Maximizing Symmetry in Upper Blepharoplasty: The Role of Microptosis Surgery

Factors that affect eyelid show and their importance in upper eyelid blepharoplasty: a systematic review

An understanding of the complexity of the surgical anatomy of the upper eyelid and the surrounding structures is mandatory when trying to minimize complications and achieve excellent cosmetic results during eyelid surgery. Postoperative upper eyelid asymmetry is one of the most common causes of patients' dissatisfaction, and several parameters should be taken into consideration when performing cosmetic blepharoplasties and ptosis surgery. Tarsal platform show and brow fat span are two of the most important variables pertaining to the perception of beauty and youthfulness that every oculoplastic and facial plastic surgeon should address when performing such surgery. The aim of this review paper is to provide a detailed anatomy of the upper eyelid and the surrounding structures, to highlight all the relevant factors that contribute to the perception of beauty and the changes that occur to the aging face and to address the preoperative factors that need to be carefully examined before performing upper eyelid surgery.

Does Double-Eyelid Blepharoplasty Improve Forehead Wrinkles? A Prospective Study Using FACE-Q Scale and Anthropometric Measurements

BACKGROUND

Single eyelids are common among Asians. It is not uncommon to see people with single eyelids raise their eyebrows to wide open their eyes. This results in frequent compensatory contraction of the frontalis muscle and thus leads to deep forehead wrinkles. Double-eyelid blepharoplasty creates a larger visual field. In theory, patients who receive the surgery will stop overusing the frontalis muscle. Therefore, the forehead wrinkles can be improved.

METHODS

35 patients who underwent double-eyelid blepharoplasty were enrolled. FACE-Q forehead wrinkle assessment scale was adopted to evaluate the forehead wrinkles preoperatively and postoperatively. In addition, anthropometric measurements were taken to indirectly evaluate frontalis muscle contraction in maximum eye-opening position.

RESULTS

According to the FACE-Q scale, forehead wrinkles were improved after double-eyelid blepharoplasty, and the improvement was long-lasting in the 3-month follow-up. This was because the frontalis muscle contraction reduced after the surgery, as shown by the anthropometric measurements.

CONCLUSION

This study used subjective and objective methods to prove that double-eyelid surgery improves forehead wrinkles.

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 .

Optimizing Management of Asymmetric Ptosis: A Comparison of Three Posterior Approach Resection Algorithms

PURPOSE

The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis.

METHODS

Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry.

RESULTS

A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723).

CONCLUSIONS

Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces.

Is It Worth Using Botulinum Toxin Injections for the Management of Mild to Moderate Blepharoptosis?

BACKGROUND

Mild ptosis can be aesthetically displeasing for patients, especially in unilateral cases. However, some patients do not desire to undergo a surgical repair. Botulinum toxin injection might be an option in these cases.

OBJECTIVES

The authors sought to objectively examine the effects of botulinum neurotoxin A (BoNT-A) injection into the orbicularis oculi muscle in the management of blepharoptosis.

METHODS

In this prospective study, 8 patients with mild to moderate ptosis received application of BoNT-A in the pretarsal orbicularis oculi muscle. Standardized photographs were obtained at baseline and 2, 4, and 24 weeks. Digital image analysis software (Image J) was employed for objective analysis. Primary outcomes were the margin reflex distance-1 and qualitative changes on a 4-point scale.

RESULTS

A significant increase in the margin reflex distance-1 on the treated side (baseline: 2.00 ± 1.13 mm; week 2: 2.52 ± 1.13 mm; P = 0.003) and a significant reduction (baseline: 3.23 ± 0.92 mm, week 2: 3.07 ± 0.96; P = 0.0268) on the contralateral eyelid were observed at week 2. After 24 weeks, the effect of BoNT-A diminished, and no significant difference from baseline was observed in either eyelid. Subjectively, 87.5% of patients reported improvement in their eyelid ptosis.

