Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members

The Incidence of Strabismus After Upper and Lower Blepharoplasty in the United States

PURPOSE

To compare the incidence of strabismus after upper and lower blepharoplasty in the United States.

METHODS

Retrospective cohort study of adults (age ≥18 years) in the IRIS Registry (Intelligent Research in Sight) who underwent blepharoplasty between January 1, 2013 and December 31, 2020. The primary outcome was the Kaplan-Meier estimated cumulative incidence of strabismus diagnosis and surgery within 3 years of blepharoplasty. Multivariable Cox regression was used to determine the association of blepharoplasty type with strabismus diagnosis and surgery, adjusting for patient age, sex, and geographic region.

RESULTS

Blepharoplasty was performed in 368,623 patients (median [interquartile range] age, 69 [63-75] years, and 69% female). Compared with those undergoing upper eyelid blepharoplasty, patients treated with lower eyelid blepharoplasty were slightly younger (median age, 66 vs. 69 years; p < 0.001) and more likely to be female (71% vs. 69%; p < 0.001). There was a greater 3-year incidence of strabismus diagnosis (2.0% vs. 1.5%; p < 0.001) and a greater 3-year incidence of strabismus surgery (0.15% vs. 0.06%; p = 0.003) for individuals undergoing lower vs. upper blepharoplasty. After adjusting for age, sex, and geographic region, lower blepharoplasty was associated with a higher 3-year risk of strabismus diagnosis (HR, 1.49; 95% CI, 1.23-1.81; p < 0.001) and surgery (HR, 2.53; 95% CI, 1.27-5.03; p = 0.008).

CONCLUSIONS

This registry-based analysis found that individuals undergoing lower eyelid blepharoplasty were at higher risk of strabismus compared with those undergoing upper eyelid blepharoplasty. Using large databases to understand the incidence of complications of frequently performed procedures may improve ophthalmologists' ability to provide data-driven counseling on surgical risks prior to intervention.

Supraperiosteal fat repositioning with midface lift in lower eyelid blepharoplasty: an 18-year experience

PURPOSE

To assess the clinical outcomes of fat repositioning via supraperiosteal dissection with midface lift for correction of tear trough deformity in a large Asian patient population.

METHODS

Retrospectively review 1152 Asian patients who underwent fat repositioning to the supraperiosteal plane with a midface lift between 2005 and 2022. Surgical technique, postoperative course, and complications were recorded. At the 6-month postoperative follow-up, the degree of patient satisfaction was assessed.

RESULTS

A total of 2304 eyes from 1152 patients with an average follow-up of 10 months. These procedures were performed using a transforniceal approach in 185 patients (16%) or a transcutaneous skin excision approach in 967 patients (84%). Among the patients who underwent the transcutaneous technique, seven individuals (0.6%) experienced effective treatment of lower lid ectropion through lateral tarsal strip procedures. Nine patients (0.7%) required revision surgery to address the remaining lateral fat pad due to inadequate lateral orbital fat excision during the initial procedure. At the 6-month follow-up, most patients reported a high level of satisfaction, with 800 patients (78%) expressing extreme satisfaction and 196 patients (19.1%) reporting satisfaction with the improvement in their appearance. No one reported facial numbness, lower eyelid or cheek paralysis, newly developed diplopia or granuloma formation.

CONCLUSION

The procedure of fat repositioning involving supraperiosteal dissection and a midface lift, whether performed using a transforniceal approach or a transcutaneous skin excision approach, in lower eyelid blepharoplasty proves to be a secure and auspicious surgical technique for rectifying tear trough deformity and attaining a pleasing aesthetic outcome.

The Whitnall Barrier: A Technique for the Management of Lacrimal Gland Prolapse

BACKGROUND

The Whitnall barrier procedure, a modified Beer and Kompatscher surgical technique to reposition the lacrimal gland, is presented alongside a case series of patients demonstrating excellent aesthetic and functional outcomes.

METHODS

The Whitnall barrier procedure is illustrated procedurally and accompanied by a case series of 20 consecutive patients treated in a single institution by a single surgical team between December of 2016 and February of 2020. Lid contour and function were assessed postoperatively, as was patient satisfaction.

RESULTS

Thirty-seven eyes of 20 patients were included. All patients were women, with an average age of 50 years. Fourteen patients underwent surgery for cosmesis, four had inactive thyroid eye disease, and two had lacrimal gland enlargement secondary to dacryoadenitis. The degree of lacrimal gland prolapse was described as mild in two eyes and moderate in 35 eyes. All patients had one or more additional surgical procedures. Mean follow-up duration was 11 months, with complete resolution of lacrimal gland prolapse in 34 eyes. The patient who did not have complete resolution had dacryoadenitis and required ongoing immunosuppressive therapy. Two patients were discharged on topical lubricants: one with thyroid eye disease and one cosmetic patient who underwent upper and lower lid blepharoplasties at the same time. There were no intraoperative complications and no incidences of infection, dehiscence, or damage to the lacrimal gland ductules.

