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Introduction: Autologous fat transfer is an increasingly popular treatment for the aging face. Recently, studies have suggested increased duration of effect with the injection of fat into or adjacent to muscles. Subcutaneous depths of facial muscles have been demonstrated using cadaver dissections, but to our knowledge this is the first study to use radiologic measurements in living subjects in order to quantify muscle depths in the face. Materials and Methods: Forty computed tomography (CT) scans were reviewed retrospectively using digital radio imaging software with a calibrated digital measurement tool that was used to measure the depths of the muscles of facial expression corresponding to fat-grafting sites. Correlation was made to formalin-preserved cadaver dissections. Results: Subcutaneous depths of facial muscles are listed as measured radio graphically and on cadaver sections. Discussion: The depths of the muscles of facial expression are more accurately measured using digital radiographs; these depths are important landmarks for facial cosmetic surgeons performing an autologous fat transfer. To our knowledge, this is the first study to characterize the anatomic depth of the facial muscles in the living human.

Objective To report the results of levator excision and frontalis suspension for moderate-to-severe Marcus-Gunn jaw-winking ptosis. Design A retrospective noncomparative case series. Participants Twenty-four patients with moderate-to-severe Marcus-Gunn jaw-winking ptosis (21 unilateral and 3 bilateral) were treated surgically between 1978 and 1997 by one surgeon. Intervention Levator excision either in the involved eyelid or in both eyelids, followed by bilateral frontalis suspension, was performed. Main outcome measures Postoperative improvement of jaw-winking was determined. The surgical results of ptosis surgery were assessed as good, fair, or poor based on habitual upper eyelid heights and symmetry. Results Postoperative follow-up periods ranged from 6 months to 153 months, with an average of 36.9 months. After levator excision in a total of 27 eyelids exhibiting jaw-winking, 10 eyelids (37.0%) showed complete resolution of jaw-winking, and 13 eyelids (48.2%) showed mild winking (1 mm or less) on the lateral jaw movement only (functionally and cosmetically not a problem). In four eyelids (14.8%), these results were not recorded. In the group of five patients undergoing bilateral frontalis suspension and levator excision only on the involved side, final results were good in two patients (40%) and poor in three (60%). Of the 19 patients who underwent bilateral levator excision, final results were good in 13 (68.4%) and fair in 6 (31.6%). Conclusions For moderate-to-severe jaw-winking ptosis, bilateral frontalis suspension after bilateral levator excision generally provided satisfactory correction of both jaw-winking and ptosis.

Lateral candial fixation is widely used. This article sought to determine if a periosteal flap used routinely in conjunction with a tarsaJ strip provides lasting lateral canthal fixation. This consecutive clinical series from two ambulatory surgery centers followed 79 patients who underwent 141 lateral canthal fixation procedures. Outcome was measured by the position of the lateral canthus. Correct positioning of the lateral canthus was achieved in 78 of 79 patients representing 139 of 141 procedures (98%). The failed case was a patient with floppy eyelid syndrome in whom the sutures tore through the tarsal strips. The tarsal strip-periosteal flap technique is a successful, technically direct method of lateral canthal fixation. It is promoted as an enhancement of the tarsal strip technique, and is especially helpful in patients with prominent eyes. [Ophthalmic Surg Lasers 1999;30:232-236.]

A 47-yr-old man with history of metastatic low-grade rectal leiomyosarcoma presented with progressive protrusion of his left eye due to an enlarging orbital mass. The differential diagnosis included tumor metastasis or orbital infection due to an unknown infectious agent. Diagnostic fine-needle aspiration (FNA) of the orbit was performed on an urgent basis to institute proper therapy and to save the patient's eyesight. Cytomorphologic examination of the material demonstrated a spindle-cell neoplasm consistent with metastatic leiomyosarcoma. It is a rare event for leiomyosarcoma to occur in the orbit. On our review of the literature, the cytology of primary orbital leiomyosarcoma on FNA has only been reported once. To our knowledge, this is the first report of the FNA cytomorphology of metastatic leiomyosarcoma to the orbit. Diagn. Cytopathol. 1997;17:369–373. © 1997 Wiley-Liss, Inc.

purpose Normal eyelid and orbital structures were studied without any disturbance in three positions of gaze and during Bell's phenomenon (eyes closed).methods Seven orbits were imaged using a high-resolution magnetic resonance imaging program and a surface coil. They were analyzed with sub-millimetric resolution in a series of contiguous vertical planes parallel to the orbital axis. The three positions of gaze (downgaze, straight ahead and up-gaze) were reproduced using the same fixation device.results Between upgaze and downgaze, a volume of intraconal fat is cleared away from the path of the optic nerve and can be measured semi-quantitatively. Concurrently, significant volumetric changes occur in the fat compartment comprised between a rectus muscle and its arc of contact with the sclera. The superior and inferior extraconal fat pads follow the movements of the corresponding eyelid retractor complex. Along with the relative movements of the intraconal and extraconal fat pads, the bulging of the contrac...

