Redraping the inferior orbicularis arc

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.     

Lower eyelid hernia repair for palpebral bags: a comparative study

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.     

Parry-Romberg syndrome associated with intracranial vascular malformations

We describe a 23-year-old woman with iridocyclitis, enophthalmos, facial hemiatrophy, and transient numbness of her contralateral upper and lower extremities. The patient was found to have white matter densities in the right hemisphere in magnetic resonance T2-weighted images and vascular malformations involving right vertebral, right carotid, and right anterior cerebral arteries. Histopathologic evaluation of a biopsy specimen of anterior orbital fat and lacrimal gland revealed fibrosis and chronic inflammation. These findings were consistent with the diagnosis of progressive facial hemiatrophy (Parry-Romberg syndrome) in association with iridocyclitis and intracranial vascular malformations.     

Outcome of hypertension management in Asian Americans

BACKGROUND: Ethnic and/or racial differences in drug response to antihypertensive agents have been recognized, yet the prescribing practices and the information on efficacy of various agents rely mainly on the response of whites to drugs. OBJECTIVES: To assess the management of hypertension in Asian Americans and to compare it with an age- and sex-matched group of white patients with hypertension. METHODS: The patients' medical records were used as the primary source of information for the data collection. The observational period was a 12-month window and included 200 patients of Asian origin with hypertension and 196 white patients with hypertension whose medical records were randomly selected. RESULTS: The study describes the pattern of use of antihypertensive agents and the differences in response to antihypertensive agents between Asian Americans and whites. The preferred antihypertensive agents in both Asian and white patients included monotherapy with either calcium channel blockers or angiotensin-converting enzyme inhibitors. However, medication changes, dose reduction, and the experience of side effects were all significantly more frequently recorded in Asian patients than in white patients (P < .001, P < .008, and P < .002, respectively). CONCLUSIONS: These findings are supportive of some previous reports on ethnic differences in drug response to antihypertensive agents. The findings also point to the need for further prospective studies on the outcome of hypertension management in Asian American patients.     

Neuromyelitis optica

Compared with white women, Asian women have about a 40%-50% and blacks a 50%-60% lower risk of hip fracture, but the reason for this racial difference is not known. Women with a shorter hip axis have a lower risk of hip fracture. To test the hypothesis that a shorter hip axis length could account for the lower risk of hip fracture among Asian and black women, we measured hip axis length in 135 Caucasian, 74 Asian and 50 black women. The mean hip axis lengths of Asian and black women were significantly shorter (1.2 and 0.7 standard deviations, respectively) than that of the whites (p < 0.0001). We estimate that, compared with white women, Asians would have a 47% lower risk (95% confidence interval: 32%-63%) and blacks would have a 32% (15%-45%) lower risk of hip fracture because of their shorter hip axis. We conclude that a shorter hip axis length might be a major factor accounting for Asian women's lower risk of hip fracture and might contribute to the lower risk in black women.     

Identification of the source of reagent variability in the xanthydrol/urea method

The purpose of this study was to compare seven skinfold equations with underwater weighing (UWW) for estimating body fat in 39 African American [age: 22.8 +/- 3.6 y (x +/- SD); weight: 59.6 +/- 8.3 kg) and 39 white (age: 22.1 +/- 2.9 y; weight: 61.7 +/- 7.3 kg) women. The hypothesis examined was that the equations would produce more accurate body fat estimates in white women, but would be appropriate for use in African American women. Body fat estimated from two quadratic, three linear, and two logarithmic skinfold equations was compared with body fat estimated from UWW; the same procedures were used to evaluate the results in both African Americans and whites. The data were analyzed by using t tests, analysis of variance, Scheffé's honestly significant difference tests, correlations, error assessments, and agreement. The results showed that total error, SEE, and SD values were larger in the African American women than in the white women and were not within acceptable limits listed in the literature. The correlation coefficients were lower in the African American women than in the white women. Agreement between the skinfold equations and UWW, based on deviations from mean differences, was better in the white women. In conclusion, the skinfold prediction equations evaluated in this study were more variable and produced more error when used in African American women. Therefore, population-specific equations for African American women should be used to estimate body fat because they will probably yield more accurate estimates.     

