The Histopathological Findings of Patients Who Underwent Blepharoplasty Due to Dermatochalasis

Ablative radiofrequency microplasma for lateral dermatochalasis-indications and treatment recommendations

To determine in which cases ablative radiofrequency microplasma is preferred for the treatment of lateral dermatochalasis over a surgical approach as well as discussing each method's benefits and limitations. Twenty-one patients underwent 3 interventions of plasma exeresis. Photographic and RCM images were acquired at baseline and 4 weeks after final plasma exeresis. The eyes were categorized into 3 groups based on the dermatochalasis severity (1- mild, 2- moderate, 3- severe). Additionally, a further division was conducted to assess the degree of enhancement observed after the treatment (1- slight improvement, 2- moderate improvement, 3- significant improvement). The classifications and assessments were performed by was graded by two trained dermatologists as blinded observers. A total of 21 eyes with a mean age of 54 years (range45-67 years) and 100% females were included in this study. The severity of dermatochalasis directly affects the clinical improvement (P=0.039) and the higher the severity, the more the improvement (R = -0.62). Noninvasive ablative microplasma may offer safe and effective therapy for upper eyelid dermatochalasis and can even be performed in patients at surgical risk. However, it may be suitable for grades 0 and 1 of DC. For more advanced grades a surgical solution achieves better results for the treatment of dermatochalasis of the upper eyelid.

Is the Severity of Preoperative Eyelid Dermatochalasis Directly Correlated with Patient Satisfaction After Upper Blepharoplasty? A Prospective Study Based on PROMs

INTRODUCTION

Facial ageing, particularly in the periorbital region, is a growing concern in contemporary culture. Upper blepharoplasty, a widely performed cosmetic surgery, addresses both aesthetic and functional issues related to eyelid dermatochalasis. This study aims to investigate patient satisfaction, the relationship between satisfaction and preoperative dermatochalasis severity, and the functional impact of preoperative skin excess.

METHODS

A prospective study was conducted from April 2022 to April 2023, evaluating primary upper blepharoplasty outcomes. Patient-reported outcomes were measured using the FACE-Q questionnaire, assessing quality of life and satisfaction. Preoperative symptoms were evaluated using a functional questionnaire. Dermatochalasis severity was classified into three groups. Statistical analyses were performed using SPSS.

RESULTS

Seventy-nine patients met inclusion criteria. Postoperative FACE-Q results demonstrated significant improvements in upper eyelid appraisal and satisfaction with eyes. Functional questionnaire results indicated an overall clinical improvement (p < 0.01). Visual field tests showed statistically significant improvement in group 3. No correlation was found between preoperative dermatochalasis severity and postoperative aesthetic satisfaction.

CONCLUSION

The study emphasizes the importance of validated questionnaires, particularly FACE-Q, in evaluating patient satisfaction and discomfort with upper lid ageing. Regardless of functional impairments, any degree of dermatochalasis may warrant treatment to ensure patient satisfaction with the cosmetic outcome. On the other hand, the functional benefits and improvements in the visual field also support the impact that the procedure has beyond purely aesthetic aspects.

LEVEL OF EVIDENCE IV

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A novel classification of senile dermatochalasis: insights from clinical and histological analysis

PURPOSE

Dermatochalasis is a common disorder of the elderly, often requiring upper blepharoplasty. Although it is mainly accepted as a process of aging, its clinical and histological findings vary among patients. The aim of this study was to classify types of dermatochalasis based on their clinical and histological findings.

METHODS

This retrospective study included patients with dermatochalasis who had undergone senile blepharoplasty at a single center. Clinical parameters such as margin-to-reflex distance 1 (MRD1), eyelid contour, visual field, and pre-existing medical conditions were assessed. Histological analysis was conducted of eyelid tissues stained with hematoxylin and eosin (H&E) and D2-40 to evaluate dermal edema, inflammation, lymphatic changes, and stromal depth.

RESULTS

This study included 67 eyes of 35 patients. The mean age of the patients was 69.0 ± 8.3 years, and the average MRD1 was 1.8 ± 1.3 mm. In correlation analysis, two distinct types of dermatochalasis based on the histological findings were identified: lymphangiectasia-dominant and stromal edema-dominant types. The difference between nasal and temporal side MRD1(NT-MRD1) showed the area under the ROC curve of 0.718 of for distinguishing the two histological types of dermatochalasis was 0.718.

