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Intravascular papillary endotelial hyperplasia is a bening vascular lesion that rarely involves the periocular region, nevertheless, it should be considered in the differential diagnosis of a periorbital mass. It is histopatologically characterized by intravascular fibrous papillary fronds covered by endothelial cells. Histopathological differentiation from angiosarcoma can be challenging but is very important to avoid aggressive treatments. Complete surgical excision is frequently curative. Uncompleted excision can lead to recurrences. We describe the clinical and histological findings of intravascular papillary endotelial hyperplasia in the left lower lid of a 72-year-old woman who had a painless mass since 15 years ago, that caused hypertropia of her left eye. Histopathological examination revealed intralesional calcification, which is not an usual feature in this entity. The patient underwent complete surgical resection of the mass and there was no evidence of recurrence after 5 months of follow-up after surgery.

Purpose: Botulinum toxin (BTX) injections are used in cosmetic surgery to efface facial wrinkles. Botulinum toxin relaxes the muscle by preventing the release of the neurotransmitter acetylcholine at the neuromuscular junction located at the posterior muscle surface causing local muscle paralysis. The purpose of this study is to provide anatomic knowledge of muscle belly depths of the frontalis, corrugator supercilii, procerus, and orbicularis oculi muscles in an attempt to improve the efficacy of BTX treatment of glabellar, forehead, and lateral eyelid rhytides. Methods: Six-millimeter punch biopsies were obtained from 7 fresh cadavers. Biopsies were taken from the corrugator supercilii, frontalis, procerus, and orbicularis oculi muscles at the sites of routine BTX injection. Specimens were fixed in formalin, and representative H&E-stained sections were used to measure muscle surface depths by light microscopy equipped with digital camera that includes a digital micrometer. One-way analysis of variance test analyses were used to identify statistical differences between measured muscle depths. Results: The measured anterior muscle depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 4.2 ± 0.6, 3.9 ± 0.6, 2.9 ± 0.4, and 2.3 ± 0.7 mm, respectively. The anterior muscle surface of the corrugator supercilii and frontalis was found to be deeper than that of the procerus and orbicularis oculi ( P < .001). The posterior surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 6.6 ± 0.8, 5.1 ± 0.7, 4.9 ± 0.7, and 3.8 ± 1.0 mm, respectively. The posterior surface depth of the corrugator supercilii was found to be significantly deeper than that of the frontalis, procerus, and orbicularis oculi ( P < .001); the posterior surface depth of the frontalis and procerus was deeper than that of the orbicularis oculi ( P < .001). The muscle belly width of the corrugator supercilii, frontalis, procerus, and orbicularis oculi measured 2.5 ± 0.9, 1.1 ± 0.4, 2.0 ± 0.6, and 1.5 ± 0.5 mm, respectively. The corrugator supercilii was found to be thicker than the frontalis and orbicularis oculi, while the procerus was found to be thicker than the frontalis ( P < .001). Conclusion: The findings above demonstrate statistical differences in the posterior muscle surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi which can be used clinically to improve BTX injection efficacy when used to efface facial rhytides.

Sebaceous carcinoma (SC) is a rare, aggressive malignancy. Most lesions occur in the periocular region, with few cases presenting with extraocular lesions. Here, we report a case of an 89-year-old woman with a 3-month history of a rapidly growing giant extraocular SC. The diagnosis was based on skin biopsy findings. We advised the patient to undergo surgical excision of the carcinoma. However, the patient and her family rejected our proposed surgical treatment, opting for topical traditional Chinese medicine as alternative treatment. The patient subsequently died of unknown causes at home, four months after the first visit. This case of treatment failure emphasizes the importance of early detection and treatment for these aggressive tumors.

The periocular region is challenging for cosmetic laser surgeons. Surgery and laser resurfacing have traditionally been used to correct periorbital lines and wrinkles. Although effective, the associated downtime with these methods has made many people reluctant to decide for such treatments. More recently, the non-ablative long-pulse 2940 nm Er:YAG laser is being used to improve the structure and function and hence the appearance of skin in the periorbital region. The objective of this study is to evaluate the safety and efficacy of long-pulse 2940 nm Er:YAG laser for non-ablative treatment of periorbital static wrinkles and skin laxity. This is a prospective analysis of 30 patients treated for periorbital rejuvenation using three sessions of non-ablative long-pulse Er:YAG laser over a 3-month period. All patients were assessed according to Fitzpatrick’s classification of periorbital wrinkles to class I, II, or III and were treated with 2940 nm Er:YAG laser using a fluence of 3.75 J/cm2, a repetition rate of 1.7–2 Hz, and with the SMOOTH™ pulse mode (250 ms). The treatment sessions were performed on each patient, 4 weeks apart. Patient improvement was assessed before each laser session as well as at 12 months after the final treatment. Blind photographic evaluations were performed by three independent physicians using unlabeled before and after photos arranged in non-chronological order. Reviewers were asked to determine the before and after photos. Patients were asked to answer a questionnaire measuring satisfaction 4 weeks after each session, and to report any adverse reactions. There was statistically and clinically significant improvement in the Fitzpatrick classification of the periorbital wrinkles. Blinded evaluators correctly identified the before and after photos in all cases. All patients reported mild edema and erythema, which persisted for 1 to 2 days, and superficial peeling of the skin for 4 to 6 days after each laser treatment. No long-term adverse effects were reported. The non-ablative long-pulse 2940 nm Er:YAG laser seems to be a safe and effective treatment for periocular rejuvenation with minimal and tolerable adverse reaction. The improvement attained from the laser sessions was persisting after 1 year denoting the long-term efficacy of the procedure.

