 things all of my fellows have put together over the years so it's like an agglomeration of three or four people as they were reading their books to study for their board review right or their board test I they just came up with the questions that they would ask or they would think would be important so and I think it's pretty helpful as far as that goes so all right this is not one that's like hold on I want you guys just to talk but I was going to give you information we're to that point of where when's your real cap yeah so this is just Peru memory eyelid cancer simulates a chalazion yeah how long do you usually take before somebody is diagnosed with the sebaceous so it's like is it like three months six months some studies say ten months even crazy right because people just keep treating it in the busy clinic and then all of a sudden they realize wait this isn't going away they biopsy yet and then why does it look like papillar conjunctivitis so this is really important there is some question of how you do biopsies on this now but map biopsies for your sake looking at your book look to me like that's what they still recommend and often you'll do a sentinel node biopsy as well with this so extension with sentinel node biopsy tissue handling staining those are big and yeah they'll actually they can actually do a study that shows them where it's draining and they go to it yep so typically it's going to be right here but they'll actually do a study to see and these are so what they deemed where the most important things are in red so why are cells vaculated on the slides classic look at how it distorts your architecture this is a good so does this work okay which glance do they come from so think about that it's also Zeiss each time i look at that i'm like oh yeah that's right most common location that's how i think of it i don't know this is really true but there's more what is it is it 40 and 20 so depending on the studies you looked at you look at some say like 60 and 30 some say 40 and 20 but there's about two times as many for the good dimension yeah so usually neuroblastoma is when they'll give you a bruise there was an infection that you hardly ever see anymore they used to do this too hemophilus yep so they burratto and then also but realistically here i would think neuroblastoma so the rap is in there as well derived from so these are from the same cells this does not come from the recti it does not that is a very important distinction management came on radiation if you have an isolated rhabdomyo sarcoma to the orbit and you treat it with radiation in most studies what is the prognosis 95 cure really good so if it's not isolated to the orbit though they're going to get that once it once it leaves the orbit or once there are meds a lot worse but i would say here i would still think of this the bruise doesn't make you think of a neuroblastoma if it's bilateral neuroblastoma what would the age difference between rhabdomyo sarcoma and neuroblastoma yeah so i usually think of like two and eight so rhabdomyo sarcoma around eight neurons usually around two stain for abnormal cells desmond you tell is superiorly located why because you have displacement downward right so you have x-up thalamus and downward displacement of a globe and it's the kind of stuff so most common is embryonal right eight percent of cases location spiron nasal specifically superior spiron nasal is the most common survival is good again 94 95 with isolation to the orbit most lethal is aviolar which is usually inferior 10 survival that's a bad one okay and then bad survival is pleomorphic look at that so it's i've only seen this one a couple of times i've seen this a bunch of times i've only seen this a couple of times everyone might know this but there's a really good mnemonic everyone has embryonal awful alveolar and please give me a pleomorphic for like the different types of like you know what they're known for that's great it's an awful questions but just in case you guys haven't read that very very good i'd like to say that again so everyone has embryonal so it's the uh it's the most common awful alveolar the most lethal and then please give me a pleomorphic because it's the best right diagnosis that's a great way of thinking about it Chris Baker thinks we're killing that man all right so let's see let's do orbital wall bones which had the spinoid wing all except for the floor right what's the floor made up of psychomatic what's that last one yeah the palatine the none ever sees right it's a little tiny bone in the back okay so roof lesser wing okay mea candle swallowing in an infant okay it's above the mea candle tendon what are you considering what are you worried about what's the differential on it yeah anything that was still hanging along those lines right so you want to get MRI do you want to probe that as it's been done you know when this usually happens is when someone has them multiple craniofacial anomalies and why would you probe a kid urgently like in an icu or something like that infant they're obligate nasal breathers right so about 30 percent of nasal alachema duct obstructions will also have a sac that goes into the nose blocks off their way they can't breathe so a great question i think would be a two-day-old baby is in order to be in