Lateral Canthus Research Articles

Хирургическое лечение базалиомы внутреннего угла глазной щели с закрытием дефекта свободным лоскутом. Клинический случай

Basal cell carcinoma is a tumor of the basal layer of the skin epithelium. It occupies an intermediate position between benign and malignant tumors. It develops from atypical basal cells of the epidermis and follicular epithelium. It does not metastasize. The occurrence on the lower eyelid is about 65 %, on the medial canthus about 15 %, on the upper eyelid about 15 % and on the lateral canthus 5 % of cases. Usually the neoplasm is painless, but more invasive basal cell carcinomas with perineural germination into the tissues of the eyelid and orbit can cause pain [1, 3]. The choice method of treatment of this disease is surgical. The operation is performed under a microscope, which allows to remove the altered tissues as much as possible and correctly match the edges of the donor material. To replace the surgical defect, a type of plastic was chosen: plastic with local tissues, free skin plastic. The skin flap was taken from the upper eyelid of the fellow eye [2]. There are several types of basal cell carcinomas: nodular, flat, and superficial. The nodular form is most common. A distinctive feature in most cases is pearl shade and waxy or translucent consistency of the tumor, more noticeable on the raised edges of the neoplasm. A characteristic and important symptom is telangiectasis marked at the edges of the neoplasm [1]. Initially, a painless nodule appears on the skin gradually, the nodule spreads over the area, accompanied by formation of ulcers, due to disturbance of blood supply and turns into ulcerative-nodular form. Ulceration can bleed. Further, basal cell carcinoma turns into a flat plaque with a peeling surface, a node protruding above the surface of the skin, or into a deep ulcer that destroys the underlying tissues. With advanced forms or inadequate treatment, the tumor can grow into the lacrimal pathways, the orbit and occasionally into the cranial cavity. The sprouting of orbital tumor causes diplopia and dislocation of the eyeball. Spontaneous regression is rare [3]. There are the following types of treatment: radiation, surgical, combined, medicinal, cryogenic, laser [4, 5]. Radiation, laser, cryogenic methods of treatment are carried out in a specialized cancer center. The surgical method is based on excision within healthy tissues with the least traumatization or destruction of surrounding tissues. Excision of a part of the eyelid weakens its horizontal tension; this circumstance requires special restorative techniques to prevent scarring. The choice method of the defect closure is the method of lateral displacement, plastic with a free flap or pedicle flap [4, 5]. Key words: basal cell carcinoma; surgery of basal cell carcinoma; plastic surgery with a free flap.

Management of eyelids’ primary malignancies

ABSTRACT Purpose: We report our experience in surgical management of primary malignant tumors of the eyelids. We have specified the various surgical techniques used, as well as functional and anatomical results. Patients and methods: A review of patients admitted for malignant tumor of the eyelids in the oculoplastic department of the Hedi Raies Institute of Ophthalmology from January 2012 to December 2021. Results: One hundred and twenty-three patients with malignant eyelid tumors were hospitalized. Surgical treatment involved 114 tumor lesions, which represents 95% of the cases. One hundred and eleven lesions (97.4%) had been operated by simple tumor resection. Safety margins were, respectively, 4 mm in 63.2% and from 5 to 6 mm in 34.2%. Extemporaneous histological examination was performed in three cases (2.6%). Reconstruction involved the anterior lamella (AL) in 92 cases (80.7%), the posterior lamella (PL) in 66 cases (57.9%), the medial canthus in 18 cases (15, 8%), and lateral canthus in 4 cases (3.5%). The excision was oncological in 85 cases (74.6%) and incomplete in 19 cases (16.7%). Tumor recurrence occurred in seven cases (6.1%), after an average delay of 36 months. Conclusion: The anatomical and functional features of the eyelids require a good reconstruction of the transfixion eyelid defect. Many reconstruction methods are available, allowing extensive and complex palpebral repairs. Oncologic prognosis is conditioned by the surgical quality.