Fat distribution and insulin response in prepubertal African American and white children

Ethnic differences in obesity-related disease prevalence may relate to differences in fat distribution or metabolism. We conducted a study in 73 African American and white children to examine the relation between fat distribution and insulin and to determine whether ethnic differences in fat distribution or in adiposity-insulin relations contribute to differences in insulin concentrations. Fasting and postchallenge insulin concentrations were determined by oral-glucose-tolerance test, total body fat by dual-energy X-ray absorptiometry, and subcutaneous abdominal (SAAT) and intraabdominal (IAAT) adipose tissue by computerized tomography. African Americans had greater fasting insulin (x +/- SD: 79 +/- 37 compared with 55 +/- 23 pmol/L, P < 0.01), incremental 30-min insulin (567 +/- 438 compared with 300 +/- 304 pmol/L, P < 0.001), and incremental area under the insulin curve (AUC; 262 +/- 209 compared with 164 +/- 156 pmol/L, P < 0.01). In multiple linear regression, fasting insulin was independently related to total fat within both ethnic groups (model R2 = 0.42 and 0.52 for African Americans and whites, respectively), incremental 30-min insulin to total fat and IAAT in whites only (model R2 = 0.71), and AUC to SAAT in African Americans only (model R2 = 0.49). Adjusting insulin indexes for adiposity did not eliminate the significant effect of ethnicity. In general, relations between adiposity and insulin were stronger in whites than in African Americans. African American children had higher insulin concentrations than white children after total body fat, IAAT, and SAAT were controlled for. However, strong relations between adiposity (total and abdominal) and insulin in both groups suggest that obesity may contribute to disease risk regardless of ethnicity.     

Increased platelet activation and fibrinogen in Asian Indians. Potential implications for coronary risk

AIMS: To determine whether Asian Indians (Indians), a group known to have high rates of coronary heart disease, have increased platelet activation and fibrinogen levels relative to white Americans of European origin (whites). METHODS AND RESULTS: Forty healthy, non-smoking Indians, aged 25-45, were matched with 40 healthy whites for age (within 3 years) and gender. Platelet activation was tested in blood exiting a bleeding time wound at 1 and 2 min post-incision (wound-induced activation), as well as in venous blood stimulated in vitro with collagen, using whole blood flow cytometry. Other risk factors, including fibrinogen levels, family history of diabetes or coronary heart disease, fasting insulin and lipid levels, and Lp(a) were also assessed. Fibrinogen levels were higher among Indians than whites, even after adjustment for gender or family history of coronary heart disease (P < 0.05). Indians had higher levels of wound-induced glycoprotein IIb/IIIa binding and platelet secretion (P-selectin expression) than whites, with the greatest differences found when comparing the upper quintile of activation for each group (Ps < 0.05). Indians with a family history of coronary heart disease (n = 15) had higher levels of platelet secretion (wound-induced and in vitro) than Indians without a family history (Ps < 0.05), while the relationship was reversed among whites. Platelet activation measures were not consistently related to other coronary risk factors, while fibrinogen was related to triglyceride and insulin levels among Indians. CONCLUSION: Indians have elevated fibrinogen and platelet activation levels relative to whites. These factors may contribute to the increased coronary risk observed in Indians.     

Adenocarcinoma of eccrine sweat glands

A man developed left-sided proptosis and orbital edema that progressed during a three-week period. Ten years ago he had a skin lesion of the left lower lid excised and the histopathologic diagnosis then was granular cell myoblastoma. In 1972, the tumor recurred; a biopsy was again performed, but no definite diagnosis was made despite multiple consultations from general and ophthalmic pathologists. Biopsy specimens of the orbit, lids, and preauricular lymph node taken in 1974 showed a poorly differentiated mucus-secreting adenocarcinoma. A comparison of the three biopsy specimens showed cells with similar characteristics. Medical evaluation failed to reveal a primary tumor elsewhere in the body. The tumor most likely arose locally from an eccrine sweat gland. This is the second reported case of an adenocarcinoma of an eccrine sweat gland invading the orbit. The tumor, usually considered radioresistant, was successfully treated with radiotherapy, and the patient has remained free of tumor for 18 months.     

Absorption of fluorescein given under the upper lid

BACKGROUND: The need for a more efficacious approach to administer topical ocular medications prompted the authors to consider applying conventional eye drops under the upper lid rather than beneath the lower lid. Preliminary observations on patients with glaucoma using a beta-blocker beneath the upper lid suggested a drop in intraocular pressure into the normal range in some previously refractory patients being treated with the same medications. To test this clinical observation, the authors observed if there were any physiologic differences in topical fluorescein absorption into the anterior chamber when given beneath the upper lid versus the lower lid. METHODS: A 5-microliters drop of fluorescein solution was placed under the upper-lid fornix of one eye and under the lower-lid fornix of the other eye in human volunteers, and absorption into the anterior chamber was measured at hourly intervals, for a total of 3 hours. RESULTS: Hotelling T2 multivariate analysis for all 3 hours demonstrates that upper-lid administration of fluorescein results in significantly higher absorption of fluorescein into the anterior chamber than does lower-lid administration (P = 0.0088; for hours 2 and 3, the statistical differences is even more dramatic: P < 0.0044). CONCLUSION: Using conventional eye drops beneath the upper lid, the authors observed increased absorption of fluorescein into the anterior chamber when compared with lower-lid administration. Profuse tearing, especially by younger subjects, significantly and rapidly diminished anterior chamber absorption of fluorescein. It is reasonable to consider further clinical studies to test this new approach to drug delivery.     

