Defining Ideal Double Eyelids With a Morphometric Analysis in Asians

BACKGROUND

Double eyelids are always considered crucial aesthetic symbols. Despite numerous studies conducted on the attractiveness of double eyelids, there remains a dearth of research on quantitative and morphological evaluation of ideal double eyelids.

OBJECTIVES

In this we study aimed to investigate the optimal height and morphological characteristics of ideal double eyelids.

METHODS

Participants were presented with a total of 9 images, consisting of 1 single eyelid image and 8 double eyelid images, featuring 2 distinct shapes and 4 varied pretarsal shows. Respondents were instructed to assign scores ranging from 1 (least attractive) to 5 (most attractive) for each image. Subsequently, the scores for each image were analyzed based on population demographics, followed by the calculation of aesthetic metrics.

RESULTS

The whole cohort deemed images with a 2-mm fold to be more attractive than 1 mm (P < .001), followed by 3 mm and 0 mm (single eyelid), and finally, 4 mm. Morphologically, significant differences were found between images with the same pretarsal shows of 3 mm (P < .001) and 4 mm (P = .026). Most subgroup analysis results were aligned with those of the cohort, with gender being the most significant factor in distinguishing double eyelid aesthetics. Additionally, aesthetic characteristics of 2-mm folds were found to be comparable to appealing double eyelids in previous studies.

CONCLUSIONS

In this study we validated the optimal heights and morphology of double eyelids, thereby addressing the existing gap in aesthetic studies on double eyelids. These findings hold significant implications for surgical planning, effect assessment, and other periocular procedures related to upper blepharoplasty.

LEVEL OF EVIDENCE: 4

Complete Preservation of Orbital Fat by Restoration of Attenuated Orbital Septa Using an Acellular Dermal Matrix in Lower Blepharoplasty

BACKGROUND

We hypothesized that application of acellular dermal matrix (ADM) over the orbital septum overlying the herniated orbital fat to tighten and strengthen the attenuated orbital septum in lower blepharoplasty would allow successful repositioning of the herniated orbital fat within the bony orbit.

METHODS

The author prospectively compared the cosmetic outcomes of lower blepharoplasty using ADM with standard blepharoplasty. We evaluated recurrence of eyelid bulging and tear trough deformity, volume of the lower periorbital region, and enophthalmos and eyelid droop 1 year after surgery.

RESULTS

Twenty-two of the 24 enrolled patients completed the study. There was no significant difference in recurrence of eyelid bulging and tear trough deformity between standard blepharoplasty and blepharoplasty with ADM graft groups. In the standard blepharoplasty group, the volume of the lower periorbital region decreased significantly after surgery. In the blepharoplasty with ADM graft group, there was no significant change in the volume of the lower periorbital region after surgery. In the standard blepharoplasty group, there was no significant change in eyelid droop on either side after surgery. In the blepharoplasty with ADM graft group, the eyelid droop decreased significantly after surgery on the right side but showed no significant change on the left side. There was no significant change in enophthalmos after surgery for either group.

CONCLUSIONS

This study demonstrated that ADM graft provided effective support for maintaining the replaced orbital fat in lower blepharoplasty. In the long-term, blepharoplasty with ADM graft might be effective in slowing development of age-related enophthalmos.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-Term Improvement of Crow's Feet Wrinkles in Combination With Cervicofacial and Temporal Lifting: Review of the Literature

BACKGROUND

The lateral orbital crow's feet area is one for which rejuvenation is most frequently requested by patients. Moreover, lateral canthal wrinkles are a common source of dissatisfaction after rhytidoplasty. Botulinum toxin injection has emerged as a most popular, easy, and effective solution; nevertheless, repeated injections are required periodically for long-term effect. Other nonsurgical options have also been described to have some demonstrable advantages. Orbicularis oculi surgical manipulations have been described as well.

MATERIAL AND METHODS

A systematic PubMed literature search was conducted to identify clinical cohort studies including more than 10 patients describing surgical approaches for improvement of crows' feet wrinkles in combination with face and/or temporal lifts. The search was complemented by Embase, Medline, and Cochrane searches in addition to screening of reference lists of selected studies and simple term searches about surgical treatment of crow's feet.

