Applicability of a sheep model for training in plastic surgery of eyelids and orbit

Objective To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit. Design Observational animal experiments. Subjects Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research. Methods Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3–7 days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model. Results The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures. Conclusions The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Transconjunctival and Subciliary Approach in the Treatment of Orbital Fractures: A Study on Oculoplastic Complication

(1) Background: The aim of the present study was to compare lower eyelid post-operative complications, such as ectropion, entropion, and scleral show of orbital floor fractures, associated to the subciliary vs transconjunctival approaches. (2) Materials and Methods: A retrospective comparative study of patients who underwent surgery for orbital fractures by means of a transconjunctival or a subciliary approach at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2013 through September 2018 was designed. Data related to the trauma and to surgical procedures were retrieved, as well as a series of anthropometric parameters extrapolated from standardized photographs. Statistical analysis was performed on the outcomes. (3) Results: 33 patients underwent surgery by means of a transconjunctival approach and 36 patients by means of a subciliary approach. Ectropion was observed to a greater extent in the subciliary group, however the difference resulted to be not statistically significant. Patients in which osteosynthesis devices were used presented with a greater incidence of scleral show with respect to the remaining patients. No statistically significant difference was observed for any of the parameters taken into account. (4) Conclusions: Since the two approaches does not seem to be associated with remarkable differences in terms of outcomes, the choice of technique should be tailored to the patient’s features and the surgeon’s experience.

Transcutaneous or Transconjunctival Botulinum Toxin Injection for Thyroid Eye Disease Associated Upper Lid Retraction

BackgroundBotulinum toxin (BTA) injection has been a standard treatment for thyroid eye disease (TED) related upper lid retraction (ULR), however, currently there is no consensus regarding the method of injection. Both transcutaneous (TC) and transconjunctival (TJ) injection of BTA has been reported to be successful. The aim of this study is to compare the changes between the lid parameters, the rate of complications and the difference in pain scores between the two groups.MethodA randomized controlled trial was carried out between 09/2017- 07/2019. 22 lids were randomized into either TC and TJ injection. Patients were blinded to receive either 2.5u of TC or TJ BTA injections and were followed up at 1, 3 and 6 months post injection by a masked investigator.Results12 and 10 lids were assigned ot the TC and TJ group respectively. At 1 month, the changes of PA were significant in the TJ group (-3.6±0.9, p=0.001), while the changes of MRD1 were significant in both groups (TC group: -1.67±1.74 (p=0.02), TJ group: -2.60±0.89 (p=0.003)). At 3 months, the change of MRD2 was only significant in the TJ group (-1.00±0.71, p=0.034). However, at 6 months, all lid parameter changes from baseline and between 2 groups were statistically insignificant. TC group had a significantly lower (-1.40±1.51, p=0.016) pain score. There was 1 case of diplopia and 1 case of ptosis in the TC group, while there were 2 cases of ptosis in the TJ group. ConclusionAt 1 month, the PA in the TJ group and the MRD1 in both groups showed statistically significant changes. At 3 months, the TJ group showed statistically significant changes in MRD2. The pain scores were significantly lower in the TC group. Although at 6 months, there were statistically insignificant changes between the 2 groups, the TJ group showed more promising results in 1 and 3 months, and the TC group has less pain. Hence, we hope to draw a consensus in the treatment of TED associated ULR by recommending the transconjunctival approach for BTA injections, however, we should expect it to be a more painful procedure. Trial registrationName of registry: HKU Clinical Trial Registry (HKUCTR)Trial registration number: HKUCTR-2306Date of registration: 08 Dec 2017URL of trial registry record: http://www.hkuctr.com/Investigator/Update/876c13c77a1a429e9283423b2d412ee1

Transconjunctival excision of a conjunctival cyst using computer-assisted 3-D surgical planning in a dog

Investigation of exophthalmos and blood-colored discharge from the left ventral punctum in a dog was consistent with a conjunctival cyst. 3-D prints of the cyst and surrounding facial bones identified a successful transconjunctival approach without an orbitotomy and patency of the left lacrimal duct was re-established.

A Modified Approach to Transconjuntival Levator Advancement Offering Intraoperative Options

Background The transconjunctival technique is a preferable and beneficial approach in mild to moderate blepharoptosis repair as without skin incision. However, accurate surgical manipulation of this method is greatly restricted by the poor intraoperative evaluation. Objectives To introduce a modified transconjunctival approach with flexible intraoperative adjustments in order to achieve more accurate ptosis correction. Methods By transconjunctival approach, the levator aponeurosis and the Müller’s muscle were folded using a square-like mattress suture for flexible adjustment and accurate correction. Results In 18 mild ptosis eyelids, 94.5% (17 eyelids) achieved adequate or normal correction. In 9 eyelids with moderate ptosis, 88.9% (8 eyelids) achieved adequate or normal correction. Amongst 24 ptosis patients, 23 (95.8%) achieved good or fair symmetry result. Conclusion We presented a modified transconjunctival technique for repair of mild to moderate ptosis, which is characterized by flexible intraoperative adjustments achieving both satisfying functional and aesthetic outcomes.

Navigated Transconjunctival Endoscopic Approaches to the Orbit

ABSTRACT BACKGROUND Standard cranial approaches to the orbit involve lengthy skin incisions, extensive soft tissue dissection, and large craniotomies, increasing morbidity. OBJECTIVE To evaluate less invasive approaches to the orbit, using endoscopic transconjunctival approaches. METHODS Neuronavigated transconjunctival approaches to the orbit were performed on 4 cadavers using 30°/3 mm and 0°/6 mm rigid endoscopes. A special head frame was designed for this study to prevent excessive movement of the endoscope tip in the orbit. Lateral and medial transconjunctival supra- and infrabulbar approaches to the extra- and intraconal spaces were performed. The incision length, maximal penetration depth in the extra- and intraconal spaces, and distance from the orbital rim to the optic nerve were measured. RESULTS All 4 approaches afforded satisfactory exposure and access to the extra- and intraconal spaces. The mean incision length for the transconjunctival approach was 10.4 mm. The optic nerve could be exposed through all 4 approaches. The mean maximal penetration depths in the extraconal space were 28.6 ± 3.5 mm for the 30°/3 mm and 20.7 ± 4.5 mm for the 0°/6 mm endoscope. In the intraconal space, the mean maximal depth of penetration was 23.8 ± 2.4 mm for the 30°/3 mm and 19.4 ± 3.4 mm for the 0°/6 mm endoscope. Based on these measurements, the orbit was classified into quadrants and zones. CONCLUSION Transconjunctival endoscopic approaches to the orbit allow maximal exposure of the extra- and intraconal spaces through a minimally invasive approach requiring no muscle transection. Infrabulbar approaches have better cosmetic results than suprabulbar approaches, which require incision of the eyelid.