CONCLUSIONS

The Whitnall barrier technique is a safe and effective surgical procedure to restore the anatomic location of the lacrimal gland. It provides excellent aesthetic and functional outcomes.

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty

BACKGROUND

Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks.

OBJECTIVES

The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB.

METHODS

Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared.

RESULTS

There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2).

CONCLUSIONS

The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

LEVEL OF EVIDENCE: 4

A Novel Approach to Reduce Lid Weight in the Upper Eyelid Blepharoplasty: Split-Thickness Excision of the Palpebral Part of Orbicularis Oculi Muscle

OBJECTIVES

With the effect of advancing age and environmental factors, excess skin and muscle start to weigh on the eyelids and cause a tired facial expression. The prevailing opinion is that by partially excising muscle in surgical treatment, this load on the eyelid will be reduced, and more successful results will be obtained. Using a classic strip orbicularis oculi excision, the integrity of the muscle is disrupted, and morbidities such as lagophthalmos and edema increase. In this paper, we share our clinical experiences regarding the split excision of the palpebral part of the orbicularis oculi muscle and the subsequent process.

METHODS

Twenty-seven patients who applied to our clinic to undergo blepharoplasty were operated on under local anesthesia. The orbicularis oculi muscle was split-excised together with the skin from the marked areas.

RESULTS

The split excision of the orbicularis oculi muscle did not cause prolonged edema. The general appearance of the eyelid and face of the patients was observed to have significantly improved in the third month after surgery compared with the preoperative period. No complications such as wound healing, hypertrophic scar, asymmetry, or infection were observed during the follow-up period.

CONCLUSIONS

The split excision of the orbicularis oculi muscle can be considered a new and effective method in cases in which a muscle excision is planned as part of blepharoplasty. Prolonged edema due to the strip muscle excision is not observed clinically. This technique can eliminate the negative effects of excess muscle tissue on the eyelid without disrupting the integrity of the muscle.

LEVEL OF EVIDENCE

Evidence Based Medicine Level V.

Modified Lacrimal Gland Suspension Technique in Patients Who Underwent Upper Eyelid Blepharoplasty

AIM

The aim of the present study was to evaluate the efficacy of modified lacrimal gland suspension surgery combined with upper lid blepharoplasty.

METHODS

Between December 2020 and December 2021, 365 patients admitted to our clinic for ptosis were included in the study. The data of 89 patients who underwent upper lid blepharoplasty with lacrimal gland repositioning for dermatochalasis were analyzed.

RESULTS

Combined surgery was performed in 24.38% of the patients included in the study; 16 (17.9%) of these patients were males and 73 (82.1%) were females, and the mean age of the patients was 47.34 ± 8.13 years. The mean follow-up period was 16.42 ± 2.63 months. In patients who underwent lacrimal gland suspension, 72 (85%) of the patients complained of swelling on the outer part of the upper lid before surgery. However, 9 (10.11%) of the patients did not have lacrimal gland prolapse, and only fat prolapse was present in these patients. No complication or recurrence was observed in any patient during the follow-up period.

DISCUSSION

With the new modified technique, the lacrimal gland can be suspended close to the anatomical position, and satisfactory results can be obtained for both the patient and the surgeon.

Evaluation of the Risk of Hypertrophic Scarring and Keloid Following Eyelid Procedures: A Systematic Review

BACKGROUND

Eyelid surgeries are common operations performed for both cosmetic and functional purposes. Because the periorbital region is highly visible, it is important to avoid poor scar formation in this cosmetically sensitive region. No study to date has investigated the possible existence of keloid formation following eyelid procedures.

OBJECTIVES

This study systematically reviewed the literature to identify cases of hypertrophic scar and keloid formation following cosmetic or functional (nonburn) eyelid procedures to aid surgeons when counseling patients.

METHODS

A PubMed/MEDLINE search was conducted on May 17, 2022, using appropriate search terms: "blepharoplasty," "tarsorrhaphy," "canthotomy," "ptosis repair," "epicanthoplasty," "keloid," "hypertrophic scar," and related lay terms. All eligible articles in English with no lower date limit were included for analysis. Descriptive statistics, exclusion criteria, and summarized results are reported.