CONCLUSION

Our novel classification of senile dermatochalasis based on morphological and histological analysis provides insights into the underlying pathology and may help to predict surgical outcomes and complications.

Relationship between histopathological findings of patients with dermatochalasis and vitamin D deficiency

PURPOSE

To compare the histopathological findings of patients who had been diagnosed with dermatochalasis (DC) and had undergone upper eyelid blepharoplasty (ULB) as well as those of controls (C-Group) according to their serum vitamin D (SVD) levels.

METHODS

The prospective study included 136 upper eyelid skin from 68 patients who underwent surgery for DC and 53 upper eyelid skin from 53 patients who underwent levator surgery with ULB. The DC Group was then divided into 3 subgroups according to the marginal reflex distance (MRD4). The lymphatic vessel (LV) count and diameter of the largest LV (DLLV) were recorded, the stromal collagen bed (SCB) was observed, and its depth was measured, the interfibrillar edema was examined, and the elastic fiber and macrophage counts and recorded, respectively, and then all of these were evaluated. The SVD levels were compared between the DC patients and the C-Group.

RESULTS

In comparison to the C-Group, significant changes were seen in the dilated LV, DLLV, SCB depth, interfibrillar edema, elastic fiber density, and macrophage count in the DC sub-Groups (P < 0.001 for all). While no difference was found between DC sub-Group 1 (MRD4 > 4 mm) and the C-Group (P > 0.05), a significant difference was found between DC sub-Group 2 (MRD4 2-4 mm) and DC sub-Group 3 (MRD4 < 2 mm) for all of the parameters (P < 0.05). A statistically significant difference was also found in the SVD levels between the DC sub-Group 1 and DC sub-Groups 2-3 (P < 0.017, P < 0.001 respectively).

CONCLUSION

According to the results of this study, SVD level was significantly lower in DC group. Moreover, an increased LV count and diameter, decreased elastic fiber count, collagen fiber and stromal edema irregularity, and increased macrophage count were found to be associated with the SVD level.

Evaluation of visual field and ocular surface parameters by clinical comparison after blepharoplasty for dermatochalasis

PURPOSE

To evaluate the effect of upper eyelid blepharoplasty surgery on corneal topography, visual field, ocular surface, meibography, corneal biomechanics and dry eye parameters.

METHODS

This prospective study included a total 80 eyes of 40 patients. Following a detailed ophthalmological examination, standardized patient satisfaction questions were posed to patients before and after upper eyelid blepharoplasty surgery. Visual field test, non-invasive break up time (NIBUT), meibography, and corneal topography parameters were analyzed and evaluated.

RESULTS

The mean (+) visible areas in the visual field were found to be 46.20±24.96 preoperatively, 56.73±21.98 at the 1st postoperative month and 65.96±18.5 at the 3rd month, which were statistically significant. NIBUT values preoperatively, at 1 month and at 3 months were 11.26±4.48, 11.16±4.5 and 10.14±4.0, respectively, which were statistically significant. Meibomian gland loss rates on meibography preoperatively and postoperatively at 1 and 3 months were found to be 30.24±8.3, 29.36±8.2 and 28.22±7.7 respectively and were statistically significant. With the scoring system after blepharoplasty, patients reported improvement in their symptoms.

CONCLUSION

Upper eyelid blepharoplasty surgery is predicted to increase the quality of vision. It was observed that there was a functional and cosmetic improvement in the complaints of the patients after blepharoplasty. However, blepharoplasty may cause changes in eyelid dynamics and cause dry eye syndrome.

Damage to the orbicularis oculi muscle may impair the development of dermatochalasis

The purpose of this article is to investigate the changes that occur in the orbicularis oculi muscle (OOM) in patients with dermatochalasis. The OOM specimens from 26 patients were collected during upper eyelid blepharoplasty. Each specimen was divided into three parts, which were then examined using different techniques: formalin embedding for light microscopy, free freezing for histochemical examination, and fixation in 3% glutaraldehyde for electron microscopy. The severity of dermatochalasis was classified according to the anatomical landmarks. 78 specimens from patients with dermatochalasis were evaluated. Under light microscopy, specimens showed an increase in muscle fiber size variation, rounding of muscle fibers, and lobulation of myocytes in a fibrotic background. Under electron microscopy, loss of myofilaments, vacuolar vesicles, and swollen mitochondria were observed, along with osmophilic aggregates resembling nemadine bodies and collagen fibrils. A statistically significant association between the progression of dermatochalasis and the presence of aggregates resembling nemaline bodies was found (p- value < 0.005). Significant changes occur in the OOM in patients with dermatochalasis and the presence of aggregates resembling nemaline bodies is correlated with the degree of eyelid drooping. Thus, OOM may contribute in dermatochalasis progression.

