A single technique to correct various degrees of upper lid retraction in patients with Graves' orbitopathy

BACKGROUND: Several lengthening techniques have been proposed for upper eyelid retraction in patients with Graves' orbitopathy and variable rates of success have been reported. Most authors recommend different procedures for different degrees of retraction, but cannot prevent residual temporal retraction in a significant number of cases. The modified levator aponeurosis recession described by Harvey and colleagues, in which the lateral horn is cut completely, seems to be an exception to this rule, but was evaluated in a limited number of cases only. METHOD: The authors further modified Harvey's technique by dissecting the aponeurosis together with Müller's muscle of the tarsus and the conjunctiva medially only to the extent necessary to achieve an acceptable position and contour of the eyelid in upright position. They also used an Ethilon 6.0 suture, instead of Vicryl, on a loop. It is placed between the tarsal plate and the detached aponeurosis to prevent spontaneous disinsertion. This modification was used in 50 Graves' patients (78 eyelids) with a upper lid margin-limbus distance ranging from 1 to 7 mm and evaluated using strict criteria. RESULTS: A perfect or acceptable result was obtained in 23 of 28 patients (82%) with bilateral retraction and in 18 of 22 patients (82%) with unilateral retraction. Seven eyelids were overcorrected (too low) and three undercorrected, necessitating reoperation. All other eyelids had an almond-like contour and a lid crease of 10 mm or less. No complications except subcutaneous haematomas were seen. Two patients showed a recurrence of lid retraction 9 months after the operation. CONCLUSION: This technique is safe and efficacious and can be used for all degrees of eyelid retraction.     

Superficial liposuction: A new application of the technique for aged and flaccid skin

From 1982 to 1991, 2500 patients underwent liposuction to thin the superficial areolar layer of fat. The patients were of all ages and had different types of skin. From the results the author concludes that the new superficial liposculpting, based on the controlled scar retraction of the thin cutaneous adipose flap remaining after the treatment, allows for very good results even in very flaccid and aged skin. A digital molding of the residual fat also improves the contouring. So-called cellulite is finally meliorated.Presented at the First and Second International RAPS Congress, Sao Paulo, Brasil, March 1989 and 1991 and at the Nineth LSNA Meeting, Seattle, Washington, September 1991     

眼球后退综合征的手术设计

目的 探讨眼球后退综合征(DRS)手术设计的特点。方法 11例眼球后退综合征患者，采用常规的方法检查眼位，单眼、双眼水平注视野，异常头位的偏斜角度。手术方式患眼外直肌不等量后徙。结果 原在位外斜，双眼注视野位于患眼颞侧，面部转向健眼一侧。手术后外斜视得到矫正，异常头位消失。结论 为了矫正原在位存在外斜视，即使外直肌力量不足，手术后外转进一步受限，也需减弱外直肌，以期获得良好效果。     

下直肌后徙加眼球筋膜囊头部复位术初步探讨

目的 探讨有效地防止下直肌后徙术后下睑退缩的手术方法。方法 37例下直肌后徙加CPH复位术病人，下直肌后徙4～6mm，中位数6mm。CPH缝合在新肌止端前浅层巩膜或肌肉断端上，手术前后采用三棱镜遮盖试验测量双眼分别注视时的斜视角，测定双眼下睑缘的位置关系。结果 术后双眼下睑缘位置关系无变化，术后无一例发生下睑退缩，15例随访1～20月，中位数6月，也未出现下睑退缩，多数病人眼位满意。结论 下直肌后徙加CPH复位术可以有效地防止下睑退缩。     

Celioscopic intra-abdominal retraction: Comparison of two mechanical devices

The proper utilization and safety of rapidly developing celioscopic instrumentation remains uncertain. A porcine model was developed for testing two different types of mechanical, intra-abdominal retraction devices. One instrument was inflatable, forming a broad compliant interface for tissue retraction. The second device consisted of three rubber-shod metal arms which formed a rigid, non-contiguous sweep. Each intra-abdominal device was placed with identical manual traction upon the spleen, ileum and liver in sequential fashion with pressure maintained for 10min. Photographic documentation of the gross effects of retraction was obtained along with histological sectioning of each portion of the involved viscera with controls. The retraction devices produced small contusions with punctate, petechial haemorrhages within the tissue, with the tips of each capable of tissue laceration. On each organ, the balloon retraction device produced the least amount of gross and histological damage, demonstrating iatrogenic injury directly attributable to device design.     