RESULTS

The PubMed search yielded 107 abstracts/articles. Full-text review resulted in 34 articles included for analysis. Twenty manuscripts reported no occurrences of hypertrophic scars. Only 13 manuscripts reported patients with hypertrophic scarring, which equated to 36 patients out of 3650. One individual was identified in a series of 77 patients who developed a keloid after a tarsorrhaphy. No articles reported a keloid as an outcome of strictly cosmetic procedures.

CONCLUSIONS

This study concludes that there are no reported instances of keloid formation following cosmetic (nonburn) eyelid procedures in the existing literature. Hypertrophic scar formation is minimally reported. The absence of keloid scar formation on the eyelid is critical knowledge for surgeons when educating patients about maladaptive scarring risks following eyelid procedures.

LEVEL OF EVIDENCE: 4

Comprehensive Treatment of Lower Eyelid Plasty Based on Intraoral Fixation and Redistribution of Lower Eyelid Fat

BACKGROUND

Eye bags especially give an impression of aging and mental exhaustion. At present, the surgical methods of bags mainly include conjunctival approach and lower eyelid skin approach. With the continuous upgrading of the concept of facial esthetics, the lower eyelid pouch surgery for middle-aged and elderly patients pays more attention to reducing surgical trauma, improving tear trough deformity along with the effacement of lid‑cheek junction.

OBJECTIVE

This paper discusses the clinical effect of the lower lid blepharoplasty involved orbital septum fat repositioning based on oral fixation via conjunctival approach combined with relaxation skin resection in the treatment of eye bags in elderly patient.

METHODS

Fifty elderly patients underwent blepharoplasty between January of 2021 and June of 2021 at our hospital. The lower eyelid orbital septum fat was released along with the prezygomatic space and the premaxillary space were stripped through the conjunctival approach. The released cellulite was redistributed in the prezygomatic space/premaxillary space and fixed in the oral vestibular with 5-0 Polysorb through the middle facial tunnel. Finally, the appropriate skin was finally removed.

RESULTS

After operation, 48 patients were satisfied with the operation results, with tight lower eyelid skin and natural lid‑cheek junction. One patient with conjunctival infection was cured after 7 days of antibiotic eye drops. One patient felt foreign body when chewing, and the symptoms disappeared naturally after 5 days without treatment.

CONCLUSION

For middle-aged and elderly patients with bags, the surgical method in this study not only has good postoperative effect, but also has small damage to the lower eyelid orbicularis muscle. The appearance is natural and the lower eyelid skin is tight. The effacement of lid‑cheek junction and recreating a smooth transition of lower lid cheek interface, which can correct lacrimal groove deformity. The patients have high acceptance and satisfaction, which can be widely used in clinical practice.

Lower Eyelid Transcutaneous Blepharoplasty, Minimizing Complications and Correction of Lower Eyelid Malposition

The periocular area is one of the first and most noticeable areas affected by ageing. Common signs of lower lid ageing include rhytids, prominent eye bags caused by prolapse of orbital fat pads, increased lid laxity leading to lid malpositioning, and deepening of tear troughs, all of which give a sunken aged appearance. Lower lid transcutaneous blepharoplasty can correct most of these problems providing excellent long-term aesthetic outcomes with minimal downtime for the patient. However, lower eyelid anatomy is complex, and a thorough understanding of its structure and function is needed to avoid serious complications such as lid malpositioning and blindness. In this review, we present the anatomy of the lower lid and useful surgical techniques to circumvent and avoid such complications.

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Global Research Trends and Perspectives of Blepharoplasty: A 20-Year Bibliometric Analysis Based on Web of Science

BACKGROUND

The number of publications on blepharoplasty is increasing rapidly. Bibliometric analysis can help surgeons quickly and systematically understand the current state of development. To our knowledge, there are no bibliometric studies on blepharoplasty, and therefore, we conducted this study to reveal research trends and perspectives of blepharoplasty.

METHODS

Relevant publications from 2002 to 2021 were extracted from the Web of Science Core Collection database. After manual screening, VOSviewer software and CiteSpace software were used to collect and analyze the acquired data.

RESULTS

A total of 1125 publications were included and the publications per year increased annually. Contributions from the USA led both quantity and quality. The University of California System was one of the most influential academic institutions. Aesthetic Plastic Surgery had the most publications, and Plastic and Reconstructive Surgery was the most frequently cited or co-cited journal. Massry GG and Hamra ST were the most prolific and co-cited authors, respectively. Additionally, Rohrich RJ had the highest number of citations per publication. References co-cited analysis identified that lower eyelid research was a hotspot. Keywords were mainly divided into 6 clusters, namely "lower lid blepharoplasty," "complications," "facial rejuvenation," "blepharoptosis," "upper blepharoplasty," and "Asian blepharoplasty and epicanthoplasty."

