Letters to the Editor Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study To the Editor: To our surprise, Quaranta-Leoni et al.,1 evaluating patients with exposed porous orbital implants, do not mention acrylic implants for replacing orbital volume after enucleation or evisceration at all, as if these implants do not exist. Since the introduction of porous implants in 1985, most oculoplastic surgeons appear to have forgotten the acrylic implant, although till now no one has ever demonstrated the superiority of porous implants without pegs. Few surgeons still use pegs, because of the frequent complications associated with these pegs. So is it not time for a reevaluation of the acrylic ball? It has been demonstrated that the motility of acrylic implants is equal to that of porous implants as long as no peg is inserted.2,3 Most patients are satisfied with the cosmetic outcome of the nonpegged implant and do not desire an additional procedure4 with increased risks for complications.5 In our 22 years of personal experience with enucleation for retinoblastoma, not the easiest group of patients receiving implants (think of chemotherapy and/or external beam radiation therapy in growing children), we have found a lower extrusion rate after acrylic ball implantation compared with that of hydroxyapatite implants. Furthermore, if explantation is required, acrylic implants are much easier to be removed. Until there is a proof that expensive porous implants are superior to inexpensive acrylic balls,6 we call for a return to the simple, easy to handle acrylic ball. We are very much interested in your opinion.
Daphne L. Mourits, M.D. Dyonne T. Hartong, M.D., Ph.D. Annette C. Moll, M.D., Ph.D. Maarten P. Mourits, M.D., Ph.D. Correspondence Daphne L. Mourits, M.D., Department of Ophthalmology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands (D.mourits@ vumc.nl) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophthal Plast Reconstr Surg 2014;30:132–6. 2. Colen TP, Paridaens DA, Lemij HG, et al. Comparison of artificial eye amplitudes with acrylic and hydroxyapatite spherical enucleation implants. Ophthalmology 2000;107:1889–94. 3. Custer PL, Trinkaus KM, Fornoff J. Comparative motility of hydroxyapatite and alloplastic enucleation implants. Ophthalmology 1999;106:513–6. 4. Shields CL, Shields JA, De Potter P, et al. Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases. Br J Ophthalmol 1994;78:702–6. 5. Jordan DR, Chan S, Mawn L, et al. Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 1999;106:505–12. 6. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
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Reply re: “Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study” To the Editor: We quite agree with Dr. Mourits’s observation: in our experience and in the literature, long-term results may be satisfactory using a great variety of implant materials and surgical techniques.1 No choice of materials or surgical technique can guarantee a successful outcome, and there are reports in the literature suggesting that there are few advantages to the use of porous implants, compared to nonporous implants, when these implants are properly placed in the orbit following evisceration or enucleation.1,2 The cost of mesh-covered porous implants is higher if compared with solid polymethyl methacrylate or silicone spheres, and in most European countries, cost–benefit analysis is becoming an increasingly important consideration in the selection of care options.1,3 However, the choice of the primary implant was not the issue of our paper. The aim of our study was to examine the clinical outcome of patients with exposed porous orbital implants where we selected to perform explant surgery followed by simultaneous replacement with an autologous dermis-fat graft.4 In all the 25 patients described, primary surgery (enucleation or evisceration) had been performed elsewhere by a number of different surgeons. We did not choose the type of the primary implant, and the patients were referred to our orbital clinic for explant surgery and socket reconstruction (see Methods). Microbiology showed the presence of infection in 59% of patients submitted to explantation, and histology showed the presence of a long-term inflammatory infiltrate in 88% of the examined implants. For these reasons, we thought that a dermis-fat graft was a suitable option to address the volume and lining deficit following explantation.4 In any case, tissue ingrowth inside