A Web-Based Survey of Oculoplastic Surgeons Regarding the Management of Lower Lid Retraction

Purpose: To survey the opinion of oculoplastic surgeons on the assessment and management of lower eyelid retraction (LLR).

Methods: A web-based survey queried oculoplastic surgeon members of Ojoplast, Spanish and Brazilian Oculoplastic Societies on the management of LLR. The frequency and percentage proportions of the responses were analyzed.

Results: One hundred ninety-six oculoplastic surgeons participated in the survey. The main cause of LLR is post-blepharoplasty (62;31.6%). The most used sign to detect LLR is scleral show. The most common approaches to managing LLR are lateral canthal surgery (164/593;27.6%), autogenous spacers (148/593; 24.9%) and retractor release (131/593;22.1%). The preferred autogenous graft material includes ear cartilage (102/260;39.2%). The majority of surgeons (161/314; 51.3%) recommend massage or steroids injection (80/314;25.5%) for early post-blepharoplasty LLR, while, 54.1% (106/196) of participants suggested waiting for at least six months prior to surgical intervention. Frost suture is used after most LLR surgeries (154/196;91.1%). Incomplete correction is the main complication (111/310;35.8%) of LLR surgery. For mild LLR, 48% of the responders prefer clinical treatment; conversely, severe cases routinely require combined surgical techniques.

Conclusions: Oculoplastic surgeons frequently diagnose LLR based on scleral show. LLR management depends on the cause and severity of lid retraction. Mild cases, in general, receive clinical treatment and severe cases need a combination of surgical techniques and grafts.     

锥形束CT测量牙龈厚度准确性的初步研究

目的评价锥形束CT(CBCT)法测量牙龈厚度的可信度及准确性。方法选择20例牙龈健康者的120颗上颌前牙,采用CBCT法和牙龈穿刺法测量唇侧中央龈缘下2mm处牙龈厚度,比较两组差异并用Kappa系数评价两种方法的一致性;应用Kappa系数评价不同检查者用CBCT法测量牙龈厚度的一致性,以及组内相关系数ICC评价同一检查者重复测量数据的可信度。结果CBCT法测量牙龈厚度为(1.23±0.27)mm,牙龈穿刺法测量结果为(1.24±0.26)mm,差异无统计学意义(P>0.05),两组之间一致率为83.33%(Kappa=0.547)。不同的检查者CBCT法测量牙龈厚度的一致性检验Kappa系数为0.814,可信度良好(ICC=0.795),同一检查者CBCT法重复测量数据之间一致性检验Kappa系数为0.864,可信度良好(ICC=0.893);CBCT法对厚牙龈生物型具有高的灵敏度(92.05%)和低的特异度(59.38%)。结论CBCT测量牙龈厚度的结果与牙龈穿刺法的结果较一致,具有良好的可信度。     

Reconstructive subperiosteal midface lift: A three nonvisible incision approach

This article describes our surgical technique for subperiosteal midface elevation in patients with paralytic lower eyelid malposition or cicatricial inferior eyelid retraction. Nineteen patients with paralytic lower eyelid malposition and 15 patients with cicatricial inferior eyelid retraction underwent a subperiosteal midface lift (n = 34). The procedure was performed under local anesthesia through three nonvisible incisions. A transconjunctival incision allows preseptal dissection to the orbital rim, followed by a subperiosteal dissection of the midface. An oral incision is useful to achieve complete subperiosteal dissection and to perform the distal periostomy, which allows complete release of the midface soft tissues. A temporal incision provides access to the temporal fascia for fixation of the elevated tissues and gives the surgeon the possibility of removing redundant skin from the scalp instead of the lower eyelid. Additional posterior lamellar grafting was performed in 24 patients. There was a statistically significant reduction in the distance from the pupil centre to the lower eyelid (margin reflex distance, MRD2) 1 month after surgery (preoperative MRD2 9.62 ± 4.52 mm, postoperative MRD2 5.28 ± 2.62 mm). The ectropion and lower eyelid retraction was resolved in all patients, except for one recurrence. Midfacial elevation is a safe and effective surgical technique in the treatment of static lower eyelid malposition after chronic facial nerve palsy or posttraumatic or iatrogenic lower eyelid retraction.