CONCLUSIONS

Blepharoplasty research is flourishing, and three clusters may be the hotspots: "Lower blepharoplasty and mid-face rejuvenation," "overall facial outcome and quality-of-life," and "Asian blepharoplasty and epicanthoplasty."

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 .

Vectra 3D Simulation in Lower Eyelid Blepharoplasty: How Accurate is it?

BACKGROUND

Estimating the volume of fat to be resected during lower lid blepharoplasty can be challenging. While the excess fat is clearly visible in the upright position, it retracts into the orbital cavity when the patient is in decubitus. Several tools have been developed to predict the volume required for adequate outcomes and to reduce the risk of complications. Among these, 3D photography, in addition to being noninvasive, radiation-free, portable and relatively inexpensive, can be used to make simulations.

OBJECTIVE

To assess the level of agreement between Vectra H1 camera simulations and the outcome of lower eyelid blepharoplasties with volume removal based on these simulations.

METHODS

Preoperatively, a 3D camera and simulation software (Vectra H1, Canfield Imaging Systems) was used to estimate the fat pad volume to be resected from the lower eyelids in a sample of 35 patients (female n = 34) aged 55 years on average. Following the procedure, the patients were photographed at 1, 3 and 6 months and the outcome was compared to the simulation.

RESULTS

The agreement between the simulated volume and the intraoperative volume was high. While the difference between the postoperative volume and the simulated volume decreased over time, at 6 months the actual volume was still 0.30 mL (right eye) and 0.24 mL (left eye) larger than the simulated volume.

CONCLUSIONS

A systematic and significant difference was found between the simulation volume and the postoperative volume. The low level of agreement observed suggests that the accuracy of the tested software is insufficient for reliable simulations.

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 .

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).

Cheek-midface lifting with lateral canthoplasy for the repair of complex iatrogenic lower eyelid ectropion

PURPOSE

To assess the efficiency and safety of cheek-midface lifting for the ophthalmoplastic reconstructive surgical repair of cicatricial lower eyelid malpositions after previously failed surgery.

METHODS

In two ophthalmoplastic clinics, 14 eyelids of 13 patients underwent transconjunctival cheek-midface lifting. In a retrospective audit, changes in margin-reflex distance 2 (MRD2), snap-back test, the position of the eyelid after surgery including improving of the presurgical scleral show, the overall patient's satisfaction as well as complications after surgery were recorded.

RESULTS

Following transconjunctival cheek-midface lifting, there was a significant improvement of MRD2, snap-back test, and the scleral show (p < 0.001, respectively). However, in three patients the scleral show persisted despite improved MRD2. All patients were satisfied with the results of the surgery. No post-surgical long-term complications were developed.

CONCLUSION

Cheek-midface lifting can be a useful technique in severe cicatricial lower eyelid ectropion after previously failed surgery and is a safe and effective reconstructive method for ophthalmic surgeons with good cosmetical results and little postoperative long-term complications.

A Modified Procedure for Single-eyelid Asian Females with Lacrimal Gland Prolapse: Lacrimal Gland Reposition combined with Fat Transposition in Double-eyelid Operation

BACKGROUND

The awareness and treatment of lacrimal gland prolapse (LGP) have been primarily improved with a further understanding of lateral eyelid bulging over the decades. However, for Asian single-eyelid females with LGP, a tailor-made procedure applicable to their comparatively young puffy eyes is needed.

METHODS

This is a retrospective study. From Jan. 2009 to Jan. 2019, two hundred and three Asian single-eyelid females with LGP, who met the inclusion criteria, underwent double-eyelid surgeries and adjunctive lacrimal gland repositions with preaponeurotic fat transposition. Pertinent demographics, complications, pre-and post-operative photography were collected.

RESULTS

A total of 167 patients completed the 4-24 months' follow-up (average: 16.3 months). One hundred and thirty-two cases (79.0%) were diagnosed as LGP preoperatively, and the rest (35/167, 21.0%) were diagnosed intraoperatively. All patients (average: 28.4 years old) received modified blepharoplasty. Postoperative symptoms involving local mild pain (2.9%, 5/167), upper eyelid tightness (3.6%, 6/167), and moderate epiphora (9.0%, 15/167) were all recovered spontaneously within one month. Prolapse recurrence and severe complications such as dry eye syndrome were not observed.

CONCLUSIONS

We proposed a modified procedure to enhance the diagnosis and treatment of LGP during Asian blepharoplasty. The lacrimal gland suspension and fat transposition assured the cosmetic outcome for selected young, puffy Asian eyes. The supratarsal creases were satisfactory, and the complication rate was low. Furthermore, the rearrangement of preaponeurotic fat smoothed the contour transition and preserved the orbital volume. Therefore, this is a safe and effective technique worth recommending.

