title: Aesthetic refinements in the treatment of graves ophthalmopathy.
abstract: BACKGROUND
  Graves ophthalmopathy is a chronic, multisystem, autoimmune disorder characterized by increased volume of intraorbital fat and hypertrophic extraocular muscles. Proptosis, impaired ocular motility, diplopia, lid retraction, and impaired visual acuity are treated with orbit decompression and fat reduction. The authors present the addition of skeletal augmentation to further improve periorbital aesthetics.
  
  
  METHODS
  Through a transconjunctival with lateral canthotomy incision, a balanced orbital decompression was executed, removing medial and lateral walls and medial floor. Intraorbital fat was excised. All patients underwent placement of porous polyethylene infraorbital rim implants and midface soft-tissue elevation, increasing inferior orbital rim projection and improving the globe-cheek relationship. From 2009 to 2012, 13 patients (11 female and two male; 26 eyes) with Graves ophthalmopathy underwent surgery at two institutions. Outcomes were evaluated for improvements of proptosis, diplopia, dry eye symptoms, and cosmetic satisfaction.
  
  
  RESULTS
  Postoperative follow-up ranged from 0.5 to 3 years (median, 1.5 years). The mean improvement on Hertel exophthalmometry was 5.4 mm. Diplopia resolved in three patients (23 percent). No patients had worsening diplopia, and 12 (92 percent) discontinued use of eye lubricants. All patients had cosmetic satisfaction. One patient suffered temporary inferior orbital nerve paresthesia. There were no infections, hematomas, or ocular complications.
  
  
  CONCLUSIONS
  Skeletal augmentation is a useful adjunct to orbital decompression and fat excision for treating Graves ophthalmopathy. Balanced orbital decompression with infraorbital rim implants is reliable, effective, and safe, with good, lasting results. Resolution of ocular symptoms is improved, as are the patient's personal well-being and social life, with a high-benefit-to-low-risk.
  
  
  METHODS
  Therapeutic, IV.
authors.affiliation: Cleveland and Cincinnati, Ohio; and Boston, Mass. From the Department of Plastic Surgery, Institute of Dermatology and Plastic Surgery, Cleveland Clinic; the Division of Plastic, Reconstructive & Hand/Burn Surgery, Department of Surgery, University of Cincinnati School of Medicine; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital.
authors.forename: Gaby
authors.initials: G
authors.lastname: Doumit
authors.forename: William
authors.initials: W
authors.lastname: Abouhassan
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Yaremchuk
mesh_terms: D019299:Decompression, Surgical / Q000379:methods; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D049970:Graves Ophthalmopathy / Q000601:surgery*; D006801:Humans; D015187:Lipectomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009915:Orbit / Q000601:surgery*; D019736:Prostheses and Implants; D019651:Plastic Surgery Procedures / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome