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New technique of levator lengthening for the retracted upper eyelid
122 tasis and evaluation LOWAY
CURRENT
of head and neck cancer.-R.
HOL-
Reprint requests to Dr Baredes; Section of Otolaryngology, Head and Neck Surgery, New Jersey Medical School, 185 S Orange Ave., Rm H-592, Newark NJ, 07103.2757. Market Forces Driving Health E. J Dent Educ 59:480, 1995
Care Reform.
Capilouto
Although the proposals considered by the Congress on health care reform were not implemented, the private market is aiming at transforming the United States health care system by negotiating with physicians and hospitals who are willing to cut prices and increase volume of patients. This report presents the fundamental driving economic forces affecting the medical and dental health care sector. Corporate purchasers demanding lower costs and higher quality care have found that managed care arrangements (health maintenance organizations and preferred provider organizations) with limited choice of providers allow for tighter cost and quality of service control for the employees. ln addition, employee insurance plan decisions are heavily based on lower out-of-pocket premiums. According to statistics cited in this report, insured individuals are price sensitive and more unlikely to choose a lower cost insurance plan in the face of higher out-of-pockets premiums. The trend for providers is to negotiate prices with the managed care organizations and allow lower health care costs, however, provider decision to lower rates in a managed care contract is a function of the local economic market. Although there is a lack of reliable data on dental managed care, parallels can be found between dental and medical health care where a decrease in health care cost can be foreseen.-H. PATINO Reprint requests to Dr Capilouto: School of Public Health, University of Alabama at Birmingham, Birmingham, Al 35294. New Technique of Levator Lengthening for the Retracted Upper Eyelid. Piggot TA, Niazi ZBM, Hodgkinson PD, et al. Br J Plast Surg 48:127, 1995 Upper eyelid retraction is defined as elevation of the eyelid above the normal level in the primary position of gaze. Shortening of the upper lid is not only a cosmetic problem from the “staring look” that it presents but may also lead to inability to protect the exposed cornea leading to comeal damage and possibly blindness. There are two main categories of eyelid retraction. The first is due to tissue loss or scarring involving the anterior lamella often following bums or superficial trauma to the eyelid. The second catagory involves shortening of the levator mechanism. This usually results from Craves’ disease, excess postsurgical retraction following blepharoplasty, deep traumatic loss of tissue or excision of tumor tissue. This second catagory may be further subdivided into peak or generalized retraction. Correction of this second catagory of deformity was discussed in this article. The authors proposed correction of the deformity with a lengthening of the levator by a castellated type aponeurotomy. The procedure can be performed under local or general anesthesia. The skin and orbicularis are incised in the supratarsal fold or may be removed as part of a blepharoplasty procedure. The orbital septum is opened and excess fat is removed to visualize the levator aponeurosis. The levator Muller’s muscle complex is dissected from the conjunctiva but no effort is made to separate them. From preoperative
LITERATURE
measurements of the degree of retraction, a castellated type of aponeurotomy is carried out by the formula: length of each castellated flap = degree of retraction in mm + 1 mm. This formula allows for a l-mm overlap of the flaps in the sutured area. The opposing tips of the aponeurotic flaps are then sutured with 6/O polydioxanone. In the generalized form of retraction, the whole aponeurosis is divided in the castellated manner while in the peak type of deformity only the effected area is divided. On completion of surgery, the upper and lower lids are taped together and the eye is patched. The dressings are removed the following day and normal movement of the upper lid is allowed. This method produced a predictable amount of lengthening of the upper lid and was found to be stable during the follow-up period of 3 to 8 years.-S. DORSCH Reprint requests to Dr Piggot: Consultant Plastic Surgeon, The Royal Victoria Infirmary and Associated Hospitals Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP. Minimal-Access Surgery for Staging of Malignant Melanoma. Krag DN, Meijer SJ, Weaver KL, et al. Arch Surg 130:654, 1995 The treatment of melanoma requires an adequate resection of the primary tumor and any clinically positive regional lymph nodes. The management of clinically negative lymph nodes is controversial. Although delayed regional node resection spares patients with negative nodes, the morbidity of node disection, it subjects those in whom clinically positive nodes later develop to a prolonged interval of tumor growth with the attendant risks of development of systemic metastases. This study demonstrates a minimally invasive technique of determining whether regional node meastatsis has occured in patients with melanoma. Recent reports show that a blue dye injected around the primary melanoma stains the lymph node(s) most likely to harbor metastatic melanoma. Unfortunately, one cannot know precisely where the blue-stained lymph node is located, and considerable dissection is often required to find the node. The authors recently reported that technetium Tc 99 prepared with sulfur colloid and injected intradermally follows the same lymphatic pathways and labels the same lymph nodes as does the blue dye. The radiolabeled lymph nodes were readily detectable with a handheld gamma detector. In this study, 118 of 121 patients (98%) had successful resection of radiolabeled sentinel lymph nodes. Blue dye was injected into 44 patients in addition to the radioactive tracer, and in no case was a bluestained node not radiolabeled. This technique significantly minimizes the extent of tissue dissection required and offers immediate verification that all radiolabeled sentinel lymph nodes have been removed. The level of radiation goes back to background once the radiolabeled lymph nodes are removed. The authors suggest this technology should be applicable to a wide variety of solid tumors in which the regional lymph nodes are resected as part of staging or therapy.P.S. LAM Reprint requests to Dr Krag: University of Vermont, Department of Surgery, Given Building, E309C, Burlington, VT 05405. Metastatic Basal Cell Carcinoma of the Eyelid: Report of a case. Davies R, Briggs JM, Levine MR, et al. Arch Ophthalmol 113:634, 1995 This case report describes a 71-year-old white male who had metastatic basal cell carcinoma (BCC) of the right upper
CURRENT
of head and neck cancer.-R.
