Upper Blepharoplasty With or Without Resection of the Orbicularis Oculi Muscle: A Randomized Double-Blind Left-Right Study

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.

Dry eye in the upper blepharoplasty patient: a study comparing orbicularis-sparing versus orbicularis-excising techniques

PURPOSE

To compare subjective and objective dry eye syndrome (DES) metrics preoperatively and postoperatively in patients undergoing bilateral upper eyelid blepharoplasty (ULB) using orbicularis-sparing versus orbicularis-excising techniques.

METHODS

A double-blind, randomized clinical trial was conducted on patients without prior DES or other severe conditions who presented to our institution between 2017 and 2019 for routine functional ULB. Patients were randomized into two treatment arms: bilateral ULB using the orbicularis-sparing technique or bilateral ULB using the orbicularis-excising technique. One subjective and seven objective DES assessments were performed on all patients preoperatively and 1 month and 1 year after surgery.

RESULTS

A total of 63 patients were recruited for the study. Standard Patient Evaluation of Eye Dryness (SPEED) scores decreased in both treatment groups at 1 month and 1 year postoperatively. This change did not significantly vary based on surgical technique. Objective DES assessments were not significantly changed at both postoperative time points for either group. There was a correlation between the severity of preoperative DES symptoms and the subjective improvement of DES symptoms postoperatively in both groups.

CONCLUSIONS

ULB with an orbicularis-sparing or orbicularis-excising technique does not worsen subjective or objective DES metrics and so, surgeons may confidently use either surgical technique. These findings may impact postoperative expectations for surgeons and patients alike.

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.

The evaluation of the skin-muscle and only-skin upper blepharoplasty featuring surface electromyography: a single-masked, randomized split-face prospective study

BACKGROUND

Even though upper blepharoplasty is one of the most commonly performed procedures in esthetic surgery, there is still no consensus regarding the management of the orbicularis oculi muscle (OOM).

AIM

To compare outcomes of upper eyelid blepharoplasty with or without OOM excision using surface electromyography in a 12 month follow-up.

METHODS

A prospective, randomized, single-blinded comparative split-face study was conducted on 26 patients with dermatochalasis. Skin-only upper blepharoplasty was performed on a randomly selected side, and on the contralateral side, a strip of OOM was resected as well. The functional outcomes were assessed using sEMG, and the esthetics were evaluated independently by the operating surgeon, blinded patients, and three blinded ophthalmic surgeons.

RESULTS

The RMS values of maximal contraction of the OOM were statistically significantly lower two weeks after blepharoplasty than the values before surgery in both groups (p < 0,001) and reached the preoperative values after six months. Lagophthalmos occurred in 2 cases in the skin-muscle group (7.69%), and no incidence of lagophthalmos was observed in the skin group. There were comparable esthetic outcomes on both operated sides.

CONCLUSIONS

This study is an objective and quantitative report using surface electromyography on upper blepharoplasty with or without a strip of OOM excision. Our results showed that OOM fully recovers after the stripping procedure. The resection of the skin-OOM flap showed no difference in long-term cosmetic results. Therefore, we recommend OOM preservation during upper blepharoplasty unless muscle excision is well-grounded.

Upper Eyelid Blepharoplasty: Surgical Techniques and Results-Systematic Review and Meta-analysis

BACKGROUND

Upper eyelid blepharoplasty is a surgical procedure that aims to correct the typical changes that occur with aging to the periorbital area. The outcomes of this surgery are aesthetic, as well as functional. Many studies have described an impact on the cornea, intraocular pressure, dry eye syndrome, and visual quality. The aim of this systematic review is to compare the different surgical techniques and their outcomes.

METHODS

The authors performed a literature review through online databases PubMed, Web of Science, Clinicaltrials.gov, and CENTRAL libraries. Information was collected about the surgery techniques and the functional and aesthetic outcomes as well as complications of the interventions. Six types of upper blepharoplasty surgery were studied. Data were analyzed using Cochrane RevMan.

RESULTS

Twenty studies were included in our systematic review and nine in our meta-analysis. We presented results about intraocular pressure, central corneal thickness, flattest keratometry, steepest keratometry, corneal astigmatism, visual acuity, Schirmer test 1 and 2, tear film break-up time and the ocular surface disease index questionnaire, according to type of surgery. Our meta-analysis showed no significant results.