respiratory distress and they have bilateral mea candle swelling what do you do i don't show there's a person makes us what i was doing but then you probe it it's blow let me look at the tendon it's sometimes bluish not always what's the management of a deckers is to seal so massage is a typical thing it's interesting how many of these you look at most studies i can't remember what your book says but a lot of days will show these things get infected but if you can reduce it just by massaging it that's great a lot of people advocate if there's any question at all these are causing any breathing issues or if they at all are getting read or anything you probe them pretty pretty quickly daggers it's still you have a blockage where superiorly and inferiorly right that's exactly what you normally would do unless it looks like it's problematic and then i can tell you so i had a colleague he was a pediatric ophthalmologist he read our main satellite and that guy can get these things to go away he was just like massage times one minute yeah he does you remember uh what's campus oh yeah yeah so what about there handbags first let it cool off and then probe it i let it cool off first why because you get more nasal you get more false passages probably and then also the infection gets spreading through is my thought but that's a general consensus you admit you might have calmed down on that problem okay forest highly closure is the orbital portion fairly closure retarcell okay mussel how many millimeters of elevation you typically get if you do a mularectomy yeah is a mularectomy considered a reticle in the acroplastic world no it's not two millimeters of the average where does it insert that's the superior border of the tarsal plate right inserts where so i think this is a great question so any any guy to come up with these my fellows did it anytime i'm cutting down onto the anterior surface of the tarsus i'm cutting there upon uruses i'm cutting the limiter right but there's so many attachments it doesn't make a difference it's the inferior one half of the anterior tarsus so if you've got a question that said if you take a pin and you stick that pin through the lid at like two millimeters above the eyelid margin if you see the aponeurosis listed underneath the obitularis then that's the answer right a lot of times it don't list this and i don't know why because that is a critically important thing to mention so most of the time you'll see the books will say it goes through skin orbicularis then tarsus and then conch it's actually not exactly right it's skin orbicularis upon uruses then the tarsus and then the conch right so if you saw that now you remember that thing's attaching down there it's like people don't even mention t-nots or something right so this is stuff he's got to memorize so intraocular millimeter to orbital this becomes a big deal for me like when i'm doing an obstinative glioma resection or something like that or a nucleation if they have a intraocular tumor or something i want to try to give as much of the nerve segment as i can so nix says to me he has 22 millimeters or 25 millimeters of obstinerm on x-weights that's pretty good but you know if i have like two millimeters on them like if i see that more you should kind of look at their nine right and then intracranial 16 obstinator segments okay which segment is the most susceptible to injury with blood trauma to the head so what do you get oh shoot it's just obstinoropathy right traumatic obstinoropathy um which bone makes up the optic canal it's a lateral there a contralateral nipple oh that's a good way of looking at it okay so okay so is it is it anterior or posterior okay is it lateral or medial lateral you guys are going down but then it's also posterior i guess the way out in lateral is lateral though from the punctum it's lateral from the punctum because think about where your turbinates are think in your nose just follow your nose trajectory it's going to go down like this so that's how it will go so if you think of where your turbinates going to be that if you're a turbinate this lateral nipple where does this go which nipple is it so that's awesome where where does this enter where does the nasal angle duck enter in the nose if you're amniatus when we do a dcr where do we put that new hole amniatus right big difference well bones you're removing when you do it in a dcr the anterior lacrimal crest and the posterior lacrimal crest is essentially right so what makes up the anterior lacrimal crest what makes up the posterior lacrimal crest are important okay so let's do canaliculitis pretty classic looking they call it a pouting punctum or whatever usually i just see some pus right here and then i see some red surrounding it right this is the most miss thing i ever see next to probably thyroid eye disease what's the number one sign in thyroid eye disease most common finding eyelid retraction it's like list one through 50 right eyelid retraction so canaliculitis though almost every time i see this the person will say i've been to like five different people right it's probably similar to i just keep treating a dry eye and then i find out they have like a critical dystrophy or something um usual bacteria genomyces israeli right okay which muscle is not affected with