Two-dimensional facial measurements for anterior tooth selection in complete denture treatment

PurposeAnterior tooth selection is one of the most challenging parts in determining tooth dimensions and critical to the aesthetic aspect of the complete denture treatment. However, the methods for anterior tooth size selection using facial measurements are still controversial. This study aimed to investigate the relationship between dental measurements and facial measurements, and to establish the anterior tooth size prediction equation using facial dimensions in the Thai population for the complete denture treatment. Materials & methodsOne hundred and twenty-five Thai participants (53 men and 72 women) aged 18–35 years old with Angle class I occlusion, did not currently undergo orthodontic treatment, had normal alignment on the maxillary anterior teeth, no attrition, abrasion, proximal restoration or prosthesis were investigated. One frontal facial photograph and one dental photograph of each participant were made using an image analyzing program (ImageJ version 1.53b) to measure the six horizontal facial distances, five vertical facial distances and three dental distances as 2D facial and dental measurements. Pearson correlation and multiple linear regression analysis were performed. ResultsThe difference of facial and dental measurements between men and women were statistically significant (P < .001). Interpupillary width, interlateral canthal width, intercommissural width and bizygomatic width were correlated to dental measurements in both sexes. Intermedial canthal width and lip thickness were correlated to dental measurements in women. Face length and lateral canthus to lower border of face were correlated to dental measurements in men. Prediction equations of each dental measurement were established using only horizontal facial dimension and using both horizontal and vertical facial dimensions. ConclusionsFacial and dental dimensions are sex-dependent. Facial measurements can be applied in a regression equation to predict dental measurements. Adding vertical dimensions of facial measurements to the prediction equations of anterior tooth size selection results in a higher R squared to 0.444. This finding can be used as a tool for anterior tooth size selection in the complete denture treatment.

An Experimental Design to Compare the Compatibility of Absorbable and Nonabsorbable Suture Materials in the Lateral Canthus Area.

Polyglactin 910 (Vicryl) and polypropylene (Prolene) are common suture materials used in ophthalmic surgical procedures. However, there are limited studies assessing tissue reactions to different sutures in eyelid areas. In this study, these suture materials were used subcutaneously in 10 lateral canthi of 5 pigs. Clinical reactive score (CRS) was assessed 14 days and 60 days after surgery. On histology, subcutaneous tissue reactions were assessed by the presence of different inflammatory cells, and the aggregate tissue irritation score was calculated. CRS and the histology score did not differ between these sutures. None of the suture materials used were superior for use in the lateral canthi of pig eyes. Therefore, we recommend both of these sutures for use in the subcutaneous tissue of the eyelid area in animal experiments or clinical practice.

"Unusual Presentation of Epitheloid Dermatofibroma- Rare Case Report".

Dermatofibroma is a commonly occurring cutaneous entity usually centered within the skin's dermis. Dermatofibromas are referred to as benign fibrous histiocytomas of the skin, superficial/cutaneous benign fibrous histiocytomas, or common fibrous histiocytoma. These mesenchymal cell lesions of the dermis clinically are firm subcutaneous nodules that occur on the extremities in the vast majority of cases and may or may not be associated with overlying skin changes.A 20years old male presented to ENT OPD, at a private hospital, with complaints of a huge mass over right side of face since 15years, which was slowly growing and not associated with pain. On clinical examination, hard, non tender, lobulated cauliflower like mass located over right side of face extending from right side temporal region to upper border of mandible from superior to inferior. From anterior to posterior it was extending from lateral 1/3rd of forehead and covering lateral canthus of right eye upto right side tragus. We have taken incisional biopsy which was suggestive of dermatofibroma. Then surgery was performed with patient's consent. Excision with 1cm free margin was done. Raw area was covered with full thickness skin grafting and advancement flap. We found no recurrence till date. Dermatofibroma in the head and neck region is less common and often present a difficult differential diagnosis like Dermatofibrosarcoma protuberans, Kaposi Sarcoma, Basal cell carcinomas. The aim of case report is to represent case of dermatofibroma of epitheloid variety which is unusual in size.