RESULTS

Fourteen studies satisfied the inclusion criteria and were included in this review describing various muscle excision techniques including vertical strip excision, lateral partial resection, wedge resection, muscle resection in "C" pattern, and enlarged myectomy of about one-third of the whole orbital extension in addition to muscle manipulation modalities, including muscle splaying, muscle division, muscle division and splaying, muscle undermining with partial denervation, and muscle suspension. Interposition of fascia between orbicularis muscle and overlying skin was also reported.

CONCLUSION

View the few studies retrieved and the wide spectrum of reported techniques, it is not possible to determine from this review the most effective modality. Nevertheless, it seems that subcutaneous undermining of the lateral canthal area combined with splaying and traction of the orbicularis oculi muscle and fixation to the temporalis fascia with or without muscle division would yield the best long-term results. This review indicates also that surgical correction of crow's feet during rhytidectomy or temporal lift could be a positive complement to improve aesthetic outcome. Unfortunately, if not underreported, it is definitely neglected. We believe that this review may be an eye-opener for surgeons.

Rejuvenation in Men Facial Aging: A Combined Approach

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Sling for the sling: a new technique for long-term correction of severe congenital ptosis

INTRODUCTION

Severe congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect.

PURPOSE

This retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place "sling for the sling".

METHODS

The medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new "sling for sling" technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months.

RESULTS

Preliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence.

CONCLUSION

This study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

Supraciliary Incision as a Modified Approach for Asian Blepharoptosis Patients

BACKGROUND

Blepharoptosis may result in an unattractive appearance and vision problems. According to the severity of ptosis, patients may undergo correction surgery using upper eyelid retractors. The conventional incision for surgical procedures was the double-eyelid incision, potentially resulting in an obvious and unnatural scar or long-lasting edema and prolonged recovery time.

OBJECTIVES

The aim of this study was to introduce a supraciliary incision as an alternative to the double-eyelid incision for blepharoptosis correction that creates a scarless, natural appearance with a quick recovery time.

METHODS

From June 2019 to June 2021, 32 patients (36 eyelids) underwent blepharoptosis correction through a supraciliary incision. MRD1, the height of the eyelid fissure, and the patient's satisfaction with the shape and scar as well as postoperative complications (eyelid insufficiency, conjunctival prolapse, inadequate correction of ptosis, and excessive correction of ptosis).

RESULTS

All 32 patients (36 eyelids) were followed up for 6 to 18 months, with an average follow-up of 11.6 months. The postoperative satisfaction rate was 96.43%. There was no overcorrection, but one patient (1 eyelid, 2.8%) was under correction that required secondary correction. One patient (1 eyelid, 2.8%) experienced conjunctival prolapse. Sixteen patients showed lagophthalmos early after surgery, in which one patient experienced early-stage keratitis and completely recovered within two months.

CONCLUSION

Blepharoptosis correction via supraciliary incision allows for broader indications and fewer surgical scars without disrupting eyelid integrity, resulting in quick recovery after surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Application of Fixation of Orbicularis Oculi Muscle and Orbital Septal Tissue Flap at the Upper Edge of Incision in Double Eyelid Plasty

PURPOSE

In order to make the postoperative effect of open double eyelid more close to the physiological and anatomical structure of double eyelid, we improved the traditional open double eyelid operation according to the anatomical characteristics of the upper eyelid. We fixed part of the orbicularis oculi muscle above the incisal margin with the orbital septum flap to make the double eyelid formed after surgery more natural and beautiful.

MATERIALS AND METHODS

A total of 76 patients who received open double blepharoplasty in department of plastic surgery from February 2019 to May 2022 were selected as this study objects, all of whom were female. Their ages ranged from 18 to 32 years, with a mean of (23.6 ± 5.2) years. The surgical method is open double blepharoplasty by fixing part of the orbicularis oculi muscle above the incisal margin with the flap of the orbital septum.

RESULTS

In this study, all 76 patients underwent successful surgery, with an average operation time of (1.5 ± 0.2) h. The postoperative double eyelid curvature was smooth and the double eyelid width was basically symmetrical. In terms of the doctors' satisfaction evaluation of the postoperative effect, 64 cases were very satisfied and 12 cases were satisfied. In terms of patients' satisfaction evaluation of the postoperative effect, 60 patients were very satisfied, 15 patients were satisfied and 1 patient was dissatisfied.