Background: The reconstruction of the upper eyelid and the periorbital region is a challenge for the surgeon. The aims of this reconstruction are to guarantee protection to the eyeball, maintain the visual field, and restore the function of the eyelid without damaging other anatomical structures. In this study, the authors describe the use of a propeller myocutaneous flap based on the small vertical branches of marginal, peripheral ed superficial arcade, for the reconstruction of the upper eyelid or periorbital region. Materials and methods: The authors enrolled 3 patients (Caucasian), between 2018 and 2019, and subjected to reconstructive surgery with the propeller myocutaneous flap of the periorbital region at the Plastic Surgery Unit of the University of Messina. The vascularization of the flap was demonstrated through an anatomical study conducted on cadavers at the dissection laboratories of the University of Bordeaux 2. Results: The authors have shown that the myocutaneous flap represents a valid alternative for loss of substance coverage and reconstruction of the upper eyelid or periorbital region, allowing the achievement of a good aesthetic and functional result. Follow up: Patients were followed up at 3-6-12 months. No complications were reported (flap retraction, periocular region deformity, donor site morbidity). Furthermore, at the last visit, the scars were almost invisible. Conclusions: The use of the propeller myocutaneous flap of the upper eyelid is a valid reconstructive alternative to the standard techniques described so far for the reconstruction of the periorbital region.

Giant cell tumor of soft tissue (GCTST) is a rare neoplasm genetically unrelated but histopathologically indistinguishable to its osseous counterpart. Histologically, GCTST is characterized as a multinodular proliferation of bland histiocytoid mononuclear cells intermixed with osteoclast-like giant cells. GCTST most commonly presents as a soft-tissue mass located in the extremities of middle-aged adults. In this report, we describe a case of a dermal GCTST arising in the periocular region of a 3-year-old girl. This is the youngest patient diagnosed with GCTST reported in the literature and is also singular because of its anatomic location: Only a handful of head and neck GCTSTs have been reported to date. Furthermore, GCTST most often presents as a superficial or deep soft-tissue mass and much less commonly as a dermal-based skin tumor, as was our case. On microscopic examination, the resected lesion demonstrated classical features including numerous osteoclast-like giant cells embedded in a background of mononuclear ovoid cells which displayed brisk mitotic activity and were surrounded by variable stromal hemorrhage. Tumor cells presented a vaguely fascicular arrangement. Immunohistochemical profile demonstrated positivity for smooth muscle actin and CD68 and negativity for desmin, myo-D1, S100, HMB-45, Melan-A, p16, and NKIC3. The unusual characteristics of this case emphasize the clinicopathologic heterogeneity of GCTST.

Objectives. Basal cell carcinomas (BCCs) are malignant tumors which rarely metastasize, are slow-growing, and extensively locally destructive. BCCs more than 5 cm in diameter are defined as giant. Most often they arise as a result of neglect, as the patient avoids, delays, or refuses to see a doctor. The large tumor diameter and consequently of the post-excisional defect make these lesions difficult to treat surgically with respect to selecting the surgical reconstruction technique. Method. We studied a group of 9 patients, aged 60 to 85 years, diagnosed with giant basal cell carcinomas (GBCCs) with periocular location in which surgery was indicated. Results. In all cases, complete excision with histologically clear margins was performed and for the coverage of the remaining defect various, complex, and sometimes two-stage reconstructive techniques were used. Conclusions. Giant cell carcinoma of the periocular region requires extensive and risky surgery, especially when performed on the elderly. Early referral to a doctor avoids all these risks, in all cases the pathological diagnosis was nodular BCCs. The aesthetic and functional outcomes were good to very good, and the patients reported being highly satisfied.

Traditionally, second intent healing (SIH) in the periocular region is reserved for small and/or concave defects, particularly those located on the medial canthus. The purpose of this study was to identify factors impacting outcomes of SIH for periocular tumors following Mohs micrographic surgery (MMS). Retrospective analysis was performed of all periocular lesions treated with MMS followed by SIH from a single academic surgical center over a 5-year period. Data regarding tumor characteristics and follow-up was recorded. The modified Manchester scale was utilized to evaluate scar outcomes. Of the 39 tumors included, 14 (35.9%) were located on the lower eyelid, 12 (30.8%) on the upper eyelid, 6 (15.4%) on the lateral canthus, and 7 (17.9%) on the medial canthus. Involvement of the eyelid margin was seen in 11 (28.2%) of cases. The average defect diameter and area were 1.3 cm and 1.04 cm-squared. Twenty-three cases (59.0%) healed with optimal results. Larger defects were significantly associated with poorer outcomes of SIH (odds ratio 0.205, p = 0.017 by multivariate analysis). Anatomic location, involvement of the lid margin, age, and follow-up interval were not significant factors; however, medial canthus defects were least likely to heal with optimal results. On average, medial canthal lesions were larger in size (mean diameter 1.76 cm, mean area 1.97 cm-squared). This retrospective study suggests that periorbital defects in all locations with area less than 1.04 cm2 heal well by SIH. In this cohort, larger lesions on the medial canthus healed with worse outcomes.

