormycosis (Phycomycosis)
Summary
Abstract: Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part VI: Inflammatory Disease
Chapter 26: Nonspecific Orbital Inflammatory Disease
Author(s)
Summary: Inflammatory pseudotumor of the orbit
Abstract: Idiopathic Sclerosing Inflammation of the Orbit: A Distinct Clinicopathologic Entity
Summary
Abstract: Molecular Diagnosis of Orbital Inflammatory Disease
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 27: IgG4-Related Orbital Disease
Author(s)
Abstract: Location and Frequency of Lesions in Patients with IgG4-Related Ophthalmic Diseases
Summary
Abstract: Consensus Statement on the Pathology of IgG4-Related Disease
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 28: Extraocular Muscle Enlargement
Author(s)
Abstract: Computed Tomographic Features of Nonthyroid Extraocular Muscle Enlargement
Summary
Abstract: Clinical-Radiological Patterns and Histopathological Outcomes in Non-thyroid Extraocular Muscle Enlargement
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 29: Observations on Prostaglandin Orbitopathy
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 30: Minocycline Effect on Meibomian Gland Lipids in Meibomianitis Patients
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part VII: Lacrimal Disorders
Chapter 31: Tear Dynamics
Author(s)
Summary
Abstract: The Dynamics and Drainage of Tears
Summary
Abstract: Tricompartment Model of the Lacrimal Pump Mechanism
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 32: Treatment of Epiphora
Author(s)
Summary
Abstract: Timing of Initial Probing and Irrigation in Congenital Nasolacrimal Duct Obstruction
Summary
Abstract: Endoscopic Laser-Assisted Lacrimal Surgery
Summary
Abstract: Comparison of External Dacryocystorhinostomy with Nonlaser Endonasal Dacryocystorhinostomy
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 33: Microbiology of Lacrimal Infection
Author(s)
Abstract: Primary Canaliculitis: Clinical Features, Microbiological Profile, and Management Outcome
Summary
Abstract: The Timing of Antibiotic Administration in the Management of Infant Dacryocystitis
Summary
Abstract: Comparative Bacteriology of Acute and Chronic Dacryocystitis
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 34: Lacrimal Sac Tumors
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part VIII: Oncology and Periorbital Lesions
Chapter 35: Micrographic Surgery for the Microscopically Controlled Excision of Eyelid Cancer
Author(s)
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 36: Survey of 1264 Patients with Orbital Tumors and Simulating Lesions
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 37: Sebaceous Carcinomas of the Ocular Adnexa: A Clinicopathologic Study of 104 Cases, with Five-Year Follow-up Data
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 38: Orbital Adnexal Lymphoma
Author(s)
Abstract: Lymphoproliferative Disease of the Ocular Adnexa: A Clinical and Pathologic Study with Statistical Analysis of 69 Patients
Summary
Abstract: Curative Radiotherapy for Primary Orbital Lymphoma
Summary
Abstract: Ultra-Low-Dose Radiotherapy for Definitive Management of Ocular Adnexal B-Cell Lymphoma
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 39: Targeted Therapy for Cutaneous Malignancies
Author(s)
Summary: Efficacy and Safety of Vismodegib in Advanced Basal-Cell Carcinoma
Summary: Phase II Study of Cetuximab as First-line Single-drug Therapy in Patients with Unresectable Squamous Cell Carcinoma of the Skin
Summary: Adjuvant Dabrafenib plus Trametinib in Stage III BRAF-mutated Melanoma
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 40: Lacrimal Gland Carcinoma
Author(s)
Abstract: Long-Term Outcomes of Neoadjuvant Intra-Arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma
Summary
Abstract: Eye-Preserving Surgery Followed By Adjuvant Radiotherapy for Lacrimal Gland Carcinoma: Outcomes in 37 Patients
Summary
Abstract: Cranio-Orbital Resection Does Not Appear to Improve Survival of Patients with Lacrimal Gland Carcinoma
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 41: Vascular Lesions
Author(s)
Abstract: Capillary Hemangioma of the Lids and Orbit: An Analysis of the Clinical Features and Therapeutic Results in 101 Cases
Summary
Summary: A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma
Abstract: A Controlled Study of Topical 0.25% Timolol Maleate Gel for the Treatment of Cutaneous Infantile Capillary Hemangiomas
Summary
Summary: Cavernous Venous Malformations of the Orbit (So-Called Cavernous Hemangioma): A Comprehensive Evaluation of their Clinical, Imaging and Histologic Nature
Abstract: Percutaneous Drainage and Ablation as First Line Therapy for Macrocystic and Microcystic Orbital Lymphatic Malformations
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part IX: Periorbital Reconstruction
Chapter 42: Eyelid Reconstruction
Author(s)
Summary: A New Method for Rebuilding a Lower Lid
Summary: A Method for Partial and Total Upper Lid Reconstruction
Summary: The Use of Flaps in the Orbital Region
Summary: Eyelid Reconstruction by the Semicircle Flap Technique
Summary: Techniques in Eyelid Wound Closure
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part X: Thyroid Eye Disease
Chapter 43: Epidemiology of Thyroid Eye Disease
Author(s)
Abstract: The Incidence of Graves’ Ophthalmopathy in Olmsted County, Minnesota
Summary
Summary: Occurrence of Ophthalmopathy after Treatment for Graves’ Hyperthyroidism
Summary: Relation Between Therapy for Hyperthyroidism and the Course of Graves’ Ophthalmopathy
Summary: Cigarette Smoking and Treatment Outcomes in Graves Ophthalmopathy
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 44: Steroids and Thyroid Eye Disease
Author(s)
Abstract: Randomized, Single Blind Trial of Intravenous Versus Oral Steroid Monotherapy in Graves’ Orbitopathy
Summary
Summary: Therapeutic Outcomes of High-Dose Intravenous Steroids in the Treatment of Dysthyroid Optic Neuropathy
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 45: Orbital Radiation for Thyroid Eye Disease
Author(s)
Abstract: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study of Orbital Radiotherapy for Graves’ Ophthalmopathy
Summary
Summary: A Randomized Controlled Trial of Orbital Radiotherapy Versus Sham Irradiation in Patients with Mild Graves’ Ophthalmopathy
Abstract: Orbital Radiotherapy Combined with Corticosteroid Treatment for Thyroid Eye Disease-Compressive Optic Neuropathy
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 46: Biologics for Thyroid Eye Disease
Author(s)
Abstract: Randomized Controlled Trial of Rituximab in Patients with Graves’ Orbitopathy
Summary
Abstract: Efficacy of B-Cell Targeted Therapy with rituximab in Patients with Active Moderate to Severe Graves’ Orbitopathy: A Randomized Controlled Study
Summary
Abstract: Efficacy of Tocilizumab in Patients with Moderate-to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial
Summary
Summary: Teprotumumab for Thyroid-Associated Ophthalmopathy
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 47: Orbital Decompression for Thyroid Eye Disease
Author(s)
Abstract: The Four Stages of Surgical Rehabilitation of the Patient with Dysthyroid Ophthalmopathy
Summary
Abstract: The Transantral Orbital Decompression Operation for Progressive Exophthalmos
Summary
Abstract: Results of transantral orbital decompression in 428 patients with severe Graves’ ophthalmopathy
Summary
Summary
Abstract: Strabismus after Balanced Medial Plus Lateral Wall Versus Lateral Wall only Orbital Decompression for Dysthyroid Orbitopathy
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Part XI: Facial Trauma and the Anophthalmic Socket
Chapter 48: Oculofacial Trauma
Author(s)
Abstract: The Pathogenesis of Canalicular Laceration
Summary
Abstract: Force Necessary to Fracture the Orbital Floor
Summary
Abstract: Nonsurgical management of blow-out fractures of the orbital floor
Summary
Abstract: Surgery on Orbital Floor Fractures: Influence of Time of Repair and Fracture Size
Summary
Abstract: Intervention Within Days for Some Orbital Floor Fractures: The White-Eyed Blowout
Summary
Abstract: Clinical Features and Treatment of Pediatric Orbit Fractures
Summary
Abstract: Efficacy of Lateral Canthotomy and Cantholysis in Orbital Hemorrhage
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 49: Wooden Intraorbital Foreign Body Injuries: Clinical Characteristics and Outcomes of 23 Patients
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 50: The Silent Sinus Syndrome: A Cause of Spontaneous Enophthalmos
Author(s)
Abstract
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Chapter 51: Anophthalmic Socket
Author(s)
Summary
Abstract: Coralline Hydroxyapatite as an Ocular Implant
Summary
Abstract: Exposure Rate of Hydroxyapatite Spheres in the Anophthalmic Socket
Summary
Abstract: Prosthetic Motility in Pegged Versus Unpegged Integrated Porous Orbital Implants
Summary
Abstract: Comparing Outcomes of Enucleation and Evisceration
Summary
Abstract: Dermis-Fat Orbital Implantation: 118 Cases
Summary
Relevance
Strengths
Weaknesses
One-Sentence Summary
Author Comment
References
Index
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Foundational Papers in Oculoplastics Sathyadeepak Ramesh

123

Foundational Papers in Oculoplastics

Sathyadeepak Ramesh

Foundational Papers in Oculoplastics

Sathyadeepak Ramesh The Center for Eye and Facial Plastic Surgery Wills Eye Hospital Somerset, NJ USA

ISBN 978-3-030-92793-6    ISBN 978-3-030-92794-3 (eBook) https://doi.org/10.1007/978-3-030-92794-3 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To S.D., A.D., and J.D. with love, and N.S.R. and M.R. for encouraging me. Job 12:12-13

Foreword

Sometimes I worry that today’s students, raised in the era of Wikipedia and Twitter, are losing their enthusiasm to read original sources. And it is understandable, in our busy lives, to take advantage of easy access to predigested short bits of information. However, taking the time to go back to the original source material can pay great dividends. First of all, it is unfiltered. That should appeal to our tendency to like to decide things for ourselves: instead of someone telling us what to think about an article, or telling us what is important, the reader of the original manuscript gets to decide that on their own. Second, it is richer. The reader of source material has access to all the details of the study and findings, including figures, tables, references, and discussion.  The investment of some extra effort into reading the entire manuscript is rewarded with deeper understanding. Finally, the source material connects us to the author and to the pyramid of knowledge, in which each author builds on the work and experience of those who came before. With luck, we get a sense of the scientific curiosity and passion that powered the author to pursue their work. With even more luck, it will inspire the reader to want to stand on those shoulders and participate in their own way in the tradition of scholarship, research, publication, and contribution to knowledge. I am very pleased that Dr. Ramesh has helped us to tap into this stream of knowledge and tradition, by doing the work to identify some of the great papers that inspired and informed his career. I hope that the readers of this outstanding collection will take away a better knowledge of the specialty, a deeper connection to our history, and a heightened motivation towards academic excellence. Los Angeles, CA, USA

Robert Alan Goldberg

vii

Preface

While certain aspects of oculoplastic practice have been transformed radically in the last several years, others have simply undergone cyclical iterations over time. As the pendulum of surgical practice swings back and forth, I felt that it was important to ground myself in the critical primary literature since the creation of our subspecialty. While poring through these early manuscripts, I was surprised to find ideas discussed that were purportedly “novel” or “recent” discussed several decades prior (e.g., lash transplants and free tarsal grafts in eyelid reconstruction discussed in Dr. Hughes’ original treatise). I was further surprised to find that several ideas I thought were uniquely my own had been previously, independently, and thoroughly investigated by others before me. Perhaps I should not have been surprised, as our (small) society is comprised of many uniquely talented individuals. Regardless, I thought I would be remiss to engage in the exploratory adventure of research without first truly understanding the history and state of the field, lest I foolishly mistake America for India like the innominate sailor from 1492. This journey has been a pleasure, both to experience the initial discoveries and observations with fresh eyes and to speak to those involved to understand their inspirations and challenges in creating this body of work. Should I have left any important and fundamental manuscript out, it is only out of ignorance, and I beg the reader’s forgiveness. I hope the commentary provided is both interesting and illuminating for the reader, whether early or late in their career. Somerset, NJ, USA

Sathyadeepak Ramesh

ix

Acknowledgments

I am fortunate to stand on the shoulders of giants, both in my clinical treatment of patients and in the writing of this text. I would like to thank the following authors who wrote the foundational papers presented here, as well as for their gracious commentary:

Allen Putterman Amit Pandya Allan Wulc Barry Jones Bhupendra Patel Bita Esmaeli Bruce Becker Chin Ho Wong Daniel Rootman David Tse Frank Nesi Frederic Mohs George Bartley Gerald Harris Guy Massry Heather Shelsta J.D. Perry Jacqueline Carrasco James Patrinely

Jean Carruthers Jeffrey Klein Jerry and Carol Shields Jim Rosenbaum Joel Pessa John Burns John Holds John Shore John Stone Katie Beleznay Ken Steinsapir Mario Salvi Marius Stan Mary Stefanyszyn Michael Groth Michael Hawes Michael Kazim Mitchel Goldman Mohammed Javed Ali

Narsing Rao Norman Shorr Philip Custer Raymond Douglas Reza Vagefi Rick Anderson Robert Goldberg Rod Rohrich Ronald Mancini Russell Gonnering Sam Hamra Stuart Seiff Sydney Coleman Ted Wojno Val Lambros Vikram Durairaj Wendell Hughes William Culbertson

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Contents

Part I Facial Aesthetics 1 Midfacial Aging – Deflation or Descent? ����������������������������������������������    3 Author(s)��������������������������������������������������������������������������������������������������     3 Abstract: The Role of Gravity in Periorbital and Midfacial Aging��������������������������������������������������������������     3 Summary��������������������������������������������������������������������������������������������������     4 Abstract: Observations on Periorbital and Midface Aging����������������������     4 Summary��������������������������������������������������������������������������������������������������     5 Relevance ������������������������������������������������������������������������������������������������     6 Strengths��������������������������������������������������������������������������������������������������     8 Weaknesses����������������������������������������������������������������������������������������������     8 One-Sentence Summary��������������������������������������������������������������������������     9 Author Comment ������������������������������������������������������������������������������������     9 References������������������������������������������������������������������������������������������������    11 2 The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery������������������������������������������   13 Author(s)��������������������������������������������������������������������������������������������������    13 Abstract����������������������������������������������������������������������������������������������������    13 Summary��������������������������������������������������������������������������������������������������    14 Relevance ������������������������������������������������������������������������������������������������    16 Strengths��������������������������������������������������������������������������������������������������    18 Weaknesses����������������������������������������������������������������������������������������������    18 One-Sentence Summary��������������������������������������������������������������������������    18 Author Comment ������������������������������������������������������������������������������������    18 References������������������������������������������������������������������������������������������������    19 3 Lower Eyelid Blepharoplasty������������������������������������������������������������������   21 Author(s)��������������������������������������������������������������������������������������������������    21 Abstract: Avoidance of Complications in Lower Lid Blepharoplasty ����������������������������������������������������������������������    21 xiii

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Summary��������������������������������������������������������������������������������������������������    21 Abstract: Transconjunctival Lower Eyelid Blepharoplasty: Technique and Complications����������������������������������������    23 Summary��������������������������������������������������������������������������������������������������    23 Abstract: Arcus Marginalis Release and Orbital Fat Preservation in Midface Rejuvenation ����������������������������������������������������    24 Summary��������������������������������������������������������������������������������������������������    25 Abstract: The Five-Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction ������������������������������������������������������    25 Summary��������������������������������������������������������������������������������������������������    27 Relevance ������������������������������������������������������������������������������������������������    28 Strengths��������������������������������������������������������������������������������������������������    30 Weaknesses����������������������������������������������������������������������������������������������    30 One-Sentence Summary��������������������������������������������������������������������������    30 Author Comments������������������������������������������������������������������������������������    30 References������������������������������������������������������������������������������������������������    32 4 Endoscopic Brow Lift: A Personal Review of 538 Patients and Comparison of Fixation Techniques��������������������������������   33 Author(s)��������������������������������������������������������������������������������������������������    33 Abstract����������������������������������������������������������������������������������������������������    33 Summary��������������������������������������������������������������������������������������������������    34 Relevance ������������������������������������������������������������������������������������������������    35 Strengths��������������������������������������������������������������������������������������������������    36 Weaknesses����������������������������������������������������������������������������������������������    36 One-Sentence Summary��������������������������������������������������������������������������    37 Author Comment ������������������������������������������������������������������������������������    37 References������������������������������������������������������������������������������������������������    37 5 The Deep-Plane Rhytidectomy ��������������������������������������������������������������   39 Author(s)��������������������������������������������������������������������������������������������������    39 Abstract����������������������������������������������������������������������������������������������������    39 Summary��������������������������������������������������������������������������������������������������    39 Relevance ������������������������������������������������������������������������������������������������    41 Strengths��������������������������������������������������������������������������������������������������    43 Weaknesses����������������������������������������������������������������������������������������������    43 One-Sentence Summary��������������������������������������������������������������������������    43 Author Comment ������������������������������������������������������������������������������������    43 References������������������������������������������������������������������������������������������������    44 6 Tumescent Technique for Local Anesthesia Improves Safety in Large-Volume Liposuction������������������������������������������������������   45 Author(s)��������������������������������������������������������������������������������������������������    45 Abstract����������������������������������������������������������������������������������������������������    45 Summary��������������������������������������������������������������������������������������������������    46 Relevance ������������������������������������������������������������������������������������������������    46 Strengths��������������������������������������������������������������������������������������������������    49

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Weaknesses����������������������������������������������������������������������������������������������    49 One-Sentence Summary��������������������������������������������������������������������������    49 Author Comment ������������������������������������������������������������������������������������    50 References������������������������������������������������������������������������������������������������    51 7 Structural Fat Grafting: More Than a Permanent Filler��������������������������������������������������������������������������������������   53 Author(s)��������������������������������������������������������������������������������������������������    53 Abstract����������������������������������������������������������������������������������������������������    53 Summary��������������������������������������������������������������������������������������������������    54 Relevance ������������������������������������������������������������������������������������������������    55 Author Comment ������������������������������������������������������������������������������������    56 Strengths��������������������������������������������������������������������������������������������������    57 Weaknesses����������������������������������������������������������������������������������������������    57 One-Sentence Summary��������������������������������������������������������������������������    57 References������������������������������������������������������������������������������������������������    57 8 Pulsed Carbon Dioxide Laser Resurfacing of Photoaged Facial Skin ����������������������������������������������������������������������������   59 Author(s)��������������������������������������������������������������������������������������������������    59 Summary��������������������������������������������������������������������������������������������������    59 Relevance ������������������������������������������������������������������������������������������������    60 Strengths��������������������������������������������������������������������������������������������������    63 Weaknesses����������������������������������������������������������������������������������������������    63 One-Sentence Summary��������������������������������������������������������������������������    63 Author Comment ������������������������������������������������������������������������������������    63 References������������������������������������������������������������������������������������������������    64 9 Treatment of Glabellar Frown Lines with C. Botulinum-A Exotoxin����������������������������������������������������������������������������   67 Author(s)��������������������������������������������������������������������������������������������������    67 Summary��������������������������������������������������������������������������������������������������    67 Relevance ������������������������������������������������������������������������������������������������    68 Strengths��������������������������������������������������������������������������������������������������    70 Weaknesses����������������������������������������������������������������������������������������������    70 One-Sentence Summary��������������������������������������������������������������������������    70 Author Comment ������������������������������������������������������������������������������������    70 References������������������������������������������������������������������������������������������������    71 10 Aesthetic and Restorative Midface Lifting with Hand-Carved, Expanded Polytetrafluoroethylene Orbital Rim Implants������������������������������������������������������������������������������   73 Author������������������������������������������������������������������������������������������������������    73 Abstract������������������������������������������������������������������������������������������������������   73 Summary��������������������������������������������������������������������������������������������������    74 Relevance ������������������������������������������������������������������������������������������������    76 Strengths��������������������������������������������������������������������������������������������������    77

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Weaknesses����������������������������������������������������������������������������������������������    77 One-Sentence Summary��������������������������������������������������������������������������    77 Author Comment ������������������������������������������������������������������������������������    77 References������������������������������������������������������������������������������������������������    78 11 Dermal Fillers for the Oculofacial Plastic Surgeon������������������������������   79 Author(s)��������������������������������������������������������������������������������������������������    79 Abstract: Filling the Periorbital Hollows with Hyaluronic Acid Gel: Initial Experience with 244 Injections ������������������������    79 Summary��������������������������������������������������������������������������������������������������    80 Abstract: Avoiding and Treating Blindness from Fillers: A Review of the World Literature������������������������������������������������    80 Summary��������������������������������������������������������������������������������������������������    82 Relevance ������������������������������������������������������������������������������������������������    83 Strengths��������������������������������������������������������������������������������������������������    87 Weaknesses����������������������������������������������������������������������������������������������    87 One-Sentence Summary��������������������������������������������������������������������������    87 Author Comment ������������������������������������������������������������������������������������    87 References������������������������������������������������������������������������������������������������    88 Part II Facial Anatomy 12 Orbital Anatomy��������������������������������������������������������������������������������������   93 Author(s)��������������������������������������������������������������������������������������������������    93 Summary: Surgical Anatomy of the Orbit ����������������������������������������������    93 Abstract: Orbital Septa: Anatomy and Function��������������������������������������    94 Summary��������������������������������������������������������������������������������������������������    94 Abstract: The Transconjunctival Approach to the Orbital Floor and Orbital Fat��������������������������������������������������������    95 Summary��������������������������������������������������������������������������������������������������    96 Abstract: Transcaruncular Approach to the Medial Orbit and Orbital Apex ����������������������������������������������������    97 Summary��������������������������������������������������������������������������������������������������    97 Abstract: Superomedial Lid Crease Approach to the Medial Intraconal Space ��������������������������������������������������������������   100 Summary��������������������������������������������������������������������������������������������������   100 Abstract: The Inferomedial Orbital Strut: An Anatomic and Radiographic Study ����������������������������������������������   102 Summary��������������������������������������������������������������������������������������������������   102 Relevance ������������������������������������������������������������������������������������������������   103 Strengths��������������������������������������������������������������������������������������������������   106 Weaknesses����������������������������������������������������������������������������������������������   106 One-Sentence Summary��������������������������������������������������������������������������   106 Author Comment ������������������������������������������������������������������������������������   106 References������������������������������������������������������������������������������������������������   107 13 Eyelid Anatomy����������������������������������������������������������������������������������������  109

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Author(s)��������������������������������������������������������������������������������������������������   109 Summary: The Levator Aponeurosis ������������������������������������������������������   109 Summary: Oriental Eyelids: An Anatomic Study������������������������������������   110 Summary: The Microscopic Anatomy of the Lower Eyelid Retractors ��������������������������������������������������������������   111 Summary: The Anatomy of the Lateral Canthal Tendon ������������������������   112 Summary: Horner’s Muscle and the Lacrimal System����������������������������   113 Relevance ������������������������������������������������������������������������������������������������   115 Strengths��������������������������������������������������������������������������������������������������   117 Weaknesses����������������������������������������������������������������������������������������������   117 One-Sentence Summary��������������������������������������������������������������������������   117 Author Comments������������������������������������������������������������������������������������   117 References������������������������������������������������������������������������������������������������   118 14 Facial Anatomy����������������������������������������������������������������������������������������  121 Author(s)��������������������������������������������������������������������������������������������������   121 Abstract: The Retaining Ligaments of the Cheek������������������������������������   121 Summary��������������������������������������������������������������������������������������������������   122 Abstract: The Tear Trough Ligament: Anatomical Basis for the Tear Trough Deformity��������������������������������������������   123 Summary��������������������������������������������������������������������������������������������������   123 Abstract: Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions��������������������   124 Summary��������������������������������������������������������������������������������������������������   125 Abstract: Facial Soft-Tissue Spaces and Retaining Ligaments of the Midcheek: Defining the Premaxillary Space����������������������   126 Summary��������������������������������������������������������������������������������������������������   127 Relevance ������������������������������������������������������������������������������������������������   128 Strengths��������������������������������������������������������������������������������������������������   129 Weaknesses����������������������������������������������������������������������������������������������   129 One-Sentence Summary��������������������������������������������������������������������������   130 Author Comment ������������������������������������������������������������������������������������   130 References������������������������������������������������������������������������������������������������   131 Part III Facial Dystonia 15 Blepharospasm and Facial Dystonia������������������������������������������������������  137 Author(s)��������������������������������������������������������������������������������������������������   137 Summary: Blepharospasm-oromandibular Dystonia Syndrome (Brueghel’s Syndrome). A Variant of Adult-onset Torsion Dystonia?��������������������������������������������������������������������������������������   137 Summary: Apraxia of Lid Opening����������������������������������������������������������   138 Relevance ������������������������������������������������������������������������������������������������   138 Strengths��������������������������������������������������������������������������������������������������   140 Weaknesses����������������������������������������������������������������������������������������������   140 One-Sentence Summary��������������������������������������������������������������������������   140 References������������������������������������������������������������������������������������������������   140

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16 Treatment of Blepharospasm with Botulinum Toxin����������������������������  143 Author(s)��������������������������������������������������������������������������������������������������   143 Summary: Treatment of Blepharospasm with Botulinum Toxin ��������������������������������������������������������������������������   143 Abstract: Long-Term Botulinum Toxin Treatment of Benign Essential Blepharospasm, Hemifacial Spasm, and Meige Syndrome ������������������������������������������������������   144 Summary��������������������������������������������������������������������������������������������������   144 Relevance ������������������������������������������������������������������������������������������������   145 Strengths��������������������������������������������������������������������������������������������������   148 Weaknesses����������������������������������������������������������������������������������������������   148 One-Sentence Summary��������������������������������������������������������������������������   148 Author Comment ������������������������������������������������������������������������������������   148 References������������������������������������������������������������������������������������������������   150 17 Blepharospasm Surgery��������������������������������������������������������������������������  153 Author(s)��������������������������������������������������������������������������������������������������   153 Summary: Treatment of Blepharospasm with Botulinum Toxin ������������   153 Relevance ������������������������������������������������������������������������������������������������   154 Strengths��������������������������������������������������������������������������������������������������   156 Weaknesses����������������������������������������������������������������������������������������������   156 One-Sentence Summary��������������������������������������������������������������������������   156 Author Comment ������������������������������������������������������������������������������������   156 References������������������������������������������������������������������������������������������������   157 Part IV Eyelid Disorders 18 Ptosis����������������������������������������������������������������������������������������������������������  161 Author(s)��������������������������������������������������������������������������������������������������   161 Summary: The Cure of Ptosis By Aponeurotic Repair����������������������������   161 Summary: Levator Resection for Minimal Ptosis: Another Simplified Operation������������������������������������������������������   162 Summary: Müller Muscle-Conjunctiva Resection: Technique for Treatment of Blepharoptosis����������������������������������   163 Abstract: Treatment of Congenital Ptosis with Frontalis Suspension ��������������������������������������������������������������������   164 Summary��������������������������������������������������������������������������������������������������   164 Abstract: Blepharoptosis Induced by Prolonged Hard Contact Lens Wear ��������������������������������������������������������������   165 Summary��������������������������������������������������������������������������������������������������   166 Relevance ������������������������������������������������������������������������������������������������   166 Strengths��������������������������������������������������������������������������������������������������   170 Weaknesses����������������������������������������������������������������������������������������������   170 One-Sentence Summary��������������������������������������������������������������������������   171 Author Comments������������������������������������������������������������������������������������   171 References������������������������������������������������������������������������������������������������   172

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19 Lagophthalmos����������������������������������������������������������������������������������������  175 Author(s)��������������������������������������������������������������������������������������������������   175 Summary: A Technique for Lid Loading in the Management of Lagophthalmos of Facial Palsy��������������������������   175 Abstract: Use of Hyaluronic Acid Gel in the Management of Paralytic Lagophthalmos: The Hyaluronic Acid Gel “Gold Weight” ������������������������������������   176 Summary��������������������������������������������������������������������������������������������������   177 Relevance ������������������������������������������������������������������������������������������������   179 Strengths��������������������������������������������������������������������������������������������������   181 Weaknesses����������������������������������������������������������������������������������������������   181 One-Sentence Summary��������������������������������������������������������������������������   181 Author Comment ������������������������������������������������������������������������������������   181 References������������������������������������������������������������������������������������������������   182 20 Entropion/Ectropion��������������������������������������������������������������������������������  183 Author(s)��������������������������������������������������������������������������������������������������   183 Summary: The Tarsal Strip Procedure ����������������������������������������������������   183 Summary: Transconjunctival Entropion Repair��������������������������������������   184 Abstract: Tarsal Margin Rotation with Posterior Lamella Superadvancement for the Management of Cicatricial Entropion of the Upper Eyelid��������������������������������   185 Summary��������������������������������������������������������������������������������������������������   186 Abstract: Results of Buccal Mucosal Grafting for Patients with Medically Controlled Ocular Cicatricial Pemphigoid������������������������������������������������������������������   187 Summary��������������������������������������������������������������������������������������������������   187 Relevance ������������������������������������������������������������������������������������������������   188 Strengths��������������������������������������������������������������������������������������������������   193 Weaknesses����������������������������������������������������������������������������������������������   193 One-Sentence Summary��������������������������������������������������������������������������   193 Author Comment ������������������������������������������������������������������������������������   193 References������������������������������������������������������������������������������������������������   194 21 Lower Eyelid Retraction ������������������������������������������������������������������������  197 Author(s)��������������������������������������������������������������������������������������������������   197 Abstract: “Madame Butterfly” Procedure: Combined Cheek and Lateral Canthal Suspension Procedure for Post-Blepharoplasty, “Round Eye,” and Lower Eyelid Retraction��������������������������������������������������������   197 Summary��������������������������������������������������������������������������������������������������   198 Abstract: Treatment of Lower Eyelid Retraction by Expansion of the Lower Eyelid with Hyaluronic Acid Gel ��������������������������������������������������������������������   199 Summary��������������������������������������������������������������������������������������������������   200 Abstract: Stop Blaming the Septum��������������������������������������������������������   201

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Summary��������������������������������������������������������������������������������������������������   202 Relevance ������������������������������������������������������������������������������������������������   203 Strengths��������������������������������������������������������������������������������������������������   207 Weaknesses����������������������������������������������������������������������������������������������   208 One-Sentence Summary��������������������������������������������������������������������������   208 Author Comment ������������������������������������������������������������������������������������   208 References������������������������������������������������������������������������������������������������   210 22 The Floppy Eyelid Syndrome�����������������������������������������������������������������  213 Author(s)��������������������������������������������������������������������������������������������������   213 Abstract����������������������������������������������������������������������������������������������������   213 Summary��������������������������������������������������������������������������������������������������   213 Relevance ������������������������������������������������������������������������������������������������   214 Strengths��������������������������������������������������������������������������������������������������   219 Weaknesses����������������������������������������������������������������������������������������������   219 One-Sentence Summary��������������������������������������������������������������������������   219 Author Comment ������������������������������������������������������������������������������������   219 References������������������������������������������������������������������������������������������������   220 23 Corneal Neurotization ����������������������������������������������������������������������������  223 Author(s)��������������������������������������������������������������������������������������������������   223 Abstract: Corneal Neurotization: A Novel Solution to Neurotrophic Keratopathy������������������������������������������������������������   223 Summary��������������������������������������������������������������������������������������������������   223 Abstract: Clinical and Morphologic Outcomes of Minimally Invasive Direct Corneal Neurotization������������������������   225 Summary��������������������������������������������������������������������������������������������������   226 Relevance ������������������������������������������������������������������������������������������������   226 Strengths��������������������������������������������������������������������������������������������������   232 Weaknesses����������������������������������������������������������������������������������������������   232 One-Sentence Summary��������������������������������������������������������������������������   232 Author Comment ������������������������������������������������������������������������������������   233 References������������������������������������������������������������������������������������������������   233 Part V Infectious Disease 24 Bacterial Infectious Disease��������������������������������������������������������������������  237 Author(s)��������������������������������������������������������������������������������������������������   237 Abstract: Bacterial Periorbital and Orbital Cellulitis in Childhood������������������������������������������������������������������   237 Summary��������������������������������������������������������������������������������������������������   238 Abstract: Subperiosteal Abscess of the Orbit: Age as a Factor in the Bacteriology and Response to Treatment����������������   238 Summary��������������������������������������������������������������������������������������������������   239 Relevance ������������������������������������������������������������������������������������������������   239 Strengths��������������������������������������������������������������������������������������������������   241

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Weaknesses����������������������������������������������������������������������������������������������   241 One-Sentence Summary��������������������������������������������������������������������������   242 Author Comment ������������������������������������������������������������������������������������   242 References������������������������������������������������������������������������������������������������   242 25 Fungal Infectious Disease������������������������������������������������������������������������  245 Author(s)��������������������������������������������������������������������������������������������������   245 Abstract: Diagnosis and Management of Rhino-OrbitocerebralMucormycosis (Phycomycosis)������������������   245 Summary��������������������������������������������������������������������������������������������������   246 Abstract: Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality����������������������������������������   246 Summary��������������������������������������������������������������������������������������������������   247 Relevance ������������������������������������������������������������������������������������������������   248 Strengths��������������������������������������������������������������������������������������������������   250 Weaknesses����������������������������������������������������������������������������������������������   250 One-Sentence Summary��������������������������������������������������������������������������   250 Author Comment ������������������������������������������������������������������������������������   251 References������������������������������������������������������������������������������������������������   252 Part VI Inflammatory Disease 26 Nonspecific Orbital Inflammatory Disease�������������������������������������������  257 Author(s)��������������������������������������������������������������������������������������������������   257 Summary: Inflammatory pseudotumor of the orbit ��������������������������������   257 Abstract: Idiopathic Sclerosing Inflammation of the Orbit: A Distinct Clinicopathologic Entity���������������������������������������������   258 Summary��������������������������������������������������������������������������������������������������   259 Abstract: Molecular Diagnosis of Orbital Inflammatory Disease ������������������������������������������������������������������   260 Summary��������������������������������������������������������������������������������������������������   260 Relevance ������������������������������������������������������������������������������������������������   262 Strengths��������������������������������������������������������������������������������������������������   263 Weaknesses����������������������������������������������������������������������������������������������   263 One-Sentence Summary��������������������������������������������������������������������������   263 Author Comment ������������������������������������������������������������������������������������   264 References������������������������������������������������������������������������������������������������   264 27 IgG4-Related Orbital Disease ����������������������������������������������������������������  267 Author(s)��������������������������������������������������������������������������������������������������   267 Abstract: Location and Frequency of Lesions in Patients with IgG4-Related Ophthalmic Diseases������������������������   267 Summary��������������������������������������������������������������������������������������������������   268 Abstract: Consensus Statement on the Pathology of IgG4-Related Disease ������������������������������������������������������������������   271 Summary��������������������������������������������������������������������������������������������������   271

