Evaluation of Eyelid Function and Aesthetics

Category of upper eyelid morphology and the preferred double eyelid shape in Asians according to questionnaire survey

BACKGROUND

The morphological classification of the upper eyelid in Asian people is complex and diverse and usually not consistent with what we know well.

AIMS

To improve the classification of upper eyelid morphology and investigate the preferred double eyelid shape by Asian people.

METHODS

An investigation of 640 patients' preferences for double eyelid shape was conducted, and the pre- and post-operative effects were assessed. The shapes of the natural eyelids of 247 people (485 eyes) who provided real photographs of the eyelids were counted. The chi-square test was used to analyze the differences.

RESULTS

There were 10 eyelid shapes: single eyelid, parallel-shaped double eyelid, fan-shaped double eyelid, parallel fan-shaped double eyelid, opened fan-shaped double eyelid, crescent-shaped double eyelid, hidden-shaped double eyelid, horizontal-shaped double eyelid, triangle-shaped double eyelid, and multiple-fold eyelid. The difference in the shape of the natural eyelid between males and females was statistically significant (p < 0.05). The most popular eyelid shapes were single eyelid (24.9%), open fan-shaped double eyelid (21.0%), fan-shaped double eyelid (16.3%), and hidden-shaped double eyelid (12.6%). Men and women preferred a parallel fan-shaped double eyelid (18.0%), a parallel-shaped double eyelids (17.0%), and an open fan-shaped double eyelids (18.1%).

CONCLUSIONS

The most popular upper eyelid shapes were single eyelid, open fan-shaped double eyelid, and fan-shaped double eyelid. The parallel fan-shaped, parallel-shaped, and open fan-shaped double eyelid were favored by men and women.

Melatonin Exerts Prominent, Differential Epidermal and Dermal Anti-Aging Properties in Aged Human Eyelid Skin Ex Vivo

Human skin aging is associated with functional deterioration on multiple levels of physiology, necessitating the development of effective skin senotherapeutics. The well-tolerated neurohormone melatonin unfolds anti-aging properties in vitro and in vivo, but it remains unclear whether these effects translate to aged human skin ex vivo. We tested this in organ-cultured, full-thickness human eyelid skin (5-6 donors; 49-77 years) by adding melatonin to the culture medium, followed by the assessment of core aging biomarkers via quantitative immunohistochemistry. Over 6 days, 200 µM melatonin significantly downregulated the intraepidermal activity of the aging-promoting mTORC1 pathway (as visualized by reduced S6 phosphorylation) and MMP-1 protein expression in the epidermis compared to vehicle-treated control skin. Conversely, the transmembrane collagen 17A1, a key stem cell niche matrix molecule that declines with aging, and mitochondrial markers (e.g., TFAM, MTCO-1, and VDAC/porin) were significantly upregulated. Interestingly, 100 µM melatonin also significantly increased the epidermal expression of VEGF-A protein, which is required and sufficient for inducing human skin rejuvenation. In aged human dermis, melatonin significantly increased fibrillin-1 protein expression and improved fibrillin structural organization, indicating an improved collagen and elastic fiber network. In contrast, other key aging biomarkers (SIRT-1, lamin-B1, p16INK4, collagen I) remained unchanged. This ex vivo study provides proof of principle that melatonin indeed exerts long-suspected but never conclusively demonstrated and surprisingly differential anti-aging effects in aged human epidermis and dermis.

Evaluation and Treatment Planning for the Aging Face Patient

Facial aging is a multifactorial process that occurs due to alterations in the skin, soft tissue, and bony skeleton. When considering treatments for the aging face and neck, a multifaceted approach targeting each of these areas should be considered. Although surgical intervention remains a key component to the holistic care of the aging face patient, a multitude of minimally invasive techniques is now available to optimize the care of the patient seeking rejuvenation. Proper patient evaluation and counseling on realistic expectations are critical and will be discussed here. A brief overview of common minimally invasive treatments will be presented.

Sliding Flap for the Wide Upper Eyelid Margin Defect After Cancer Removal

BACKGROUND

Reconstruction of eyelid margin defects following resection of upper-eyelid skin malignancies is typically performed using a lower eyelid switch flap, including eyelash reconstruction. However, a subsequent procedure for flap separation, and prolonged swelling of the flap may occur as a complication.

OBJECTIVE

The authors performed anterior lamellar reconstruction using a sliding flap with excess upper eyelid skin, a procedure that is a less invasive and simpler.

MATERIALS AND METHODS

The authors performed anterior lamellar reconstruction using a sliding flap in 7 patients with full-thickness upper eyelid margin defect after skin cancer resection. The mean age of the patients was 76.0 years. The horizontal width of the defect in our cohort ranged from 11 to 25 mm and the vertical width ranged from 5 to 10 mm.

RESULTS

All the flaps and mucosal grafts were well taken, and none of the patients complained of lack of eyelash reconstruction. However, eyelid margin irregularity, possibly due to flap or mucosal graft contraction, was observed in 2 patients, and 1 patient developed keratoconjunctivitis.