Summary Background: Application of distant skin flaps in facial defect reconstruction has limitations such as leaving a patch like appearance and being restricted by the length of the vascular pedicles. Leveraging the abundance of blood supply from superficial muscular aponeurotic system (SMAS), a local skin flap pedicled by SMAS can be used to avoid the aforementioned problems. Herein, we report the clinical application as well as the anatomical study of SMAS-pedicled skin flaps. Methods: This study enrolled patients who underwent facial defect reconstruction surgery between 2013 and 2018 using SMAS-pedicled skin flaps. The flaps were designed according to the size and location of the defect. A follow-up was performed to evaluate the treatment outcomes and incidence of adverse events. In addition, six cadaveric heads were used to perform an anatomical study on the distribution and blood supply of SMAS. Results: Twenty-three cases underwent the defect reconstruction surgery in the frontal regions (three cases), temporal region (four cases), periocular region (four cases), nasal region (seven cases), and other regions (five cases). All the flaps survived well. During the follow-up period up to 12 months, the flaps showed a satisfactory appearance, blood supply, and elasticity. The distribution and blood supply of SMAS at different anatomical regions have been successfully observed. Abundant vascular networks could be found in the SMAS layer. Conclusion: Based on the broad distribution of SMAS and the abundant blood supply, an SMAS-pedicled skin flap could be flexibly designed and versatilely used to reconstruct post-traumatic or post-excisional facial defects.

Objective The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with “histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation.” An expert consensus was sought to create a standardised approach in the use of this novel treatment. Methods Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. Results The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. Conclusions These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

Introduction: Intravascular papillary endothelial hyperplasia (IPEH) is a rare proliferation of endothelial cells with uncertain etiology related to thrombus formation. Diagnosis is usually confirmed histopathologically. This condition has been previously described in the periocular region but not in the conjunctiva. Methods: It is a retrospective case series in which we evaluated seven patients with histopathologically confirmed IPEH cases. Data regarding the demographics, clinical presentation, radiological description, histopathological features including any IHC staining, suspected underlying vascular etiology, management options, and follow up outcome were collected. Results: A total of seven cases of histologically confirmed IPEH were included. Five out of seven patients were male (71.4%). The age range was between 6 and 69 years with a median age of 36 years. Three cases involved the eyelid (42.8%) and another three were found in the conjunctiva (42.8%). Pre-existing underlying vascular lesions were observed in all patients, five malformations (mostly lymphatic-venous) and two conjunctival hemorrhagic lymphangiectasis. All cases were treated with excisional biopsy with no signs of recurrence within an average of 7 months follow up. Conclusions: Periocular IPEH is a rare tumor that is likely to coexist with underlying vascular lesions and thrombus formation. We are reporting its existence in the conjunctiva for the first time. Therefore, pathologists should be aware of the histopathological spectrum of this lesion.

Ophthalmic problems account for up to 20% of emergencies in equine practice. Presenting problems may involve the periocular region, adnexa, or globe. Practitioners must have the experience to restrain horses with painful ocular conditions and the knowledge of how to perform a thorough eye examination. A range of clinical skills is required for the necessary diagnostic tests such as corneal cytology, ultrasound and tonometry, and common standing surgical procedures such as eyelid repair or instillation of a subpalpebral lavage system. Therapy, which may involve frequent administration of multiple medications, must be targeted to the specific diagnosis.

The periorbital area is the first area of the face to show signs of aging. To provide safe and natural looking rejuvenation of the delicate eyelids, and supporting structures, an advanced understanding of anatomy, ideal facial proportions, and the most effective methods for rejuvenation is discussed. Periocular rejuvenation is particularly challenging due to the intricate and delicate anatomy of the periocular area. To ensure safe and successful outcomes, it is crucial that injectors use a global approach when providing treatments and that they consider soft tissue, vasculature, and bone structure of the periocular region before administering treatments for aesthetic rejuvenation. Neuromodulators, specifically botulinum toxin A (BoNT-A), and hyaluronic acid (HA) dermal fillers are 2 nonsurgical treatments frequently used to address signs of aging in the periocular area. The objective of this article is to review different BoNT-A and HA filler treatments and discuss how these treatments can be used for optimal rejuvenation of the periocular area.

An unusual case is presented of a 29 year-old Caucasian woman with a granuloma in an old scar in the right periocular region as a first clinical sign of a systemic sarcoidosis. An excisional biopsy was performed, for which the histological diagnosis was a chronic non-necrotising granulomatous inflammation, suggestive of scar sarcoidosis. The lesion re-appeared one year after initial treatment, and was treated with intralesional depot steroids, showing adequate progression. This disease occurs more frequently in wound areas where there are foreign bodies and could be the first sign of systemic sarcoidosis.

OBJECTIVE To determine the lesion distribution patterns in different breeds of dogs affected by atopic dermatitis in South Australia. METHODS The presence or absence of erythematous skin lesions in 267 cases of canine atopic dermatitis (CAD) was recorded across 36 anatomical sites. Breeds represented by ≥ 9 dogs were included in the analysis. The percentage of dogs showing lesions at each of the body sites was calculated and illustrated on colour-coded diagrams. Variations in affected body sites within and between breeds were compared using Kruskal-Wallis ANOVA and Dunn's multiple comparison tests. RESULTS The prevalence of skin lesions at different body sites differed significantly both in the population as a whole and within breeds. The sites affected in ≥ 75% dogs were the dorsal and ventral aspects of the front and hind paws. The sites affected in 50-74% were the medial pinnae, axillae, ventral chest, abdomen and perineum. Sites affected in 25-49% of dogs included the face, periocular region and forelimb. Remaining body sites were affected in < 25% of dogs. Analysis at the breed level revealed some differences from this standard distribution pattern. CONCLUSION The results of this study confirmed the typical lesion distributions seen in CAD and highlighted some subtle differences in breeds commonly seen in South Australia. This will be useful for clinical practitioners in prioritising differential diagnoses for pruritic skin conditions.