your retrobobar block so these are just good to know what are the possible complications of a retrobobar block respiratory depression yeah so it can have permanent diplopia from it right open globe yeah all those things um diplopia is actually a relatively common one that doesn't go away so i haven't maintained encyclotorgy okay structure between the greater and lesser wings of the sphenoid okay it's growth of fissure right structures that go through this growth of fissure it's time so before we digress what i'm doing something surgically and i'm even right back there this never crosses my mind has never never will all i know is i don't want to get into it all right so i'm much more worried about my planes i'm much more worried about if i can see i'm much more worried about what i'm doing then having some academic thoughts in my head as to what is there that whole area back there's bad you just want to stay away from it all right but you have to know these that i know it's great there's a bunch of mnemonics for all the stuff i would recommend that's a good one yep and then is a squared is it insights into is it the sympathetics there's an at somewhere you get nasal squared yeah because of nasal squared okay okay and then look i'm actually gonna say football team tell them what i do like think of the lfts are out so all those will help you just think through it and if anybody wants i have a good have a good power point on that that has all those mnemonics and if you wanted to see my meals in it yeah that's a lot of fun stuff right there so this is why let's get into this for one second okay let's say somebody has a bb oh i don't know like right there and they ask me if i want to go chase after it and they're 2020 and they have no deblopia and they have no issues whatsoever but they have a lawyer but they have a lawyer do you think i want to touch that no i don't think anybody should touch that and the general consensus is you don't so if you have an interactive form body like a bb and it's not causing any problems then you don't do anything with it because the chances of you giving that person problems coming way back in that apex like that is crazy high if they didn't have to deblopia afterwards i would be shocked or they'd lose some vision so thinking through things is helpful so branch of which nerve of family division one branch into what super orbital instrument real clear maxillary nerve grab that McBain all right this i think is really really important and we do surgery like when i do a lot of combined cases with ent these days so this is awesome so to get back into the sphenoid sinus they do it through the nose which is really cool what sinuses yeah it's a sphenoid right so if they have like sweet they have the sphenoid if they have really really bad sinusitis right to their sphenoid i can start to actually affect things pretty quickly right so i think this is a really good question because your basic science book on your whatever you call your orbital book i read that thing over christmas right spain falls well written now it is very well written so i'll tell you there's one thing i disagree with in that book but then i'll tell you and this is where you should know for your test i think so medial pretarsal is the angular vein right lateral pretarsal is a superficial temporal and then the orbital veins deep branch and your facial and material plexus here's a picture of it i think just having a general understanding of that drainage is important so i'll tell you so in that book it says to image the orbit ct is the imaging modality of choice it's not in my opinion i like an MRI for anything that's truly in the orbit itself now the book does say something in the apex you want to use MRI which i agree with and i think for trauma and for how to mean the ct is obviously superior but i think the answer for you is image modality of choice you don't know if the ct scan initially on an orbit if i'm trying to see what something is i can be able to add enough information or something like that and i can never write no question orbital septum where does it come from what's the structure it's from it's off the periostean where is it fused in Caucasians this is hugely important in surgery hugely so to the elevator about two to five millimeters above the tarsus so when you see any of us make an incision through their lid crease which is going to be at about 10 right in a woman it's a 10 the guy is typically what in a Caucasian 8 centrally right so 8 centrally in a man 10 in a woman you make that incision that means the septum is quite a bit above that so if you cut through and through it let's say you're at 10 right and you cut through and through we're going to go skin or vicularis then what are you going to have their leafator right because the septum is stopped and then the leafators there and then you're going to hit something really fun what are you going to hit their peripheral arcade because it runs right on top of the tarsus right and then you're going to hit the miller's muscle and they're going to hit their cons and all of a sudden you look in their eye so anytime we make a lid crease incision we are always angling like Murray what do i do every single time so we'll always pick it up we pick the tissue up right so i always grab