porous orbital implants may offer some advantages, and better blood support may help to reduce the risk of migration of the implant, which is a common problem with implants such as polymethyl methacrylate or silicone.1,2,5 We have recently described a series of patients who underwent secondary ball implantation with porous implants wrapped with a polyglactin mesh after enucleation or evisceration, and we showed that implant stability can be achieved for long term.6 A reliable surgical technique may be the most important factor in predicting implant stability and a low complication rate.6,7 Dermis-fat graft is a suitable option to address the volume deficit following explantation of exposed implants at the same time of implant removal4 or following removal of hydrogel orbital expanders,8 but of course morbidity is higher.9
Francesco M. Quaranta-Leoni, M.D. Correspondence: Francesco M. Quaranta-Leoni, M.D., Oftalmoplastica Roma, Via Archimede 201, 00197 Roma, Italy ([email protected])
REFERENCES 1. Quaranta-Leoni FM. Treatment of the anophthalmic socket. Curr Opin Ophthalmol 2008;19:422–7. 2. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
3. Viswanathan P, Sagoo MS, Olver JM. UK national survey of enucleation, evisceration and orbital implants trends. Br J Ophthalmol 2007;91;616–9. 4. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophth Plast Reconstr Surg 2014;30:132–6. 5. Jung SK, Cho WK, Paik JS, et al. Long-term surgical outcomes of porous polyethylene orbital implants: a review of 314 cases. Br J Ophthalmol 2012;96:494–8. 6. Quaranta-Leoni FM, Sposato S, Lorenzano D. Secondary orbital ball implants after enucleation and evisceration: surgical management, morbidity and long-term outcome. Ophthal Plast Reconstr Surg. 2014; [Epub ahead of print, July 14, 2014]. 7. Sagoo MS, Rose GE. Mechanisms and treatment of extruding intraconal implants: socket aging and tissue restitution (the “Cactus Syndrome”). Arch Ophthalmol 2007;125:1616–20. 8. Quaranta-Leoni FM. Congenital anophthalmia: current concepts in management. Curr Opin Ophthalmol 2011;22:380–4. 9. Nentwich MM, Schebitz-Walter K, Hirneiss C, et al. Dermis fat grafts as primary and secondary orbital implants. Orbit 2014;33:33–8.
Re: “Calcium Hydroxyl-Apatite (Radiesse) for the Correction of Periorbital Hollows, Dark Circles, and Lower Eyelid Bags” To the Editor: I read with interest the article by Bernardini et al.1 on injection of calcium hydroxylapatite in the periorbital region. I congratulate the authors on their successful use of this product in an anatomically sensitive region. The authors reported that of the 63 subjects they treated, there were no cases of irregular contour, palpable lumpiness, or unevenness. These findings may be due to a combination of patient selection and injection technique. In my practice, I am frequently referred patients for management of complications after soft tissue filler injections. I have encountered several cases of persistent lumpiness, visible contour abnormalities, and cosmetic dissatisfaction following injection of calcium hydroxylapatite. Unfortunately, these cases are challenging to treat as there is no simple “antidote” for calcium hydroxylapatite. As opposed to hyaluronic acid (HA) products, calcium hydroxylapatite cannot be easily modified, removed, or dissolved once the immediate postinjection time frame has passed. One of the most common scenarios in which soft tissue fillers are used in the periorbital region is the one in which the midfacial soft tissues have descended and the orbicularis muscle is thin. In these cases, the bony orbital rim is covered only by a very thin layer of soft tissue making the margin for error with injectable fillers extremely small. The authors comment that HA fillers are less desirable in the periorbital region on account of their hydrophilic nature. They do not differentiate between the various HA products available in the United States. This is important as each HA filler has its own unique rheostatic properties and hydrophilic nature. Therefore, a blanket statement about HA fillers cannot be made. To be sure, some HA products are better suited for use in the periorbital region than others and, as the authors correctly point out, all HA products have the distinct advantage that they can be removed with hyaluronidase. Based on my anecdotal experience, I urge great caution when using calcium hydroxylapatite in the periorbital region as this product is less forgiving than HA fillers.
