Tightening Procedure Research Articles

Reduced surgical success rate of rectus muscle plication compared to resection

To evaluate the surgical success of rectus muscle plication compared to resection and to compare the short- and long-term changes in ocular alignment after both procedures. The medical records of all patients who underwent a rectus muscle tightening procedure (resection or plication) at a single institution over a 5-year period by a single surgeon were reviewed retrospectively. Binocular alignment was recorded before and immediately after surgery and again at 6-12weeks and final follow-up visit. Primary outcome was surgical success rate, defined as distance alignment of ≤10Δ for horizontal and ≤6Δ for vertical strabismus. Secondary outcomes were reoperation rate and postoperative alignment drift. A total of 72 surgeries were identified for inclusion: 48 resections and 24 plications. Surgical success was significantly higher in the resection group than in the plication group (89% vs 58%; P=0.005) at both 6-12weeks' follow-up (P=0.005) and at mean final follow-up of 19±13months (range, 3-56months [n=48]; P=0.03). Reoperations were performed in 3 patients in the plication group (12.5%), all for undercorrection; there were no reoperations in the resection group (P=0.03). Rectus muscle plication has many potential advantages over resection, including sparing ofthe ciliary circulation. In our experience, however, patients treated with plication hadlowersurgical success rates and a higher reoperation rate. Surgeons should monitor theirlong-term results before considering plication as their procedure of choice over resection.

Application of direct tension indicators in preloaded bolted connections

AbstractThe direct tension indicator (DTI) method is specified in EN 1090‐2 as one of the tightening procedures for preloading bolting assemblies to a specified level of preload. As Germany so far has no experience of using the DTI method, recent experimental and theoretical investigations were carried at the Institute for Metal and Lightweight Structures, University of Duisburg‐Essen, Germany, with the main focus being the loadbearing behaviour of preloaded bolting assemblies with DTIs under external axial tensile loading. Whereas tension connections employing preloaded bolting assemblies are quite common in Germany, in the UK, for example, bolted connections are preferably designed as shear connections, as far as is known. As a result of the investigations presented below, it can be summarized that, under tensile loading especially, preloaded bolting assemblies with DTIs might suffer from a severe loss of preload – something that should be considered in preloaded bolted connections in which the preload is taken into account in the design of the connections, e.g. in slip‐resistant connections, to activate the slip resistance, and in tension connections subjected to fatigue. Based on these investigations, recommendations have been formulated for preloaded bolting assemblies with DTIs under external axial tensile loading.

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia

Wright central plication is a minimally invasive tightening procedure described for the first time by Wright and colleagues in 2012. We compare outcomes of lateral rectus central plication (LRCP) to medial rectus recession (MRR) in the treatment of adult divergence insufficiency esotropia (ADIE). A retrospective chart review of 30 consecutive patients with ADIE, who underwent either LRCP or MRR between 2010 and 2015 was performed. age ≥45years, LRCP or MRR surgery fixed suture technique, esotropia (ET) at least 10Δ greater at distance than at near, subjective diplopia at distance, fusion at near fixation, follow-up of at least 6months. Primary outcome was postoperative single binocular vision. Secondary outcome was postoperative deviation of <5Δ. A total of 28 patients (15 females) met inclusion criteria: 15 had LRCP and 13 MRR. Primary outcome of no diplopia was not significantly different between LRCP and MRR group having a success rate of 93.3% versus 92.3%, respectively (P≤0.01). Secondary outcome of a deviation of ≤5Δ at distance was better in the LRCP group than the MRR group (15/15 vs 11/13 [P≥0.01]). One patient in LRCP group had an early overcorrection corrected by in-office suture lysis. Both procedures had excellent primary outcomes eliminating diplopia in over 90% of cases. The LRCP group had statistically better postoperative alignment of <5Δ. The Wright LRCP has the advantage of being minimally invasive, semi-reversible, vessel sparing, and can be done with topical anesthesia.