since i use my right hand i always grab for on the right side i grab the bottom portion of the incision you grab the top portion and you tent it up i pull it straight back you tent it up and i go in and like a 45 degree angle that allows me to go through the sub it's a retrovicularis plane is what it is you're going underneath the ovicularis in that basically that the stuff is on top of the ovicularis muscle right and then you're getting to the aponeurosis or not the aponeurosis you're getting to the septum and you're opening it so you'll never see any of us go straight through the lid crease and just keep cutting straight through right there we're always angled the one exception is if you're trying to get to the top of the tarsus then we'll make that incision then go through the ovicularis and we'll aim down actually to go to the tarsal plate like we're putting in a gold weight so that to me this is critically important to understand is it fused to the so the orbital septum comes down does it fuse to the like the aponeuroses of the levator that's essentially we're going to be hitting on because by then the muscle is transitioned to the aponeurosis and is it like i mean i guess does it come down and it's i would assume it's like the anterior portion of the aponeuroses it's the anterior portion of it and the septum to be fair is like multiple onion layers so the books draw it's like one like structure almost like a muscle it's actually multiple it's like multiple amela but you can think of it as one structure just to like simplify and make it make sense but just realize the reason it has to stop there the reason you have a lid crease is because this does stop higher and then the levator fibers can come forward and give you a lid crease in a classic asian lid it doesn't do that and that's why it comes down much much inferior when we're talking about there in a second it comes way more down and that's why the lid crease is lower it all has to do with where the orbital septum attaches so it's huge in the previous slide it says that the levator fuses to the anterior portion of the tarsus so does it have like fibers that go there and onto the skin so the septum comes so the levator now comes out of this so so septum comes straight down like this right so the septum comes straight down the levator is going like this right septum hits it right here and then on the anterior surface of it and then that allows the levator fibers to come forward and attach down onto the bottom half of the tarsus but what about the actual lid crease the lid crease it says it's for it the fibers go anterior to the orbicularis muscle so it's both that the levator fibers so it's got it's got multiple attachments and that's why if i cut through that the lid doesn't become tonic because there's multiple attachments and insertions does that make sense i didn't get that for forever but that's why you have to aim up and i think this is like one of the most important things you'll learn from this whole lecture is understanding that in the upper lid that septum stops because the levator is coming it's coming at this angle so the septum is coming straight down the levator is coming like this hits into it that then allows the levator to send its fibers everywhere and that's what gives you crease and that's what goes to the inferior border of the tarsus and that's how you pull it is anybody want me to talk more about it good one other question about the so like i know that one of my friends sisters she's asian and she had surgery to like create a crease so what what is that surgery exactly what do they do so actually to do that that's a very very common procedure that's performed so you would make an incision in the lid where you want to put the crease let's say it's a woman i'd say it's a 10 and you would have this discussion with them very very clearly beforehand so you make that decision at 10 where you want it through one at two you go through the obi-cularis right you get down to the septum which will be really low because it comes all the way down onto the tarsus which is way low you open that up to expose in the levator and then all you do is just take a bite of the skin to the levator at the height you want the crease to be at and then a bite of the bottom skin that makes sense so you've got your incision here you take a the bite of the top portion of the incision the skin and then you go through the levator you have to attach to the levator right where you want that crease and then you attach it to the skin but it's pretty easy to do because essentially if you've made your incision right where you want your crease to be once you open up your septum the levator will be right there you just make the bite right there it's not heart surgery at all frankly it's a very lucrative surgery so does that does that make sense are you cinching the the um the septum then? no you just open it oh you just open the septum and you leave it why why do you not recruit why do you not put the septum into the suture scar but what will it do? lack of families they won't be able to look down right so the septum is really strong when it comes out of the periosteum right so it's a very strong structure and the way you can tell interoperatively if you have it or not what do you do start on