Letters to the Editor
Brian Biesman, M.D. Correspondence: Brian Biesman, M.D., Nashville Centre for Laser and Facial Surgery, 345 23rd Avenue North, Suite 416, Nashville, TN 37203 ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCE 1. Bernardini FP, Cetinkaya A, Devoto MH, et al. Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags. Ophthal Plast Reconstr Surg 2014;30:34–9.
Reply re: “Calcium Hydroxyl-Apatite (Radiesse) for the Correction of Periorbital Hollows, Dark Circles, and Lower Eyelid Bags” To the Editor: We thank Dr. Biesman for his interest in our article. It appears that nowadays patients’ self-awareness of volume defects of the periorbital region is on the rise as it has the increasing demand for its nonsurgical treatment. As injectors, we have the duty to provide the best possible aesthetic results while at the same time avoiding complications or choosing the potential complications that have the least impact on our patients. It is crucial to reinforce the statement that my coauthors and I do not have any financial support in any of the material discussed on the article, and that our personal preference is based only on what we believe provides the best benefit to complication ratio. In particular, Dr. Devoto and I have started injecting the periocular area with hyaluronic acid (HA)-based products and only after seeing our own HA-related complications, we decided to explore a calcium hydroxylapatite (CaHa)based alternative. Now, 1 year after the publication of the article and 100 more patients treated, we are still favoring CaHa as the first choice filler for periocular use in our respective practices. Based on our growing experience, there are 2 problems with CaHabased fillers that are material related and that need to be disclosed to patients. The main problem is the pseudoxantelasma effect that may occur in 17% of patients.1 This is a self-resolving complication that may last up to 8 weeks and that can be concealed to imperception with make-up. The second problem is a short-term complication that consists of a variable inflammatory response that may occur 24 to 48 hours after the injection. Patients are instructed to report it, and an oral dose of 25 mg prednisone is prescribed for 3 to 5 days. So far, both complications have been well accepted by our patients. We have yet to encounter 1 case of irregular contour or lumpiness. However, the risks of visible lumpiness, persistent malar edema, and patient dissatisfaction are reportedly quite frequent as is the need for hyaluronidase treatment. The assumption that an HA-based product is preferable because there is an antidote is not convincing, as we believe it is much preferable a material that does not require one. A comparative study of Radiesse vs HA fillers available and marketed as indicated for their use in the periocular region was not the goal of our study. We agree with Dr. Biesman, and we have stated in our article and firmly believe that Radiesse should not be used by novice injectors because there is no antidote. However, there are 2 unique properties of Radiesse
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
529
Daphne L. Mourits, M.D. Dyonne T. Hartong, M.D., Ph.D. Annette C. Moll, M.D., Ph.D. Maarten P. Mourits, M.D., Ph.D. Correspondence Daphne L. Mourits, M.D., Department of Ophthalmology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands (D.mourits@ vumc.nl) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophthal Plast Reconstr Surg 2014;30:132–6. 2. Colen TP, Paridaens DA, Lemij HG, et al. Comparison of artificial eye amplitudes with acrylic and hydroxyapatite spherical enucleation implants. Ophthalmology 2000;107:1889–94. 3. Custer PL, Trinkaus KM, Fornoff J. Comparative motility of hydroxyapatite and alloplastic enucleation implants. Ophthalmology 1999;106:513–6. 4. Shields CL, Shields JA, De Potter P, et al. Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases. Br J Ophthalmol 1994;78:702–6. 5. Jordan DR, Chan S, Mawn L, et al. Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 1999;106:505–12. 6. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