Interfragmentary compression and pull-out properties of 6.5-mm AO cancellous lag screws in a uniform synthetic material during tightening procedures

AO lag screws are widely used in surgical intra-articular fracture treatment for anatomical reduction and rigid fixation. Interfragmentary compressive force (IFCF) and pull-out strength (POS) are two critical parameters generated by AO lag screws during tightening, and both of these parameters could be used to estimate screw insert conditions to prevent screw stripping. The aim of this study is to evaluate the IFCF and POS of AO cancellous screws inserted into uniform synthetic cancellous bone during tightening procedures. Seven synthetic cancellous bone blocks were used for this research. Each test contained two continuous portions as follows: the rotation test portion and the pull-out test portion. IFCF and POS were captured by the pressure transducer and the sensor of the test machine. The properties of IFCF and POS based on tightening degrees were obtained in this study. The ideal balance between POS and IFCF during screw tightening exists, and the peak values of these parameters cannot be simultaneously achieved. Moreover, rotation angles of 100–150° appear to serve as the optimum balance between IFCF and POS in the present study.

A spatial branch-and-cut method for nonconvex QCQP with bounded complex variables

We develop a spatial branch-and-cut approach for nonconvex quadratically constrained quadratic programs with bounded complex variables (CQCQP). Linear valid inequalities are added at each node of the search tree to strengthen semidefinite programming relaxations of CQCQP. These valid inequalities are derived from the convex hull description of a nonconvex set of $$2 \times 2$$ positive semidefinite Hermitian matrices subject to a rank-one constraint. We propose branching rules based on an alternative to the rank-one constraint that allows for local measurement of constraint violation. Closed-form bound tightening procedures are used to reduce the domain of the problem. We apply the algorithm to solve the alternating current optimal power flow problem with complex variables as well as the box-constrained quadratic programming problem with real variables.

Bound Tightening for the Alternating Current Optimal Power Flow Problem

We consider the Alternating Current Optimal Power Flow (ACOPF) problem, formulated as a nonconvex Quadratically-Constrained Quadratic Program (QCQP) with complex variables. ACOPF may be solved to global optimality with a semidefinite programming (SDP) relaxation in cases where its QCQP formulation attains zero duality gap. However, when there is positive duality gap, no optimal solution to the SDP relaxation is feasible for ACOPF. One way to find a global optimum is to partition the problem using a spatial branch-and-bound method. Tightening upper and lower variable bounds can improve solution times in spatial branching by potentially reducing the number of partitions needed. We propose special-purpose closed-form bound tightening methods to tighten limits on nodal powers, line flows, phase angle differences, and voltage magnitudes. Computational experiments are conducted using a spatial branch-and-cut solver. We construct variants of IEEE test cases with high duality gaps to demonstrate the effectiveness of the bound tightening procedures.

Optimized bolt tightening procedure for different tightening strategies—FEA study

This paper presents results of detailed nonlinear finite element analysis of gasketed bolted flange pipe joints of different sizes (1, 4, 5, 6, 8, 10, 20 in.) of 900# pressure class for achieving proper preload close to the target stress values with and without considering yielding at bolt and flange and gasket crushing recommended by ASME and industrial guidelines for optimized performance using customized optimization algorithm. In addition, two strategies torque control method and stretch control method are used which is a normal practice in the industry.

Three enhancements for optimization-based bound tightening

Optimization-based bound tightening (OBBT) is one of the most effective procedures to reduce variable domains of nonconvex mixed-integer nonlinear programs (MINLPs). At the same time it is one of the most expensive bound tightening procedures, since it solves auxiliary linear programs (LPs)--up to twice the number of variables many. The main goal of this paper is to discuss algorithmic techniques for an efficient implementation of OBBT. Most state-of-the-art MINLP solvers apply some restricted version of OBBT and it seems to be common belief that OBBT is beneficial if only one is able to keep its computational cost under control. To this end, we introduce three techniques to increase the efficiency of OBBT: filtering strategies to reduce the number of solved LPs, ordering heuristics to exploit simplex warm starts, and the generation of Lagrangian variable bounds (LVBs). The propagation of LVBs during tree search is a fast approximation to OBBT without the need to solve auxiliary LPs. We conduct extensive computational experiments on MINLPLib2. Our results indicate that OBBT is most beneficial on hard instances, for which we observe a speedup of 17---19 % on average. Most importantly, more instances can be solved when using OBBT.