The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

The presence of orbital lymphatics in the primate model is demonstrated using light and electron microscopic enzyme histochemistry. In addition, strictly morphological definitions of lymphatics, such as discontinuous basal lamina, thin and irregular walls, anchoring filaments, and attenuated endothe

The most common complications of levator palpebrae superioris muscle blepharoptosis repair are undercorrection, overcorrection, and abnormalities of the eyelid contour. Previously described nonsurgical as well as surgical methods delay the repair of such complications and introduce the same confounding factors that can affect judgment of the eyelid level as during the initial surgical procedure. Twenty-two patients underwent a highly predictable surgical technique to revise unsatisfactory postoperative eyelid positions. Twenty-five of 26 eyelids (96%) had a satisfactory result and only one of 26 (4%) remained under-corrected. The revision is performed three to four days after the initial blepharoptosis correction and involves blunt separation of the wound without local anesthesia. The levator aponeurosis is advanced or recessed and resutured to the tarsus to achieve the proper eyelid height and contour. The advantages of this revision technique are as follows: (1) the procedure can be quickly and easily performed in the office; (2) the anatomic defects are corrected; (3) sharp dissection, bleeding, and edema are avoided; (4) the technique is painless and usually requires no local anesthetic injections; (5) the tone and function of the levator palpebrae superioris muscle, Muller's, and orbicularis oculi muscles remain undisturbed intraoperatively; and (6) early correction is achieved, thereby enhancing patient acceptance.

We present new information regarding the sympathetic nerve anatomy in the cavernous sinus and retrobulbar orbit of the cynomolgus monkey. Postganglionic sympathetic nerves were identified using an immunoperoxidase technique in which the primary antiserum was directed against tyrosine hydroxylase, the rate-limiting enzyme in norepinephrine synthesis. Our work is unique in adapting this staining method to paraffin-embedded tissue. This technique allows sympathetic nerve fibers to be distinguished from other autonomic, sensory, and motor nerves. A large sympathetic nerve bundle lateral to the internal carotid artery in the cavernous sinus gave off one or more branches that leave the artery to encircle the abducens nerve. Further division occurs within the cavernous sinus, but all sympathetic nerve fibers destined for the orbit entered it through the superior orbital fissure. None pass through the optic canal. In the orbit, sympathetics were associated with the ophthalmic artery and some of its branches and with the sensory root to the ciliary ganglion. After entering the ganglion, the sympathetic fibers were lost to detection in most specimens, but they were again seen in a single short ciliary nerve in one instance. Sympathetic nerve fibers were not detected adjacent to several structures identified in the human anatomy literature, such as the intracranial and intracanalicular segments of the ophthalmic artery, the nasociliary nerve, the long ciliary nerves, the nerve to the inferior oblique muscle, or the lacrimal artery and nerve.

A stepped surgical incision, in which an initial small cutaneous incision is followed by progressively longer incisions in the subcutaneous tissues, limits postoperative scar formation in the skin. Placement of incisions parallel to relaxed skin-tension lines further reduces the size of the scar. We describe how these principles may be applied to ophthalmic plastic surgical procedures to improve cosmesis. Autogenous fascia lata can be harvested with scissors through a 15-mm incision parallel to relaxed skintension lines, placed over the middle of the iliotibial tract. Lacrimal bypass operations can be performed well and with good cosmesis through a 12 to 15-mm skin wound if the above principles are followed.

The pathophysiologic mechanisms responsible for the clinical features of the anophthalmic socket are poorly understood. Atrophy of orbital fat has been thought to be a major contributing cause of enophthalmos and the superior sulcus deformities that develop after enucleation, but it has never been demonstrated histopathologically or confirmed by scientific analysis. This study was undertaken to investigate the changes that occur in the orbital fat compartment of the anophthalmic socket in an animal model by measuring orbital soft tissue mass and evaluating adipocyte cell size. Instead of reduction in the tissue mass, a statistically significant greater weight of the fat and connective tissue compartment was found in the anophthalmic orbit by nearly 13% compared to the control orbit in the animals in the long-term group. No significant change in the mean maximal diameter of adipocytes developed 7 months after enucleation. These analyses do not support the concept that orbital fat atrophy or a reduction of metabolic activity occurs in the anophthalmic socket in this animal model. From these results and our previous findings that the circulation dynamics and blood flow to orbital tissues do not change after enucleation, we propose that the pathophysiologic basis of the problems associated with anophthalmos is a disturbance in the spatial architecture and interrelationships of the multiple tissue components of the orbit, not a change in the orbital blood flow or development of fat atrophy.