Topography of the frontal branch of the facial nerve and its clinical implication for temporal direct browplasty

Due to anatomic proximity to the surgical site, iatrogenic trauma to the frontal branch of the facial nerve (FbFN) with resultant brow paralysis is a recognized major complication of temporal direct browplasty. This study was aimed to elucidate the course of the FbFN in the area superolateral to the brow in order to facilitate safer temporal direct browplasty by preventing facial nerve injury. Forty-five hemifaces from 32 embalmed Korean cadavers were dissected. A horizontal line connecting the tragion to lateral canthus was established. Then, an oblique line passing through the lateral canthus and 45° to the horizontal line was used as reference line. The mean distance from the lateral canthus to the points where the FbFN cross the reference line was measured. The angle between the FbFN and reference line at the crossing points were also recorded. After crossing the zygomatic arch, FbFN continues in an anteriorly inclining curve across the temporal region, passing near the lateral end of the brow as it heads toward frontalis muscles. During the course, the FbFN laying in the innominate fascial layer was divided into 3 branches. The anterior and posterior branch of FbFN crossed the reference line superiorly and laterally at 3 and 4 cm from the lateral canthus, respectively. In conclusion, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the 3 cm superolaterally to the lateral canthus in the direction of 45° from the horizontal line in order to avoid nerve injury.

1303 The Role of Cemiplimab in the Management of Locally Advanced and Metastatic Squamous Cell Skin Cancers: A Case Report

Abstract This case report discusses the use of cemiplimab, an immune checkpoint inhibitor, as a single agent for management of locally advanced basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) in a 79-year-old male patient. The patient was initially referred to plastic surgery for facial lacerations closure after a fall and was incidentally found to have suspicious lesions on his central forehead, right lateral canthus, mid-face, &amp; anterior shoulder. He had history of skin lesions treated with photodynamic therapy, and recent palliative radiotherapy and fixation of a right humerus pathological fracture. Biopsy of the lesions confirmed locally advanced BCC and SCC malignancies, and underwent staging imaging, which showed evidence of osseous metastasis and lymphadenopathy. The patient was offered operative treatment with hemi-maxillectomy, orbital exenteration, and neck and axillary dissection but opted for immunotherapy drug with cemiplimab in accordance with National Institute for Health and Care Excellence (NICE) guidelines for treatment. The patient's skin lesions improved significantly after 3 rounds of treatment with shrinkage of the right lateral canthus and right midface lesions, apparent resolution of the forehead lesion, and improvement in the chronic shoulder wound, and no palpable regional lymphadenopathy. This case report adds to the growing body of evidence supporting the use of checkpoint inhibitors for SCCs and BCCs, particularly in cases where surgery and radiotherapy are not suitable. It also discusses current guidelines and socio-economic implications of this treatment. Overall, further research/trials are needed to determine optimal management strategies and improve outcomes for patients with SCC and BCC.

Restoration of the Lateral Canthus and Stabilization of the Lower Eyelid After Failed Esthetic Lateral Canthoplasty.

An improper procedure of esthetic lateral canthoplasty can lead to lateral canthal deformity with other complications. To ensure proper canthal contour and eyelid function, the lateral canthus must be restored and the lower eyelid must be stabilized. This was a retrospective study that included a group of consecutive patients who had failed esthetical lateral canthoplasty between 2020 and 2022. All patients underwent the modified lateral tarsal strip procedure to restore the normal anatomy of the lateral canthus and stabilize the lower eyelid. Clinical data (age, sex, laterality, follow-up, ocular symptoms, previous medical history, and lateral canthal deformity) were collected. Preoperative and postoperative photographs were analyzed for cosmetic outcomes. Among the 15 female patients, 25 eyelids were treated, including both eyes in 10 patients and only the left eye in 5 others. The mean age was 32.6 years. The mean follow-up was 13.34 months. All the patients had undergone esthetic lateral canthoplasty with other esthetic surgeries. Lateral canthus deformities include canthal webbing, rounding canthus, eyelid margin defect, remnant raw surface, mucosal exposure, lower eyelid retraction, sclera show, ectropion, symblepharon, and lagophthalmos. All the patients exhibited esthetically satisfactory results with improved ocular symptoms. In statistical analysis, horizontal palpebral aperture, vertical palpebral aperture, MRD2, and lateral canthus angle were statistically different pre to postprocedure (paired t test, P < 0.001). Restoration of the lateral canthus and stabilization of the lower eyelid using the modified lateral tarsal strip procedure showed good functional and cosmetic outcomes in patients who had failed lateral canthoplasty.

