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Cataract Extraction↗
Biomedical subjects
N Shorr
Publications and source records attributed to N Shorr.
Transcaruncular approach to the medial orbit 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.
Decompression, Surgical↗
The deep plane facelift: a 20-year evolution of technique.
PURPOSE: This report reviews the unique technical and conceptual oculoplastic innovations in the discipline of facelift surgery by analyzing the evolution of facelift technique at a university-based oculoplastic program. DESIGNED: Retrospective, noncomparative case series. PARTICIPANTS: We analyzed 313 patients undergoing a facelift from 1980 through 1997. Most procedures were performed by the senior author. METHODS: Three primary eras of surgical technique were identified: limited skin flap with superficial musculo-aponeurotic system plication (25 patients), extended skin flap with neck dissection and superficial musculo-aponeurotic system plication (210 patients), and deep plane facelift with robust superficial musculo-aponeurotic system flap (78 patients). RESULTS: The steps in the evolution were designed to improve the results of the surgery regarding rejuvenation of the neck, jowls, and nasolabial fold, and to reduce the "tattletale signs" of facelift surgery including postauricular scarring, change in the position of the sideburn and temporal hairline, and unnatural results caused by pulling the tissues posteriorly, rather than repositioning them vertically. There were no complications in the skin flap only group. In the extended skin flap and superficial musculo-aponeurotic system plication group, there was one mandibular paresis which partially resolved. In the deep plane facelift (n = 78), there was one laceration of the parotid duct, successfully stented during surgery. CONCLUSIONS: The deep plane facelift, with vertical elevation of the midface, jowls, and neck, is a logical extension of the mid-facelifting techniques that have been used by oculoplastic surgeons. Compared with cutaneous undermining with superficial musculo-aponeurotic system plication, we found patient and physician acceptance higher using the deep plane technique.
Facial Muscles↗
Frontalis muscle flap advancement for correction of blepharoptosis.
PURPOSE: To describe a technique of frontalis muscle flap advancement to repair myogenic ptosis in lieu of a graft or suture material. METHODS: Ten ptotic eyelids in eight patients were repaired using the frontalis flap technique. Patients were selected at random by two separate surgeons; all patients had eyelid excursion measured as poor (or less than 6 mm). RESULTS: Nine of 10 ptotic eyelids were adequately corrected by the frontalis flap technique, with follow-up intervals ranging from 18 to 42 months. Adequate correction was defined as ptosis corrected within 1 mm of the fellow eyelid. Complications of frontalis advancement were few and primarily transient. CONCLUSIONS: Frontalis flap advancement is a technically simple, safe, and effective technique for the repair of myogenic ptosis. The primary advantage of frontalis muscle flap advancement over a graft or suture material that it elevates the eyelid directly by moving the insertion of the frontalis muscle into the eyelid, rather than by graft or suture material.
Adult↗
The safety and applications of acellular human dermal allograft in ophthalmic plastic and reconstructive surgery: a preliminary report.
PURPOSE: To describe the uses and determine the safety of a commercially available acellular dermal allograft in ophthalmic plastic and reconstructive surgery. The existing literature regarding current applications and results using acellular dermal allograft is reviewed. METHODS: The study design was a retrospective, noncomparative case series. Participants consisted of 63 consecutive patients undergoing ophthalmic plastic and reconstructive surgery using an acellular dermal matrix graft. The main intervention was placement of a dermal allograft. Outcome measures included the degree of clinical improvement and complications for each patient. RESULTS: We used AlloDerm (LifeCell Corporation, The Woodlands, TX, U.S.A.) as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and an orbital implant wrapping material. Clinical improvement was noted in all cases. There were no complications attributable to the acellular dermal matrix material. CONCLUSIONS: We describe several novel ophthalmic plastic and reconstructive surgical applications using acellular dermal allograft tissue. This material may be used safely as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and a wrapping material. Clinically, the allograft appears to be biocompatible, nontoxic, and nonallergenic in the orbit, eyelid, and midfacial tissues. Long-term data and studies comparing the efficacy of acellular dermal allograft with conventional materials are necessary.
Coated Materials, Biocompatible↗
Management of severe cicatricial entropion using shared mucosal grafts.