Lower eyelid blepharoplasty: An overview

Of the two common techniques of lower blepharoplasty, the transconjunctival approach is limited to young patients with prominent herniation of lower fat pad without skin excess and the transcutaneous approach to patients requiring skin excision. However, the current trends not only highlight the traditional sculpting of the three orbital fat pads in lower lid blepharoplasty but also additional relocation of the intraorbital fats for correcting the inferior orbital hollowing. The purpose of this review is to analyze the published literature on common types, techniques, indications, and outcomes of the multiple surgical variants of lower lid blepharoplasty often aimed at treating the redundant skin, steatoblepharon, tear trough deformity, lid laxity, and dermatochalasis, thereby to correct the negative vector and inferior orbital hollowing along with effacement of the lid cheek junction. An extensive survey of peer-reviewed literature published in English in electronic databases, as well as bibliographies from cited articles, was conducted. Databases such as MEDLINE PubMed, the Cochrane Library, and Embase were scanned using relevant medical subject heading (MeSH) terms. Clinical studies with a minimum of five study cases were included. Level III evidence, case reports, letters, editorials, and case series with fewer than five eyes were excluded. This article provides a concise overview of available literature and as such no meta-analysis was done due to the narrowed scope of the involved studies and the variety in surgical approaches and techniques of lower lid blepharoplasty.

Transconjunctival Lower Lid Blepharoplasty with and Without Fat Preservation and Skin Resurfacing

Transconjunctival lower lid blepharoplasty is a safe and effective procedure with a low complication rate. Success with this procedure depends on proper patient analysis and selection. The lower lid periorbital fat can be resected, or preserved, and draped over the orbital rim or used as free fat grafts, depending on the clinical presentation. The lower lid skin can be resurfaced with a peel, with a laser, or by skin pinch depending on surgeon preference.

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.

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.

Comparison of tumescent local anesthesia vs normal anesthesia technology in upper blepharoplasty in Asian women

BACKGROUND

Blepharoplasty is the most common type of plastic surgery, used to improve most of the eyelid skin sag caused by aging. In the past, local infiltration anesthesia was widely used in blepharoplasty. Tumescent local analgesia (TLA) is safe and reliable method for anesthesia, even children can use this method.

AIMS

This research aimed to systematically compare the differences between conventional local infiltration anesthesia and TLA in blepharoplasty.

PATIENTS/METHODS

One hundred and seventy-eight bilateral upper blepharoplasty patients participated in this research. Visual analog scale (VAS) was employed to evaluate the postoperative pain in the patients. Periorbital appearances are based on light photography and judged by both medical and nonmedical panel.

RESULTS

The use of TLA decreased the surgery duration but had no influence on the other surgery characteristics of upper blepharoplasty. Using TLA for anesthesia in bilateral upper blepharoplasty generated less pain than using local infiltration anesthesia. At day 7 after upper blepharoplasty, the rate of generation of both ecchymosis and erythema in normal anesthesia (NA) side were higher than in TLA side. The satisfaction of patients after upper blepharoplasty was not influenced by the use of different anesthesia methods.

CONCLUSION

Compared with the normal anesthesia technology, the use of TLA in the upper blepharoplasty shortened the surgery duration, alleviated the postoperative pain, and mitigated the generation of ecchymosis and erythema. So, TLA is suitable for the performance of anesthesia in blepharoplasty.

Diplopia following lower blepharoplasty

PURPOSE

To investigate the likelihood of surgeons performing lower blepharoplasties having cases of diplopia persisting for more than 1 week after surgery.

METHODS

An anonymous survey (13 questions) on the frequency and characteristics of persistent diplopia (lasting >1 week) after lower blepharoplasty was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery.

RESULTS

Of 703 members, 371 (52.8%) responded to the survey. Of these, 86 (23.2%) had at least 1 case of persistent diplopia following lower blepharoplasty. Complete data were available for 84 of the 86 physicians. The inferior oblique muscle was involved in 51 cases (61%), the inferior rectus muscle in 7 cases (8%), both the inferior oblique and inferior rectus muscles in 4 cases (5%), and the muscle involved was not identified in 22 patients (26%). The diplopia was paretic in 49 patients (58%) and restrictive in 35 (42%). The diplopia persisted in primary position in 7 patients (8%), in gaze positions other than primary position in 16 patients (19%), and resolved completely in 61 patients (73%).

CONCLUSIONS

There is a significant chance of surgeons performing lower blepharoplasties having at least 1 case of diplopia lasting over a week postoperatively. Our survey results indicate that this complication may be more common than is suggested by the medical literature.