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Relevance ������������������������������������������������������������������������������������������������   272 Strengths��������������������������������������������������������������������������������������������������   274 Weaknesses����������������������������������������������������������������������������������������������   274 One-Sentence Summary��������������������������������������������������������������������������   274 Author Comment ������������������������������������������������������������������������������������   275 References������������������������������������������������������������������������������������������������   275 28 Extraocular Muscle Enlargement����������������������������������������������������������  279 Author(s)��������������������������������������������������������������������������������������������������   279 Abstract: Computed Tomographic Features of Nonthyroid Extraocular Muscle Enlargement������������������������������   279 Summary��������������������������������������������������������������������������������������������������   280 Abstract: Clinical-Radiological Patterns and Histopathological Outcomes in Non-thyroid Extraocular Muscle Enlargement��������������������������������������������������   281 Summary��������������������������������������������������������������������������������������������������   281 Relevance ������������������������������������������������������������������������������������������������   282 Strengths��������������������������������������������������������������������������������������������������   284 Weaknesses����������������������������������������������������������������������������������������������   284 One-Sentence Summary��������������������������������������������������������������������������   284 Author Comment ������������������������������������������������������������������������������������   284 References������������������������������������������������������������������������������������������������   285 29 Observations on Prostaglandin Orbitopathy����������������������������������������  287 Author(s)��������������������������������������������������������������������������������������������������   287 Abstract����������������������������������������������������������������������������������������������������   287 Summary��������������������������������������������������������������������������������������������������   288 Relevance ������������������������������������������������������������������������������������������������   288 Strengths��������������������������������������������������������������������������������������������������   292 Weaknesses����������������������������������������������������������������������������������������������   292 One-Sentence Summary��������������������������������������������������������������������������   292 Author Comment ������������������������������������������������������������������������������������   292 References������������������������������������������������������������������������������������������������   293 30 Minocycline Effect on Meibomian Gland Lipids in Meibomianitis Patients������������������������������������������������������������  295 Author(s)��������������������������������������������������������������������������������������������������   295 Abstract����������������������������������������������������������������������������������������������������   295 Summary��������������������������������������������������������������������������������������������������   296 Relevance ������������������������������������������������������������������������������������������������   296 Strengths��������������������������������������������������������������������������������������������������   298 Weaknesses����������������������������������������������������������������������������������������������   298 One-Sentence Summary��������������������������������������������������������������������������   298 Author Comment ������������������������������������������������������������������������������������   298 References������������������������������������������������������������������������������������������������   298

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Part VII Lacrimal Disorders 31 Tear Dynamics������������������������������������������������������������������������������������������  303 Author(s)��������������������������������������������������������������������������������������������������   303 Summary��������������������������������������������������������������������������������������������������   303 Abstract: The Dynamics and Drainage of Tears��������������������������������������   305 Summary��������������������������������������������������������������������������������������������������   305 Abstract: Tricompartment Model of the Lacrimal Pump Mechanism����������������������������������������������������������   307 Summary��������������������������������������������������������������������������������������������������   307 Relevance ������������������������������������������������������������������������������������������������   309 Strengths��������������������������������������������������������������������������������������������������   311 Weaknesses����������������������������������������������������������������������������������������������   311 One-Sentence Summary��������������������������������������������������������������������������   311 Author Comment ������������������������������������������������������������������������������������   311 References������������������������������������������������������������������������������������������������   312 32 Treatment of Epiphora����������������������������������������������������������������������������  315 Author(s)��������������������������������������������������������������������������������������������������   315 Summary��������������������������������������������������������������������������������������������������   315 Abstract: Timing of Initial Probing and Irrigation in Congenital Nasolacrimal Duct Obstruction����������������������������������   316 Summary��������������������������������������������������������������������������������������������������   318 Abstract: Endoscopic Laser-Assisted Lacrimal Surgery ������������������������   318 Summary��������������������������������������������������������������������������������������������������   318 Abstract: Comparison of External Dacryocystorhinostomy with Nonlaser Endonasal Dacryocystorhinostomy ����������������������   319 Summary��������������������������������������������������������������������������������������������������   320 Relevance ������������������������������������������������������������������������������������������������   322 Strengths��������������������������������������������������������������������������������������������������   325 Weaknesses����������������������������������������������������������������������������������������������   325 One-Sentence Summary��������������������������������������������������������������������������   325 Author Comment ������������������������������������������������������������������������������������   326 References������������������������������������������������������������������������������������������������   326 33 Microbiology of Lacrimal Infection ������������������������������������������������������  329 Author(s)��������������������������������������������������������������������������������������������������   329 Abstract: Primary Canaliculitis: Clinical Features, Microbiological Profile, and Management Outcome��������������������   329 Summary��������������������������������������������������������������������������������������������������   330 Abstract: The Timing of Antibiotic Administration in the Management of Infant Dacryocystitis������������������������������������������   331 Summary��������������������������������������������������������������������������������������������������   331 Abstract: Comparative Bacteriology of Acute and Chronic Dacryocystitis ������������������������������������������������������������������������������   332 Summary��������������������������������������������������������������������������������������������������   333

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Relevance ������������������������������������������������������������������������������������������������   334 Strengths��������������������������������������������������������������������������������������������������   337 Weaknesses����������������������������������������������������������������������������������������������   337 One-Sentence Summary��������������������������������������������������������������������������   337 Author Comment ������������������������������������������������������������������������������������   337 References������������������������������������������������������������������������������������������������   338 34 Lacrimal Sac Tumors������������������������������������������������������������������������������  341 Author(s)��������������������������������������������������������������������������������������������������   341 Abstract����������������������������������������������������������������������������������������������������   341 Summary��������������������������������������������������������������������������������������������������   342 Relevance ������������������������������������������������������������������������������������������������   343 Strengths��������������������������������������������������������������������������������������������������   344 Weaknesses����������������������������������������������������������������������������������������������   344 One-Sentence Summary��������������������������������������������������������������������������   345 Author Comment ������������������������������������������������������������������������������������   345 References������������������������������������������������������������������������������������������������   346 Part VIII Oncology and Periorbital Lesions 35 Micrographic Surgery for the Microscopically Controlled Excision of Eyelid Cancer��������������������������������������������������������������������������������������  351 Author(s)��������������������������������������������������������������������������������������������������   351 Summary��������������������������������������������������������������������������������������������������   351 Relevance ������������������������������������������������������������������������������������������������   352 Strengths��������������������������������������������������������������������������������������������������   356 Weaknesses����������������������������������������������������������������������������������������������   356 One-Sentence Summary��������������������������������������������������������������������������   356 Author Comment ������������������������������������������������������������������������������������   356 References������������������������������������������������������������������������������������������������   357 36 Survey of 1264 Patients with Orbital Tumors and Simulating Lesions������������������������������������������������������������������������������������������������������  359 Author(s)��������������������������������������������������������������������������������������������������   359 Abstract����������������������������������������������������������������������������������������������������   359 Summary��������������������������������������������������������������������������������������������������   360 Relevance ������������������������������������������������������������������������������������������������   362 Strengths��������������������������������������������������������������������������������������������������   363 Weaknesses����������������������������������������������������������������������������������������������   364 One-Sentence Summary��������������������������������������������������������������������������   364 Author Comment ������������������������������������������������������������������������������������   364 References������������������������������������������������������������������������������������������������   364

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37 Sebaceous Carcinomas of the Ocular Adnexa: A Clinicopathologic Study of 104 Cases, with Five-Year Follow-up Data����������������������������  367 Author(s)��������������������������������������������������������������������������������������������������   367 Abstract����������������������������������������������������������������������������������������������������   367 Summary��������������������������������������������������������������������������������������������������   368 Relevance ������������������������������������������������������������������������������������������������   369 Strengths��������������������������������������������������������������������������������������������������   372 Weaknesses����������������������������������������������������������������������������������������������   372 One-Sentence Summary��������������������������������������������������������������������������   372 Author Comment ������������������������������������������������������������������������������������   372 References������������������������������������������������������������������������������������������������   373 38 Orbital Adnexal Lymphoma ������������������������������������������������������������������  375 Author(s)��������������������������������������������������������������������������������������������������   375 Abstract: Lymphoproliferative Disease of the Ocular Adnexa: A Clinical and Pathologic Study with Statistical Analysis of 69 Patients������������������������������������������������������������������   375 Summary��������������������������������������������������������������������������������������������������   376 Abstract: Curative Radiotherapy for Primary Orbital Lymphoma����������   377 Summary��������������������������������������������������������������������������������������������������   380 Abstract: Ultra-Low-Dose Radiotherapy for Definitive Management of Ocular Adnexal B-Cell Lymphoma��������������������   381 Summary��������������������������������������������������������������������������������������������������   381 Relevance ������������������������������������������������������������������������������������������������   383 Strengths��������������������������������������������������������������������������������������������������   386 Weaknesses����������������������������������������������������������������������������������������������   386 One-Sentence Summary��������������������������������������������������������������������������   386 Author Comment ������������������������������������������������������������������������������������   387 References������������������������������������������������������������������������������������������������   387 39 Targeted Therapy for Cutaneous Malignancies������������������������������������  389 Author(s)��������������������������������������������������������������������������������������������������   389 Summary: Efficacy and Safety of Vismodegib in Advanced Basal-Cell Carcinoma����������������������������������������������   389 Summary: Phase II Study of Cetuximab as First-line Single-drug Therapy in Patients with Unresectable Squamous Cell Carcinoma of the Skin ����������   390 Summary: Adjuvant Dabrafenib plus Trametinib in Stage III BRAF-mutated Melanoma����������������������������������������   392 Relevance ������������������������������������������������������������������������������������������������   393 Strengths��������������������������������������������������������������������������������������������������   398 Weaknesses����������������������������������������������������������������������������������������������   398 One-Sentence Summary��������������������������������������������������������������������������   398 Author Comment ������������������������������������������������������������������������������������   398 References������������������������������������������������������������������������������������������������   399

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40 Lacrimal Gland Carcinoma��������������������������������������������������������������������  401 Author(s)��������������������������������������������������������������������������������������������������   401 Abstract: Long-Term Outcomes of Neoadjuvant Intra-­Arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma������������������������������������������������   401 Summary��������������������������������������������������������������������������������������������������   402 Abstract: Eye-Preserving Surgery Followed By Adjuvant Radiotherapy for Lacrimal Gland Carcinoma: Outcomes in 37 Patients����������������������������������������������������������������   405 Summary��������������������������������������������������������������������������������������������������   406 Abstract: Cranio-Orbital Resection Does Not Appear to Improve Survival of Patients with Lacrimal Gland Carcinoma����   407 Summary��������������������������������������������������������������������������������������������������   408 Relevance ������������������������������������������������������������������������������������������������   409 Strengths��������������������������������������������������������������������������������������������������   413 Weaknesses����������������������������������������������������������������������������������������������   413 One-Sentence Summary��������������������������������������������������������������������������   413 Author Comment ������������������������������������������������������������������������������������   413 References������������������������������������������������������������������������������������������������   415 41 Vascular Lesions��������������������������������������������������������������������������������������  417 Author(s)��������������������������������������������������������������������������������������������������   417 Abstract: Capillary Hemangioma of the Lids and Orbit: An Analysis of the Clinical Features and Therapeutic Results in 101 Cases ������������������������������������������������   417 Summary��������������������������������������������������������������������������������������������������   418 Summary: A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma������������������������������������������   420 Abstract: A Controlled Study of Topical 0.25% Timolol Maleate Gel for the Treatment of Cutaneous Infantile Capillary Hemangiomas ������������������������������������������������   420 Summary��������������������������������������������������������������������������������������������������   421 Summary: Cavernous Venous Malformations of the Orbit (So-Called Cavernous Hemangioma): A Comprehensive Evaluation of their Clinical, Imaging and Histologic Nature����������������������������������������������������   422 Abstract: Percutaneous Drainage and Ablation as First Line Therapy for Macrocystic and Microcystic Orbital Lymphatic Malformations������������������������������������������������   423 Summary��������������������������������������������������������������������������������������������������   425 Relevance ������������������������������������������������������������������������������������������������   426 Strengths��������������������������������������������������������������������������������������������������   428 Weaknesses����������������������������������������������������������������������������������������������   429 One-Sentence Summary��������������������������������������������������������������������������   429 Author Comment ������������������������������������������������������������������������������������   429 References������������������������������������������������������������������������������������������������   431

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Part IX Periorbital Reconstruction 42 Eyelid Reconstruction������������������������������������������������������������������������������  435 Author(s)��������������������������������������������������������������������������������������������������   435 Summary: A New Method for Rebuilding a Lower Lid��������������������������   435 Summary: A Method for Partial and Total Upper Lid Reconstruction����   437 Summary: The Use of Flaps in the Orbital Region����������������������������������   440 Summary: Eyelid Reconstruction by the Semicircle Flap Technique������   441 Summary: Techniques in Eyelid Wound Closure������������������������������������   442 Relevance ������������������������������������������������������������������������������������������������   444 Strengths��������������������������������������������������������������������������������������������������   445 Weaknesses����������������������������������������������������������������������������������������������   445 One-Sentence Summary��������������������������������������������������������������������������   446 Author Comment ������������������������������������������������������������������������������������   446 References������������������������������������������������������������������������������������������������   447 Part X Thyroid Eye Disease 43 Epidemiology of Thyroid Eye Disease����������������������������������������������������  451 Author(s)��������������������������������������������������������������������������������������������������   451 Abstract: The Incidence of Graves’ Ophthalmopathy in Olmsted County, Minnesota����������������������������������������������������������   451 Summary��������������������������������������������������������������������������������������������������   452 Summary: Occurrence of Ophthalmopathy after Treatment for Graves’ Hyperthyroidism��������������������������������������������������������   452 Summary: Relation Between Therapy for Hyperthyroidism and the Course of Graves’ Ophthalmopathy��������������������������������   454 Summary: Cigarette Smoking and Treatment Outcomes in Graves Ophthalmopathy ��������������������������������������������������������������   454 Relevance ������������������������������������������������������������������������������������������������   455 Strengths��������������������������������������������������������������������������������������������������   460 Weaknesses����������������������������������������������������������������������������������������������   460 One-Sentence Summary��������������������������������������������������������������������������   460 Author Comment ������������������������������������������������������������������������������������   460 References������������������������������������������������������������������������������������������������   461 44 Steroids and Thyroid Eye Disease����������������������������������������������������������  463 Author(s)��������������������������������������������������������������������������������������������������   463 Abstract: Randomized, Single Blind Trial of Intravenous Versus Oral Steroid Monotherapy in Graves’ Orbitopathy����������   463 Summary��������������������������������������������������������������������������������������������������   464 Summary: Therapeutic Outcomes of High-Dose Intravenous Steroids in the Treatment of Dysthyroid Optic Neuropathy ��������   464 Relevance ������������������������������������������������������������������������������������������������   466 Strengths��������������������������������������������������������������������������������������������������   468 Weaknesses����������������������������������������������������������������������������������������������   468

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One-Sentence Summary��������������������������������������������������������������������������   468 Author Comment ������������������������������������������������������������������������������������   468 References������������������������������������������������������������������������������������������������   468 45 Orbital Radiation for Thyroid Eye Disease ������������������������������������������  471 Author(s)��������������������������������������������������������������������������������������������������   471 Abstract: A Prospective, Randomized, Double-Blind, Placebo-­Controlled Study of Orbital Radiotherapy for Graves’ Ophthalmopathy����������������������������������   471 Summary��������������������������������������������������������������������������������������������������   472 Summary: A Randomized Controlled Trial of Orbital Radiotherapy Versus Sham Irradiation in Patients with Mild Graves’ Ophthalmopathy��������������������������������   473 Abstract: Orbital Radiotherapy Combined with Corticosteroid Treatment for Thyroid Eye Disease-­Compressive Optic Neuropathy��������������������������������������   474 Summary��������������������������������������������������������������������������������������������������   474 Relevance ������������������������������������������������������������������������������������������������   475 Strengths��������������������������������������������������������������������������������������������������   477 Weaknesses����������������������������������������������������������������������������������������������   477 One-Sentence Summary��������������������������������������������������������������������������   478 Author Comment ������������������������������������������������������������������������������������   478 References������������������������������������������������������������������������������������������������   478 46 Biologics for Thyroid Eye Disease����������������������������������������������������������  481 Author(s)��������������������������������������������������������������������������������������������������   481 Abstract: Randomized Controlled Trial of Rituximab in Patients with Graves’ Orbitopathy������������������������������������������������   481 Summary��������������������������������������������������������������������������������������������������   482 Abstract: Efficacy of B-Cell Targeted Therapy with rituximab in Patients with Active Moderate to Severe Graves’ Orbitopathy: A Randomized Controlled Study����������������������������   484 Summary��������������������������������������������������������������������������������������������������   485 Abstract: Efficacy of Tocilizumab in Patients with Moderate-­to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial��������������������������������������������������������   487 Summary��������������������������������������������������������������������������������������������������   488 Summary: Teprotumumab for Thyroid-Associated Ophthalmopathy����������������������������������������������������������������������������   489 Relevance ������������������������������������������������������������������������������������������������   491 Strengths��������������������������������������������������������������������������������������������������   494 Weaknesses����������������������������������������������������������������������������������������������   494 One-Sentence Summary��������������������������������������������������������������������������   494 Author Comment ������������������������������������������������������������������������������������   494 References������������������������������������������������������������������������������������������������   497

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47 Orbital Decompression for Thyroid Eye Disease����������������������������������  499 Author(s)��������������������������������������������������������������������������������������������������   499 Abstract: The Four Stages of Surgical Rehabilitation of the Patient with Dysthyroid Ophthalmopathy������������������������������   499 Summary��������������������������������������������������������������������������������������������������   499 Abstract: The Transantral Orbital Decompression Operation for Progressive Exophthalmos ������������������������������������   500 Summary��������������������������������������������������������������������������������������������������   501 Abstract: Results of transantral orbital decompression in 428 patients with severe Graves’ ophthalmopathy ����������������������   502 Summary��������������������������������������������������������������������������������������������������   504 Summary��������������������������������������������������������������������������������������������������   507 Abstract: Strabismus after Balanced Medial Plus Lateral Wall Versus Lateral Wall only Orbital Decompression for Dysthyroid Orbitopathy����������������������������������������������������������   509 Summary��������������������������������������������������������������������������������������������������   510 Relevance ������������������������������������������������������������������������������������������������   510 Strengths��������������������������������������������������������������������������������������������������   514 Weaknesses����������������������������������������������������������������������������������������������   516 One-Sentence Summary��������������������������������������������������������������������������   516 Author Comment ������������������������������������������������������������������������������������   516 References������������������������������������������������������������������������������������������������   518 Part XI Facial Trauma and the Anophthalmic Socket 48 Oculofacial Trauma ��������������������������������������������������������������������������������  523 Author(s)��������������������������������������������������������������������������������������������������   523 Abstract: The Pathogenesis of Canalicular Laceration����������������������������   523 Summary��������������������������������������������������������������������������������������������������   524 Abstract: Force Necessary to Fracture the Orbital Floor ������������������������   525 Summary��������������������������������������������������������������������������������������������������   525 Abstract: Nonsurgical management of blow-out fractures of the orbital floor ����������������������������������������������������������������������������������������������   526 Summary��������������������������������������������������������������������������������������������������   526 Abstract: Surgery on Orbital Floor Fractures: Influence of Time of Repair and Fracture Size ������������������������������������������������   528 Summary��������������������������������������������������������������������������������������������������   529 Abstract: Intervention Within Days for Some Orbital Floor Fractures: The White-Eyed Blowout����������������������������������   529 Summary��������������������������������������������������������������������������������������������������   530 Abstract: Clinical Features and Treatment of Pediatric Orbit Fractures������������������������������������������������������������������������������   530 Summary��������������������������������������������������������������������������������������������������   532 Abstract: Efficacy of Lateral Canthotomy and Cantholysis in Orbital Hemorrhage������������������������������������������������������������������   532

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Summary��������������������������������������������������������������������������������������������������   534 Relevance ������������������������������������������������������������������������������������������������   534 Strengths��������������������������������������������������������������������������������������������������   540 Weaknesses����������������������������������������������������������������������������������������������   540 One-Sentence Summary��������������������������������������������������������������������������   541 Author Comment ������������������������������������������������������������������������������������   541 References������������������������������������������������������������������������������������������������   541 49 Wooden Intraorbital Foreign Body Injuries: Clinical Characteristics and Outcomes of 23 Patients��������������������������  545 Author(s)��������������������������������������������������������������������������������������������������   545 Abstract����������������������������������������������������������������������������������������������������   545 Summary��������������������������������������������������������������������������������������������������   546 Relevance ������������������������������������������������������������������������������������������������   546 Strengths��������������������������������������������������������������������������������������������������   549 Weaknesses����������������������������������������������������������������������������������������������   549 One-Sentence Summary��������������������������������������������������������������������������   549 Author Comment ������������������������������������������������������������������������������������   550 References������������������������������������������������������������������������������������������������   551 50 The Silent Sinus Syndrome: A Cause of Spontaneous Enophthalmos��������������������������������������������������������������������  553 Author(s)��������������������������������������������������������������������������������������������������   553 Abstract����������������������������������������������������������������������������������������������������   553 Summary��������������������������������������������������������������������������������������������������   554 Relevance ������������������������������������������������������������������������������������������������   556 Strengths��������������������������������������������������������������������������������������������������   557 Weaknesses����������������������������������������������������������������������������������������������   558 One-Sentence Summary��������������������������������������������������������������������������   558 Author Comment ������������������������������������������������������������������������������������   558 References������������������������������������������������������������������������������������������������   559 51 Anophthalmic Socket������������������������������������������������������������������������������  561 Author(s)��������������������������������������������������������������������������������������������������   561 Summary��������������������������������������������������������������������������������������������������   561 Abstract: Coralline Hydroxyapatite as an Ocular Implant����������������������   564 Summary��������������������������������������������������������������������������������������������������   564 Abstract: Exposure Rate of Hydroxyapatite Spheres in the Anophthalmic Socket��������������������������������������������������������������������   566 Summary��������������������������������������������������������������������������������������������������   566 Abstract: Prosthetic Motility in Pegged Versus Unpegged Integrated Porous Orbital Implants����������������������������������������������   569 Summary��������������������������������������������������������������������������������������������������   569 Abstract: Comparing Outcomes of Enucleation and Evisceration����������������������������������������������������������������������������������   570 Summary��������������������������������������������������������������������������������������������������   571

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Abstract: Dermis-Fat Orbital Implantation: 118 Cases ��������������������������   572 Summary��������������������������������������������������������������������������������������������������   573 Relevance ������������������������������������������������������������������������������������������������   574 Strengths��������������������������������������������������������������������������������������������������   579 Weaknesses����������������������������������������������������������������������������������������������   579 One-Sentence Summary��������������������������������������������������������������������������   579 Author Comment ������������������������������������������������������������������������������������   580 References������������������������������������������������������������������������������������������������   580 Index������������������������������������������������������������������������������������������������������������������  583

Part I

Facial Aesthetics

Optimal management of the patient with facial aesthetic concerns depends on an inside-out knowledge of facial anatomy, from osteology to soft tissue anatomy, as well as a comfort with both noninvasive, minimally invasive, and traditional surgical treatments. The collection of articles in this chapter spans detailed anatomic dissections, novel or refined surgical techniques, as well as important milestones such as fat grafting, laser resurfacing, and toxin/filler treatments. The modern aesthetic practice must integrate all of these innovations in tailoring a treatment plan for each patient’s specific goals.

Chapter 1

Midfacial Aging – Deflation or Descent?

Author(s) Pooja Mally; Craig N. Czyz; and Allan E. Wulc Val Lambros

 bstract: The Role of Gravity in Periorbital A and Midfacial Aging Background: With respect to the pathogenesis of periorbital and midfacial aging, gravity may play a greater role than volume loss. Objectives: The authors determined the effect of shifting from the upright to the supine position on specific attributes of facial appearance and ascertained whether facial appearance in the supine position bore any resemblance to its appearance in youth. Methods: Participants who showed signs of midface aging were positioned in the upright and supine positions, and photographs were obtained during smiling and repose. For each photograph, examiners graded the following anatomic parameters, using a standardized scale: brow position, tear trough length and depth, steatoblepharon, cheek volume, malar bags/festoons, and nasolabial folds. Some participants provided photographs of themselves taken 10–15  years earlier; these were compared with the study images. Results: Interobserver correlation was strong. When participants were transferred from upright to supine, all anatomic parameters examined became more youthful in appearance; findings were statistically significant. The grading of anatomic parameters of the earlier photographs most closely matched that of current supine photographs of the subjects smiling. Conclusions: In the supine position, as opposed to the upright position, participants with signs of midface aging appear to have much more volume in the periorbita and midface. For the subset of participants © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_1

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who provided photographs obtained 10–15 years earlier, the appearance of facial volume was similar between those images and the current supine photographs. This suggests that volume displacement due to gravitational forces plays an integral role in the morphogenesis of midface aging.

Summary Purpose  To determine if gravity is a significant component of facial aging. Design  A prospective case series of 61 women (mean age 51 years old). Inclusion criteria were age >30 years old; exclusion criteria were a history of any facial surgery other than rhinoplasty. Outcome Variables  Full face photos were taken of the patients in upright and supine positions. Upright photographs were taken in repose and with an active smile. Full-face photographs were also obtained from 10 to 15 years prior to the time of the study. The following anatomic features were assessed according to a standardized Likert-type or Glogau scale by three blinded observers: brow position, tear trough length/depth, steatoblepharon, cheek volume, malar festoons, and nasolabial folds. The current upright (repose and smiling) and supine photographs were compared to each other as well as to the photographs from 10 to 15 years prior. Results  Patients were observed to have a statistically significant improvement in their facial features both with active smile and with supine posture. Supine posture caused such significant improvement that there was no difference in the grading between current supine and youthful upright photographs (Fig. 1.1). Gravitational descent appears to play a significant role in midfacial aging.

Abstract: Observations on Periorbital and Midface Aging Background: Many of the anatomical changes of facial aging are still poorly understood. This study looked at the aging process in individuals linearly over time, focusing on aspects of periorbital aging and the upper midface. Methods: The author compared photographs of patients’ friends and relatives taken 10–50 years before with closely matched recent follow-up pictures. The best-matching old and recent pictures were equally sized and superimposed in the computer. The images were then assembled into GIF animations, which automate the fading of one image into the other and back again indefinitely. Results: The following findings were new to the author: (1) the border of the pigmented lid skin and thicker cheek skin (the lid-­ cheek junction) is remarkably stable in position over time, becoming more visible by contrast, not by vertical descent as is commonly assumed. (2) Orbicularis

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Fig. 1.1  Adapted from Mally et al. [1] Mean grades for anatomic features were significantly improved from upright to supine position, and supine posture grades were not statistically different from grading of the same patients in youth

wrinkles on the cheek and moles and other markers on the upper midface were also stable over decades. (3) With aging, there can be a distinct change in the shape of the upper eyelid. The young upper lid frequently has a medially biased peak. The upper lid peak becomes more central in the older lid. This article addresses these three issues. No evidence was seen here for descent of the globe in the orbit. Conclusions: There seems to be very little ptosis (inferior descent) of the lid-cheek junction or of the upper midface. These findings suggest that vertical descent of skin, and by association, subcutaneous tissue, is not necessarily a major component of aging in those areas. In addition, the arc of the upper lid changes shape in a characteristic way in some patients. Other known changes of the periorbital area are visualized.

Summary Purpose  To learn more about the aging process over time. Design  A prospective case series of 130 patients (range 10–89 years old) with two-­ dimensional, full-face photographs a mean of 25 years apart. Current photographs were taken in an identical position and expression compared to the youthful photographs. Photographs were then superimposed in digital image analysis software (Photoshop, Adobe, San Jose, CA) and assembled into an animation. Qualitative changes were observed and discussed.

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1  Midfacial Aging – Deflation or Descent?

Results  The lid-cheek junction was noted to descend in only 3.6% of patients evaluated (n = 83). The upper eyelid contour changed to a more lateral peak in 38% of patients evaluated (n  =  130). Facial nevi appear to be stable over time without descent.

Relevance These twostudies by Wulc and colleagues [1] and Lambros [2] explore the findings and theories behind periorbital and midfacial aging. In Wulc’s study, gravitational descent is demonstrated to play a profound role in aging. The active smile (to a lesser degree) and supination (to a greater degree) counteract the effects of gravity; showing that reversal of gravitational effects directly improves facial aesthetics is foundational to facial cosmetic surgery. More impressive, however, is the analysis of youthful photographs from the subjects with a comparison to present-day. The fact that supination yields an aesthetic improvement similar to reversing 10–15 years of aging is a compelling finding. Lambros’ thought-provoking study [2] provides an interesting contradistinction. In his ground-breaking analysis, he observed that neither the lid-cheek junction nor facial nevi descended over time and concluded that gravitational descent was not a significant component of midfacial aging (Fig. 1.2). Lambros also noted characteristic changes in the contour of the upper eyelid, with the peak shifting from medial to centrolateral over time. Volume loss and gravitational descent have both been thought to contribute to facial aging, but it is not always clear which is more important and which to target clinically. The decision of whether to inflate (with autologous fat or dermal fillers) or to surgically lift (with minimally invasive or conventional techniques) is a controversial one, and a poll of 100 aesthetic practitioners would likely yield as many different opinions based on the clinician’s training, skills, and comfort level with nonsurgical and surgical therapies. This decision is also big business, with

Fig. 1.2  Photographs of a woman at age 21 (left) and age 54 (right); nevus (arrow) and lid-cheek junction appear to be stable. (Reproduced with permission from [2])

Relevance

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pharmaceutical companies spending vast sums on marketing injectables that they claim provide lift through volumization. With billion-dollar budgets to muddying the waters, it is ever more important to clarify which is more important in aging: descent or deflation. At first glance, these two studies, both landmark and authoritative in their own manner, would seem to contradict each other. However, subtle differences in the populations and analyses suggest these two observations may be two sides of the same coin. All of the patients in Wulc’s study were Caucasian females, while 90% in Lambros’ were Caucasian females. Both were retrospective, two-dimensional, photographic analyses that suffer from uncontrolled lighting and facial expression in the youthful photographs that could bias the results. Most importantly, Wulc et al. analyzed changes by utilizing a Likert-type grading scale with masked reviewers, while Lambros utilized superimposed animations to capture dynamic changes. Neither measured (digitally or otherwise) the exact position of the anatomic structures of interest. Without direct measurement, we are left with somewhat ambiguous outcomes – either an ordinal scale from 0 to 3, or Lambros’ Boolean observation of midfacial change. Critical to reconciling these studies is the knowledge that the interaction of light and shadows on anatomic structures greatly influences the observer’s perception of the structure. This is perhaps nowhere more salient than in the tear trough. My own group’s research demonstrates the role of light and shadows on the location and depth of the lid-cheek junction or tear trough [3, 4]. The lid-cheek junction is not one specific structure, nor are the underlying anatomic components single points in space. The orbital retaining ligament is an arborizing and highly variable structure [5], and the presence of actinic skin change, orbital fat protrusion, and tissue descent can all influence the thickness and the apparent depth of the lid-cheek junction such that whilst the underlying ligaments may have minimal motility, the perceived aesthetic change may be quite significant [4]. Even in observing Lambros’ photographs, my personal perception is that the lower eyelid appears longer, akin to Fezza and Massry’s observations [6], despite Lambros’observation that the lidcheek junction remains anatomically static. In other words, Lambros’ conclusions could be taken as commenting on the physical position lid-cheek junction, which may have minimal motility due to its proximity to the orbital retaining ligament. Conversely, Wulc’s analysis could be understood as an observation of the composite aesthetic change resulting from the effects of gravity, and finds that the aged lower eyelid can be cosmetically improved by counteracting those gravitational changes. The first analysis is anatomic; the second is perceptual. Both are critical to understand as understanding why and how patients age can lead to more targeted treatment. Both authors have released subsequent versions of their studies utilizing three-­ dimensional analysis to address the major criticism of inconsistent lighting. Wulc and colleagues [7] repeat their prior study with 3D supine and upright photography, and corroborate their previous findings. Indeed, patients experience overall aesthetic improvement upon supination due to reversal of gravity, and this reversal provides revolumization of the periorbita and midface in amounts comparable to

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that which is commonly injected [8] in each aesthetic subunit. Lambros longitudinally followed patients over 54 years using two- and three-dimensional photography, and produced striking composite images that allow for qualitative analysis of the periorbita and midface [9] in men and women. Most interestingly, with this more accurate method of analysis, he does note descent of the lid-cheek junction of 1.3 mm in males and 1 mm in females. Quantitative volumetric analysis is not performed, although qualitatively, anterior projection is lost from the periorbita and midface and perhaps redistributed inferiorly into the nasolabial folds and jowls, which demonstrate increased anterior projection over time. These findings are corroborated by cadaveric [10] and imaging [11] studies that demonstrate that the deep facial fat both redistributes amongst its fascial connections [12] and deflates with some amount of volume loss [13]. On gross observation of Lambros’ and Wulc’s three-dimensional reconstructions and animations, I observe similar findings between the two. Aging does appear to lead to descent, although the descent is attenuated in areas in close proximity to ligaments. Aging also leads to volume deflation with reduced anterior projection in the midface. Both volumization and lifting would provide aesthetic improvement for most patients. Aging exists on a spectrum and some patients may have much more deflation than descent, or vice versa. As always, the decision of which cosmetic treatment to offer  – volumization or lifting  – is an intensely personal decision that depends on the patient’s specific phenotype and desires.Aesthetic complications exist on either end of the spectrum – overfill ora “pulled” look. In fact, modern aesthetic techniques involve both surgical lifting and volumization to achieve the most natural cosmetic result, particularly at the tear trough and midface [4, 14–16]. I leave it to the reader to be aware of their own limitations so that he or she can offer a tailored and balanced facial rejuvenation plan for their patient.

Strengths • Both studies offer rigorous analysis with longitudinal follow-up of patients over time. • The addition of three-dimensional volumetric analysis in the follow-up studies eliminates much of the criticism surrounding the originals. • Both studies offer new and foundational insights into the etiology of periorbital and midfacial aging.

Weaknesses • Neither study provides quantitative analysis, which would be helpful to precisely understand observations such as the descent (or lack thereof) of nevi over time. • Subtle changes in facial expression (e.g., smiling) can profoundly alter the results.

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• Patients may have undergone cosmetic treatments such as dermal fillers that could introduce bias. • The chronology of aging is not addressed and the time intervals between photographs are not specified. These studies do not answer the question of whether aging is gradual or punctuated.

One-Sentence Summary Midfacial aging can be considered both anatomically and perceptually; volume deflation and gravitational descent both play a role in periorbital and midfacial aging.