OBJECTIVE: To retrospectively analyze our experience using nasal turbinate and hard palate mucosal grafts as shared buttress grafts between the upper and lower eyelid for reconstruction in severe cicatricial entropion. SURGICAL TECHNIQUES: A horizontal tarsectomy is performed in the upper and lower eyelid approximately 2 mm posterior to the gray line. The distal tarsal segments are then dissected and rotated 180 degrees. A graft of nasal turbinate mucosa or hard palate mucosa measuring 1.5 x 3 cm is harvested. The graft is sutured to the cut edge of tarsus in the upper and lower eyelid. The rotated distal tarsal segment is stabilized against the graft using 5 mattress sutures. After 3 weeks, the graft is split by sharp dissection between the upper and lower eyelids. METHODS: The medical records of 12 consecutive patients, representing 15 shared buttress grafts, were reviewed. There were 5 hard palate and 10 nasal turbinate mucosal grafts placed. Follow-up ranged from 2 months to 7 years. RESULTS: The amount of corneal stipple, as well as subjective patient comfort, improved after eyelid margin reconstruction in 12 of the 15 eyes. One patient's visual acuity improved by more than 2 lines after surgery. There were no cases of failure of graft survival and no complications directly related to the shared graft technique. Recurrent entropion and trichiasis were noted in 3 eyelids more than a year after graft placement, reflecting ongoing cicatrization in these eyelids. Hard palate mucosal grafts were irritating to the corneal surface, requiring removal of the epithelium using a diamond burr and bandage contact lens wear. Nasal turbinate mucosal grafts were better tolerated by the corneal surface and had the added benefit of mucous production. CONCLUSIONS: Eyelid reconstruction using nasal turbinate and hard palate mucosal tissues as a shared buttress graft is a viable treatment option for patients with severe cicatricial entropion. Resolution of trichiasis and mechanical corneal abrasion was noted in 13 (86%) of 15 patients with no specific complications related to the technique. The shared buttress technique successfully autostents the healing eyelid margins, makes good use of the large turbinate mucosal graft, and minimizes trips to the operating room. When the mechanical requirements of eyelid margin reconstruction do not require the sturdiness of hard palate mucosa, nasal turbinate mucosa is a preferable graft tissue because it is better tolerated by the corneal surface and produces mucous.
Adult↗
Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour.
The objective of facial rejuvenative surgery is to restore a youthful contour. With age, changes occur in the lower eyelid and cheek that involve descent of the cheek tissues as well as prolapse of orbital fat in the lower eyelid. This often results in the formation of a tear trough groove at the level of the inferior orbital rim. Lower eyelid rejuvenation surgery can then be achieved through the transposition of this fat over the orbital rim on to the superior face of the maxilla. In this article describe the transconjunctival approach to orbital fat repositioning.
Adipose Tissue↗
Management of relative proptosis with a porous polyethylene orbital rim onlay implant.
PURPOSE: The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated. METHODS: Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant. RESULTS: Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions. CONCLUSIONS: Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.
Exophthalmos↗
Use of isobutyl cyanoacrylate tissue adhesive to stabilize mucous membrane grafts in total socket reconstruction.
PURPOSE: To describe a technique to secure a mucous membrane graft to a custom conformer during reconstruction of the conjunctival fornices and socket. METHODS: A cyanoacrylate-based tissue glue was used instead of sutures to secure the mucous membrane graft to the conformer. RESULTS: The adhesion between the graft and the conformer weakens over time, permitting easy removal of the conformer from the socket 6 to 12 weeks postoperatively. No complications were encountered in six patients in whom this technique was used. CONCLUSION: Using a cyanoacrylate-based tissue glue is simpler and quicker than suturing a mucous membrane graft.
Bucrylate↗
The endoscopic forehead lift.
Endoscopic techniques are being successfully applied to address eyebrow and forehead ptosis. The methods rely on extensive subperiosteal and subgaleal release of the forehead and scalp flap, allowing the elevation of soft tissues. Ablation of the depressor supercilli and procerus can be performed to address skin folding in the glabellar region. The mobilized frontotemporal flap is then elevated to the desired level and fixated with microscrews to the outer table of the skull. Laterally, the flap is fixed to the deep temporalis fascia. The technique relies upon a solid knowledge of the regional anatomy and the use of specialized instruments now available for dissecting under the flap. The endoscopic forehead lift can achieve results comparable to those obtained by the open coronal forehead lift while minimizing the incidence and extent of postoperative cutaneous anesthesia and telogenic hair loss, which frequently follows open coronal forehead surgery. In addition, the endoscopic technique is able to address eyebrow ptosis in the balding male without causing disfiguring scarring.
Adult↗
Deep transorbital approach to the apex and cavernous sinus.
