Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Letter to the Editor
that make it a sophisticated tool to correct the periocular area: its white color improves dark circles, and its nonhydrophilic nature prevents Tyndall effect and long-term edema. We acknowledge that there may be newer HA products with improved rheostatic properties and better fit for this region compared with the past, but still the hydrophilic properties of any HA filler hold true and with it the potential of persistent edema and Tyndall effect. In conclusion, as it appears that the perfect filler for the periocular region is not available yet, our quest for one should not rest. At this stage, we are bound to explore all the possibilities with an open mind; for this reason, we suggest to consider CaHa, if not as a superior option at least as a viable alternative for those patients who had a negative experience with HA filler and are still seeking nonsurgical rejuvenation of the periocular region. We thank again Dr. Biesman for his safety concerns with fillers in the periocular region and for giving us an opportunity to clarify once more the indications for the use of CaHa-based fillers in the periocular region.
Francesco P. Bernardini, Martin H. Devoto, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Francesco P. Bernardini, M.D., Via Cecchi 8\4, 16145 Genova, Italy ([email protected]) The authors have 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.
Re: “Foam Sclerotherapy for Periorbital Dermoid Cysts”
Ved Prakash Gupta, m.b.b.s., m.d., d.n.b., Pragati Gupta, M.S., D.N.B., and Rigved Gupta, M.B.B.S., M.D.
To the Editor: We read the article by Naik et al.1 with keen interest. We wish to express the following comments. Dermoid cysts are developmental choristomas which may manifest soon after birth. Periorbital dermoids constitute the commonest periocular cystic lesion. Complete excision still remains the treatment of choice. We appreciate the authors for commendable attempt to treat periorbital dermoids with foam sclerotherapy using sodium tetradecyl sulfate. Authors mention that an extensive literature search revealed that sclerotherapy had never been attempted for dermoid cysts. However, our pubmed search revealed report of minimally invasive percutaneous drainage and dual drug chemical ablation of orbital dermoid cysts using sodium tetradecyl sulfate and ethanol which resulted in complete resolution of large orbital dermoid cysts in 2 patients.2 Foam sclerotherapy has been extensively used as nonsurgical treatment of varicose veins. Tessari3 described the “3-way tap method” of foam production for the treatment of larger varicose veins with sclerotherapy. Foam increases the surface area of the drug so that the sclerosing power of the solution is increased two- to threefold, while decreasing the toxicity fourfold. However, sclerotherapist should be aware that there is rapid degradation of foam which may last only seconds to minutes before degrading into a liquid
530
solution. Foam stability varies little with sodium tetradecyl sulfate concentration.4 The authors mention drainage of cyst contents using 18 G needle and manual expression in case of difficulty. However, it is very difficult to successfully aspirate the cyst contents using the authors’ method1 in view of the usually thick pultaceous or even solid contents of dermoid cyst which frequently include sebum, fat, clumps of long hair, blood, bone, nails, teeth, and cartilage. We, therefore, suggest aspiration of cyst contents using suction catheter. Moreover, the presence of array of developmentally mature, solid tissues may be a menace in the success of foam sclerotherapy. In our opinion, the authors’1 technique appears to be minimally invasive surgical approach rather than nonsurgical as it involves incision, hair removal, suturing, etc. In contradiction to the authors,1 we believe that easy accessibility due to superficial location makes the periorbital dermoids ideal for surgical removal with scar hidden in natural creases. Foam sclerotherapy appears to be a promising treatment for vision threatening large orbital dermoid cysts which would otherwise require extensive surgery to excise.2 Although scar has never been a concern after removal of such dermoids by experienced hands, excision using a subcutaneoscopic technique avoids scarring on the face.5 The authors mention complete resolution of the cyst with no palpable mass.1 However, the photograph of Case 1 (Fig. 2)1 has been taken only after 3 months which is a short follow up to comment about the resolution. Dermoid cysts enlarge very slowly in years or may remain stationary. Photograph of other 3 cases (Figs. 3–5)1 shows asymmetry due to residual or recurrent swelling. In our opinion, final outcome should have been evaluated by performing CT orbit and histopathology after excision of residual mass to highlight the status of ablation of the stratified keratinized epithelium. Rare possibility of a malignant transformation seems yet another concern.6
Correspondence: Ved Prakash Gupta, m.b.b.s., m.d., d.n.b., Department of Ophthalmology, University College of Medical Sciences & G. T. B. Hospital, 275, Ground Floor, Gagan Vihar, Delhi 110051, India ([email protected]) The authors have no conflicts of interest to disclose.
REFERENCES 1. Naik MN, Batra J, Nair AG, et al. Foam sclerotherapy for periorbital dermoid cysts. Ophthal Plast Reconstr Surg 2014;30(3):267–70. 2. Golden RP, Shiels WE 2nd, Cahill KV, Rogers GL. Percutaneous drainage and ablation of orbital dermoid cysts. J AAPOS 2007;11(5):438–42. 3. Tessari L. Nouvelle technique d’obtention de la sclero-mousse. Phlebologie 1997;53:129. 4. McMaster S. Sodium tetradecyl sulphate foam stability prior to injection: factors affecting liquid reformation. Phlebology 2011;26:222–6. 5. Agrawal V, Acharya H, Agarwal P, et al. Subcutaneoscopic excision of external angular dermoid cyst in children without conspicuous scarring. Asian J Endosc Surg 2013;6(3):241–4. 6. Tangjitgamol S, Manusirivithaya S, Sheanakul C, et al. Squamous cell carcinoma arising from dermoid cyst: case reports and review of literature. Int J Gynecol Cancer 2003;13(4):558–63.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Letter to the Editor
that make it a sophisticated tool to correct the periocular area: its white color improves dark circles, and its nonhydrophilic nature prevents Tyndall effect and long-term edema. We acknowledge that there may be newer HA products with improved rheostatic properties and better fit for this region compared with the past, but still the hydrophilic properties of any HA filler hold true and with it the potential of persistent edema and Tyndall effect. In conclusion, as it appears that the perfect filler for the periocular region is not available yet, our quest for one should not rest. At this stage, we are bound to explore all the possibilities with an open mind; for this reason, we suggest to consider CaHa, if not as a superior option at least as a viable alternative for those patients who had a negative experience with HA filler and are still seeking nonsurgical rejuvenation of the periocular region. We thank again Dr. Biesman for his safety concerns with fillers in the periocular region and for giving us an opportunity to clarify once more the indications for the use of CaHa-based fillers in the periocular region.
