Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
.pdf
Aesthetic Ophthalmoplastic with CO2 Laser 429
If necessary a lateral canthoplasty procedure is performed. The tip of the myocutaneus flap is stretched to determine how much the lateral portion of the flap overlaps the underlying incision. If necessary, carefully excise the excess
of tissue.
Closure of the skin flap is performed using 6-0 nylon sutures.
BIBLIOGRAPHY
1.Aiache AE, Coll. The suborbicularis oculi fat pad: an anatomic and clinical study 1995;95(1):37-42.
2.Bames H Baggy. Eyelids Plast Reconstr Surg 1958;22:264.
3.Boo-Chai K. Blefaroplastia nas palpebras orientais. In Avelar MA: Anestesia loco-regional em Cirurgia Estetica. Heditora Hipocrates, 1993:pp 116-20.
4.C.Lucchini, Coll “Laser Chirurgia Estetica delle Palpebre e del Viso” Dogma Edizioni 2001;45-57.
5.Castanares S. Blepharoplasty for herniated intraorbital fat. Anatomic bases for a new approach. Plast Reconstr Surg 1951;8:46.
6.De Miranda JC, Coll. Blefaroplastia. In Avelar MA: Anestesia locoregional em Cirurgia Estetica. Heditora Hipocrates 1993:109-15.
7.Freund RM, Coll. Correlation between brow lift outcomes and aesthetic ideal for eyebrow height and shape in females Plast Reconstr Surg 1996;97(7):1343-8.
8.Lessa S, Coll. A Simple Canthopexy. Rev Soc Bras Cir Plast 1999;14 (1):59-70.
9.Loeb R “Esclera Aparente”. In Loeb R Cirurgia Estetica das Palpebras. Sao Paulo (ed) 1988:17-32.
10.Loeb R. Cirurgia Estetica das Palpebras. Sao Paulo (ed) 1988.
11.Loeb R. Ectropios, hematomas e outras complicaçoes. In Loeb R. Cirurgia Estetica das Palpebras. Sao Paulo (ed) 1988:163-86.
12.Loeb R. Saliencias tegumentais, adiposas, muscolares e ossea. In Loeb R. Cirurgia Estetica das Palpebras. Sao Paulo (ed) 1988 pp 3394.
13.May JW, Coll. Retro-Orbicularis Oculus Fat (ROOF). Resection in aesthetic blepharoplasty: a 6 years study in 63 patients 1990;86(4):68289.
14.Monasterio OF, Coll. Lateral Canthoplasty to change the eye slant. Plast Reconstr Surg 1985;75(1):1-10.
430 Oculoplasty and Reconstructive Surgery
15.Pitanguy I, Coll. Atlas de Cirurgia Palpebral. Revinter (ed) 1994.
16.Pitanguy I. Anatomia. In Pitanguy I and Coll Atlas de Cirurgia Palpebral Revinter (ed) 1994 pp 21-32.
17.Rees TD. Blepharoplasty and Facialplasty. In McCarthy JG Plastic Surgery Volume 3 Saunders (ed) 1990 pp 2320-414.
18.Watanabe K. Ocidentalizaçao das palpebras. In Avelar MA: Anestesia loco-regional em Cirurgia Estetica. Heditora Hipocrates, 1993:121-4.
19.Wesstfall CT, ShoreJW, Nunery WR, et al. Operative complications of the of the transconjunctival inferior fornix approach. Ophtalmology 1992;98:1525-8.
ABLATIVE LASERS SKIN RESURFACING
The changes of aging in facial skin, like wrinkles, atrophy of the skin, superficial irregularities, actinic damage, hyperpigmentation, dermal thickening and hyperkeratosis are not correctable by skin-tightening procedures alone.
Introduction
With the development of short-pulsed, high peak power or rapidly scanned CO2 lasers and erbium: yttriumaluminiumgarnet (Er:Yag), very good results can be obtained in reducing wrinkles in the periocular region using the skin resurfacing technique, with minimal thermal damage.
Principles of Laser Skin Resurfacing
CO2 laser (10.600 nm) is strongly absorbed by water. Water is present in more than 80% of the skin’s volume.
Ninety percent of CO2 laser light energy is absorbed within 20 to 50 µm
The absorption of this laser energy causes rapid heating and ultimately the vaporization of intracellular water with resulting tissue ablation.
It is very important to stop the laser action when papillary dermis is achieved, to avoid further, deeper damage to the tissue.
Aesthetic Ophthalmoplastic with CO2 Laser 431
The effect of the CO2 laser is immediately noticeable by thermal shrinkage and the stimulation of a long-term healing response characterized by the formation of new sub epidermal collagen and elastin fibers.
The tightening of the dermis creates wrinkle reduction. To reduce the thermal damage zone the laser pulse
duration must be shorter than 0.5 to 1 ms; this is called the thermal relaxation time. The energy fluency per pulse necessary to vaporized tissue is approximately 5J/ cm2.
Several CO2 lasers have been developed that can achieve tissue vaporization 20 to 30 µm. of depth with residual thermal damage zones of 25 -70 µm.