Temporal Facelift: A New Method for Temporal and Mid-face Lifting.

Lifting the temporal and mid-face areas creates a very dynamic change in the facial appearance and different planes of dissection were described before. In this article, a new plane of dissection is described which allows the surgeon to perform a very quick and safe dissection in both the temporal and mid-face regions. Patients were operated on using the presented technique and brow lift, cantopexy, and mid-facelift were performed. The outcome of the surgery was analyzed by the authors from standardized photos before and 6 months after the surgery with measurements of the brow and lateral canthus. The plane of dissection is just over the subgaleal fascia which is actually the sub-superficial musculoaponeurotic system layer in the mid-face. This plane of dissection is easy and quick and creates a very mobile mid-face and temporal flap. Forty female patients were operated using the presented technique with a mean follow-up period of 15 months, the longest follow-up was 26 months. No major complication was encountered in these patients. In 5 patients, transient unilateral frontal branch palsy was encountered. In 1 patient, bilateral temporal area depression was observed 8 months after the surgery and treated with a fat injection under local anesthesia. One patient had alopecia in the temporal suture line which can be covered with hair. Temporal facelift is a versatile method with long-lasting results due to its important features; creating a very mobile flap for suspension dissection area, a large surface for adherence, and numerous sutures sharing the tension on the key sutures. Despite its slightly difficult early healing period, the technique should be kept in mind for the rejuvenation of the periorbital area and mid-face. Level of Evidence: Level I.

The incidence of periocular melanoma: An epidemiologic study in Olmsted County, Minnesota

To the Editor: Melanoma arising in the periocular area presents a unique treatment challenge due to anatomic and functional constraints. To date, most information regarding periocular melanoma is gleaned from extrapolated data from other sites of the body, assuming similar biologic behavior. We aimed to identify the overall incidence, pathologic features, and surgical outcomes of periocular melanoma. Following Institutional Review Board (IRB) approval, using the Rochester Epidemiology Project (a multicenter medical records–linkage system encompassing the Olmsted County population), we identified patients with a first lifetime diagnosis of periocular melanoma between January 1, 1970, and December 31, 2020, while a local resident of Olmsted County, Minnesota. Outside (nonresident) referral cases were excluded. Periocular melanoma was defined as a melanoma arising within the orbital rim – on the upper or lower eyelid, lateral canthus, or eyebrow. A total of 10 patients with primary periocular melanoma were identified. The overall incidence rate of periocular melanoma was 0.2686 per 100,000 patient-years. Among all melanomas diagnosed during that timeframe in Olmsted County, 0.43% were periocular in location. No cases extended onto conjunctiva. The histogenic subtype was lentigo maligna in 8 (80.0%). There was 1 superficial spreading melanoma and 1 case without documentation of histogenic subtype. Incidence of in situ (50.0%) and invasive (50.0%) melanomas was equal. Among invasive melanomas, the average Breslow depth was 0.90 mm (range, 0.2-2.6 mm). Seven (70.0%) were treated with Mohs micrographic surgery (MMS). One (10%) was treated with wide local excision. The 2 cases that did not undergo further surgical treatment were both diagnosed prior to 2000 and were removed entirely via initial excisional biopsy. There was 1 regional metastasis to the parotid gland and lymph node, 2.5 years after diagnosis of a superficial spreading melanoma, Breslow 0.7 mm, status-post treatment with MMS. There were no other local or distant recurrences. There were no melanoma-specific deaths. Mean follow-up time was 7.4 years (range 3.1-13.2). This study demonstrates the relative rarity of periocular melanoma, comprising only 0.43% of all melanomas. Comparatively, basal cell carcinoma (BCC) occurs on the eyelid 16% of the time.1Salomon J. Bieniek A. Baran E. Szepietowski J.C. Basal cell carcinoma on the eyelids: own experience.Dermatol Surg. 2004; 30: 257-263PubMed Google Scholar Our study found an overall periocular melanoma incidence rate of 0.2686 per 100,000 patient-years. A previous Olmsted County cohort reported an incidence of eyelid BCC as 14.35 per 10,000 individuals per year, and an incidence of eyelid SCC as 1.37 cases per 100,000 individuals per year.2Cook Jr., B.E. Bartley G.B. Epidemiologic characteristics and clinical course of patients with malignant eyelid tumors in an incidence cohort in Olmsted County, Minnesota.Ophthalmology. 1999; 106: 746-750Abstract Full Text Full Text PDF PubMed Google Scholar The behavior of melanoma seems to parallel primary cutaneous melanoma of head and neck sites. Most tumors were associated with chronic sun exposure; 80% of cases were lentigo maligna subtype. There was 1 regional recurrence in our study, no distant recurrences, and no deaths due to melanoma. The most significant advantage of our study is in its epidemiologic design. The limitations of this study include the retrospective nature of our analysis and the homogenous demographics of Olmsted County, comprised of mostly Caucasian individuals of higher socioeconomic status.3St Sauver J.L. Grossardt B.R. Leibson C.L. Yawn B.P. Melton 3rd, L.J. Rocca W.A. Generalizability of epidemiological findings and public health decisions: an illustration from the Rochester Epidemiology Project.Mayo Clin Proc. 2012; 87: 151-160Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar Additionally, some melanomas may have been missed if the tumor was initially labeled as another anatomic site (cheek, nose, temple, etc.) and had extension onto the lid proper. None disclosed. We would like to acknowledge Austin Todd, MS, for his assistance in statistical analysis.