CONCLUSIONS

Through this study, we found that this surgical method invented by us has short operation time, good operation effect, few postoperative complications and high patient satisfaction, which is worthy of promotion and application in plastic surgery clinical practice.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to www.springer.com/00266 .

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients

BACKGROUND

With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty.

METHODS

Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction.

RESULTS

Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome.

CONCLUSIONS

The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary blepharoplasty.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision

BACKGROUND

Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids.

METHODS

We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months).

RESULTS

The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations.

CONCLUSIONS

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparisons of the Fusion Point of Orbital Septum and Levator Aponeurosis in Patients with and Without Mild Ptosis

OBJECTIVE

By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis.

METHODS

In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed.

RESULTS

The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001).

CONCLUSION

The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Digital analysis of unilateral ptosis repair: external levator advancement vs. Müller's muscle conjunctival resection

PURPOSE

Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Müller's muscle conjunctival resection surgery in unilateral ptosis.

METHODS

We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Müller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid.

RESULTS

Sixteen patients underwent external levator advancement and 16 patients had Müller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Müller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11).

CONCLUSIONS

Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.

A new technique to prevent conjunctival prolapse in Asian patients for correcting severe blepharoptosis

BACKGROUND

In Asian patients with severe ptosis,the use of conjoint fascia sheath (CFS) suspension or levator aponeurosis fascia complex shortening surgery can correct the ptosis. During these surgery, a significant amount of levator aponeurosis fascia shortening is performed, which often leads to serious complications such as conjunctival prolapse.This study compares two surgical approaches for correcting severe blepharoptosis:Conjoint fascial sheath (CFS) + levator aponeurosis and muller's muscle complex (LM complex) suspension and conjoint fascial sheath (CFS) + LM complex+conjunctival suspension.The postoperative efficacy and the incidence of complications such as conjunctival prolapse are investigated for both procedures.

METHODS

This study retrospectively analyzed 70 patients (77eyes) with severe blepharoptosis from January 2019 to December 2021. The patients were divided into the experimental group (34 cases, 38 eyes) and the control group (36 cases, 39 eyes). The experimental group was treated with CFS+LM complex + conjunctival suspension, and the control group was treated with CFS+LM complex suspension.The curative effect of blepharoptosis, the incidence of complications such as conjunctival prolapse and patient satisfaction were compared between the two different surgical methods.

RESULTS

There was no significant difference in the correction effective rate between the experimental group (84.21%) and the control group (82.05%) (P > 0.05). There was no significant difference in the total incidence of complications between the experimental group (23.68%) and the control group (38.46%) (P > 0.05), but in the complication of conjunctival prolapse, the incidence of conjunctival prolapse in the experimental group was significantly lower than that in the control group. The difference was statistically significant (P < 0.05). In the survey of patient satisfaction rate, the satisfaction rate of the experimental group was significantly higher than that of the control group,which was statistically significant (P < 0.05).

CONCLUSIONS

Compared to CFS+LM complex suspension surgery, the CFS+LM complex + conjunctival suspension has a definite effect in preventing postoperative conjunctival prolapse .The procedure has a high feasibility, good corrective effect, and improves patient satisfaction after surgery.

A simplified technique for correction of complete ptosis secondary to palpebral neurofibromatosis

PURPOSE

To present a simplified technique in management of complete ptosis secondary to neurofibromatosis.

METHODS

This prospective, non-comparative, clinical interventional study included 13 patients with complete ptosis secondary to histologically proved plexiform neurofibromas. It was conducted at the Orbital Unit of Assiut University Hospital, the referral center of Upper Egypt in the period between June 2013 and October 2021. In all cases, a simplified technique of 5 surgical steps was applied: (A) Division of the involved eyelid surgically into three parts by drawing 2 curvilinear lines, the superior line 11 mm below and parallel to the lower eyebrow hairline and the inferior one 10 mm above the lid margin, (B) Resection (full-thickness) of the large middle part which involves the main pathology and lies between the 2 lines, (C) Preservation of the upper part with identification, dissection and clamping of the levator muscle, (D) Refinement of the lower part by removal of any tissue between the skin and the debulked tarsus and (E) Re-suturing of the upper and lower parts in layers; conjunctiva to conjunctiva, levator to tarsus (after resection of a part that corrects the ptosis) and skin to skin.

RESULTS

Ptosis was completely corrected in 8 cases (61.5%) and residual mild ptosis occurred in 5 patients (38.5%). No exposure keratopathy or tumor growth was reported during the follow-up period of minimum 1 year.