Author Comment “I had been asking pts to bring in old photographs since about 1991, just so they and I could learn more about their faces. In about 1997 it occurred to me to try to match the old photos with recently taken photos, then registering the two images and then fading from one to the other. This proved to be extraordinarily difficult to do because in order to have a meaningful combination of two pictures, they have to be very close in position, less than a degree. While this is relatively straightforward with a 3D camera, with a regular camera one has to take multiple pictures, shifting slightly between photos to try to duplicate the angle and distance to the subject of a picture taken, say 40 years before. One then has to test each picture against the original in photoshop to find a closest match. Incredibly tedious. I’d never do it again. Matching AP images are the easiest; one can usually get a good match with 5 to 10 tries. Obliques are more difficult and laterals are almost impossible. Very few of the image pairs were perfect, though the eye can compensate for the motion between the old and recent photos in the animations. However, the results of this effort seemed to show some true things about facial aging: that there was less geographic motion of skin than previously thought, especially around the orbits and cheek, and that in and out changes in skin contour look like vertical skin travel.” – Val Lambros, MD Gravity exerts an effect on the aging face. A simple method to demonstrate the benefit of many facial aesthetic procedures is to allow the aging patient to examine themselves in the supine position. The improvements benefit most of the facial aesthetic subunits: protuberant orbital fat returns to nestle within the orbit, the hollow upper sulcus fills, the brows re-volumize and appear repositioned in a higher location. Other observations that can be made: the midface repositions, the lid cheek junction becomes higher, the tear trough diminishes as do the nasolabial folds, the jowls, and the marionettes. The nose gains projection, the tip elevates, and the downturned aging lip reverts to a faint smile.

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1  Midfacial Aging – Deflation or Descent?

This study was performed in an attempt to reconcile the contention that periorbital and midface aging is a primary result of volume loss. In a widely quoted study, Lambros demonstrated a series of photos which showed little change in the position of landmarks (nevi) particularly at the lid cheek junction in his landmark study of 2007 [2]. Since that study and believing this to be only a part of the story, we compiled a series of nevus photos demonstrating that in many patients, particularly with advanced facial aging, nevi did drift downwards. In these patients, when assuming the supine position, the nevi returned to a more youthful position. More significantly, the face revolumized over these areas, and the entire midface appeared more youthful. Our study attempted to evaluate qualitatively the morphologic changes that occurred positionally and compare photos in the supine position to photographs taken more than a decade prior in a group of patients. The majority of photos that our subjects shared with us showed them smiling. We affirmed that aesthetic improvements occurred in each subunit in the midface and periorbit with high interobserver correlation and determined that photos from 15 years prior resembled the older examined face in supine repose. There were multiple flaws in this study. The cohort was small. We did not test men. Prior photographs showed patients in the act of smiling which affected facial subunits, deepening the nasolabial fold and elevating the cheeks and lid cheek junction. Gravity was still at work in the supine position, only influencing the face in a different vector. Most importantly, lighting was variable and not controlled: less facial shadowing occurred lying flat, evening out the curves, hollows and shadows seen in 2 dimensional photographs in the upright position. The latter very valid flaw led us to perform the same study with controlled lighting using 3-dimensional photography. In this study, we were able to measure the volumetric changes that occurred when going from upright to supine, as well as areas of skin displacement, and confirm some of our previous findings [7]. I believe Lambros is partially right: the aging midface does lose volume. But volume loss may actually be volume displacement due to the effects of gravity. Nevi do not drift down in the periorbita because they are at points of strong ligamentous attachment: in the elderly, with less strong ligamentous attachments, they do drift. Facial ligaments attenuate and the fat compartments that they suspend are subject to the whims of gravity—things go downwards and vertically when we are upright, and postero-superiorly and laterally when we are supine. The skin passively follows the descent of the facial fat compartments except in locations where it is more firmly attached to ligaments. These locations empty of volume but do not drift because they are anchored at ligamentous points, but nonetheless The latter very valid flaw led us to perform the same study with controlled lighting using 3-dimensional photography. In this study, we were able to measure the volumetric changes that occurred when going from upright to supine, as well as areas of skin displacement, and confirm some of our previous findings [7]. submit to the effects of gravity.

References

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Displacement of the fat compartments has now been documented and confirmed via CT and in cadaveric studies [10, 11, 17]. – Allan Wulc, MD

References 1. Mally P, Czyz CN, Wulc AE (2014) The role of gravity in periorbital and midfacial aging. Aesthet Surg J 34:809–822 2. Lambros V (2007) Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367–1376 3. Ramesh S, Goldberg RA, Wulc AE, Brackup AB (2019) Objective comparison of nasojugal fold depth and lower eyelid length after fat excision versus fat transpositional lower blepharoplasty. Aesthet Surg J 39:1048–1054 4. Ramesh S, Goldberg RA, Wulc AE, Brackup AB. Observations on the Tear Trough. Aesthet Surg J. 2020;40(9):938–947. https://doi.org/10.1093/asj/sjz345. PMID: 31760423. 5. Jehoon O, Kwon H-J, Choi Y-J, Cho T-H, Yang H-M (2018) Three-dimensional structure of the orbicularis retaining ligament: an anatomical study using micro-computed tomography. Sci Rep 8:17042 6. Fezza JP, Massry G (2015) Lower eyelid length. Plast Reconstr Surg 136:152e–159e 7. Ramesh S, Johnson P, Sarcu D, Wulc AE (2020) Gravity in midfacial aging: a 3-dimensional study. Aesthet Surg J. https://doi.org/10.1093/asj/sjaa021 8. Shue S, Kurlander DE, Guyuron B (2018) Fat injection: a systematic review of injection volumes by facial subunit. Aesthet Plast Surg 42:1261–1270 9. Lambros V (2020) Facial aging: a 54-year, three-dimensional population study. Plast Reconstr Surg 145:921–928 10. Cotofana S, Gotkin RH, Frank K, Koban KC, Targosinski S, Sykes JM, Schlager M, Schlattau A, Schenck TL (2019) The functional anatomy of the deep facial fat compartments. Plast Reconstr Surg 143:53–63 11. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J (2012) Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg 129:263–273 12. Furnas DW (1989) The retaining ligaments of the cheek. Plast Reconstr Surg 83:11–16 13. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ (2013) The science and theory behind facial aging. Plast Reconstr Surg Glob Open 1:1–8 14. Massry GG, Hartstein ME (2012) The lift and fill lower blepharoplasty. Ophthalmic Plast Reconstr Surg 28:213–218 15. Rohrich RJ, Ghavami A, Mojallal A (2011) The five-step lower blepharoplasty: blending the eyelid-cheek junction. Plast Reconstr Surg 128:775–783 16. Shtraks JP, Fundakowski C, Yu D, Hartstein ME, Sarcu D, Lu X, Wulc AE (2019) Investigation of the longevity of the endoscopic midface lift. JAMA Facial Plast Surg 21:535–541 17. Munn L, Stephan CN (2018) Changes in face topography from supine-to-upright position— and soft tissue correction values for craniofacial identification. Forensic Sci Int 289:40–50

Chapter 2

The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery

Author(s) Rod J. Rohrich, Joel E. Pessa

Abstract Background: Observation suggests that the subcutaneous fat of the face is partitioned as distinct anatomical compartments. Methods: 30 hemifacial cadaver dissections were performed after methylene blue had been injected into specified regions. Initial work focused on the nasolabial fat. Dye was allowed to set for a minimum of 24 hours to achieve consistent diffusion. Dissection was performed in the cadaver laboratory using microscopic and loupe magnification. Results: The subcutaneous fat of the face is partitioned into multiple, independent anatomical compartments. The nasolabial fold is a discrete unit with distinct anatomical boundaries. What has been referred to as malar fat is com- posed of three separate compartments: medial, middle, and lateral temporal- cheek fat. The forehead is similarly composed of three anatomical units including central, middle, and lateral temporal-­ cheek fat. Orbital fat is noted in three compartments determined by septal borders. Jowl fat is the most inferior of the subcutaneous fat compartments. Some of the structures referred to as “retaining ligaments” are formed simply by fusion points of abutting septal barriers of these compartments. Conclusions: The subcutaneous fat of the face is partitioned into discrete an- atomic compartments. Facial aging is, in part, characterized by how these compartments change with age. The concept of separate compartments of fat suggests that the face does not age as a confluent or composite mass. Shearing between adjacent compartments may be an additional

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_2

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2  The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic…

factor in the etiology of soft-tissue malposition. Knowledge of this anatomy will lead to better under- standing and greater precision in the preoperative analysis and surgical treatment of the aging face.

Summary Purpose  To describe the subcutaneous fat compartments of the face. Design  A cadaveric dissection study of 30 hemifaces (18 males, 12 females). Methylene blue dye was injected into the hemifaces and the dye allowed to redistribute for 48–72 hours. Each identified fat compartment was confirmed in a minimum of 3 or maximum of 10 hemifaces. The morphology of the fat compartments and boundary structures are described. Results  The following subcutaneous facial fat compartments were identified (Figs. 2.1 and 2.2): 1. Nasolabial Fat Compartment: This fat compartment is bordered superiorly by the orbital retaining ligament (ORL), inferiorly by the jowl fat (which it overlaps), laterally by the suborbicularis oculi fat, and lies anterior to the deep medial cheek fat compartment. 2. Malar Fat Compartments: There are three identifiable and distinct malar fat compartments, described below.



(a) Medial Cheek Fat: This fat pad lies just lateral to the nasolabial fat pad, inferior to the ORL, superior to the jowl fat, and inferomedial to the deep lateral cheek fat compartment. (b) Middle Cheek Fat: This fat pad lies just anterior and superior to the parotid gland, and its superior boundary are the zygomaticocutaneous ligaments (McGregor’s patch) and the zygomaticus major muscles. The border of the deep middle and medial fat pads fuses with the parotid-masseteric ligaments. (c) Lateral Cheek fat: This fat pad lies superficial to the parotid gland, lies inferior to the temporal fat, and superior to the cervical fat. A septum lies at the superior border of this fat pad, which is encountered in the face lift and endoscopic temporal brow or midface lift dissections.

3. Forehead Fat Compartment: Subcutaneous fat in the forehead can be divided into three separate compartments. The inferior border for these compartments lies, from medial to lateral, along the nasal dorsum, arcus marginalis, and the temporal septa that separate the temple from the cheek. The superior border likely ends where the frontalis muscle transitions to the galea. While there are no well-defined structures that separate the fat pads in the horizontal plane, there are variable thin septa that separate these into the medial, central, and lateral forehead fat compartments.

Summary

15

Fig. 2.1  Subcutaneous fat compartments of the face. (Reproduced with permission from Rohrich and Pessa [1])

4. Eyelid Fat Compartments: The eyelid subcutaneous fat can be divided into three compartments.

(a) The superior eyelid fat is bounded externally by the ORL and is limited by the raphé of the orbicularis oculi muscle adjacent to the lateral and medial canthal tendons. (b) The inferior eyelid fat is bounded superiorly by the inferior tarsal border, inferiorly by the ORL, and is also limited by the raphé of the lateral and medial canthal tendons as they interdigitate with the orbicularis oculi muscle. (c) The lateral eyelid fat lies lateral to the lateral canthus and is bounded superiorly by the inferior temporal septum, inferiorly by the cheek septum, and inferolaterally by the zygomaticocutaneous ligaments. 5. Jowl Fat Compartment: The jowl fat is just superior to the platysma, lateral to the depressor anguli oris, and inferior to the nasolabial fat pad. The authors comment that this is the most poorly understood fat pad in terms of facial aging.

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2  The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic…

Fig. 2.2  The lateral temporal-cheek fat spans the forehead to the cervical region. It is the most lateral of the cheek fat compartments and has an identifiable septal barrier medially called the lateral cheek septum (LCS). The superior and inferior temporal septa (STS and ITS, respectively) represent the superior boundaries. This cadaver dissection is noteworthy because several fat compartments are seen without dye staining, including the inferior orbital fat (IOF) and medial cheek fat (M). Nasolabial fat has been stained with methylene blue dye. (Reproduced with permission from Rohrich and Pessa [1])

Relevance This study by Rohrich and Pessa [1] provides detailed anatomic analysis that furthers our understanding of facial anatomy and lays the foundation for safe and effective facial surgery. The authors’ concept of facial fat compartments is not entirely novel, and detailed studies of the fascial system that organizes these fat pads has been presented by these authors [2–4] and others [5, 6]. However, the authors’ method of dye-based diffusion analysis provides striking photographic support to their observations. Their conclusions have several interesting implications. Firstly, the authors’ conclusions provide valuable guidance for facial surgery. Fascial fusion zones lie at the borders between these fat compartments, which can be identified and anticipated intraoperatively. For example, the zygomaticocutaneous ligaments lie at the juncture of the middle cheek fat, lateral cheek fat, and lateral eyelid fat, with the zygomaticus major muscle adherent to this zone. This scenario is recapitulated at the mandibular ligaments, platysmal ligaments, and parotid-­ masseteric ligaments. The surgeon should anticipate the transition between these fat pads and proceed carefully, as ligamentous attachments and variance in the thickness of these fat pads can lead to inadvertent facial nerve or vascular injury. As the authors note, “the eye sees what the mind knows”. Moreover, changes in fat pad thickness in these transition zones can lead to unintended dissection into deeper

Relevance

17

planes, e.g., the buccal space, if the dissection is carried at exactly the same depth. On the other hand, several of these fascial structures must be identified and released if aesthetic improvement adjacent to the structure is to be obtained. For example, dissection medial to the zygomaticocutaneous ligaments and into the medial cheek fat pad and nasolabial fat pad is necessary to efface the nasolabial fold. A thorough understanding of the fat pads, their locations, and relative thicknesses, will allow for mental preplanning to minimize the risk of iatrogenic injury and maximize the aesthetic improvement. Secondly, the authors suggest that these anatomic findings may have implications for understanding facial aging. Aging is thought to be a combination of ligamentous attenuation and facial volume loss [7, 8]; this is discussed in detail in Chap. 1. If these described fat pads experience heterogenous atrophy over time but remain relatively fixed in position by the fascial sling, contour deformities can develop where the transition zones between compartments were once smooth [9]. This theory can account for the characteristic rhytids seen in the aging face and provide clues for how to improve them. Perhaps the most prolific contemporary anatomists to Rohrich and Pessa, Mendelson and Wong have published parallel cadaveric dissections that corroborate the anatomic descriptions herein [6, 10]. Perhaps the most striking difference between the duos is that while Mendelson and Wong provide detailed anatomic descriptions of the ligaments, septa, and neurovascular structures that occupy and surround these compartments, Rohrich and Pessa emphasize the fat pads themselves as structures of interest. A detailed understanding of both the boundary structures as well as the thickness and location of the fat pads themselves is critical for safe surgery. Once this foundation has been laid, the reader can fine-tune their understanding by reading the incredibly detailed descriptions of the ligamentous and neural microanatomy performed in Korea [11–13]. The authors’ conclusions have important caveats. Significant ethnic variation is present in facial anatomy and the thickness of skin and fat. In particular, the eyelid tissues have an attenuated dermis and hypodermis such that they are almost absent in many patients; Asian patients, however, have additional and thicker layers of subcutaneous fat that are not found in others [14]. In practice, I have not observed significant fat between the skin and the preseptal orbicularis muscle in the upper or lower eyelid in non-Asians intraoperatively. Aging also affects men, women, and persons of different ages differently such that the expected landmarks may not be where the surgeon expects. Finally, more and more patients are undergoing procedures at a younger age; even “minimally invasive” procedures such as thread lift or dermal filler injection can disturb these fascial structures and dissection planes, especially when repeated over years. As such, the reader should interpret these findings with caution as very seldom do patients tend to read the anatomy textbook before laying on the operation table. In summary, the authors present a compelling and detailed anatomic description of the facial subcutaneous fat pads. I encourage the reader to review the references cited as well as the authors’ excellent compendium [15] which summarizes their years of anatomic dissections.

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2  The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic…

Strengths • Detailed anatomic discussion of cadaveric hemifaces with reproducible results. • Conclusions drawn are supported by a wide body of literature, while providing novel observations that affect surgical planning.

Weaknesses • Ethnic and other variation among the cadavers is not addressed. • The eyelid fat pads in particular may be somewhat less robust in vivo than the authors describe.

One-Sentence Summary The facial fat pads can be divided into stereotyped compartments thatare separated by various septa, which has anatomic and surgical implications.

Author Comment An under-appreciated classic paper is [James] Stuzin's on retaining ligaments [9]. We showed in our dissections that the intersections of the unique fat compartments in the face were indeed where these so-called retaining ligaments arose, and where the power of surgery is. Stuzin saw early on the importance of releasing these boundaries, for example, between the deep lateral fat and the buccal fat. More and more that seems to be the key to improving jowls, which as you know are probably related to an expanded buccal space from stress (chewing with activation of the masseter muscle). Reefing the SMAS simply decreases that space volume. This also applies to the periorbital area, which we published in another PRS paper [16]. Here, the cornerstone for improving the lower eyelid is blending the eyelid-cheek junction by filling the deep malar fat compartment and nasolabial compartments and releasing the orbitomalar ligament with interposed fractional fat. Rod Rohrich, MD, and Joel Pessa, MD

References

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References 1. Rohrich RJ, Pessa JE (2007) The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219–2227 2. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE (2009) The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg 124:946–951 3. Rohrich RJ, Pessa JE, Ristow B (2008) The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 121:2107–2112 4. Pessa JE, Zadoo VP, Adrian EK, Woodwards R, Garza JR (1998) Anatomy of a “black eye”: a newly described fascial system of the lower eyelid. Clin Anat 11:157–161 5. Mendelson BC, Muzaffar AR, Adams WP (2002) Surgical anatomy of the Midcheek and Malar mounds. Plast Reconstr Surg 110:885–896 6. Wong CH, Mendelson B (2013) Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg 132:49–56 7. Mally P, Czyz CN, Wulc AE (2014) The role of gravity in periorbital and midfacial aging. Aesthet Surg J 34:809–822 8. Lambros V (2007) Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367–1376 9. Stuzin JM, Baker TJ, Gordon HL (1992) The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 89:441–449 10. Mendelson BC, Wong CH (2013) Surgical anatomy of the middle premasseter space and its application in sub-smas face lift surgery. Plast Reconstr Surg 132:57–64 11. Hwang K (2014) Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofac Surg 25:1476–1481 12. Hwang K, Nam YS, Kim DJ, Han SH, Hwang SH (2009) Anatomic study of the lateral palpebral raphe and lateral palpebral ligament. Ann Plast Surg 62:232–236 13. Jehoon O, Kwon H-J, Choi Y-J, Cho T-H, Yang H-M (2018) Three-dimensional structure of the orbicularis retaining ligament: an anatomical study using micro-computed tomography. Sci Rep 8:17042 14. Doxanas MT, Anderson RL (1984) Oriental eyelids. Arch Ophthalmol 102:1232 15. Pessa JE, Rohrich RJ (2012) Facial topography: clinical anatomy of the face. Quality Medical Publishing, St. Louis 16. Rohrich RJ, Ghavami A, Mojallal A (2011) The five-step lower blepharoplasty: blending the eyelid-cheek junction. Plast Reconstr Surg 128:775–783

Chapter 3

Lower Eyelid Blepharoplasty

Author(s) Clinton D. McCord, JR., Lieutenant Colonel, John W. Shore Henry I. Baylis, John A. Long, Michael J. Groth Sam T Hamra Rohrich, Rod J., Ghavami, Ashkan, Mojallal, Ali

 bstract: Avoidance of Complications in Lower A Lid Blepharoplasty The most common complication of lower lid blepharoplasty is lower lid malposition either lower lid retraction or frank ectropion. This is caused by the vertical pull of skin shortage or shrinkage on a lax tarso-ligamentous sling. A method of tightening the tarso-ligamentous sling combined with a lower lid blepharoplasty is presented. An alternate method of lower lid fat removal through the fornix without skin incision is presented to be used in patients with taut lower lid skin.

Summary Purpose  To describe two surgical techniques for lower blepharoplasty, that may lead to a reduced risk of postoperative lower eyelid retraction. Design  A description of two surgical techniques that can help reduce the risk of lower eyelid retraction with lower blepharoplasty (Fig. 3.1). © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_3

21

22 Fig. 3.1 Diagrammatic representation of the fat pads present in the eyelid. In the lower lid there are generally three fat pad prominences that present clinically. The nasal and central fat pad are divided by the inferior oblique muscle, the temporal fat pad is separated from the central fat pad by a well-defined septum. It is possible that interconnections exist between the three fatty pads. (Reproduced with permission from McCord et al. [1])

3  Lower Eyelid Blepharoplasty

Interpad septum

Preaponeurotic fat pad

Lacrimal gland

Nasal fat pad

Temporal fat pad Central fat pad

1. A transcutaneous lower blepharoplasty technique with routine lateral canthal tightening is described. A skin-muscle flap is fashioned via a subciliary incision, and the tissue dissected inferiorly to the level of the inferior orbital rim. The orbital septum is entered and the desired orbital fat is resected. At point, a horizontal tightening procedure (lateral tarsal strip) is performed to address lower eyelid laxity. The excess skin is resected and the tissue sutured. 2. A transconjunctival, or “behind the lid”, lower blepharoplasty technique is described. The authors suggest the procedure may be helpful in revisional cases or younger patients in whom skin laxity is not a significant concern. The lower eyelid is retracted with a rake, and the monopolar cautery used to incise the conjunctiva and capsulopalpebral fascia until the eyelid fat pads are revealed. The lateral fat pad may require more dissection and/or a lateral canthotomy for adequate exposure. After the fat pads are successfully debulked, a 5-0 polypropylene suture is used to close the conjunctiva and fascia. Results  No review of patients is performed. However, the authors suggest that these techniques have been beneficial in their practice in reducing the risk of lower eyelid malposition, as manifested by inferior scleral show and ectropion, after lower blepharoplasty.

Summary

23

 bstract: Transconjunctival Lower Eyelid Blepharoplasty: A Technique and Complications The transconjunctival lower eyelid blepharoplasty is extremely effective at reducing lower lid fullness due to prominent orbital fat. The authors performed 122 consecutive transconjunctival blepharoplasties over a 24-month period. Four patients had skin excision via the pinch technique in conjunction with the transconjunctival fat excision. The main complication was under excision of fat which occurred in nine patients (7.4%). Moderate postoperative wound hemorrhage without hematoma formation occurred in one patient (0.8%). There were no cases of lid retraction, ectropion, entropion, inferior oblique palsy, or over excision of fat. The main advantage of this technique is that it avoids the most common complication of transcutaneous lower eyelid blepharoplasty, namely lower eyelid retraction.

Summary Purpose  To describe the authors’ experience with lower eyelid blepharoplasty via a transconjunctival approach. Design  A retrospective case series of 122 patients (mean age 51  years, range 29–78 years old) who underwent lower eyelid blepharoplasty via a transconjunctival approach (Fig. 3.2): 1. Local anesthetic was infiltrated into the inferior fornix and the inferior orbit, and the lower eyelid is retracted with a Desmarres retractor. 2. A monopolar needle-tip cautery is used to incise the conjunctiva and lower eyelid retractors, 1–2 mm posterior the orbital rim. The incision must be made at least 4 mm inferior to the punctum. 3. Gentle pressure on the globe can be used to tease the orbital fat forward. The inferior oblique muscle and the arcuate expanse are located and the arcuate expanse released to allow adequate resection of the desired amount of fat. The endpoint of excision is when the anterior border of the fat is flush with the inferior orbital rim, with light digital pressure on the globe. 4. The conjunctiva and retractors are closed with a single 6-0 chromic gut suture. Results  All patients (n = 122) underwent successful lower eyelid blepharoplasty through a transconjunctival approach. Of the cohort, four patients underwent concomitant skin pinch excision for anterior lamellar enhancement. All patients were satisfied with the surgery. Complications were inadequate fat excision (9/122

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a

b

Conjunctiva Lower lid retractors

Orbital septum Orbital fat

Fig. 3.2  Transconjunctival lower eyelid blepharoplasty. Sagittal sections of the lower eyelid. (a) Notice relationships of orbital septum, orbital fat, and lower lid retractors. (b) Eversion of the lower lid with Desmarres retractor exposes the conjunctiva. Ballotment of the globe with a lid plate produces a bulge of orbital fat over the orbital rim. An incision of the conjunctiva is made with a monopolar cutting-cautery unit directed 1–2 mm posterior to the orbital rim. (Reproduced with permission from Baylis et al. [2])

patients) treated with repeat transconjunctival surgery, and postoperative hemorrhage (1/122) that was not vision-threatening. No patients had lower eyelid retraction, ectropion, entropion, inferior oblique palsy, or over-excision of orbital fat.

 bstract: Arcus Marginalis Release and Orbital Fat A Preservation in Midface Rejuvenation With aging, the periorbital area reveals progressive exposure of underlying skeletal anatomy as compared with the lower areas of the face, whose thicker soft tissues continue to cover underlying bony landmarks. With recent techniques in cheek fat repositioning and orbicularis muscle repositioning, rejuvenation results of the midface have been markedly improved. Conventional lower blepharoplasty techniques that remove lower eyelid fat can create a concave contour deformity of the lower eyelids that causes the “operated” appearance. This paper describes a new technique to preserve the lower eyelid fat and to advance it beyond the infraorbital rim. An arcus marginalis release is accomplished, and the subseptal fat is advanced and sutured beyond the entire infraorbital rim and under the repositioned orbicularis muscle. By camouflaging the lower orbital rim anatomy, rejuvenation of the midface is more complete. A total of 152 cases have been done over a 3-year period with impressive results and minimal complications. This procedure is done in all composite rhytidectomies and in isolated blepharoplasty patients without advanced

Abstract: The Five-Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction

25

facial aging. It is particularly indicated in secondary procedures correcting over-­ resection of orbital fat or deformities resulting from malar augmentation.

Summary Purpose  To describe a novel technique of lower blepharoplasty with fat repositioning onto the anterior surface of the cheek. Design  A retrospective case series of 152 patients over 3  years who underwent lower eyelid blepharoplasty with orbital fat repositioning. All patients had concurrent deep-plane rhytidectomy. Surgical technique was as follows (Fig. 3.3): 1. A transcutaneous, subciliary approach is taken with a skin-muscle flap dissected to the inferior orbital rim. 2. The orbital septum is opened with monopolar cautery, and the orbital fat pads are released. 3. Desired fat is resected, and the remaining fat is then sutured inferiorly below the orbital rim with multiple 5-0 Vicryl sutures. Results  There were no patients with postoperative infection, retraction, or ectropion. One patient had postoperative hematoma that required evacuation, and two patients had under-excision that required a second procedure to remove excess medial fat.

 bstract: The Five-Step Lower Blepharoplasty: Blending A the Eyelid-Cheek Junction BACKGROUND Lower lid blepharoplasty has potential for significant long-lasting complications and marginal aesthetic outcomes if not performed correctly, or if one disregards the anatomical aspects of the orbicularis oculi muscle. This has detracted surgeons from performing the technical maneuvers necessary for optimal periorbital rejuvenation. A simplified, “five-step” clinical approach based on sound anatomical principles is presented. METHODS A review of 50 lower lid blepharoplasty patients (each bilateral) using the five-step technique was conducted to delineate the efficacy in improving lower eyelid aesthetics. Digital images from 50 consecutive primary lower blepharoplasty patients (100 lower lids: 37 women and 13 men) were measured using a computer program with standardized data points that were later converted to ratios. RESULTS Of the 100 lower eyelid five-step blepharoplasties analyzed, complication rates were low and data points measured demonstrated improvements in all aesthetic parameters. The width and position of the tear trough,

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3  Lower Eyelid Blepharoplasty

a

c

Arcus marginalis

b

d

Fig. 3.3 (a) The skin-muscle flap is elevated 1.5–2 cm inferiorly, exposing the inferior border of the orbicularis muscle. A suture retracts the ciliary rim. (b) The arcus marginalis is incised from the medial to the lateral orbital rim. (c) The orbital fat is gently freed, and a strip of septum orbitale is removed. (d) The orbital fat is tailored and sutured over the orbital rim with 5-0 Vicryl. (Reproduced with permission from Hamra [3])

position of the lower lid relative to the pupil, and the intercanthal angle were all improved. There were no cases of lower lid malposition. CONCLUSIONS Aesthetic outcomes in lower lid blepharoplasty can be improved using a five-step technical sequence that addresses all of the anatomical findings. Lower lid blepharoplasty results are improved when (1) the supportive deep malar fat compartment is augmented; (2) lower lid orbicularis oculi muscle is preserved with minimal fat removal (if at all); (3) the main retaining structure (orbicularis retaining ligament) is selectively released; (4) lateral canthal support is established or strengthened (lateral retinacular suspension); and (5) minimal skin is removed.

Summary

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Summary Purpose  To describe the author’s experience and detail a theoretical framework for lower blepharoplasty. Design  A retrospective case series of 50 patients who underwent lower eyelid blepharoplasty with the senior authors’ technique. Of these, 47 had deep-plane rhytidectomy concomitantly. Marginal reflex distance-2 and lower eyelid length were measured using digital analysis software. Surgical technique was as follows (Fig. 3.4): 1. Structural fat grafting was performed with abdominal fat transfer to the deep malar fat compartments. 2. Conservative removal of orbital fat was performed via a transconjunctival approach. 3. The orbital retaining ligament was released via the transconjunctival incision. 4. A lateral canthopexy was performed, preserving the lateral canthal angle. 5. Skin pinch removal was performed for skin redundancy. Results  All patients underwent successful lower blepharoplasty (mean age 51.3 years, range 39 – 65 years). MRD2 and lower eyelid length decreased postoperatively. Two patients experienced postoperative chemosis and one experienced eyelid retraction; both patients were managed conservatively and no patients required intervention for any complications. No other complications were reported.

4

2

Fat removal

Lateral canthopexy

5 Pinch skin removal

3 1

Malar tat graft

ORL release

Fig. 3.4  . The five-step lower lid blepharoplasty: step 1, fat augmentation to the deep malar fat compartment; step 2, conservative fat removal; step 3, orbicularis retaining ligament selective release; step 4, lateral retinacular canthopexy; and step 5, skin pinch and excision. (Reproduced with permission from Rohrich et al. [4])

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3  Lower Eyelid Blepharoplasty

Relevance Lower blepharoplasty is a cornerstone of facial and periorbital rejuvenation, but the lower lids remain exquisitely sensitive to disturbances due to aging or surgical intervention. McCord and Shore’s treatise [1] brought to light two critical concepts for specifically reducing the risk of eyelid retraction after surgery: the importance of identifying and treating lower eyelid laxity, and the idea of the transconjunctival over the transcutaneous approach. Baylis and colleagues [2] expounded on the concept of transconjunctival lower blepharoplasty by publishing the first major case series of such patients, and demonstrated that this was a safe and aesthetically effective method of addressing lower eyelid bags. Hamra [3] refined the idea of preservation rather than excision of the orbital fat, with transposition these fat pedicles over the anterior surface of the maxilla to efface the nasojugal groove. Rohrich and colleagues [4] synthesized these thoughts into a modern theoretical framework for lower blepharoplasty. Lower eyelid retraction is the bane of the blepharoplasty surgeon. The lower eyelid must overcome the continual force of gravity with only the canthal tendons and the activity of the orbicularis muscle to counteract this [5]. Both aging and surgery can weaken these protective factors and lead to an aesthetically undesirable and functionally troublesome result [6]. McCord and Shore recognized the importance of reducing these complications. There are two major lessons from their report. Firstly, the presence of lower eyelid laxity can predispose to eyelid retraction after blepharoplasty, and eyelid tone should be assessed and addressed if necessary. Secondly, the transconjunctival approach is introduced as a method by which the surgeon can avoid extensive subcutaneous dissection and skin resection, and thereby avoid ectropion. The authors provide details about their surgical techniques which include a lateral tarsal strip procedure [7] and a fornix approach to the inferior orbital fat (Fig. 3.1), but do not present any review of their patients. At the time of publication, the authors reserved this technique for revisional cases or young patients who did not present with skin excess. Baylis and colleagues [2] expound on this initial report by presenting a large case series of patients who underwent transconjunctival blepharoplasty (Fig. 3.2). The authors in this instance utilize this approach for all patients, even combining this with an anterior skin pinch if anterior lamellar redundancy is detected. Horizontal eyelid shortening is also performed if necessary. This study solidified the role of transconjunctival lower blepharoplasty as a workhorse in lower eyelid rejuvenation. The authors report a lower incidence of complications including postoperative lower eyelid malposition, as well as a high rate of patient satisfaction. Moreover, the surgery was repeatable and could be combined with adjunctive procedures such as canthoplasty. However, aesthetic improvement is not qualitatively or quantitively assessed which would have been beneficial for the reader. Sultan et al. [8] published the largest modern series of transcutaneous blepharoplasty, and find a predictable increase in marginal reflex distance-2 (MRD2) of 0.33 mm and a 2% risk of eyelid malposition requiring revisional surgery, although the authors also performed

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concomitant canthopexy in roughly 30% of cases. In comparison, modern analyses of transconjunctival blepharoplasty suggest no change in MRD2 with transconjunctival surgery, with fat excision or repositioning [9]. Hamra [3] observed that pure removal of the orbital fat leads to a skeletonized and “operated” appearance with unveiling of the relatively static orbital bony anatomy [10]. To rectify this, he developed the idea of preserving this fat and repositioning this into the nasojugal groove to eliminate the “double convexity” deformity (Fig. 3.3), based on Loeb’s prior work [11]. Hamra’s presentation of this technique has proved prescient as the concept of preservation of fat and adequate volumization is a cornerstone of modern facial rejuvenation. There is no review of aesthetic results or formal review of complications. In the authors experience, minor complications such as granulomas, chemosis, or subclinical eyelid malposition are common in the initial postoperative period with this technique and these are not addressed, which would have made the dataset from this study richer. Rohrich [4] synthesized this body of work and refined into a five-step theoretical framework for lower blepharoplasty. In addition to what was previously described, Rohrich suggested that structure fat grafting to reinflate the deep fat compartments of the face [12] and orbital retaining ligament release would give additional benefit in restoring youthful contours and blending the lid-cheek junction. A quantitative analysis does show an appropriate lower eyelid position after surgery without retraction. However, no aesthetic analysis is performed to assess effacement of the lid-­ cheek junction. The first report of transconjunctival lower blepharoplasty was in the French literature [13] in the early twentieth century. McCord’s and Baylis’ contributions popularized this technique and detailed the surgical anatomy. Subsequent literature corroborates McCord’s observation that routine lateral canthopexy reduced the risk of retraction after blepharoplasty [14, 15]. Ensuing prospective and retrospective studies reinforce McCord’s and Baylis’ hypothesis that the transconjunctival approach reduces the risk of postoperative lower eyelid malposition [16, 17] over the transcutaneous approach. Hamra’s initial report of fat repositioning was loosely based on Loeb’s sliding fat pads [11] and modifications of this technique were widely popularized within the oculofacial plastic surgery community by Goldberg [18] and Massry [19]. Massry in particular observed that there were no aesthetic or functional differences between transposition of the fat pads in the subperiosteal versus preperiosteal planes [20], although the subperiosteal approach may lead to increased postoperative bruising that resolves. Orbital septum tightening was also proposed by de la Plaza [21], although the risk of retraction proved too high with this technique. Finally, Mendelson and colleagues studied in great anatomic and clinical detail the concept of orbital retaining ligament release [22] akin to Rohrich’s work, and my own research has clarified the role of adjunctive procedures such as midface lifting, laser resurfacing, and fat grafting on the lid-cheek junction specifically [23]. In summary, modern lower blepharoplasty requires the surgeon to be competent with all of techniques so that treatment can be individualized to the patient’s

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3  Lower Eyelid Blepharoplasty

anatomy and desires. A one-size-fits-all approach to lower blepharoplasty will invariably lead to complications and unhappy patients. While the above manuscripts do not have robust aesthetic outcomes or rigorous methodology, the techniques presented represent important innovations in the theory of lower blepharoplasty and have made the surgery safer and more predictable. Subsequent studies with more rigorous analyses have corroborated their findings and the fundamentals of these techniques remain in use today. A solid theoretical framework and proficiency with these techniques is mandatory for delivering consistent and aesthetically pleasing results.