Application of Orbital Septum Fat Flap Stuffing to Correct Inferior Orbital Sulcus Deformities

The inferior orbitopalpebral sulcus deformity is challenging during lower eyelid blepharoplasty. Plastic surgeons are currently addressing each case individually, depending on the patient’s unique circumstances. Nevertheless, patients with large orbital grooves often complain that the inferior orbitopalpebral sulcus is not sufficiently improved. Altogether, 189 patients underwent transcutaneous blepharoplasty. According to their local anatomy, 98 underwent transcutaneous blepharoplasty surgery only, 59 had it combined with arcus marginalis release, and 32 had it combined with orbital septum fat flap stuffing. For the latter 32 patients, the orbital fat was trimmed and flipped to roll over the edge 10 mm from the infraorbital rim to form a base to repair the tear trough deformity and palpebromalar groove. Excessive dermatochalasis was removed, excrescent bulging fat was released, and the sulcus deformity was flattened using the orbital fat flap. The cosmetic results were satisfactory. Releasing the orbital septal fat helped restructure the deformity. The lower eyelid bags and lower orbital sulcus deformities were well corrected, allowing recovery with a convex-type facial contour. Using an orbital fat flap to treat a tear trough deformity and palpebromalar groove is effective and safe. Careful performances by surgeons can avoid serious complications. This operation satisfies both patients and surgeons.

Subunit Approach to Facelifting and Facial Rejuvenation

Facial analysis techniques traditionally separate the upper, middle, and lower facial thirds as distinct entities without guidance in achieving aesthetic youthfulness. There is now an opportunity to develop better analytical tools and specific algorithms to help create an overall harmony to the face and restore a youthful appearance. Facial anatomic subunits have similar three-dimensional qualities based on underlying anatomic structures, craniofacial skeletal modeling, superficial and deep facial fat compartments, skin thickness, facial muscle activity, and curvature (flat, convex, concave). This article discusses using the relationships of the facial anatomic subunits to obtain more consistent and natural facial rejuvenation outcomes.

Lacrimal gland prolapse in upper blepharoplasty

Purpose: To report the characteristics of lacrimal gland prolapse among the patients who underwent upper blepharoplasty.Materials and Methods: In a retrospective study, consecutive upper blepharoplasty patients with significant lacrimal gland prolapse were included. The degree of prolapse was measured as anterior protrusion of lacrimal gland from the orbital rim. Reposition of the lacrimal gland was performed by using non-absorbable sutures to fixate the gland to the periosteum of lacrimal fossa. In cases with unusually large lacrimal glands, an incisional biopsy of the gland was obtained. The orbital septum was left unsutured.Results: Twenty patients (19 females and one male) out of a total of 198 patients who underwent upper blepharoplasty (10.1%) had clinically significant lacrimal gland prolapse. Mean age was 54.8 ± 9.4 years (range, 31-69). Fourteen patients (70%) were asymptomatic. Anterior protrusion of lacrimal gland was measured to be 6.4 ± 1.2 mm (range, 5-10 mm) from the orbital rim. Incisional biopsy of the lacrimal gland was obtained in 10 patients (50%). Nine biopsies showed mild chronic inflammation and one revealed only normal lacrimal gland tissue. Postoperative course was uncomplicated in 15 patients (75%), with mild symptoms in the others and only one instance of mild unilateral recurrence of lacrimal gland prolapse.Conclusions: Reposition of a prolapsed lacrimal gland is a safe and effective adjunctive procedure in upper blepharoplasty, with minimal complications and acceptable postoperative outcome. Prolapsed lacrimal glands showed mild inflammation which could be due to repetitious movements of a lax gland, although various other etiologies can be involved.

Demographic Differences Among Patients Undergoing Blepharoplasty Based on Surgeon Training in New York State

PURPOSE

To evaluate whether patient demographics and surgical metrics varied among differently trained surgeons performing blepharoplasty.

METHODS

The Statewide Planning and Research Cooperative System database was used to identify patients who underwent blepharoplasty in New York State. Surgeons were grouped based on residency training as listed in the New York State Physician Profile. Multivariate regression analysis was used to determine predictors of patient characteristics based on surgeon training.

RESULTS

There were 361 surgeons who performed 39,932 cases of blepharoplasty in New York State from 2008 to 2016. When aggregated by surgeon training, there were significant differences among procedure times and total charges for blepharoplasty. On average, cases performed by ophthalmologists took 66.7 minutes and patients were charged $6,860; cases performed by otolaryngologists took 158.2 minutes and patients were charged $9,084; and cases performed by plastic surgeons took 131.8 minutes and patients were charged $11,028. Unlike plastic surgeons or otolaryngologists, ophthalmologists tended to have older patients and more male patients. Ophthalmologists were more likely to operate on patients with comorbidities as well as non-white patients (p < 0.0001). They were also significantly more likely to have patients with insurance coverage than self-pay (p < 0.0001).