Anatomical Relationship between the Inferior Temporal Septum and the Temporal Branch of the Facial Nerve for Clinical Applications.

The inferior temporal septum (ITS) is a fibrous adhesion between the superficial temporal fascia and the superficial layer of the deep temporal fascia. This study identified detailed the anatomical relationship between the ITS and the temporal branch of the facial nerve (TBFN) for facial nerve preservation during temple interventions. Among 33 Korean cadavers, 43 sides of TBFNs in temporal regions were dissected after identifying the ITS between the superficial temporal fascia and superficial layer of the deep temporal fascia through blunt dissection. The topography of the ITS and TBFN were investigated with reference to several facial landmarks. Regional relationships with the ITS and TBFN within the temporal fascial layers were histologically defined from five specimens. At the level of the inferior orbital margin by the tragion, the mean distances from the lateral canthus to the anterior and posterior branches of the TBFN were 5 and 6.2 cm, respectively. At the lateral canthus level, the mean distance from the lateral canthus to the posterior branch of the TBFN was similar to that to the ITS, at 5.5 cm. At the superior orbital margin level, the posterior branch of the TBFN ran cranial to the ITS adjacent to the frontotemporal region. The TBFN ran through the subsuperficial temporal fascia layer and the nerve fibers located cranially, and within the ITS meshwork in the upper temporal compartment. The area of caution during superficial temporal fascia interventions related to the TBFN was clearly identified in the upper temporal compartment, which is known to lack important structures.

Development of a new surgical technique to infuse kynurenic acid to optic nerves in chickens for studying loss of myelination

Prolonged infusion of a high dose of kynurenic acid (KYNA) reduces the myelin content in the rat spinal cord with preservation of the axonal integrity and without inducing an inflammatory response. We hypothesized that subdural infusion of a high concentration of KYNA can induce myelin loss in the optic nerves (ONs) of chickens. However, existing methods to deliver agents to the ON are inefficient, unlocalized and provide only acute exposure. Thus, we developed a surgical approach for sustained delivery of KYNA to the chicken ON. In brief, the novel surgical technique, which does not include excision of the extraocular muscles, involves incision of the skin and underlying fascial sheath to access the optic nerve within the muscle cone, implantation of a catheter in the dura of the optic nerve, the other end of which exits the orbit under the skin. The catheter runs under the skin near the lateral canthus, over the ears to the back of the neck, where a second incision is made to both implant the osmotic pump and to attach the catheter to the osmotic pump. India ink was used to confirm prolonged sustained administration to the optic nerves and across the chiasm. This surgical model was used to investigate KYNA's effect(s) on myelin loss in the ON. ONs of 7-day old chickens were infused with 50 mM KYNA or phosphate buffered saline (PBS) for seven days. Analysis of KYNA-infused contralateral ON g-ratios and protein levels indicated a reduction in myelin. These findings demonstrate the utility of our surgical approach for sustained delivery of KYNA into the ON and suggest a role for KYNA in modulating CNS myelination.