CONCLUSIONS

No significant results were found; however, many studies reported an impact of upper blepharoplasty surgery in the outcomes studied. Only a small number of complications were reported, and patients were satisfied with the aesthetic outcomes.

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 https://www.springer.com/00266 .

Rejuvenating the aging upper periorbita

PURPOSE

To investigate the efficacy of a comprehensive surgical approach in rejuvenating the aging upper periorbita.

METHODS

Three hundred and twenty eyes of 160 patients who were treated for dermatochalasis(D), eyebrow ptosis (EP) and blepharoptosis (BP) were included in the study. One hundred and ninety-eight patients had only dermatochalasis, 74 patients had D and EP, 39 patients had D and BP, 7 patients had D, EP and BP and 2 patients had D, EP and blepharospasm. The patients were evaluated before surgery, at 1 week, 1 month and 6 months after surgery. Dermatochalasis was scored between 0 and 3 points according to upper lid laxity and IP drooping. EP was scored between 0 and 2 points as normal, lateral EP and total EP. Aging was classified as mild in those with a total score of less than 3 points, moderate in those with a score of 3-6 and severe in those above 6 points.

RESULTS

Of the patients, 121 were female and 39 were male, with a mean age of 52 (40-87) years. The surgeries were performed as follows: upper eyelid blepharoplasty (UEB) 197(61.6%) patients, UEB + browpexy(B) 77(24.1%) patients, UEB + B + levator resection(LR) 7(2.2%) and UEB + LR 39 (12.2%) patients. While a statistically significant improvement was observed in patients who underwent UEB + B (p < 0.001), postoperative improvements were not found statistically significant compared to preoperative scores in other surgeries. The postsurgical scores showed statistically significant improvement in all age groups (p < 0.001).

CONCLUSIONS

A comprehensive surgical treatment can provide effective results in upper periorbital rejuvenation for patients with varying degrees of upper periorbital aging.

Upper Blepharoplasty: An Evidence-Based Assessment of Preoperative Considerations and Surgical Techniques

Upper blepharoplasty is one of the most common facial plastic surgical procedures performed. Due to its growing popularity, an abundance of articles is available describing variations in the surgical technique and outcomes. As a result, it has become increasingly difficult to identify appropriate surgical literature validated by a high level of evidence. The purpose of this review is to identify and describe specific evidence-based components of the preoperative evaluation and surgical approach in upper blepharoplasty surgery.

Changes in Tear Meniscus Analysis After Ptosis Procedure and Upper Blepharoplasty

INTRODUCTION

To quantitatively evaluate dry eye test and tear measurements following oculoplastic surgery.

METHODS

This comparative prospective clinical study comprised three groups of adult patients: the 1) blepharoplasty group: those with dermatochalasis; and 2) the blepharoplasty + Muller's muscle-conjunctival resection and 3) blepharoplasty + anterior levator resection groups: those with dermatochalasis and ptosis showing significant improvement after 10% phenylephrine administration. Ocular Surface Disease Index, tear film break-up time, corneal staining, and Schirmer test values were recorded. Tear meniscus area and height were measured using anterior segment-optical coherence tomography.

RESULTS

This study comprised 56 patients (18 males, 38 females). The blepharoplasty group included 40 eyes of 20 patients. The blepharoplasty + MMCR group included 21 eyes of 16 patients. The blepharoplasty + ALR group included 30 eyes of 20 patients. No significant differences resulted between the preoperative and postoperative dry eye test and tear measurements in the blepharoplasty group (P> 0.005/for all). Significant increases were seen in the corneal staining, TMH, TMA, and Schirmer test values were significantly decreased compared to those postoperatively in the blepharoplasty + MMCR group (P= 0.018, P< 0.001, P= 0.033 and P= 0.030, respectively). In the blepharoplasty + ALR group, the TMH and TMA were significantly decreased (P= 0.031, P= 0.036).

CONCLUSION

No changes resulted in dry eye tests following blepharoplasty in patients without dry eye symptoms. Changes were more pronounced following ptosis surgery, especially MMCR. Patients should be carefully examined for dry eye and treated during follow-up.

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 .

