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.

A quantitative analysis of the brow shape after frontalis muscle contraction

PURPOSE

To measure the changes of the eyebrow's contour after frontalis muscle (FM) contraction.

METHODS

Two consecutive pictures of the eyes and frontal region of 36 volunteers (15 men and 21 women) were obtained with the forehead relaxed and upon maximal frontalis muscle contraction. Bézier lines representing the brows' contours, obtained with the ImageJ software, were graphically sampled with a resolution of 0.025 mm. The contours of the relaxed and elevated brows were compared regarding the position of the contour peak (CP), the degree of elevation of brow central point, and the medial and lateral areas outlined between the brow contours before and after frontalis contraction. The asymmetry of the brow contour after FM contraction was calculated by the Naeije formula as (Medial-Lateral)/(Medial + Lateral). A difference of 10% or less between the lateral and medial areas was taken as a cutoff value for symmetrical brow elevation.

RESULTS

In 62 (86.1%) of the eyes, the location of the brow's CP was lateral to the brow's midpoint. When the brows were raised, the CP of 60% of the brows was displaced medially and 40% laterally. The motion of the CP with medial displacement (mean = 3.7 mm) was significantly larger than those displaced laterally (mean = 1.9 mm) decreasing the number of brows with lateral peaks from 62 (86.1%) to 54 (75%). No difference was observed between the mean elevation of the central point of the brow for males (7.9 mm (3.2 SD) and females (7.4 mm, 3.0 SD). In 58.3% of the sample, the positional change of the medial and lateral sectors of the brows was symmetrical, and among the 41.7% asymmetrical cases, the elevation of the medial side was higher than the lateral in 66.7% of the brows.

CONCLUSIONS

The brow changes during FM contraction concur well with the anatomic data of the FM shape. The contour of most brows is displaced toward the medial direction when the brow is elevated. The pattern of brow shape change is an indication of the FM anatomy and must be carefully analyzed before any procedure involving the FM, such as chemodenervation injections or frontalis slings for blepharoptosis correction.

Aesthetic Enhancement of the Brow using Hydroxyapatite

Background

An aesthetically pleasing appearance of the ‘eyes’ usually includes good projection of the outer brow. Weak bony projection of the superolateral periorbital region tends to be not only less attractive, but also predisposes to hooding over the temporal part of the upper lid. Congenital lack of skeletal volume is exacerbated by ageing due to lipoatrophy and soft tissue laxity. The rationale and technique for performing skeletal augmentation of the superolateral orbital rim is described, along with long-term results from a series of cases.

Material and Methods

A series of patients having augmentation of the superolateral orbital rim, using the technique described, were evaluated. A forehead crease incision was used, then a precise subperiosteal pocket developed in the lateral brow region between the supraorbital foramen and the superior temporal septum. The hydroxyapatite granule mixture was incrementally placed using modified syringes. The patients were followed to assess the long-term results.

Results

Two hundred and fifty patients, 80% women, mean age = 53 years [range 23–78] underwent supraorbital rim augmentation using subperiosteal hydroxyapatite granules, during a 12-year period, commencing in 2007. The mean follow-up was 41 months (range 1–12 years). The mean volume used for augmentation was 1.0 mL per side (range 0.4–2.3 mL). Projection of the upper lateral periorbital prominence was effectively increased, resulting in enhancement of the brow position and shape. Twenty-seven patients (11%) had an undercorrection, requiring additional volume augmentation, all during the first three years of the experience. Twelve patients (5%) required correction of contour irregularities. There were no infections and no long-term complications. Resorption of the hydroxyapatite volume over time was not noted.

Conclusion

The aesthetic significance of superolateral orbital rim projection is introduced. Patients who have a degree of skeletal deficiency of the zygomatic process of the frontal bone should be considered for hydroxyapatite augmentation of the bone as a complement to upper lid blepharoplasty and brow elevation. This procedure should be considered in the spectrum of upper periorbital aesthetic procedures.

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.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-022-02793-y.

Anatomic Trends and Directions in Periorbital Aesthetic Surgery

The anatomy of the eyelids and periorbital region is delicate. The individual anatomic variations determine each person's eyelid appearance and function. It is essential that every surgeon that evaluates and treats the aesthetic conditions of patients desiring periorbital enhancement understands the association of anatomy and diagnosis. Each periorbital aesthetic diagnosis has an anatomic basis, and knowledge of the applied anatomy allows a targeted treatment plan. This article outlines the layered anatomy with its clinical significance for the eyelids and periorbital region. Specific examples are used to illustrate the applied anatomy. A contemporary treatment plan for each anatomic problem is given.

