Raman Malhotra

We present a case of a periocular painless perifolliculitis clinically mimicking basal cell carcinoma (BCC), excised by margin-controlled excision. This case reminds readers that perifolliculitis as a response to rosacea can mimic BCC. The value of diagnostic biopsy and dermoscopy to support management planning and avoid unnecessary surgery is discussed.

Introduction In chronic facial palsy, synkinetic muscle overactivity and shortening causes muscle stiffness resulting in reduced movement and functional activity. This article studies the role of multimodal therapy in improving outcomes. Methods Seventy-five facial palsy patients completed facial rehabilitation before being successfully discharged by the facial therapy team. The cohort was divided into four subgroups depending on the time of initial attendance post-onset. The requirement for facial therapy, chemodenervation, or surgery was assessed with East Grinstead Grade of Stiffness (EGGS). Outcomes were measured using the Facial Grading Scale (FGS), Facial Disability Index, House-Brackmann scores, and the Facial Clinimetric Evaluation scale. Results FGS composite scores significantly improved posttherapy (mean-standard deviation, 60.13 ± 23.24 vs. 79.9 ± 13.01; confidence interval, –24.51 to –14.66, p < 0.0001). Analysis of FGS subsets showed that synkinesis also reduced significantly (p < 0.0001). Increasingly, late clinical presentations were associated with patients requiring longer durations of chemodenervation treatment (p < 0.01), more chemodenervation episodes (p < 0.01), increased doses of botulinum toxin (p < 0.001), and having higher EGGS score (p < 0.001). Conclusions This study shows that multimodal facial rehabilitation in the management of facial palsy is effective, even in patients with chronically neglected synkinesis. In terms of the latency periods between facial palsy onset and treatment initiation, patients presenting later than 2 years were still responsive to multimodal treatment albeit to a lesser extent, which we postulate is due to increasing muscle contracture within their facial muscles.

Purpose: The authors present a new series of our experience using posterior approach levatorpexy for congenital ptosis with poorer levator function (LF) in comparison with our first published report. This technique avoids a skin incision or any resection in addition to no excision of tissue. Methods: A consecutive series of 16 patients. Retrospective review of levatorpexy for congenital ptosis. Data included eyelid margin reflex distance 1, pretarsal show, contour, and complications, including nocturnal lagophthalmos, eyelid lag on downgaze, and dry eye. Surgery was considered successful if the following 4 criteria were simultaneously met: a postoperative margin reflex distance 1 of ≥2 mm and ≤4.5 mm, intereyelid height asymmetry of ≤1 mm, no overcorrection compare to opposite eye, and satisfactory eyelid contour. Results: Mean age was 10.3 years (range 1–26 years). Mean LF was 7.3 mm (2–14 mm), while 66% (12) had LF ≤7 mm. Preoperative phenylephrine test was positive in 87.5% of patients. Mean preoperative and postoperative margin reflex distance 1 was 1.34 mm and 3.2 mm, respectively. Fourteen patients (87%) achieved the desired eyelid height and fulfilled our criteria set of success. Among 10 patients with LF ≤7 mm, 9 (90%) achieved the desired eyelid height and fulfilled our criteria set of success. Ninety-four percent did not report nocturnal lagophthalmos. Three patients needed a further levatorpexy procedure due to undercorrection. Mean postoperative follow up was up 11.2 (range 6–36) months. Conclusions: Posterior approach levatorpexy is an useful first-line choice for congenital ptosis for all ranges of LF. It is popular among parents due to its avoidance of a skin incision or any resection or excision of tissue.

Dermal fillers have been in use for many years for aesthetic rejuvenation of the face. More recently, however, fillers have been increasingly used as an alternative to traditional surgical procedures for non-aesthetic indications. These indications include lagophthalmos, eyelid malpositions and orbital volume deficiency. The advantages of these filler injections are multiple: minimally invasive, repeatable, titratable and even reversible (depending on the product used). We review the current literature of functional uses of filler injections as mentioned above and evaluate the safety profile and efficacy of filler injections for this purpose.

Purpose: To report the complications of grafting of excised posterior orbital fat into the lower lid-cheek junction at the time of orbital decompression surgery. Methods: Retrospective review of consecutive patients undergoing orbital decompression combined with grafting of posterior orbital fat to the pre-malar and lateral canthal area (FG). A second group of consecutive patients undergoing orbital decompression but no orbital fat grafting (NoFG) were also studied as a form of comparative control. Standard patient data, including age, sex, visual acuity, degree of proptosis, operative details, diplopia or any other complications was collected. Independent assessment of pre- and post-operative photographs graded the lower lid-cheek junction. Results: Thirty-four orbits of 29 patients, of which 21 orbits underwent orbital decompression with orbital fat grafting (FG). There were no intraoperative complications, postoperative infections, or visual loss. Complications relating to fat grafting included prolonged swelling in 3 (17%) patients at 3 months, in 1 case lasting 6 months, lower lid lumps in 3 (17%), and fat seepage in 1 (6%). The FG group achieved a greater improvement in the appearance of the lower-lid-cheek junction at 12 months in comparison to NoFG. Mean grade improvement 1.24 +/- 1.09 vs 0 +/- 0.82 (p = 0.025). Median follow-up was 20 months (range 6-30 months). Conclusion: Grafting of excised orbital fat during orbital decompression can improve the appearance of the lower lid-cheek junction in patients being treated for thyroid orbitopathy. However, 24% of patients will experience swelling and/or lumpiness requiring several months to settle or further fat excision.

To report outcomes and complications of lower eyelid retractor recession and lateral horn lysis (RR) for lower eyelid elevation in patients with facial nerve palsy (FNP). Retrospective review. Patients with FNP undergoing RR alone (group 1) or with adjunctive procedures (canthal suspension—group 2, tarsorrhaphy—group 3, and full-thickness skin graft—group 4) during a 5-year period were included. Patient demographics, lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. Measures of lower eyelid height (LEH) and lid lag on downgaze were obtained from standard photographs. Forty-two patients (23 females, mean age was 59 years) were included. Mean follow-up was 24 months (range 6–77). Median improvement in LEH following surgery was significant in Group 1 (0.90 mm, IQR: 0.37–0.91, P=0.20) and in Group 2 (0.51 mm, IQR: 0.30–1.37, PP=0.02) in Group 1 and 3.50 mm (IQR: 1.75–5.00, PP=0.02) in Group 1 and 1.00 mm (IQR: 0–2.13, P=0.006) in Group 2. No new cases of ectropion were noted. 23.5% of patients required a repeat RR at a mean interval of 20 (range 1–70) months and a further 9.8% required a third procedure at a mean interval of 21 (range 18–29) months. RR improves lower eyelid retraction and lagophthalmos in FNP either alone or when combined as an adjunctive procedure. It does not aggravate paralytic ectropion although repeated retractor recessions may be required to improve retraction.

Bell’s facial nerve palsy (FNP) during pregnancy and the puerperium can present significant challenges for the patient and clinician. Presentation and prognosis can be worse in this group of patients. This article reviews the background, manifestation and management options of FNP. In particular, it focuses on the controversies that exist regarding corticosteroid use during pregnancy and outlines approaches to diagnosis and treatment. Based on this review, we recommend an early evidence-based approach using guidelines derived from non-pregnant populations. This includes assessment for atypical causes, a multidisciplinary input and early introduction of corticosteroids to limit progression and improve prognosis.