The Relationship Between Eyebrow and Eyelid Position in Patients With Ptosis, Dermatochalasis and Controls

Influence of Upper Eyelid Surgeries on Corneal Morphology Detected with Pentacam

PURPOSE

To analyze the corneal morphological parameters before and one month after the upper eyelid (UE) blepharoplasty and external levator resection (ELR) for ptosis surgery.

MATERIALS AND METHODS

Seventy eyes of 70 patients with dermatochalasis (50 eyes) and acquired aponeurotic ptosis (AAP) (20 eyes) included in this prospective study. Detailed ophthalmologic examination was performed including the best corrected visual acuity (BCVA), slit lamp examination and dilated fundoscopy. Measurements were made before and one month after the surgeries using Pentacam. Central corneal thickness (CCT), pupil center pachymetry (PCP) and thinnest pachymetry (TP), cornea front astigmatism (AST), flat keratometry (K1), steep keratometry (K2) and mean keratometry (Km) values were evaluated.

RESULTS

Higher postoperative Km measurements were observed in dermatochalasis (p = 0.038) patients. Postoperative AST values were significantly lower in both dermatochalasis and ptosis cases (p = 0.034, p = 0.003, respectively). Increased PCP and TP were found in the AAP patients (p = 0.014, p = 0.015, respectively).

DISCUSSION

UE blepharoplasty and ELR surgeries both lead to some significant changes on corneal structure post-operatively.

LEVEL OF EVIDENCE IV

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The Prevalence of Undiagnosed Ptosis Among Candidates for Upper Eyelid Blepharoplasty

Background

Because upper eyelid blepharoplasty has become a popular aesthetic facial surgery, surgeons should be aware that age-related changes in the eyelid are not confined to skin laxity and orbital fat prolapse.

Objectives

This study was designed to assess the prevalence of undiagnosed ptosis among blepharoplasty candidates as one of the causes of unsatisfactory surgical results.

Methods

From December 2018 to December 2022, blepharoplasty candidates were meticulously assessed for their upper eyelid and eyebrow position. Patients who were aware of their ptosis were excluded, and the other patients were classified as mild, moderate, or severe ptotic based on margin reflex distance 1. The eyebrow height was also assessed in the mid-pupillary line to assess the relationship between the severity of ptosis and eyebrow asymmetry.

Results

The authors found that 13.7% of the 2530 blepharoplasty candidates in this study had undiagnosed ptosis. Most of these patients had mild ptosis (85.5%), and they were significantly older than nonptotic patients. The rate of prevalence of ptosis was significantly higher in patients with eyebrow asymmetry (75.3% vs 3.7%); however, the severity of ptosis was not associated with the severity of eyebrow asymmetry.

Conclusions

Ptosis should be cautiously looked for and addressed for treatment in candidates for upper blepharoplasty. In most patients with masked ptosis, the severity of eyelid drooping is mild and could remain undiagnosed until after the surgery and cause unsatisfactory aesthetic results. The presence of eyebrow asymmetry could be a key feature to unmask an undiagnosed ptosis.

Level of Evidence 3

Effect of external eyelid weighting on eyelid and eyebrow position in normal and ptosis patients

PURPOSE

This study aims to characterize the physiologic response of both eyelid and eyebrow position to increasing downward forces simulated by external weights.

METHODS

In this prospective observational study, both normal individuals and patients affected by ptosis were tested. External eyelid weights were placed on one upper eyelid with incrementally increasing weight from 0.2 to 2.4 g. The eyelid carrying the weight was randomly selected for normal subjects and patients with bilateral ptosis, whereas for unilateral ptosis, the ptotic eyelid was utilized. Photographs were obtained at baseline and with increasing weight until MRD1 reached 0 on the weighted side or, until 2.4 g was reached. Eyelid and brow position on the weighted and unweighted sides were digitally measured in millimeter. Primary outcome measures were change in the margin to reflex distance (MRD1) and pupil to brow distance (PTB) with weight on the weighted and unweighted sides for normal and ptosis subjects.

RESULTS

The weighted eyelid MRD1 decreased linearly with increasing weight. This was true for normal and ptosis subjects. The unweighted eyelid MRD1 increased linearly with increasing weight. This was also the case for both normal and ptosis subjects. With increasing weight, PTB increased linearly on the weighted side. No significant intergroup differences were noted.

CONCLUSIONS

In normal and ptosis subjects, when external weight on the eyelid is incrementally increased, the weighted eyelid MRD1 decreases, the unweighted eyelid MRD1 increases, and both brows elevate in a linear fashion.