it you say look up look down look up look down the septum will not move if it's the levator they look up and down it'll move it's a huge it's a great way to tell nothing there's times I can't tell doesn't do that's like a weird one uh and then on that skin you have to leave with a bluff tougher bluff okay this is hugely important that's a bare minimum right and I see this violated all the time and then the brows like like this there's like no skin there and I can't close their eye really important okay so then here I'm actually showing you the incision uh okay doing a lower lid bluff you have to be careful when removing the fat because what is positioned between the blank and the blank fat pads so when you do this I'm gonna go through this with you a little bit so when you do this when you do this surgery and you're trying to these days most people will only debulk these a bit and then they reposition them in the tear trough right and either a sub periosteoplane or a pre periosteoplane so what they've done is they've they've elevated this mass everything all those muscles will move your face right and then you just stick the fat down in there to try to get rid of the tear trough to make this a safe procedure what has been more recently described and people are doing is they actually will move the two fat pads because they're contiguous right and you should be able to go like this they call it reverse shoe shine technique as an api master give it you just you move it and you should be able to freely move because there's a bunch of adhesions between these fat pads and that oblique muscle so you want those all gone you'll see if you will do that with a cottery I think that's crazy you can damage all the tissue there right so like a q-tip we'll totally separate that right up just one nice section that's important because if you hit it and they get torsion all the plopia it's extremely hard to fix all right three main causes of anvilish lantropion you have to go I think rubbing might be one of the reasons they got it right oh more than a laxity okay disinsertion of the lower eyelid tractors of a rhinovicularis okay so you need to correct all three of them so how do you fix this I think this would be a great question how do you fix that it's the same thing as an epiblophoron as well by the way same idea so lower trussle strip but then you have to advance the retractors how do you do that what do you make your incisions infracellary right because the way you're going to get to the retractors infracellary so that gets you to the retractors which means you have to open the ubiquularis and the septum those muscles are always under the septum so you open the septum and they're usually disinserted by like a centimeter or so they're usually pretty far down it's crazy so you find them you reattach them and then you also do a lot of trussle strip because you have this laxity right what can happen if the retractors are retracted so much and you reinsert them what can you get out to the surgery yeah the plant can have this position about what millimeter is higher than the so where is the pervarkate we just talked about this yes and exactly where is it superior to what yeah so think about think about a pin and the key that's so hard for me to get this is some structures are going straight down inferior is superior to inferior right like the septum is straight down the levator is going like this everything else is going like this so and then the tarsus is going to be relatively like this too straight up and down so you have to if you think of it from a side profile i think it'll be easier for you in your head to picture what's going on and where thinnest bone a thinnest portion of the maxillary bone and orbital floor so where is the most commonly fractured right there most commonly fractured orbital bone the floor the ethmoids actually the thinnest right the laminate pervrisha but this actually the most common places you fracture so so this kind of stuff you see you do right so the big ones you're going to see are mucor and then aspergillus aspergillus will often actually be more of like an allergic aspergillus i used to see this in kids all the time in houston bridge you see this a lot houston might you see this houston uh this will just like just like i was better i mean this is literally it's like excuse me now it was brown just like peanut butter and the consistency peanut butter disgusting stuff it's usually an allergy okay what should you what should you not use entropi could somebody describe what you see here i don't know what you see here just know you didn't understand they've got some weirdness going on here you just did your internships it's probably a right bundle branch block guess just did you receive utah's intern here what an amazing year here's what i'm saying if you see some weirdness on their stuff you want to avoid the monopolar connery just don't use monopolar monopoli you gotta be careful i think it needs a piece he has a piece but he has a piece and you can't use it with a pacer yeah so you have this uh yeah this is what you do on the holidays so you don't have to worry about this all right what's the mechanism i actually have lied to came right this is so irregular sorry jenna walker right okay what's the mechanism actually