Lateral tarsal strip with everting suture and inferior retractor plication for correction of entropion

PurposeTo describe a surgical technique that involves combining a lateral tarsal strip with one everting suture and one inferior retractor plication suture for correction of involutional lower eyelid entropion. MethodsA retrospective review of patients who underwent correction of lower eyelid entropion with a combination of lateral tarsal strip, everting suture and inferior retractor plication was conducted. ResultsSixty-six patients (42 males and 24 females) underwent this surgical procedure between December 2020 and October 2022. Complete resolution of eyelid malposition was noted in all patients at 1-month follow-up. No recurrences were noted in the follow-up period extending up to 22 months after surgery. One patient developed a suture granuloma at the lateral canthus, which resolved with conservative management with topical steroids. One patient developed a hemorrhage 4days post-operatively, which resolved spontaneously. No other intra-operative or post-operative complications were noted. ConclusionThe combination of lateral tarsal strip with everting suture and inferior retractor plication suture achieved a good surgical success rate in correcting involutional lower eyelid entropion.

Assessment of Laser Parameters to Improve Lid Tension-A Proof of Concept towards Lasercanthoplasty.

Preliminary clinical work indicates that increasing eyelid tension improves the function of the meibomian glands. The aim of this study was to optimize laser parameters for a minimally invasive laser treatment to increase eyelid tension by coagulation of the lateral tarsal plate and canthus. Experiments were performed on a total of 24 porcine lower lids post mortem, with six lids in each group. Three groups were irradiated with an infrared B radiation laser. Laser-induced lower eyelid shortening was measured and the increase in eyelid tension was assessed with a force sensor. A histology was performed to evaluate coagulation size and laser-induced tissue damage. In all three groups, a significant shortening of the eyelids after irradiation was noticed (p < 0.0001). The strongest effect was seen with 1940 nm/1 W/5 s, showing -15.1 ± 3.7% and -2.5 ± 0.6 mm lid shortening. The largest significant increase in eyelid tension was seen after placing the third coagulation. Laser coagulation leads to lower eyelid shortening and an increase in lower eyelid tension. The strongest effect with the least tissue damage was shown for laser parameters of 1470 nm/2.5 W/2 s. In vivo studies of this effect have to confirm the efficacy of this concept prior to clinical application.

Widening Aging Eyes and Ending Outdoor Tearing with Retrobulbar Injections of Dermal Fillers.

Retrobulbar injections of 3.5-mL high-viscous dermal fillers (Bellafill or Radiesse) pushed the eyeballs forward, aligned the bulbus with the conjunctiva, and closed the wind trap behind the lateral canthus. Magnetic resonance imaging confirmed the filler material in the posterior lateral corner of the orbit. The effect was immediate: the patient's constant outdoor tearing had resolved after the first treatment of his senile enophthalmos. In addition, the narrow palpebral fissure had widened by 2 mm and rejuvenated his aging eyes. An eyeball that has receded with age can be pushed forward with a retrobulbar injection of a long lasting dermal filler to reattach to the eyelids.

Ipilimumab and Nivolumab for Treatment of Eyelid Spindle Cell Melanoma

A 70-year-old man presented with recurrent left upper eyelid spindle cell melanoma. He was initially diagnosed with eyelid spindle cell melanoma three years prior and underwent excision with negative sentinel lymph node biopsy. He refused radiation and was observed without evidence of local or systemic disease. Seventeen months later, he developed a biopsy-proven local recurrence and presented for additional evaluation. Exam demonstrated a large, firm, amelanotic lesion encasing the entire left upper eyelid from the medial to lateral canthus and attaching to the brow tissues and frontal bone (A). Due to the extensive surgery required for complete excision, he opted for checkpoint inhibitor immunotherapy. He received ipilimumab 1 mg/kg and nivolumab 3 mg/kg intravenously every three weeks for 4 cycles. He had pseudoprogression after the first cycle within one week after receiving the first cycle (B) but demonstrated dramatic clinical improvement after his fourth cycle (C) that remained evident three months after he received his last cycle of combined ipilimumab and nivolumab (D). He continues to undergo treatment with intravenous nivolumab with plan for 3 additional cycles of nivolumab monotherapy given his improvement. Ipilimumab and nivolumab are checkpoint inhibitors that provide effective noninvasive treatment for malignant melanoma, especially in locations such as the periorbital region where Mohs surgery with possible extensive excision and subsequent reconstruction would result in high morbidity, including cicatricial lagophthalmos, ectropion, exposure keratopathy, or restrictive strabismus. In patients with extensive disease, including our patient, checkpoint inhibitor immunotherapy may reduce the need for orbital exenteration. Awareness that immunotherapy may lead to pseudoprogression, increased tumor size after immune cell infiltration of the tumor due to effective treatment response, is important to avoid premature cessation of efficacious immunotherapeutic agents.