CONCLUSIONS

This simplified technique could be considered as a surgical basis for correction of complete ptosis in neurofibromatosis.

Modified lateral canthopexy with upper and lower blepharoplasties for aesthetic refinements: My personal technique

BACKGROUND

Blepharoplasty is a surgical procedure that modifies the shape and structure of the eyelids to restore a more youthful appearance. The procedure comprises the removal of extra muscle, fat, and skin. In order to get the optimum functional and aesthetic result, supporting components like canthal tendons can also be tightened.

AIM

To evaluate the efficacy of canthopexy in conjunction with the upper and lower blepharoplasty technique and its complications.

METHODS

A total of 400 individuals who underwent these procedures between January 2020 and January 2021 had been recruited for this study. The frequency and clinical complications were analyzed.

RESULTS

The complications were found to be 17 (4 %) cases of relapse, 12 (3 %) temporary hematoma formation, 11 (3 %) cases of epiphora, 8 (2 %) cases of unequal eyelid positioning, 5 (1 %) patients developed conjunctivitis and chemosis.

CONCLUSION

This method appears to be effective since it is simple, practicable, and capable of delivering positive functional and aesthetic effects with a minimum of side effects.

Choosing Upper Blepharoplasty, Infra-brow Lift, and Forehead Lift in Asians: An Algorithmic Approach from Personal Experience

BACKGROUND

Eyelid surgery is a cosmetic procedure performed worldwide in the field of plastic surgery. However, achieving optimal outcomes for the upper eyelids presents a challenge, necessitating careful patient selection and appropriate surgical choices.

OBJECTIVES

This article aims to provide recommendations for selecting the most suitable surgical procedure among three commonly performed treatments for aged upper eyelids.

METHODS

A retrospective cohort study was conducted from October 2020 to May 2022, involving 518 patients. Pre- and postoperative photographs were analyzed to evaluate changes in the distance between the eyelids and brows. Notably, patients who habitually use the frontalis muscle to manage upper eyelid redundancy showed significant variations in the lid-brow distance after eyelid surgery.

RESULTS

The study confirmed that addressing skin laxity through upper blepharoplasty or infra-brow excision reduced the stimulus for frontalis activity, resulting in true brow ptosis. However, the degree of compensatory frontalis movement differed among individuals, and changes in the lid-brow distance observed before and after the photos were influenced by various factors. As a result, obtaining clear numerical data regarding the changes in the lid-brow distance following eyelid surgery proved challenging. Nevertheless, after analyzing 518 cases, the author has classified the patients into three groups, which can contribute to more predictable and satisfying outcomes.

CONCLUSION

Based on the analysis of pre- and postoperative results from 518 patients, this study recommends specific strategies to enhance patient satisfaction. The proposed treatment algorithm may assist beginner surgeons in avoiding angry or tired-looking eyes after periorbital rejuvenation.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Small-Incisional Double Eyelid Blepharoplasty: A Retrospective Study of Our Minimally Invasive Technique with Three Mini Incisions

BACKGROUND

Small-incisional double eyelid surgery has been increasingly performed these years and achieved good aesthetic results, but the techniques vary greatly between literatures. The authors reviewed the cases of three-small-incisional double eyelid surgery performed in the past three years and introduced their surgical technique in detail.

METHODS

A total of 87 patients receiving bilateral three-small-incisional double eyelid surgery were included in this retrospective study. The pretarsal folds were designed meticulously, along which three evenly distributed 2 mm-long incisions were made. A minimal amount of orbicularis oculi muscle and pretarsal soft tissue were removed to expose the pretarsal fascia for further fixation. An appropriate amount of orbital septal fat was removed through the lateral incision if required. The superficial orbicularis oculi muscle and dermis on the lower margin of the incision were fixed onto the pretarsal fascia with some underlying tarsus on the upper margin of the tarsus. The skin was closed by one stitch for each incision.

RESULTS

The average follow-up was 9.9 ± 5.2 months (range: 6-27 months). All the patients were satisfied with the result. None of them experienced loss of the pretarsal fold, bilateral asymmetry, scar hyperplasia, or persistent swelling after surgery.