Evaluating the Behavior of Anchor Rod Foundations for High-Mast Light Poles Using Nonlinear Finite-Element Analysis

AbstractThis study examines the behavior of high-mast lighting pole (HMLP) foundations through the use of nonlinear finite-element modeling. HMLPs utilize nuts and threaded rods to clamp the light pole structure’s base plate to the foundation. Inspections by the Alaska Department of Transportation and Public Facilities (AKDOT&PF) have revealed widespread loosening of the nuts used on HMLPs over time. The threaded rods used are F1554 Grade 55, which are heat treated from mild steel rods, Fy=248 MPa (36 ksi) to gain additional yield strength. This study briefly highlights the difference in postyield behavior in mild steel and high-strength steel, and proposes a probable mechanism behind the clamp-load loss experienced by Alaska’s HMLPs. Because the HMLPs are much taller than traditional lighting poles, they experience larger external wind loading. This wind load is potentially stressing threaded rods into the postyield range. A previous study shows that the current tightening procedure is likely not undert...

Management of fourth degree obstetric perineal tear without colostomy using non - stimulated gracilis - our experience over eleven years.

Background:Although gracilis muscle transposition for faecal incontinence has been well-described method, its literature for use in obstetric perineal tear without colostomy is sparse. In this study, we have tried to analyse its use in fourth-degree obstetric perineal tears.Patients and Methods:A total of 30 patients with recto-vaginal fistula with faecal incontinence secondary to obstetric perineal tear were retrospectively studied between February 2003 and May 2014. The recto-vaginal fistula was explored, dissected and identification of sphincters was done using muscle stimulator. Fistula closure was done followed by sphincter repair, vaginal tightening procedure and single gracilis transposition. None of the patients had covering colostomy. Faecal incontinence was assessed pre- and post-operatively by digital rectal examination (single examiner), Park's score and Corman's score in all cases and using barium hold and transperineal ultrasonography, manometric studies in a few cases. The outcome was measured at an average follow-up of 8.8 months (7–24 months).Results:As per Park's score 26 patients had Grade I continence, two had Grade II and two patients had Grade III continence. Corman's score improved from fair to excellent in 26 patients. The patients in whom manometry was performed showed a remarkable rise in both resting and squeeze pressures. Two patients developed post-operative infections in upper 1/3 thigh incision site and three patients at gluteal region scar site.Conclusion:Satisfactory continence following gracilis muscle could be achieved.

Write and Erase Threshold Voltage Interdependence in Resistive Switching Memory Cells

A statistical dependence of set voltage V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">set</sub> on the preceding reset voltage V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">reset</sub> is observed in resistive memory arrays and explained in terms of two interlocking mechanisms. This dependence can be replicated on a single device by intentionally varying V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">reset</sub> values by various linear voltage ramp rates. The latter mechanism is well modeled under the assumption that a critical heat deposited locally in the filament triggers the rupture of the filament. Mechanisms are proposed to explain the impact of different ramp rates of the reset operation on the ruptured gap in the filament that affect, in turn, the V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">set</sub> value of the subsequent set operation. Based on these observations, a one-time tightening procedure is designed, leading to tightened V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">set</sub> and V <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">reset</sub> distributions.

Combinatorics of tight geodesics and stable lengths

We give an algorithm to compute the stable lengths of pseudo-Anosovs on the curve graph, answering a question of Bowditch. We also give a procedure to compute all invariant tight geodesic axes of pseudo-Anosovs. Along the way we show that there are constants 1 &gt; a 1 &gt; a 2 1&gt;a_1&gt;a_2 such that the minimal upper bound on ‘slices’ of tight geodesics is bounded below and above by a 1 ξ ( S ) a_1^{\xi (S)} and a 2 ξ ( S ) a_2^{\xi (S)} , where ξ ( S ) \xi (S) is the complexity of the surface. As a consequence, we give the first computable bounds on the asymptotic dimension of curve graphs and mapping class groups. Our techniques involve a generalization of Masur–Minsky’s tight geodesics and a new class of paths on which their tightening procedure works.

Use of an imaging device after nonablative radiofrequency (Pellevé): treatment of periorbital rhytids.