CONCLUSIONS

The sliding flap technique is a minimally invasive and simple procedure for wide eyelid margin reconstruction. However, 2 patients developed eyelid margin irregularities and 1 patient developed keratoconjunctivitis. Those complications might have occurred owing to the condition of posterior lamellar reconstruction. Therefore, for the successful use of a sliding flap for anterior lamellar reconstruction, the form of the eyelid edge and the choice of posterior lamellar reconstruction are key considerations. In future, we plan to establish a better reconstructive technique by accumulating more evidence.

Upper Eyelid Blepharoplasty Improved the Overall Periorbital Aesthetics Ratio by Enhancing Harmony Between the Eyes and Eyebrows

Purpose

In upper eyelid blepharoplasty, most aesthetic surgeons and patients focus on improvements in the appearance of the upper eyelids, such as changing the vertical dimension of the palpebral fissure and the width of the pretarsal crease. Nevertheless, appropriately balanced periorbital aesthetics stemming from harmony between the eyelids and eyebrows is often ignored. The aim of this study was to explore the use of upper eyelid blepharoplasty to improve the overall periorbital aesthetics by enhancing the harmony between the eyes and eyebrows in young Asian women.

Patients and Methods

From December 2019 to December 2020, 45 young Asian female patients underwent external incision upper eyelidplasty without ptosis repair or brow lift at The Second Affiliated Hospital of Harbin Medical University. The pre- and 6-month post-operative follow-up changes in the overall periorbital aesthetics were studied retrospectively.

Results

The vertical position of the eyebrows in the upper face and shape of the brow apex were significantly improved after surgery. As a result, the height of the upper face was increased. Furthermore, the facial width proportion and midface ratio were closer to the ideal aesthetic golden ratio due to changes in the size of the periorbital area. All patients were satisfied with the result, and they achieved excellent surgical outcomes for not only the upper eyelids but also the overall periorbital region.

Conclusion

This study revealed that upper eyelid blepharoplasty, which enhances the appearance of the upper eyelids while regulating the eyelid position and shape of the eyebrows by considering the eye to eyebrow ratio, optimizes the proportion of the periorbital area and improves the overall periorbital aesthetics.

The combined coronal-transconjunctival approach: an innovative surgical access for orbital exenteration in craniofacial resection

Malignant tumours arising in the paranasal sinuses or maxilla usually spread to the surrounding regions. The skull base and the anterior cranial fossa are frequently affected as well. When the resection of a tumour involves an orbital exenteration, a transconjunctival-perilimbic incision can be added to a coronal approach in order to preserve the eyelids and the conjunctiva, avoiding cutaneous midfacial incisions. Patients with a diagnosis of malignant tumour affecting the orbit, upper jaw, paranasal sinuses, and/or anterior skull base were eligible for this technique. Tumoural invasion of the eyelids, conjunctiva, lacrimal system, or surrounding skin was considered a contraindication for this technique. A retrospective study of the clinical records was performed and age, type of tumour, location, and reconstructive technique were evaluated. Eight patients referred to the study department between 2015 and 2019 were selected. All patients underwent craniofacial surgery and orbital exenteration. The transconjunctival-perilimbic approach was combined with a coronal incision in all cases. In our experience, the transconjunctival-perilimbic approach to orbital exenteration proposed in this paper can be used successfully in skull base surgery. Combined with a coronal and transmandibular approach, it allows wide access to the facial skeleton/anterior skull base while avoiding skin incisions in the midface.

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift

BACKGROUND

Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated.

OBJECTIVES

The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift.

METHODS

In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic.

RESULTS

From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men).

CONCLUSIONS

Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning.

LEVEL OF EVIDENCE 4

Periocular dermatoses

The periocular area may be affected by infectious or noninfectious diseases such as inflammatory dermatoses, systemic disease, drug reactions, benign and malignant lesions, traumatic lesions, and esthetic complications. We present a review of the most common periocular dermatoses.

Aesthetic Lateral Canthoplasty: a Gray Line Split Approach

BACKGROUND

Many women in Asian countries chase larger and brighter eyes, but to most Asian people only double eye plasty and epicanthoplasty is not enough. As a result, aesthetic lateral canthoplasty, another procedure to lengthen the palpebral fissure, is becoming more and more popular. However, the current procedure of aesthetic lateral canthoplasty has many potential complications, restricting the wide application of this procedure.

METHODS

Here, the authors developed a minimally invasive method through gray line split and canthopexy to achieve lateral canthoplasty. Eighty-seven patients from February 2013 to January 2016 were included and had the procedure. The lengthen of the palpebral fissure was measured and photographs were also taken before the surgery and in the follow-up periods. Besides, the complications related to this procedure were also investigated.

RESULTS

The authors have performed aesthetic lateral canthoplasty in 87 patients, almost all of the follow-up patients have satisfactory results with a lengthen of palpebral fissure ranging from 2.3 to 4.2 mm. Through the long-term follow-up the authors found the lengthen of the palpebral fissure is stable. No serious complications like lacrimal system fistula or hypertrophic scars emerged except 1 patient with conjunctival exposure.

CONCLUSIONS

Through this gray line split method, the authors can acquire larger and brighter eyes without serious complications. The authors think that this is a good method and worthy of promotion.