528
Reply re: “Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study” To the Editor: We quite agree with Dr. Mourits’s observation: in our experience and in the literature, long-term results may be satisfactory using a great variety of implant materials and surgical techniques.1 No choice of materials or surgical technique can guarantee a successful outcome, and there are reports in the literature suggesting that there are few advantages to the use of porous implants, compared to nonporous implants, when these implants are properly placed in the orbit following evisceration or enucleation.1,2 The cost of mesh-covered porous implants is higher if compared with solid polymethyl methacrylate or silicone spheres, and in most European countries, cost–benefit analysis is becoming an increasingly important consideration in the selection of care options.1,3 However, the choice of the primary implant was not the issue of our paper. The aim of our study was to examine the clinical outcome of patients with exposed porous orbital implants where we selected to perform explant surgery followed by simultaneous replacement with an autologous dermis-fat graft.4 In all the 25 patients described, primary surgery (enucleation or evisceration) had been performed elsewhere by a number of different surgeons. We did not choose the type of the primary implant, and the patients were referred to our orbital clinic for explant surgery and socket reconstruction (see Methods). Microbiology showed the presence of infection in 59% of patients submitted to explantation, and histology showed the presence of a long-term inflammatory infiltrate in 88% of the examined implants. For these reasons, we thought that a dermis-fat graft was a suitable option to address the volume and lining deficit following explantation.4 In any case, tissue ingrowth inside porous orbital implants may offer some advantages, and better blood support may help to reduce the risk of migration of the implant, which is a common problem with implants such as polymethyl methacrylate or silicone.1,2,5 We have recently described a series of patients who underwent secondary ball implantation with porous implants wrapped with a polyglactin mesh after enucleation or evisceration, and we showed that implant stability can be achieved for long term.6 A reliable surgical technique may be the most important factor in predicting implant stability and a low complication rate.6,7 Dermis-fat graft is a suitable option to address the volume deficit following explantation of exposed implants at the same time of implant removal4 or following removal of hydrogel orbital expanders,8 but of course morbidity is higher.9
Francesco M. Quaranta-Leoni, M.D. Correspondence: Francesco M. Quaranta-Leoni, M.D., Oftalmoplastica Roma, Via Archimede 201, 00197 Roma, Italy ([email protected])
REFERENCES 1. Quaranta-Leoni FM. Treatment of the anophthalmic socket. Curr Opin Ophthalmol 2008;19:422–7. 2. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
3. Viswanathan P, Sagoo MS, Olver JM. UK national survey of enucleation, evisceration and orbital implants trends. Br J Ophthalmol 2007;91;616–9. 4. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophth Plast Reconstr Surg 2014;30:132–6. 5. Jung SK, Cho WK, Paik JS, et al. Long-term surgical outcomes of porous polyethylene orbital implants: a review of 314 cases. Br J Ophthalmol 2012;96:494–8. 6. Quaranta-Leoni FM, Sposato S, Lorenzano D. Secondary orbital ball implants after enucleation and evisceration: surgical management, morbidity and long-term outcome. Ophthal Plast Reconstr Surg. 2014; [Epub ahead of print, July 14, 2014]. 7. Sagoo MS, Rose GE. Mechanisms and treatment of extruding intraconal implants: socket aging and tissue restitution (the “Cactus Syndrome”). Arch Ophthalmol 2007;125:1616–20. 8. Quaranta-Leoni FM. Congenital anophthalmia: current concepts in management. Curr Opin Ophthalmol 2011;22:380–4. 9. Nentwich MM, Schebitz-Walter K, Hirneiss C, et al. Dermis fat grafts as primary and secondary orbital implants. Orbit 2014;33:33–8.