CONCLUSIONS

Demographic and surgical metrics of blepharoplasty cases performed by surgeons trained in otolaryngology and plastic surgery are similar. Ophthalmology-trained surgeons performed blepharoplasty on patients that were more likely to be older, male, non-white, and had insurance coverage. Ophthalmologist procedure time for blepharoplasty was also less than half of the procedure time of otolaryngologists and plastic surgeons.Blepharoplasty is a surgical procedure commonly performed by ophthalmologists, otolaryngologists, and plastic surgeons to address cosmetic concerns or visual impairment related to the eyelids.

The Outcomes Assessment of the Plasma Blade Technology in Upper Blepharoplasties: A Prospective Study on a Series of 25 Patients

BACKGROUND

The Dermo Ablation Surgery (DAS) Medical® (Technolux, Italy) device is a plasma blade which induces a plasma voltaic arc causing a retraction in the epidermis and superficial dermis.

OBJECTIVE

The aim of our study is to prove the efficacy and safety of the DAS Medical® device in dermatochalasis size reduction.

METHODS

Our prospective study included 25 adult patients presenting with upper eyelid dermatochalasis undergoing a two-session treatment protocol with the DAS Medical® device (with a month treatment-free interval). The primary end point was the reduction in the size of the dermatochalasis. The secondary end points were patient satisfaction, and a blinded assessment of the outcomes was carried out by 15 plastic surgery specialists on post-procedural pictures.

RESULTS

The mean reduction in the size of the dermatochalasis was estimated at 2.47 mm on a 6-month follow-up (13.5 mm at T0 vs. 11.03 mm at 6 months, p = 0.0002) and 1.97 mm on a 12-month follow-up ((13.5 mm at T0 vs. 11.53 mm at 12 months, p = 0.0055). Eighty per cent of the patients and 78% of the assessing clinicians were globally satisfied with the results on a 12-month follow-up. The mean visual analogue pain score reported during the treatment was 4.5/10; MEOPA® was used in 23% of cases. No irreversible post-procedural sequelae (complications) were observed.

CONCLUSION

Voltaic plasma arc treatment with DAS Medical® is an effective technique for non-invasive blepharoplasty on moderate dermatochalasis patients not suffering from palpebral lipoptosis and is very well tolerated. It can be usefully and successfully associated with 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 .

[Update on upper eyelid blepharoplasty]

BACKGROUND

Upper eyelid blepharoplasty is among the most frequent oculoplastic surgical procedures. It is often performed as one of the first esthetic surgical interventions by surgeons of various disciplines. While there is a high probability of happy and satisfied patients postoperatively, there are important potential surgical complications that should be prevented. This requires a careful preoperative, perioperative and postoperative approach.

OBJECTIVE

This synopsis presents the basic considerations concerning upper eyelid blepharoplasty to serve as practical surgical guidelines.

MATERIAL AND METHODS

This is a compendium of important preoperative, perioperative and postoperative contemplations derived from the medical literature, expert opinions and the authors' personal experiences.

RESULTS

Careful examination and documentation of eyelid and periorbital findings are required in order to identify additional pathologies to dermatochalasis and plan the surgical approach accordingly. There is a trend in the literature and in expert opinions away from large tissue resection and towards volume preserving and volume reconstructing surgical techniques. Correct placement of the skin fold as well as maintaining lid symmetry are crucial points in order to achieve a natural appearance and patient satisfaction.

CONCLUSION

Careful and realistic patient information, state of the art surgery including cautious tissue resection and correct symmetrical formation of the skin fold as well as postoperative assistance and availability increase the likelihood of satisfied patients after blepharoplasty.

Antibiotic use in facial plastic surgery

PURPOSE OF REVIEW

The aim of this study was to review and discuss recent literature regarding perioperative use of antibiotics in the context of facial plastic surgery.

RECENT FINDINGS

Despite research efforts, there continues to be insufficient evidence in support of, or against, the use of antimicrobial prophylaxis.

SUMMARY

Current available evidence regarding antibiotic use in facial plastic surgery procedures fails to demonstrate routine benefit. Therefore, the advantages accompanying administration of preoperative antibiotics should be weighed against any potential complications on a case-by-case basis. Future large-scale prospective studies will be beneficial in developing standardized criteria directing appropriate antibiotic use.

Lower Eyelid Blepharoplasty: Does the Literature Support the Longevity of this Procedure?