Objectives To illustrate the varying clinical presentations of cutaneous sarcoidosis affecting the periocular region, which may masquerade as other clinical entities such as basal cell carcinoma or seborrheic dermatitis. Furthermore, the authors present an unusual observation of lupus pernio involving the adnexal region with the rare presence of perineural granulomas on histology following incisional biopsy. Methods We report a consecutive series of four cases with lesions involving the eyelids with varying clinical appearances. All four patients presented to our adnexal service undergoing incisional diagnostic biopsy. Histology following biopsy subsequently resulted in further investigation and management of both local cutaneous lesions and systemic sarcoidosis. Results Three of our four cases had evidence of pulmonary involvement on chest X-ray. Over an 18-month period, one of two patients responded to intralesional triamcinolone and subsequently to oral methotrexate (15 mg/week). Two patients were observed with their periocular lesions remaining stable without therapy. Conclusions All four patients presented to the adnexal service with lesions of varying morphology and were diagnosed with sarcoidosis following incisional biopsy highlighting the vital role of oculoplastic surgeons in diagnosing this multisystem inflammatory disease. We describe our experience of intralesional triamcinolone, oral methotrexate and watchful observation in the management of such lesions.

Purpose To longitudinally evaluate for changes in globe position as part of the natural aging process. Methods A Cleveland Clinic Foundation imaging database of all head imaging scans performed from 1995 to 2017 was used to identify adults with normal orbits undergoing imaging studies at least 20 years apart. A total of 100 patients (200 globes) who had CT or MRI scans were studied. Globe position was determined by measuring the distance from the anterior aspect of the cornea to the zygomaticofrontal processes baseline. Clinically significant changes in globe position were defined as changes of ≥2 mm posteriorly (enophthalmos) or anteriorly (exophthalmos). Results On average, globe projection decreased by 0.25 ± 2.3 and 0.26 ± 2.2 mm in the right and left eyes, respectively. Clinically significant enophthalmos with age was measured in 55 (27.5%) globes in 35 (35%) individuals, while clinically significant exophthalmos with age was measured in 43 (21.5%) globes in 26 (26%) individuals. The proportion of cases that developed enophthalmos, exophthalmos, or experienced no change were not significantly different from each other (p = 0.26). No patients developed clinically significant enophthalmos in one eye and exophthalmos in the other. Conclusions Adults may develop clinically significant enophthalmos, exophthalmos, or no change in globe position over a 20-year period. This lack of uniform change in globe position with age impacts surgical considerations for treatment of the aging periocular region.

Background The main challenge of periocular fat grafting is the risk of contour irregularities, especially in the lower eyelid. Injection of diluted fat can decrease the likelihood of poor contour. Objectives The authors developed a simple method of periocular fat grafting in which the fat was harvested through unconventional cannulas and diluted before the injection to avoid the risk of contour irregularities. Methods A retrospective study was conducted on 200 patients who underwent fat grafting to the periocular region. Lipoaspirate was obtained through a 0.5-mm multiple-hole cannula and then was centrifuged. A solution of 70% fat was prepared (ie, properly diluted fat [PDF]) with saline and infranatant fluid as the diluent. The recipient site was tunnelized with a 1.2-mm cannula, and PDF was transferred utilizing a 1.2-mm cannula containing a single 1-mm hole. Aesthetic improvement was ascertained from pre- and postoperative photographs evaluated by 3 examiners. Results A total of 164 (82%) patients received follow-up 6 months postoperatively, and 83 of these patients (41.5%) returned for monitoring 1 year postoperatively. Nearly all patients had improvement in periocular contour, but variable loss of volume was observed by 1 year. Patients who presented initially with scleral show often had noticeable improvement. At 1 year, only 3 patients experienced contour irregularities comprising soft bulges, similar to fat hernias. Two patients showed fat accumulation after substantial weight gain later than 1 year postoperatively. Conclusions Preparation and periocular delivery of PDF by the described techniques yield good contour with a low risk of visible masses occurrence. Level of Evidence: 4

Sebaceous carcinoma is a malignant neoplasm of the sebaceous glands, which is most often found in the periocular region. Periocular sebaceous carcinoma is frequently found arising from the meibomian glands within the tarsus, especially on the upper eyelid. Other ocular sites include the caruncle, Zeiss glands, eyebrow, and conjunctiva. The most common presentation of periocular sebaceous carcinoma is a fixed, non-painful eyelid nodule. Diagnosis of sebaceous carcinoma requires biopsy and histopathological examination. Given the neoplasm’s ability to undergo subclinical pagetoid spread, conjunctival map biopsies are recommended to help guide treatment of sebaceous carcinoma. The mainstay of treatment for sebaceous carcinoma is surgical excision of the primary lesion. Both wide local excision and Mohs micrographic surgery have been successfully employed for surgical management of the ocular neoplasm. This chapter takes an in-depth look at ocular adnexal sebaceous carcinoma including its epidemiology, pathogenesis, origins, clinical presentation, differential diagnoses, histology, diagnosis, management strategies, and prognosis.

The face is the most important area of the entire body when assessing one’s physical beauty and attractiveness. The face itself is composed of numerous cosmetic subunits. The eyes and periocular region, in particular, play a very important role in aesthetics as well as expression of one’s mood. As the population continues to age, the number of cosmetic procedures performed annually continues to increase. While a great number of the procedures are in the noninvasive realm such as injectables, blepharoplasty was the fifth most common surgical procedure performed in 2018 based on the American Society for Aesthetic Plastic Surgery (Surgery, T. A. S. f. A. P., Cosmetic (Aesthetic) Surgery National Data Bank, 2018). Blepharoplasty is a relatively simple procedure that has minimal downtime for patients and can provide a significant impact in restoring the youthfulness of the face.