Strengths • These studies offer important theoretical innovations that form the foundation of modern lower blepharoplasty. • Detailed anatomic and surgical depictions guide the beginning surgeon.

Weaknesses • Detailed demographic data are not given. • There is no objective analysis of aesthetic outcomes. • The concept of a “negative vector” and its importance in lower blepharoplasty is not described in these studies.

One-Sentence Summary A detailed theoretical framework and proficiency with multiple surgical techniques allows for safe and natural lower blepharoplasty outcomes.

Author Comments “In 1988, transcutaneous blepharoplasty with its comparatively high incidence of post-operative lower lid retraction was the standard in aesthetic eyelid surgery. In fact, several practices flourished primarily on the repair of post-operative lower lid retraction. Shortly after arriving for my fellowship with Dr. Henry Baylis that year, I was given an assignment to write a paper on the alternative approach of

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transconjunctival blepharoplasty. It was important to Hank that the procedure be described simply so that an average surgeon on an average day could obtain a safe, effective, and predictable result. It was also important that non-ophthalmologists be comfortable performing a blepharoplasty via this innovative conjunctival route. At that time, blepharoplasty was gaining popularity among ophthalmologists. Reimbursements for many insurance-based procedures were plummeting and refractive surgery was still in its infancy. The annual UCLA blepharoplasty course was standing room only with 125-150 participants across many specialties. Many if not most of these participants were non-ophthalmologists. Aesthetic surgery had yet to gain widespread acceptance in ophthalmology. When I mentioned this paper during the Academy meeting in 1988 many of my ophthalmologist colleagues looked at me as if I were a director keen on making an adult film. Since there were few computers and no internet at that time, Hank sent me to the musty stacks of the UCLA medical library to do a Medline search and pull the original description of transconjunctival blepharoplasty from the French literature from the 1920’s. He also connected me with Gwen Gloege, a top medical illustrator, with whom I spent many afternoons trying to perfect the line drawings to help make the anatomy more understandable. Unfortunately, it took almost a year to complete the paper. I pleaded with Hank to allow me to use this study as my ASOPRS thesis, which would mean it had to be published in the Green OPRS Journal. Even though he was editor of the OPRS Journal, he insisted we try to get it published in the Blue Ophthalmology Journal which had a much greater readership in the hopes of reaching more people. He did not think we had yet gained enough credibility in the aesthetic arena to be consider for the White PRS journal. In the ensuing years, remarkably similar reports can be found in the General Plastic, Facial Plastic and Dermatology literature.” – Michael Groth, MD With traditional techniques, the lower eyelids, regardless of improvement with the orbicularis elevation, still did not have a truly youthful appearance and in fact often remained too hollow in spite of a shortened lower eyelid. I found no answer until I read a little-known book by Loeb, who had taken the most medial fat pad of the lower eyelid and transposed it into the nasojugal groove.I decided to preserve all of the fat pads under the repositioned orbicularis muscle. To keep all of the fat, I incised the arcus marginalis, which is the junction between the septum orbitale and the orbital rim. Releasing this junction would allow visualization of all of the fat that could exit the orbit most directly and fall inferiorly so it could be sutured to the soft tissue inferior to the orbital rim. The septum orbitale was otherwise untouched because of the traditional thinking that manipulation of the septum may create lower eyelid malposition. This procedure was published and was entitled the “arcus marginalis release.” – Sam T Hamra, MD, with portions reproduced from Hamra (2016) [24]

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References 1. McCord CD, Shore JW (1983) Avoidance of complications in lower lid blepharoplasty. Ophthalmology 90:1039–1046 2. Baylis HI, Long JA, Groth MJ (1989) Transconjunctival lower eyelid blepharoplasty: technique and complications. Ophthalmology 96:1027–1032 3. Hamra ST (1995) Arcus Marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 96:354–362 4. Rohrich RJ, Ghavami A, Mojallal A (2011) The five-step lower blepharoplasty: blending the eyelid-cheek junction. Plast Reconstr Surg 128:775–783 5. Bartley GB (1996) The differential diagnosis and classification of eyelid retraction. Ophthalmology 103:168–176 6. Harounian J, Wulc AE, Brackup AB, Ramesh S (2019) Subtle eyelid retraction after lower blepharoplasty. J Plast Reconstr Aesthet Surg 72:1682–1687 7. Anderson RL, Gordy DD (1979) The tarsal strip procedure. Arch Ophthalmol 97:2192–2196 8. Sultan B, Genther DJ, Perkins SW (2016) Measurement of change in lower eyelid position in patients undergoing transcutaneous skin-muscle flap lower eyelid blepharoplasty. JAMA Facial Plast Surg 18:429–435 9. Ramesh S, Goldberg RA, Wulc AE, Brackup AB (2019) Objective comparison of nasojugal fold depth and lower eyelid length after fat excision versus fat transpositional lower blepharoplasty. Aesthet Surg J 39:1048–1054 10. Hamra S (1996) The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 23:17–28 11. Loeb R (1981) Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 8:757–776 12. Rohrich RJ, Pessa JE (2007) The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219–2227 13. Bourguet J (1924) Les hernies graisseuses de l’orbite: Notre traitement chirurgical. Bull Acad Med 92:1227–1232 14. Codner MA, Wolfli JN, Anzarut A (2008) Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 121:241–250 15. Flowers RS (1993) Canthopexy as a routine blepharoplasty component. Clin Plast Surg 20:351–365 16. Appling WD, Patrinely JR, Salzer TA (1993) Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg 119:1000–1007 17. Netscher DT, Patrinely JR, Peltier M, Polsen C, Thornby J (1995) Transconjunctival versus transcutaneous lower eyelid blepharoplasty. Plast Reconstr Surg 96:1053–1060 18. Goldberg RA (2000) Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 105:743–748 19. Griffin GR, Massry GG, Nassif PS (2015) Transconjunctival lower lid blepharoplasty with and without fat repositioning. In: Pearls pitfalls cosmet oculoplastic surgery, vol 42, Second edn, pp 213–218 20. Yoo DB, Peng GL, Massry GG (2013) Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of transposing fat to the subperiosteal vs supraperiosteal planes. JAMA Facial Plast Surg 15:176–181 21. de la Plaza R, Arroyo JM (1988) A new technique for the treatment of palpebral bags. Plast Reconstr Surg 81:677–685 22. Wong CH, Mendelson B (2017) Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg 140:273–282 23. Ramesh S, Goldberg RA, Wulc AE, Brackup AB. Observations on the Tear Trough. Aesthet Surg J. 2020;40(9):938–947. https://doi.org/10.1093/asj/sjz345. PMID: 31760423. 24. Hamra ST (2016) Building the composite face lift. Plast Reconstr Surg 138:85–96

Chapter 4

Endoscopic Brow Lift: A Personal Review of 538 Patients and Comparison of Fixation Techniques

Author(s) Barry M. Jones, and Rajiv Grover

Abstract Since the introduction of endoscopic brow lifting in the mid-1990s, it has become widely accepted as a method for rejuvenation of the upper third of the face. Despite the multitude of brow fixation techniques, there are few long-term studies providing accurate analysis of outcome. The aims of this investigation were to evaluate the long-term objective results of endoscopic brow lifting and to establish whether the technique of fixation altered the longevity of aesthetic outcome. The outcome of endoscopic brow lifts carried out on 538 consecutive patients over a 6-year period was assessed. For each patient, mid-pupil-to-brow distance was measured preoperatively and at intervals postoperatively. Two different fixation methods were compared: fibrin glue (n  =  189, group 1; 104 records available) and polydioxanone sutures tied through bone tunnels (n = 349, group 2; 220 records available). In 214 patients, an upper lid blepharoplasty was performed simultaneously (85 in group 1 and 129 in group 2). At 1 month postoperatively, each fixation technique had produced a significant change in mean pupil to brow height (5.93 mm in group 1 and 6.21  mm in group 2, with no significant difference between the two methods; p = 0.17). However, when measurements were compared more than 3 months postoperatively (mean, 9.4  months), there was a significant difference, with some relapse in the patients treated with fibrin glue (p  0.4 in group 2). Complications were few in both groups. In group 1, there was one infection, two instances of significant alopecia (both temporary), and one reoperation for relapse. In group 2, four patients required minor surgical revision of a lateral port scar and three minor areas of temporal alopecia, which recovered in less than 3 months. One patient had a paresis of the frontal branch that had recovered after 4 months. The endoscopic brow lift is therefore a safe and effective technique for increasing mean pupil to brow height. Fixation with polydioxanone sutures tied through bone tunnels produces a significantly more stable result than fibrin glue, without greater risk. This lends weight to experimental evidence that periosteal fixation must be maintained for at least 6 weeks to be secure.

Summary Purpose  To describe the authors’ experience with endoscopic brow lift surgery. Design  A retrospective, single-surgeon case series of 538 patients (mean age 50.3  years) over 6  years who underwent endoscopic brow lifting with two techniques. The first 189 patients were fixated with fibrin glue, and the subsequent 349 patients were fixated with bone tunnels and 2–0 polydioxanone suture due to the author’s belief that fibrin glue gave inferior results. Full-face photographs were taken preoperatively and at minimum 3  months postoperatively; mean follow-up was 9.4 months (range 3–60 months). The pupil-to-browheight was measured preoperatively, at 1 month after surgery, and at the last postoperative visit. Statistical analysis was performed with a Student’s t test. Results  Measurements are summarized in Table  4.1. Patients who underwent endoscopic brow lifting had significant and sustained elevation of the brows postoperatively. While initial postoperative brow height was similar between the two groups, patients who had bone tunnel fixation had a higher brow position at the last postoperative visit. Complications are summarized in Table 4.2; serious complications were rare and tended to be transient. Concurrent upper blepharoplasty had no

Table 4.1  Summary of data for patients undergoing endoscopic brow lift Fixation Fibrin glue (n = 104) Bone tunnel (n = 220) p

Preoperative 19.71 mm 19.20 mm ns

Adapted from Jones et al. [1]

1 month postoperatively 25.64 mm 25.41 mm ns

Last postoperative visit 23.50 mm 25.36 mm 3 mm (maximum: 3.5 mm). No change in healing time or fornix depth was noted due to closure of the conjunctiva. One patient experienced a self-­resolving granuloma on the sutured side treated with topical steroid. Two patients experienced temporary postoperative entropion that resolved over weeks; no patients had ectropion or eyelid retraction. The transconjunctival approach provides appropriate surgical access to the inferior orbit with a low rate of complications.

 bstract: Transcaruncular Approach to the Medial Orbit A and Orbital Apex Objective  To present a versatile approach to the medial orbit and orbital apex through the caruncle. Design: Retrospective, noncomparative, case series with description of surgical technique. Participants: Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach. Intervention: Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach. Main Outcome Measures: The surgical indications and complications were recorded for each patient. Results: Ten patients (10 orbits) underwent Combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach. Conclusions: Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

Summary Purpose  To describe surgical technique and the authors’ experience with a novel method to access the medial orbit and the orbital apex. Design  A retrospective case series of 25 consecutive patients who underwent transcaruncular surgery (n = 34) for orbital fracture repair (n = 10) or orbital decompression (n = 24). Surgical technique was as follows (Figs. 12.3 and 12.4):

98 Fig. 12.3  Schematic axial sections illustrate the surgical anatomy underlying the transcaruncular approach. (a) The lacrimal sac and Horner’s muscle lie outside the medial orbital septum. Horner’s muscle and the medial orbital septum insert into periorbita immediately posterior to the posterior lacrimal crest. (b) The transcaruncular dissection plane passes between Horner’s muscle medially and the medial orbital septum laterally. (Reproduced with permission from Shorr et al. [4])

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a

Caruncle

Med. palpebral lig.

Conjunctiva Conjunctiva Tenon’s capsule Tenon’s capsule Levator aponeurosis

Lacrimal sac

Orbital septum

Homer’s m. Orbital septum Tenson’s capsule Ant. ethmold a.

Whitnall’s tubercle

Periorbita

Periorbita

Med. rectus m. Post. ethmold a. Lat. rectus m.

b Caruncle divided

Orbital septum

Periorbita

Bone

Summary Fig. 12.4 (a) The subperiorbital dissection begins posterior to the lacrimal sac and medial to the levator aponeurosis, avoiding these critical structures. (b) A 12 mm vertical incision extends through the lateral one third of the caruncle. (Reproduced with permission from Shorr et al. [4])

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a

Levator aponeurosis

Medial canthal tendon Semilunar fold Caruncle Incision

Lacrimal sac

b

Caruncle

1. The medial orbit was infiltrated with local anesthetic. A 12 mm vertical incision is carried through the lateral 1/third of the caruncle, and the retrocaruncular fascia incised towards the posterior lacrimal crest. 2. A malleable retractor is inserted, and a blunt tenotomy scissors used to widely expose the posterior lacrimal crest. 3. The cutting cautery is used to create a periosteal incision posterior to the posterior lacrimal crest, and a subperiosteal dissection plane established. This plane is extended superiorly and inferiorly, connecting to an inferior transconjunctival incision when necessary.

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4. The anterior and posterior ethmoidal arteries are identified and cauterized with bipolar cautery. The inferior oblique muscle may be temporarily disinserted in case of orbital fracture repair. Inferomedial orbital decompression may also be carried out at this time. 5. At the conclusion of the case, interrupted 6–0 chromic gut sutures are used to close the caruncular incision. Results  25 patients underwent 34 successful orbital surgeries via a transcaruncular approach. There were no complications specifically attributable to the surgical approach, including eyelid malposition, injury to the nasolacrimal system, injury to the globe or extraocular muscles, or vision loss.

 bstract: Superomedial Lid Crease Approach to the Medial A Intraconal Space Purpose  To present clinical and cadaver studies of a new approach to the medial intraconal space. METHODS: We retrospectively review our clinical results by using a new technique to gain access to the medial intraconal space through a superomedial lid crease incision. We also use cadaver dissection studies to compare this new approach with the medial transconjunctival approach, the lateral orbitotomy without bone-flap, and the lateral orbitotomy with bone-flap. RESULTS: Access to the medial intraconal orbital space through the superomedial lid crease incision allowed optic nerve sheath fenestration or biopsy in 18 eyes with few postoperative complications. One case of tonic pupil, one case of transient vertical diplopia, and two cases of transient medial ptosis were seen. Five cavernous hemangiomas were removed from the intraconal space with this approach, with one case of transient vertical diplopia and one case of transient medial ptosis. The cadaver studies showed that when the superomedial lid crease approach is used, the tangent angle with the optic nerve and the incision-to-nerve distance measurements compare favorably with the medial transconjunctival and the lateral orbital approaches. CONCLUSIONS: The superomedial lid crease approach to the medial intraconal space has a number of advantages over the medial transconjunctival and lateral orbital approaches, including ease of dissection, incision-to-nerve distance, and angle of approach to the optic nerve. This technique allows for optic nerve sheath fenestration or tumor removal from the central space with few complications.

Summary Purpose  To describe the authors’ experience with a new technique to access the superomedial intraconal space.

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Design  A retrospective case series of 23 surgeries in 22 patients (range 13–72 years of age) who underwent surgery via the authors’ technique described below. Range of postoperative follow-up was 6–24  months. Surgery was performed for optic nerve sheath fenestration (n = 12) or biopsy (n = 6), or tumor removal (n = 5). Four male cadavers were also dissected further characterize the surgical anatomy. Surgical technique is as follows (Fig. 12.5): 1. A 10  mm eyelid crease incision is fashioned at the medial third of the upper eyelid, and sharp dissection carried through the orbicularis and the orbital septum. 2. When the orbital fat is encountered, blunt dissection is performed to gently spread the fat and fascia towards the intraconal space. The superior ophthalmic vein is gently distracted laterally if encountered. 3. This dissection proceeds inferomedial to the superior oblique tendon, superior to the medial rectus muscle, and lateral to the superior rectus muscle until the desired structure in the intraconal space is visualized (e.g., optic nerve, or tumor). 4. The wound is closed with 6–0 plain gut suture at the conclusion of the case. Results  23 successful surgeries were performed with the authors’ technique. No patients lost vision after surgery, and most patients had improvement in vision. Most common complaints post-operatively include vertical diplopia (resolved in 2–8 weeks), mild medial blepharoptosis (resolved in 1–2 weeks), and complete or partial third-nerve palsy (n  =  2, resolved spontaneously). Average distance from skin to optic nerve was 30-33 mm via a lateral approach, 18–22 mm with a medial transconjunctival approach, and 23–27 mm with the authors’ described superomeFig. 12.5  Illustration of plane of dissection by superomedial approach. Arrow follows dissection plane, which is inferior to superior oblique tendon but superior to medial rectus muscle. Arrow travels from superior-medial quadrant of globe and intersects retrobulbar optic nerve 2 mm to 3 mm posterior to globe. (Reproduced with permission from Pelton et al. [5])

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dial lid crease approach. The lateral approach gives the most perpendicular view of the optic nerve, with the medial transconjunctival approach giving the most acute angle view.

 bstract: The Inferomedial Orbital Strut: An Anatomic A and Radiographic Study Purpose  To study the anatomic and radiographic features of the inferomedial orbital strut (IOS), with particular emphasis on the region of the posterior IOS. METHODS: Cadaver dissection study of the IOS was performed on 20 orbits of 10 fresh-frozen cadaver specimens. Radiographic volumetric analysis was performed on CT scans of 20 orbits to measure the volume available for decompression in the region of the posterior IOS. RESULTS: The anterior IOS provided bony support to the orbit and served as a site of attachment for globe-supporting suspensory ligaments. The midportion of the IOS demonstrated a contiguous anatomic relation to the maxillary sinus ostium. The posterior IOS consisted of two components: the intraorbital process of the palatine bone and ethmoidal air cells that extended inferior and posterior to the IOS. Radiographic volumetric analysis demonstrated that there was an average of 2.1 mL of volume available for decompression in the region of the posterior IOS (range, 1.2 to 3.3 mL). CONCLUSIONS: The findings of this anatomic and radiographic study of the inferomedial orbital strut support the concept of a posterior inferomedial orbital decompression. The region of the posterior IOS appears to offer significant volume for axial globe mobilization while minimizing the risk of globe dystopia and/or impairment of the maxillary sinus drainage.

Summary Purpose  To describe the features of the inferomedial orbital strut. Design  A cadaveric dissection of 20 orbits (10 cadaver heads) with computed tomography radiographic volumetric analysis. The orbit was exenterated and the inferomedial orbital strut (IOS) was identified. The relationship of the IOS to adjacent structures was studied and volumetric analysis performed. Results  The IOS is described in detail (Fig.  12.6). The IOS is formed from the thick bone of the infraorbital rim and extends posteriorly towards the orbital apex until thickens to become the orbital process of the palatine bone. The strut serves as a buttress for the inferomedial orbit, and can be variably aerated by maxillary or ethmoidal air cells. The maxillary sinus ostium lies roughly 24 mm posteriorly from the anterior border of the IOS. The mean length of the IOS was 37.6 mm (range

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Fig. 12.6  Frontal view of isolated IOS specimen (right orbit), shows buttress to the anterior IOS being provided by the thick bone of the maxilla (arrowhead). Note thin diameter of the middle IOS and the posterior IOS formed by the junction of the palatine bone (short arrow) and posterior ethmoid bone (long arrow). (Reproduced with permission from Kim et al. [6])

34-41 mm). The posterior IOS contained a mean of 2.1 mL (range 1.2–3.3 mL) of volume which may be significant in orbital decompression procedures.

Relevance Human anatomy has been discovered and rediscovered countless times across civilizations. If we choose to restrict ourselves to the modern era since the dawn of the field of oculofacial plastic surgery, however, several important studies establish a strong foundation for clinical and surgery anatomy. While not exhaustive, the following studies have strong surgical relevance and form the basis for the operative approach to the majority of orbital disorders. Rontal et al. [1] describe the osteology of the orbit in terms of surgical relevance. Measurements from easily identifiable intraoperative landmarks (the orbital rim at each of its 4 walls) to highly conserved foramina (through which important neurovascular structures course), the fissures, and the optic canal allow anticipation of these structures during dissection. The eye sees what the mind is prepared to comprehend. A detailed three-dimensional mental map of the bony orbit is critical for safe orbital surgery. Of particular importance is the 24–12-6 rule which has since been handed down to orbital surgeons over generations. This rule denotes the distances from the posterior lacrimal crest to the anterior and posterior ethmoidal foramina and the optic canal. This is crucial not only to identify the neurovasculature that could cause significant bleeding in the tight space of the medial orbit, but also as relative markers for the skull base. Creation of a bony ostium inferior to these foramina typically leads into the ethmoid sinuses, which is desirable in medial orbital decompression, while entry superior to the foramina can lead into the intracranial cavity and significant morbidity or mortality. Finally, the authors measure

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the distance from anterior orbital boundary to the optic canal, which is by far the shortest medially. As such, many treatments for optic neuropathy or optic nerve compression focus on a medial approach to facilitate surgical exposure here. More recent studies have confirmed the presence of supernumerary foramina [7], foramina which can course either superior or inferior to the level of the skull base and connect with large recurrent vessels from the intracranial circulation [8], and suggest that there is significant ethnic variation in orbital osteology [9]. However, the 24–12-6 rule remains remarkably consistent for the identification of these critical neurovascular structures. Leo Koornneef’s [2] treatise on the delicate intraorbital fascial septae has also transformed our understanding of the orbit. Koornneef observed that the globe and extraocular muscles, rather than swimming in a pool of homogenous fat, were anchored and connected by a delicate hammock of pulleys and septae that divided the orbital soft tissues into compartments. This connective tissue also yokes the extraocular muscles so that smooth and coordinated globe movement can be accomplished. Finally, the fascial system supports the globe itself, and suspends it in the center of the orbital cavity. Koornneef postulated that this interconnectedness is why patients experienced upgaze and downgaze deficits in orbital floor fractures that did not have frank entrapment of the inferior rectus muscle. This theory was later supported by Harris et  al.’s radiologic study [10], which demonstrated that patients who had more significant prolapse of orbital fat and connective tissue had worse motility. Harris subsequently divided blowout fracture patients into Type A (trapdoor) and Type B (significant tissue prolapse) groups, where Type B patients experience a greater disturbance of Koornneef’s delicate septae and subsequently, more motility deficits. Demer et al. [11] provide a rigorous analysis of small motility deficits in older patients and discovered the entity of sagging eye syndrome (SES). Demer demonstrates the involutional attenuation of the fascial pulleys that Koornneef described, and correlated them to specific strabismus phenotypes [12]. Most interestingly, Demer’s histological analyses [13] suggest that extraocular muscles have two components – a component that attaches to the globe, and a component that specifically connects to the orbital fascial pulleys to provide coordinated and yoked eye movement. These detailed reports in human and simian orbits provide strong support to Koornneef’s initial postulates. Shifting from orbital anatomy to surgical approaches, Goldberg et al. [14] provide a prospective report on the transconjunctival surgical approach to the orbit. While this technique has described previously by Bourguet [15], Tenzel [16], and others [17], this study is the first to prospectively evaluate the safety and ease of this technique. The results show that the transconjunctival incision does shorten the fornix, although this is not clinically significant. Moreover, suturing of the conjunctival flap is not necessary as observed by their split-face subgroup analysis. Finally, complications observed were rare and managed conservatively without operative intervention; most importantly, there were no cases of lower eyelid retraction or increased inferior scleral show with this approach. Contemporaries compared the transconjunctival to the subciliary approach [18] and found that the incidence of eyelid retraction was significantly lower with the former. Currently, this approach remains

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the workhorse for access to the inferior orbital tissues, and detailed analysis suggests that this is both safe and effective in large cohorts [19]. The same group [4] also provides us with the transcaruncular approach to the medial orbit and orbital apex. Previously, the Lynch incision [20] was the preferred method of accessing the medial orbit. However, this necessarily involves an incision near the medial canthus, which is prone to scarring and formation of webs. Furthermore, the lacrimal apparatus must be traversed to access the orbital tissues. The transcaruncular approach provides a cosmetically favorable incision that starts posterior to the lacrimal apparatus. This can also be connected to the transconjunctival incision to create a broad opening into the inferomedial orbit. Shorr et al. demonstrate this incision’s utility in both orbital decompression and fracture repair [4] with a low rate of complications. Again, this incision has become the mainstay for access to the orbit. Currently, transorbital approaches via this incision and others to address skull base and intracranial pathology are growing in popularity [21], which has certainly reduced recovery times and less morbidity for patients. Pelton and Patel [5] provide an insightful analysis on the lid crease approach to the superomedial intraconal space. By comparing the distance to the optic nerve via three approaches – lateral lid crease, medial transconjunctival (with medial rectus disinsertion), and the authors’ own approach – they demonstrate that the shortest path to the nerve is via the medial orbit. The authors’ superomedial approach is comparable to the transconjunctival approach but does not necessitate muscle disinsertion, which adds surgical time and increases the risk of complications. By taking advantage of the natural corridor between the superior oblique tendon and the medial and superior rectus muscles, this approach allows for quick access to the intraconal space and optic nerve. This approach is my preferred approach for optic nerve sheath fenestration, and the surgery can be completed in under 10 minutes as the rectus muscle does not need to be disinserted. The authors also report removal of cavernous venous malformations in the intraconal space via this method, and demonstrate its efficacy for the treatment of superonasal intraconal orbital lesions. Finally, Kim et al.’s treatise [6] on the inferomedial strut establishes this structure as a firm buttress for the inferomedial orbit. Kim describes the morphology of this structure, highlights its relation to the maxillary sinus ostium, and observes that it is frequently aerated by the ethmoidal and maxillary sinuses. Crucially, he also establishes the orbital process of the palatine bone as the posterior bound of the strut at the orbital apex, and measures this to typically lie anterior to and within 1 cm of the sphenoethmoidal junction. This has ramifications for both surgery and disease processes. Firstly, the strut is a bony support that if damaged in trauma, can lead to globe dystopia. The anterior strut in particular has connections to Lockwood’s ligaments and Koornneef’s septal pulleys that function in maintain globe position and coordinating motility.While the diaphanous orbital floor and medial wall function as barriers, the strut and orbital rim provide the sturdiness of the orbit to withstand trauma [22]. While the floor and medial wall can be reconstructed using a variety of materials, the strut, if damaged, needs permanent and durable fixation to prevent globe dystopia or enophthalmos [23]. Kim’s work outlines the three-dimensional plane that the plating material must traverse, finally resting on the palatine bone, to

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provide adequate restoration of orbital bony contour. The inferomedial strut is also critical in orbital decompression; removal of the posterior strut allows for decompression of the apex and is important in cases of optic neuropathy, although removal of the anterior strut can lead to recalcitrant globe dystopia and diplopia for the aforementioned reasons [24]. Understanding the anatomy of the inferomedial strut in normal and diseased states allows for more effective orbital surgery. These seminal articles expand our knowledge of orbital anatomy and introduce foundational surgical approaches. While not exhaustive, these manuscripts can certainly serve as a jumping off point for the student of orbital anatomy. Interested readers can also peruse Jack Rootman’s sui generis orbital atlas with detailed illustrations by Bruce Stewart [25], which has been highly instructive to me personally.

Strengths • Detailed cadaveric, radiologic, and intraoperative descriptions that have stood the test of time. • Novel surgical techniques that remain mainstays of current practice.

Weaknesses • Small cohorts that may be underpowered to capture all attendant risks and complications. • Do not deal with ethnic or gender variation, which must be kept in mind when assessing the findings.

One-Sentence Summary Orbital anatomy is a complex and variable subject, and detailed study of radiographic, cadaveric, and operative findings is necessary to achieve mastery.

Author Comment This paper was initially rejected due to its original length and lack of many specific outcomes measures, and because we combined different indications such as fracture repair and decompression. Fortunately, with more data retrieval and consolidation the paper found a home in the Blue Journal. We followed this study with one specifically looking at dysthyroid compressive optic neuropathy where we had better

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outcomes measures and found excellent results. Over the years, it has become a standard technique. – JD Perry, MD When I first wrote about the transcaruncular approach with Henry [Baylis] and others, the journals thought it was too long and that it was not a mainstream procedure. They were happy to consider it as a letter to the editor at that time. I was sure that this was going to be the standard in the future, so when JD [Perry] finished the fellowship, I gave him my stacks of data and he really ran with it, publishing several articles on the topic. It has certainly become standard-of-care to approach the medial orbit over the years. – Norman Shorr, MD

References 1. Rontal E, Rontal M, Guilford FT (1979) Surgical anatomy of the orbit. Ann Otol Rhinol Laryngol 88:382–386 2. Koornneef L (1979) Orbital septa: anatomy and function. Ophthalmology 86:876–880 3. Baylis HI, Long JA, Groth MJ (1989) Transconjunctival lower eyelid blepharoplasty: technique and complications. Ophthalmology 96:1027–1032 4. Shorr N, Baylis HI, Goldberg RA, Perry JD (2000) Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 107:1459–1463 5. Pelton RW, Patel BCK (2001) Superomedial lid crease approach to the medial intraconal space: a new technique for access to the optic nerve and central space. Ophthal Plast Reconstr Surg 17:241–253 6. Kim JW, Goldberg RA, Shorr N (2002) The inferomedial orbital strut: an anatomic and radiographic study. Ophthal Plast Reconstr Surg 18:355–364 7. Yoon J, Pather N (2016) The orbit: a re-appraisal of the surgical landmarks of the medial and lateral walls. Clin Anat 29:998–1010 8. Macchi V, Regoli M, Bracco S, Nicoletti C, Morra A, Porzionato A, De Caro R, Bertelli E (2016) Clinical anatomy of the orbitomeningeal foramina: variational anatomy of the canals connecting the orbit with the cranial cavity. Surg Radiol Anat 38:165–177 9. Mueller SK, Bleier BS (2018) Osteologic analysis of ethnic differences in supernumerary ethmoidal foramina: implications for endoscopic sinus and orbit surgery. Int Forum Allergy Rhinol 8:655–658 10. Harris GJ, Garcia GH, Logani SC, Murphy ML (2000) Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures. Ophthal Plast Reconstr Surg 16:179–187 11. Chaudhuri Z, Demer JL (2013) Sagging Eye Syndrome. JAMA Ophthalmol 131:619 12. Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL (2019) Prevalence of sagging eye syndrome in adults with binocular diplopia. Am J Ophthalmol. https://doi.org/10.1016/j. ajo.2019.09.006 13. DEMER JL (2002) The orbital pulley system: a revolution in concepts of orbital anatomy. Ann N Y Acad Sci 956:17–32 14. Goldberg RA, Lessner AM, Shorr N, Baylis HI (1990) The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthal Plast Reconstr Surg 6:241–246 15. J. B (1924) Les hernies graisseuses de l’orbite: Notre traitement chirurgical. Bull Acad Med 92:1227–1232 16. Tenzel RR, Miller GR (1971) Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol 71:1141–1142

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17. McCord CD, Shore JW (1983) Avoidance of complications in lower lid blepharoplasty. Ophthalmology 90:1039–1046 18. Wray RC, Holtmann B, Ribaudo JM, Keiter J, Weeks PM (1977) A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142–145 19. Schwarcz R, Fezza JP, Jacono A, Massry GG (2016) Stop blaming the septum. Ophthalmic Plast Reconstr Surg 32:49–52 20. RC L (1921) The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope 31:1–5 21. Raza SM, Quinones-Hinojosa A, Lim M, Boahene KDO, Owusu Boahene KD (2013) The transconjunctival transorbital approach: a keyhole approach to the midline anterior skull base. World Neurosurg 80:864–871 22. Ramesh S, Bokman C, Mustak H, Lo C, Goldberg R, Rootman D (2018) Medial buttressing in orbital blowout fractures. Ophthal Plast Reconstr Surg 34:1 23. Ramesh S, Hubschman S, Goldberg R (2018) Resorbable implants for orbital fractures. Ann Plast Surg 81:372–379 24. Goldberg RA, Perry JD, Hortaleza V, Tong JT (2000) Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy. Ophthal Plast Reconstr Surg 16:271–277 25. Rootman J (2013) Orbital surgery: a conceptual approach, 2nd edn. Lippincott Williams & Wilkins, Philadelphia, PA

Chapter 13

Eyelid Anatomy

Author(s) Anderson, Richard L., Beard C. Marcos T. Doxanas, Richard L. Anderson. Michael J. Hawes, Richard K. Dortzbach. Vincent M. Gioia; John V. Linberg; Steven A. McCormick. Norman C. Ahl, Joseph C. Hill.

Summary: The Levator Aponeurosis Purpose  To describe the anatomy of the levator aponeurosis. Design  Cadaveric dissection, histologic examination, and intraoperative examination are used to describe the anatomy of the levator palpebrae superioris muscle. Results  The authors make several important observations about the levator aponeurosis (Fig. 13.1): 1. The body of the levator muscle transitions to the aponeurosis at the level of the superior transverse ligament, or Whitnall’s ligament. Whitnall’s ligament stretches from the trochlea medially to the lateral orbital rim, passing through and incorporating into the capsule of the orbital lobe of the lacrimal gland. 2. The levator splits into anterior and posterior lamellae 14–20 mm superior to the tarsal border; the anterior leaf is the levator aponeurosis, and the posterior leaf is Muller’s muscle.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_13

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Levator muscle

Orbicular muscle

Levator aponeurosis

Orbital septum Müller’s muscle

Tarsus

Fig. 13.1  Cross-sectional anatomy of the Western upper eyelid. (Adapted from Doxanas et al. [2])

3. The aponeurosis fuses with the orbital septum at the level of the eyelid crease, which is typically at the superior tarsal border in non-Asians. The aponeurosis then branches into 3 components:

(a) a small band of superior fibers that inserts into subcutaneous tissue at the eyelid crease, (b) a diffuse pattern of septa that insert onto the pretarsal orbicularis and skin, (c) and a posterior component that attaches firmly to the lower 2/3rds of the tarsus, and is most firmly attached 3 mm superior to the eyelid margin. 4. The aponeurosis attaches laterally via a firm band (4 mm in width) to the lateral orbital tubercule (Whitnall’s tubercule) and the lateral canthal tendon, splitting the lacrimal gland into orbital and palpebral lobes. 5. The aponeurosis attaches medially, much more weakly, to the posterior component of the medial canthal tendon and the posterior lacrimal crest.

