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PURPOSE: This study quantifies the incision location in transconjunctival lower eyelid blepharoplasty to optimize postspetal (direct) access to the eyelid/orbital fat. METHODS: A retrospective chart review of patients undergoing transconjunctival blepharoplasty by one surgeon (GGM) from January 2013 to January 2014 was performed. Simultaneous globe retropulsion and lower eyelid inferior displacement was used to balloon the conjunctiva forward to maximally visualize the transconjunctival surface anatomical landmarks of importance. A caliper was used to measure the distance in millimeters from the inferior tarsus to the most superior projection of visible fat. The conjunctival incision was made 0.5 mm posterior to this measured distance. For each procedure it was noted whether the preseptal or postseptal plane was entered. RESULTS: Sixty-six patients were assessed. Fifty patients were women, and the mean patient age was 54 years (range 36-71 years). The mean distance from the inferior tarsus to the visualized superior tip of fat was 6.03 mm (range 5-7 mm) and the mean incision placement was 6.53 mm (range 5.5-7.5 mm). The postseptal space (direct access to fat) was entered in 54 cases (82%). The inferior vascular arcade was identified in 23 cases (35%) cases. In this instance, the incision was placed below this landmark in 16 cases (70%). There were 5 cases (7.6%) of postoperative chemosis which all resolved within 2 months with conservative measures. There were no other complications related to the conjunctival incision. CONCLUSION: Placing the conjunctival incision for postseptal approach transconjunctival blepharoplasty 0.5 mm posterior to the most superior projection of clinically visible fat (with adjunctive globe retropulsion and lower eyelid infraplacement) accesses the postspetal space directly in 82% of cases. Previously suggested incision placements: between 2 and 5 mm below the tarsus, at the fornix, or at the inferior vascular arcade are subjective/anecdotal at best and without similar quantitative validation.

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BACKGROUND: The purpose of this study was to determine whether functional rhinoplasty alone results in a significant improvement in obstructive sleep apnea parameters in patients with nasal obstruction. METHODS: Records of consecutive adult patients with nasal obstruction who underwent surgery to repair their nasal inlet and completed preoperative and postoperative polysomnography were reviewed. Patients underwent polysomnography before and after functional septorhinoplasty. Long-term follow-up using Nasal Obstruction Symptom Evaluation scores was conducted. Statistical analysis was performed using the Wilcoxon signed rank sum test. A Holm-Bonferroni sequential correction was also used because of multiple statistical comparisons being made. RESULTS: Twenty-six patients were included in this study. Mean apnea-hypopnea index scores preoperatively was 24.7, which dropped to a mean postoperative apnea-hypopnea index of 16, a reduction of 35 percent (p = 0.013). Excluding patients with a body mass index greater than 30 resulted in improved apnea-hypopnea index scores, from 22.5 to 9.6, a mean 57 percent reduction (p < 0.01). CONCLUSIONS: Functional rhinoplasty may have the potential to significantly improve the severity of obstructive sleep apnea for select patients with nasal obstruction. The nasal airflow improvement may modify pharyngeal aerodynamics. This is a fast and minimally invasive approach to consider in patients with obstructive sleep apnea and nasal obstruction, especially in patients with a body mass index less than 30. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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The eyes play a central role in the perception of facial beauty. The goal of periorbital rejuvenation surgery is to restore youthful proportions and focus attention on the eyes. Blepharoplasty is the third most common cosmetic procedure performed today. Because of the attention placed on the periorbital region, preventing and managing complications is important. Obtaining a thorough preoperative history and physical examination can significantly reduce the incidence of many of the complications. This article focuses on the preoperative evaluation as it relates to preventable complications, followed by common intraoperative and postoperative complications and their management.

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Killian-Jamieson diverticulum (KJD) is rare hypopharyngeal defect. As in other forms of esophageal diverticuli (i.e., Zenker's), recent literature has described minimally invasive endoscopic approaches to its management.1, 2 We present a case of a 62-year-old female with symptoms consistent with an esophageal diverticulum. A barium swallow study was consistent with a KJD. The patient was brought to the operating room and endoscopically examined to confirm the presence of this entity. A open transcervical approach was performed to remove the diverticulum without complication. During our dissection, the recurrent laryngeal nerve (RLN) was noted to be adherent to the base of the diverticulum and needed to be freed prior to performing the diverticulectomy. We provide a review of recent literature and medical illustrations to highlight the importance of the open transcervical approach in the management of KJD to avoid inadvertent transection of the RLN.

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