BACKGROUND

Lower eyelid blepharoplasty has continued to evolve with ongoing debate regarding optimal techniques. Despite large case series publishing excellent results and minimal complications, the true longevity of these procedures remains unclear.

OBJECTIVES

The aim of this study was to determine how thoroughly the aesthetic surgery literature assesses the longevity of lower blepharoplasty.

METHODS

A 20-year comprehensive literature review from 1997 to 2017 was conducted. The titles and abstracts of 180 articles were reviewed, yielding 86 potential publications; 49 studies met inclusion criteria and were analyzed.

RESULTS

A total of 10,698 patients were included for analysis. Reported follow-up ranged between 1 week and 192 months. Mean follow-up was 14.8 months for the 29 studies (59.2%) that reported these data. Pooled analysis of complication rates demonstrated 0.77% (n = 82) reoperation, 0.37% (n = 39) scleral show, 0.25% (n = 27) lid malposition, and 0.24% (n = 25) ectropion rates, among others. Forty-four studies (89.8%) published postoperative photographs with a total of 141 unique postoperative time points that were supported with photographic evidence (mean: 15.3 months; range: 1 week-192 months). In this series, for only 10 patients (0.094%) were postoperative photographs available at time points beyond 24 months.

CONCLUSIONS

Lower eyelid blepharoplasty is a powerful procedure with seemingly minimal morbidity despite its technical demands. The longevity of this procedure is poorly supported with photographic evidence in the literature. Studies do not adequately report or represent their follow-up to capture long-lasting results. Standardized reporting of results is needed to ensure that anyone seeking this treatment can be adequately counseled.

LEVEL OF EVIDENCE 4

Upper Eyelid Blepharoplasty: A Novel Method to Predict and Improve Outcomes

BACKGROUND

In some upper eyelid blepharoplasties, maximal skin removal may not result in desired outcomes; raising crease height can therefore be considered. Currently, there is no method to determine the amount of skin to be excised and/or crease elevation required to achieve a specific outcome.

OBJECTIVE

This study extrapolated an equation to determine amount of skin excision and/or lid crease elevation needed to achieve a specific eyelid margin to fold distance (MFD).

METHODS

This institutional review board-approved, HIPAA-compliant study was a prospective, nonrandomized clinical trial. Patients were included if aged 30 to 100 years old and underwent upper eyelid blepharoplasty with one surgeon between 2012 and 2014. Exclusion criteria were thyroid eye disease, myasthenia gravis, myotonic dystrophy, pregnancy, blepharoptosis, prior eyelid surgery or trauma, concurrent brow surgery, and topical alpha-agonists. The following data were collected preoperatively and at postoperative months 1 and 6: age, gender, BMI, brow position, MFD, margin to crease distance (distance between eyelid margin and crease, MCD), and vertical skin distance (distance between eyelid margin and brow, VSD).

RESULTS

A total 322 eyelids of 164 patients underwent 208 skin excisions, 26 crease elevations, and 88 combined skin excision and crease elevation. Age, gender, and BMI category were all nonsignificant and excluded from the final model. This equation was extrapolated with regression analysis: Change in MFD = -0.40 + (-0.28 × Change VSD) + (0.53 × Change MCD) with |R| = 0.28.

CONCLUSION

To better predict and obtain desired upper eyelid blepharoplasty outcomes, the authors created an equation.

LEVEL OF EVIDENCE 4

Retrospective Analysis of Physician-based Surveys Published in OPRS

PURPOSE

To review physician-based clinical surveys published in Ophthalmic Plastic and Reconstructive Surgery.

METHODS

Complementary Ovid and PubMed searches of Ophthalmic Plastic and Reconstructive Surgery journal content were performed for the term "survey." Results were narrowed to studies that specifically addressed physicians' clinical practices. This search resulted in 162 articles, and after dual-investigator independent screening, 13 surveys met inclusion criteria.

RESULTS

Of the 13 surveys published from 2007 to January 2017, 6 were published since 2015, showing an increased trend in survey-based publications. Topics included assessing practice patterns regarding eyelid disorders, thyroid eye disease, optic nerve sheath fenestration, anophthalmic socket, and diagnosing lacrimal disorders. Average response rate was 38.7% (range 17.5-60%), with 201 average number of replies (range 72-310). Nine out of 13 surveys included some form of statistical analysis with the remainder presenting data in percentages.

CONCLUSIONS

There has been an increased rate of survey-type publications in Ophthalmic Plastic and Reconstructive Surgery over the past 10 years. The low response rate and frequent lack of statistical analysis raise concerns regarding the validity and usefulness of such studies. The authors believe that survey studies can be improved through better standardization and the use of author guidelines. They have made specific recommendations to improve the impact of survey papers in the future.