To use the Canfield Reveal imager in objective photo documentation of the effect of nonablative radiofrequency (Pellevé) treatment on periorbital rhytids. This is a prospective cohort study. Twelve patients underwent 1 to 2 sessions of nonablative radiofrequency (Pellevé) treatment over the periorbital region. aged 30 to 60 years old, minimal tissue laxity, and shallow wrinkle development. Standardized reproducible photographs (left, frontal, right views) with use of the Canfield Reveal imager's superimposition feature were taken of each patient prior, immediately after application, and on 2nd, 4th, 6th, and 8th week follow up. Brow elevation was measured in the pre- and posttreatment photographs with the use of the Canfield Reveal imager and rendered the photographs in 3-dimensional images. Comparison of the pre- and posttreatment photographs taken via the Canfield Reveal imager showed reduction in the wrinkles, smoothening, and tightening of the eyelid and the periorbital tissue. Patients exhibited an average increase of 2.05 mm (p<0.001) of eyebrow lift and 0.98 mm (p<0.001) of superior eyelid crease elevation immediately after treatment. Eight weeks after, average brow elevation was measured at 3.52 mm (p<0.001) and crease elevation at 1.84 mm (p<0.001). The 3-dimensional imaging feature rendered in normal skin tone, and shades of gray showed softening of fine lines and crow's feet after treatment. Furthermore, it also rendered in color relief that highlighted the changes seen with depressions noted to decrease after treatment. The Canfield Reveal imager can be used in the objective photodocumentation of subtle and modest effects of nonablative radiofrequency (Pellevé) treatment to the periorbital region.

The effect of rectus muscle recession, resection and plication on anterior segment circulation in humans

BackgroundPlication is an alternative tightening procedure to resection. In monkeys, plication has been shown to preserve anterior segment circulation compared with full-tendon tenotomy, but this is unconfirmed in humans.PurposeTo evaluate...

Total Face Rejuvenation: Simultaneous 3-Plane Surgical Approach Combined with Ablative Laser Resurfacing

Introduction: Among the public, the gold standard in facial rejuvenation surgery is often thought of as face-lift surgery or rhytidectomy; however, a lifting and tightening procedure more optimally treats the jawline and neck by smoothing the jowls and addressing the submental waddle. In the middle third of the face, a lifting or tightening procedure may result in widening and flattening of the mid-face, producing an unnatural, pulled appearance. Volume restoration in the mid-face region often creates a more natural-appearing rejuvenation by reversing the deflation of the facial middle third that has occurred over time. While rhytidectomy and volume restoration create excellent results, the aging of the facial skin through extrinsic factors such as sun exposure or tobacco use remains untreated. Consequently, for a more complete facial rejuvenation, ablative laser resurfacing may be added to address fine facial lines and pigment irregularities to smooth the overlying skin texture. More complete facial rejuvenation may be achieved through combined rhytidectomy, mid-face volume restoration, and full-face ablative laser resurfacing performed concomitantly. Although there seem to be inherent risks of simultaneous laser resurfacing and rhytidectomy, previous studies have demonstrated the safety in these combined procedures. To achieve a more complete facial rejuvenation, a third plane of surgical dissection may be performed to restore mid-face volume through a subperiosteal approach; however, the inherent risks of laser resurfacing in patients undergoing a triplanar procedure, including subcutaneous, sub–superficial musculoaponeurotic system (SMAS), and subperiosteal dissection have not been previously established in the literature. The objective is to evaluate the safety of combined extended-SMAS rhytidectomy, mid-face implant placement, and full-face erbium:YAG resurfacing. Materials and Methods: A retrospective review of patients undergoing combined extended-SMAS rhytidectomy, mid-face augmentation, and full-face erbium:YAG laser resurfacing by a single surgeon was conducted. Demographic data, surgical complications, and associated factors were recorded. Results: Twenty-one patients were identified. All were female and aged from 58 to 71 years. There were no cases of flap necrosis or slough. There was 1 case of hematoma that resolved with conservative management. One patient with a history of Roux-en-Y gastric bypass had an implant infection. She was found to have malabsorption of her antibiotics, which immediately resolved once her antibiotics were crushed. Epithelization occurred within 10 days, and all patients were able to wear makeup after 10 days. It is important to note that none of these complications are felt to be the result of combining the procedures. Conclusions: Simultaneous extended-SMAS rhytidectomy, mid-face augmentation, and full-face erbium:YAG resurfacing is a safe and effective strategy in providing facial rejuvenation.

