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Background: A group of experts from different disciplines was convened to develop guidelines for the management of upper visual field impairments related to eyelid ptosis and dermatochalasis. The goal was to provide evidence-based recommendations to improve patient care., Methods: A multidisciplinary group of experts representing their specialty organizations was selected. A systematic literature review was performed including topics regarding documentation of the underlying cause for visual field impairment, selection of an appropriate surgical repair, assessment of the type of anesthesia, the use of adjunctive brow procedures, and follow-up assessments. The Grading of Recommendations, Assessment, Development, and Evaluation methodology process was used to evaluate the relevant studies. Clinical practice recommendations were developed using BRIDGE-Wiz (Building Recommendations In a Developers' Guideline Editor) software., Results: Each topic area was assessed. A clinical recommendation was made, and the relevant literature was discussed., Conclusions: The review of the literature revealed varied complication rates and diverse treatment modalities for the correction of upper visual field deficit. Strong recommendations could not be made in most topic areas because of a paucity of methodologically sound studies in the literature. More rigorously designed studies are needed to measure outcomes of interest, with fewer sources of potential error or bias., Clinical Question/level of Evidence: Therapeutic, V., (Copyright © 2022 by the American Society of Plastic Surgeons.)

The subperiosteal face lift is a procedure designed to rejuvenate the upper and middle thirds of the face. Herein is reviewed a 4-year series of 200 consecutive patients who have undergone a subperiosteal face lift with a special emphasis on handling of the zygomatic arch. The main operative indication was significant ptosis of the midface soft tissue. Dissection of the maxilla, zygoma, periorbital areas, and the anterior arch was carried out through either a gingivo-buccal sulcus incision (39 cases) or a subciliary incision (161 cases). Dissection of the posterior arch was carried out in a plane superficial to the innominate fascia. A back-cut was made in the superficial musculoaponeurotic system and subcutaneous tissue down to midtragus, and a subperiosteal tunnel was entered by piercing through the posterior arch periosteum. By using a Cottle elevator (sweeping superiorly and inferiorly), the arch dissection was completed in a posterior to anterior direction. All patients underwent a concurrent brow lift (190 endoscopically and 10 by means of coronal incision). The forehead incision was used to dissect the lateral orbital rims. Twelve patients (6 percent) had undergone a previous rhytidectomy. All but four patients were women and ranged in age from 34 to 76 years (mean, 54+/-11). Mean follow-up period was 27 months (1 to 41 months). The postoperative complication rate was 5 percent and included transient frontal branch weakness (n = 2), resolved at 41 and 71 days postoperatively; hematoma (n = 2); transient infraorbital nerve paresthesia (n = 1); asymmetrical smile (n = 3); and facial tics (n = 2). Two patients (1 percent) required a secondary surgery on their brows or midface. An upper blepharoplasty was needed in 26 patients (13 percent). The overall aesthetic results were excellent, with good elevation of the eyebrows, lateral canthus, and the midface soft tissues. In conclusion, the subperiosteal face lift is a procedure designed to rejuvenate the upper and middle thirds of the face. Approaching the arch posteriorly and in a systematic fashion simplifies the procedure and reduces the risk of facial nerve injury.

This study investigates the effects of preoperative IV administration of IL-6 and anti IL-6 on peritoneal adhesion formation and wound healing. Thirty-six male Sprague-Dawley rats (350-400 mg) were divided into three groups: control (group 1); IL-6 (group 2); and anti IL-6 (group 3). Under sterile conditions, all rats underwent a midline laparotomy. Ten cm2 of cecal serosa was abraded, the cecum further irritated with 0.1 ml of 70 per cent alcohol, and the incision closed in layers. At 3 weeks, peritoneal adhesions were graded using a score of 0 (none) to 3 (extensive, dense). Skin samples from incisional sites were examined tensiometrically (true stress and true strain), biochemically (collagen content), and histologically. Adhesion formation score was significantly increased in IL-6 group (2.78 +/- 0.44, Mean +/- SD) and decreased in anti IL-6 group (1.40 +/- 0.52) compared to control (2.00 +/- 0.50). (P < 0.03 by Kruskal Wallis test). There was no significant difference in true stress, true strain, and collagen content between the two treatment groups and controls at the 0.05 level by ANOVA. Histological analysis showed higher number of inflammatory cells and fibroblasts in IL-6 treated groups. We conclude that IL-6 plays a major role in peritoneal adhesion formation. Selective immunosuppression, using IL-6 neutralizing antibodies preoperatively, leads to a reduction of such adhesion formation without a significant effect on wound healing.