A wide variety of complications of the anophthalmic socket develop in patients after enucleation, including enophthalmos, superior sulcus deformities, eyelid malpositions, implant migration and extrusion, poor prosthetic motility, and socket contraction. Changes in the orbital blood flow and metabolic activity of the socket tissues and atrophy of the orbital fat occurring after enucleation have been suggested as two theoretical mechanisms that result in the development of these clinical conditions. Lack of scientific evidence and a limited understanding of the pathophysiologic basis of the features of anophthalmos led us to evaluate the validity of these proposed mechanisms in an animal model. Selected parameters of the normal orbits were compared with the contralateral anophthalmic orbits at different time intervals after surgery. Orbital blood flow was studied with selective ophthalmic artery angiography and radioactive microsphere techniques. Ophthalmic arteriography demonstrated symmetric caliber and filling characteristics of the major orbital vessels of the control and experimental orbits, although their topographic course was slightly more tortuous in the anophthalmic socket. Results of radioactive microsphere analysis of capillary blood flow per weight of the different orbital tissue compartments of the animals in the long-term group showed no significant difference between the normal and anophthalmic sockets. These findings provide evidence that the circulation dynamics and blood flow to orbital tissues do not change after enucleation surgery.

Purpose To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation. Methods An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff-stained specimens was then performed. Results Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing. Conclusions Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.

Paediatric ptosis is routinely more challenging than adult ptosis with considerations such as amblyopia, difficulty of examination and at what age surgery should be performed. Unilateral severe congenital ptosis and jaw-winking ptosis raise additional questions of which surgical procedure and whether unilateral or bilateral surgery should be performed. A panel of international experts answer questions relating to two clinical scenarios.

Purpose: To investigate the Cynomolgus monkey eyelid as an experimental model for oculoplastic surgery Methods: Eyelid and periocular tissue were removed from Cynomolgus monkeys being euthanized. After fixation, the macroscopic and microscopic characteristics of the Cynomolgus monkey eyelid were studied. Results: Macroscopic and microscopic characteristics of the Cynomolgus monkey eyelids were described. The Cynomolgus monkey eyelid bears resemblance to the human eyelid in its compartmentalization and complexity. Conclusions: The Cynomolgus monkey eyelid is a suitable experimental research model. Its compartmentalization resembles that of the human eyelid both microscopically and macroscopically.

Purpose: To study the lymphatic drainage of the cynomolgus monkey and human eyelid and periocular tissue by means of histochemistry. Methods: Eyelid and periocular tissue from three cynomolgus monkeys undergoing sacrifice for glaucoma and retina research purposes and discarded tissue from a wedge resection of one human eyelid were used for histochemical analysis. Lymphatic capillaries were distinguished histochemically in monkey and human eyelids by light microscopy with a 5'-nucleotidase (5'-Nase) staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining. Results: Histochemical analysis with 5'-nucleotidase revealed a subcutaneous and pretarsal lymphatic plexus in both the human and monkey. Conclusions: Histochemical results demonstrate similar lymphatic plexi in the monkey and human. Future studies will help to clarify the lymphatic drainage pathways of monkey and human eyelids.

To study the lymphatic drainage of the cynomolgus monkey through the use of lymphoscintigraphy.Lymphoscintigraphy with 500 microCi of 99mTechnetium sulfur colloid injected at specific sites around the eyelids was performed with five cynomolgus monkeys in lateral and ventral positions.Lymphoscintigraphy of the monkey eyelid and periocular tissue revealed lymphatic drainage to the parotid lymph nodes from the entire upper eyelid, medial canthus, and lateral lower eyelid and drainage to the submandibular lymph nodes from the medial and central lower eyelid. In addition to draining to the parotid lymph nodes, the central upper eyelid was also seen to drain to the submandibular lymph nodes.Lymphoscintigraphy of the cynomolgus monkey eyelids reveals discrete lymphatic drainage pathways for the upper and lower eyelids and a dual pathway for the central upper eyelid. Future studies will help to clarify the lymphatic drainage pathways of human eyelids.

Temporary closure of the eyelids is frequently recommended for ocular surface disorders in which reepithelialization of the cornea is problematic, as well as for acute Bell's palsy. We describe an easily performed technique of temporary tarsorrhaphy using plastic tubes sutured externally to the upper and lower eyelids, with eyelid closure accomplished by tightening a loop of suture passed through the two tubes. Corneal epithelial defects in 11 of 13 patients in whom we used this technique resolved satisfactorily without complications. In the remaining two, the polypropylene sutures eroded through the eyelids between 5 and 6 weeks after surgery. The sutured tubes loosened and the loosened sutures had to be replaced. In one patient, the overly long end of a suture rotated between the apposed eyelids, inducing a corneal abrasion, but no permanent damage to the eye. We conclude that the sutured tube-tarsorrhaphy provides excellent short-term closure of the eyelids, while allowing simple, painless opening for examining the globe. The risks of inflammation and infection associated with previously described techniques are minimized.

PURPOSE: To report an unusual response to bilateral frontalis suspension surgery for congenital ptosis. METHODS: Case report. RESULTS: A 6-year-old child with infantile esotropia and bilateral congenital ptosis received a homologous fascia lata frontalis suspension. After surgery, the patient exhibited an alternating ptosis, caused by alternating unilateral frontalis muscle contraction, which has persisted throughout 3 years of postoperative observation. CONCLUSION: Symmetric frontalis muscle activation may not always occur after bilateral frontalis muscle suspension surgery for congenital ptosis. Amblyopia, strabismus, or fixation preference may predispose patients to use unilateral brow elevation, despite bilateral frontalis muscle suspension surgery.

Purpose Lower eyelid involutional entropion is a significant disorder of the aging population resulting from horizontal eyelid laxity, overriding orbicularis oculi muscle, and attenuation of the lower eyelid retractors. The purpose of this study is to describe the long-term results of transconjunctival entropion repair. Design Interventional noncomparative case series. Participants Thirty-six eyelids in 31 patients. Methods Charts were reviewed of all transconjunctival entropion repairs, which included myectomy, retractor fixation, and horizontal shortening performed by three oculoplastic surgeons between January 1993 and January 1999. Cases with less than 12 months follow-up were excluded. Main outcome measures Entropion recurrence. Results Thirty-six lids in 31 patients were followed for mean of 31.5 months (12.5–79). Six of 36 lids (16.7%) had postoperative complications. Recurrent entropion occurred in 3 of 36 lids (8.3%) an average 16.3 months (7–35) after surgery. An average of 6 trichiasis lashes (1–10) occurred in 4 of 36 lids (11.1%) at a mean of 2.25 months (1–4) after surgery. There were no overcorrections. Three of 36 lids (8.3%) required additional surgery. Conclusions Entropion recurrence after three-step transconjunctival repair is within the 0% to 30% reported recurrence for other repair techniques but more frequent than reported for a similar transcutaneous procedure. The 8.3% recurrence rate might have resulted from inadequate myectomy, inadequate retractor fixation, cicatricial changes directly related to the transconjunctival incision, or progressive involutional changes. Trichiasis was the most frequent complication. Transconjunctival entropion repair may be slightly less effective than transcutaneous repair.

Purpose To investigate the anatomic and histologic changes present in midfacial ptosis. Methods Experimental study applying gross anatomic and histologic techniques to formalin-preserved and fresh-frozen cadaver heads with and without midfacial ptosis. High-resolution surface coil magnetic resonance imaging (MRI) was performed to obtain radiologic correlations. Results The orbitomalar ligament was further characterized by identification of a well-developed lateral component in the sub-superficial musculoaponeurotic plane; abnormalities of this important supporting structure were present in the subcutaneous plane in 8 of 10 specimens with midfacial ptosis. The zygomatic and masseteric cutaneous ligaments also were further characterized on a gross anatomic level, and histologic evidence of these two structures was produced. The subcutaneous components of the zygomatic and masseteric cutaneous ligaments were attenuated or not identifiable in 40% and 30% of specimens with midfacial ptosis, respectively. High-resolution surface coil MRI provided exquisite correlations of midfacial anatomy. Conclusions The lateral component of the orbitomalar ligament provides major osteocutaneous midfacial support. Subcutaneous attenuation of the orbitomalar, masseteric cutaneous, and zygomatic ligaments was associated with midfacial ptosis.

