Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Letters to the Editor
more homogeneous distribution of the material. The 1.5 ml content of the syringe is diluted with 0.5 ml lidocaine. This has the double purpose of making the procedure virtually painless, and facilitating the injection of a more fluid filler than the original one. It may be possible that this has helped us to avoid granuloma formation. Calcium hydroxylapatite (Radiesse) is indeed a powerful filler for the correction of periorbital hollows, dark circles, and lower eyelid bags. We have stated in our report that the advantage of this material is not limited to the absence of Tyndall effect, but more importantly that it avoids the risks of eyelid and malar edema inherent to the hydrophilic nature of any HA filler. Finally, its white color has a distinct advantage in improving dark circles. Concerning the advantages of cannulas, we agree with the concept that it is safer and reduces the risk of hematomas. We also believe that the tear trough region, being an area void of big vessels, is inherently a safe area to inject. We thank again Dr. Burroughs for his insight into this topic and for allowing us to further discuss the use of calcium hydroxylapatite in the rejuvenation of the periocular region.
Marco Carifi, M.D. Monica Morandi Gianluca Carifi, M.D. Correspondence: Marco Carifi, M.D., Department of Otolaryngology, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli” (A.O.R.N. “A. Cardarelli”), Via Antonio Cardarelli 9, 80131 Naples, Italy ([email protected]) The authors have no financial or conflicts of interest to disclose
REFERENCES
The authors have no financial or conflicts of interest to disclose.
1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Chan W, Malhotra R, Kakizaki H, et al. Perspective: what does the term functional mean in the context of epiphora? Clin Experiment Ophthalmol 2012;40:749–54. 3. Cho WK, Paik JS, Yang SW. Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2013;270:535–40. 4. Feng YF, Cai JQ, Zhang JY, et al. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521–7. 5. Mohamad SH, Khan I, Shakeel M, et al. Long-term results of endonasal dacryocystorhinostomy with and without stenting. Ann R Coll Surg Engl 2013;95:196–9. 6. Yigit O, Samancioglu M, Taskin U, et al. External and endoscopic dacryocystorhinostomy in chronic dacryocystitis: comparison of results. Eur Arch Otorhinolaryngol 2007;264:879–85. 7. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: “Use of Mitomycin C in Dacryocystorhinostomies”
Reply re: “Use of Mitomycin C in Dacryocystorhinostomies”
To the Editor: We were interested in the recent article from Kamal et al.1 regarding the use of mitomycin C during dacryocystorhinostomy. We read that patients diagnosed with epiphora secondary to different etiopathogenesis were enrolled, including patients undergoing surgery following previous surgical failure (redo dacryocystorhinostomy). Moreover, both external and endonasal approaches were performed, and the authors wanted to clarify the criteria they adopted to choose the type of surgical procedure. Although the study reports on the authors’ experience in the time period they investigated, we fear that the information provided may be of limited clinical interest. In fact, the case-mix might be different in other settings or even at the authors’ institution in a different time period. The specific etiopathogenesis of the nasolacrimal duct obstruction, the surgical approach (external versus endonasal), the application of a stent, and whether the case is naïve or a redo are important prognostic factors.2–6 The reliability of the reported outcomes might have also been affected by the follow-up length, which was very short for a considerable proportion of the studied patients. Lastly, mitomycin C injections were performed all around the ostium and its morphology assessed as a outcome measure of functional success; however, it would be important to read details regarding the ostium area, which has been reported to directly relate to the likelihood of success of dacryocystorhinostomy procedures.7
To the Editor: We appreciate Drs Carifi and Morandi for their interest in a surgical technique we had recently described1 regarding the use of mitomycin C in dacryocystorhinostomy. Many of the queries raised have already been discussed within the article; however, we thank the authors for this opportunity to redress certain important issues in greater detail. While we agree with the fact that the patient group was heterogeneous with different approaches, the significance of such consecutive patient inclusion with regard to clinical practice implications cannot be entirely discredited. The letter later mentions, “In fact the case-mix might be different in other settings.” This we believe is a contradictory statement to the query raised itself and precisely answers why we chose a case-mix that spanned the spectrum of varied etiopathologies and approaches. In addition, a subset analysis of each end of this spectrum has been provided, facilitating surgeons to draw their own conclusions based on the subset(s) most frequently encountered in their clinical practice. The patients had a minimum follow up of 6 months following stent removal, which was performed at 3 months following surgery. In essence, the follow up was 9 months postsurgery, which is very much acceptable as an adequate follow up in lacrimal literature.2,3 We believe it would be inappropriate for the authors to directly correlate the ostium area to the success of dacryocystorhinostomy since it is not evidence based and there are numerous
Martin H. Devoto, Francesco P. Bernardini, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Martin H. Devoto, M.D., Consultores Oftalmológicos, Arenales 1611, Piso 4, 1061 Buenos Aires, Argentina ([email protected])
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
441
Letters to the Editor
more homogeneous distribution of the material. The 1.5 ml content of the syringe is diluted with 0.5 ml lidocaine. This has the double purpose of making the procedure virtually painless, and facilitating the injection of a more fluid filler than the original one. It may be possible that this has helped us to avoid granuloma formation. Calcium hydroxylapatite (Radiesse) is indeed a powerful filler for the correction of periorbital hollows, dark circles, and lower eyelid bags. We have stated in our report that the advantage of this material is not limited to the absence of Tyndall effect, but more importantly that it avoids the risks of eyelid and malar edema inherent to the hydrophilic nature of any HA filler. Finally, its white color has a distinct advantage in improving dark circles. Concerning the advantages of cannulas, we agree with the concept that it is safer and reduces the risk of hematomas. We also believe that the tear trough region, being an area void of big vessels, is inherently a safe area to inject. We thank again Dr. Burroughs for his insight into this topic and for allowing us to further discuss the use of calcium hydroxylapatite in the rejuvenation of the periocular region.