Evaluation of upper blepharoplasty outcome-objective measurements and patients` satisfaction

Background/Aim. Upper blepharoplasty is one of the most often performed aesthetic operations and is indicated for periorbital rejuvenation or correction of some functional problems. The aim of the study was to evaluate the outcome of this procedure and to assess patients? satisfaction and possibilities of objective measurement of operative results. Methods. A two-year prospective observational study was conducted among female patients who had upper blepharoplasty done by the same surgeon. Data were collected from medical documentation, questionnaire, and objective measurements conducted via standardized digital photographs taken before and two months after surgery. Tarsal platform show (TPS) and brow fat span (BFS) were measured at three points (P1, P2, P3) before and two months after the surgery. A questionnaire conducted before surgery and two months after it included general complaints considering upper eyelids (visual field narrowing, fallen eyelids, the sensation of heavy eyelids, raising head backward in order to enhance vision, headache), patients? assessment of eyelid asymmetry and an additional questionnaire after surgery included questions for the surgeon and patients concerning satisfaction with treatment outcome. Results. This study involved 50 female patients aged be-tween 33 and 67 years (49.98 ? 8.6 years). There was a statistically significant difference in all points for TPS and BFS measurements before and after the operation. No significant asymmetries were noticed between eyes neither before nor after surgery. There was a statistically significant difference in operation success among 3 age categories in TPS-P1 (?2 = 13.089, df = 2, p = 0.001) and TPS-P2 (?2 = 8.386, df = 2, p = 0.015) with best results achieved in older patients (> 55 years). There was strong positive, statistically significant correlation between patient?s and surgeon?s satisfaction (r= 0.704, p = 0.002), as well as between patients? satisfaction and their age (r = 0.704, p = 0.002). Conclusion. Realistic expectations, adequate information about the surgery and possible complications, are essential to satisfied patients. Objective measurements correlate with patients? satisfaction and together with photographs can be a useful tool in communication with them.

Is Orbicularis Oculi Muscle Resection Necessary in Upper Blepharoplasty? A Systematic Review

BACKGROUND

Our objective is to evaluate the evidence on the aesthetic effect and complications of skin-OOM strip resection compared to skin only upper blepharoplasty.

METHODS

A systematic search of EMBASE, PubMed, Cochrane and Google Scholar databases was performed using our search strategy through to 31 December 2019. Only comparative studies of the two upper blepharoplasty techniques were included. Three reviewers performed study selection process, data extraction, and quality assessment.

RESULTS

A total of six articles were eligible for final inclusion. The included studies consist of two controlled retrospective cohorts and four small randomized controlled studies (RCT). Three of which, were double blinded. Those RCTs were assigned level 2 evidence due to small size and methodological limitations. The sample size of included was studies 407 in the two retrospective studies and 57 in the four RCTs. The outcomes showed that resection of OOM along with skin in upper blepharoplasty showed no difference in long-term aesthetic outcome when skin only procedure is performed. Muscle strip resection was associated with initially higher ophthalmological morbidity (edema, bruising, pain, dry eye, sluggish eye closure and lagopthalmos). Those resolved a few weeks later with conservative treatment.

CONCLUSION

The resection of OOM along with skin in upper blepharoplasty showed no difference in long-term aesthetic outcome and was associated with initially higher ophthalmological morbidity compared to skin only procedure. While we are not suggesting that OOM resection is never required, the evidence strongly support its preservation during standard upper blepharoplasty.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Blepharoplasty Combined With Mini-incision and Interrupted Buried Suture Techniques

BACKGROUND

Blepharoplasty has become one of the most popular plastic surgery techniques for generating double-eyelid folds. The mini-incision blepharoplasty technique results in minimal trauma and the formation of supratarsal folds.

METHODS

In this study, the authors combined mini-incisions with interrupted buried sutures. To perform the blepharoplasty procedure, the authors marked the supratarsal folds and divided them into 5 line segments: 3 cutting lines and 2 noncutting lines. For the cutting lines, the authors used orbicularis-tarsus fixation to form double eyelids and only removed a small strip of muscle under the incision to maintain the physiological structure of the pretarsal tissue. For the noncutting lines, the authors used the interrupted buried suture technique to add 2 fixed points.

