Lateral canthal anchoring: special situations.
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Blepharoplasty↗
Biomedical subjects
Mark A Codner
Publications and source records attributed to Mark A Codner.
Evaluation of conventional subciliary incision used in blepharoplasty: preoperative and postoperative videography and electromyography findings.
BACKGROUND: The purpose of this study was to evaluate the innervation and function of the orbicularis oculi area clinically, with video imaging, and electrically, with electromyography, before and after lower-eyelid blepharoplasty using a conventional subciliary incision. METHODS: Nine patients (18 eyes) were studied before and 4 to 12 weeks after lower-eyelid blepharoplasty. Video imaging documented clinical changes in involuntary (blink) and voluntary (squeeze and squint) eyelid function as well as resting lid position and tone. Electromyography was performed using concentric needle electrodes (25 mm in length, 0.03 mm in diameter) placed in the lateral and medial subciliary orbicularis oculi. A total of 36 sites in nine patients (four sites per patient) were studied. Acute denervation was identified by the presence of fasciculation; fibrillation potentials; insertional activity; sharp waves; and grade based on standard electromyography techniques. All patients underwent lower-eyelid blepharoplasty with a subciliary incision, skin-muscle flap and canthal anchoring with canthopexy or cantholysis, and canthoplasty. RESULTS: Video imaging of the lower eyelid before and after blepharoplasty showed evidence of eyelid malposition or abnormal voluntary or involuntary orbicularis oculi muscle function. There was no evidence of acute denervation in 34 of 36 sites (94 percent). Two patients had abnormal fasciculation in the left lateral position on two of 36 sites (6 percent). Thirty-three weeks postoperatively, one patient was retested and a normal electromyography result was obtained. CONCLUSIONS: This study demonstrated that lower-lid malposition or abnormal function after lower-lid blepharoplasty cannot be explained by denervation of the zygomatic branch of the facial nerve. Any acute or residual denervation seen in the subciliary orbicularis is not clinically significant. The importance of lower-lid support and canthal anchoring cannot be emphasized enough in preventing lower-lid malposition. Blepharoplasty is a challenging procedure that requires careful preoperative planning, intraoperative reassessment, and meticulous surgical technique to optimize facial rejuvenation and patient safety.
Adult↗
Use of the infusion pain pump following transverse rectus abdominis muscle flap breast reconstruction.
The infusion pain pump has been a valuable addition to postoperative pain management in plastic and reconstructive surgery. Concerns have been raised regarding the potential ischemic or infectious complications of placing a catheter beneath the operative site for infusion of local anesthesia (+/- epinephrine). The purpose of this review is to document our experience with this form of postoperative pain control in plastic surgical procedures. Thirty-six consecutive transverse rectus abdominis muscle (TRAM) flap breast reconstruction patients were reviewed and included in the series (16 left, 10 right, and 10 bilateral). The average age was 52 years, and 4 patients had a simultaneous symmetry procedure. The cohort was divided into those with a postoperative pain pump versus those without a pain pump. Data points queried included type, route, and amount of narcotic administered per day in the postoperative period, as well as complications. All patients received patient-controlled analgesia (PCA) (morphine, n = 34; meperidine (Demerol, Sanofi-Synthelabo), n = 1; hydromorphone hydrochloride (Dilaudid, Abbott Pharmaceutical) n = 1). The pain pump was used in 16 patients (bupivacaine (Marcaine, AstraZeneca, n = 16). It was typically infused starting postoperatively at a rate of 4 mL/d and discontinued on postoperative day 2. Supplemental intravenous narcotics were required in 12% (n = 2/16) of patients with a pain pump versus 35% (n = 7/20) in those patients without a pain pump. There were no significant differences in the average number of days the PCA was used (1.8 days with a pain pump versus 2.2 without), and patients with the pain pump started postoperative medications slightly earlier (1.8 versus 2.0 days). PCA requirements were significantly lower in those patients with the pain pump. The average days to discharge for patients with a pain pump were 3.4 compared with 4.7 days in those patients without the pain pump. There were no differences in donor-site or breast complications. The postoperative pain pump has been useful in reducing the intravenous narcotic requirements and length of stay in patients following TRAM flap breast reconstruction. There were no flap, donor-site, or implant complications related to the presence of the catheter. Cost-effectiveness and patient satisfaction data would be interesting.
Adult↗
Upper eyelid reconstruction.
There are several options available for upper eyelid reconstruction that depend on the extent of involvement of the anterior and posterior lamella. Knowledge of the anatomy will ensure that in addition to the creation of an aesthetically acceptable eyelid reconstruction, a functional upper lid will be restored. The purpose of this article is to outline the anatomy of the eyelid, to analyze the components of eyelid defects, and to provide options for lid reconstruction.
Algorithms↗
Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.
The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.
Adult↗