botulinum toxin inhibits release of acetylcholine and the neuromuscular junction these things are important so clustering of botulinum gram positive or negative so angiolachymalcrest botulinum toxin right okay where is she be entering let's see that's just maybe happy yeah maybe i saw something so i asked the resident once we were doing they reminded me of doing like an endoscopy of your other right i asked the resident what time we're about to go do surgery on one of his herbations right and i said what is a blepharoplasty in here she said i don't know but i know you use an endoscope i want you to show me all right anyway dcr four weeks post op okay and this can be the same for any lid surgery yes do you see this you do fun times fun fun times to get that treated they're on stuff for months and months and months trying to get rid of that okay so what do i do for this yeah i get i d involved we figured out it takes some months to clear it it's a bad deal you don't see it much but when you do it's horrible what it does you just keep getting more and more of these things all over their face so something that occurs about a month later these are thinking about things like atypical mycobacteria if it's if it's a cue it's going to be staff or strap and it's extremely rare but if it's a month out atypical mycobacteria orbital mass what's going on in one time women even if it's unilateral yeah it's thyroid eye disease a unilateral disease it can be very very asymmetric right and then an adult's bilateral thyroid eye disease in kids it's actually what we're saying is so all right in large extract and muscle and imaging and i remember this slide oh yeah tendon sparing what tears sparing what spares tendons tendon evolving i run into this all the time so this becomes a big deal when i'm trying to get rheumatology to treat this and these days rheumatology will be treating this too right with temporal tumor map i haven't just got FDA approval so that's pretty cool by the way does it work uh studies look pretty good yeah yeah so the thing about this this is important and these are relatively what what's the mnemonic for knowing the order of involvement in the muscles right actually does follow that pretty well okay so steroids are initially what we do with this typically an orbital pseudo tumor with the exception of ITG formulator disease which we think is the equivalent of what we have called sclerosing pseudo tumor for many years but with the exception of sclerosing pseudo tumor or ITG formulator disease they're usually very sensitive to steroids i expect them to respond within 24 to 40 hours max okay you don't need to biopsy it initially that's a big deal if you're on scan if it looks like non-specific global inflammation you can do a steroid trial that is considered reasonable and you do a systemic work up if they don't improve or if they rebound right once you come off the steroid and it was a if you did a slow taper and they come off of it and the disease reactivates then that's when you do a biopsy and a systemic work up right i actually think that's a very safe way to go if if you have a good CT or MRI that shows it looks like a specific orbital inflammation it's a safe way to go it's unilateral if it's bilateral you gotta consider biopsying it would i ever biopsy both orbits simultaneously never ever ever would i do that why would i do that what's the advantage to doing that lower eyelid structure analogous to the levator in the upper lid rises from the inferior rectus okay inserts where so it's just a little different right it's on the border of the lower tarsis whereas so kind of more like what muscle right and that's just one major difference traction after you do it if you're just recession right so this is why in thyroid eye disease you do a decompression first and then you do their strabismus and then you do their lids this one the major reasons why right some of the abs i'm slow demonic usually involves your inferior rectus right okay okay so wolf ring non-marginal tarsis borders right and they crowds is in the corner right fantasies yeah how everyone wants to remember this they are excellent plants okay but i can ask you something i'd ask you this kind of stuff so if it's difficult to manage a cannula and it refluxes through the same kind of liquefus that means you have narrowing right there right so you go through the pumpkin you can't push your cannula and far enough how many millimeters should it go in about eight right because it the pumpkin you have two it's two down then eight over right so you go in let's say you only get in like three millimeters and you can't go any farther and then you try to irrigate it just comes right out that same cannula so that's even pumped in that you were in right and that means you have some cannula scarring so where your options to fix that picture lower and they're tearing like crazy you have two options really cdcr is where i would go you can also try to cut out that scarring portion and put it back together and just put tubes in like a croffer tube right my experience with that has been it works if they only have little scars there's a guy brian beesman's one that blacks people around here he does a ton of that stuff he has good results but i think he figures out kind of if they only