Purpose To identify lymphatic vessels in the human orbit. Methods Lymphatic and blood capillaries were distinguished histochemically by light microscopy using a 5'-nucleotidase (5'-Nase) and alkaline phosphatase (ALPase) double staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining. Results The presence of conjunctival lymphatics was confirmed and used as a control tissue. Lymphatic vessels were identified in the lacrimal gland and in the dura mater of the optic nerve. Structures demonstrating positive 5'-Nase staining at the orbital apex were highly suggestive of lymphatics but did not meet the morphologic criteria established. Lymphatic vessels were not identified in the extraocular muscles or orbital fat. Conclusion To the authors' knowledge, this study presents the first evidence for lymphatic capillaries in the dura mater of the human optic nerve and lacrimal gland.

This study was designed to evaluate the characteristics of human orbital fat and connective tissue. Two exenteration specimens were studied by light microscopy with special stains. Four distinct regions were identified on the basis of their connective tissue septa, which contained blood vessels and were composed of elastin and collagen types I, III, and IV. Transmission electron microscopy was performed on the opposite orbits. The fibroblasts and adipocytes appeared metabolically inactive and showed no regional differences. The fat was phase extracted from the connective tissue and subjected to biochemical analysis. No regional differences were found in the content of fatty acids and protein. The fatty acids included palmitic acid (22-24.6%), oleic acid (45-51.5%), and linoleic acid (15-18.6%). Despite demarcation of the orbital fat into distinct regions by the connective tissue septa, ultrastructural and biochemical analysis revealed no regional variations in the fat. The diagnostic and therapeutic implications of these findings are discussed.

The authors describe a patient with an orbital floor fracture that did not demonstrate a distinct fracture on computed tomography (CT) imaging. The key radiologic finding was rounding of the inferior rectus muscle.

We studied the relationship between eye dominance (Scobee test) and upper lid level (MRD) in 54 patients with unilateral ptosis or asymmetric bilateral ptosis (> or = 2 mm difference in MRD) using the phenylephrine test. A contralateral lid drop was measured in 12/54 patients after instillation of 2.5% phenylephrine in the more ptotic eye and occurred in both congenital (3) and acquired (9) ptosis cases. A contralateral lid drop was seen in 7/14 (50%) patients whose ptosis was greater in the dominant eye and in 5/40 (12.5%) patients whose ptosis was greater in the nondominant eye (p = .01). Contralateral lid drops > or = 1 mm were present in 7/54 patients, and 6/14 (43%) of them had greater ptosis on the dominant side and 1/40 (2.5%) on the non-dominant side (p = .001). There was no association between contralateral pseudoretraction and either visual acuity or severity of ptosis. These results suggest that levator muscle tone is influenced by eye dominance when ptosis is present. The preoperative evaluation of unilateral or asymmetrical bilateral ptosis cases should include the Scobee and phenylephrine tests to unmask contralateral upper lid pseudoretraction.

Monopolar electrocautery in the cutting mode is a superb surgical technique in many types of oculoplastic surgery because it efficiently dissects tissue with excellent hemostasis. The purpose of this article is to define how monopolar electrocautery functions and point out specific steps of certain oculoplastic procedures in which electrocautery dissection is useful. We have found it to be a helpful adjunct in over 1,200 clinical cases. We review the problems with electrocautery reported in the literature and discuss ways to avoid them.

This light and electron microscopic study demonstrates an elastic fiber network (EFN) for the levator palpebrae superioris muscle complex, which forms an intricate insertion into the upper eyelid. The EFN is examined in the monkey, in a fresh exenteration specimen, and in fresh frozen cadaver specimens from both sexes of different age groups. Multiple elastic insertions of the levator aponeurosis and Muller's muscle attachment with well-organized elastic fibers are demonstrated using special staining techniques and serial microscopic sectioning. Transmission electron microscopy (TEM) confirms the ultrastructure of "mature" elastin fibers in Muller's muscle tendon and their close relationship with the elastin-related fiber, oxytalan. Current thinking concerning the nature of elastic fibers and their possible implications in acquired involutional blepharoptosis is discussed. This microscopic study of the EFN of the upper eyelid focuses attention on the multiple elastic fiber insertions of the levator muscle complex that includes the levator aponeurosis, the conjoined fascia, the lid crease area, and Muller's muscle tendon, which have not been previously described.

Botulinum toxin has recently been used as a nonsurgical treatment for blepharospasm and other facial dyskinesias. This report describes four patients between the ages of 32 and 37 years who failed to respond to botulinum injections for severe blepharospasm. Other than age, no other features could be identified in these patients that would differentiate this group. Particularly early age of onset for essential blepharospasm might be an indicator of failure to respond to the injections.