Marco Carifi, M.D. Monica Morandi Gianluca Carifi, M.D. Correspondence: Marco Carifi, M.D., Department of Otolaryngology, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli” (A.O.R.N. “A. Cardarelli”), Via Antonio Cardarelli 9, 80131 Naples, Italy ([email protected]) The authors have no financial or conflicts of interest to disclose
REFERENCES
The authors have no financial or conflicts of interest to disclose.
1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Chan W, Malhotra R, Kakizaki H, et al. Perspective: what does the term functional mean in the context of epiphora? Clin Experiment Ophthalmol 2012;40:749–54. 3. Cho WK, Paik JS, Yang SW. Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2013;270:535–40. 4. Feng YF, Cai JQ, Zhang JY, et al. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521–7. 5. Mohamad SH, Khan I, Shakeel M, et al. Long-term results of endonasal dacryocystorhinostomy with and without stenting. Ann R Coll Surg Engl 2013;95:196–9. 6. Yigit O, Samancioglu M, Taskin U, et al. External and endoscopic dacryocystorhinostomy in chronic dacryocystitis: comparison of results. Eur Arch Otorhinolaryngol 2007;264:879–85. 7. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: “Use of Mitomycin C in Dacryocystorhinostomies”
Reply re: “Use of Mitomycin C in Dacryocystorhinostomies”
To the Editor: We were interested in the recent article from Kamal et al.1 regarding the use of mitomycin C during dacryocystorhinostomy. We read that patients diagnosed with epiphora secondary to different etiopathogenesis were enrolled, including patients undergoing surgery following previous surgical failure (redo dacryocystorhinostomy). Moreover, both external and endonasal approaches were performed, and the authors wanted to clarify the criteria they adopted to choose the type of surgical procedure. Although the study reports on the authors’ experience in the time period they investigated, we fear that the information provided may be of limited clinical interest. In fact, the case-mix might be different in other settings or even at the authors’ institution in a different time period. The specific etiopathogenesis of the nasolacrimal duct obstruction, the surgical approach (external versus endonasal), the application of a stent, and whether the case is naïve or a redo are important prognostic factors.2–6 The reliability of the reported outcomes might have also been affected by the follow-up length, which was very short for a considerable proportion of the studied patients. Lastly, mitomycin C injections were performed all around the ostium and its morphology assessed as a outcome measure of functional success; however, it would be important to read details regarding the ostium area, which has been reported to directly relate to the likelihood of success of dacryocystorhinostomy procedures.7
To the Editor: We appreciate Drs Carifi and Morandi for their interest in a surgical technique we had recently described1 regarding the use of mitomycin C in dacryocystorhinostomy. Many of the queries raised have already been discussed within the article; however, we thank the authors for this opportunity to redress certain important issues in greater detail. While we agree with the fact that the patient group was heterogeneous with different approaches, the significance of such consecutive patient inclusion with regard to clinical practice implications cannot be entirely discredited. The letter later mentions, “In fact the case-mix might be different in other settings.” This we believe is a contradictory statement to the query raised itself and precisely answers why we chose a case-mix that spanned the spectrum of varied etiopathologies and approaches. In addition, a subset analysis of each end of this spectrum has been provided, facilitating surgeons to draw their own conclusions based on the subset(s) most frequently encountered in their clinical practice. The patients had a minimum follow up of 6 months following stent removal, which was performed at 3 months following surgery. In essence, the follow up was 9 months postsurgery, which is very much acceptable as an adequate follow up in lacrimal literature.2,3 We believe it would be inappropriate for the authors to directly correlate the ostium area to the success of dacryocystorhinostomy since it is not evidence based and there are numerous
Martin H. Devoto, Francesco P. Bernardini, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Martin H. Devoto, M.D., Consultores Oftalmológicos, Arenales 1611, Piso 4, 1061 Buenos Aires, Argentina ([email protected])
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
441