Purpose Langerhans cell histiocytosis (LCH) is a disorder of dendritic cell proliferation that typically involves bone. It can be diagnostically challenging when LCH presents without bony involvement, leading to delays in diagnosis and treatment. In this study, the periocular manifestations of LCH in cases where the underlying orbital bones are not involved are described through a systematic review. Methods A systematic review of the literature was performed to capture all cases of LCH that involved the periocular region but not the underlying orbital bones. These included LCH cases that involved the periocular skin, the ocular surface, and the orbital tissue. The authors also highlight an additional case where LCH presented with periocular edema and multifocal, nodular conjunctival lesions. Result This review illustrates that LCH rarely presents with periocular infiltration without orbital bone involvement. In these atypical cases, LCH can present as an eyelid mass, a chalazion-like lesion, generalized periocular swelling, ocular surface lesions, or infiltration of any orbital structure. Ocular surface LCH has a higher rate of recurrence than other periocular LCH. Orbital LCH can involve any tissue including extraocular muscles, the lacrimal gland, or indistinct areas within the orbit. Conclusions LCH is a clinicopathologic diagnosis. Although most cases involve the bone, any soft tissue can be involved. Biopsy is required to confirm the diagnosis of this heterogeneous disease.

Mixed tumour of the skin is a rare entity also known as chondroid syringoma and pleomorphic adenoma. These usually present as slow-growing skin nodules with a smooth surface, clear boundaries, and no ulceration. Case series exist describing pleomorphic adenomas in the periocular region including the lids and orbit, separate to the more familiar lacrimal gland pleomorphic adenoma. These may arise from accessory or ectopic lacrimal gland tissue but in the eyelids are more likely to arise from sweat glands in the skin. Histopathological analysis of these lesions is important to identify complete excision, minimising recurrences and in identifying rare but potential malignant transformation. We describe the clinical features and outcomes in three cases of pleomorphic adenoma with two at the medial canthus (including one recurrence) and one in the brow region.

Surgical management of thyroid eye disease (TED) has two general aims: (1) relieve symptoms of orbital congestion and fibrosis, including possibly compressive optic neuropathy, and (2) reconstruct the periocular region to reduce deformity and renormalize appearance. Surgical management follows a sequence that is tailored to individual patient needs. The signs and symptoms of TED that can be addressed surgically include proptosis, orbital pressure/pain, orbital inflammatory signs, diplopia secondary to restrictive strabismus, ocular surface exposure secondary to lagophthalmos, and eyelid retraction. Because orbital decompression surgery can improve lagophthalmos and eyelid retraction, and can affect strabismus (positively or negatively), these issues are traditionally addressed sequentially by orbital decompression first, followed by strabismus surgery, and finally eyelid retraction repair, as needed. In this chapter, we focus primarily on orbital decompression surgery and eyelid surgery, although key aspects of strabismus surgery are also discussed.

The periocular region sees high rates of cancer compared to the rest of the body and can be affected by several unique tumors. Treatment typically involves surgical excision, although adjunctive therapies and prognosis vary depending on the diagnosis. Basal cell carcinoma (BCC) is the most common malignancy affecting this region and should be excised promptly. This is followed by squamous cell carcinoma, which is often mistaken for BCC but is treated similarly. Melanoma is less common but more deadly, with relatively high rates of metastasis and death. Rare tumors that may be found in this region include sebaceous carcinoma, Merkel cell carcinoma, and microcystic adnexal carcinoma. While uncommon, these tumors are associated with poor outcomes and frequent recurrence. Recognition of periocular skin cancer is an important skill for primary care physicians, as prompt diagnosis and treatment can be sight or life-saving.

Basal cell carcinoma (BCC) is the most common type of malignant tumor in the periocular region. BCCs with neuroendocrine differentiation in the periocular region, however, have not been described in the literature.We present a retrospective case review of a patient with an eyelid BCC with neuroendocrine differentiation. Demographical, clinical, radiological, surgical, histological, and follow-up data are presented.The patient presented with a slow-growing lesion of the eyelid with associated epiphora and dull ache. Initial incisional biopsy of the lesion revealed an infiltrating carcinoma composed of epithelial cells. Immunohistochemistry showed that the tumor was positive for p40, Ber-Ep4, neuron specific enolase (NSE), chromogranin A, CD56 (NCAM), and synaptophysin. The pathology from the margin-controlled excision showed basosquamous cell carcinoma with neuroendocrine differentiation. Tumor recurrence was not detected clinically at the post-operative six-month review.BCC with neuroendocrine marker positivity represents an important diagnostic differential for rare eyelid carcinomas such as primary cutaneous neuroendocrine carcinoma and metastatic small cell carcinoma that have a poor prognosis. The prognostic importance of neuroendocrine marker positivity in BCCs is uncertain. The present case provides further evidence for neuroendocrine differentiation in BCCs.

The use of hyaluronic acid (HA) gel fillers for rejuvenation of the face has been increasing in popularity over the years. This nonsurgical, temporary technique is commonly used in the periocular region to restore volume. The aim of this study was creating awareness in the potential causes of edema after hyaluronic acid gel filler injections under the eyes. A 32-year-old woman presented for a cosmetic consultation to address unilateral swelling of the left check. She states she had an HA filler injected in the tear trough on both sides. Extensive evaluation and ultrasound were performed by physicians of different specialties. Intra-oral and radiological examination revealed a tooth-related cause known as apical periodontitis. Removal of this tooth resulted in complete resolution of the patient's presenting symptoms. Familiarity with all the potential causes of adverse events after injections with hyaluronic acid gel fillers accelerates the treatment and healing of the patient with complications. Reporting this case should raise awareness about possible teeth-related complications.