Effects of Upper Blepharoplasty Techniques on Headaches, Eyebrow Position, and Electromyographic Outcomes: A Randomized Controlled Trial

The aim of this study was to assess changes in headaches, eyebrow height, and electromyographic (EMG) outcomes of the frontalis and orbicularis oculi muscles, after an upper blepharoplasty with or without resecting a strip of orbicularis oculi muscle. In a randomized controlled trial, 54 patients received an upper blepharoplasty involving either only removing skin (group A) or removing skin with an additional strip of orbicularis muscle (group B). Preoperative, and 6 and 12 months postoperative headache complaints were assessed using the HIT-6 scores and eyebrow heights were measured on standardised photographs. Surface EMG measurements, i.e., electrical activity and muscle fatigue, were assessed for the frontalis and orbicularis oculi muscles preoperatively and 2, 6, and 12 months postoperatively. Significantly fewer headaches were reported following a blepharoplasty. The eyebrow height had decreased, but did not differ between groups. Regarding the surface EMG measurements, only group A's frontalis muscle electrical activity had decreased significantly during maximal contraction 12 months after surgery (80 vs. 39 mV, p = 0.026). Fatigue of both the frontalis and the orbicularis oculi muscles did not change significantly postoperatively compared to baseline. EMG differences between groups were minor and clinically insignificant. The eyebrow height decreased and patients reported less headaches after upper blepharoplasty irrespective of the used technique.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Early Experience With the Clinical Use of Teprotumumab in a Heterogenous Thyroid Eye Disease Population

PURPOSE

To describe the clinical course in a heterogeneous series of subjects with thyroid eye disease (TED) treated with teprotumumab.

METHODS

Cross-sectional cohort study including patients with clinical diagnosis of TED who was treated with teprotumumab. The entire cohort was analyzed together and subsequently in clinical subgroups based on stage and grade of disease. Primary outcome measure was change in proptosis ≥2 mm. Secondary outcome measures included change in clinical activity score (CAS), ductions, strabismic deviation, MRD1, and MRD2. Bivariate and multivariate statistics were performed.

RESULTS

The study included 21 patients. Mean ± SD age was 61.5 ± 12.6 years and 71.4% were female. Reduction in proptosis ≥2 mm was achieved in 71.4% of the sample. Stage and grade were not significant predictors of outcome. Treatment with teprotumumab resulted in a 2.5 ± 1.8 mm reduction of proptosis (P < 0.001), 2.2 ± 1.4 reduction in CAS (P < 0.001), and 16.9 ± 19.3 degree improvement in extraocular motility (P < 0.001). There were no significant differences for change in CAS, proptosis, ductions, or MRD2 between different grades and stages of disease. Total strabismus and MRD1 improvement were greater in the active stage of disease (P < 0.05). Three cases of dysthyroid optic neuropathy, refractory to methylprednisolone therapy improved after initiation of teprotumumab.

CONCLUSIONS

Treatment of TED with teprotumumab in a heterogeneous patient population is associated with improvement in proptosis, extraocular motility, and CAS. Patients beyond those defined in the clinical trials, including those affected by stable stage, milder grade, and vision-threatening TED may benefit from this therapy. There are, however, limits on the overall efficacy of this medication in the management of certain physical characteristics in TED including eyelid position and strabismus.

The Effect of Zero Gravity on Eyelid and Brow Position

PURPOSE

To describe the effect of spaceflight on upper eyelid and brow position.

MATERIALS AND METHODS

Images of astronauts on earth and in space were collected from a National Aeronautics and Space Administration image library. For each astronaut, front facing portraits captured within a 5-year period were obtained. At least 6 photos were collected per astronaut, 3 taken on earth, and 3 in zero gravity. Measurements from the center of the pupil to the upper eyelid margin (MRD1) and center of the pupil to the inferior eyebrow margin [pupil-to-brow (PTB)] were performed digitally for each image and averaged for each condition and each individual. Differences in mean MRD1 and PTB were assessed to illustrate the effects of zero gravity on eyelid and eyebrow position respectively. Linear-mixed effects modeling, analysis of variance and post hoc power analysis were performed.

RESULTS

One hundred and twelve photographs (55 earth, 57 space) from 18 astronauts (4 women, 14 men; mean age 45.9 years) were retrieved. Zero gravity resulted in a mean PTB increase of 3.7 mm (p < 0.01) but did not result in significant change in MRD1 (p = 0.21). Post hoc power analysis of the measured MRD1 difference was performed by simulation. At an MRD1 difference of 0.5 mm, the probability of a type II error is 2.6%, equivalent to a beta power of 97.4%. Thus, we can be 97.4% confident that a difference in MRD of 0.5 mm or greater would be detected.

CONCLUSIONS

While spaceflight led to significant elevation of PTB, it did not consistently alter MRD1. As such, the brow and eyelid appear to be independently regulated with respect to gravitational changes.

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).

Blepharoptosis Repair: External Versus Posterior Approach Surgery: Why I Select One over the Other

Ptosis surgery is performed via an anterior/external or posterior/internal approach, primarily defined by the eyelid elevator muscle surgically addressed: the levator complex anteriorly or Muller muscle posteriorly. Posterior ptosis surgery via Muller muscle conjunctival resection is an excellent first choice for cases of mild to moderate ptosis with good levator function, as it is predictable, provides a reliable cosmetic outcome, requires no patient cooperation during surgery, portends a lower rate of reoperation, and rarely leads to lagophthalmos and/or eyelid retraction postoperatively. External levator resection is preferred in patients with severe ocular surface/cicatricial conjunctival disease, shortened fornices, and lesser levator function.