Strategies of upper blepharoplasty in aging patients with involutional ptosis

Reducing the Volume of Upper Eyelids in East Asians Increases Vertical Palpebral Height

BACKGROUND

Correcting puffy eyelids is important for improving the first impression. The puffiness is most predictable corrected by tissue resection and fat excision. Fold asymmetry, overcorrection, and recurrence can sometimes occur after levator aponeurosis manipulation. The objective of this study was to introduce a method of volume-controlled blepharoptosis correction (VC) without levator manipulation.

METHODS

The medical records of patients who had undergone upper blepharoplasty between 2017 and 2022 were retrospectively reviewed. Questionnaires, digital photographs, and charts were used to evaluate the surgical outcomes and complications. The degree of levator function was graded as poor, fair, good, or very good. Levator function must be above good (>8 mm) to employ the VC method. Poor and fair grades of levator function were excluded because they require levator aponeurosis manipulation. The margin to reflex distance (MRD) 1 was assessed preoperatively, 2 weeks postoperatively, and at follow-up visits.

RESULTS

Postoperative satisfaction was 4.3 ± 0.8 with no postoperative discomfort (0%), and the duration of swelling was 10.1 ± 2.0 days. Regarding other complications, no fold asymmetry (0%) was observed, although hematoma formation was observed in 1 (2.9%) patient in the VC group. Significant differences were observed in the changes in palpebral fissure height over time (p < 0.001).

CONCLUSIONS

VC can effectively correct puffy eyelids and create natural-looking, beautiful, and thin eyelids. Thus, VC is associated with higher patient satisfaction and surgical longevity without serious complications.

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

Long-Term Effects of Extended Upper Blepharoplasty Combined With Subbrow Skin Removal for Correction of Lateral Hooding in Asian Women

Upper eyelid aging with lateral hooding is common among Asian women older than 40 years. Since Asians tend to develop more visible scars than White people, we used an extended upper blepharoplasty technique to correct lateral hooding and conceal the scar, combined with the removal of the thick subbrow skin for women over 60 years of age, to achieve a stable, improved outcome. An extended cutaneous scalpel-shaped excision was designed and hid the extended part of the excision in the patient's upward crow's feet to address the redundant skin of lateral hooding. For patients older than 60 years, we used a crescent-shaped excision and simultaneously removed the thick skin under the eyebrow to reduce the likelihood of long-term postoperative pseudoexcess. A retrospective study was conducted on 40 Asian women who underwent upper eyelid rejuvenation surgery with the above methods from July 2020 to March 2021 (follow-up, 12-15 mo). Extended blepharoplasty notably corrected the lateral hooding and achieved a natural double eyelid. The postoperative scar was inconspicuous. For patients older than 60 years, the long-term rejuvenation outcome was stable when associated with subbrow skin removal. However, two patients older than 60 years in whom the subbrow skin was not removed developed pseudoexcess of the upper eyelid 1 year postoperatively. Extended blepharoplasty is a simple and effective technique for improving periorbital aging in Asian women, and the postoperative scarring was inconspicuous. For patients older than 60 years, we recommend removal of the thick subbrow skin to avoid long-term postoperative pseudoexcess.

Upper Eyelid Skin Laxity in Elderly Patients: Correction Surgery With Eyelid Marginal Incision

BACKGROUND

Laxity of the upper eyelid skin in the elderly usually leads to an aged appearance and visual field defect, which affects their quality of life. However, there are very few reports on the evaluation and treatment strategy for upper eyelid skin redundancy in elderly Asians. Hence, this article describes an upper eyelid skin laxity correction surgery using an innovative parallel palpebral margin incision to improve ptosis and enlarge the visual field.

METHODS

From August 2012 to March 2021, 87 patients with severe eyelid laxity and ptosis presented to the Plastic Surgery Department of the Zhongda Hospital Affiliated to Southeast University. Upper eyelid skin laxity correction surgery with eyelid marginal incision was performed to correct the excessive tissue between the eyebrow and the upper eyelid and improve patients' vision field. Thereafter, a postoperative follow-up was conducted to observe the results in terms of skin laxity, eyelid shape changes, visual field improvement, postoperative scars, and patients' satisfaction.

RESULTS

During the follow-up, information was collected between 3 months and 1 year after surgery. No visible scars were seen in patients after the operation, and the sagging skin of the upper eyelid was corrected. In addition, the effect of correcting visual field defect is stable, with no recurrence within 1 year. The operation was effective, and patients were satisfied.

CONCLUSION

This surgical strategy significantly improved severe upper eyelid skin laxity with inconspicuous postoperative scars. After the operation, patients felt satisfied, and their quality of life was notably improved.

One Patient of Blepharoptosis Caused by Levator Palpebrae Superioris Aponeurosis Degeneration

Ptosis is one of the common diseases of plastic surgery, which is caused by various causes of levator palpebrae superioris dysfunction or Müller muscle insufficiency, which is manifested by the upper eyelid margin being lower than normal when level viewed. Ptosis can be divided into congenital and acquired, and the main cause of congenital ptosis is due to congenital levator palpebrae superioris dysplasia or the motor nerve innervation that innervates it is caused by abnormal oculomotor neurodevelopment and dysfunction. Acquired ptosis can be divided into traumatic, neurogenic, myogenic, senile, mechanical, and false ptosis. At present, there are few reports of ptosis due to the degeneration of the aponeurosis of the upper eyelid muscle. We received a case of ptosis caused by degeneration of the levator palpebrae superioris aponeurotic membrane, we use the method of the levator palpebrae superioris high advancement. The levator palpebrae superioris-Miller muscle was folded to form a stable composite structure by the levator palpebrae superioris high advancement. During the operation, the levator palpebrae superioris was separated along the gap, and the surrounding tissues were less damaged. Therefore, postoperative adhesion was less, and the main complications of severe blepharoptosis after the operation, such as upper eyelid hysteresis and incomplete closure, almost did not occur, and after surgery, the results were good.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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