Synthetic skin replacement for temporary wound coverage in eyelid surgery

BACKGROUND: Large uncovered defects of lid-skin which extend beyond the margin of the orbital rim frequently cause wound contracture and malposition of the lid. PATIENTS AND METHODS: Between April 1989 and October 1992 we have successfully used synthetic skin in severe cases of traumatic skin ablation (n = 3) and in complicated tumor surgery of the lids and of the medial canthal area (n = 14). Polyurethan foam material was used for temporary skin replacement (Epigard). RESULTS: The synthetic skin stimulated wound granulation and vascularization of the host area before final closure of the defect was achieved. No wound contracture occurred. CONCLUSION: Temporary bandage with synthetic skin is recommended if large skin defects can not be closed within 48 hours.     

Black/white differences in leukocyte subpopulations in men

BACKGROUND: Although counts of leukocytes differ substantially between blacks and whites, and are predictive of ischaemic heart disease (IHD), racial differences in counts of leukocyte subpopulations have received less attention. METHODS: We examined black/white differences in leukocyte subpopulations among 3467 white and 493 black 31-45 year-old-men who had previously served in the US Army. Laboratory determinations were performed at a central location during 1985-1986. RESULTS: Black men had an 840 cell/microliter (or 15%) lower mean total leukocyte count than did white men, largely due to a 960 cell/microliter (or 25%) lower mean neutrophil count. Although black men also had a 20% lower mean monocyte count (= 70 cells/microliter) than did white men, their mean lymphocyte count was 10% higher (approximately = 200 cells/microliter). Counts of various leukocyte subpopulations were associated with cigarette smoking, haemoglobin levels, platelet counts, and several other characteristics, but black/white differences in counts of neutrophils, lymphocytes, monocytes and other subpopulations could not be attributed to any of the examined covariates. CONCLUSIONS: Despite the relatively low counts of leukocytes and neutrophils among black men, their lymphocyte counts are generally higher than those among white men. It is possible that black/white differences in counts of various cell types may influence race-specific rates of IHD, and future studies should attempt to assess the importance of leukocyte subpopulations in the development of clinical disease.     

Three-dimensional reconstruction of the human central sulcus reveals a morphological correlate of the hand area

OBJECTIVE: To examine the impact of ethnic group on aspects of weight concern and to assess the role of family values in explaining this association. SUBJECTS AND MEASURES: 20 Asian and 20 white daughters gave a questionnaire to their mother, father and sibling closest in age, concerning their profile characteristics (age, education) values and beliefs and completed a matched questionnaire containing additional measures of aspects of their weight concern. RESULTS: The results showed no differences between the white and Asian daughters in terms of either their restrained eating or body dissatisfaction. However, the results showed consistent differences between the members of the two family groups in terms of the value placed on achievement, child/parent relationships, competition, the role of women, and some differences in terms of materialism, the value of appearance and their idea of the perfect female body. The results were then analysed to assess the best predictors of the daughter's weight concern. Whereas restrained eating was related to the mother's rating of the value of physical appearance and the sibling's ratings of competitiveness and a non-traditional role for women (40% of the variance), the results showed that body dissatisfaction was related to the daughter's rating of materialism, having a father who preferred a thinner female body, the siblings ratings of a non-traditional role for women, degree of concordance within the family concerning the value of competitiveness and the educational level of the 'head of the family' (49% of variance). CONCLUSION: Whereas a dichotomous model of ethnicity may be insufficient to explain differences in aspects of weight concern, an expanded model of cultural beliefs may be a more powerful construct. Accordingly, the absence or presence of differences in weight concern according to ethnic group may simply reflect the extent to which the different groups chosen for analysis are differentiated by these predictive values.     

Differences in body composition of black and white girls

Adults have racial differences in body composition that may modulate risks resulting from obesity. Although black and white children have been shown previously to have differences in bone mineral density and subcutaneous body fat, differences in visceral adipose tissue have not been evaluated. We studied 20 black and 20 white normal-weight girls aged 7-10 y, who were matched for weight, body mass index (BMI), bone age, chronological age, Tanner breast stage, and socioeconomic status. Each underwent anthropometric measurements, bioelectrical impedance analysis, dual-energy X-ray absorptiometry (DXA), and abdominal magnetic resonance imaging (MRI) for determination of total (TAT), visceral (VAT), and subcutaneous (SAT) adipose tissue. Serum lipids and fasting and 2-h oral-glucose-tolerance test (OGTT) glucose and insulin concentrations were also measured. There were no differences between groups in absolute waist circumference or waist-to-hip ratio, but waist-to-thigh ratio was smaller in black than in white girls. Black girls had greater bone mineral density and less TAT, VAT, and SAT than whites. VAT was not significantly correlated with any measure of insulin, or with serum lipids. However, both basal and 2-h OGTT serum insulin were significantly correlated with SAT as assessed by MRI in black girls (r2 = 0.46 for basal insulin, P = 0.001: r2 = 0.31 for 2-h insulin, P = 0.01) but not in white girls (r2 < 0.05, for basal and 2-h insulin, NS). We conclude that there are significant racial differences in body composition and differences in the strength of association between abdominal adipose tissue depots and insulin sensitivity in black and white girls.     