Never forget that the lid’s skin thickness is about 60 µm, the thinnest layer of skin on the human body!
The Erbium laser emits a light with a wavelength of 2940 nm; the absorption of this wavelength in water is 12 to 18fold that of the CO2 laser. This increase of energy from the Er:YAG laser within the superficial layers of tissue produces a thermal damage zone of less than 10 µm. The minimum energy fluency per pulse necessary to vaporized tissue is approximately 1.6 J/cm2. The thermal damage zone does not increase with additional passages of the Erbium laser, making this laser an extremely precise ablative tool (Table 1 and
Figure 6).
Preoperative Evaluation
Laser skin resurfacing performed only in the periorbital region is much safer than a full face treatment.
In any case, it is suggested to follow some basic rules when selecting patients.
Avoid treating patients with a history of immune system compromise, autoimmune diseases, keloid formation, Fitzpatrik class IV, or primary Herpes simplex.
432 Oculoplasty and Reconstructive Surgery
Table 1: Comparison of CO2 and Erbium laser
|
CO2 |
Er:YAG |
Ablation fluence |
4-5 J/cm² |
1.6 J/cm² |
|
|
|
Wavelength |
10.6 µm |
2.94 µm |
|
|
|
Thermal damage |
70-150 µm |
10-50 µm |
|
|
|
Tissue penetration |
30 µm |
1 µm |
|
|
|
Collagen shrinkage |
++++ |
+ |
Figure 6: Erbium laser a precise ablative tool
Isoretinoin (Accutane) treatment or deep peeling in the recent past may impair follicle and sweat gland activity, thus generating a delayed or absent re-epithelialization after resurfacing.
Lower eye lid laxity may predispose a patient to ectropion.
Wound Healing
Generally re-epithelialzation is completed within 7 days for Er:YAG and 10 days for CO2 laser.
Erythema takes 2-3 weeks to resolve after Erbium laser or 5- 6 weeks after one pass in delicate resurfacing mode (Feathertouch, Ultra Pulse 5000 C).
Aesthetic Ophthalmoplastic with CO2 Laser 433
Anesthesia
CO2 resurfacing may be performed with a local or regional anaesthetic.
Topical anesthetic cream (Emla®) applied 45 minutes before the Erbium laser resurfacing is normally sufficient.
Laser Safety
Regard the paragraph in Laser Blepharoplastic
Laser Treatment Strategy
In my personal experience, I have found that using ablative resurfacing to complete laser transconjunctival blepharoplasty reduces the laxity of the lid’s skin and enhances the cosmetic effect on the non dynamic wrinkles.
In some patients only laser skin resurfacing is indicated to reduce the aging effects on the periorbital area.
In young patients I prefer to use Erbium laser as apposed to the CO2 laser, which I use when the wrinkles are deeper and skin laxity is present.
I prefer not to be aggressive on the crow’s feet or glabellar region for two reasons:
There is a longer time of recovery and erythema, and I can obtain excellent result with botulin toxine.
Laser Treatment Technique
A betadine solution or other not volatile solution is used for the disinfection of the lids and periocular region. Antibiotic drops are instilled.
The cornea is anesthetized with 2 drops of 4% tetracaine, the metal scleral shield is lubricated with cellulose gel and placed on the cornea, the surgeon marks the resurfacing area, and then the lower lids and periorbital region are infiltrated with lidocaine (CO2 treatment).
434 Oculoplasty and Reconstructive Surgery
CO2 Laser Skin Resurfacing of Crow’s Feet and Lower Lid Cheek Junction Area
Use a square, medium sized spot to treat the marked area. Pay attention not to damage lashes. Laser spots impacts must be perpendicular to the skin surface, on the peripheral contour, just on the pen marks. I impact the laser spots with an angle of 45° to reduce the step between treated and non treated area.
With just one pass of the pulsed CO2 laser, epidermal debris is not wiped away, therefore reducing the healing process. Spots overlapping is allowed in order of 10%
(Figure 7).
Erbium Laser Skin Resurfacing of Crow’s Feet and Lower Lid Cheek Junction Area
Use a square medium size spot to treat the marked area, pay close attention not to damage the lashes. Laser spot impacts must be perpendicular on the skin surface, set the laser: fluence 14.2, spot 3.0 mm, energy 1.0 mJ, frequency 8Hz; 5 passes are generally needed to arrive to the papillary dermal. Stop, in any case, when bleeding starts (Figure 8).
Figure 7: Laser CO2 skin resurfacing after laser blepharoplasty
Aesthetic Ophthalmoplastic with CO2 Laser 435
Figure 8: Laser skin resurfacing Er. YAG after laser transconjunctival blepharoplasty
Postoperative Wound Care
Vaseline is applied 4 or 5 times a day until re-epithelialization is completed. The patient is asked to apply a wet compress, 4 times a day, with a solution of 1 tablespoon of white vinegar in 1 cup of water.
Oral antibiotic is prescribed for one week.
Steroid cream is applied nightly for 3 days. A mix of Vaseline with steroid cream (1:3) is applied 4 times a day for 5 days.
