Hering’s Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair

Brow Position Change and its Potential Risk Factors Following Upper Blepharoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Eyebrow position affects human facial expression and aesthetic appearance. However, upper-eyelid surgeries may cause brow position changes and affect the function and aesthetics of the eyebrow. The purpose of this review was to assess the influence of upper-eyelid surgeries on brow position and morphology.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for clinical trials and observational studies published between 1992 and 2022. The brow height from the center of the pupil is analyzed to show the brow height change. The change in brow morphology is measured by the change in brow height from the lateral palpebral and the medial palpebral. Studies are further divided into subgroups according to different surgical techniques, author locations, and whether to conduct skin excision.

RESULTS

Seventeen studies met the inclusion criteria. Nine studies and 13 groups were included in the meta-analysis, indicating that brow height decreased significantly after upper-eyelid surgeries (MD = 1.45, 95% CI [0.87, 2.07], P < 0.0001), and simple blepharoplasty, double-eyelid surgery, and ptosis correction can cause the brow position to drop by 0.67, 2.52, and 2.10 mm, respectively. East Asian authors group had a significant decrease in brow height compared with the non-East Asian authors group (28 groups, p = 0.001). Skin excision during blepharoplasty does not affect brow height.

CONCLUSIONS

Brow position changes significantly following upper blepharoplasty according to the decrease in brow-pupil distance. The morphology of the brow showed no significant postoperative change. Different techniques and authors locations may result in different levels of postoperative brow descent.

LEVEL OF EVIDENCE III

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Upper eyelid weighting for lagophthalmos results in contralateral upper eyelid elevation

INTRODUCTION

Upper eyelid weighting decreases lagophthalmos by improving blink dynamics. The effect of weighting on static eyelid position is less well understood. This study describes the effect of upper eyelid weighting on ipsilateral and contralateral upper eyelid position.

METHODS

Patients with unilateral lagophthalmos who underwent upper eyelid weight implantation were included. Primary outcome measures were ipsilateral and contralateral margin to reflex distance 1 (MRD1), preoperatively and postoperatively. MRD1 symmetry was assessed as a secondary outcome measure. Weight mass was examined as a covariate of MRD1 change.

RESULTS

23 patients (16 female, 7 male) met inclusion criteria. After weighting, contralateral MRD1 increased from mean [SD] 2.91 [1.41] mm to 3.77 [1.75] mm (p < .05). Ipsilateral (weighted) MRD1 did not significantly change (2.64 [1.41] mm to 2.40 [1.18] mm, p = .11). Preoperatively, paretic and normal side MRD1 were not different (p = .52). Postoperatively, weighted and unweighted MRD1 were significantly different (p < .05). Weight mass was not a covariate of MRD1 change, neither ipsilateral nor contralateral (p = .76, p = .71, respectively). The proportion of patients with MRD1 asymmetry ≥ 1 mm preoperatively (12/23, 52.2%) did not change following surgery (17/23, 73.9%, p = .12).

CONCLUSION

Weight insertion led to contralateral eyelid elevation, a manifestation of Hering's law. Weight mass did not impact the magnitude of MRD1 change, and the proportion of patients with MRD1 asymmetry ≥ 1 mm did not change following surgery. These findings may guide surgeons in their preoperative planning and in counseling of patients.

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry

PURPOSE

To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis.

METHODS

A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation.

RESULTS

Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference.

CONCLUSION

Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula

BACKGROUND

The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes.

OBJECTIVES

The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented.

METHODS

Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance.

RESULTS

A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.

CONCLUSIONS

This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

LEVEL OF EVIDENCE: 4

Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection

OBJECTIVE

To determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis.

METHODS

A retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures.

RESULTS

Repeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3-48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms.

CONCLUSION

Repeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.