HOL-
Reprint requests to Dr Baredes; Section of Otolaryngology, Head and Neck Surgery, New Jersey Medical School, 185 S Orange Ave., Rm H-592, Newark NJ, 07103.2757. Market Forces Driving Health E. J Dent Educ 59:480, 1995
Care Reform.
Capilouto
Although the proposals considered by the Congress on health care reform were not implemented, the private market is aiming at transforming the United States health care system by negotiating with physicians and hospitals who are willing to cut prices and increase volume of patients. This report presents the fundamental driving economic forces affecting the medical and dental health care sector. Corporate purchasers demanding lower costs and higher quality care have found that managed care arrangements (health maintenance organizations and preferred provider organizations) with limited choice of providers allow for tighter cost and quality of service control for the employees. ln addition, employee insurance plan decisions are heavily based on lower out-of-pocket premiums. According to statistics cited in this report, insured individuals are price sensitive and more unlikely to choose a lower cost insurance plan in the face of higher out-of-pockets premiums. The trend for providers is to negotiate prices with the managed care organizations and allow lower health care costs, however, provider decision to lower rates in a managed care contract is a function of the local economic market. Although there is a lack of reliable data on dental managed care, parallels can be found between dental and medical health care where a decrease in health care cost can be foreseen.-H. PATINO Reprint requests to Dr Capilouto: School of Public Health, University of Alabama at Birmingham, Birmingham, Al 35294. New Technique of Levator Lengthening for the Retracted Upper Eyelid. Piggot TA, Niazi ZBM, Hodgkinson PD, et al. Br J Plast Surg 48:127, 1995 Upper eyelid retraction is defined as elevation of the eyelid above the normal level in the primary position of gaze. Shortening of the upper lid is not only a cosmetic problem from the “staring look” that it presents but may also lead to inability to protect the exposed cornea leading to comeal damage and possibly blindness. There are two main categories of eyelid retraction. The first is due to tissue loss or scarring involving the anterior lamella often following bums or superficial trauma to the eyelid. The second catagory involves shortening of the levator mechanism. This usually results from Craves’ disease, excess postsurgical retraction following blepharoplasty, deep traumatic loss of tissue or excision of tumor tissue. This second catagory may be further subdivided into peak or generalized retraction. Correction of this second catagory of deformity was discussed in this article. The authors proposed correction of the deformity with a lengthening of the levator by a castellated type aponeurotomy. The procedure can be performed under local or general anesthesia. The skin and orbicularis are incised in the supratarsal fold or may be removed as part of a blepharoplasty procedure. The orbital septum is opened and excess fat is removed to visualize the levator aponeurosis. The levator Muller’s muscle complex is dissected from the conjunctiva but no effort is made to separate them. From preoperative
LITERATURE
measurements of the degree of retraction, a castellated type of aponeurotomy is carried out by the formula: length of each castellated flap = degree of retraction in mm + 1 mm. This formula allows for a l-mm overlap of the flaps in the sutured area. The opposing tips of the aponeurotic flaps are then sutured with 6/O polydioxanone. In the generalized form of retraction, the whole aponeurosis is divided in the castellated manner while in the peak type of deformity only the effected area is divided. On completion of surgery, the upper and lower lids are taped together and the eye is patched. The dressings are removed the following day and normal movement of the upper lid is allowed. This method produced a predictable amount of lengthening of the upper lid and was found to be stable during the follow-up period of 3 to 8 years.-S. DORSCH Reprint requests to Dr Piggot: Consultant Plastic Surgeon, The Royal Victoria Infirmary and Associated Hospitals Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP. Minimal-Access Surgery for Staging of Malignant Melanoma. Krag DN, Meijer SJ, Weaver KL, et al. Arch Surg 130:654, 1995 The treatment of melanoma requires an adequate resection of the primary tumor and any clinically positive regional lymph nodes. The management of clinically negative lymph nodes is controversial. Although delayed regional node resection spares patients with negative nodes, the morbidity of node disection, it subjects those in whom clinically positive nodes later develop to a prolonged interval of tumor growth with the attendant risks of development of systemic metastases. This study demonstrates a minimally invasive technique of determining whether regional node meastatsis has occured in patients with melanoma. Recent reports show that a blue dye injected around the primary melanoma stains the lymph node(s) most likely to harbor metastatic melanoma. Unfortunately, one cannot know precisely where the blue-stained lymph node is located, and considerable dissection is often required to find the node. The authors recently reported that technetium Tc 99 prepared with sulfur colloid and injected intradermally follows the same lymphatic pathways and labels the same lymph nodes as does the blue dye. The radiolabeled lymph nodes were readily detectable with a handheld gamma detector. In this study, 118 of 121 patients (98%) had successful resection of radiolabeled sentinel lymph nodes. Blue dye was injected into 44 patients in addition to the radioactive tracer, and in no case was a bluestained node not radiolabeled. This technique significantly minimizes the extent of tissue dissection required and offers immediate verification that all radiolabeled sentinel lymph nodes have been removed. The level of radiation goes back to background once the radiolabeled lymph nodes are removed. The authors suggest this technology should be applicable to a wide variety of solid tumors in which the regional lymph nodes are resected as part of staging or therapy.P.S. LAM Reprint requests to Dr Krag: University of Vermont, Department of Surgery, Given Building, E309C, Burlington, VT 05405. Metastatic Basal Cell Carcinoma of the Eyelid: Report of a case. Davies R, Briggs JM, Levine MR, et al. Arch Ophthalmol 113:634, 1995 This case report describes a 71-year-old white male who had metastatic basal cell carcinoma (BCC) of the right upper