Infantile hemangiomas (IH) are the most common benign tumor of infancy, and in the periocular region can be associated with permanent visual impairment from amblyopia. Previous treatment options included systemic and local corticosteroids, surgical excision, laser therapy, and in rare cases immunomodulatory therapy, many of which had variable outcomes with undesirable side effect profiles. Since their initial use for IH in 2008, beta blockers have become the mainstay of therapy for periocular IH due to their excellent clinical efficacy and tolerability. While the exact mechanism of action of beta blockers in IH has not been fully elucidated, both oral and topical therapy have demonstrated low rates of adverse events and improved outcomes in the management of periocular IH. This review summarizes the most recent studies on the clinical outcomes, management, and guidelines for the treatment of periocular IH with topical and oral beta blockers.

Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.

Merkel cell carcinoma (MCC) is a highly aggressive cutaneous malignancy, with a high metastasis rate and a significant proportion of cases affecting the eyelid or periocular region. Current treatments for periocular MCC include wide local excision (WLE) with or without adjuvant radiotherapy and can result in profound morbidity and visual deficit. Metastatic disease has been traditionally treated with chemotherapy, though durable responses are typically poor and toxicity is high. Avelumab (Bavencio®, Merck KgaA, Darmstadt, Germany and Pfizer Inc., New York, NY, USA), the first FDA-approved human anti-programmed death-ligand 1 (PD-L1) antibody for the treatment of metastatic MCC (mMCC), has demonstrated safety and efficacy as first-line treatment and in chemotherapy-refractory cases. This review summarizes pivotal clinical trial data for avelumab in the treatment of mMCC, including efficacy, safety and tolerability, and describes the efficacy of two other immune checkpoint inhibitors, pembrolizumab (Keytruda®, Merck & Co., Inc., Kenilworth, NJ, USA) and nivolumab (Opdivo®, Bristol‐Myers Squibb, New York, NY, USA and Ono Pharmaceuticals, Trenton, NJ, USA) for the treatment of advanced MCC. Our purpose is to provide the rationale to further investigate avelumab as a potential therapy for advanced or metastatic eyelid and periocular MCC.

The purpose of this study was to describe the histopathologic appearance of dermal eyelid fillers that were unexpectedly encountered in ophthalmic plastic surgery samples from patients with mild eyelid disfigurements, and to review eyelid cases with complications that had previously been described in the literature. A retrospective histopathologic study with Alcian blue, elastic, and Masson trichrome stains of 2 cases that were submitted to the Ocular Pathology Department was conducted, and a critical review of previously published cases of the histopathologic characteristics of dermal filler material in the periocular region was also conducted. Two periocular tissue samples were found to contain dermal filler material. In one case, porcine collagen appeared as amorphous or indistinctly microfibrillar aggregates that stained light blue with the Masson trichrome method. In the other case, hyaluronic acid gel appeared as vivid blue amorphous pools of material in extracellular locules after staining with the Alcian blue method. An inflammatory response was not observed in either case. Patients who undergo facial filler procedures may, at a later time, require a surgical excisional procedure from which a specimen is generated. Previously injected dermal filler that the patient neglected to mention may be present in the pathologic sample, potentially perplexing the unsuspecting pathologist. Both ophthalmic plastic surgeons and ocular pathologists should be aware of the histopathologic features of dermal fillers. It is helpful if a surgeon who submits a specimen to the pathology service makes note of any known prior use of facial filler material or is alert to its possible presence when unfamiliar foreign material is discovered in the dermis of the eyelids.

Basal cell carcinoma (BCC) of the periocular region presents unique challenges owing to the unique anatomic and functional implications of proximity of the cancer to the eye and the potential negative impact of treatments on both the visual function and aesthetic outcomes. This chapter will review the various treatment modalities and special considerations for the periocular BCC.

Eyelid tumors are often periocular skin lesions but can also be derived from adnexal structures or the conjunctiva. Treatment is primarily surgical, especially for malignant tumors, whereby complete excision is strived for to minimize the local rate of recurrence. Adjuvant therapy and conservative alternative methods (e.g. radiotherapy, cryotherapy and immunomodulation) are reserved for specific cases. The main goal for reconstruction of the eyelids is the functional and aesthetic rehabilitation. This article focuses on the principles and underlying techniques for the reconstruction of the periocular region.

Mohs micrographic surgery achieves high cure rates while preserving healthy tissue making it the optimal treatment for skin cancer. The goals of eyelid reconstruction after Mohs surgery include restoring eyelid structure and function while attaining acceptable aesthetic results. Given the variety of eyelid defects encountered after Mohs surgery, a thorough understanding of the complex eyelid anatomy as well as an in-depth knowledge of the numerous reconstructive techniques available are required to accomplish these reconstructive goals. In this article, the authors review eyelid anatomy and discuss a variety of techniques used for the reconstruction of defects involving the periocular region.