CONCLUSIONS

Botulinum toxin injection in the pretarsal orbicularis oculi muscle can be an option to temporarily manage ptosis in patients who do not desire to undergo a surgical procedure. This alternative treatment can also be employed to manage temporary ptosis induced by botulinum toxin diffusion to the levator aponeurosis.

LEVEL OF EVIDENCE: 4

Aesthetic Changes of Brow-Eyelid Continuum After Correction of Moderate-Severe Blepharoptosis with Conjoint Fascial Sheath Suspension

BACKGROUND

As periorbital aesthetic commonly improved in blepharoptosis patients after correction surgery, the aim of this study was to elaborate the brow-eyelid continuum changes in moderate-severe ptosis patients who underwent conjoint fascial sheath suspension systematically.

METHODS

Patients with moderate-severe ptosis who underwent conjoint fascial sheath suspension were assessed by using pre- and post-operative digital photographs in the primary gaze position of the eye. The main outcome measurements included marginal reflex distance1 (MRD1), palpebral fissure height (PFH), eyebrow position, the symmetry of face and the horizontal forehead lines condition.

RESULTS

There were 43 patients (53 eyelids) in our study, including 33 unilateral and 10 bilateral patients. The mean levator function was 3.00 ± 1.07 mm. Before surgery, the mean MRD1 and PFH were 0.60 ± 1.14 mm and 6.75 ± 1.71 mm, respectively. The mean eyebrow height at medial, center, lateral position was 33.16 ± 3.95 mm, 35.99 ± 4.02 mm and 34.35 ± 4.80 mm, respectively. It was found that MRD1 and PFH symmetry both were 23.26% and eyebrow symmetry was 62.79%. For forehead wrinkles, 48.84% of the patients was mild, 34.88% was moderate, and 16.28% was severe. The average follow-up was 12.78 months (ranged from 12 to 18 months). One month after surgery, the mean MRD1 and PFH were 5.68 ± 0.86 mm, 11.61 ± 0.97 mm, respectively, both of which improved significantly (P < 0.0001). The mean eyebrow height at medial, center, lateral position descended to 28.22 ± 4.77 mm (P = 0.017), 31.41 ± 4.58 mm (P = 0.033) and 30.28 ± 3.41 mm (P = 0.018), respectively. The result showed that the rate of patients with MRD1 symmetry was 32.56%, PFH symmetry was 30.23%, and eyebrow symmetry was 90.7%. For forehead wrinkles, 69.77% was mild and 30.23% was moderate. Then, patients' eyebrow gradually elevated, while their upper eyelid dropped. At the last follow-up, the mean MRD1 and PFH were 3.83 ± 0.98 mm and 9.84 ± 1.56 mm, respectively. The mean eyebrow height at medial, center, lateral position improved to 30.52 ± 4.59 mm (P = 0.031), 32.40 ± 4.68 mm (P = 0.033), 31.19 ± 4.16 mm (P = 0.028), respectively. The patients with MRD1 symmetry accounted for 86.05%, PFH symmetry 86.05%, and eyebrow symmetry 90.7%. For forehead wrinkles, 67.44% was mild and 32.56% was moderate.

CONCLUSION

CFS suspension can effectively reconstruct moderate-severe ptosis patients' aesthetics of the brow-eyelid continuum by descending elevated eyebrow, improving facial symmetry and reducing forehead rhytids.

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 .

Effect of Muller's muscle-conjunctival resection on the upper eyelid crease position in Asian eyelids: a retrospective cohort study

Purpose

Investigating the effect of Muller’s muscle-conjunctival resection (MMCR) on the eyelid crease position.

Methods

This retrospective study included patients with unilateral acquired blepharoptosis who underwent MMCR during October 2018–December 2021. The following factors were recorded: preoperative, after phenylephrine, postoperative marginal reflex distance1 (MRD1) and tarsal platform show (TPS) of bilateral eyelids. The primary outcome was to measure the change in TPS and evaluate the factors associated with post-operative TPS. The secondary outcomes included exploring the rate of MRD1 and TPS symmetry after the operation.