Objective To evaluate the differences between Asian and Caucasian upper eyelid anatomy through cadaver dissection, histopathological study, and magnetic resonance imaging. Materials and Methods Upper eyelids of 9 Korean and 5 Caucasian cadavers were dissected, and then were studied microscopically with hematoxylin-eosin, Masson trichrome, and elastin stains. Four healthy young Korean men were studied by dynamic high-resolution magnetic resonance imaging with regard to demonstration of upper eyelid structure. Results More subcutaneous and suborbicularis fat, with a pretarsal fat component, is present in Asian eyelids. The Asian double eyelids showed an amount of fat intermediate between Asian single eyelids and Caucasian eyelids. Asian single eyelids showed fusion of the orbital septum to the levator aponeurosis below the superior tarsal border, while fusion is above the superior tarsal border in Caucasians. The preaponeurotic fat pad descends anteriorly to the tarsal plate in the Asian single eyelid, but not in the Caucasian eyelid. A pretarsal fat pad is identified in the Asian single eyelids. Conclusions The causes of absent or lower crease in the Asian upper eyelid are as follows: (1) the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border; (2) preaponeurotic fat pad protusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Structural differences relating to increased fat in the Asian upper eyelid include the presence of a pretarsal fat pad and a moderate fat increase in the double Asian eyelid.

A 43-year-old woman had unilateral exophthalmos caused by primary orbital Ewing sarcoma. Specialized immunohistochemical stains, primarily MIC-2 (CD99), aided in the diagnosis of Ewing sarcoma. Twenty-two months after radiotherapy and multiagent chemotherapy, the patient remained tumor free. To our knowledge, this is the first reported case of orbital Ewing sarcoma to present in an adult beyond the fourth decade of life.

Distichiasis is a rare congenital or acquired condition in which an accessory row of eyelashes arises from the posterior lamella of the eyelid margin. Previously described surgical techniques to treat distichiasis can result in complications including trichiasis, loss of normal eyelashes, cicatricial entropion, and eyelid margin deformities. We describe a new technique in which the eyelid margin is split to expose the distichiasis eyelash follicles. Each aberrant eyelash follicle is individually excised or microhyfrecated and then removed. Seventeen eyelids in 5 patients with congenital or acquired distichiasis have been treated. We have achieved excellent functional and cosmetic results using this new technique.

Retrobulbar injection is a routine procedure for achieving akinesia and anesthesia prior to ophthalmic surgery. Previously reported complications to this procedure have included central nervous system toxic effects, globe perforation, retinal vascular occlusion, optic nerve damage, extraocular muscle palsies, ptosis, and retrobulbar hemorrhage. 1 Visual loss has been reported following retrobulbar hemorrhage from retrobulbar and even peribulbar anesthesia. 2 We report a case of subperiosteal orbital hemorrhage following a retrobulbar injection resulting in permanent severe visual loss. Report of a Case. An 81-year-old woman was transferred emergently for evaluation of a retrobulbar hemorrhage of her left eye that occurred within minutes of receiving a retrobulbar injection prior to a planned cataract extraction. The patient was not receiving any anticoagulant medications. A lateral canthotomy and inferior cantholysis had been performed by the referring ophthalmologist for intraocular pressure as high as 80 mm Hg. The patient had also been started on a

Primary liposarcomas occur only rarely in the orbit. 1 Liposarcomas can be divided into four distinct histologic types: well differentiated, myxoid, round cell, and pleomorphic, with myxoid being the most common. Twenty-two cases of orbital liposarcoma have been reported in the literature, nine of which were myxoid. 1-4 There are no characteristic clinical findings or diagnostic tests that are specific for this tumor. No predilections for sex, location within the orbit, or age have been described, although people with the myxoid type tend to be younger than those with other cell types. The most common presentations are painless proptosis of insidious onset and diplopia. There is only one report of painful proptosis as a primary symptom. 4 Report of a Case. A 45-year-old woman reported the sudden onset of sharp pain and swelling in her medial left lower lid over a 2- to 3-day period. The swelling in her lower

