Ablative Fractional Laser Resurfacing With Laser-Assisted Delivery of 5-Fluorouracil for the Treatment of Cicatricial Ectropion and Periocular Scarring

Ophthalmic injuries from the beirut blast: Managing long-term consequences

The 2020 Beirut Port explosion was one of the largest non-nuclear urban explosions in history, and resulted in a plethora of oculofacial injuries. In this retrospective study, we present the two year follow up ophthalmic outcomes of the survivors of the blast. Only 16 out of 39 patients continued follow up at our center, with 13 having delayed complications and 7 requiring further surgery. The most common delayed complications related to the eyelid, lacrimal system, and orbit. Treatment of disfiguring facial and peri-ocular scarring with laser-assisted drug delivery of topical 5-fluorouracil showed great promise and significantly improved patients' functional and well as cosmetic outcomes.

Laser-Assisted Drug Delivery: A Systematic Review of Safety and Adverse Events

Laser-assisted drug delivery (LADD) is an increasingly studied and applied methodology for drug delivery. It has been used in a wide variety of clinical applications. Given the relatively low barrier to entry for clinicians as well as ongoing research in this area, the authors aimed to review outcomes relating to safety in laser-assisted drug delivery. A systematic review was conducted, with the databases PubMed, Medline and Embase searched in September 2022. Included articles were those that mentioned laser-assisted drug delivery in human subjects that also reported adverse effects or safety outcomes. There were no language-based exclusions. Conference abstracts and literature reviews were excluded. The results were then tabulated and categorized according to the application of LADD. In total, 501 articles were obtained. Following deduplication, screening, and full text review 70 articles of various study designs were included. Common findings were erythema, oedema, pain, and crusting following LADD. Several notably more severe adverse effects such as generalized urticaria, infection, scarring and dyspigmentation were noted. However, these events were varied depending on the clinical use of LADD. Relevant negatives were also noted whereby no studies reported life-threatening adverse effects. Limitations included limited details regarding the adverse effects within the full texts, lack of follow-up, and risk of bias. In conclusion, there were multiple adverse effects that clinicians should consider prior to carrying out LADD, where treatment goals and patient tolerability should be considered. Further evidence is needed to quantitatively determine these risks.

Efficacy of Early Application of 1540 nm Non-ablative Fractional Laser and Silicones to Improve Post-epicanthoplasty Scars

The combination of epicanthoplasty and blepharoplasty is a popular choice in Asians to acquire a pair of charming big eyes. However, the obvious scarring in the medial canthal area may result in unsatisfactory aesthetic outcomes. Recently, various laser treatments have been used to deal with scars had achieved detectable improvement, but only a few studies investigating the efficacy of lasers used in post-epicanthoplasty scarring were developed. A total of 70 participants who underwent Z-epicanthoplasty were enrolled in this prospective clinical trial and were randomly assigned to the groups of 1540nm non-ablative fractional laser (NAFL) combined with silicones treatment and silicones alone treatment. The NAFL-exposure in the treated group was additionally applied to the medial canthal area on day 21 postoperatively, compared with the participants in the control group who had only been treated with the daily usage of silicone sheets for 12 hours and silicone gels twice for 5 months after scab had fallen from the skin. Scar evolution was performed by patient and observer scar assessment Scales (POSAS) and visual analogue scale (VAS) for 21 days, and 6 months postoperatively. 64 participants have completed the entire follow-up process. The scar recovery was statistically detected in treated group compared with the control group at 6-month postoperatively assessed by POSAS, especially in pliability of scars. Furthermore, the VAS evaluations showed superior satisfaction in treated group. The early treatment of NAFL combined with silicones has improved scar formation in medial canthal region after epicantholplasties efficiently.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hughes flap in the management of lower lid retraction

PURPOSE

We present a retrospective case series on the use of Hughes flap in managing acquired cicatricial lower lid retraction.

METHODS

This was a multicentre, retrospective case series. Data was collected from medical records across different sites within Australia (Adelaide, Melbourne, and Sydney) and New Zealand (Hamilton).

RESULTS

Fourteen patients were identified. The aetiology of cicatricial lower lid retraction included previous lid lesion excision and reconstruction, eyelid trauma, orbital fracture repair, orbital radiotherapy, and lateral canthal dystopia from previous lid surgeries. 4/14 (29%) cases had undergone other surgery to correct the retraction prior to the Hughes flap. Pre-operative lagophthalmos due to lower lid retraction was noted in 11/14 (79%) cases with a median 2 mm (range: 1-5 mm). Exposure keratopathy was present in 7/14 (50%) cases. There were no peri-operative complications during Hughes flap reconstruction. One patient had post-operative upper eyelid retraction that did not require any further intervention. One patient had persistent lagophthalmos and exposure keratopathy that is being managed conservatively. One patient had wound dehiscence and further lid retraction following flap division, which required further surgery. Median length of follow-up was 15 months (range: 0.5-84 months). At final review, improvement or resolution of symptoms was seen in 13/14 (93%) cases.