Pain in Naïve and Non-naïve Subjects Undergoing Nonablative Skin Tightening Dermatologic Procedures: A Nested Randomized Control Trial

Pain is expected during noninvasive skin tightening and can be anxiety provoking, especially for those who have not had prior treatments. To compare pain reported by patients naïve to nonablative skin tightening energy devices with those who were not naive. The non-naïve group at least three nonablative laser procedures or one nonablative skin tightening procedure, and the naïve group no previous treatments. Four sites at each of two anatomic locations (periorbital and midface or cheek) were treated in each subject with needle prick, pulsed dye laser, radiofrequency, and ultrasound with the order of the interventions randomized. All interventions except ultrasound were also applied to three abdominal sites. The difference in mean pain scores between naïve and nonnaïve subjects were averaged over the anatomic sites. Ten naïve and 10 non-naïve subjects completed study procedures. Mean pain scores ranged from 1.3 to 4.9. The mean for all naïve conditions was 2.3 ± 1.0, vs 2.2 ± 1.4 for non-naïve conditions. There was no overall difference according to group, device, or anatomic area. There was no significant difference in pain between naïve and non-naïve subjects undergoing cutaneous energy treatments. Individual devices may elicit more pain at specific anatomic locations.

Measured Anchor Rod Tightening of High-Mast Light Poles in Alaska

The Alaska Department of Transportation and Public Facilities owns and maintains 124 high-mast lighting poles (HMLPs) in south-central Alaska. Some of the anchor nuts that secured these poles, 100 ft and taller, to their foundations had been found to loosen without apparent cause. In this study, the axial force was measured in the 1½-in. (38-mm) diameter anchor rods of one HMLP during the tightening of new rods. These rods had a relatively low grip-length to diameter ratio of approximately 3. The force was measured by strain gauges mounted in a small hole along the anchor rod axis and a computer-controlled data acquisition system. The FHWA tightening procedure was followed. This included a snug-tight condition, followed by 60° of turn-of-the-nut method. The snug-tight condition was created by the full force of a workman pulling on a 24-in. (610-mm) wrench. A specified verification torque was applied to the nuts after 1 week to ensure adequate tension in the anchor rods. It was found that after the tightening procedure, the axial force in several of the 12 rods exceeded their yield capacity. In each rod that yielded, the axial force caused by the snug-tight condition was higher than the anticipated values. It was concluded that several variables contributed to the yielding. These included snug-tight axial loads that were higher than expected, effects of low grip-length to diameter ratios, and an unnecessarily large verification torque.

Treatment of refractory exposure keratitis with modified medial tarsorrhaphy using tarsoconjunctival flap

This study reports the surgical technique of modified medial tarsorrhaphy using tarsoconjunctival advancement flap for treatment of exposure keratitis secondary to incomplete lid closure combined with ocular dysmotility or decreased corneal sensation. Three patients suffered from intractable exposure keratitis due to incomplete lid closure with ocular motility limitation or decreased corneal sensation, even after the lateral tightening procedure. Because they did not want a cosmetically unacceptable appearance by permanent tarsorrhaphy, modified medial tarsorrhaphy using tarsoconjunctival advancement flap was performed. Clinical manifestation and surgical outcome were investigated through retrospective chart review. The minimum follow-up period was 10months. All patients showed successful surgical results. Ocular symptoms were satisfactorily treated, corneal re-epithelialization was achieved and maintained during the follow-up period, lagophthalmos improved, and all patients were satisfied with their appearance. We describe modified medial tarsorrhaphy with tarsoconjunctival advancement flap which was effective in treatment of severe exposure keratitis with incomplete lid closure in patients who elected not to have cosmetically problematic, permanent corrective surgery.