We describe 10 patients with inverted papillomas (IPs), uncommon endophytic epithelial tumors that arose in the nose, paranasal sinuses, and lacrimal sac, that invaded the orbit; review the world literature on IP; and discuss treatment options. Patients ranged in age from 49 to 72 years (mean age, 62 years; median age, 66 years). Six patients were men and four were women. Presenting symptoms and signs included a medial canthal mass (n = 5), epiphora/lacrimal drainage obstruction (n = 3), inability to wear eyeglasses (n = 2), diplopia (n = 1), and painful dentures (n = 1). Histopathologic examination was performed in each patient and revealed all patients to have areas with malignant transformation: six patients with IPs that contained areas of squamous cell carcinoma and four with areas of transitional cell carcinoma in the tumor within the orbit. Eight of the patients with IPs had a recurrence after initial resection. In two patients, the IPs were completely excised and did not recur; yet, follow-up was short. Eight patients required orbital exenteration for local control of disease. Nevertheless, local spread of tumor through bone to brain occurred in three patients with orbital involvement. Indeed, IPs that invade the orbit have a high incidence of malignancy and are locally aggressive tumors. Treatment is difficult, and the recurrence rate is high. Early, wide excision of this aggressive tumor provides the best chance of cure.

The purpose of this book is to describe procedures in ophthalmic plastic surgery that the author, based on his experience and that of many colleagues, has found most useful over the course of time. The text is not intended to be encyclopedic, and few of the operations are new. It is directed in particular toward the less experienced surgeon in ophthalmic plastic surgery procedures, namely, residents and those who perform these operations less frequently. The atlas is organized into three parts based on surgery in the three major areas of ophthalmic plastic surgery—eyelid, lacrimal drainage system, and orbit. Each of these three major divisions is introduced by a section on the relevant surgical anatomy and an overview of related general principles. The three sections are further subdivided into related procedures, each preceded by a description of the underlying pathologic characteristics, preoperative evaluation, and proper selection of procedure. Each operation is

A canalicular stenosis was identified in 29 of 66 (44%) children and 35 of 80 (44%) lacrimal drainage systems undergoing silicone intubation for congenital nasolacrimal duct obstruction, having previously had unsuccessful probings. The stenoses were equally divided between boys and girls and between right and left sides. There was no significant difference in age at the time of probing, number of prior probings, or age at intubation between children with and without canalicular stenosis. Stenoses may be congenital or acquired as a result of faulty probing. Any child undergoing a second lacrimal procedure after a failed probing should be evaluated for evidence of a canalicular stenosis. If a stenosis is present, a silicone stent should be placed to try to salvage the canaliculus.

• Colloid solutions of technetium Tc 99m and india ink injected into the retrobulbar space of the cynomolgus monkey outside the extraocular muscle cone were removed from the orbit by the lymphatic vessels of the conjunctiva and eyelids and were then concentrated within the lymph nodes that drained the conjunctival and eyelid areas. Colloid solutions injected into the retrobulbar space inside the extraocular muscle cone did not reach the conjunctiva and did not collect in any lymph nodes over a 24-hour period. Within the orbit, the injected colloids spread along the planes of the connective-tissue septa. No lymphatic vessels were identified within the orbits posterior to the conjunctiva. Small amounts of india ink left the posterior orbit and ultimately entered the contralateral orbit. This posterior pathway did not lead to lymphatic vessels or lymph nodes and therefore does not appear to represent a prelymphatic pathway.

We performed 63 intubations with silicone tubing for nasolacrimal duct obstruction in children in whom nasolacrimal duct probings had failed. Fifty-nine (93.7%) obstructions were congenital and four (6.3%) were acquired. The average length of intubation was 4.3 months. The final results for both congenital and acquired obstructions combined were good in 52 cases (82.5%), fair in three (4.8%), and poor in eight (12.7%). Complications, with the exception of some with infection, were easily treated or minimal and did not affect the outcome significantly. We recommend silicone intubation as the procedure of choice for congenital or acquired nasolacrimal duct obstructions in children after failure of medical therapy and nasolacrimal duct probings.

Resection of the superior tarsal muscle (STM) is effective in correcting congenital or acquired blepharoptosis in patients who have satisfactory elevation of the eyelid with a preoperative phenylephrine eye drops test. Advantages of this procedure are that only the STM is resected, the conjunctiva and basic lacrimal secretors are preserved, tarsal stability is maintained, no special instruments are required, and the preoperative phenylephrine eye drops test reliably predicts the postoperative result.