have a small portion that's like a stenotic area or something then that's how it works for him and he basically just marks it off as he goes in he marks up where it stops he cuts it out and advances it cdcr be a very reasonable answer right there okay difficult to advance and you get reflux for the opposite cannuliculus how many percent what percentage of people have a common cannuliculus yeah 90 right able to advance in the sack but you have reflux of saline and americamucoperyland stuff it's gonna be these lackable ducts right because the sack you actually know you have some sort of blockage down farther most common epithelitumor of the lackable gland benign mixed tumor clemar forget know my how do you treat it complete excision why you can as a malignant right this is a good remember complete excision most common auger finding a Parkinson's disease yeah decreased blink how that affect my world well if they have a reduced blink rate and they command because they have ptosis or dramatic laces and they live in utah with our dry climate i need to be really careful right i'm going to raise our eyelids so conversation you have to have before and end most common primal legacy of lackable sack sack organism responsible for necrotizing fasciitis there are many things that can cause it what's the most common how do you treat it so these days IV antibiotics are used you admit them and then limited debulking on the lids as little as you have to do so you're preserving as much tissue as possible i hardly ever debulk a whole lot of these of these these days because the IV antibiotics are so good but the answer is essentially you keep cutting tissue way until bleeds right all the tissues dead and bad so you do okay it's the same for something like mu core you just keep cutting until bleeds i teach you just dead marcus gun jowl winking oh man somebody pinned me on this one day so let's go back to that they're going muscle so and so what happens they move their jaw they go into lateral contour a lot of how's it change external pterigoid raises the eyelid and internal closes it just so i think that's actually so if they go to the isolato cycle usually happens kind of goes tautic and then you go to the other side it goes retracts my bomy glands locations pure and your tarsus so they're superior more they're spacious it's kind of something about every day it's so exciting you know what though right okay 30 cc is volume the widest part is one centimeter posterior to orbital rim so why does that become important for me well if i'm draining a roof abscess orbital roof abscess right if i make my lid crease incision on my brow incision or whatever i'm doing let's say do a brow incision okay and i'm coming down and i cut the periosteum and if i just go straight back i'm into orbital contents who knows what right whereas if i aim up deeper then i'm going to get into the actual plan i should be in so you don't want to be poking straight back because that makes sense you want to be aiming up and it's really weird because think about it you're aiming fill your orbit fill how far back that goes up you need to be aiming it's really it's kind of an awkward angle so i actually move and i come so i'm looking at the patient like their heads here and i'm looking up and i do it that way it's an easier approach but that's actually very important for that surgically to know that shortest wall so when you see people have a floor fracture and it involves all the way back to the inferior orbital fissure that's where it ends when you're fixing the floor fracture you chase a posterior edge no you don't because if you chase a posterior edge what are you going to put the implant on what's back there you're going to be back in their apex right by their optic canal does this happen all the time like all the time the implants way too big and then the person will say stuff like when i look up i get this real dark spot my vision is crazy right they're too long so you don't chase that posterior ledge if it's a if it's a fracture that only involves the middle portion of it then fine you can find that posterior ledge which don't keep dissecting and try to find the posterior ledge it's not there how do you know if there's a posterior ledge you look at the sagittal view before you do the surgery i mean if it's a huge fracture they won't have a posterior ledge does that make sense so if you fixate it immediately laterally and then superior anteriorly there's plenty the implant's not going to go anywhere right over lymphoma most common location lacrimal gland fossa vast majority are of which type non hodgkin's b-cell or malt lymphomas very good prognosis how do you say in the biopsy yeah fresh why for flow cytometry right specifically here at the university of Utah i have found flow completely utterly worthless they always tell me it's poor viability doesn't matter how much i send them it's like but it's the standard of care a lymph operative lesion arising in this proactive site gives the highest risk in developing a systemic non hodgkin's lymphoma i think that is a great it's not the lacrimal gland fossa locations of island basal cells list from most of the least common locations so lower me you can't this upper lateral can't this tire tire yeah i think that sounds right yeah yeah it