Francesco P. Bernardini, Martin H. Devoto, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Francesco P. Bernardini, M.D., Via Cecchi 8\4, 16145 Genova, Italy ([email protected]) The authors have 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.
Re: “Foam Sclerotherapy for Periorbital Dermoid Cysts”
Ved Prakash Gupta, m.b.b.s., m.d., d.n.b., Pragati Gupta, M.S., D.N.B., and Rigved Gupta, M.B.B.S., M.D.
To the Editor: We read the article by Naik et al.1 with keen interest. We wish to express the following comments. Dermoid cysts are developmental choristomas which may manifest soon after birth. Periorbital dermoids constitute the commonest periocular cystic lesion. Complete excision still remains the treatment of choice. We appreciate the authors for commendable attempt to treat periorbital dermoids with foam sclerotherapy using sodium tetradecyl sulfate. Authors mention that an extensive literature search revealed that sclerotherapy had never been attempted for dermoid cysts. However, our pubmed search revealed report of minimally invasive percutaneous drainage and dual drug chemical ablation of orbital dermoid cysts using sodium tetradecyl sulfate and ethanol which resulted in complete resolution of large orbital dermoid cysts in 2 patients.2 Foam sclerotherapy has been extensively used as nonsurgical treatment of varicose veins. Tessari3 described the “3-way tap method” of foam production for the treatment of larger varicose veins with sclerotherapy. Foam increases the surface area of the drug so that the sclerosing power of the solution is increased two- to threefold, while decreasing the toxicity fourfold. However, sclerotherapist should be aware that there is rapid degradation of foam which may last only seconds to minutes before degrading into a liquid
530
solution. Foam stability varies little with sodium tetradecyl sulfate concentration.4 The authors mention drainage of cyst contents using 18 G needle and manual expression in case of difficulty. However, it is very difficult to successfully aspirate the cyst contents using the authors’ method1 in view of the usually thick pultaceous or even solid contents of dermoid cyst which frequently include sebum, fat, clumps of long hair, blood, bone, nails, teeth, and cartilage. We, therefore, suggest aspiration of cyst contents using suction catheter. Moreover, the presence of array of developmentally mature, solid tissues may be a menace in the success of foam sclerotherapy. In our opinion, the authors’1 technique appears to be minimally invasive surgical approach rather than nonsurgical as it involves incision, hair removal, suturing, etc. In contradiction to the authors,1 we believe that easy accessibility due to superficial location makes the periorbital dermoids ideal for surgical removal with scar hidden in natural creases. Foam sclerotherapy appears to be a promising treatment for vision threatening large orbital dermoid cysts which would otherwise require extensive surgery to excise.2 Although scar has never been a concern after removal of such dermoids by experienced hands, excision using a subcutaneoscopic technique avoids scarring on the face.5 The authors mention complete resolution of the cyst with no palpable mass.1 However, the photograph of Case 1 (Fig. 2)1 has been taken only after 3 months which is a short follow up to comment about the resolution. Dermoid cysts enlarge very slowly in years or may remain stationary. Photograph of other 3 cases (Figs. 3–5)1 shows asymmetry due to residual or recurrent swelling. In our opinion, final outcome should have been evaluated by performing CT orbit and histopathology after excision of residual mass to highlight the status of ablation of the stratified keratinized epithelium. Rare possibility of a malignant transformation seems yet another concern.6
Correspondence: Ved Prakash Gupta, m.b.b.s., m.d., d.n.b., Department of Ophthalmology, University College of Medical Sciences & G. T. B. Hospital, 275, Ground Floor, Gagan Vihar, Delhi 110051, India ([email protected]) The authors have no conflicts of interest to disclose.
REFERENCES 1. Naik MN, Batra J, Nair AG, et al. Foam sclerotherapy for periorbital dermoid cysts. Ophthal Plast Reconstr Surg 2014;30(3):267–70. 2. Golden RP, Shiels WE 2nd, Cahill KV, Rogers GL. Percutaneous drainage and ablation of orbital dermoid cysts. J AAPOS 2007;11(5):438–42. 3. Tessari L. Nouvelle technique d’obtention de la sclero-mousse. Phlebologie 1997;53:129. 4. McMaster S. Sodium tetradecyl sulphate foam stability prior to injection: factors affecting liquid reformation. Phlebology 2011;26:222–6. 5. Agrawal V, Acharya H, Agarwal P, et al. Subcutaneoscopic excision of external angular dermoid cyst in children without conspicuous scarring. Asian J Endosc Surg 2013;6(3):241–4. 6. Tangjitgamol S, Manusirivithaya S, Sheanakul C, et al. Squamous cell carcinoma arising from dermoid cyst: case reports and review of literature. Int J Gynecol Cancer 2003;13(4):558–63.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