This study investigates the effects of preoperative intravenous administration of antibodies against TNF-alpha and IL-1 on peritoneal adhesion formation. Fifty-six Sprague-Dawley rats (350-400 gm) were used in this study. Eight rats were used to empirically determine the amount of anti TNF-alpha and anti IL-1 needed for complete in vivo neutralization. This amount was used for preoperative treatment of selected groups. Forty-eight rats were divided into four equal groups (n = 12). All rats underwent a midline laparotomy. Ten cm square of cecal serosa was abraded, the peritoneal cavity was irrigated with normal saline, and the incision was closed in layers. Cultures were obtained intraoperatively and rats with positive cultures were excluded. Rats in Group 1 were not treated (control), while rats in Groups 2, 3, and 4 were treated with anti TNF-alpha, anti IL-1, and a combination of anti TNF-alpha and IL-1 respectively. All rats were killed at 3 weeks, and peritoneal adhesions were graded using a scale of 0 (none) to 3 (extensive, dense). Rats treated with anti IL-1 (Group 3) and those treated with a combination of anti TNF-alpha and anti IL-1 (Group 4) had significantly fewer adhesions when compared with Group 1 (control) (P < 0.01 and < 0.005, respectively). Least adhesion formation was associated with Group 4 rats. In conclusion, selective immunosuppression, at a molecular level, appears to have a significant impact on rates of postoperative peritoneal adhesion formation.

This study investigates the possible correlation between higher levels of tumor necrosis factor-alpha (TNF-alpha) and higher rates of adhesion formation following standard bowel injury. Forty-five Sprague-Dawley rats were divided into three equal groups. Blood was obtained from all rats preoperatively. All rats were subjected to a laparotomy. In group 1 the peritoneal cavity was irrigated with normal saline. In group 2 the cecal serosa was abraded, while rats in group 3 had 2 cm of their small bowel resected. A peritoneal catheter was placed in all rats prior to closure. Blood samples were obtained at 30, 90, and 180 min following injury. Peritoneal exudate (PE) was collected and the catheter removed in 3 hr. Blood samples and peritoneal exudate were processed and levels of TNF-alpha were determined. The severity of adhesions was graded 3 weeks postoperatively using a score of 0 (absent) to III (extensive, dense). Histological evaluation for collagen deposition and fibroblasts was carried out. Rats in group 1 had significantly lower adhesion grades when compared to groups 2 and 3 (grade 0; P < 0.0001). Postoperatively, groups 2 and 3 had higher serum and PE TNF-alpha levels when compared with group 1 (P < 0.01). There was a significant correlation between higher grades of adhesions and higher levels of serum and PE at 30, 90, and 180 min following operation (P < 0.01 and < 0.05, respectively). TNF-alpha, a proinflammatory cytokine, appears to be a good biological marker for postoperative intraabdominal adhesion formation.

Intradural disc herniation accounts for < 0.3% of all disc herniations. Intraradicular disc herniation accounts for 4.1% of all such cases. Preoperative diagnosis is difficult, and a high index of suspicion during surgery is required for the diagnosis. We present a patient with intraradicular disc herniation in the lumbar region whose symptoms were severe enough to recommend surgery. The myelogram showed a block at the involved nerve root. Diagnosis of intraradicular herniation was made during surgery. The symptoms were immediately relieved by surgery. The literature on intradural and intraradicular disc herniation is reviewed.