CONCLUSIONS

Our three-small-incisional technique with minor soft tissue debulking offers a simple, safe, and reproducible approach to double eyelids. It can create a stable and natural-looking pretarsal fold with a short recovery period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Late-Onset Traumatic Corneal Conjunctival Epithelial Disorders due to Granular Formation After Cosmetic Suture Blepharoplasty

PURPOSE

The purpose of this study was to report conjunctival granular formation as one of the causative factors of a traumatic corneal conjunctival epithelial disorder after plastic suture blepharoplasty.

METHODS

Clinical charts of 7 patients who had visited Ohshima Eye Hospital with a symptomatic corneal epithelial disorder and history of suture blepharoplasty were reviewed. Clinical evidence of conjunctival granular formations was observed in all patients at the tarsal conjunctiva facing to corneal conjunctival traumatic epithelial disorders. The desired outcome was to alleviate the disorder. The assessment included tabulating results after the placement of a soft contact lens bandage and subsequent partial tarsal plate resection of the granular formation.

RESULT

Seven women (mean age 45.0 ± 10.9 years) enrolled in this study had previously undergone suture blepharoplasty (mean 18.3 ± 6.9 years before). Soft contact lens bandages relieved all of the patients' complaints immediately. After resecting the granular formation, the traumatic corneal conjunctival epithelial disorder disappeared, and no recurrence was observed after surgery.

CONCLUSIONS

The conjunctival granular formation within the tarsal conjunctiva after suture blepharoplasty caused the late-onset traumatic corneal conjunctival epithelial disorder. A complete cure was obtained after resection of the granular formation at the tarsal conjunctiva. To the best of our knowledge, this is the first report to identify the removal of granular formations in 7 patients with late-onset traumatic corneal conjunctival disorders many years after blepharoplasty. The resection of these lesions is a promising procedure to treat late-onset ocular epithelial disorder after suture blepharoplasty.

Can Local Infiltration Influence Postoperative Recovery in Upper Blepharoplasty? A Case Series Study on Two Different Infiltration Methods

Upper blepharoplasty is a common aesthetic surgery procedure which is frequently performed wide awake, under local anesthesia. However, advancements concerning the patients' perception during and after the procedure are still needed. This study aimed to evaluate the efficacy of a new method for local anesthetic infiltration in the upper eyelid comparing it to the traditional needle injections.A prospective, randomized, and clinical trial was conducted on 20 patients who underwent upper eyelid blepharoplasty in local anesthesia. After randomization, one eyelid was infiltrated using a Nanosoft technology needle, while on the contralateral side traditional needle injections were performed. Preoperative demographics, Fitzpatrick, and SNAP test were recorded. Postoperative patients visual analog scale (VAS) scores for both infiltration methods and ecchymosis and edema were recorded.Our results showed that the mean VAS scores for perceived pain were significantly lower on the eye infiltrated with Nanosoft technology (p < 0.05). Furthermore, the rate of postoperative ecchymosis and edema were also significantly lower with Nanosoft technology (p = 0.0012 and 0 = 0.0197, respectively). All 20 patients were satisfied with outcomes, and there were no major complications or need for a revision.Our case series study suggests that Nanosoft technology may be a more effective and efficient method for the local anesthetic infiltration in upper eyelid blepharoplasty in reducing discomfort and downtime for the patient.

Comparison of Stab Incision and Eyelid Crease Incision Techniques in Children with Revision Frontalis Sling Surgeries Using Silicone Rods

PURPOSE

To compare stab and eyelid crease incision techniques in revision frontalis sling surgeries using silicone rods.

METHODS

This retrospective study involved 52 eyes in 48 consecutive pediatric patients who underwent revision frontalis sling surgery between 2008 and 2019. All primary surgeries were performed by making eyelid crease incisions and suturing of silicone rods onto the tarsal plates. The revision surgeries were performed by either making stab incisions over the eyelid through which to pass the silicone rods (group A), or by refixing the same or a new silicone rod to the tarsal plate (group B). The surgical results were compared.

RESULTS

The mean follow-up period was 22.4 months (range, 6-62 months) and the mean age of the patients was 6.1 years (range, 1-16 years). There were 28 female and 20 male patients. Surgical success was achieved in 23 of 28 patients (82.1%) in group A, and 12 of 24 patients (50.0%) in group B. The difference between the groups was statistically significant (p = 0.012). Superficial punctate epithelial defects were detected in six group A patients (21.4%) and seven group B patients (29.1%). In group B, lid hematoma occurred in three patients (12.5%) and entropion occurred in three patients (12.5%). The silicone rods were removed from two eyes, and entropion spontaneously resolved in one eye with close follow-up.