Results

Forty patients were included in the final analysis. The mean MRD1 of the ptotic eye was 1.28 ± 0.78 mm, 2.79 ± 0.66 mm and 3.20 ± 0.67 mm before, after phenylephrine and after the operation, respectively. The mean TPS of the ptotic eye was 5.90 ± 1.86 mm, 3.96 ± 1.49 mm and 2.79 ± 1.63 mm before, after phenylephrine and after the operation, respectively. Changes in mean TPS after the phenylephrine test and post-operation were statistically significant (p < 0.001). The linear regression model revealed that the absolute change in TPS after phenylephrine drop and absolute change in MRD1 post-operation were significantly correlated with the absolute change in TPS post-operation. Besides, the ratio of symmetry in MRD1 and TPS was greatly improved post-operation (82.5% and 70.0% respectively).

Conclusion

MMCR is an effective surgical method for ptosis correction as it can not only correct the eyelid crease position but also narrow the wide TPS. This method is particularly beneficial to patients with both mild to moderate ptosis and an asymmetric crease height.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02605-6.

Prevalence of Masked versus Unmasked Blepharoptosis in Subjects Seeking for Blepharoplasty and or Eyebrow Lift

PURPOSE

To report the prevalence of unmasked versus masked in subjects seeking for eyelid and eyebrow rejuvenation.

METHODS

This retrospective study included subjects (>18 years) who were seeking for blepharoplasty and/or eyebrow lift procedures in the year 2020. They were either having No ptosis, Unmasked or Exposed ptosis (complaining of simultaneous droopy eyelid, which was confirmed on examination), or Masked or Hidden ptosis (not complaining of simultaneous droopy eyelid, but its presence was revealed on the examination). Margin reflex distance 1 (MRD1) and levator function (LF) were recorded. Associated ptosis was defined as MRD1 of ≤3 mm and regarded as mild (3 and 2.5 mm), moderate (2 and 1.5 mm), and severe (≤1 mm).

RESULTS

Included were 1401 subjects with a mean age of 47.2 years. The prevalence of masked and unmasked ptosis was 31% (90% unilateral) and 15.6% (59% bilateral), respectively. A significantly younger mean age (45.6 vs. 59.7 years), higher MRD1 (2.6 vs. 1.9 mm), and better LF (13.3 vs. 11.3 mm) were observed in the masked vs. unmasked ptosis group. More than 80% of the subjects with masked ptosis presented with indirect signs. A majority of both groups (68.8% of masked and 63.5% of unmasked ptosis) were mild to moderate.

CONCLUSION

Almost half of the subjects seeking for eyelid and eyebrow rejuvenation had either masked (2/3) or unmasked (1/3) associated ptosis. Masked ptosis was mostly unilateral and presenting with indirect signs of ptosis.

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as “beautiful.” Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease.

Eyelid Malposition after Blepharoplasty: An Ounce of Prevention

Upper and lower eyelid blepharoplasty are common procedures performed to provide a more youthful and rejuvenated appearance. However, this seemingly straightforward procedure may result in lid malpositions, frustrating the patient and surgeon alike, which ultimately require further treatment. We review preoperative assessment pearls to avoid these lid malpositions, as well as options for treating any postoperative complications related to lid position. Many of the techniques discussed in this article, in addition to many other oculoplastic procedures, are available to view in Dr. Richard C. Allen's operative video library at: http://webeye.ophth.uiowa.edu/eyeforum/video/plastics/ .

Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members

BACKGROUND

Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society.

OBJECTIVES

The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society.

METHODS

A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses.

RESULTS

In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique.

CONCLUSIONS

High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.