Tumors of the orbital apex are difficult to approach through a standard lateral orbitotomy exposure. The transcranial approach has been described, but it requires an open craniotomy as well as dissection through the annulus of Zinn in its tight superior segment to reach intraconal and inferior lateral tumors. It is well recognized that the transcranial approach is optimal only for tumors of the superomedial orbital apex. Our study demonstrates that by enlarging the bony incision of a classic lateral orbitotomy to include a generous marginotomy and removing the deep sphenoid wing up to the superior orbital fissure, good exposure of the lateral orbital apex can be obtained. Tumors of the apex, including those that extend slightly into the cavernous sinus, can be removed from the cranial nerves and extraocular muscle origins in en face fashion, providing optimal ability to identify the delicate neurovascular structures of the orbital apex and avoid damage to them. The operating microscope is extremely useful for bony and soft tissue dissection. We report four benign tumors of the orbital apex removed using this approach. Two tumors encroached slightly into the cavernous sinus. Three of four patients were told that they had inoperable tumors. By use of the deep orbital apex approach described, all four tumors were successfully exposed and removed. Visual and motor function was unchanged or improved in all four patients, with the exception of one tumor that incorporated the inferior division of the third cranial nerve; in that patient, the transected nerve was anastomosed microscopically, and partial return of function was noted. The transorbital ophthalmic approach to tumors of the inferolateral orbital apex has significant potential advantages in comparison with a frontal craniotomy approach.
Adult↗
Oculoplastic experience with the cosmetic use of botulinum A exotoxin.
BACKGROUND: Botulinum toxin is a neuromuscular blocking agent produced by the bacterium Clostridium botulinum. It has been used as a therapeutic agent in ophthalmology for over 18 years. OBJECTIVE: To present the cosmetic use of botulinum toxin in oculoplastic surgery. METHODS: We present our experience with botulinum toxin as a cosmetic agent. RESULTS: Botulinum toxin was successful in treating hyperfunctional lines of the face and neck. CONCLUSIONS: Botulinum toxin is a safe and effective method of treating dynamic lines of the face and neck.
Botulinum Toxins, Type A↗
Fat repositioning in lower eyelid blepharoplasty.
Cosmetic lower eyelid surgery is not about removing excess skin, muscle, and fat. Rather, it is about restoring eyelid/midface contour. By the third decade of life, the suborbital orbicularis oculi fat begins to descend and the orbital septum weakens and bows forward creating the classic "double convexity deformity." The removal of eyelid fat simply converts this deformity to a "concavity/convexity deformity." The lower eyelid fat redistribution procedure, as described herein, can be used to address this problem.
Adipose Tissue↗
The transeyelid subperiosteal midface-lift in the unhappy postblepharoplasty patient.
The unhappy postblepharoplasty patient with lateral canthal dystopia, round eye, and scleral show presents perhaps the single greatest challenge to the aesthetic reconstructive surgeon. The problem may be as simple as a lax eyelid, which is inferiorly displaced by gravity or as complex as an eyelid, which has full thickness vertical inadequacy in each of the three eyelid lamellae. The transeyelid subperiosteal midface-lift with lower eyelid reconstruction is a reliable procedure for addressing full thickness lower eyelid vertical tissue inadequacy by totally reconstructing the lower eyelid by the classic three individual layer reconstructive technique. Vertical and horizontal adequacy or inadequacy for each of the three eyelid layers is determined and then individually addressed in the total eyelid reconstruction. This procedure has the potential to fully reconstruct and reposition the lower eyelid and lateral canthus such that the final position, function, and appearance is as good or better than it was before the changes caused by time, gravity, and previous surgery.
Blepharoplasty↗
The transcaruncular approach in repair of orbital fractures: a retrospective study.
The use of a transcaruncular approach to the medial orbit provides excellent exposure of the medial wall and avoids a cutaneous scar. This article presents the clinical procedure in a retrospective study of 8 patients. An incision through the caruncle, combined with an incision along the inferior conjunctival fornix, provides wide exposure of the medial and inferior orbit. Traumatic fractures of the orbit typically involve the thin bone of the medial and inferior walls. The clinical history and findings in 8 patients with bony orbital fractures are presented. In each case, surgical repair was based on the transcaruncular approach. Results of postoperative evaluation (range of 24 days to 32.5 months) are described, with a mean follow-up period of 8.5 months. The authors conclude that the transcaruncular approach is well suited to surgical repair of blow-out fractures to the medial orbit, in combination with an inferior transconjunctival incision.
Adult↗
Surgical correction of incomplete cryptophthalmos in Fraser syndrome.
PURPOSE: To demonstrate favorable long-term visual outcome after ocular reconstruction in an infant with Fraser syndrome and with complete left cryptophthalmos. METHODS: Reconstruction of incomplete right cryptophthalmos in our patient was accomplished in a stepwise manner, beginning in the third week of life, by dissecting the eyelids from the cornea, reconstructing the conjunctival fornices with buccal mucosa, and repairing the upper lid coloboma in a flap reconstruction using the inferior eyelid margin. RESULTS: At age 3 years, the patient currently has good movement of the right eyelids when blinking, reasonable right tear function, and a visual acuity in the right eye between 20/200 and 20/360 on forced preferential looking. CONCLUSION: In selected cases of incomplete cryptophthalmos, oculoplastic and corneal surgery may result in useful vision and in good eyelid movement when blinking.
Abnormalities, Multiple↗