Width of the orbicularis oculi fibers extending to the upper lip with the lateral and inferior lengths of the orbicularis oculi at the lateral canthus level: application to botulinum neurotoxin type A injection for crow's feet.

The aim of this study was to determine the width of the fibers that extend from the orbicularis oculi muscle (OOc) to the upper lip, and the lateral and inferior lengths of the OOc at the lateral canthus level. The OOc was investigated in the 40 hemifaces of 20 Korean cadavers. The lateral fibers of the OOc (OOc lat) were traced to determine whether or not these fibers extended to the upper lip. The OOc lat extended to the upper lip at the lateral canthus level in 31 of the 40 specimens (77.5%), whereas some inferolateral fibers of the OOc that extended to the upper lip were observed near the level of the lower margin of the OOc in the other 9 specimens (22.5%). The mean ± SD and maximum widths of the OOc lat that extended to the upper lip at the lateral canthus level were 6.9 ± 3.3mm and 14.3mm, respectively. The obtained data will be helpful to distinguish the muscles that underly the wrinkles around the lateral canthus for safer and more-efficientBoNT-A treatments for crow's feet.

A case of dermoid cyst

Dermoid cyst is a common ocular tumour, it accounts for 3-9% of paediatic ocular tumour. Childers with dermoid tumour persent with other congenital abnormality 13 year old girl presented to our OPD, with complains of swelling in her left eye upperlid since birth, patient has multiple facial anomalies. On ocular examination, her vision in both eyes were 6/6. A 3*3cm noted in the left upper lid near the lateral canthus. Clinical diagnosis of Dermoid cyst left eye upperlid made. A surgical excision biopsy was planned under General anaesthesia. Intraoperatively the cyst removed with the cyst wall intact. Cut section revealed cystic lesion with tangle of hair follicles. Specimen sent for histopathology. HPE confirmed the diagnosis of teratomatous dermoid cyst. Dermoid cysts account for 5% of all orbital lesions and are among the most common orbital tumors of childhood. Ophthalmologist should be aware to surgically excise these cyst meticulously so as to provide good cosmetic result to the patient.

Facial masculinization surgery

Facial masculinization surgery

Comparison of Safety and Efficacy of Two Brands of Botulinum Toxin A for the Treatment of Lateral Canthal Lines (Crow's Feet): A Split-Face Study.

To compare the safety and efficacy of Stunnox with the international brand of botulinum toxin A on lateral canthal lines. This was a nonrandomized, controlled, pilot, split-face study in 47 patients who were given two brands of Botulinum toxin A for the treatment of lateral canthal lines for 12 weeks. Evaluation of lines was assessed with grades of 0 (none), 1 (mild), 2 (moderate), and 3 (severe) at a maximum smile and rest by using ANTERA 3D camera. There was a statistical significance in lateral canthal lines wrinkles reduction on the Stunnox sides compared to pretreatment and at weeks 4, 8, and 12, respectively (all P < 0.05). The wrinkle reduction was similar to the effects of the control internationally available brand of botulinum toxin A. The clinical improvement of lateral canthal line wrinkles was greatest at 4 weeks after injection and the improvement lasted until 12 weeks of treatment with no adverse events observed. In this split-face study, Stunnox botulinum toxin A showed a moderate but significant wrinkle-soothing effect without obvious side effects on the lateral canthal.