CONCLUSIONS

Using the stab incision technique increases revision frontalis sling surgery success rates when primary surgeries are performed using eyelid crease incisions and suturing silicone rods to the tarsal plates in children.

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon

BACKGROUND

Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos.

METHODS

We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes.

RESULTS

Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment.

CONCLUSION

We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults

A posterior approach is recommended for the correction of mild to moderate upper eyelid ptosis in adults. The aim of this study is to propose a new algorithm that helps to predict outcomes in the transconjunctival correction of moderate to severe blepharoptosis. This study included adult patients with moderate to severe upper eyelid ptosis treated between 2019 and 2021. Patients meeting inclusion criteria underwent ptosis correction through a posterior approach using an algorithm: 4 mm Mueller's muscle transconjunctival resection to correct 1 mm ptosis (depending on a test with 10% phenylephrine: 3-12 mm) ± tarsal plate resection: 1 mm for every 1 mm of residual ptosis after phenylephrine test, but leaving a minimum of 4 mm upper tarsus intact. Outcomes were ovserved within at least 6-months. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications. Outcomes of 118 procedures in 81 patients (average age 69, range: 47-87) were analyzed. MRD1 changes were statistically significant, from 0.2 ± 1.6 mm before to 4.1 ± 1 mm after surgery. The function of the levator palpebrae superioris muscle was 10.2 ± 3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8 ± 0.7 (range 0-3) mm after the instillation of 10% phenylephrine eyedrops. An average of 8.5 ± 0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2 ± 0.9 (range 1-5) mm of the tarsal plate were resected during the procedure. Inter-eyelid height symmetry within 1 mm was achieved in 95% of outcomes. The algorithm introduced in this study appears to be useful to achieve repeatable satisfactory outcomes in the transconjunctival correction of moderate to severe upper eyelid ptosis in adults with at least "fair" levator function.

Outcomes of a novel algorithm for levator muscle plication surgery in congenital blepharoptosis

AIM

to assess the outcomes of a novel algorithm for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery.

METHODS

this retrospective comparative study included 34 patients with congenital ptosis subjected to levator muscle plication surgery during the period from October 2021 to November 2022. They were divided into two groups. Group A: the amount of levator muscle plication was calculated by a traditional formula [(amount of ptosis x 3) + 9 mm in cases with good levator function or (amount of ptosis x 3) + 11 mm in cases with fair levator function]. Group B: the amount of levator muscle plication was calculated by a novel nomogram [the result of the traditional formula was modified by subtracting 4 mm if the calculated amount was ≥ 15 mm or subtracting 3 mm if the calculated amount was < 15 mm]. Demographic data, baseline ptosis characteristics and postoperative results at 1st week, 1st month, 3rd month and 6th month were compared between the groups. Primary outcome measure was postoperative Marginal Reflex Distance (MRD1). Secondary outcome measures were lid contour, lid crease and any reported complications.

RESULTS

Group A included 20 eyes of 18 patients while Group B included 20 eyes of 16 patients. The mean amount of levator muscle plication was 16.98 ± 2.44 mm and 13.48 ± 2.42 mm in group A and group B respectively. The difference between the two groups was highly statistically significant (p < 0.001). Mean MRD1 at the 1st postoperative week was 4.95 ± 0.37 mm in group A and 4.08 ± 0.64 mm in group B. This difference was highly statistically significant (P < 0.001). Overcorrection was seen in 8 (40%) eyes in group A and 1 (5%) eye in group B. The difference was statistically significant between the two groups (p = 0.008). Undercorrection was seen in only 1 (5%) eye in group B. No other complications were reported. Surgical success was achieved in 12 (60%) eyes in group A versus 18 (90%) eyes in group B. The difference between the two groups was statistically significant (p = 0.03).

CONCLUSION

our novel nomogram for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery is effective in achieving a satisfactory postoperative MRD1.

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for the repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: "good" (improvement of palpebral fissure height without laterality, Margin reflex distance-1 gap between right and left side <0.5 mm), "fair" (improvement of palpebral fissure height with laterality), or "poor" (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity, or recurrence of ptosis. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This grafting technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.