Summary: Oriental Eyelids: An Anatomic Study Purpose  To describe the anatomy of the Asian eyelid. Design  A cadaveric dissection of 4Asian orbits with histological examination. Results  The authors make several important observations about the Asian eyelid in distinction to the Western eyelid (Fig. 13.2):

Summary: The Microscopic Anatomy of the Lower Eyelid Retractors

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Preaponeurotic fat Orbicular muscle Orbital septum

Levator muscle

Müller’s muscle Levator aponeurosis Tarsus

Fig. 13.2  Cross-sectional anatomy of the Asian upper eyelid. (Adapted from Doxanas et al. [2])

1. Rather than fusing at the superior tarsal border, the orbital septum proceeds inferiorly and fuses with the levator aponeurosis well below this point. This has to important ramifications: (a) the preaponeurotic fat extends closer to the eyelid margin, producing a thicker and fuller upper eyelid, and (b) The inferior extent of the orbital septum prevents aponeurotic attachments from passing through to the subcutaneous tissues, creating a lower or absent eyelid crease. 2. In some patients, an additional layer of fat is present between the orbital septum and the orbicularis muscle. 3. These differences are recapitulated in the lower eyelid, sometimes resulting in a roll of redundant skin and muscle overriding the eyelashes, known as epiblepharon.

Summary: The Microscopic Anatomy of the Lower Eyelid Retractors Purpose  To describe the normal and abnormal anatomy of the lower eyelid retractors. Design  A cadaveric study with specimens from fresh cadavers (n = 5), preserved cadavers (n = 16), and orbital exenteration (n = 1). Lower eyelid specimens from patients with involutional entropion (n  =  8) and ectropion (n  =  5) were studied as well.

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Fig. 13.3 Cross-sectional anatomy of the lower eyelid retractors. (Adapted from Hawes et al. [3]) T

O

Te F IR

ITM CPF L

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CPM

SO

OF

Results  The authors make the following observations about the normal anatomy of the lower eyelid retractors (Fig. 13.3): 1. The retractorsarise from the tendon of the inferior rectus muscle, wrap around the sheath of the inferior oblique muscle as it proceeds anteriorly, and contain smooth muscle fibers on the more superior aspect. 2. Anterior to the inferior oblique, the two portions condense to form Lockwood’s ligament and are hereafter referred to as the capsulopalpebral fascia. This fascia extends to the orbital septum and the inferior fornix, as well as into Tenon’s capsule around the globe. 3. There are abundant smooth muscle fibers, or the inferior tarsal muscle, just superior to the inferior fornix which diminish as they proceed superiorly to the inferior tarsal border, until they terminate 2.5 mm inferior to the inferior tarsal border. 4. Roughly 5 mm inferior to the inferior tarsal border, the orbital septum and the capsulopalpebral fascia fuse and proceed superiorly to insert on the inferior border of the tarsus. This insertion proceeds to the lower 1/third of the tarsus. 5. Rare fibers of the capsulopalpebral fascia extend through the orbicularis muscle and insert on the skin, contributing to the lower eyelid crease, if present. The authors also compared samples from patients with involutional entropion and ectropion to age-matched controls with normal lower eyelids. The attachment of the capsulopalpebral fascia to the inferior tarsus was comparable to normal eyelids and did not appear significantly attenuated. The distance from the inferior tarsal border to the inferior tarsal muscle fibers was increased from 2.5 mm to 3.9 mm (entropion) and 4.5 mm (ectropion).

Summary: The Anatomy of the Lateral Canthal Tendon Purpose  To describe the anatomy of the lateral canthal tendon.

Summary: Horner’s Muscle and the Lacrimal System

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Design  An analysis of the lateral canthal tendon incorporating cadaveric dissection (16 orbits), histologic and radiographic examination, and clinical measurement. Results  The authors make the following observations about the lateral canthal tendon (LCT) (Fig. 13.4): 1. The LCT arises from the lateral horn of the levator aponeurosis and the lateral ends of the tarsal plates and narrows from 10mm to 6 mm to its insertion at the lateral orbital tubercule, 1.5 mm posterior to the orbital septum and the lateral orbital rim. 2. The lateral orbital tubercule is roughly 10  mm inferior to the frontozygomatic suture. 3. The preseptal and preorbital orbicularis muscle interdigitate and form a lateral raphé which fuses to the anterior surface of the LCT. 4. The pretarsal orbicularis muscle sends fibers posterior to the orbital septum and interdigitates with the posterior surface of the LCT. 5. The posterior aspect of the LCT also contains attachments to the fascia surrounding the lateral rectus muscle. This attachment causes the lateral canthus to move laterally by 2 mm with extreme abduction of the globe in normal individuals (n = 20). 6. Eisler’s pocket, or a small pocket of orbital fat, is noted just anterior to the LCT insertion.

Summary: Horner’s Muscle and the Lacrimal System Purpose  To describe the anatomy of the medial canthal tendon and Horner’s muscle.

Fig. 13.4  Illustration of lateral canthal anatomy. (Reproduced with permission from Hwang et al. [4])

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Design  A cadaveric dissection of fixed orbits (n = 8), with measurement of intracanalicular pressures with simulation of different components of the orbicularis muscle. Results  The authors make the following observations about the medial canthal tendon (MCT), Horner’s muscle, and the lacrimal apparatus (Fig. 13.5): 1. The MCT averages 2–4 mm in width, and arises from the superior and inferior pretarsal orbicularis muscles as well as the medial borders of the upper and lower eyelid tarsus. The upper and lower tendons fuse to form the medial canthal angle, and the MCT then bifurcates into anterior and posterior leaflets. 2. The anterior leaflet attaches to the anterior lacrimal crest and proceeds further medially to insert onto the frontal process of the maxilla. 3. The posterior leaflet inserts onto the posterior lacrimal crest along with Horner’s muscle. 4. Horner’s muscle, a striated muscle originating from the deep head of the pretarsal orbicularis oculi muscle, completely encircles the medial 1/third of the upper and lower canaliculi before passing to the common canaliculus at its junction with the MCT. Horner’s muscle then proceeds posteriorly with the posterior leaflet of the MCT to insert on the posterior lacrimal crest and the periosteum of the medial orbit. 5. The pretarsal orbicularis also sends fibers to the lacrimal sac fascia that are separate from the contributions to Horner’s muscle.

D J I

B

G

F

H

E

A C

K

Fig. 13.5  Anatomy of the medial canthal tendon and Horner’s muscle. Note anterior medial canthal tendon (a); superior (b) and inferior (c) superficial preseptal muscle; superior (d) and inferior (e) superficial pretarsal muscle; posterior reflection of medial canthal tendon (f); superior (g) and inferior (h); Horner’s muscle medial rectus muscle (i); lacrimal fascia (j); and posterior lacrimal crest (k). Conjunctiva is reflected laterally (I). (Adapted from Ahl et al. [5])

Pressure with Horner’s Muscle/Orbicularis Contraction

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Intracanalicular pressure

Time

Lacrimal sac pressure

Fig. 13.6  Positive intracanalicular pressure and negative lacrimal sac pressure are observed with simulated contraction of the orbicularis and Horner’s muscles. (Adapted from Ahl et al. [5])

6. Simulated contracture of the orbicularis and Horner’s muscles induce positive intracanalicular pressure and negative lacrimal sac pressure, allowing the tear pump to function (Fig. 13.6).

Relevance As mentioned in the previous section, it is generally impossible to write a treatise on anatomy without inadvertently leaving out important anatomists across time and civilizations. Briefly, the work of Wong [6], Horner [7], Whitnall [8], Wolff [9], Duke-Elder [10], Fox [11], Kestenbaum [12], Jones and Wobig [13], Beard and Quickert [14], and many others underpins the studies described in this chapter. Many of the fascial connections are based on Koornneef’s description of the orbital septa [15]. However, these studies in particular utilize modern analytic methods in histology and radiography that were unavailable to these previous anatomists. As such, the studies presented herein either present novel knowledge or confirm scientifically what was previously thought about eyelid anatomy. Anderson’s description of the levator aponeurosis [1] has two major implications. Firstly, Anderson describes the insertion of the aponeurosis onto the lower 2/ third of the tarsus. Anderson notes that aponeurotic dehiscence is often present in involutional ptosis, and anatomic repositioning can lead to predictable outcomes. Interestingly, he makes the point that if the aponeurosis is sutured too inferiorly on the tarsus, ectropion can occur, while suturing too superiorly can lead to lash ptosis. Anderson also describes the extensions from the aponeurosis to the orbicularis and

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the skin, forming the eyelid crease. This minute anatomy forms the basis for this very prominent aesthetic landmark. Anderson and colleagues’ subsequent analysis [2] on the Asian eyelid expands on this topic by highlighting the anatomic differences between the two eyelid configurations. The inferiorly displaced fusion point between the orbital septum and the levator aponeurosis allows preaponeurotic fat to rest in the pretarsal space, creating fullness in the eyelid. This also shields the overlying skin from the aponeurotic extensions, leading to a lower or absent eyelid crease. The anatomy of the eyelid crease is critical in functional and aesthetic upper eyelid surgery [16]. Crease-­ formation surgery is a field in its own right, and techniques in general focus on creating adhesions between the aponeurosis, orbicularis, and skin in the Asian eyelid to create a configuration similar to the Western eyelid [17]. Recent research has clarified further the ethnic differences in Hispanics, who share genetic polymorphisms with Asians and Caucasians such that their eyelid configuration can be on a spectrum between the two [18]. Further microanatomy of the levator and Muller’s muscle suggests that the aponeurosis is multilaminar, with different portions inserting on different eyelid structures [19]. Hawes and Dortzbach [20] conduct an analogous study to describe the lower eyelid retractors. While the lower eyelid retractors are somewhat more ill-defined, their activity or lack thereof is still associatedwith disease states such as involutional entropion or ectropion. The authors’ observation that the inferior tarsal muscle may be disinserted in these conditions suggests some disruption of eyelid homeostasis is implicated. Surgical treatments for entropion [21] and ectropion [22] partially take advantage of the eyelid retractors to restore a physiologic eyelid position. Surgical approaches [23] based on preservation of the orbital septum and orbicularis to reduce eyelid retraction [24] have also been based on the anatomy described in this study. Finally, Gioia et al. [4] and Ahl et al.’s [5] descriptions of the medial and lateral canthal tendons provide a deeper understanding of these support structures in the orbit. Firstly, both groups note that these tendons have connections to the extraocular muscle system, suggesting that they are part of a coordinated set of pulleys, corroborating Koornneef’s work [15]. In fact, distraction of the canthus is noted on extremes of gaze. Secondly, the canthal tendons are not simple structures that pass from the ends of the tarsus into the bony orbit. Rather, there are multiple interdigitations with the orbicular muscle, check ligaments from the lateral and medial recti, and contributions from the tarsus itself to form a three-dimensional, multilaminar structure. Medially, this anatomy was critical in the development of surgical approaches to the medial orbit [25], treatment of punctal ectropion [26], as well as understanding the pump mechanism of the nasolacrimal apparatus [27]. Current research has greatly enhanced our understanding of these structures, with microsurgical dissection and advanced histology and radiography revealing branched innervation patterns [28], possible proprioceptive structures [29], and the three-dimensional relationship of these structures in the orbit [30]. Countless surgical techniques have also been based on the anatomic descriptions herein. A thorough understanding of the eyelid anatomy and spatial relationship of these structures will the surgeon to be safe and innovative intraoperatively.

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Strengths • Detailed cadaveric, histologic, and intraoperative descriptions that have spurred many novel surgical techniques. • Corroborated by sensitive anatomic microdissections performed in recent years.

Weaknesses • Little description of ethnic or gender variation, which is now recognized to be quite significant.

One-Sentence Summary Eyelid anatomy is a complex and variable subject, and detailed study of radiographic, histologic, and operative findings is necessary to achieve mastery.

Author Comments “I’m glad I grew up as a farm boy in Iowa. When a fence was broken, I didn’t replace the whole fence or work on the backside of the fence, I fixed the part that was broken. When I entered the field, I thought people were overlooking the anatomic problems. They had procedures, and they were trying to make the problem fit their procedure. This was because they weren’t using their anatomic knowledge. For example, acquired ptosis is usually a stretching, anatomic problem of the levator aponeurosis. People needed to understand the anatomy of the levator and the eyelids, and I really talked about anatomy in all areas. In the Asian eyelid, we would want to change their eyelid to what they would anatomically desire. The first primum is “do no harm”, and I think if you don’t understand the anatomy of the eyelid, you shouldn’t be working on the eyelid! Later, as I was teaching my fellows, I insisted they learned the anatomy. If they didn’t want to, I was quite happy to have them sew up all the eyelids, but to do the procedure they needed to learn the anatomy.” – Rick Anderson, MD. “Dr. Richard Dortzbach (“Dortz” to those who know him well) loved anatomical studies and he felt there were plenty of studies yet to be performed using a microscopic approach when I was his fellow. It was his idea to look at the anatomy of the lower lid retractors using microscopic sections of cadaver eyelids. He suggested this could be a good thesis topic for me, and we worked diligently during my fellowship to obtain the anatomic material for the study. Dortz already had a good relationship

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with the anatomy lab at the University of Wisconsin medical school, and with a substantial effort, pleading our case and explaining our goal, we were able to eventually obtain the 22 specimens used for our study. It took about two years from completion of my fellowship to publication of the paper. Quite a number of Dortz’s fellows (at least 7) went on to win the Marvin Quickert Award for best thesis submitted to ASOPRS. I was fortunate to win the award in 1981 for this paper. In addition to Dortz’s fellows working on anatomic studies, others have followed this course as well. I have been especially impressed by the large number of excellent anatomical studies performed and published by Dr. Hirohiko Kakizaki and colleagues.” – Michael Hawes, MD

References 1. Anderson RLBC (1977) The Levator aponeurosis. Arch Ophthalmol 95:1437 2. Doxanas MT, Anderson RL (1984) Oriental Eyelids. Arch Ophthalmol 102:1232 3. Hawes MJ, Dortzbach RK (1982) The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol 100:1313–1318 4. Hwang K, Nam YS, Kim DJ, Han SH, Hwang SH (2009) Anatomic study of the lateral palpebral raphe and lateral palpebral ligament. Ann Plast Surg 62(3):232–236. https://doi. org/10.1097/sap.0b013e31817f9e90 5. Ahl NC, Hill JC (1982) Horner’s muscle and the lacrimal system. Arch Ophthalmol 100:488–493 6. Wong C-H, Hsieh MKH, Mendelson B (2012) The tear trough ligament. Plast Reconstr Surg 129:1392–1402 7. Horner W (1824) Description of a small muscle at the internal commisure of the eyelids. Phila J Med Phys Sci 8:70–77 8. Whitnall S (1932) The anatomy of the human orbit, 2nd edn. Oxford University Press, London 9. Wolff E (1954) The anatomy ofthe eye and orbit, 2nd edn. HK Lewis and Co, LTD, London 10. Duke-Elder S (1961) System of ophthalmology. CV Mosby, St. Louis, MO 11. Fox S (1963) Ophthalmic plastic surgery. Grune and Stratton, New York, NY 12. Kestenbaum A (1963) Applied anatomy of the eye. Grune and Stratton, New York, NY 13. Jones L, Wobig J (1976) Anatomy of the eyelids in surgery of the eyelids and lacrimal system. Aesculapius Publishing Co, Birmingham, AL 14. Beard C, Quickert M (1969) Anatomy of the orbit. Aesculapius Publishing Co., Birmingham, AL 15. Koornneef L (1979) Orbital septa: anatomy and function. Ophthalmology 86:876–880 16. Jones LT, Quickert MH, Wobig JL (1975) The cure of ptosis by aponeurotic repair. Arch Ophthalmol 93:629–634 17. Zhang H, Zhuang H, Yu H, Feng Y, Wang T, Hu S, Yang Y, Wang Q (2006) A new Z-epicanthoplasty and a concomitant double eyelidplasty in Chinese eyelids. Plast Reconstr Surg 118:900–907 18. Fry CL, Naugle TC, Cole SA, Gelfond J, Chittoor G, Mariani AF, Goros MW, Haik BG, Voruganti VS (2017) The latino eyelid: anthropometric analysis of a spectrum of findings. Ophthal Plast Reconstr Surg 33:440–445 19. Zhang M, Wu J, Chen L, Ren Z, Gao W (2020) A new anatomy finding of Levator aponeurosis and Müller muscle at Pretarsal plate in Asian males. Ophthal Plast Reconstr Surg 36:1 20. Hawes MJ, Dortzbach RK (1983) Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 90:1066–1070

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2 1. Quickert MH, Rathbun E (1971) Suture repair of Entropion. Arch Ophthalmol 85:304–305 22. Anderson RL, Gordy DD (1979) The tarsal strip procedure. Arch Ophthalmol 97:2192–2196 23. Goldberg RA, Lessner AM, Shorr N, Baylis HI (1990) The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthal Plast Reconstr Surg 6:241–246 24. Schwarcz R, Fezza JP, Jacono A, Massry GG (2016) Stop blaming the septum. Ophthalmic Plast Reconstr Surg 32:49–52 25. Shorr N, Baylis HI, Goldberg RA, Perry JD (2000) Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 107:1459–1463 26. Nowinski TS, Anderson RL (1985) The medial spindle procedure for involutional medial ectropion. Arch Ophthalmol 103:1750–1753 27. Becker BB (1992) Tricompartment model of the lacrimal pump mechanism. Ophthalmology 99:1139–1145 28. Choi Y, Kang HG, Nam YS, Kang J-G, Kim I-B (2017) Facial nerve supply to the orbicularis oculi around the lower eyelid. Plast Reconstr Surg 140:261–271 29. Vrcek I, Blumer R, Blandford A, Somogyi M, Durairaj V, Blaydon S, Shore J, Amato M, Nakra T (2020) Histologic evaluation of nonvisual afferent sensory upper eyelid proprioception. Ophthal Plast Reconstr Surg 36:7–12 30. Yamamoto H, Morikawa K, Uchinuma E, Yamashina S (2001) An anatomical study of the medial canthus using a three-dimensional model. Aesthet Plast Surg 25:189–193

Chapter 14

Facial Anatomy

Author(s) David Furnas. Wong, Chin-Ho, Michael H Hsieh, Fams K, Mendelson, Bryan. Moss, Christopher, Mendelson, Bryan C., Taylor, G. Ian. Wong, Chin-Ho, Mendelson, Bryan.

Abstract: The Retaining Ligaments of the Cheek The zygomatic ligaments (McGregor’s patch) anchor the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle. The mandibular ligaments tether the overlying skin to the anterior mandible. Both these ligaments are obstacles to surgical maneuvers intended to advance the overlying skin. They also restrain the facial skin against gravitational changes, and they delineate the anterior border of the “jowl” area. The platysma-auricular ligament is a thin fascial sheet that extends from the posterosuperior border of the platysma and that is intimately attached to the periauricular skin; it serves as a surgical guide to the posterosuperior border of the platysma. The anterior platysma-­ cutaneous ligaments are variable fascial condensations that anchor the SMAS and platysma to the dermis. They can cause anatomic disorientation with dissection of false planes into the dermis. These four ligaments are useful as anatomic landmarks during facial dissections. The tethering effects of the zygomatic and mandibular ligaments must be interrupted if a maximum upward movement of the facial skin is desired.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_14

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Summary Purpose  To describe the retaining ligaments of the face. Design  An examination of 30 cadaveric hemifaces and 50 faces intraoperatively. Results  The following 4 ligamentous structures are described (Fig. 14.1): 1. The zygomaticocutaneous ligaments (McGregor’s patch) are a firm bundle of connective tissue 3 mm in width and 0.5 mm in thickness, arising from the anterior face of the zygomatic arch behind the insertion of the zygomaticus minor muscle and coursing through the facial layers to insert on the skin. Multiple smaller bundles may be present adjacent to this, and a zygomatic branch of the facial nerve lies directly beneath the SMAS near the ligaments along with a branch of the transverse facial artery and sensory nerve. 2. The mandibular ligaments arise from the anterior 1/3rd of the mandible and roughly 1 cm superior to the inferior mandibular border. The ligaments course anteriorly, interdigitating with the platysmal fibers and inserting at the anterior border of the jowl. The ptotic jowl fat pad lies just posterior to this ligament. 3. The platysma-auricular ligaments arise from the platysma at the inferior border of the auricle and course anteriorly over the parotid gland to insert on the dermis.

Art. and n.

Zygomatic ligament

Parotid Facial n. Platysmaauricular ligament Anterior platysmacutaneous ligament Gr. auricular n.

Art. and n. Mandibular ligaments

Platysma m.

Fig. 14.1  Retaining ligaments of the cheek. (Reproduced with permission from Furnas [1].)

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The great auricular nerve is often interwoven with the fibers of this ligament in its deeper portions. 4. The anterior platysma-cutaneous ligaments can be found at the anterior border of the platysma and the cheek coursing from the platysma to the dermis.

 bstract: The Tear Trough Ligament: Anatomical Basis A for the Tear Trough Deformity Background  The exact anatomical cause of the tear trough remains undefined. This study was performed to identify the anatomical basis for the tear trough deformity. Methods: Forty-eight cadaveric hemifaces were dissected. With the skin over the midcheek intact, the tear trough area was approached through the preseptal space above and prezygomatic space below. The origins of the palpebral and orbital parts of the orbicularis oculi (which sandwich the ligament) were released meticulously from the maxilla, and the tear trough ligament was isolated intact and in continuity with the orbicularis retaining ligament. The ligaments were submitted for histologic analysis. Results: A true osseocutaneous ligament called the tear trough ligament was consistently found on the maxilla, between the palpebral and orbital parts of the orbicularis oculi, cephalad and caudal to the ligament, respectively. It commences medially, at the level of the insertion of the medial canthal tendon, just inferior to the anterior lacrimal crest, to approximately the medial-pupil line, where it continues laterally as the bilayered orbicularis retaining ligament. Histologic evaluation confirmed the ligamentous nature of the tear trough ligament, with features identical to those of the zygomatic ligament. Conclusions: This study clearly demonstrated that the prominence of the tear trough has its anatomical origin in the tear trough ligament. This ligament has not been isolated previously using standard dissection, but using the approach described, the tear trough ligament is clearly seen. The description of this ligament sheds new light on considerations when designing procedures to address the tear trough and the midcheek.

Summary Purpose  To describe the anatomy of the tear trough ligament. Design  A cadaveric dissection of 48 hemifaces with histological examination. Results  The authors make the following observations about the tear trough ligament (Fig. 14.2): 1. The tear trough ligament is an osseocutaneous ligament that is present at the lid cheek junction. Superficially, this is the boundary between the thin eyelid skin

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Fig. 14.2  The tear trough ligament–orbicularis retaining ligament complex has been marked and divided. The orbicularis retaining ligament (ORL) is a bilayered structure, merging medially as the tear trough ligament. (Reproduced with permission from Wong et al. [2])

and the thicker cheek skin, which has a thick subcutaneous fat layer. This is also the boundary between the septal and orbital portions of the orbicularis oculi muscle. 2. This ligament arises from the anterior face of the maxilla and inserts on the skin exactly at the location of the observed nasojugal groove. 3. The superior extent of this ligament is the medial canthal tendon and anterior lacrimal crest and continues until the medial limbus where it continues laterally as the orbital retaining ligament. 4. The ligament is roughly 0.5 mm in thickness and similar to the zygomaticocutaneous ligaments histologically. It increases from a length of 7 mm medially at the medial canthal tendon to a length of nearly 16 mm as it transitions to the orbital retaining ligament.

 bstract: Surgical Anatomy of the Ligamentous Attachments A in the Temple and Periorbital Regions This study documents the anatomy of the deep attachments of the superficial fasciae within the temporal and periorbital regions. A highly organized and consistent three-dimensional connective tissue framework supports the overlying skin and soft tissues in these areas. The regional nerves and vessels display constant and predictable relationships with both the fascial planes and their ligamentous attachments. Knowledge of these relationships allows the surgeon to use the tissue planes and soft-tissue ligaments as intraoperative landmarks for the vital neurovascular structures. This results in improved efficiency and safety for aesthetic procedures in these regions.

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Summary Purpose  To describe the surgical anatomy of the forehead and temple. Design  A cadaveric study with 22 fresh-frozen hemifaces. Intraoperative recordings from forehead and brow lifts were also studied. Results  The authors make the following observations about the anatomy of the temple and forehead (Figs. 14.3 and 14.4): 1. The temporal ligamentous adhesion (also termed the conjoint tendon, superior temporal fusion line, and others) is a keystone structure that represents the fusion of the superior temporal septum, the inferior temporal septum, the supraorbital adhesion, the frontal periosteum, and the deep and superficial temporalis fascia. 2. The temporal branches of the facial nerve pass from the inferior border of the zygomatic arch, over the middle third of the arch to a plane just underneath the superficial temporalis fascia. These branches travel within a fat pad and are protected by ligamentous condensations at the zygomatic arch. 3. The superior and inferior temporal septa bound the temporal compartment, and form the transition zones to the galea superiorly and the temporal fat pad that houses the facial nerve branches inferiorly. 4. The sentinel vein is found just inferior to the inferior temporal septum, and facial nerves typically course justinferior of this structure, at the underside of the superficial temporalis fascia. 5. The supraorbital thickening transitions laterally into the lateral orbital tubercule, which is contiguous with the lateral canthus. Medially, branches of the supraorFig. 14.3 Temporal anatomy. Temporal ligamentous adhesion (TLA), supraorbital ligamentous adhesion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), later brow thickening (LBT), lateral orbital thickening (LOT), sentinel vein (SV), temporal branches of facial nerve (TFN), zygomaticotemporal nerve (ZTN), zygomaticofacial nerve (ZFN). (Reproduced with permission from Moss et al. [3])

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Subcutaneous fat Temporal fascia proper Skull Temporal fat pad Deep layer of deep temporal fascia Temporal extension of buccal fat pad Temporalis m.

Temporal br. of VlI Sentinel v. Temporoparietal fascia Skin Superficial layer of deep temporal fascia Zygomatic bone Masseter m. Parotid gland SMAS Mandible

Fig. 14.4  Cross-sectional anatomy of the temporal region. (Reproduced with permission from Trinei et al. [4])

bital nerves course via a foramen or notch on the deep surface of the muscles and become more superficial as they proceed superiorly.

 bstract: Facial Soft-Tissue Spaces and Retaining Ligaments A of the Midcheek: Defining the Premaxillary Space Background  This anatomical study was undertaken to define the soft-tissue spaces, retaining ligaments, and their relations in the midcheek. METHODS: Sixty fresh hemifaces were dissected. The retaining ligaments and facial spaces were defined and their dimensions recorded. The course of the key vessels and branches of the facial and infraorbital nerves were defined and their anatomical relations noted. RESULTS: The preseptal and prezygomatic spaces underlie the lid-cheek and malar segments of the midcheek. A previously undocumented soft-tissue space, the premaxillary space, was found to underlie the nasolabial segment. The retaining ligaments of the midcheek are the tear trough-orbicularis retaining ligament complex in the upper midcheek and the zygomatic and maxillary ligaments in the lower midcheek. The tear trough-orbicularis retaining ligament complex separates the preseptal space above from the prezygomatic and premaxillary spaces below. Facial

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nerve branches in the midcheek are closely associated with the zygomatic ligaments located outside the lower boundary of the prezygomatic space and are protected so long as the dissection is kept within this space. The infraorbital nerve is protected by the floor of the premaxillary space, formed by the levator labii superioris and, at the inferior boundary of the space, by the close relation with the maxillary ligaments. CONCLUSIONS: This study completely defined the spaces and retaining ligaments of the midcheek. Knowledge of this anatomy is key to safe and atraumatic suborbicular dissection for effective midcheek lifts.

Summary Purpose  To describe the anatomy of the midcheek and premaxillary space. Design  A cadaveric dissection of fresh-frozen cadaveric hemifaces (n = 60). Results  The authors describe the following potential spaces (Fig. 14.5): 1. The preseptal space is bounded inferiorly by the tear trough ligament and orbital retaining ligament (ORL), superiorly by the lower eyelid retractors, and posteriorly by the orbital septum. This space contains no named nerves or vessels and is important in lower blepharoplasty. 2. The prezygomatic space is a triangular compartment over the body of the zygoma. It is bounded superiorly by the ORL, inferiorly by the zygomaticocutaneous ligaments, and posteriorly by the body of the zygoma. The ORL and zygo-

Fig. 14.5  Retractor elevating the roof of the middle premasseter space (PMS). There has been further dissection of the upper boundary (UB) and lower boundary (LB) membranes. Overlying the upper masseter cephalad to the middle space is the accessory lobe of the parotid (AP). Above that are the zygomaticus major (z maj) and zygomatic ligaments (zyglig). (Reproduced with permission from Mendelson et al. [5])

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maticocutaneous ligaments merge at its medial boundary, forming the apex of the triangle. The origins of the zygomaticus muscles are found at the floor of this space. 3. The premaxillary space is a potential space at the anterior face of the maxilla. The floor of this space is the levator labii superioris muscle and its roof is the SMAS and orbital orbicularis muscle. It is bounded superiorly by the ORL and tear trough ligament and inferiorly by the firm maxillary osseocutaneous ligaments, which course from the maxilla to the upper portion of the nasolabial fold. It is bordered medially by the lateral nasal sidewall, and laterally by loose areolar tissue near the prezygomatic space. The premaxillary space contains the angular artery (medially) and vein (laterally), and zygomatic and buccal branches of the facial nerve which travel with the vein. The infraorbital nerve travels medially at the floor of the space.

Relevance A thorough knowledge of facial anatomy is critical to avoiding complications and performing an effective surgery. The studies presented herein presented important concepts that are foundational to modern facial surgery. Furnas’ description of the facial retaining ligaments [1] laid the foundation for modern facial rejuvenation. Whether the surgeon is performing a midface lift or a deep-plane face lift, a knowledge of the osseocutaneous ligaments of the face is critical, as these structures lie adjacent to important neurovascular structures and also represent transition zones between aesthetic subunits [6]. In fact, these transition zones can herald variance in skin thickness such that the surgeon must consciously adjust for this as the dissection proceeds [7]. In particular, McGregor’s patch [8] remains an oft-used landmark for multiple types of facial surgeries. Contemporary anatomists and surgeons Wong and Mendelson expand on this topic with their study of the tear trough ligament [2]. Their dissections demonstrate that this osseocutaneous ligament not only forms the basis for the aesthetically important tear trough, but also that ligamentous release aids in effacement of the lid-cheek junction [9] by allowing mobility of the malar fat that lies inferior to this [10]. In fact, release of this ligament is important in many types of blepharoplasty procedures [11]. Wong and Mendelson make a distinction between the tear trough ligament and the orbital retaining ligament (ORL) laterally, although this may not be a true distinction. In fact, subsequent studies demonstrate that the ligament arborizes and is highly variable as it proceeds laterally [12]. Furthermore, this ligament is not the only structure which contributes to the clinical appearance of the tear trough [13]. However, the ligament remains an easily identifiable structure, and the surgeon must anticipate this in order to preserve or release it as the surgical plan dictates. Mendelson and colleagues continue their research by expounding on Mitz and Peyronie’s [14] initial descriptions of the SMAS to further detail the anatomy of the forehead and temple [3], and the midface [15]. These anatomic descriptions are

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critical for safe and effective brow and face lifting procedures. In particular, the descriptions of the temporal septa and their relationship to the temporal branch of the facial nerve is highly important. Release of the septa is necessary to achieve adequate mobility in the brow lift, while anticipating and preserving the nerve avoids a permanent brow paresis. Further study on the sentinel vein [4] suggests that the temporal branch lies within 2 mm of this structure [16], and subsequent studies have elaborated on the course of this nerve [17, 18]. The description of the supraorbital nerve corroborates and complements analysis performed previously [19]. Finally, the description of the potential spaces of the midface allows for safety in lower facial rejuvenation. Mendelson expands on his descriptions of the premaxillary space [15] with a description of the premasseteric space [5], the midcheek [20], the lateral canthus [21], and the SMAS [22]. Taken together as a composite, these descriptions form a detailed roadmap of the critical structures of the face which are the basis for the modern, composite face lift. Mendelson and colleagues’ descriptions focus on ligaments, nerves, and the potential spaces created therein, while Rohrich and Pessa focus on the fat pads themselves [23]. However, an understanding from both perspectives is necessary for comprehensive facial rejuvenation. Both ligamentous release and revolumization of the fat pads is important in obtaining natural results. Restoration of the natural ligaments after tissue repositioning may allow for a more durable outcome as well, and newer, anatomically-based surgical techniques both in the midface [24], lower face [25], and the eyelid [26, 27] depend on detailed knowledge of these structures. Subsequent radiologic and photographic analysis has also described the functional anatomy of these structures with positional change [28–30], suggesting that the deep fat pads often allow adipose to freely flow amongst the compartment bounded by the retaining ligaments. Longitudinal studies of anatomy over time have also shown how these ligaments attenuate but remain relatively fixed in position, although fat pads that are not anchored by these ligaments experience significantly more ptosis with time [31]. Future research shouldclarify racial and gender variation as well as the microanatomy of these structures. Undoubtedly, these will build on the sturdy foundation laid by the above studies, which form the anatomic basis for many modern oculofacial plastic surgery techniques.

Strengths • Detailed cadaveric and histologic descriptions that have allowed for elegant surgical techniques based on anatomy.

Weaknesses • No ethnic or gender-based variations given.

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One-Sentence Summary A three-dimensional spatial understanding of facial anatomy is critical to performing safe and effective surgery.