Effect of kininogen on the activity of human blood serum kininogenase system

A case of a tumor of the upper lid involving the bons in a 6 1/2 year old body is reported. Histology revealed a solitary eosinophilic granuloma. The classification of this systemic disease which almost always shows an orbital manifestation is discussed.     

Differential effects of BMI on diabetes risk among black and white Americans

OBJECTIVE: To determine whether the associations of BMI and fat distribution with diabetes risk are modified by race. RESEARCH DESIGN AND METHODS: Data from the National Health and Nutrition Examination Survey, Epidemiologic Follow-up Study (1971-1992), were used to investigate potential interactions of BMI and fat distribution with race. Incident diabetes was defined by self-report of physician-diagnosed diabetes, hospital and nursing home discharge records, and death certificates. RESULTS: Among the 1,531 black and 9,852 white subjects who were nondiabetic at baseline, 1,139 (10.0%) developed diabetes during 20 years of follow-up. Although the cumulative risk of diabetes increased with baseline BMI in all four race-sex groups, the sex-specific odds ratios (ORs) for black:white subjects decreased with increasing BMI. In particular, for BMI of 22 kg/m2, the OR of diabetes for black:white individuals was 1.87 and 1.76 (P < 0.01) for men and women, respectively; for BMI of 32 kg/m2, the OR decreased to 0.99 and 1.20 (NS) for men and women, respectively. Skinfold ratio was also associated with increased diabetes risk in all race-sex groups, but did not modify the association between race and diabetes. CONCLUSIONS: These findings suggest that the effect of BMI on diabetes risk is different for black and white Americans, with a larger risk for blacks than whites at low BMI and an equivalent risk for both groups at high BMI. A lower degree of visceral adiposity among blacks at higher BMI or a greater impact of visceral adiposity among blacks at low BMI may help explain the interaction of race and BMI on diabetes risk.     

Pituitary abscess. A rare complication of sinusitis]

Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275,000 of whom 53,000 have an ethnic background from the Indian subcontinent (South Asian). In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P = 0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration. Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community.     

Subtotal eyelid reconstruction

I hope to stress that with familiarity with this procedure: (A) 50% of one or both lids as well as canthal excision can be adequately reconstructed in one operation without the need for canthotomy. (B) Scarring is minimized and resultant function and cosmetic results are good. (C) For the purposes of ablative surgery or traumatic loss the eyelids may be considered comparable to other external sphincters and amenable to the same reconstructive procedures and concepts which obtain in these other structures. Although many procedures have been recommended for sizeable lid losses, I feel that this operation offers certain advantages, particularly in its simplicity. These 7 cases demonstrate sizeable resections of lid tissue with satisfactory results even when as much as 50% or more is removed from one or both lids. The cardinal principle of the use of local tissues as recommended by Von Imre is to be stressed and still holds true today.     

Massive plexiform neurofibroma in the orbit in a child with von Recklinghausen's disease

We report a case of orbital plexiform neurofibroma presenting in a 10-year-old boy with von Recklinghausen's neurofibromatosis. The patient had shown a slow enlargement of exophthalmos of the right eye present since birth, together with multiple café au lait spots on the skin of the trunk. Magnetic resonance (MR) images revealed diffuse and irregular nodular involvement of the retrobulbar nerves within the muscle cone, which was confirmed at the surgery. The tumour extended into the ipsilateral cavernous sinus. We discuss the MR findings as pathognomonic signs of this rare orbital tumour, including its multinodular nature among dispersed intraconal fat tissue, location around the optic nerve, extension through the superior orbital fissure into the cavernous sinus and association with von Recklinghausen disease.     

Biofeedback in the treatment of long-term temporomandibular joint pain: an outcome study

The forehead lift, with interruption of the continuity of the frontalis muscle, has been an effective method in our hands for improving the appearance of the upper third of the face. It can be done independently, or combined with a facial rhytidectomy, a blepharoplasty, and/or other ancillary procedures. In some cases of apparent upper lid redundancy, it can eliminate the need for an upper lid blepharoplasty. The results are pleasing and seem to be lasting, while the complications have been few and mild. We describe the operation and discuss its indications, contraindications, advantages, and disadvantages.