Magnetic resonance has twin capabilities. It can provide anatomical (magnetic resonance imaging, MRI) and physiochemical (magnetic resonance spectroscopy) information. Nuclei with an odd mass number, particularly hydrogen in free water, have electromagnetic properties. When placed in a strong static magnetic field and excited by radiofrequency waves of a specific wavelength, these nuclei emit a signal. The MR signal can then be digitized, stored in a computer, and subsequently converted into an image. Factors that affect these images are tissue parameters (T1 and T2 time constants, proton density, and flow) and radiofrequency pulse sequences. Surface coils are useful for improving images of the orbit. The magnet can have a major and potentially dangerous influence on the surrounding environment, and access to the MRI area must be carefully controlled. Shielding of the MRI room prevents external factors from adversely affecting the MRI unit and the images produced.

Enucleation is more likely to be associated with certain intraoperative and postoperative complications but remains the procedure of choice in cases where detailed histopathologic examination of the globe is required, in many cases of intraocular neoplasm, and in selected cases of ocular trauma with visual loss. In many patients, evisceration results in enhanced cosmesis compared to enucleation and is a technically simpler and faster operation. Evisceration may be indicated in patients with blind and unsightly or painful eyes and in selected instances of ocular trauma following discussion of the risk of sympathetic ophthalmia with the patient. It is contraindicated in patients with possible intraocular malignancy. In appropriate cases, a cosmetic shell or contact lens may constitute an alternative to enucleation or evisceration, and may provide superior cosmesis. Management of patients requiring these procedures should be tailored to the particular clinical situation with consideration of the wishes of the well-informed patient.

51 patients with orbital floor fractures were studied retrospectively to evaluate results in relation to time of surgical repair and fracture size. Early repair (less than 2 months) gave better results than late repair (greater than 2 months) in regard to both enophthalmos and extraocular muscle dysfunction. Large fractures (greater than one-half floor or greater than or equal to 15 fracture volume units) were most likely to be associated with significant enophthalmos after surgery. We recommend tomography when necessary to estimate fracture size, and advise early repair of large fractures, preferably within two weeks after injury. Patients with significant extraocular muscle dysfunction due to tissue entrapment, regardless of fracture size, should be repaired early, preferably within 2 weeks after injury, if improvement does not occur spontaneously by that time.

Medial wall fractures are often overlooked during routine radiographic examination and rarely develop complications. We present complications associated with medial wall fracture in six cases. Complications from medial rectus muscle entrapment include restricted and painful abduction, pseudo-sixth-nerve paresis and pseudo-Duane's-retraction syndrome. Massive orbital emphysema, in one case, was responsible for temporary loss of vision prior to definitive treatment. Two patients developed severe enophthalmos secondary to the medial wall fractures. We suggest that orbital exploration is indicated for painful or limited ocular motility, significant diplopia, severe orbital emphysema, or severe enophthalmos. An inferior approach to the medial wall through the lower eyelid provides good exposure and minimal cosmetic deformity. Postoperative complications included transient paresis of the medial rectus muscle, residual motility disturbance, and residual enophthalmos.

Most complications in lower eyelid blepharoplasty by the anterior approach can be prevented if the surgeon has a thorough knowledge of the anatomy and physiology of the lower eyelid and anterior orbit, selects the proper procedure to correct the patient's specific problems, is meticulous in his technique, and provides appropriate postoperative management. Particular attention should be paid to hemostasis prior to wound closure and to avoiding postoperative ectropion or retraction of the lower eyelid.

Twenty-two cases of lacerated canaliculi were repaired with the use of silicone tube stents. Of the 18 patients having early repair, 17 (94%) had a good result and one (6%) fair. The four patients with late repair yielded three (75%) with a poor result and one (25%) fair. Primary repair of lacerated canaliculi by this method has a good prognosis. Secondary repair is more difficult, and the outcome is likely to be poor.

• Symptomatic maxillary sinus cysts are diagnosed less frequently than similar cysts of the frontal and ethmoidal sinuses and are rarely reported in the ophthalmic literature. Patients with cysts of the maxillary sinus may present to the ophthalmologist with proptosis, enophthalmos, diplopia, ptosis, epiphora, and, rarely, decreased visual acuity. Four patients with maxillary sinus mucoceles are presented; one of these patients had a concurrent retention cyst in the orbit. Clinical history, radiologic findings, and histopathologic mechanisms are discussed. Mucocele is a recognized complication of the Caldwell-Luc procedure and midface trauma. Blockage of the sinus ostia was the cause previously proposed to explain antral mucocele development. Clinical and histopathologic features may support more than one single mechanism for the pathogenesis of maxillary sinus cysts. Maxillary sinus mucocele or retention cysts should be considered in the differential diagnosis of exophthalmos or enophthalmos following blowout fracture of the orbital floor.