Author Comment When I started to research into the anatomical origins of the tear trough deformity, I was surprised to find that, despite being so commonly referred to, its anatomy has not been definitively described with many conflicting descriptions in the literature. The prevailing opinion then was that the tear trough was thought to have originated at the arcus marginalis (the orbital rim). Others have noted that it was located between the origins of the palpebral and orbital parts of the orbicularis oculi (i.e. more inferiorly) and even in the gap between the origins of the orbicularis oculi and the levator labii superioris and levator labii alaeque nasi (even more inferiorly located). The exact structure of the tear trough was also debated. Notably, some authors have stated that there are no ligamentous structures in the tear trough. This paper therefore filled an important gap in our knowledge of this critical area of anatomy by definitively defining the anatomical basis of the tear trough deformity. A previously unrecognized true osteocutaneous ligament exists, that originates from the maxilla, in the location between the origins of the palpebral and orbital parts of the orbicularis oculi, passing through all layers of the facial soft tissues to insert into the dermis. We named this osteocutaneous ligament the tear trough ligament. Today this structure is accepted as the anatomical origin of the tear trough deformity and surgical procedures that aim to correct the tear trough deformity necessarily have to directly address the tear trough ligament to effectively treat this problem. I am often asked why earlier anatomists/ surgeons had not been able to isolate this ligament before. Looking back, I was most fortunate to have 2 advantages in my favor – a great mentor in Dr. Mendelson, and access to quality cadaveric specimens. Dr. Mendelson pioneered the concept of facial soft tissue spaces and retaining ligaments. He described the prezygomatic space and the orbicularis retaining ligament in the upper boundary of the prezygomatic space in 2002. As was already accepted then, the orbicularis retaining ligament is the anatomical cause of the palpebral malar groove that develops with aging. This groove becomes continuous with the tear trough ligament with age. This observation hinted to me that the tear trough, like the palpebro-malar groove, has its origins in an undocumented facial retaining ligament as well. At that point, I was working as an attending Plastic Surgeon at the Singapore General Hospital. The availability of a world class cadaver laboratory there, funding and the many enthusiastic residents provided me the opportunity to spent many hours immersing myself in the dissections.

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Despite these advantages, I wandered in dissection ‘wilderness’ for 6 to 8 months and dissected over 30 hemi-faces without much to show for. I have read most of the key facial and mid cheek anatomy papers in researching the tear trough deformity. I explored and reproduced some of these dissections in my own dissections but was unable to locate even a hint of any ligamentous structures that I thought should be there. In retrospect, this was because I was performing the dissection in a layer-by-­ layer manner as used by most authors before me. With this approach, the skin was removed, followed by subcutaneous fat, followed by facial muscles and so on. In retrospect, this method of dissection does not lend itself to the study of osteocutaneous ligaments, such as the tear trough ligament, because with the removal of the skin, the ligament was cut and with that, there resulted a loss of tension on the ligament. The cut tear trough ligament had ‘lost’ its identity as a ligament and now appeared’ as a contracted fibrosity on the bone. This was aptly described by another author as a ‘gap’ between the palpebral and orbital parts of the orbicularis oculi. Thus, when the layer-by-layer approach was used, the tear trough ligament was not identifiable, and hence had not been found by previous investigators or myself (up to that point). The discovery of the ligament was somewhat by serendipity. One day, I decided to change my approach by keeping the skin intact and making a vertical incision straight down to the bone at the level of the medial canthus down the nasal side wall. When the orbicularis was placed under tension, I saw immediately, a very distinct whitish, fibrous structure (Fig. 14.4). When I then released the origins of the orbicularis oculi located cephalic and caudal to the fibrous structure, a distinct osteocutaneous ligament was isolated (Fig. 14.5). As luck would have it, the specimen that day had the most robust and fibrous tear trough ligament I have ever seen! It was so strong that I could lift the entire head off the bench by grasping onto the ligament. This was my personal eureka moment with tear trough dissection and I was immediately convinced that I had found the anatomical cause of the tear trough deformity. From then, I was able to dissect out the ligament in every single specimen as documented in the paper, and as may been seen in the dissection video that accompanied the paper. – Chin-Ho Wong, MBBS, MRCS (Ed), M.Med (Surg), FAMS (Plast Surg)

References 1. Furnas DW (1989) The retaining ligaments of the cheek. Plast Reconstr Surg 83:11–16 2. Wong C-H, Hsieh MKH, Mendelson B (2012) The tear trough ligament. Plast Reconstr Surg 129:1392–1402 3. Moss C, Mendelson BC, Taylor GI (2000) Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 105:1475–1490 4. Trinei FA, Januszkiewicz J, Nahai F (1998) The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg 101:27–32

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5. Mendelson BC, Wong CH (2013) Surgical anatomy of the middle premasseter space and its application in sub-smas face lift surgery. Plast Reconstr Surg 132:57–64 6. Alghoul M, Bitik O, McBride J, Zins JE (2013) Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the sub-SMAS danger zone. Plast Reconstr Surg 131:245–252 7. Rohrich RJ, Pessa JE (2007) The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219–2227 8. Mcgregor M (1959) Face Lift Techniques. Annu. Meet. Calif. Soc. Plast, Surg 9. Haddock NT, Saadeh PB, Boutros S, Thorne CH (2009) The tear trough and lid/cheek junction: anatomy and implications for surgical correction. Plast Reconstr Surg 123:1332–1340 10. Wong CH, Mendelson B (2017) Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg 140:273–282 11. Goldberg RA (2000) Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 105:743–748 12. O J, Kwon H-J, Choi Y-J, Cho T-H, Yang H-M (2018) Three-dimensional structure of the orbicularis retaining ligament: an anatomical study using micro-computed tomography. Sci Rep 8:17042 13. Ramesh S, Goldberg RA, Wulc AE, Brackup AB (2019) Observations on the tear trough. Aesthetic Surg J:1–10 14. Mitz V, Peyronie M (1976) The SMAS in the parotid and cheek area. Plast Reconstr Surg 58:80–88 15. Wong CH, Mendelson B (2013) Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg 132:49–56 16. Green Sanderson K, Conti A, Colussi M, Connolly C (2019) A simple clinical application for locating the frontotemporal branch of the facial nerve using the zygomatic arch and the tragus. Aesthetic Surg J. https://doi.org/10.1093/asj/sjz186 17. Hwang K (2014) Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofac Surg 25:1476–1481 18. Sabini P, Wayne I, Quatela VC (2003) Anatomical guides to precisely localize the frontal branch of the facial nerve. Arch Facial Plast Surg 5:150 19. Knize DM (1995) A study of the supraorbital nerve. Plast Reconstr Surg 96:564–569 20. Mendelson BC, Muzaffar AR, Adams WP (2002) Surgical anatomy of the Midcheek and malar mounds. Plast Reconstr Surg 110:885–896 21. Muzaffar AR, Mendelson BC, Adams WP (2002) Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873–884 22. Mendelson BC (2001) Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg 107:1545–1552 23. Pessa JE, Rohrich RJ (2012) Facial topography: clinical anatomy of the face. Quality Medical Publishing, St. Louis, MO 24. Shtraks JP, Fundakowski C, Yu D, Hartstein ME, Sarcu D, Lu X, Wulc AE (2019) Investigation of the longevity of the endoscopic midface lift. JAMA Facial Plast Surg 21:535–541 25. Jacono A, Bryant LM (2018) Extended deep plane facelift: incorporating facial retaining ligament release and composite flap shifts to maximize midface, jawline and neck rejuvenation. Clin Plast Surg 45:527–554 26. Yoo DB, Peng GL, Massry GG (2013) Effacing the orbitoglabellar groove with transposed upper eyelid fat. Ophthal Plast Reconstr Surg 29:220–224 27. Huggins A, Somogyi M, Nakra T (2019) Transposition upper blepharoplasty with orbital retaining ligament release. Ophthal Plast Reconstr Surg XX:1 28. Schenck TL, Koban KC, Schlattau A, Frank K, Sykes JM, Targosinski S, Erlbacher K, Cotofana S (2018) The functional anatomy of the superficial fat compartments of the face: a detailed imaging study. Plast Reconstr Surg 141:1351–1359

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29. Cotofana S, Gotkin RH, Frank K, Koban KC, Targosinski S, Sykes JM, Schlager M, Schlattau A, Schenck TL (2019) The functional anatomy of the deep facial fat compartments. Plast Reconstr Surg 143:53–63 30. Ramesh S, Johnson P, Sarcu D, Wulc AE (2020) Gravity in Midfacial aging: a 3-dimensional study. Aesthetic Surg J. https://doi.org/10.1093/asj/sjaa021 31. Lambros V (2020) Facial aging: a 54-year, three-dimensional population study. Plast Reconstr Surg 145:921–928

Part III

Facial Dystonia

Facial dystonia can be disabling and distressing, both due to its functional and its psychosocial ramifications. It was not until recently that many facial movement disorders were recognized as true medical conditions, and as such treatment for these was only developed in the last several decades. In particular, the widespread use of botulinum toxin has been a godsend in the quality of life of these suffering patients. In this chapter, we discuss significant innovations in the diagnosis and treatment of facial dystonia, and in particular, blepharospasm.

Chapter 15

Blepharospasm and Facial Dystonia

Author(s) C.D. Marsden Jack Goldstein, and David Cogan

Summary: Blepharospasm-oromandibular Dystonia Syndrome (Brueghel’s Syndrome). A Variant of Adult-onset Torsion Dystonia? Purpose  To describe the clinical phenotype of blepharospasm with or without oromandibular dystonia. Design  A retrospective case series of 39 patients with benign essential blepharospasm or blepharospasm-oromandibular dystonia syndrome. Results  The authors describe patients with benign essential blepharospasm (n  =  13), isolated oromandibular dystonia (n  =  9), or combined blepharospasm-­ oromandibular dystonia (n  =  17). The disease was more prevalent in females (n = 25) than males (n = 14), and mean age of onset was 57 years (range 41–71). Clinical phenotypes were as follows: 1. Benign Essential Blepharospasm: Patients experienced spasms of orbicularis oculi muscle contracture causing eyelid closure; disease often started unilaterally but proceeded to bilateral over time. Disease started intermittently and progressed to spasms as frequently as every 15 seconds and as long as 20 minutes of spasm at a time. Spasms were often provoked by sunlight. Patients were rendered functionally blind, and had developed many tricks including forced jaw © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_15

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opening, yawning, and digital opening of the eyelids to treat the spasm. 50% of patients were clinically depressed. 2. Isolated Oromandibular Dystonia: Patients experienced spasms with mouth closure (n = 5) or mouth opening (n = 4). Tongue protrusion, mouth pursing, speech difficulty, swallowing difficulty, and clinical depression were common associated symptoms. 3. Combined Blepharospasm-Mandibular Dystonia: In the majority of patients, mandibular and eyelid dystonia appeared concurrently. The eyelid symptoms were identical to those experienced by patients with isolated blepharospasm. Jaw spasms were strong enough to lead to temporomandibular joint dislocation or snapping of dental wiring with subsequent tongue or cheek laceration. Attempted facial movements could trigger spasms. Clinical depression was highly prevalent in the cohort. In all patients with isolated blepharospasm, dystonia was limited to the eyelids. Two patients experienced dystonia in the lower neck, truncal musculature, or tremor. No imaging or significant laboratory abnormalities were noted in any patients. Benzodiazepines, anticholinergics, and tricyclics gave little relief. Some improvement was noted with dopamine receptor blockade, although drug-induced Parkinsonism was common. Three patients had limited success with surgical myotomy.

Summary: Apraxia of Lid Opening Purpose  To report four cases of apraxia of eyelid opening. Design  A retrospective case series of four patients who were observed to have apraxia of eyelid opening. Apraxia of eyelid opening was defined as a nonparalytic motor abnormality wherein the patient cannot initiate the act of eyelid opening, is present only at the start of the eyelid opening movement, and is not associated with sustained contraction of the orbicularis oculi muscles. Results  Four patients with apraxia of eyelid opening are described. Three patients had systemic symptoms suggestive of parkinsonism. One patient had nystagmus and one patient had significant limitation of extraocular movements. A supranuclear syndrome is postulated as a possible etiology for this condition.

Relevance Benign essential blepharospasm can be an extremely debilitating condition. Unfortunately, the lack of significant neurologic comorbidities and the often mild onset led many to consider these patients “hysterical” [1]. Marsden’s case series [2] was the first to describe a large cohort of these patients and classify them according

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to clinical phenotype. Recognition of a disease must necessarily precede treatment, and clearly describing the phenotypes of facial dystonia laid the groundwork for subsequent surgical and medical treatments. Firstly, Marsden described the epidemiology of facial dystonia, in that the disease had a female preponderance and typically presented in the sixth decade of life; patients often experience symptoms for years prior to formal diagnosis. Secondly, Marsden described the frequency and severity of the eyelid spasms, which could be as frequent as every 15 seconds and last as long as 20 minutes at a time. This creates significant functional disability, with patients unable to leave the house or cross the street. Symptoms were also provoked by sunlight, television, or reading. Finally, Marsden noted that psychological comorbidity was high, recognizing that the psychological aspects of the disease were as important as the neurologic. Laboratory and radiologic investigation was negative, as is common these patients. Marsden suggests that patients oromandibular dystonia may have Brueghel’s syndrome, although a distinction between spastic jaw opening (Brueghel’s) and spastic jaw closure with mouth pursing (Meige syndrome) can be drawn, which may have prognostic or therapeutic implications [3]. However, the majority of Marsden’s observations regarding the phenotype of disease and the association with oromandibular dystonia have been corroborated by subsequent literature, including the epidemiology [4], clinical course [5], and psychosocial aspects [6]. Current research is focused on understanding the pathogenesis [7, 8] and targeted therapy [9]. Goldstein and Cogan [10] further describe apraxia of eyelid opening (ALO) as a neurologic sign in its own right. Apraxia of the act of initiation of contraction of the levator palpebrae superioris muscle is difficult to diagnosis as this may be frequently confused with paralytic, myogenic, or neuromuscular junction disease. While the authors did not recognize the specific association of ALO with blepharospasm, Krack and Marion [11] subsequently described a cohort of 32 patients with ALO, of whom 20 had benign essential blepharospasm. In fact, they suggest that ALO, rather than being a completely separate sign, exists on the spectrum of orbicularis oculi dystonia and can also be treated with botulinum toxin. The recognition of ALO as a specific manifestation of blepharospasm has allowed relief for many of these patients who previously relied on sensory tricks or eyelid crutches. While the specifics of treatments are discussed later in this chapter, the initial recognition and description of these clinical syndromes was crucial in legitimizing the diagnosis of blepharospasm as a true neurologic disorder with frequent psychiatric comorbidities, rather than as a pure psychiatric condition in a disease with female preponderance. Radiography was also relatively primitive at that time, and subsequent functional imaging has added to our understanding of these disorders. Current evidence from animal models suggests that abnormal basal ganglia and cerebellar activity leads to an exaggerated response to triggers from the ocular surface; trigeminal nerve hyperexcitability may also play a role [7]. This triggered hyperreaction may then solidify into a constant dystonia. This hypothesis may have been foreshadowed by Marsden’s observation that many of these patients were observed to have blepharitis [2]. Ancillary treatments such as UV-blocking lenses and ocular surface treatment certainly have a role in reducing symptoms. Genetic

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counseling is also important as the disease has been shown to have a heritable component [12]. Finally, neural stimulation may have a role in reprogramming the established abnormal pathways that are a feature of the disease [9].Future research will undoubtedly focus on the molecular biology of the disease and hopefully, lead the way for more targeted therapy.

Strengths • Detailed clinical descriptions of blepharospasm, facial dystonia, and apraxia of eyelid opening with a large sample size. • Epidemiological insights have been corroborated in subsequent studies.

Weaknesses • At the time of publication of these studies, little treatment was available, and no outcomes analysis was possible. • Conflation of various neurologic syndromes of oromandibular dystonia may be confusing in the light of more recent literature.

One-Sentence Summary Benign essential blepharospasm is a neurologic disorder with potentially severe and disabling clinical and psychiatric manifestations.

References 1. Henderson JW (1956) Essential blepharospasm. Trans Am Acad Ophthall Soc 54:453–520 2. Marsden CD (1976) Blepharospasm-oromandibular dystonia syndrome (Brueghel’s syndrome). A variant of adult-onset torsion dystonia? J Neurol Neurosurg Psychiatry 39:1204–1209 3. Gilbert GJ (1996) Brueghel syndrome: its distinction from Meige syndrome. Neurology 46:1767–1769 4. Bradley EA, Hodge DO, Bartley GB (2003) Benign essential blepharospasm among residents of Olmsted county, Minnesota, 1976 to 1995: an epidemiologic study. Ophthal Plast Reconstr Surg 19:177–181 5. Czyz CN, Burns JA, Petrie TP, Watkins JR, Cahill KV, Foster JA (2013) Long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and Meige syndrome. Am J Ophthalmol 156:173–177.e2 6. Anderson RL, Patel BCK, Holds JB, Jordan DR (1998) Blepharospasm: past, present, and future. Ophthal Plast Reconstr Surg 14:305–317

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7. Evinger C (2015) Benign essential blepharospasm is a disorder of neuroplasticity: lessons from animal models. J Neuroophthalmol 35:374–379 8. Digre KB (2015) Benign essential blepharospasm – there is more to it than just blinking. J Neuroophthalmol 35:379–381 9. Baizabal-Carvallo JF, Alonso-Juarez M (2016) Low-frequency deep brain stimulation for movement disorders. Park Relat Disord 31:14–22 10. Goldstein JE, Cogan DG (1965) Apraxia of lid opening. Arch Ophthalmol 73:155–159 11. Krack P, Marion MH (1994) “Apraxia of lid opening,” a focal eyelid dystonia: clinical study of 32 patients. Mov Disord 9:610–615 12. Hammer M, Abravanel A, Peckham E, Mahloogi A, Majounie E, Hallett M, Singleton A (2019) Blepharospasm: a genetic screening study in 132 patients. Parkinsonism Relat Disord 64:315–318

Chapter 16

Treatment of Blepharospasm with Botulinum Toxin

Author(s) Frueh BR, Felt DP, Wojno TH, Musch DC Czyz, Craig N., Burns, John A., Petrie, Thomas P., Watkins, John R., Cahill, Kenneth V., Foster, Jill A.

Summary: Treatment of Blepharospasm with Botulinum Toxin Purpose  To describe the authors’ experience with botulinum A toxin injections for the treatment of facial dystonia. Design  A retrospective case series of patients who received botulinum toxin injections for benign essential blepharospasm (n = 22) and hemifacial spasm (n = 3). Of the 22 patients with blepharospasm, 3 patients had previous myectomy. Patients were treated with approximately 3.25 U of botulinum A toxin to each eyelid, 2 mm proximal to the eyelid margin and distributed across the length of the upper and lower eyelids, sparing the central third of the upper eyelid. Patients with hemifacial spasm were injected only on the eyelids ipsilateral to the facial spasm. The dose was increased as needed if patients did not have complete response. The posterior force vector of forced closure by blinking was measured with a force transducer attached to a scleral contact lens. Results  Of the 25 patients treated in total, all but one experienced symptomatic relief. This patient was subsequently reinjected in the brows and the orbital portion

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_16

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of the orbicularis, along with the eyelid margin, and obtained relief. Mean age was 57 years old (range 21–78), and there was a roughly 2:1 female preponderance. Patients experienced relief within 2–3 days, which lasted a mean of 10 weeks (range 2–20 weeks) for their first recurrence and 12 weeks for their second recurrence. Mean force of forced blink was reduced by a mean of 82% at a time point of 1–3 weeks after the injection. The mean force of forced blink was reduced by 41% at the time of recurrence of spasms, compared to the pre-injection force. Of the cohort, side effects included exposure keratitis (n = 10), ptosis (n = 10), and diplopia (n = 1). Marginal reflex distance-1 was decreased by 1–2.5 mm in patients who had ptosis. These side effects resolved after 1–6 weeks.

 bstract: Long-Term Botulinum Toxin Treatment of Benign A Essential Blepharospasm, Hemifacial Spasm, and Meige Syndrome Purpose: To report the clinical success and incidence of adverse events of repetitive botulinum toxin treatment of 15  years or greater. Design: Retrospective cohort study. Methods: The study sample consisted of 37 patients from a clinical practice, 11 male and 26 female. Inclusion criteria consisted of patients treated a minimum of 15 consecutive years for facial dystonia. Seven patients had hemifacial spasm, 4 Meige syndrome, and 26 benign essential blepharospasm. Main outcome measures consisted of treatment efficacy and adverse events. Results: Mean treatment duration was 19.4 years (SD 2.2) with an average of 62 (SD 22) treatments of 70.2 (SD 20.8) neurotoxin units. Mean duration of treatment efficacy was 127 days (SD 37) with a 5% physician-reported minor adverse event rate and no major adverse events over each patient’s clinical course. Patients reported no major and 20% incidence of minor adverse events over the treatment course. Conclusion: Results suggest that long-term botulinum toxin treatment produces clinical success in the alleviation of facial dystonia symptoms. Treatment produced a low incidence of major adverse events and minor adverse events. Previous studies may under-report clinical success and over-report adverse events because of study design.

Summary Purpose  To describe the authors’ long-term experience with botulinum toxin injection for facial dystonia. Design  A retrospective review of 37 patients who were treated for a minimum of 15 years for facial dystonia. Patients had benign essential blepharospasm (n = 26), hemifacial spasm (n = 7), and Meige syndrome (n = 4). Patients were excluded if

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they developed a condition that was a contraindication to botulinum toxin treatment (e.g., pregnancy, allergic reaction, neuromuscular junction disease) or had a gap in treatment for longer than 1 year. Patients were treated with received botulinum toxin A, with the exception of 30 total visits over 15 years where patients were treated with botulinum toxin B due to a temporary unavailability of Botox (Allergan, Dublin, Ireland). Dose and treatment interval was titrated over the three initial visits, and the fourth treatment was taken for analysis in this study. Results  37 patients were treated for at least 15 years for facial dystonia; mean age was 58.2 years at initial treatment, and there were 11 males and 26 females in the cohort. Mean duration of treatment was 19.4 years and 62 total treatments; mean treatment dose was 70.2  U over 10 treatment sites per visit, and mean interval between treatments was 127  days. Mean initial treatment dose was 69.6  U, and mean treatment dose at the most recent visit was 67.0 U, which was not statistically significant. There was no statistically significant change in treatment interval from the initial visits (mean 135 days) to the most recent visits (mean 140 days). Complications included physician-observed side effects (diplopia: 3%, ptosis: 2%) and patient-reported side effects (diplopia: 3%, ptosis: 7%, and nonspecific symptoms such as dry eye, photosensitivity, or eye pain: 10%) over all 2170 total treatment visits. There were significantly higher incidence (p 2 mm between eyelids. The following observations were made: 1. Mean age of hard CTL wearers was 38.5 years (range 18–56), with mean wearing time 15.2 years. Mean age of patients presenting with involutional ptosis was 69 years (range 48–88), which represents a significant difference in age distribution between the two populations. Intraoperatively, both groups were noted to have levator aponeurosis disinsertion. 2. The average MRD1 was 4.2 mm in controls and 3.7 mm in hard CTL wearers (p 135 mg/dL. Retrospective pathologic examination of orbital tissuebased on these criteria suggests that up to 50% of patients initially diagnosed as NSOI may meet Umehara’shistopathologic criteria for IgG4-related orbital disease on re-examination [13, 14]. However, the mere presence of these cells in the orbit does not necessarily mean the patient will exhibit classic clinical manifestations of IgG4-ROD, and it is as yet unclear if the IgG4 molecule is somehow pathogenic or merely a bystander. Most circulating IgG4+ plasma cells are polyclonal, suggesting they are not stimulated by a specific antigen [15]. IgG4 cannot activate the complement pathway and is not known to be an effector of inflammation [16]. IgG4+ plasma cells and serum IgG4 can also be elevated in inflammatory [17, 18] and neoplastic conditions [19] suggesting it is an acute phase reactant.In fact, reviews of patients with a diagnosis of ANCA-associated vasculitis [17, 20], Rosai-Dorfman [21], xanthogranulomatous disease [18, 22], and other chronic inflammatory conditions [19] have all demonstrated a mean IgG4+ plasma cell count >10/hpf. Deshpande et al. [23] provided an updated consensus statement to further refine the histopathologic criteria for the diagnosis of IgG4-related disease. Specifically, they focus on the presence of histopathologic morphologic changes including storiform fibrosis, obliterative phlebitis, and a dense lymphoplasmacytic infiltrate with IgG4+ plasma cells present at >50–100/hpf. Serum IgG4 levels are not considered, and the clinician is advised to keep in mind the entire clinical context. These narrower criteria decrease the number of orbital specimens retrospectively classified as IgG4-related from 50% to 5% [24]. However, Deshpande et al. [23] note that organ-­ specific histopathologic findings may overrule the established criteria – the orbit in particular need not exhibit storiform fibrosis or obliterative phlebitis. Clinical examination of patients with histopathologically suggestive IgG4-ROD does not reveal any difference in response to treatment [25], although high levels of IgG4+ plasma cells may be associated with a prolonged disease course [24]. Serum IgG4 levels decrease with corticosteroid administration, and a delay in decrease may suggest continued inflammation [26] but has no correlation to disease severity. There is a mixed response to steroids, and rituximab may be more effective than other agents [27]. However, histopathologic diagnosis with the updated criteria still does not accurately distinguish between IgG4-related orbital disease and other inflammatory orbital conditions [28]. In fact, the histological morphology of orbital disease in the presence of IgG4+ plasma cells is highly variable  – it can be

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sclerosing or non-sclerosing [29], and the presence storiform fibrosis or obliterative phlebitis is the exception, rather than the rule [16]. Furthermore, sclerosing orbital inflammation can be present with or without IgG4+ plasma cells [30]. If a disease does not have consistent histopathology or a unifying clinical finding, is it really a disease? IgG4+ plasma cells in the orbit are highly nonspecific, and orbital histology in diagnosed IgG4-ROD can diverge widely from systemic histologic findings in the same patient. In my opinion, our understanding of the pathophysiology of this condition has not evolved to the point where we can consistently distinguish IgG4-ROD from other inflammatory syndromes histologically. In fact, our current understanding of the orbital disease suggests that the IgG4+ cells are simply passengers in the underlying autoimmune process. However, certain clinical phenotypes such as sensory nerve enlargement [31] and an increased response to rituximab are unique and clinically relevant distinctions that suggest this is a real entity in some form or fashion. It is particularly important to identify these patients asthey may have an increased lifetime risk of non-Hodgkin’s lymphoma. Future research should focus on clarifying the pathophysiology of IgG4-ROD with its associated clinical and histopathologic manifestations, such that sensitive and specific standards are devised to identify this group of patients.

Strengths • Initial subtyping of clinical manifestations has been confirmed by multiple subsequent studies. • Narrower histopathologic criteria provide increased specificity in the diagnosis of IgG4-ROD.

Weaknesses • Noting that organ-specific findings need not conform to the established histopathologic criteria undermines the entire construct.

One-Sentence Summary Our understanding of IgG4-related orbital disease is rapidly evolving; much research has yet to be done to devise a sensitive and specific means of identifying these patients.

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Author Comment First, one of the interesting points pertaining to IgG4-RD is the excitement of participating in the identification and characterization of a “new” disease more than a decade after finishing my rheumatology training. IgG4-RD has been one ‘eureka’ moment after another, now more than a decade AFTER recognizing the condition. Second, the importance of questioning current diagnostic categories. For years, I had been referred patients with “orbital myositis” by ophthalmologists who anticipated that I would treat the patients with prednisone and cyclophosphamide because of the efficacy of that agent in the disease once called Wegener’s granulomatosis (now granulomatosis with polyangiitis), which also often causes orbital disease. I now realize that many of those patients had IgG4-related disease of the orbits. Third, and perhaps most important, is my peeve about the entity often still called “IOI” - idiopathic orbital inflammation. One cannot call something idiopathic if the work-up is incomplete, and the workup of this condition is general incomplete without a biopsy. These patients should NOT be put on glucocorticoids or any other treatment until a biopsy has been performed, unless the precise diagnosis is clear from other testing. – John Stone, MD, MPH

References 1. Pasquali T, Schoenfield L, Spalding SJ, Singh AD (2011) Orbital inflammation in IgG4-related sclerosing disease. Orbit 30:258–260 2. Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nikaido T, Nakayama K, Usuda N (2001) High serum IgG4 concentrations in patients with sclerosing pancreatitis. NEJM 344:732–738 3. Hagiya C, Tsuboi H, Yokosawa M et al (2014) Clinicopathological features of IgG4-related disease complicated with orbital involvement. Mod Rheumatol 24:471–476 4. Sogabe Y, Ohshima K-i, Azumi A, Takahira M, Kase S, Tsuji H, Hiroshi Yoshikawa TN (2014) Location and frequency of lesions in patients with IgG4-related ophthalmic diseases. Graefes Arch Clin Exp Ophthalmol 252:531–538 5. Sato Y, Ohshima KI, Ichimura K, Sato M, Yamadori I, Tanaka T, Takata K, Morito T, Kondo E, Yoshino T (2008) Ocular adnexal IgG4-related disease has uniform clinicopathology. Pathol Int 58:465–470 6. Ginat DT, Freitag SK, Kieff D, Grove A, Fay A, Cunnane M, Moonis G (2013) Radiographic patterns of orbital involvement in igg4-related disease. Ophthal Plast Reconstr Surg 29:261–266 7. Hardy TG, McNab AA, Rose GE (2014) Enlargement of the infraorbital nerve: an important sign associated with orbital reactive lymphoid hyperplasia or immunoglobulin G4-related disease. Ophthalmology 121:1297–1303 8. Tiegs-Heiden CA, Eckel LJ, Hunt CH, Diehn FE, Schwartz KM, Kallmes DF, Salomão DR, Witzig TE, Garrity JA (2014) Immunoglobulin G4-related disease of the orbit: imaging features in 27 patients. Am J Neuroradiol 35:1393–1397 9. Disease JSG of IO (2013) A prevalence study of IgG4-related ophthalmic disease in Japan. Jpn J Ophthalmol 57:573–579

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10. McNab AA, McKelvie P (2015) IgG4-related ophthalmic disease. Part I: background and pathology. Ophthal Plast Reconstr Surg 31:83–88 11. Yamamoto M, Takahashi H, Tabeya T et al (2012) Risk of malignancies in IgG4-related disease. Mod Rheumatol 22:414–418 12. Umehara H, Okazaki K, Masaki Y, et al (2012) Comprehensive diagnostic criteria for IgG4-­ related disease. 21–30 13. Deschamps R, Deschamps L, Depaz R et al (2013) High prevalence of IgG4-related lymphoplasmacytic infiltrative disorder in 25 patients with orbital inflammation: a retrospective case series. Br J Ophthalmol 97:999–1004 14. Plaza JA, Plaza JA, Garrity JA, Dogan A, Ananthamurthy A, Witzig TE, Salomão DR (2011) Orbital inflammation with IgG4-positive plasma cells. Arch Ophthalmol 129:421 15. Yamada K, Kawano M, Inoue R et al (2008) Clonal relationship between infiltrating immunoglobulin G4 (IgG4)-positive plasma cells in lacrimal glands and circulating IgG4-positive lymphocytes in Mikulicz’s disease. Clin Exp Immunol 152:432–439 16. Andrew N, Kearney D, Selva D (2013) IgG4-related orbital disease: a meta-analysis and review. Acta Ophthalmol 91:694–700 17. Chang SY, Keogh KA, Lewis JE, Ryu JH, Cornell LD, Garrity JA, Yi ES (2013) IgG4-positive plasma cells in granulomatosis with polyangiitis (Wegener’s): a clinicopathologic and immunohistochemical study on 43 granulomatosis with polyangiitis and 20 control cases. Hum Pathol 44:2432–2437 18. Verdijk RM, Heidari P, Verschooten R, Van Daele PL, Simonsz HJ, Paridaens D (2014) Raised numbers of IgG4-positive plasma cells are a common histopathological finding in orbital xanthogranulomatous disease. Orbit 33:17–22 19. Go H, Kim JE, Kim YA, Chung HK, Khwarg SI, Kim CW, Jeon YK (2012) Ocular adnexal IgG4-related disease: comparative analysis with mucosa-associated lymphoid tissue lymphoma and other chronic inflammatory conditions. Histopathology 60:296–312 20. Danlos FX, Rossi GM, Blockmans D et  al (2017) Antineutrophil cytoplasmic antibody-­ associated vasculitides and IgG4-related disease: a new overlap syndrome. Autoimmun Rev 16:1036–1043 21. Ferry JA, Klepeis V, Sohani AR, Harris NL, Preffer FI, Stone JH, Grove A, Deshpande V (2015) IgG4-related orbital disease and its mimics in a western population. Am J Surg Pathol 39:1688–1700 22. McKelvie P, McNab AA, Hardy T, Rathi V (2017) Comparative study of clinical, pathological, radiological, and genetic features of patients with adult ocular adnexal xanthogranulomatous disease, erdheim-chester disease, and IgG4-related disease of the orbit/ocular adnexa. Ophthal Plast Reconstr Surg 33:112–119 23. Deshpande V, Zen Y, Chan JKC et al (2012) Consensus statement on the pathology of IgG4-­ related disease. Mod Pathol 25:1181–1192 24. Andrew NH, Sladden N, Kearney DJ, Selva D (2015) An analysis of IgG4-related disease ( IgG4-RD ) among idiopathic orbital in fl ammations and benign lymphoid hyperplasias using two consensus-based diagnostic criteria for IgG4-RD. 376–381 25. Ryu G, Cho H-J, Lee KE, Lee JJ, Hong SD, Kim HY, Chung S-K, Dhong H-J (2019) Clinical significance of IgG4 in sinonasal and skull base inflammatory pseudotumor. Eur Arch Oto-­ Rhino-­Laryngol 1:3 26. Woo YJ, Kim JW, Yoon JS (2017) Clinical implications of serum IgG4 levels in patients with IgG4-related ophthalmic disease. Br J Ophthalmol 101:256–260 27. Detiger SE, Karim AF, Verdijk RM, van Hagen PM, van Laar JAM, Paridaens D (2019) The treatment outcomes in IgG4-related orbital disease: a systematic review of the literature. Acta Ophthalmol:1–9 28. Sweeney AR, Keene CD, Cimino PJ, Chang S-H (2019) IgG4-positive cell quantifica tion distinguishes between inflammatory and noninflammatory diseases of the orbit. Appl Immunohistochem Mol Morphol 00:1

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29. Tsai CY, Kuo KT, Cheng AMS, Wei YH, Chang HC, Chang K, Liao SL (2019) IgG4-related ophthalmic disease in idiopathic sclerosing and non-sclerosing orbital inflammation: a 25-year experience. Curr Eye Res 44:1220–1225 30. McCarthy JM, White VA, Harris G, Simons KB, Kennerdell J, Rootman J (1993) Idiopathic sclerosing inflammation of the orbit: immunohistologic analysis and comparison with retroperitoneal fibrosis. Mod Pathol 6:581–587 31. Elkhamary SM, Cruz AA V., Zotin MC, Cintra M, Akaishi P, Galindo-Ferreiro A, Alkatan HM, Chahud F (2020) Involvement of multiple trigeminal nerve branches in IgG4-related orbital Disease. Ophthalmic Plast Reconstr Surg Publish Ah. 176–178

Chapter 28

Extraocular Muscle Enlargement

Author(s) Patrinely, James R, Osborn, Anne G, Anderson, Richard L, Whiting, A Sidney Savino, Gustavo, Midena, Giulia, Tartaglione, Tommaso, Milonia, Luca, Caputo, Carmela Grazia, Grimaldi, Gabriela

 bstract: Computed Tomographic Features of Nonthyroid A Extraocular Muscle Enlargement While Graves’ disease is the most common cause of enlarged extraocular muscles, other disorders may masquerade as dysthyroid orbitopathy. The authors conducted a retrospective analysis of the computed tomographic (CT) scans of 60 patients with nonthyroid enlarged extraocular muscles to establish the differential radiographic features of these disorders. The diseases were classified as primary or local invasion of neoplasm (26%), inflammatory (25%), metastatic tumor (20%), vascular (13%), infection (12%), and acromegaly (3%). The inflammatory cases demonstrated more bilateral involvement (40%) and less involvement of the tendons (47%) than previously appreciated. The relatively high incidence of these features in the inflammatory group is important because both features have been considered pathognomonic for Graves’ disease. Primary and metastatic tumors produced a nodular muscle enlargement with sharp borders and frequent bone changes. Certain tumors showed a predilection for certain muscle groups. Vascular cases involved multiple unilateral muscles and usually enlarged the superior ophthalmic vein. Infectious cases usually demonstrated fusiform muscle enlargement with blurred margins, whereas acromegaly caused moderate enlargement of all recti. Although certain diagnosis-­specific radiographic patterns are described, no feature is pathognomonic for any disorder. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_28

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Summary Purpose  To describe the clinical features of patients with extraocular muscle (EOM) enlargement not related to thyroid orbitopathy. Design  A retrospective review of computed tomography (CT) with clinical data of all patients with extraocular muscle enlargement at a single center. Patients either had a histopathologic diagnosis or pathognomonic serologic and clinical features. Patients with diffuse nonspecific orbital inflammatory disease where excluded. Results  60 patients were identified with EOM enlargement unrelated to thyroid orbitopathy. Patients were classified into the following etiologies: 1. Neoplastic (46%)

(a) Primary or Locally Invasive (57%): the most common tumors were rhabdomyosarcoma, lymphoma, meningioma, and maxillary sinus tumors. Typically unilateral, with single muscle involvement (81% of these cases). There was not a strong predilection for particular muscles. Muscle enlargement typically spared the tendon, and the muscle bellies were quite large in diameter (often >11 mm). (b) Metastasis (43%): most commonly adenocarcinoma from breast or lung, followed by other sites. Typically unilateral (83%) and isolated to a single muscle (64%). Seems to show a predilection for the horizontal recti. Muscle bellies were enlarged, but less so than primary or locally invasive tumors (95% in patients 24 m (n = 63). Patients over 18 m of age increasingly required silicone intubation or dacryocystorhinostomy for cure. 2 patients >24 m required conjunctivodacrocystorhinostomy. The authors note that nearly 90% of patients respond well to conservative management by 13 m of age, but delay beyond 13 m results in a reduction in success rate for initial probing with multiple, more involved procedures being necessary in older patients.