RESULTS

A total of 42 patients (mean age 25.25 years) underwent this minimally invasive blepharoplasty. Among these patients, 42 underwent bilateral surgery. The average follow-up period was 35.91 months (range: 13-47 months). Only one patient underwent a second operation to address a shallow, unilateral supratarsal crease. Nonetheless, all patients were satisfied with their results.

CONCLUSION

Our minimally invasive blepharoplasty approach resulted in minimal damage to the pretarsal tissues and robust supratarsal folds and is relatively easy to perform for the novice surgeon.

EVIDENCE STATEMENT

Level IV.

Upper eyelid blepharoplasty using plasma exeresis: Evaluation of outcomes, satisfaction, and symptoms after procedure

BACKGROUND

Facial care treatments have grown a remarkable demand for effective and minimally invasive techniques with fast recovery time. Plasma technology is a nonsurgical alternative technique for skin rejuvenation.

AIMS

We assessed patient satisfaction and symptoms after upper eyelid blepharoplasty with plasma technology.

PATIENTS/METHODS

Observational study including 16 patients submitted to upper eyelid blepharoplasty using plasma technology to treat dermatochalasis. Patient satisfaction, symptoms, and quality of life were assessed using 2 questionnaires at follow-up days 7 and 30. Also, the answers were correlated with age, Fitzpatrick skin type, and quantity of eyelid skin treated with plasma.

RESULTS

All 16 patients were treated and completed the survey. Fourteen (87.5%) were female, and the mean age was 50.5 years. Physical appearance was the most relevant factor impacting on quality of life at first week postoperative. Regarding satisfaction with results, most patients stated higher level of satisfaction at day 7 follow-up analysis (P = .038). Less impact on quality of life and higher satisfaction was associated with eyelid-treated area (P = .044 and P = .036) and Fitzpatrick skin type (P = .043) at 7 and 30 days after procedure, respectively. Eyelid edema and itching were the symptoms most reported at 7 and 30 days, respectively.

CONCLUSIONS

Upper blepharoplasty with plasma is a minimally invasive treatment with low impact on quality of life. However, overall patient satisfaction is questionable when considering less willing of undergoing procedure again and decreased expectation with results over postoperative period. Symptoms are reported mainly at the first week after procedure.

Effects of Muller's muscle-conjunctival resection for ptosis on ocular surface scores and dry eye symptoms

This article evaluates the effects of Muller's muscle-conjunctival resection (MMCR) on ocular surface scores and dry eye symptoms. Forty-six patients were enrolled in the study. Eighteen underwent bilateral upper eyelid skin excision with MMCR and 28 underwent bilateral upper eyelid skin-only excision (control group). The Salisbury Eye Evaluation Questionnaire and an ocular surface evaluation protocol consisting of Schirmer's test, tear break-up time (TBUT), fluorescein and rose bengal corneal staining were performed during the pre-operative consultation and on postoperative days 7, 30, and 90. Improvement in symptoms questionnaire scores from baseline was observed on postoperative day 90 in the blepharoplasty plus MMCR group. There was no change in questionnaire scores in patients who underwent blepharoplasty alone. No between-group difference in Schirmer's test, TBUT, or fluorescein and rose bengal staining was found at any time point. In the blepharoplasty-only (control group), the fluorescein staining score was reduced on postoperative day 30 as compared to baseline, but not on day 90. In this sample, addition of MMCR to upper eyelid blepharoplasty did not worsen ocular surface scores or dry eye symptoms.

Upper Blepharoplasty and Lateral Wound Dehiscence

Purpose:

To report the frequency of lateral wound dehiscence (LWD) after upper blepharoplasty (UB), a technique and its outcome to prevent LWD.

Materials and Methods:

A retrospective review was performed for cases of LWD after UB presenting between 2003 and 2009, and then a prospective comparative study was performed between February 2009 and March 2013. For the comparison, subjects were divided into two groups based on intraoperative assessment of lateral wound tension (same technique and surgeon). Group 1 received 1-3 orbicularis/subcutaneous buried sutures (6-0 polyglactin) before interrupted 6-0 nylon skin closure. Group 2 underwent skin closure only. Subjects, who had re-operation, skin healing disorders, and incomplete follow-up (<6 months), were excluded. P < 0.05 was considered as statistically significant.