Then a hydrant cream with a sunscreen of 15 SPF is used. If the patient is exposed to the sun, a 100% SPF (total sun block) is recommended to avoid hyperpigmentation. This regime is followed for three months.
Postoperative Complications
Following these rules, it is unlikely that complications will arise during or after surgery.
Prolonged erythema, lasting more than 3 months, is possible but can be resolved with topical steroid therapy.
436 Oculoplasty and Reconstructive Surgery
Hyperpigmentation can be resolved with the application of topical bleaching agents.
BIBLIOGRAPHY
1.Alster Tina S. Cutaneous resurfacing with CO2 and erbium: YAG lasers: preoperative,intraoperative and postoperative considerations. Plastic and reconstructive surgery 1999;103(2):619-32.
2.Alster TS, West TB. Ultrapulse CO2 laser ablation of xanthelasma. J.American Academy of Dermatology 1996;34:848-49.
3.C.Lucchini, Coll. “Laser Chirurgia Estetica delle Palpebre e del Viso” Dogma Edizioni 2001;pp 45-57.
4.Collawn SS, Boissy RE, Vasconez LO. Skin ultrastructure after CO2 laser resurfacing. Plast Reconstr Surg 1998;102:509-15.
5.Dover JS, Hruza GJ. Laser skin resurfacing. Semin Cutan Med Surg 1996;15:177-88.
6.Fitzpatrich RE. Facial resurfacing with the pulsed CO2 laser. Facial Plast Surg Clin 1996;4:231-40.
7.Fitzpatrick RE, Williams B, Goldman MP. Preoperative anesthesia and postoperative considerations in laser resurfacing. Semin Cutan Med Surg 1996;15:170-76.
8.Fitzpatrick Richard E. Laser resurfacing of rhytides. Dermatologic Clinics 1997;15(3):431-47.
9.Fulton JE. Complication of laser resurfacing. Dermatol Surg 1997; 24:91-9.
10.Geronemus RG, Alster TS, Brandt FS, Dover JS, Fitzpatrick RE. Tabletalk: Common questions about laser resurfacing . Dermatol Surg 1999;24:121-30.
11.Goodman GJ. Combining laser resurfacing and ancillary procedures. Dermatol Surg 1998;24:75-8.
12.Ho C, Nguyen Q, Lowe NJ, Griffin ME, Lask G. Laser resurfacing in pigmented skin . Dermatol Surg 1995;21:1035-7.
13.Hruza GJ. Skin resurfacing with lasers. Fitzpatrick ‘s J Clin Dermatol 1996; 3:38-9.
14.Lewis AB, Alster TS. Laser resurfacing: persistent erythema and post-inflammatory hyperpigmentation. J Geriatr Dermatol 1996; 4: 75-6.
INTRODUCTION
Dacryocystorhinostomy or DCR is done for nasolacrimal duct obstruction via either an external approach or an endoscopic approach.
HISTORY
The first reported dacryocystectomy was performed by Celsus in 50 AD followed by Galenas of Pergamos. Anel first irrigated the lacrimal duct and Bowman reported the technique of probing. Toti, an Italian performed the first external dacryocystorhinostomy for obstruction. In 1895, Caldwell first reported the endonasal approach and Rice in 1990 was the first to report good results with the same.
ANATOMY AND PHYSIOLOGY 1
The lacrimal apparatus includes superior and inferior punctum, the superior and inferior canaliculi, the sac and the nasolacrimal duct, that opens into the inferior meatus. The lacrimal pump functions due to the lid movement which causes the puncta to acquire tears into the lacrimal sac. When the eyes open a negative pressure is created in the lacrimal sac and causes the valves in the canaliculi to open and suck
438 Oculoplasty and Reconstructive Surgery
in tears and when the eyes close positive pressure open the valve at the nasolacrimal duct to push the tears down further into the nose.
The anterior portion of the middle turbinate is an anatomical landmark for the lacrimal apparatus.The lacrimal fossa has the anterior lacrimal crest, which consists of the frontal process of the maxillary bone and the posterior lacrimal crest is made up of the lacrimal bone.
EVALUATION OF EPIPHORA
Watering from eyes can be due to a variety of reasons like the blockage of the nasolacrimal duct, over secretion of tears or foreign body in the eye, etc.
Epiphora is excess tearing due to insufficient drainage and can be differentiated from pseudo-epiphora, which is reflux tearing due to the main gland oversecreting.
The causes for Epiphora can be broadly divided into anatomical or physiological causes. Anatomical causes can be complete or partial obstruction of the nasolacrimal duct (NLD) or canaliculi. Where as a physiological obstruction is due to a functional problem even though the anatomy of the NLD is normal, which could be due to lacrimal pump failure or punctal eversion.
Causes of the Nasolacrimal Duct Obstruction
A.Dacryocystitis due to nasal allergy, septal deviation and sinusitis.
B.Lacrimal stones.
C.Inflammations like tuberculosis, leprosy
D.Non infectious inflammations like sarcoid
E.Tumors—malignant epithelial neoplasms
F.Lacrimal sac cysts