A Six-Year Review of the Latest Oculoplastic Surgical Development

PURPOSE

The aim of this study was to summarize the literature from 2012 to 2018 on 4 common cosmetic periocular operative procedures including epicanthoplasty, lateral canthoplasty, and upper and lower blepharoplasty.

DESIGN

Systematic review of epicanthoplasty, lateral canthoplasty, upper and lower blepharoplasty in the period of 6 years.

METHODS

A systematic MEDLINE search by 2 independent reviewers was performed on PubMed using the search terms (blepharoplasty) OR double eyelid) OR lateral canthopexy) OR fat repositioning) OR epicanthoplasty) OR love band) AND (From January 2012 to January 2018).

RESULTS

After screening 1456 abstracts from search results, 1377 were eliminated due to irrelevant content. Full text of the remaining 79 articles and relevant cross-references were reviewed and summarized. Studies on cosmetic epicanthoplasty reported Z-plasty or modifications (n=8), advancement flap (n=4) or skin redraping procedures (n=1), removal or release of the orbicularis muscle (n = 14), with (n = 6) or without (n = 11) tightening medial canthal tendon. In lateral canthoplasty, approaches to preserve continuity of eyelid margin prevent lateral canthal deformity with inconspicuous incision via gray line (n = 2) or upper eyelid (n = 2) were described. Techniques of upper blepharoplasties described included open incision method (n = 9) with (n = 5) or without (n = 3) orbicularis resection, subbrow approach (n = 1), nonincisional suture blepharoplasty (n = 2), or partial incision blepharoplasty (n = 1). For lower blepharoplasties, techniques described included blepharoplasty with fat transposition (n = 7), transconjunctival blepharoplasty (n = 3), transcutaneous blepharoplasty and canthopexy (n = 1) or orbicularis flap (n = 2), minimally invasive or laser-assisted blepharoplasty (n = 2).

CONCLUSIONS

The recent trend of periocular surgical rejuvenation focuses on preserving soft tissue volume, avoiding skin or use hidden incision, taking the eyebrow and midface position into account, and measures to minimize iatrogenic eyelid malposition.

The Mathematical Analysis of the Aesthetically Pleasing Eyelid

PURPOSE

To analyze and quantify the characteristics and parameters of the eyelid and adnexa of males and females and correlate these findings to an aesthetically pleasing score.

METHODS

This is an Institutional Review Board approved study involving healthy male and female volunteers. The margin-to-reflex distance, palpebral fissure, inferior scleral show, tarsal platform show, and brow fat span were measured using Image J digital photographic analysis and the images were scored by 110 non-ophthalmologists. The eyelid parameters were compared between the groups with Student t tests and the total aesthetic score was correlated to the measured parameters with Pearson's correlation coefficients (r). This study was HIPAA-compliant with protection of individually identifiable information.

RESULTS

Twenty male and 22 female participants were included and divided into 2 groups based on the aesthetic score. The average aesthetic score was 3.06 for males and 3.36 for females. None of the eyelid parameters were found to be significantly significant between the 2 male groups. In females, both inferior scleral show and tarsal platform show were significantly lower in the more aesthetic group. A greater margin-to-reflex distance correlated with increased aesthetic appeal. The ratio of brow fat span/tarsal platform show was not significantly different between the 2 female groups.

CONCLUSIONS

Quantifying goals are important for the surgical and nonsurgical management of the eyelid and periorbita. Beauty is considered to be subjective and is comprised of various criteria. However, this study reveals that the female sex may have certain quantifiable goals for eyelid parameters that are considered more aesthetically pleasing.

Effect of Eyelid Crease Formation on Aesthetic Outcomes post Frontalis Suspension for Unilateral Ptosis

Background:

The eyelid crease plays a very important role in determining eyelid symmetry. This study was performed to compare the cosmetic results post silicone rod frontalis suspension surgery, performed with and without eyelid crease formation, for correction of unilateral, congenital ptosis.