Evaluation of 25-Hydroxyvitamin D levels in patients with dermatochalasis

PURPOSE

To compare serum 25-hydroxyvitamin D (25(OH)D) levels of patients with dermatochalasis who underwent upper lid blepharoplasty and healthy controls.

METHODS

This retrospective comparative study included dermatochalasis patients who underwent upper lid blepharoplasty and age-and sex-matched controls from January 2019 to January 2021. The data, including comprehensive ophthalmological examination, internal medicine outpatient examination, and laboratory results of the dermatochalasis patients and healthy controls, were collected from the electronic patient records. Serum 25(OH)D, creatinine, calcium (Ca), phosphate (P), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels were evaluated and compared between the dermatochalasis patients and healthy controls.

RESULT

Of our participants, consisting of 46 patients with dermatochalasis and 52 healthy controls, 54 (55.10%) were female and 44 (44.90%) were male. A statistically significant difference was observed in vitamin D levels between the healthy and dermatochalasis groups (p ≤ 0.001). The percentage of individuals with vitamin D deficiency (< 20 ng/mL) was significantly higher in the dermatochalasis group (p = 0.001). In addition, the percentage of individuals with severe vitamin D deficiency (< 10 ng/mL) was again significantly higher in the dermatochalasis group (p = 0.001). The risk of dermatochalasis incidence was found to increase in cases of low vitamin D (OR = 1.210; p = 0.017).

CONCLUSION

Low serum 25(OH)D levels may play a role in the etiopathogenesis of dermatochalasis. Future research should include longitudinal studies and prospective clinical studies to investigate the mechanism responsible for the low vitamin D observed in dermatochalasis patients.

Dermatochalasis Aggravates Meibomian Gland Dysfunction Related Dry Eyes

This study aimed to investigate the relationships between subjective symptoms, objective signs, and dermatochalasis severity in dry-eye patients and the effects of lid hygiene on dry-eye parameters. We retrospectively enrolled 2328 patients who underwent dry-eye examinations and classified them into four groups by dermatochalasis severity. The SPEED and OSDI questionnaires were used to evaluate subjective symptoms. LipiView® II interferometry was used to measure lipid-layer thickness (LLT) and blink/incomplete blink rates and perform meibography. A slit-lamp–aided standardized evaluator measured meibomian gland expressibility (MGE). A meiboscale was used to grade meibomian gland dropout. Fluorescein tear-film break-up time (FTBUT) and superficial punctate keratitis (SPK) were recorded. The Schirmer test II with anesthetics was used to evaluate aqueous tear secretion. The effects of lid hygiene were evaluated in 644 patients who underwent second comprehensive examinations. The median age of patients was 55.3 [46.0–66.0] years (76.0% female). Patients with more severe dermatochalasis were less symptomatic and had less MGE, higher meiboscale grades and average LLT. Dermatochalasis severity was significantly associated with MGE and meiboscale grade in the upper lid. There were no significant differences in the Schirmer test, FTBUT, and SPK among the severity groups. Females were older and had higher LLT and less severe dermatochalasis. Lid hygiene significantly decreased subjective symptoms, LLT, and Schirmer results, increased FTBUT, but did not change MGE or meiboscale grades. Dermatochalasis severity participated in the pathophysiology of dry eyes. Lid hygiene significantly improved subjective symptoms and reduced LLT, more significantly in patients with less severe dermatochalasis.

The histopathological findings in excised upper eyelids of patients with dermatochalasis following collagen cross-linking treatment

PURPOSE

To evaluate the histopathological effects of collagen cross-linking (CCL) on excised skin samples of patients undergoing upper eyelid blepharoplasty due to dermatochalasis.