Abstract: Endoscopic Laser-Assisted Lacrimal Surgery Since Sept. 1, 1989, we have successfully performed 20 video-endoscopic, transnasal, laser-assisted lacrimal procedures on 18 patients ranging in age from 3 to 88 years. This technique avoided a cutaneous scar and caused less surgical trauma and bleeding than that seen in conventional lacrimal surgery, which shortened postoperative recovery time and lessened postoperative pain. With minor modifications in surgical technique, both dacryocystorhinostomy and conjunctivodacryocystorhinostomy were performed with either the potassium titanyl phosphate or carbon dioxide lasers. The use of the video endoscope allowed laser surgery to be performed across a broad range of intranasal structural variations and provided an excellent medium for teaching this new technique.

Summary Purpose  To describe the authors’ experience with endoscopic lacrimal surgery.

Abstract: Comparison of External Dacryocystorhinostomy with Nonlaser Endonasal…

319

Design  A retrospective review of all patients who underwent endoscopic, laser-­ assisted lacrimal surgery by the authors. Surgical technique was as follows: 1. The nasal mucosa was packed with 4% topical cocaine. A light pipe was inserted through the canaliculi and used to illuminate the lacrimal sac. Local anesthetic was then injected into this area. 2. A CO2 or potassium titanyl phosphate (KTP) laser was used to ablate the mucosa and bone, to create an ostium of the desired size. 3. Silicone intubation (in the case of dacryocystorhinostomy) or Jones tube placement (in the case of conjunctivodacryocystorhinostomy) was performed. Silicone stents were left in place for 4–6 months. Topical antibiotics and intranasal steroids were given postoperatively. Results  20 patients underwent dacryocystorhinostomy (n = 15) or conjunctivodacryocystorhinostomy with Jones tube placement (n  =  5). One patient experienced Jones tube dislocation at one week postoperatively, requiring revisional surgery. All patients hard relief of symptoms and normal dye-disappearance testing after surgery.

 bstract: Comparison of External Dacryocystorhinostomy A with Nonlaser Endonasal Dacryocystorhinostomy Objective: We compared outcomes after dacryocystorhinostomies (DCRs) performed by the traditional external approach (EX-DCR) or by a nonlaser, nonendoscopic endonasal approach (EN-DCR). Design: Retrospective, nonrandomized, comparative interventional case series. Participants: A total of 354 consecutive cases of DCR were reviewed in 349 patients performed by one surgeon over a 4-year period with a minimum 1  year of follow-up using either EX-DCR or EN-DCR. Only patients with primary nasolacrimal duct obstruction and no eyelid, lacrimal sac, or canalicular pathology were included. Intervention: A total of 153 EX-DCR and 201 EN-DCR patients were identified. EX-DCR was performed under sterile conditions, and EN-DCR was performed with a clean setup. Silicone stents were placed for 3 months. Main Outcome Measures: Patency of the lacrimal system as assessed by history and irrigation. Outcomes were graded as full success, partial success, or failure. Operative durations and postoperative complications were recorded from hospital charts. Results: There was no significant difference in age or gender distribution between the two groups. The mean operative duration was 34.3 minutes for EX-DCR and 18.5 minutes for EN-DCR (P < 0.0001, t test). Full success was achieved in 90.2% of EX-DCRs and 89.1% of EN-DCRs. Partial success was recorded in 2.0% of EX-DCRs and 4.0% of EN-DCRs. The failure rate was 7.8% for EX-DCR and 7.0% for EN-DCR. There was no statistical significance between these outcomes with a two-sample test for equality of proportions with continuity correction (P < 0.914, power 80% for alpha 0.05 to detect a decreased

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success rate of 12%). Eleven of the failed cases in each group underwent revision EN-DCR surgery, with 90.9% success in each group. Epistaxis requiring perioperative nasal packing occurred in 7 (4.6%) EX-DCR patients and 11 (5.5%) EN-DCR patients. Wound complications in EX-DCR included bruising in four patients, localized infections in two patients, and punctal eversion in six patients. In EN-DCR, inadvertent incision of the periorbita occurred in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled during an EN-DCR. Five patients had an EX-DCR on one side and an EN-DCR on the other side. All five reported retrospectively that they preferred the endonasal approach. Conclusions: The EN-DCR approach is more rapid than the traditional external approach, has an equivalent surgical success rate, and was preferred by patients who had alternative techniques performed on opposite sides.

Summary Purpose  To compare outcomes after endoscopic versus external dacryocystorhinostomy (DCR). Design  A retrospective review of external versus endonasal DCR performed by the author with a minimum of 1 year follow-up. Patients were included if they had primary nasolacrimal duct obstruction. Patients were not randomized. Surgical technique was as follows: 1. External DCR: a 1.5 cm incision was created lateral to the medial canthus, and the bone exposed. A 10 mm osteotomy was created with a drill, and the lacrimal sac opened. The adjoining nasal mucosa was removed, and the sac flap was sutured to the periosteum of the osteotomy edge. Silicone stents were placed and skin was then closed. 2. Endonasal DCR: A light pipe was advanced through the canaliculi to the lacrimal sac, and an osteotomy created intranasally with rongeurs and ethmoid forceps. The sac was tented with the light pipe, and a U-shaped flap cut with a crescent blade and removed (Fig. 32.4). Silicone stents were placed, and nasal packs were not used. Results  349 patients were included in the study, with 153 patients undergoing external DCR and 201 endonasal DCR. 5 patients had external DCR on one side and endonasal DCR on the other side. Mean age was 60 years (range 7–92), with a 3:1 female preponderance. Mean operative time was 34 min for external and 18 min for endonasal DCR. Local anesthesia with sedation was well tolerated in both groups.

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Fig. 32.4  The 3-mm up-biting Kerrison rongeur is slid posterior to the ridge of bone formed by the internal portion of the frontal process of the maxilla and is used to nibble away the bone anteriorly and superiorly. The inset shows the light pipe tenting the underlying lacrimal sac mucosa nasally through the bony opening. A myringotomy knife or cataract crescent knife is then used to incise the mucosa at the anterior margins, allowing the flap to fold posteriorly. The flap can then be torn free with Rhotonmicropituitary forceps or with the ethmoid forceps. Reproduced with permission from Dolman [4].

Complete success was achieved in 90.2% of patients with external DCR and 89.1% of patients with endonasal DCR. Failure rate was 7.8% with external and 7.0% with endonasal DCR.  Revision was performed endonasally, and 90.9% achieved complete success on revision. Failure was observed to be due to bridging scars from the ostium to the middle turbinate in both approaches, and inadequate osteotomy in endonasal cases. Common complications in both groups included epistaxis which required packing (n = 1 in each group), and cheese-wiring of the canaliculi by the stent (4 patients with external and 3 patients with endonasal DCR).In external DCR, 4 patients had profound bruising, and 2 patients had surgical site infections. In endonasal DCR, 3 patients had emphysema of the orbit after nose-blowing due to a dehiscence in the lamina papyracea, 1 patient had transient diplopia for 3 weeks, and 1 patient had a presumed cerebrospinal fluid leak which resolved spontaneously. Patients who had both external and endonasal DCR preferred the endonasal approach due to decreased postoperative discomfort and the lack of skin incision.

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Relevance The treatment of epiphora was often neglected in the early days of oculoplastic surgery, as epiphora was seen as merely an “inconvenience”. However, constant tearing with or without superimposed infection can severely impact quality of life. Jones builds on his anatomic treatises of the lacrimal anatomy [5] to describe the causes and cures for epiphora [1]. Jones’ study has two parts. In the first, he describes the eponymous tests that allow identification of the level of obstruction in epiphora. The second details procedures targeted towards these specific causes for epiphora, including a method for punctoplasty, canalicular probing, and the conjunctivodacryorhinostomy with Pyrex tube placement. While the dye disappearance test has largely fallen into disuse today in favor of canalicular irrigation and even radiographic examination [6], Jones’ concept that the treatment of epiphora must be targeted to the level of obstruction is crucial. At the time, surgeons were often probing and dilating patients repeatedly regardless of the etiology of the epiphora, with poor rate of cure [7, 8]. The conjunctivodacryocystorhinostomy (CDCR), in particular, has largely remained unchanged in the present day such that the Pyrex tubes have now been named after Jones. Minor modifications today include the use of the endoscope, frosting on the Pyrex tubes to improve fixation, and simultaneous placement of the tubes with the rhinostomy [9]. Katowitz et al. [10] present their rich experience in the treatment of congenital dacryostenosis. The authors make two key findings. Firstly, conservative therapy can be effective in up to 90% of children less than 13 months of age. Secondly, the success of primary probing diminishes markedly as patients grow older, with a significantly increased need for more involved procedures such as silicone intubation, inferior turbinate infracture, or dacryocystorhinostomy (DCR) in older patients. The authors note that as the study was nonrandomized and patients were referred at various ages, exact parallels about the treatment response between groups is not possible. However, parents should be counseled that while conservative therapy is an excellent starting point for infants, probingalone without any ancillary procedures, if necessary, should be attempted prior to 13 months of age. Embryologically, the proximal nasolacrimal system canalizes before the distal [11], and up to 30% of infants are born with an imperforate valve of Hasner [12]. Katowitz et  al.’s analysis demonstrates that the large majority of these neonatal obstructions resolve without necessitating surgical intervention. Furthermore, simple probing without intubation or ancillary procedures is sufficient for most patients when undertaken in infancy. These results are corroborated by a subsequent analysis demonstrating that routine inferior turbinate infracture does not improve outcomes in congenital dacryostenosis [13]. However, Katowitz et al. do note that intranasal examination at the time of probing is mandatory as intranasal pathology must be ruled out; for this reason, and that of patient comfort, probing is preferably performed with a team experienced in pediatric anesthesia, rather than in the office. In adults, stenosis of the nasolacrimal duct requires marsupialization of the sac, and silicone intubation [14], balloon dilatation [8] or attempts to recanalize the duct

Relevance

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[15] have around a 50% success rate. This may be due to inflammation that is present along the whole length of the nasolacrimal duct in these cases [16]. These procedures also carry a risk of injury to the canaliculi, which is a much more difficult condition to treat compared to duct obstruction [17]. Modern external DCR was first described by Toti [18], and Dupuy-Dutemps published a case series of 1000 patients with a 94.8% success rate [19] by suturing sac flaps to the nasal mucosa. Caldwell [20] described the intranasal approach to the same anatomy, which also demonstrated an up to 90% success rate [21]. Despite comparable results and high success rates in the early literature, controversy exists over the preferred approach to DCR with more surgeons preferring the external approach [22] in a 2013 survey. Gonnering et al. [23] were among the first to champion the endoscopic, endonasal approach to DCR, achieving 100% success with a 5% revision rate in their pilot study. While the authors used a laser to create the ostium, others have used a drill [24] or simply rongeurs [25]. Dolman presents his single-surgeon, nonrandomized experience of external versus endonasal (although not endoscopic!) DCR, and finds a comparable and high success rate (90%) with both techniques. Moreover, there appears to be similar and acceptable rate of revision (7%) that responds well to revisional surgery. Comparison of literature rates of external versus endonasal DCR is thorny given the difference in techniques used, and a recent meta-analysis was inconclusive [26]. However, several conclusions can be drawn from their findings. Specifically, laser-­ assisted DCR may have a lower success due to induction of an inflammatory response, as observed in a randomized trial demonstrating 63% success for laser-­ assisted and 91% for external DCR [27]. However, retrospective reviews of laser-­ assisted DCR report much higher rates, from 82–100% [23, 28]. Transcanalicular laser-assisted DCR also has been reported to have an up to 97% success rate [29]. Comparison of external versus mechanical endonasal DCR revealed no significant difference in two studies by Ben Simon et al. [30] and Dolman [4]. The comparable success of external and endonasal DCR has also been demonstrated in the pediatric cohort [31]. Patients largely prefer the endonasal route due to decreased bruising and lack of a skin incision [32]. The role of silicone intubation is controversial [33], although most surgeons still place stents after surgery. Complications and failures are typically similar between groups, with several notable exceptions. Common causes of failure in both approaches are cicatricial closure, possibly due to inadvertent injury to adjacent nasal mucosa, or inadequate osteotomy. The latter may have been more prominent in early experience with endonasal DCR [4] as the oculofacial surgery field as a whole had to gain comfort with the intranasal and endoscopic anatomy. The former may be due to patient-specific biologic factors [34] or injury to the middle turbinate or nasal septum; antimetabolites do not necessarily increase rate of success in these instances [35, 36]. Serious complications are rare with both approaches. A unique and serious complication of external DCR is injury to the buccal branches that supply the orbicularis, which traverse that area and can result in postoperative lagophthalmos (Fig. 32.5) [37] and is seen in up to 7% of patients. A potentially fatal complication of endonasal DCR is injury to the skull base leading to a cerebrospinal fluid leak

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Fig. 32.5  Illustration of the facial nerve pathways at the anterior cheek showing three terminal motor nerves (lower palpebral branch, upper medial palpebral branch, and angular nerve) and their nerve sources (Z1, Z2, and B). The nerves running through the intramuscular or submuscular planes of the orbicularis oculi muscle are drawn over the muscle so that the pathways can more easily be understood. Z1 zygomatic branch crossing the zygoma body after passing under or over the origin of the zygomaticus major, Z2 zygomatic branch crossing the inferior portion of the zygomatic process of the maxilla, after traversing below the zygoma body under the zygomaticus major, B buccal branch below Z2 under the zygomaticus major, LLS levator labii superioris, ZM zygomaticus major, Zm zygomaticus minor, AN angular nerve, LPB lower palpebral branch; UmPB, upper medial palpebral branch; MC, medial canthus; IMP, inferior malar prominence. (Reproduced with permission from Choi et al. [39])

(Fig. 32.6) [38]; fortunately this is quite rare. Nevertheless, the surgeon must thoroughly review the involved anatomy prior to undertaking either approach. In view of the data, there seems to be little reason to prefer external DCR in the present day. Unless the relevant lacrimal anatomy is inaccessible due to an orbital implant, the endoscopic approach provides the rich visualization necessary to address not only the lacrimal duct but other intranasal pathology [40]. Both surgeries can be performed with local anesthetic and intravenous sedation. Early failures in endonasal DCR were largely due to inexperience with the technique and the anatomy, leading to inadequate osteotomy [4], or thermal injury from laser leading to increased rate of recurrence [29]. Surgeons can learn the procedure through focused cadaveric dissections and initial collaboration with otolaryngologists, although in the latter scenario the ophthalmologist is often relegated to placing stents at the end of the procedure [41]. When rhinologists can remove the entire maxilla, sinus contents, and approach the skull base endoscopically, creating a sufficiently wide ostium to expose the lacrimal sac should be consistently achievable

One-Sentence Summary Fig. 32.6  Coronal section demonstrating a fracture of the cribriform plate and attenuated floor of the anterior cranial fossa secondary to enlarging ethmoid air cell, arrow. (Reproduced with permission from Baylis et al. [38])

325 Cribriform plate

Orbit Ethmoid air cells

for the oculofacial surgeon. Finally, the patient experience is significantly better with endonasal DCR [42], and patients who have undergone both methods largely prefer the endonasal approach. Future studies can focus on more accurate diagnosis of the level of obstruction, non-surgical methods of intervention, and of course, the treatment of functional epiphora which may or may not resolve after DCR. Fortunately, the body of work presented above provides elegant and highly successful treatment options for the great majority of patients who present with epiphora.

Strengths • The concept of treating epiphora based on the location of obstruction is fundamental to modern lacrimal surgery. • CDCR technique is largely unchanged since its initial presentation. • Direct comparison of external and endonasal DCR suggests comparable efficacy.

Weaknesses • Surgeon technique may introduce bias as very few of studies are randomized.

One-Sentence Summary Treatment of epiphora depends on identifying the specific cause and location of obstruction, followed by targeted treatment to this area.

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Author Comment Lester Jones’ description of the conjunctivodacryorhinostomy procedure was not accepted initially, with objections being that the surgery “entirely [disregards]” his own anatomic descriptions of the delicate relationship of the orbicularis and Horner’s muscle to the canaliculi, with contemporaries suggesting that they “do not believe such canalicular obstruction requires such drastic surgery.” Jones replies, “Imagine! These fellows are buddies of mine! I know how Caesar felt when he said, ‘Et tu, Brute?’ First, I’d like to form a ‘Society for the Prevention of Cruelty to Canaliculi.’ Only too often we seem willing to attach a normal structure instead of the abnormal one that is the cause of the disease. A wife of a recent patient said, ‘Doctor, you will never know what a change the operation (glass tube) has made in my husband. It is the first time in three years I have seen him without a piece of Kleenex in his hand.’ Today is Columbus Day. It is said Columbus received similar treatment when he presented evidence of his success to the King and Queen. But the test of time was in his favor. I also am willing to submit the recommendations presented to you this morning to the test of time.” –Lester Jones, MD [1].

References 1. Jones LT (1962) The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol 66:506–524 2. Jones LT (2018) Conjunctivodacryocystorhinostomy. Am J Ophthalmol 187:xxxvi–xliv 3. Crigler L (1923) The treatment of congenital dacryocystitis. JAMA Ophthalmol 81:23–24 4. Dolman PJ (2003) Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology 110:78–84 5. Jones L, Wobig J (1976) Anatomy of the eyelids in surgery of the eyelids and lacrimal system. Aesculapius Publishing Co, Birmingham 6. Singh S, Ali MJ, Paulsen F (2019) Dacryocystography: from theory to current practice. Ann Anat 224:33–40 7. Hu X, Lin X, Ma G, Jin Y, Chen H, Chen X, Ye X, Qiu Y (2012) Two-Z-epicanthoplasty in a three-dimensional model of Asian eyelids. Aesthet Plast Surg 36:788–794 8. Konuk O, Ilgit E, Erdinc A, Onal B, Unal M (2008) Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction. Eye 22:1483–1487 9. Steele EA, Dailey RA (2009) Conjunctivodacryocystorhinostomy with the frosted Jones Pyrex tube. Ophthalmic Plast Reconstr Surg 25:42–43 10. Katowitz JA, Welsh MG (1987) Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 94:698–705 11. Schaeffer J (1912) The genesis and development of the nasolacrimal passages in man. Am J Anat 13:1–24 12. Sjögren H (1955) The lacrimal secretion in newborn premature and fully developed children. Acta Ophthalmol 33:557–560 13. Attarzadeh A, Sajjadi M, Owji N, Talebnejad MR, Farvardin M, Attarzadeh A (2006) Inferior turbinate fracture and congenital nasolacrimal duct obstruction. Eur J Ophthalmol 16:520–524

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14. Bleyen I, Paridaens A (2008) Bicanalicular silicone intubation in acquired partial nasolacrimal duct obstruction. Bull Soc Belg Ophthalmol 23:309–310 15. Chen D, Ge J, Wang L, Gao Q, Ma P, Li N, Li DQ, Wang Z (2009) A simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction. Br J Ophthalmol 93:1438–1443 16. Linberg JV, McCormick SA (1986) Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology 93:1055–1063 17. Anderson RL, Edwards JJ (1979) Indications, complications and results with silicone stents. Ophthalmology 86:1474–1487 18. Toti A (1904) Nuovo metodo conservatore di cura radicale delle suppurazioni croniche del sacco lacrimale (dacriocistorinostomia). Clin Mod Firenze 10:385–387 19. Dupuy-Detemps B (1921) Plastic operation for chronic Dacryocystitis. Bull Acad Med 86:293 20. Caldwell G (1893) Two new operations for obstruction of the nasal duct, with preservation of the canaliculi. Am J Ophthalmol 10:189–192 21. West J (1910) A window resection of the nasal duct. Trans Am Acad Ophthalmol Otolaryngol 12:654–658 22. Barmettler A, Erlich J, Lelli G (2013) Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit 32:20–26 23. Gonnering RS, Lyon DB, Fisher JC (1991) Endoscopic laser-assisted lacrimal surgery. Am J Ophthalmol 111:152–157 24. Chisty N, Singh M, Ali MJ, Naik MN (2016) Long-term outcomes of powered endoscopic dacryocystorhinostomy in acute dacryocystitis. Laryngoscope 126:551–553 25. Tsirbas A, Wormald PJ (2003) Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol 87:43–47 26. Sobel RK, Aakalu VK, Wladis EJ, Bilyk JR, Yen MT, Mawn LA (2019) A comparison of endonasal dacryocystorhinostomy and external dacryocystorhinostomy: a report by the American Academy of ophthalmology. Ophthalmology 126:1580–1585 27. Hartikainen J, Antila J, Varpula M, Puukka P, Seppä H, Grénman R (1998) Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 108:1861–1866 28. Woog JJ, Metson R, Puliafito CA (1993) Holmium:YAG endonasal laser dacryocystorhinostomy. Am J Ophthalmol 116:1–10 29. Mor JM, Matthaei M, Schrumpf H, Koch KR, Bölke E, Heindl LM (2018) Transcanalicular laser dacryocystorhinostomy for acquired nasolacrimal duct obstruction: an audit of 104 patients 11 medical and health sciences 1103 clinical sciences. Eur J Med Res 23:1–7 30. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA (2005) External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 112:1463–1468 31. Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, Re M (2015) The outcomes of endoscopic dacryocystorhinostomy in children: a systematic review. Int J Pediatr Otorhinolaryngol 79:947–952 32. Ozer S, Ozer PA (2014) Endoscopic vs external dacryocystorhinostomy-comparison from the patients’ aspect. Int J Ophthalmol 7:689–68996 33. Okuyucu S, Gorur H, Oksuz H, Akoglu E (2015) Endoscopic dacryocystorhinostomy with silicone, polypropylene, and T-tube stents; randomized controlled trial of efficacy and safety. Am J Rhinol Allergy 29:63–68 34. Sobel RK, Carter KD, Allen RC (2014) Bilateral lacrimal drainage obstruction and its association with secondary causes. Ophthal Plast Reconstr Surg 30:152–156 35. Xue K, Mellington FE, Norris JH (2014) Meta-analysis of the adjunctive use of mitomycin c in primary and revision, external and endonasal dacryocystorhinostomy. Orbit 33:239–244 36. Ragab SM, Elsherif HS, Shehata EM, Younes A, Gamea AM (2012) Mitomycin c-enhanced revision endoscopic dacryocystorhinostomy: a prospective randomized controlled trial. Otolaryngol Head Neck Surg (United States) 147:937–942

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37. Vagefi MR, Winn BJ, Lin CC, Sires BS, LauKaitis SJ, Anderson RL, McCann JD (2009) Facial nerve injury during external dacryocystorhinostomy. Ophthalmology 116:585–590 38. Neuhaus RW, Baylis HI (1983) Cerebrospinal fluid leakage after dacryocystorhinostomy. Ophthalmology 90:1091–1095 39. Choi Y, Kang HG, Nam YS, Kang J-GG, Kim I-BB (2017) Facial nerve supply to the orbicularis oculi around the lower eyelid: anatomy and its clinical implications. Plast Reconstr Surg 140:261–271 40. Ali MJ, Psaltis AJ, Wormald PJ (2015) The frequency of concomitant adjunctive nasal procedures in powered endoscopic dacryocystorhinostomy. Orbit 34:142–145 41. Chen S, Le CH, Liang J (2016) Practice patterns in endoscopic dacryocystorhinostomy: survey of the American Rhinologic society. Int Forum Allergy Rhinol 6:990–997 42. Miyake MM, Gregorio LL, Freitag SK, Lefebvre DR, Gray ST, Holbrook EH, Bleier BS (2016) Impact of endoscopic dacryocystorhinostomy on sinonasal quality of life. Am J Rhinol Allergy 30:e189–e191

Chapter 33

Microbiology of Lacrimal Infection

Author(s) Kaliki, Swathi, Ali, Mohammad Javed, Honavar, Santosh G., Chandrasekhar, Garudadri, Naik, Milind N. Baskin, Darrell E., Reddy, Ashvini K., Chu, Yvonne I., Coats, David K. Bharathi, M. J., Ramakrishnan, R., Maneksha, V., Shivakumar, C., Nithya, V., Mittal, S.

 bstract: Primary Canaliculitis: Clinical Features, A Microbiological Profile, and Management Outcome PURPOSE:: To describe the demographic profile, clinical presentation, microbiological profile, and management outcome of primary canaliculitis. METHODS:: Single-center, retrospective, interventional case series. Clinical records of all patients diagnosed with primary canaliculitis and treated at the Department of Ophthalmic Plastic Surgery, LV Prasad Eye Institute, Hyderabad, India, between 1987 and 2010 were reviewed. Retrospective data analysis included demographic profile, clinical presentation, microbiological profile, and management outcomes. The management outcome was further analyzed regarding conservative medical treatment alone, versus punctoplasty with canalicular curettage. RESULTS:: Of the 74 patients, 40 (54%) were women. Mean age at presentation was 48 years. Right eye was involved in 38 (51%) patients, left eye in 34 (46%) patients, and both eyes in 2 (3%) patients. The mean delay in diagnosis was 10 months. Lower canaliculus was involved in 48 (65%) patients, upper canaliculus in 17 (23%) patients, and both canaliculi in 9 (12%) patients. The most common presenting symptom was epiphora, noted in 63 (85%) patients, and the most common clinical sign was thickening © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_33

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of canalicular portion of eyelid seen in 53 (72%) patients. Microbiological workup was available in 54 patients, of whom 49 (91%) yielded positive results. The most common isolate was staphylococcus species in 19 (39%) patients. Conservative medical therapy (punctal dilatation, canalicular expression, and topical antibiotics) resulted in resolution in 35 of 51 (69%) patients, whereas punctoplasty with canalicular curettage resulted in resolution in all 39 (100%) patients. Of the 74 patients, 57 (70%) resolved completely with single intervention, 14 (19%) with 2 interventions, 6 (8%) with 3 interventions, and 2 (3%) with 4 interventions. Recurrence was noted in 2 (3%) patients that subsequently resolved with treatment. CONCLUSION:: Primary canaliculitis is predominantly a unilateral disease with a significant delay in diagnosis. The microbiological profile of canaliculitis is evolving, with staphylococcus species emerging as the most common pathogen. Although conservative medical therapy is beneficial, punctoplasty with canalicular curettage combined with topical antibiotic therapy is the gold standard treatment for canaliculitis.

Summary Purpose  To describe the clinical profile, microbiology, and management of primary canaliculitis. Design  A retrospective review of all patients diagnosed with primary canaliculitis. Patients were initially treated with conservative medical therapy, with punctal dilation and manual expression of canalicular contents. Surgical intervention was performed with a 3-snip punctoplasty followed by curettage with a chalazion curette (Fig. 33.1). Patients in both groups were prescribed 0.3% ciprofloxacin drops. a

b

c

d

e

f

Fig. 33.1  External photograph showing the milking of the canaliculus (a). A punctoplasty being performed (b). Canalicular curettage of concretions (c). Clinical presentation with upper eyelid swelling (d). Smears with gram stain showing Nocardia (e). Positive culture growth in blood and chocolate agar for staphylococcus species (f). (Reproduced with permission from Kaliki et al. [1])

Summary

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Results  74 patients were identified with primary canaliculitis. 54% were female and mean age was 48 years (range 8–80 years). Right and left eyes were equally involved, and 3% of disease was bilateral. Disease was predominantly in the lower canaliculus (65%), followed by the upper (23%) and both (12%). Most common symptoms were epiphora (85%), eyelid swelling (32%), and pain (27%). 3% of patients were asymptomatic. Commonly observed signs were eyelid marginal thickening over the canaliculus (72%), reflux of canalicular contents (36%), pouting punctum (34%), and a firm, nontender nodule (14%). Bacteria were isolated in 91% of patients cultured. Species isolated were Staphylococcus spp. (39%), Streptococcus spp. (29%), Actinomyces spp. (20%), and less commonly Corynebacterium, Pseudomonas, Nocardia, Propionibacterium, and others. Conservative therapy was performed in 69% of patients; 59% of these underwent complete resolution. 96% of patients who had surgical intervention resolved, with 4% requiring an additional curettage. 70% of patients had complete resolution with a single intervention. 2 patients had recurrence after 3 months, with resolution after curettage.

 bstract: The Timing of Antibiotic Administration A in the Management of Infant Dacryocystitis Purpose: To report (1) the prevalence of bacteremia among infants with dacryocystitis and (2) the influence of timing of antibiotic administration on the need for repeat probing in the management of these patients. Methods: A retrospective analysis of the hospital records of 25 infants ≤6 weeks of age treated for acute dacryocystitis was conducted, including analysis of laboratory data and outcomes. Results: Of 22 infants who underwent blood cultures, 5 (22.7%) were bacteremic. Twenty-­one of the 25 infants underwent nasolacrimal duct probing. Infants who received preoperative antibiotics were less likely to require a repeat probing than those who did not (6% vs. 80%), and this difference was statistically significant (p  =  0.004). Conclusions: The high rate of bacteremia in this series of patients and the significantly lower incidence of repeat probing among infants who received preprocedural antibiotics suggests that blood cultures and subsequent administration of intravenous antibiotics should be considered prior to probing of infants with dacryocystitis.

Summary Purpose  To describe the clinical profile of neonatal dacryocystitis. Design  A retrospective review of the clinical and microbiologic data in patients who presented with neonatal dacryocystitis (at age 6 weeks or younger).

332

33  Microbiology of Lacrimal Infection

100 90 80

Percent (%)

70 60 50 40 30 20 10 0 Probed with < 1 day of prior systemic antibiotics Successful first probe

Probed with > 1 day of prior systemic antibiotics Unsuccessful first probe

Fig. 33.2  Duration of systemic antibiotic therapy before probing. (Reproduced with permission from Baskin et al. [2])

Results  25 neonates were identified, of whom 15 were female. Mean age was 16 days (range 4–42 days). Patients initially presented with cellulitis and dacryocystocele (36%), and very few (16%) were febrile. 22.7% of neonates were bacteremic, predominantly growing coagulase-negative Staphylococcus and other Gram-positive organisms. Ocular cultures predominantly grew alpha-hemolytic Streptococci and Gram-negative organisms. One patient had evidence of meningitis with pleocytosis on lumbar puncture, but a negative culture. All patients were hospitalized and treated with intravenous antibiotics. 84% went nasolacrimal duct probing; patients who received antibiotics for at least 24 hours prior to proving were significantly more likely to have successful resolution with a single procedure (80% vs 6%) (Fig. 33.2). Patients who were not probed achieved rapid resolution of the infection with antibiotics, and were followed conservatively. Probing at the bedside was less successful than that performed in the operating room (69% vs 100%).

 bstract: Comparative Bacteriology of Acute A and Chronic Dacryocystitis Aims: To compare the bacterial aetiology and their in vitroantibacterial susceptibilities of acute and chronic dacryocystitis. Methods: A retrospective analysis of patients with clinically diagnosed acute and chronic dacryocystitis who underwent

Summary

333

microbiological evaluation presenting between January 2000 and December 2005 was carried out. Mucopurulent discharge through punctum, pus from burst abscess, incision drainage, and lacrimal sac content were taken and subjected to microbiological evaluation. Results: A total of 1891 patients of dacryocystitis were evaluated and subjected to microbiological evaluation, of which 566 (29.9%) had acute dacryocystitis and 1325 (70.1%) had chronic dacryocystitis. Of 1891 eyes, 1518 (80.3%) had pure bacterial growth and the remaining 373 (19.7%) had no growth. The percentage of culture-positivity was found to be higher in chronic dacryocystitis (90%) than in acute dacryocystitis (57.4%) (P  3 cm (80% for BCC, 50% for SCC). Location of the malignancy did not have a significant effect on the cure rate. Higher grade was also associated with increased risk of recurrence.