Mini-plication to treat small-angle strabismus: A minimally invasive procedure

Mini-plication is a new rectus muscle tightening procedure for the correction of small-angle strabismus that can be performed under topical anesthesia. The purpose of this study was to report the outcomes of mini-rectus muscle plication. We retrospectively reviewed the medical records of patients who underwent mini-plication. In this procedure, 6-0 polyglactin 910 suture was secured to the central 3 to 4mm of the muscle belly 5 mm posterior to the insertion and was then passed through the sclera just anterior to the muscle insertion to plicate the central portion of the muscle.This differs from the standard procedure, in which the entire width of the muscle is plicated. Two groups were analyzed: those who underwent mini-plication alone andthose who underwent mini-plication after prior antagonist muscle-weakening surgery. Our review identified nine patients aged 5 to 78 years. Topical anesthesia was used for all adults, who experienced no local or systemic complications. Mini-plication reduced vertical and horizontal deviations an average (± SD) of 6.7(Δ)±3.5(Δ). The mini-plication-only group (3 patients) had an average postoperative correction of 5.5(Δ) ± 2.6(Δ); the prior surgery group (6 patients), an average of 9(Δ)±2.7(Δ). Diplopia was noted in 50% of the adults preoperatively and none postoperatively. All patients experienced a decrease in strabismus, with an average outcome of <5(Δ) of postoperative deviation. Mini-plication, which can be performed under topical anesthesia, corrected small deviations and was especially useful for adult strabismus patients with diplopia.

Is Traditional Lower Blepharoplasty a Superior Technique?

Sir:FigureWe read with interest the article entitled “Traditional Lower Blepharoplasty: Is Additional Support Necessary? A 30-Year Review” by Maffi et al. (Plast Reconstr Surg. 2011;128:265–273). This article describes the senior author's experience with traditional blepharoplasty and concludes that external incision with fat removal has a low complication rate and that routine support procedures are unnecessary. We have used both the traditional lower blepharoplasty and the fat-preserving technique1 for over 30 years and have only used the latter for the past 20 years. This technique consists of reducing the fatty hernia and approximating the capsulopalpebral fascia to the arcus marginalis1–5 (Fig. 1). Prospective studies comparing the “traditional” method with the “fat-preserving” method show that hernia repair is simple, safe, and reproducible, with very low morbidity and superior long-term results2,5 (Table 1).Fig. 1: (Above) Intraoperative photograph of fat hernia before reduction and capsulopalpebral hernia repair. (Below) The fat hernia is shown after reduction and repair by approximating the capsulopalpebral fascia to the arcus marginalis with interrupted 5-0 absorbable monofilament sutures.Table 1: Preoperative Tests Recommended for Selecting Patients for “Tightening/Anchoring” Procedures*Although we agree with Maffi et al. that a tightening procedure is not indicated when the eyelid tone is “adequate,” we disagree with their concept of concomitant “canthopexy” when the preoperative distraction test is “less than 6 mm” and “canthoplasty” when it measures more. We have found that both the values that reflect the muscle tone (snap-back test) and the degree of stretching of the canthal ligaments (distraction test) are necessary in selecting patients for lower lid support procedures and that over 80 percent of our patients qualify for such an intervention in contrast to their very small percentage. We define “adequate/normal tone” when the snap-back test and the distraction test are less than 1 second or less than 2 mm, respectively. In “mild” and in the majority of “moderate” and “severe” cases, we perform a tightening/anchoring procedure we call musculoplasty, as shown in Figure 2. Only in a small percentage of moderate and severe cases (<5 percent) do we perform other procedures in addition to musculoplasty. Musculoplasty consists of a single stitch of 5-0 absorbable monofilament that approximates the lower lid's orbicularis muscles to the dense fibrous tissue of the lateral orbital rim. No soft-tissue dissection and no undermining is performed in the lateral canthal region, and chemosis is typically either minimal (<5 percent of patients) or absent and, when present, subsides within 7 to 14 days without the use of steroid preparations. We have observed that chemosis is absent when the lateral canthal area is not invaded, and we attribute postoperative chemosis to surgical trauma to this region and not to lower blepharoplasty per se because in our experience chemosis is absent in these instances.Fig. 2: Musculoplasty consists of approximating the pretarsal and preseptal orbicularis to the dense fibrous tissue of the lateral canthal region.Finally, we disagree with Maffi et al. that the “traditional” approach of fat removal is easier to teach. We have found that surgeons in training who have been exposed to the basic principles of hernia repair in general surgery understand and learn readily the principles of hernia repair in the lower eyelids and are impressed by its simplicity2,5 (Fig. 1). In addition, the procedure requires less sedation, and no intraorbital bleeding/blindness has ever been reported because fatty tissue is not injected or manipulated.1–5 Fereydoun Don Parsa, M.D. Daniel Murariu, M.D., M.P.H. Alan Ali Parsa, M.D. Michael Cyrus Siah, B.A. Jennifer Armstrong, B.A. John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.