CONCLUSIONS

A Hughes flap is an effective surgical technique for the management of cicatricial lower lid retraction.

5-Fluorouracil Management of Oculofacial Scars: A Systematic Literature Review

PURPOSE

To review the literature for the safety and efficacy of intralesional 5-fluorouracil (5-FU) in the management of oculofacial scars.

METHODS

A literature search was performed in July 2019 in the PubMed database to identify reports of the use of 5-FU injections for modulating oculofacial cutaneous scars. The search yielded 152 articles, of which 15 met criteria outlined for assessment. Data were abstracted from these 15 relevant articles.

RESULTS

While there were no high-level prospective randomized controlled trials, 8 were lower-quality randomized controlled trial, 3 were retrospective cohort studies, and 4 were case series. Most studies pooled results of facial and nonfacial cutaneous applications. Three studies focused solely on oculofacial applications, and these were all lower-level evidence studies. The study outcomes included scar dimension reduction, erythema, patient satisfaction score, observer assessment of scar improvement, and recurrence rates. 5-Fluorouracil was administered as monotherapy or as part of multimodality treatment with other agents (usually corticosteroids) or with CO2 laser, radiotherapy, or pulsed dye laser. 5-Fluorouracil was usually given as an intralesional injection, but in some studies, it was applied topically after micropuncture of the skin. The number and timing of treatments varied between studies. Overall, the level of safety of 5-FU was high. Pain with injection was the most common reported side effect. Other common adverse side effects included pruritus, telangiectasias, changes in pigmentation, and purpura, and 2 studies noted more serious events, such as ulceration, superficial necrosis, and local infection. There were no severe side effects such as anaphylaxis, immune suppression, secondary malignancy, systemic infection, blindness, or death. In all studies, 5-FU was associated with prophylaxis of oculofacial scars or improvement of keloids or hypertrophic scars in terms of reducing size, erythema, and pruritus. 5-Fluorouracil application was associated with favorable patient satisfaction and observer assessment scores especially compared with corticosteroid injections alone.

CONCLUSIONS

High-quality randomized controlled trials are currently lacking, and the existing literature is predominately not specific to use of 5-FU on the face. These studies, however, suggest that intralesional 5-FU is safe and probably more effective than other options in the management of cutaneous scars in the oculofacial region. The delivery methods, timing, dosing, and concomitant therapies were highly variable. Further high-quality controlled studies specific to oculofacial scars may be indicated to assess the efficacy of 5-FU and to establish the best protocols for administering this medication.

Laser Resurfacing for the Management of Periorbital Scarring

Laser (light amplification by the stimulated emission of radiation) skin resurfacing is currently one of the most widely adopted technologies in facial rejuvenation. While most often used for aesthetic purposes, lasers also have applications in the management of scars. Since the introduction of the CO₂ laser for skin rejuvenation in the 1990s, the last three decades have seen significant growth in the number of laser devices available to the physician. More recently, promising alternatives to light-based resurfacing technologies have emerged that include radiofrequency and intense focused ultrasound. To help the physician navigate the most current laser technologies as they apply to periocular scars, this review discusses the available treatment modalities, pre-treatment assessment of periorbital scars, treatment selection, and reported outcomes and complications. The recommendations described herein are based on published literature and the authors' experience in an academic oculoplastics practice.

Laser therapy in the treatment of cicatricial ectropion

INTRODUCTION

The objective of this study was to investigate the clinical effects of laser therapy in treating cicatricial ectropion.

METHODS

Seven patients with cicatricial ectropion were entered into this clinical study. The ectropions were pretreated with the 595-nm pulsed dye laser if the scar color was red. If there was no red, the UltraPulse fractional CO₂ laser was used and parameters were adapted according to the height of scar. MEBT/MEBO was used after laser treatment for wound healing. The degree of ectropion was measured for changes before and after treatment, and the scars were evaluated for changes in melanin, height, vascularity, and pliability using the Vancouver Scar Scale (VSS) before and after treatment.

RESULTS

All seven patients with cicatricial ectropion entered into this protocol were completely corrected after 1-2 treatment sessions. The total VSS score, as well as the score for melanin and pliability in 7 patients, showed a decrease following the treatments, and this was statistically significant (P < 0.05). The scores for height and vascularity showed a decrease following the treatments, but there was no significant difference by statistical analysis (P ≥ 0.05). There were no adverse reactions reported.