is actually right yeah that's a good way to look at it so but now what side you're looking at right this is where you can get into trouble with the basal cell if this gets back into the orbit that's a problem what's the drug you can use now if you have somebody who can't have surgery and you're worried about trying to control you have his monogib is a sonic hedgehog inhibitor i'd be aware of it that never one side effect side effect if skin changes in the air loss later on on the island most important prognostic factor for patient survival it's always going to be the depth right these oda risk of you know my 1 in 400 what percentage giga coma 10 risk of you know i'm uh six in a million can't you know island ever malice sorry i'm going super fast because we don't have much time i had a whole other lecture for you too um so this what is this specifically this is an epigliferon in a kid right how do you treat it the same way we were talking about this overriding orbicularis you make that infracellular incision right here get the majority of these kids need surgery or can you watch the majority watch okay why why can you watch it it's a lower lid if ever the upper that was doing that you'd probably have a much bigger problem because the excursion of the lid but as their nasal dorsum grows as their nose grows it tends to actually pull that whole region into a better position so a lot of the kids will grow out of this same deal we talked about right so let's see oh what's that how do you treat that it's awesome he's cut the thing um this inseparate so then what's this how do you treat a urethra you can try this that's what i would what i would do is pull on this just like i would to see if like you have a cicatricial versus the involuntary tropion right i would see how tight this is and you could consider a lot of torso strip you might have to do a skin graft right here and you can't in a kid you really can't do like a mid-face advantage or anything it's not as if the mid-face descended they still haven't a fancied lamella right so now let's do classic condition is it blepharophimosis ptosis epicanthus inversus telecanthus right so almost invariably these kids need that lids raised let's see how much brow recruitment there is here and then usually you can do treatments here too so you do need transnasal wiring is a good way to do it i actually don't do that i do a little icky sign incision right here um i just learned from watching a cool video on a yo's website it's great and you just you tuck that in used to be they did that little like the little man victor right here you just bring all that stuff in multiple incisions it looks terrible but a small little swish right here it can get rid of all this stuff it's pretty nice so it's interesting i've only seen that in a couple of people so and it is as i have one family like every single person has that but then the majority of ones i see are sporadic so and then this is based on your book i don't necessarily agree with all this but it is what it is right so if i have a defect it's even 90 percent of the lower lid i'll still do a tensile flap i take it all the way over so i was at a conference where gt period was describing that i'm like that's what i'm going to be from now on instead of doing a uh a one instead of doing a hues flap right so hues would be if you're doing the lower and then a kelly beard to be if you're doing it into the upper from the lower like sense so direct closure again these numbers are really arbitrary because if you have a young person they have a 33 percent defect i can't close that directly i can't they're too tight like if i try to do that in any of you i don't think i could get it closed i think you're literally probably going underneath your eye particularly if you have a negative vector right so if your mela region is is less than your eye protrudes it's probably going to go underneath your eyeball right so i don't think that's an ideal but anyway for 30 50 lotto can thought of me in semi-circuit flap or tensile right and then debugger than 50 cut the beard for your intensive purposes that's what i would say realistically for me that's still a tensile flap i only do a hues flap if i know so you only do a hues if it's like more than 90 percent and then i would do all kinds of other stuff over your intense purposes that's what you do thyroid disease are responsible we're okay fibroblasts right so what do you get the cosinic like it's right more common in females very good most common scene that you're fighting is the libretraction right okay we're almost done we are not actually so okay so i think all that stuff on there is important to understand the gland things are just easy and it's so when i said the okay i thought this stuff was like a joke nobody cared it didn't matter they care a lot now so just do your best as far as like fellowships and stuff go it's the only time in your life when you can actually like dedicate this much time to studying it's hard because you're busy on calling stuff do the best you can it's worth it so steady hard and just for that kind of stuff all the question answers are supposedly in the basic science book tips down used to be my chair is the chair of that okay committee and every and he makes it very clear every question comes