METHODS

This study examined 74 excised eyelid skin samples from 37 dermatochalasis patients. Following an upper eyelid blepharoplasty, CCL with hypotonic riboflavin (0.1%) was applied. Both treated (right eyelid, CCL group) and untreated eyelid specimen (left eyelid, non-CCL group) sections were stained with hematoxylin-eosin and Masson's trichrome. The sections were evaluated for the following parameters: the collagen status (parallel, oblique, and perpendicular), the distance between collagen fibers, the diameter of collagen fibers, and the length of collagen fibers.

RESULTS

There were no statistically significant differences in the collagen status, the distance between collagen fibers, the diameter of collagen fibers, and the length of collagen fibers between the CCL and non-CCL groups (p > 0.05 for all). Although the lack of statistically significant differences, the structure of the treated eyelid collagen fibers was more parallel in 48% of the participants than in the untreated ones. For male patients, a statistically significant shorter distance between collagen fibers was observed in the CCL group (8.05 ± 2.04 µm) compared to the non-CCL group (9.97 ± 2.33 µm) (p = 0.042).

CONCLUSION

In this study, more parallel collagen structures and tightly packed collagen fibers were detected in eyelid samples following CCL treatment. The authors note that the results of this study may be promising for further research, so the effect of CCL therapy on the eyelid may be an interesting subject for the treatment of non-severe or surgically inadequately corrected dermatochalasis.

A New Classification of the Lateral Dermatochalasis of Upper Eyelids

Eyelid dermatochalasis is an abnormal distention of the upper eyelid. This article presents a new classification of the lateral dermatochalasis (LDC) of the upper eyelids, which compares the pre- and post-blepharoplasty results and matches its results with those of the well-established Jacobs classification (JEC).

Dermatochalasis Through Decades: A Histopathologic Study

OBJECTIVES

Three prior studies (2008, 2011, 2018) histopathologically compared the eyelid specimens of patients with dermatochalasis (DC, undergoing blepharoplasty) with a control group and proposed that DC may begin with subclinical inflammation leading to elastolysis and lymphostasis. With growing number of younger patients consulting for blepharoplasty, the unanswered question is whether histopathologic changes of DC differ between the younger and the older.

PATIENTS AND METHODS

In this prospective case series, 20 right upper eyelid skin of 20 nonsmoker, class 3 Fitzpatrik skin type women (30-68 years old) were histopathologically examined. Patients were divided into 2 age groups of 50 years or older and older than 50 years. Upper eyelid skin was preoperatively marked, intraoperatively removed, postoperatively divided into 3 sections: lateral (lateral limbus to lateral canthus), central (between medial and lateral limbi), and medial (medial limbus to medial canthus), and separately (totally 60 specimens) sent for histopathological examination. A masked pathologist recorded skin thickness in all specimens (60) as well as lymphatic vessels diameter and density, elastic fiber density, macrophage number, collagen intrafibril edema, and depth of collagen stromal bed in central sections (20 specimens).

RESULTS

There were 10 patients at each age group. Histopathological measurements were not significantly different between the 2 age groups except mean lymphatic vessel diameter (P = 0.034) that was larger in the second group (>50 years). A significant positive correlation was also observed between the age and lymphatic vessel diameter (rs = 0.3, P = 0.009).

CONCLUSIONS

Lymphangiectasia progresses significantly by age. Histopathological characteristics of DC are the same in the 2 age groups.

A novel ablative radiofrequency microplasma nonsurgical blepharoplasty for dermatochalasis

Dermatochalasis (DC) is part of the aging process of the eyelids, characterized by lax, redundant, and overhanging excess eyelid skin. Mostly, it is treated by surgical blepharoplasty. Lately alternative nonsurgical blepharoplasty technologies have been introduced. In this study, we evaluated the efficacy and safety of a novel noninvasive RF microplasma technology for upper eyelid DC. A prospective single center study included 17 patients with moderate to severe upper eyelid DC. Subjects were treated by controlled micro-plasma sparks via a single tip leading to superficial ablation and coagulation at the treatment area. One to three treatment sessions at 2 months interval were performed. Three blinded observers evaluated the photographs taken at baseline and at 6 to 8 months follow-up visit following the final treatment session. Treatment efficacy was assessed using a 4-point grading scale. Seven out of 17 patients (41%) treated for DC by the single microplasma spark exhibited a 2 grade improvement on a 4 point DC scale. 10 out of 17 (59%) patients showed a single grade improvement on a 4 point DC scale. No adverse side effects were observed. Noninvasive ablative microplasma may offer safe and effective therapy for upper eyelid DC.