Background Hyaluronic acid (HA) is a popular, nonsurgical, temporary technique that is commonly used in the periocular region to restore volume in areas that have undergone volume loss, as well as adjusting the height and contour of the eyebrow. Aims Due to the location of glands, nerves, and vasculature, the facial anatomy should be well understood to avoid injections into areas that may result in complications. Patient/methods A 54-year-old woman presented for a cosmetic consultation to address "puffy eyelids". She states she had HA filler injected along the orbital ridge inferior to the eyebrow and medially at the glabellar crease two years prior. Two months after her injection, she began to notice upper eyelid edema, xerophthalmia, and dryness of her nasal mucous membranes. Extensive evaluation and imaging were done by physicians of different specialties with a negative workup. Results A total of 60 units of hyaluronidase were injected into the areas of previous filler placement over a three-week period. This resulted in complete resolution of the patient's presenting symptoms. Conclusion Familiarity with potential adverse events is arguably the most important aspect of treating patients with HA filler. The anatomy of the orbit and lacrimal system are important to keep in mind when evaluating symptoms related to possible long-term complications of retained filler injections. Reporting this case should raise awareness about this potential adverse event and further explain the delicate anatomy of the periorbital area.

Periorbital pigmentation is a commonly encountered condition which presents clinically as bilateral round, oval or semicircular homogenous dark brown pigmented macules in the periocular region. It may influence quality of life of an individual with its strong psychological impact. We present a case of middle-aged female patient, who had periorbital pigmentation as a manifestation of acanthosis nigricans. On evaluation, she was found to have hypertension, hyperglycemia, and dyslipidemia and she fulfilled the criteria for metabolic syndrome. We believe, it is important to evaluate the patients who present as periorbital pigmentation with clinical features of acanthosis nigricans for underlying metabolic syndrome.

Saksenaea erythrospora is a rare pathogen in humans. Ten adult cases have been previously reported, eight manifested with cutaneous infection, and two presented with invasive rhinosinusitis infection. The authors present a 16-month-old boy with progressive painful mass at the right medial canthus and upper cheek that was unresponsive to broad-spectrum antibiotics. He underwent an anterior orbitotomy and biopsy. Histopathology revealed broad nonseptate sterile hyphae and grew S. erythrospora, which was confirmed by molecular techniques. The patient was treated with intravenous liposomal amphotericin B and oral itraconazole combined with aggressive surgical debridement. The patient made a complete recovery without long-term complications at 4 months of follow-up. Primary cutaneous mucormycosis caused by S. erythrospora may rarely involve the periocular region and mimic chronic dacryocystitis. We report the first case of pediatric periocular cutaneous mucormycosis caused by S. erythrospora.

Introduction: Basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom, and accounts for over 90% of eyelid malignancies. The periocular region is considered a high-risk area requiring specialist management. This review focuses on the key prognostic factors and management considerations for patients with periocular BCC.Areas covered: The presentation, investigation and management priorities for patients with periocular BCC are discussed. Particular focus upon challenging cases and areas of controversy, drawing on the latest literature.Expert commentary: We recommend that all patients with suspected periocular BCC be referred for a specialist opinion, and in most cases undergo biopsy to determine histological subtype and guide management. Post-operative margin control with 3 mm surgical margins are recommended for primary, low-risk BCCs, and these patients may not require follow-up if excision is complete. 2 mm margins may be considered for small, well-circumscribed BCCs close to cr...

The human face is composed of small functional and cosmetic units, of which the eyes and periocular region constitute the main point of focus in routine face-to-face interactions. This dynamic region plays a pivotal role in the expression of mood, emotion, and character, thus making it the most relevant component of the facial esthetic and functional unit. Any change in the periocular unit leads to facial imbalance and functional disharmony, leading both the young and the elderly to seek consultation, thus making blepharoplasty the surgical procedure of choice for both cosmetic and functional amelioration. The applied anatomy, indications of upper eyelid blepharoplasty, preoperative workup, surgical procedure, postoperative care, and complications would be discussed in detail in this review article.

A 51-year-old man presented to the ophthalmology service with binocular diplopia and facial numbness. The patient was returning from a trip to Mexico. He reported having been hit in the left periocular region by a fish while swimming. Local doctors repaired a laceration in the left lateral canthus shortly after the incident. Orbital imaging revealed 2 needle-like foreign bodies corresponding to retained pieces of a needlefish jaw in the left orbit. Given the location of the foreign bodies, observation with repeat imaging was deemed more appropriate than surgical exploration. Subsequent imaging studies showed no migration of the foreign body, and the patient did not suffer from any related complications more than 7 years after the initial injury.

WOS: 000477774300013, PubMed ID: 31384164, A 27-year-old male with a repetitive behavior of eyeball pressing for six months presented with decreasing visual acuity for three months. Upon arrival his best corrected visual acuity was 0.2 on the right and 0.6 on the left eyes. Scheimpflug camera system demonstrated grade 4 and grade 2 keratoconus, respectively. Psychiatric consultation revealed Tourette syndrome and treatment was started. Despite psychiatric treatment, acute hydrops occurred in both eyes decreasing visual acuity to hand motions bilaterally. Left corneal perforation due to ongoing habit of eyeball pressure was experienced which led the loss of light perception and phtisis bulbi. Although Tourette syndrome is rare, it might cause bilateral acute onset keratoconus when the repetitive movements affect periocular region. Psychiatric treatment should be considered as early as possible in these patients in order to prevent unfavorable complications.