Results:

There were 14 (14/678, 2%) cases with LWD with a mean age of 36.2 years in the audit (2003–2009). The prospective study included 68 subjects (68/293, 23.2%) in Group 1 and 225 in Group 2. Gender and simultaneous forehead and eyebrow procedures were similar between groups (P = 0.3 and P = 0.4 respectively). Group 1 was statistically significantly younger at mean age of 41.4 years, compared to Group 2 at 56.1 years (P = 0.000). The frequency of LWD significantly (P = 0.04) decreased to 0.3% (1/293).

Conclusion:

In the presence of wound tension on skin closure (intraoperative assessment), tension relieving buried orbicularis/subcutaneous 6-0 polyglactin suturing of the lateral UB incision could prevent LWD.

Muscle-sparing blepharoplasty: a prospective left-right comparative study

BACKGROUND

Standard upper blepharoplasty involves removal of both the skin and a portion of the underlying orbicularis oculi muscle. The senior author had observed sluggishness of eyelid closure, lagophthalmos as well as varying degrees of eye irritation in certain patients during the early postoperative period. He postulated that these findings could be due to orbicularis muscle excision. He therefore undertook a prospective study 27 years ago comparing standard blepharoplasty on one eyelid to skin-only excision on the fellow eyelid.

METHODS

A randomized, prospective, single-blinded study was designed using the fellow eye as an internal control. 22 patients undergoing upper blepharoplasty procedure requiring greater than 5 mm of skin resection and with no history of ophthalmologic disease, dry eye, or previous eyelid surgery were selected. Upper blepharoplasty was performed with skin-only removal on one side, and combined skin-muscle removal on the other side. Patients were evaluated until six months after surgery except for two patients who were lost to follow-up after three months. Sluggish eyelid closure, lagophthalmos, dry eye and aesthetic result were outcome measures scored by patient survey, the operating surgeon, and a blinded expert panel.

RESULTS

There were comparable aesthetic outcomes in both eyelids. The incidence of sluggish eyelid closure, lagophthalmos and dry eye syndrome were significantly higher in eyelids where wide segments of muscle had been resected.

CONCLUSIONS

Muscle-sparing upper blepharoplasty produces similar aesthetic outcomes as conventional blepharoplasty, while significantly reducing the complications of sluggish eyelid closure, lagophthalmos and dry eye disease. The authors therefore recommend muscle-sparing upper blepharoplasty.

A new approach: resection and suture of orbicularis oculi muscle to define the upper eyelid fold and correct asymmetries

Upper-eyelid blepharoplasty is a very common procedure in aesthetic plastic surgery. Among all the literature in favor of orbicularis muscle resection, there are no commentaries associated with orbicularis muscle suture and its convenience. This article discusses a new approach: independent resection of the orbicularis oculi muscle similar in size to the resected skin and the subsequent suture of the orbicularis muscle after its resection. This results in a fine reconstruction of the upper-eyelid crease, achieves a good definition of this anatomical structure, and allows correction of asymmetries with the contralateral upper eyelid. The results obtained (98 % of patients satisfied) and no complications with this procedure make it a safe alternative for upper blepharoplasty.

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 .

Aesthetic surgery of the orbits and eyelids

This article discusses the relevant anatomy, the aging process of the eyelid with periorbital structure, and how to evaluate patients for a proper surgical approach. A description is given of how to achieve an aesthetic balance between the forehead, eyelids, and midface to provide the patient with a natural youthful appearance. The paradigm in oculoplastic surgery has shifted to more conservative eyelid skin, muscle, and fat resection as well as more periorbital soft tissue lift, suspension, and volumization. Recent innovations and developments are discussed as well as the most common complications in eyelid and periorbital surgery.

How to correct frontal facialis palsy after radical tumour surgery: upper blepharoplasty and direct brow lift

Radical surgery of fronto-temporal non-melanoma skin cancer (NMSC) sometimes causes palsy of the frontal facialis branch. Patients may experience visual impairment due to brow and upper eyelid ptosis. Since NMSC predominantly affects elderly people, the corrective surgical procedures have to be adapted to age, comorbidities and individual needs. The direct brow lift and the upper lid blepharoplasty are two reliable and safe surgical techniques with proved efficacy. Here we present our way to deal with post-surgical brow and lid ptosis.