Methods:

Prospective, interventional study. One hundred patients with unilateral, congenital ptosis, with poor levator muscle action, operated on by a single facial plastic surgeon, over 5-year duration (2011–2016). Group I had 50 patients, who underwent silicone sling (Bvi Visitec) frontalis suspension surgery. Group II had 50 patients, who underwent frontalis suspension silicone sling (Bvi Visitec) surgery, in combination with eyelid crease formation and levator muscle excision (when required). The cosmetic outcomes were evaluated by the patients themselves and by 3 blinded physician observers and recorded objectively via a 5-point questionnaire, after a 1-year follow-up.

Results:

Patients in group II were much more satisfied than the patients in group I, as confirmed by the subjective and objective evaluations.

Conclusion:

The silicone sling frontalis suspension surgery, when combined with eyelid crease creation and levator excision procedure (when required), provides better symmetry, superior cosmesis, and excellent patient satisfaction.

Horizontal Forehead Lines: A Reflection of Eyelid Ptosis or Blepharodermachalasia

BACKGROUND

In his facial aesthetics practice, the senior author (B.G.) observed that many patients presenting with horizontal forehead lines also demonstrated upper eyelid ptosis or enough blepharodermachalasia to require compensation. This study was conducted to investigate this observation.

METHODS

Photographs of patients presenting for facial rejuvenation were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasia. Patient age, gender, and race were reported. Only patients over age 50 were included. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5-mm overlap between the upper eyelid and the iris. Patients were divided into two groups based on presence of forehead lines for comparative analysis.

RESULTS

One hundred sixty patients, including 100 patients with and 60 patients without horizontal forehead lines, were included. Patients with forehead lines were likely to be older (age 61.56 ± 8.93 vs. 58.58 ± 7.59; P = 0.0337), male (36 vs. 11.67%; P = 0.0008), have ptosis (90 vs. 76.67%; P = 0.0377), and have blepharodermatochalasis (20 vs. 5%; P = 0.0097). All 28 patients with unilateral forehead lines (17 left, 11 right) had ipsilateral ptosis.

CONCLUSIONS

Ptosis and blepharodermatochalasis may result in the development of horizontal forehead lines through compensatory frontalis activation. Whenever horizontal forehead rhytids are noted, it is imperative to search for ptosis or blepharodermachalasia in repose. Otherwise, forehead rejuvenation may fail to eliminate these compensatory forehead lines, and chemodenervation may have significant adverse effects on the visual field by forcibly blocking frontalis compensation.

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 .

Effect of iris show on perceived upper eyelid height

OBJECTIVE

To introduce "iris show," the amount of visible iris tissue between the superior pupil border and the upper eyelid margin, to evaluate the effect of iris show on perceived upper eyelid height, and to discuss potential nonsurgical treatment options for mild blepharoptosis.

METHODS

Participants completed a survey containing 4 subject photographs. These photographs depicted images of varying iris colouration (blue, green, light brown, and dark brown) with identical upper eyelid marginal reflex distance (MRD1) values, but asymmetric pupil size/amount of visible iris show. Study participants were asked to select the eyelid that appeared "droopier," or choose "same height." Statistical analyses used 1-tailed and 2-tailed t tests.

RESULTS

390 participants completed the survey. In photographs of blue and green irides, both eyelids had equal MRD1s, but the eyelid with less iris show was perceived as more ptotic (p = 0.002 and 0.03, respectively). In patients with dark brown irides, eyelid heights were perceived as identical despite differences in iris show (p = 0.002).

CONCLUSIONS

Decreased iris show corresponds to perceived lowering of the upper eyelid in light-coloured irides (e.g., blue and green), but may be less impactful in brown and/or dark brown irides where the iris tissue is less distinguishable from the pupil. Topical instillation of apraclonidine may represent a nonsurgical option for treatment of mild blepharoptosis in patients with light irides as it both elevates the upper eyelid margin and induces miosis, resulting in an increase in iris show and corresponding enhanced perception of upper eyelid elevation.

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