Relevance Frederic Mohs’ serendipitous discovery of zinc chloride as a paste that devitalized and coagulated basal or squamous cell carcinomas, without destroying cellular architecture and allowing subsequent histopathologic examination, would revolutionize the management of cutaneous malignancies thereafter [1]. However, this “fixed tissue technique” required multiple days for complete removal of the cancers, as the zinc chloride paste took 18 hours to adequately destroy the malignant tissue. The paste was also painful and caused significant inflammation. Mohs’ subsequent description of the “fresh tissue technique”, as popularized by Tromovitch [2], allowed the infiltration of local anesthetic and histopathologic examination of the tissue in 1 hour [3]. In this study, Mohs reports a 98% and 98.1% 5-year cure rate for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), respectively. The “fresh tissue technique” also allowed primary closure if necessary, which is particularly important in the periocular region. Mohs’ initial studies were limited, although his aspirations were much broader. Mohs intended for his technique to be useful for many subspecialties, including dermatology, oculoplastics, plastic surgery, and others [5], although dermatologists were the group to truly champion and establish Mohs micrographic surgery (MMS) as the standard-of-care for the management of cutaneous malignancies [6]. The majority of patients were left to granulate with secondary intention healing in Mohs’ initial studies [3]. While this could result in cosmetically excellent results in the medial canthus or other locations, the mobile eyelids risk loss of function if left to granulate, and primary closure can be beneficial [4] (Figs. 35.1 and 35.2). Mohs’ initial study does not specifically report complications, and subsequent studies report a 1–2% risk of hematoma, infection, or wound dehiscence [7, 8]. The incidence of eyelid-specific complications such as ectropion, lagophthalmos, canthal phimosis, notching, trichiasis, or others is not precisely known due to variation in surgeon technique, but is estimated to be from 10% to 14% of patients [9] (Fig. 35.3). Perhaps in response to this, numerous techniques for reconstruction have been developed for the reconstruction of post-MMS defects, which will be reviewed in the next chapter of this book. Particularly in the face and periocular area, the concept of facial aesthetic

Relevance

353

Fig. 35.1  Patient after Mohs micrographic surgery for basal cell carcinoma of the medial canthus. (Reproduced with permission from Baylis et al. [4])

Fig. 35.2  Patient from Fig. 35.1, 10 weeks after plastic reconstruction of the medial canthal defect. (Reproduced with permission from Baylis et al. [4])

subunits has been crucial to devising optimal reconstructive strategies that restore form and function [10]. Mohs’ technique was certainly not without detractors. Sidney Fox, in 1976, called it a “dying-if not already dead modality” [11]. Particular areas of controversy include the adequacy of the fixation compared to conventional frozen sections, problems with multifocal tumors, the need for multiple surgeons, tissue orientation problems, and the fact that histopathologic analysis is performed by a reader who may not have completed a full pathology training program [12]. The question of what exactly sets MMS apart from traditional frozen section analysis has also been raised, as in principle, frozen section analysis can provide intraoperative margin analysis similar to the MMS procedure [13]. Proponents of MMS argue that the unique sectioning of Mohs’ technique allows for analysis of 100% of the margins of a particular specimen, compared to 10 mm in size, or have been present for >6 months carry the highest risk of metastasis and mortality.Thirdly, specific histopathologic patterns carry a higher rate of mortality – these include undifferentiated cells, pagetoid spread, and invasion of lymphatic and vascular channels. Finally, the authors describe carcinomatous changes of the overlying conjunctival and even corneal epithelium, leading to a chronic inflammatory reaction that could manifest as chronic, unilateral blepharoconjunctivitis (Fig. 37.1). This presentation often led to delay in diagnosis and an increased risk of mortality. These findings provide valuable prognostic information for clinicians in counseling patients with sebaceous cell carcinoma. Several other groups have also published their experience with the disease. A compilation of 156 cases from Shanghai [2] describes a similar age and distribution with upper eyelid predominance. The authors note that these lesions were commonly misdiagnosed as chalazia, cysts, or papillomas; they also divide the lesions into histological subtypes including squamoid (most common), differentiated, basaloid, adenoid, and spindle cell types. Basaloid subtype carried the highest mortality rate, followed by squamoid. Patients with primary wide excision without recurrence had the highest survival, while patients who required exenteration or multiple excisions had the highest mortality.Shields et al. [3] also present their experience, noting Fig. 37.1 Conjunctival epithelium is replaced with neoplastic cells presenting a similar picture to carcinoma in situ of the conjunctiva. (Reproduced with permission from Rao et al. [1])

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37  Sebaceous Carcinomas of the Ocular Adnexa: A Clinicopathologic Study of 104…

that referred patients had an initial clinical diagnosis of blepharoconjunctivitis (25%), chalazion (20%), basal cell carcinoma (13%), or squamous cell carcinoma (10%). Furthermore, histopathologic diagnosis was sebaceous cell carcinoma only 50% of the time. They also note that pagetoid spread was associated with a higher risk for exenteration, but not a higher risk of metastasis [4]. A national study from the United States notes a 75% 5-year overall survival rate for patients with ocular adnexal involvement, and a 6X higher rate of developing sebaceous cell carcinoma for Asians/Pacific Islanders [5]. Finally, human immunodeficiency virus has been linked to the development of sebaceous cell carcinoma [6]. Mortality has improved with modern management of sebaceous cell carcinoma, with increased accuracy of histopathologic diagnosis [8] and more effective adjuvant techniques [7] (Fig.  37.2). Neoadjuvant chemotherapy has anecdotally been observed to downstage tumors and allow globe-preservation in the resection of these lesions [9], with reduction in tumor diameter by a mean of 74% [10]. Wide excision with margin control is current standard-of-care, and surgeons must be aware that pagetoid spread, multicentric location, or large tumors specifically increase the risk of recurrence and may necessitate wider margins, map biopsies, and closer follow-up [11]. Random map biopsies may not be high-yield, although targeted conjunctival biopsy to suspicious areas, and particularly in patients with pagetoid spread [12]. Mohs surgery may be a feasible option for localized disease, although this is still controversial given the risk of skip lesions and pagetoid spread [13]. The role of sentinel lymph node biopsy is controversial, with an up to 13% positivity rate [14]; there may be higher false negatives from eyelid lesions, and lesions >10 mm in diameter have a higher risk for positivity [15]. Adjuvant radiation therapy can also be helpful [16, 17], particularly in cases with perineural invasion [18] (Fig. 37.3). Metastatic disease can be discovered as late as 5 years after initial treatment [19]. Radical surgery with neck dissection [20] and adjuvant chemotherapy [19] and even biologic therapy with immune checkpoint inhibitors [21] have been used for metastatic disease with variable effect. Mortality rate still remains high due to the severity of the illness.The improved recognition of disease in recent years, both in the clinic and under the pathologist’s microscope have certainly allowed earlier diagnosis and treatment which can improve prognosis. Current research into the molecular biology of sebaceous cell carcinoma has enhanced our understanding of disease pathogenesis and yielded promising targets for intervention [22]. As with other fields within oncology, future research must identify molecular targets for intervention, as well as focus on immune response to cancer cells to provide next-generation therapies that will improve outcomes in this aggressive cancer.

Relevance

371

a

b

c

d

e

f

g

h

Fig. 37.2 (a) Tigroid appearance of sebaceous cell carcinoma in the right upper eyelid with lipid material in the meibomian ducts. (b) The tigroid appearance of papillary hypertrophy against a yellow background. (c) A 52-year-old woman with sebaceous cell carcinoma presenting as ulceration of the right upper eyelid required wide excision. Four years later, she developed metastatic disease to the regional lymph nodes. She underwent parotidectomy, neck dissection, and radiotherapy and had done well without recurrence for 5 years. She died of unrelated causes after 9 years of followup. (d) Sebaceous cell carcinoma presenting as a nodular lesion of the right lower eyelid in a 62-year-old man. The tumor was well differentiated without pagetoid spread. There has been no recurrence. (e) Right lower eyelid ectropion in a 51-year-old woman with sebaceous cell carcinoma that was misdiagnosed as contact dermatitis. Well-differentiated sebaceous cell carcinoma with pagetoid spread was present. Recurrence occurred medially. Further excision and reconstruction was performed. A Jones tube was inserted 5 years later. The patient has done well for the last 9 years without further recurrence. (f, g) A 61-year-old woman presented with unilateral blepharoconjunctivitis. The right upper eyelid was thickened and erythematous with diffuse conjunctival involvement. (h) Well-differentiated sebaceous cell carcinoma with pagetoid spread along the conjunctiva (hematoxylin-eosin, ×50). Exenteration of the right orbit with osseointegration was performed. There has been no recurrence for 12 years. (Reproduced with permission from Song et al. [7])

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37  Sebaceous Carcinomas of the Ocular Adnexa: A Clinicopathologic Study of 104…

Fig. 37.3 Sebaceous carcinoma with marked pleomorphism and vacuolated cytoplasm enveloping a large subcutaneous nerve (hematoxylin-eosin, ×200). (Reproduced with permission from Connor et al. [18])

Strengths • Detailed histopathologic classification provides clear risk factors for worsened mortality. • Corroborated by multiple contemporary and subsequent analyses.

Weaknesses • Little robust outcomes data given the lack of randomized or controlled trials for sebaceous cell carcinoma.

One-Sentence Summary Sebaceous cell carcinoma is associated with a high rate of recurrence and mortality; prompt diagnosis and aggressive surgery provide the best chance of cure.

Author Comment When I joined the faculty in 1978, I saw a clinic patient with sebaceous cell carcinoma; literature review at that time did not reveal much about prognostic factors and I was curious to know more. That led to my collaboration with the Armed Forces Institute of Pathology to answer this question. We had an idea that the incidence of sebaceous cell carcinoma was higher in the upper eyelids because of the increased

References

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number of glands. I was surprised to find that the mortality was much lower in the lower eyelids. I asked an oculoplastic surgeon, Dr. Barniak, and he theorized that surgeons may be more aggressive with surgical margins with the lower eyelids compared to the other. I still don’t have an exact explanation for this. This field is not as advanced compared to a tumor like melanoma due to its rarity. However, advances in diagnosis have led to improved outcomes – I rarely see a misdiagnosed sebaceous tumor on my desk anymore. – Narsing Rao, MD

References 1. Rao NA, Hidayat LCAA, McLean LCIW, Zimmerman LE (1982) Sebaceous carcinomas of the ocular adnexa: a clinicopathologic study of 104 cases, with five-year follow-up data. Hum Pathol 13:113–122 2. Ni C, Searl SS, Kuo PK, Chu FR, Chong CS, Albert DM (1982) Sebaceous cell carcinomas of the ocular adnexa. Int Ophthalmol Clin 22:23–61 3. Shields JA, Demirci H, Marr BP, Eagle RC, Shields CL (2004) Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology 111:2151–2157 4. Chao AN, Shields CL, Krema H, Shields JA (2001) Outcome of patients with periocular sebaceous gland carcinoma with and without conjunctival intraepithelial invasion. Ophthalmology 108:1877–1883 5. Dasgupta T, Wilson LD, Yu JB (2009) A retrospective review of 1349 cases of sebaceous carcinoma. Cancer 115:158–165 6. Yen MT, Tse DT (2000) Sebaceous cell carcinoma of the eyelid and the human immunodeficiency virus. Ophthal Plast Reconstr Surg 16:206–210 7. Song A, Carter KD, Syed NA, Song J, Nerad JA (2008) Sebaceous cell carcinoma of the ocular adnexa: clinical presentations, histopathology, and outcomes. Ophthal Plast Reconstr Surg 24:194–200 8. Doxanas MT, Green WR (1984) Sebaceous gland carcinoma: review of 40 cases. Arch Ophthalmol 102:245–249 9. Gogia A, Pushker N, Sen S, Bakhshi S (2013) Avoidance of exenteration in orbital sebaceous gland carcinoma with neoadjuvant chemotherapy. Graefes Arch Clin Exp Ophthalmol 251:2479–2480 10. Kaliki S, Ayyar A, Nair AG, Mishra DK, Reddy VAP, Naik MN (2016) Neoadjuvant systemic chemotherapy in the management of extensive eyelid sebaceous gland carcinoma: a study of 10 cases. Ophthal Plast Reconstr Surg 32:35–39 11. Takahashi Y, Takahashi E, Nakakura S, Kitaguchi Y, Mupas-Uy J, Kakizaki H (2016) Risk factors for local recurrence or metastasis of eyelid sebaceous gland carcinoma after wide excision with paraffin section control. Am J Ophthalmol 171:67–74 12. Sa HS, Tetzlaff MT, Esmaeli B (2019) Predictors of local recurrence for eyelid sebaceous carcinoma: questionable value of routine conjunctival map biopsies for detection of pagetoid spread. Ophthal Plast Reconstr Surg 35:419–425 13. Su C, Nguyen KA, Bai HX, Christensen SR, Cao Y, Tao Y, Karakousis G, Zhang PJ, Zhang G, Xiao R (2019) Comparison of Mohs surgery and surgical excision in the treatment of localized sebaceous carcinoma. Dermatologic Surg 45:1125–1135 14. Ho VH, Ross MI, Prieto VG, Khaleeq A, Kim S, Esmaeli B (2007) Sentinel lymph node biopsy for sebaceous cell carcinoma and melanoma of the ocular adnexa. Arch Otolaryngol Head Neck Surg 133:820–826

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15. Pfeiffer ML, Savar A, Esmaeli B (2013) Sentinel lymph node biopsy for eyelid and conjunctival tumors: what have we learned in the past decade? Ophthal Plast Reconstr Surg 29:57–62 16. Yen MT, Tse DT, Wu X, Wolfson AH (2000) Radiation therapy for local control of eyelid sebaceous cell carcinoma: report of two cases and review of the literature. Ophthal Plast Reconstr Surg 16:211–215 17. Deo SVS, Shukla NK, Singh M, Jha D, Khanna P, Kallianpur A (2012) Locally advanced sebaceous cell carcinoma (T3) of eyelid: incidence and pattern of nodal metastases and combined modality management approach. Orbit 31:150–154 18. Connor M, Droll L, Ivan D, Cutlan J, Weber RS, Frank SJ, Esmaeli B (2011) Management of perineural invasion in sebaceous carcinoma of the eyelid. Ophthal Plast Reconstr Surg 27:356–359 19. Husain A, Blumenschein G, Esmaeli B (2008) Treatment and outcomes for metastatic sebaceous cell carcinoma of the eyelid. Int J Dermatol 47:276–279 20. Bonavolontà P, Dell’Aversana Orabona G, Abbate V, Iaconetta G, Bonavolontà G, Califano L (2017) Treatment of metastatic eyelid carcinoma. J Craniofac Surg 28:1–3 21. Kodali S, Tipirneni E, Gibson PC, Cook D, Verschraegen C, Lane KA (2018) Carboplatin and pembrolizumab chemoimmunotherapy achieves remission in recurrent, metastatic sebaceous carcinoma. Ophthal Plast Reconstr Surg 34:e149–e151 22. Rigas PK, Kase S, Rao NA (2009) Expression of alpha-crystallins in human sebaceous carcinoma of the eyelid. Eur J Ophthalmol 19:702–707

Chapter 38

Orbital Adnexal Lymphoma

Author(s) Sullivan, Timothy John, Whitehead, Kevin, Williamson, Richard, Grimes, David, Schlect, David, Brown, Ian, Dickie, Graeme Bhatia, Sudershan, Paulino, Arnold C., Buatti, John M., Mayr, Nina A., Wen, B. Chen Pinnix, Chelsea C., Dabaja, Bouthaina S., Milgrom, Sarah A., Smith, Grace L., Abou, Zeinab Nastoupil, Loretta, Romaguera, Jorge, Turturro, Francesco, Fowler, Nathan, Fayad, Luis, Westin, Jason, Neelapu, Sattva, Fanale, Michelle A., Rodriguez, Maria A., Hagemeister, Frederick, Lee, Hun Ju, Oki, Yasuhiro, Wang, Michael, Samaniego, Felipe, Chi, Linda, Esmaeli, Bita

 bstract: Lymphoproliferative Disease of the Ocular Adnexa: A A Clinical and Pathologic Study with Statistical Analysis of 69 Patients Purpose: To evaluate the clinical features, treatment, and outcomes of a cohort of patients with ocular adnexal lymphoproliferative disease classified according to the World Health Organization modification of the Revised European-American Classification of Lymphoid neoplasms and to perform a robust statistical analysis of these data. Methods: Sixty-nine cases of ocular adnexal lymphoproliferative disease, seen in a tertiary referral center from 1992 to 2003, were included in the study. Lesions were classified by using the World Health Organization modification of the Revised European-American Classification of Lymphoid neoplasms classification.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 S. Ramesh, Foundational Papers in Oculoplastics, https://doi.org/10.1007/978-3-030-92794-3_38

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38  Orbital Adnexal Lymphoma

Outcome variables included disease-specific survival, relapse-free survival, local control, and distant control. Results: Stage IV disease at presentation, aggressive lymphoma histology, the presence of prior or concurrent systemic lymphoma at presentation, and bilateral adnexal disease were significant predictors for reduced disease-specific survival, local control, and distant control. Multivariate analysis found that aggressive histology and bilateral adnexal disease had significantly reduced disease-specific survival. Conclusions: The typical presentation of adnexal lymphoproliferative disease is with a painless mass, swelling, or proptosis; however, pain and inflammation occurred in 20% and 30% of patients, respectively. Stage at presentation, tumor histology, primary or secondary status, and whether the process was unilateral or bilateral were significant variables for disease outcome. In this study, distant spread of lymphoma was lower in patients who received greater than 20 Gy of orbital radiotherapy.

Summary Purpose  To describe the authors’ experience with ocular adnexal lymphoma. Design  A retrospective review of all patients with ocular adnexal lymphoma over 10  years. Clinical manifestations, treatment, and outcomes are reviewed. Classification [1], grading [2], and staging [3] were according to established protocols. Main Outcome Measures • Disease-specific survival (DSS): time to death due to cancer from date of diagnosis of lymphoma • Relapse-free survival (RFS): time to first local failure, distant failure, or death due to cancer. • Local control (LC): time to local failure, excluding death without local failure. • Distant control (DC): time to distant failure, excluding death without prior distant failure. Results  69 patients were identified with minimum 6-month follow-up. There was a female preponderance (56%). Median age was 66 years (range 11–90 years), and mean duration of symptoms prior to diagnosis was 7.4 months (range 1–55 months). Only 17% of patients were suspected to have lymphoma prior to referral to the authors’ practice. Common presenting signs were proptosis (70%), swelling (59%), mass (55%), inflammation (30%), salmon patch (20%), pain (19%), diplopia (14%), and vision loss (12%).Disease commonly involved the orbit (77%) with a predilection for the lacrimal gland (33%), extraocular muscles (13%), and conjunctiva (12%). Lymphoma was most commonly MALT (35%), follicular (22%), diffuse large B-cell (7%), CLL (6%), and NK/T-cell (6%). Reactive lymphoid hyperplasia

Abstract: Curative Radiotherapy for Primary Orbital Lymphoma

377

Ocular adnexal lymphoma

% SURVIVAL

100 90 80

81% (69-17) DSS

70

71% (69-14) DC

60

56% (69-11) DC 49% (69-9) RFS

50 40 30 20 10 0

12 69 69 69 69

53 47 44 43

24

36 MONTHS

38 31 27 24

29 22 20 17

48 24 18 16 13

60 17 14 11 9

95 % CI [69.1, 92.2] [58.5, 82.9] [42.7, 70.2] [35.1, 63.1]

Median S

32 Mths

Fig. 38.1  Kaplan-Meier curves for disease-specific survival, local control, distant control, and relapse-free survival. (Reproduced with permission from Sullivan et al. [4])

encompassed 13% of this cohort.Lesions were typically low-grade (67%) and either stage I (45%) or stage IV (29%). Periorbital disease was the first presentation of lymphoma in 53% of patients, and 14% later developed systemic disease.2 patients did not undergo periocular biopsy as they had known systemic, end-stagelymphoproliferative disease. Patients with systemic disease had a much higher mortality rate (31% versus 3%), as did patients with bilateral disease (33% versus 9%).On multivariate analysis, risk factors for better outcome were lower grade, unilateral or primary presentation, and low stage at presentation. Kaplan-Meier curves are given in Figs. 38.1 and 38.2.

 bstract: Curative Radiotherapy for Primary A Orbital Lymphoma PURPOSE: To review our institutional experience with primary orbital lymphoma and determine the prognostic factors for survival, local control, and distant metastases. In addition, we also analyzed the risk factors for complications in the radiotherapeutic management of this tumor. METHODS AND MATERIALS: Between 1973 and 1998, 47 patients (29 women [62%] and 18 men [38%], median age 69 years, range 32–89) with Stage IAE orbital lymphoma were treated with curative intent at one department. Five had bilateral orbital involvement. The tumor was located in the eyelid and extraocular muscles in 23 (44%), conjunctiva in 17 (33%),

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38  Orbital Adnexal Lymphoma

and lacrimal apparatus in 12 (23%). The histologic features according to the World Health Organization classification of lymphoid neoplasms was follicular lymphoma in 25, extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in 8, diffuse large B-cell lymphoma in 12, mantle cell lymphoma in 6, and peripheral T-cell lymphoma in 1. For the purposes of comparison with the existing literature on orbital lymphomas, the grading system according to the Working Formulation was also recorded. The histologic grade was low in 33 (63%),

% DISEASE SPECIFIC SURVIVAL

a

Ocular adnexal lymphoma - Histology 100 88% (59-16) Unil VOther

90 80 70 60 50 40

36% (10-1) Aggressive

30 20 10 0

12

24

36

48

60

23 1

16 1

MONTHS 59 10

% DISEASE SPECIFIC SURVIVAL

b

49 4

35 3

27 2

95 % CI [ 77, 99 ] [ 4, 67 ]

Median 8 Mths

Ocular adnexal lymphoma - Status 100

94% (37-10) Primary

90 80 70 60

65% (32-7) Secondary

50 40 30 20 10 0

12 37 32

30 23

24

36

MONTHS 22 17 16 12

48 15 9

60 10 7

95 % CI [83.9, 100.0] [ 44.9, 85.3 ]

Median S

Fig. 38.2  Kaplan-Meier curves showing decreased disease-specific survival with aggressive grade (a), secondary disease (b), bilateral disease (c), and higher stage at presentation (d). (Reproduced with permission from Sullivan et al. [4])

Abstract: Curative Radiotherapy for Primary Orbital Lymphoma

% DISEASE SPECIFIC SURVIVAL

c

Ocular adnexal lymphoma - Laterality 100 90 80

89% (52-14) Unilateral

70 60

54% (17-3) Bilateral

50 40 30 20 10 0

12 52 17

d % DISEASE SPECIFIC SURVIVAL

379

43 10

24

36 MONTHS

32 6

24 5

48 20 4

60 14 3

95 % CI [79.3, 98.2] [21.0, 87.5]

Median S

Ocular adnexal lymphoma - Stage 100

93% (31-7) S1

90 80 70 60 50

47% (20-4) S4

40 30 20 10 0

12 31 20

25 13

24

36 MONTHS

18 9

13 7

48 10 5

60 7 4

95 % CI [79.4, 100.0] [ 21.6, 73.0 ]

Median S 46 Mths

Fig. 38.2 (continued)

intermediate in 18 (35%), and high in 1 (2%). All patients were treated with primary radiotherapy alone. The median dose for low-grade tumors was 3000 cGy (range 2000–4020); the median dose for intermediate and high-grade tumors was 4000 cGy (range 3000–5100). A lens-sparing approach was used in 19 patients (37%). Late complications for the lens and cornea were scored according to the subjective, objective, management, and analytic (SOMA) scale of the Late Effects of Normal Tissue (LENT) scoring system. The median follow-up was 55  months (range 6–232). RESULTS: The local control rate was 100% in the 52 orbits treated. The 5-year overall survival and relapse-free survival rate was 73.6% and 65.5%,

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38  Orbital Adnexal Lymphoma

respectively. Tumor grade and location did not predict for overall survival or relapsefree survival. Seven patients (15%) developed distant recurrence (brain 2, extremity 2, mediastinum 1, liver 1, and retroperitoneum 1). One patient (2%) developed cervical node metastasis. The 5- and 10-year cataract-free survival rate was 56.7% and 32.9%, respectively. Of the 12 lens complications, 8 were LENT Grade 1 and 4 were Grade 3 toxicity. Only male gender predicted for an increased risk of cataract formation. Radiotherapy dose and technique did not predict for cataract formation; however, none of the patients who underwent the lens-sparing technique developed Grade 3 lens toxicity or required surgical correction. Of the nine corneal events, two were Grade 1, four Grade 2, and three were Grade 3 toxicity. Ten dry eyes were recorded; all were mild, and no patient had severe dry eye syndrome. Neovascular glaucoma was seen in 1 patient. No injury to the retina or optic nerve was reported. CONCLUSION: Radiotherapy alone is a highly effective modality in the curative management of primary orbital lymphoma. Most complications were minimal and did not require medical or surgical intervention. Although the use of the lens-­sparing technique did not influence the incidence of cataractogenesis, we continue to recommend this approach whenever possible, because our experience indicates a higher grade of toxicity occurs and a higher incidence of corrective surgery is needed in patients treated without lens protection.

Summary Purpose  To describe the authors’ experience with radiotherapy for primary orbital lymphoma. Design  A retrospective review of all patients with primary orbital lymphoma who were treated with radiotherapy. Initial biopsy was performed, and patients were treated with a median dose of 3000 cGy for low-grade tumors and 4000 cGy for intermediate- and high-grade tumors. A lens-sparing approach was used in 37% of patients. Clinical response and complications are reviewed. Results  47 patients (median age 69 years, 68% female) were identified. Lymphoma subtypes were follicular (48%), MALT (15%), diffuse large B-cell (23%), mantle cell (12%), and peripheral T-cell (2%). Patients presented with a mass (64%), proptosis (28%), swelling and redness (38%), and tearing (11%). Bilateral disease was found in 10% of patients. Tumors were in the eyelid or extraocular muscles (44%), conjunctiva (33%), and lacrimal gland (23%). 5-year overall survival was 73.6% and relapse-free survival was 65.5%. No significant differences were found in survival by tumor location or grade. Median relapse-free survival time was 7.1 years (high-grade) and 13.9 years (low-grade). No patients experienced local recurrence. Distant metastasis was observed in 15% at a median of 36 months after diagnosis.

Summary

381

Toxicity observed included cataract (n = 12), corneal ulceration (n = 3), and mild dry eye (n  =  10). The 5- and 10-year cataract-free survival rate was 56.7% and 32.9%, respectively. No patients experienced permanent vision loss, bony hypoplasia, retinopathy, or optic nerve damage.

 bstract: Ultra-Low-Dose Radiotherapy for Definitive A Management of Ocular Adnexal B-Cell Lymphoma Background: The purpose of this study was to report the response to and toxicity of ultra-low-dose radiotherapy (RT) for B-cell ocular adnexal lymphoma (OAL). Methods: We conducted a retrospective review of patients with indolent B-cell and mantle cell OAL treated with 4 Gy to the orbit(s) in two 2-Gy fractions. Disease response was assessed clinically and/or radiographically at 2 to 4-month intervals after RT. Data collected included rates of overall response, complete response (CR), partial response (PR), and treatment-related toxic effects. Results: Twenty-two patients (median age, 65  years) had the following histologic subtypes: mucosa-­ associated lymphoid tissue (MALT; 14 patients; 64%); follicular lymphoma (5 patients; 23%); mantle cell lymphoma (MCL; 2 patients; 9%); and unclassifiable (1 patient, 4%). The overall response rate was 100%; 19 patients (86%) had a CR and 3 patients (14%) had a PR. The only acute toxic effect was grade 1 dry eye syndrome in 1 patient. Conclusion: Ultra-low-dose RT in patients with OAL is associated with high response rates and minimal toxic effects, and is much shorter in duration and cost.

Summary Purpose  To describe the authors’ experience with ultra-low-dose radiotherapy for B-cell ocular adnexal lymphoma (OAL) Design  A retrospective review of all patients with low-grade B-cell and mantle cell OAL who had been biopsied. Patients were treated with ultra-low-dose radiotherapy, which consisted of 4Gy given in 2 2Gy fractions (Fig. 38.3). Lens shielding was not used. Imaging and clinical examination was performed at 2- to 4-month intervals. Main Outcome Measures  Overall response, complete response (CR), partial response (PR), and treatment toxicity. Results  22 patients with B-cell OAL were treated with the authors’ ultra-low-dose protocol. Median age was 64.5  years (range 25–88  years), and 54% were male.

382

38  Orbital Adnexal Lymphoma

a

b

c

d

Fig. 38.3  Complete response to ultra– low-dose orbital radiotherapy (RT) for mantle cell lymphoma (MCL) achieved 10 months after completion of RT. (a) A 70-year-old woman with stage IV MCL had a dominant enhancing left lacrimal gland mass measuring 2.631.5 cm on axial postcontrast CT imaging. (b) She was treated with 4Gy in 2 fractions with 16-MeV electrons. (c) She had a partial response to RT at 4 months after completion of RT. (d) She had a complete response to RT at 10.5 months after completion of RT without any interval treatment. (Reproduced with permission from Pinnix et al. [5])

Subtypes were MALT (64%), follicular (23%), and mantle cell (9%). 27% had bilateral disease. 10 patients had prior systemic therapy for lymphoma. At 4 months post-treatment, 65% had CR and 35% had PR; 50% of patients with PR at 4 months had CR at 6 months. At 6 months, 86% had CR and 14% had PR (Fig. 38.4). Of the 3 patients who did not achieve CR at 6 months, 1 achieved CR with rituximab and 20Gy of radiotherapy, and 2 were observed due to mild disease. 1 patient with mantle cell had local recurrence at 21  months, and 1 patient with MALT had contralateral disease at 19 months after treatment. 1 patient developed mild dry eye; no other complications were noted.

Relevance

Orbital Response to Ultra Low Dose 4 Gy RT 100

CR

90

PR

80 Percentage

Fig. 38.4  Orbital response to 4Gy orbital radiotherapy (RT) rates of complete response (CR) and partial response (PR) after completion of ultra–low-­ dose radiotherapy to the orbit. At 4 months, 20 patients were evaluated for disease response and CR was achieved among 65% of patients (n13). At 6 months, 21 patients were evaluated and CR was apparent in 86% of patients (n = 19). (Reproduced with permission from Pinnix et al. [5])

383

70 60 50 40 30 20 10 0

4 months (n=20)

6 months (n=21)

Follow Up Time

Relevance Orbital adnexal lymphoma (OAL) is the most common orbital malignancy, and presents predominantly in older patients [6]. Sullivan et al. [4] present their 10-years’ experience of OAL, with several key observations. Firstly, subtypes are commonly MALT, follicular, and diffuse large B-cell (DLBCL), in order of prevalence. Secondly, common presenting signs and locations are reviewed. Proptosis and swelling are common, while the classic “salmon patch” is rare. The lacrimal gland was the most common site of involvement, followed by the extraocular muscles and conjunctiva. Finally, the authors provide valuable prognostic information on survival at 5 years, with risk factors for worse outcome being bilateral disease, systemic disease, aggressive grade, and higher stage at presentation. These data allow appropriate counseling of patients with OAL based on their clinical characteristics. Subsequent research has corroborated and elaborated on the authors’ results. Rootman et al. [7] provide an analysis of primary, unilateral OAL and confirm the high prevalence of MALT and follicular subtypes. Progression-free and disease-­ specific survivals were 71% and 98% at 5  years, and 61% and 90% at 10  years, although DLBCL had a significantly increased risk of progression and mortality (Figs. 38.5 and 38.6). The authors comment that lower 10–15-year overall survival rates in the prior literature may be due to the fact that these patients are in general, an elderly cohort, while disease-specific survival rates remain high. An international, multicenter study of 797 cases of orbital lymphoma [8] reports a high incidence of MALT lymphoma (57%), followed by DLBCL (15%), follicular (11%), and mantle cell (MCL, 8%). DLBCL and MCL, as well as disseminated lymphoma, were treated with chemotherapy. 10-year disease-specific survival was 92% and 71% for MALT and follicular lymphoma, respectively, while it was 41% and 32% for DLBCL and MCL, respectively. The same group studied 86 cases of eyelid lymphoma and found similar proportions, with the exception of a 9%

384

38  Orbital Adnexal Lymphoma NHL Histology

1.0 Follicular 0.8

SLL

Other

MALT Follicular DLBC SLL Other MALT-censored Follicular-censored DLBC-censored SLL-censored Other-censored

Cum Survival

MALT 0.6

0.4 DLBC 0.2

0.0 0

5

10

15

20

Disease specific survival (y)

Fig. 38.5  Disease-specific survival Kaplan-Meier curve for primary, unilateral ocular adnexal lymphoma divided by lymphoma type. (Reproduced with permission from Rootman et al. [7])

prevalence of mycosis fungoides [9]. The authors note here that DLBCL, MCL, and mycosis fungoides were frequently secondary lymphomas. DLBCL and MCL had a poor prognosis (21% and 50% 5-year disease-specific survival, respectively), while MALT, follicular, and mycosis fungoides all had 5-year disease-specific survival >86%. Overall death rate from lymphoma presenting in the extraocular muscles is higher at 15.8% [10]. Bhatia et al. [11] describe their protocol for curative radiotherapy for primary orbital lymphoma, which ranges from 20  – 40Gy given in 2Gy fractions. The authors report a 5-year progression-free survival of 65.5%, although they did not perform subgroup analysis by type or stage of lymphoma. There were 3 vision-­ threatening complications of corneal ulceration, with several other milder complications including cataract and dry eye. A specific analysis of early stage orbital lymphoma (stages I  – II) by another group suggests a much higher 5-year local progression-free survival of 100% with 30Gy radiotherapy [12]. MALT lymphoma specifically has been demonstrated to have a 91% 5-year overall survival rate with a mean of 36Gy treatment [13]. Bolek et al. [14] describe a 5-year disease-free survival of 89% for low-grade and 33% for intermediate/high-grade disease with a mean of 25Gy treatment. The Mayo Clinic experience also suggests variability in survival by stage (Fig. 38.7). Clearly, subtype, grade, and stage all have prognostic significance for disease relapse and survival.

Relevance

385 NHL Histology

1.0

0.8

SLL

Other

MALT Follicular DLBC SLL Other MALT-censored Follicular-censored DLBC-censored SLL-censored Other-censored

Cum Survival

Follicular 0.6

0.4 MALT 0.2

DLBC

0.0 0

5

10 15 Time to progression (y)

20

Fig. 38.6  Time to progression Kaplan-Meier curve for primary, unilateral ocular adnexal lymphoma divided by lymphoma type. MALT, extranodal marginal zone lymphoma of mucosa-­ associated lymphoid tissue type; DLBC, diffuse large B-cell lymphoma; SLL, small lymphocytic lymphoma. *Other includes B-cell lymphoma: nonspecified, lymphoplasmacytoid lymphoma, diffuse large cell lymphoma, immunoblastic lymphoma, and mantle cell lymphoma. (Reproduced with permission from Rootman et al. [7])

1.0 Fraction surviving

Fig. 38.7 Disease-specific survival in orbital lymphoma: entire cohort and patients with clinical stage I or II disease vs. III or IV. Dashed line represents entire cohort. (Reproduced with permission from Stafford et al. [15])

Stage I/II

0.8 0.6 P