CONCLUSIONS

The treatment of cicatricial ectropion with laser therapy can not only correct the ectropion, but also improve the scars in the treatment area. Compared with the traditional repair of cicatricial ectropion, the use of fractional CO₂ laser provides surgical precision and the advantage of a timely treatment without the need to wait for the scar to stabilize.

A Modified Hughes Flap for Correction of Refractory Cicatricial Lower Lid Retraction With Concomitant Ectropion

INTRODUCTION

Correction of lower eyelid retraction commonly involves one or more techniques, including recession of the eyelid retractors, spacer grafts, horizontal lid tightening, and midface lifting. However, patients presenting with cicatricial lower lid retraction following prior eyelid surgery often have scarring and concomitant ectropion or entropion that cause unpredictable wound healing, recicatrization, and suboptimal outcomes. The modified Hughes tarsoconjunctival flap is typically used to repair full-thickness eyelid defects. Prior reports describe treating refractory lower lid retraction with a modified Hughes flap placed beneath the tarsus after full-thickness blepharotomy. We present our experience with a novel surgical technique for treating refractory cicatricial lower lid retraction using a modified Hughes flap above the tarsus after excision of the scarred lid margin.

METHODS

Three patients were treated using this technique. The upper edge of the lower eyelid and associated scar tissue are excised. A modified Hughes flap is mobilized and secured above the posterior lamellar remnant. A full-thickness skin graft is placed over the flap. The flap is divided 4-5 weeks later.

RESULTS

This surgical technique was employed in all 3 cases. All cases were revisional, with 2 having extensive multioperative histories with multiple unsuccessful reconstructions and lid retraction repairs. All patients had improvement in cicatricial eyelid retraction, lagophthalmos, exposure keratopathy, and resolution of concomitant cicatricial ectropion.

CONCLUSIONS

The technique of using a modified Hughes flap to reconstruct above the tarsus with excision of the scarred lid margin was effective in correcting refractory cicatricial lower lid retraction. This procedure can be considered in multioperative cases in which traditional techniques for lower lid retraction repair have failed. Reconstructing a new lid margin reduces the risk of recicatrization and suboptimal results.

Dynamic Brow Restoration Using a Soft Tissue Expander in Adult Patients With Arteriovenous Malformation

BACKGROUND

Impaired brow function in adult patients with arteriovenous malformation is a serious disability that can even influence the field of vision. Brow reanimation techniques are used to recover a more natural appearance and brow function. Many static procedures have been set to augment brow elevation, but only dynamic procedures can lead to better functional results. In this study, the experience of a single surgeon addressing the challenge of brow restoration with dynamic procedures is presented.

METHODS

A retrospective review was performed using the records of 4 adult patients who underwent dynamic procedures using a soft tissue expander for brow restoration after arteriovenous malformation excision in the unilateral site of the forehead with the expander on the contralateral side. Movement and electrodiagnostic examinations were performed postoperatively at 2 months.

RESULTS

The patients included 3 males and 1 female (mean age, 20.5 ± 4.04 years). Brow improvement was noted in all patients. The results of the electrodiagnostic examination showed synchronous and spontaneous motor unit potentials and compound muscle action potentials with the contralateral forehead.

CONCLUSIONS

Dynamic procedures using a soft tissue expander can provide both static and dynamic functional brow elevation of the contralateral frontalis and skin.

Approach to treatment of cicatricial ectropion: a systematic review and meta-analysis comparing surgical and minimally invasive options

Cicatricial ectropion can involve the skin, subcutaneous tissue, muscle, and septum to result in chronic tearing and keratopathy. Surgery involving the orbital rim or eyelid is a common cause. Minimally invasive techniques may provide alternative options for correction, but the comparative benefit to surgery is unknown. To compare the efficacy of surgical and minimally invasive minimally invasive treatment options for cicatricial ectropion. A comprehensive literature search of Medline, EMBASE, and the Cochrane Library published from 1960 to August 2019 was performed for studies that described any treatment of cicatricial ectropion. 1391 studies were found, of which 31 had extractable data for 299 patients. Pooling of outcome data occurred for the primary and secondary outcomes. The complete and partial response rates to treatment (primary outcomes) as well as the recurrence rate and physician global assessment of cosmesis (secondary outcomes) were analyzed. Surgical correction resulted in complete correction in 79% of patients compared to 63% of hyaluronic acid treated patients. Hyaluronic acid injection had a better aesthetic outcome, but a higher recurrence rate overall. Hyaluronic acid filler with a high G' along with delayed dissolution trended toward a lower recurrence rate. Other minimally invasive treatments had little data. The literature found was limited to mostly single-center, observational studies. Hyaluronic acid may be a viable alternative for cicatricial ectropion in those patients who cannot undergo surgery. Further prospective studies are required to routinely recommend minimally invasive techniques.