Re: “Calcium Hydroxyl-Apatite (Radiesse) for the Correction of Periorbital Hollows, Dark Circles, and Lower Eyelid Bags” To the Editor: I read with interest the article by Bernardini et al.1 on injection of calcium hydroxylapatite in the periorbital region. I congratulate the authors on their successful use of this product in an anatomically sensitive region. The authors reported that of the 63 subjects they treated, there were no cases of irregular contour, palpable lumpiness, or unevenness. These findings may be due to a combination of patient selection and injection technique. In my practice, I am frequently referred patients for management of complications after soft tissue filler injections. I have encountered several cases of persistent lumpiness, visible contour abnormalities, and cosmetic dissatisfaction following injection of calcium hydroxylapatite. Unfortunately, these cases are challenging to treat as there is no simple “antidote” for calcium hydroxylapatite. As opposed to hyaluronic acid (HA) products, calcium hydroxylapatite cannot be easily modified, removed, or dissolved once the immediate postinjection time frame has passed. One of the most common scenarios in which soft tissue fillers are used in the periorbital region is the one in which the midfacial soft tissues have descended and the orbicularis muscle is thin. In these cases, the bony orbital rim is covered only by a very thin layer of soft tissue making the margin for error with injectable fillers extremely small. The authors comment that HA fillers are less desirable in the periorbital region on account of their hydrophilic nature. They do not differentiate between the various HA products available in the United States. This is important as each HA filler has its own unique rheostatic properties and hydrophilic nature. Therefore, a blanket statement about HA fillers cannot be made. To be sure, some HA products are better suited for use in the periorbital region than others and, as the authors correctly point out, all HA products have the distinct advantage that they can be removed with hyaluronidase. Based on my anecdotal experience, I urge great caution when using calcium hydroxylapatite in the periorbital region as this product is less forgiving than HA fillers.
Letters to the Editor
Brian Biesman, M.D. Correspondence: Brian Biesman, M.D., Nashville Centre for Laser and Facial Surgery, 345 23rd Avenue North, Suite 416, Nashville, TN 37203 ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCE 1. Bernardini FP, Cetinkaya A, Devoto MH, et al. Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags. Ophthal Plast Reconstr Surg 2014;30:34–9.
Reply re: “Calcium Hydroxyl-Apatite (Radiesse) for the Correction of Periorbital Hollows, Dark Circles, and Lower Eyelid Bags” To the Editor: We thank Dr. Biesman for his interest in our article. It appears that nowadays patients’ self-awareness of volume defects of the periorbital region is on the rise as it has the increasing demand for its nonsurgical treatment. As injectors, we have the duty to provide the best possible aesthetic results while at the same time avoiding complications or choosing the potential complications that have the least impact on our patients. It is crucial to reinforce the statement that my coauthors and I do not have any financial support in any of the material discussed on the article, and that our personal preference is based only on what we believe provides the best benefit to complication ratio. In particular, Dr. Devoto and I have started injecting the periocular area with hyaluronic acid (HA)-based products and only after seeing our own HA-related complications, we decided to explore a calcium hydroxylapatite (CaHa)based alternative. Now, 1 year after the publication of the article and 100 more patients treated, we are still favoring CaHa as the first choice filler for periocular use in our respective practices. Based on our growing experience, there are 2 problems with CaHabased fillers that are material related and that need to be disclosed to patients. The main problem is the pseudoxantelasma effect that may occur in 17% of patients.1 This is a self-resolving complication that may last up to 8 weeks and that can be concealed to imperception with make-up. The second problem is a short-term complication that consists of a variable inflammatory response that may occur 24 to 48 hours after the injection. Patients are instructed to report it, and an oral dose of 25 mg prednisone is prescribed for 3 to 5 days. So far, both complications have been well accepted by our patients. We have yet to encounter 1 case of irregular contour or lumpiness. However, the risks of visible lumpiness, persistent malar edema, and patient dissatisfaction are reportedly quite frequent as is the need for hyaluronidase treatment. The assumption that an HA-based product is preferable because there is an antidote is not convincing, as we believe it is much preferable a material that does not require one. A comparative study of Radiesse vs HA fillers available and marketed as indicated for their use in the periocular region was not the goal of our study. We agree with Dr. Biesman, and we have stated in our article and firmly believe that Radiesse should not be used by novice injectors because there is no antidote. However, there are 2 unique properties of Radiesse
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
529