Purpose The submental and neck regions share cutaneous features with the face and are suitable donor sites for facial full-thickness skin grafts (FTSGs). Age-related laxity and skin redundancy in the cervicomental region may be an additional motivator to use its skin. We aim to describe, raise awareness, and remind surgeons of the utilization of submental and anterior neck as sources of FTSG for the periocular region, particularly when traditional donor sites are unavailable. Methods Retrospective case series of 5 patients who underwent periocular FTSG from anterior neck and submental regions between January 2017 and January 2019. All patients had contraindications to the usually preferred graft donor sites. Main outcome measures were surgical functional results and cosmesis. Results Five patients (all female) received FTSGs using anterior neck and submental regions as donor sites. Two patients required skin grafts due to eyelid retraction and anterior lamella shortening; one due to previous multiple basal cell carcinoma excisions with FTSG reconstructions and the other due to chronic Bell's palsy. Three patients required skin grafts for Hughes flap reconstruction after excision of lower eyelid basal cell carcinoma. In all patients, conventional skin donor sites were unavailable or unsuitable due to previous skin grafting, actinic changes, postauricular situated hearing aids or patient's preference. All patients achieved good cosmesis and functional results. None of the patients experienced donor site morbidities. Conclusions Submental and anterior neck regions are useful FTSG donor sites for periocular procedures, particularly in elderly female patients with submental fullness and neck skin redundancy.

Intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion, typically found in the skin, consisting of a papillary proliferation of endothelial cells intimately related to a thrombus; it appears to be a rare variant of an organizing process. IPEH very rarely develops in the periocular region, with fewer than 20 such cases currently reported in the English language literature. We describe one of the largest ever case series of this uncommon lesion occurring in the periocular region and discuss its clinical features, imaging characteristics, and surgical management.

Periorbital aging involves all layers of the skin, fat, and the bony orbit. Therefore, a multimodal approach is necessary. Twenty Korean subjects who required periorbital rejuvenation were enrolled in this study. First, micro-focused ultrasound with visualization (MFU-V) was performed across the supra-brow area, lateral canthus, and the infraorbital area. Next, the filler was injected into the sunken upper eyelid, lateral eyebrow, and the infraorbital area. Lastly, botulinum toxin was administered into the forehead, glabella, crow's feet, and the lateral orbital rim below the brow on the same day. Photographs were taken at baseline; immediately after treatment; and at 1, 4, and 12 weeks of follow-up. The average eyebrow height was increased by 3.5 mm, and the maximum height was elevated by 3.9 mm at week 12. Physician visual analogue scale (VAS) scores regarding the whole periorbital area and eyebrow ptosis were continuously improved throughout the observation period. Physician VAS scores for infraorbital hollow and superior sulcus deformity improved immediately after the procedure and were maintained at week 12. Adverse events were mild and transient. We believe that a multimodal approach combining MFU-V, fillers, and botulinum toxin results in significant periocular rejuvenation.

Basal cell carcinomas are the commonest solid malignancy in humans and thought to grow faster in the periocular region. We measured growth rates between periocular and non-periocular nodular basal cell carcinomas in the head and neck region from high-resolution digital photos and operative notes. The non-periocular basal cell carcinomas (head and neck) showed a mean tumour volume doubling time of 129.8 ± 21.74 (n = 79) days, and the periocular basal cell carcinoma a mean of 177.5 ± 37.21 (n = 47) days. The unpaired t-test with Welch correction showed that this difference was not significant (p = 0.2719). The mean tumour volume doubling time was 147.59 ± 37.75 days for head and neck basal cell carcinomas overall. For the first time, tumour volume doubling times for nodular basal cell carcinomas in the periocular versus non-periocular regions for the head and neck area were analysed, with no significant differences demonstrated. Further, comparison of basal cell carcinoma growth rates with other common solid tumours confirmed that basal cell carcinomas are slow growing malignancies.

The upper face and periocular region is a complex and dynamic part of the face. Successful rejuvenation requires a combination of minimally invasive modalities to fill dents and hollows, resurface rhytides, improve pigmentation, and smooth the mimetic muscles of the face without masking facial expression.Using review of the literature and clinical experience, the authors discuss our strategy for combining botulinum toxin, facial filler, ablative laser, intense pulsed light, microfocused ultrasound, and microneedle fractional radiofrequency to treat aesthetic problems of the upper face including brow ptosis, temple volume loss, A-frame deformity of the superior sulcus, and superficial and deep rhytides.With attention to safety recommendations, injectable, light, laser, and energy-based treatments can be safely combined in experienced hands to provide enhanced outcomes in the rejuvenation of the upper face.Providing multiple treatments in 1 session improves patient satisfaction by producing greater improvements in a shorter amount of time and with less overall downtime than would be necessary with multiple office visits.

The role of hyaluronic acid (HA) fillers in the periocular region continues to expand. In addition to cosmetic uses in the periocular region, HA fillers are increasingly being used to correct eyelid malpositions. This is changing the perspective on the anatomic changes responsible for these malpositions.

Cutaneous horns uncommonly involve the periocular region. Involvement of the ocular surface is particularly rare. The authors present a patient who underwent a perinatal buccal mucosal graft for corneal perforation due to congenital corneal ectasia, most likely resulting from Peters anomaly. She developed a giant ocular horn 10 years later.

A male patient, 57 years old, presented with trauma by transfixed wood fragment, with entry into the left eyeball and exit on the soft palate. On physical examination, he was conscious, oriented, eupneic, normocorated with presence of edema and bruise on the left eyelid. A computed tomography scan of the skull was performed, which showed no alterations, and then the patient was referred to the surgical center to remove the object under general anesthesia. In surgery, it was observed that the object pierced the periorbital adipose body without causing damage to the cornea or adjacent structures. Suture was performed on the lower eyelid and soft palate. In the postoperative period, the patient had preserved visual acuity, maintained internal and external motricity, and compatible palpebral edema. The importance of rapid care and the availability of other medical specialties in emergency services are indispensable for proper care and proper management of the patient, providing a better prognosis.