The Ideal Eyebrow: Lessons Learnt From the Literature

The concept of facial aesthetic has been around for centuries, popularised in the Renaissance period by artists such as Da Vinci. The eyebrow is also known as the master line of the face and is used as a reference for other facial angels and contours. The criterion of the aesthetically pleasing eyebrow has been a subject of much debate over the years, ever since make-up artists such as Westmore described the modern concept of the ideal brow in the 1970s. The concept of the ideal brow has evolved over the decades, subjected to influence by cultural trends and differences. This narrative review aims to examine the current evidence in the literature with regard to the ideal eyebrow from an aesthetic point of view, taking into account gender, age and ethnic differences. A set of guidelines are also proposed in order to help clinicians tailor the appearance of the eyebrow to individual patients based on the author's personal opinion.Level of Evidence V 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 novel approach quantifying the periorbital morphology: A comparison of direct, 2-dimensional, and 3-dimensional technologies

BACKGROUND

The measurement of anatomical structures is critical in plastic and reconstructive surgery. However, few detailed and standardized measurements have been widely used in the periorbital region. This study aimed to evaluate the feasibility of a novel detailed and standardized protocol with 2D and 3D technologies, and explore the relationship between them and direct measurements.

METHODS

Fifty healthy Caucasians (100 eyes) between 20 and 68 years old were recruited and captured for 3D photographs by VECTRA M3 3D Imaging System. Subsequently, 24 landmarks were located on each 3D photographs following a standardized protocol, and then 19 linear and 3 angular periorbital variables were measured. Furthermore, two-dimensional (2D) and direct measurements were conducted on each subject and compared with 3D measurements and one another.

RESULTS

The grand r means across all measurements were 0.77, 0.78, and 0.88 for direct vs. 2D values, direct vs. 3D values, and 3D vs. 2D values, respectively. The mean absolute differences were 1 mm (ranging from 0.2 mm to 3.7 mm) between direct and 3D measurements, 1 mm (ranging from 0.04 mm to 2.4 mm) between direct and 2D measurements, and 1 mm and 6.6° (ranging from 0.04 mm or 0.5° to 3 mm or 12.8°) between 2D and 3D measurements.

CONCLUSIONS

This study verified the feasibility of this detailed and standardized landmark localization protocol for assessing the periorbital morphology with 2D and 3D technologies. This protocol may work as a bridge communicating with all studies involving any of the three technologies in the future.

Reliability of periocular anthropometry using three-dimensional digital stereophotogrammetry

PURPOSE

Non-invasive three-dimensional (3D) stereophotogrammetry is becoming increasingly popular in many fields. However, few studies have focused on its periocular application. We aimed to provide evidence for the periocular application of a novel anthropometric procedure using 3D stereophotogrammetry by evaluating its reliability.

METHODS

Fifty-one Caucasians were recruited (102 eyes; mean age, 31.9 ± 13.6 years). Two sets of 3D images were acquired for each subject, and two measurement sessions were performed on each image by two raters. Fifty-two periocular landmarks were identified, and then 49 corresponding linear, curvilinear, and angular measurements were evaluated for intrarater, interrater, and intramethod reliability.

RESULTS

Our findings showed highly reliable results for mean absolute difference (0.59 and 0.68 unit), relative error measurement (2.66% and 3.08%), technical error of measurement (0.59 and 0.66 unit), relative technical error of measurement (2.71% and 2.96%), and intraclass correlation coefficient (0.98) for intrarater 1 and intrarater 2 reliability; respectively 0.94 unit, 4.06%, 0.89 unit, and 3.94%, as well as 0.97 for interrater reliability; and respectively 0.98 unit, 4.66%, 0.96 unit, and 4.64%, as well as 0.96 for intramethod reliability.

CONCLUSIONS

This imaging system and the landmark identification protocol are highly reliable. The collected measurements and their errors can be applied for the comparison of reliability among various 3D imaging systems and populations. It could be utilized for planning surgeries and evaluating treatment outcomes for physicians in ophthalmology, plastic and esthetic surgery, and in the maxillofacial field where periocular morphology alterations are made.

Brow/Upper lid anatomy, aging and aesthetic analysis

The upper eyelid serves the important anatomic function of protecting the eye and rewetting the cornea to maintain vision. The complex dynamic action of the upper eyelid explains its relatively complex anatomy. The brow has an important supportive role. Studies have revealed facial characteristics perceived as youthful and aged, and the anatomic basis of these changes is defined at many levels. Characteristic aging changes in the upper eyelid and brow create an appearance of aging and opportunities for functional and aesthetic improvement.

Minimally invasive options for the brow and upper lid

Eyebrow and upper eyelid aging occurs in all tissue planes, and manifests most commonly in skin quality, tissue volume loss (soft tissue and bone), and tissue descent. All these involutional changes are amenable to less-invasive (nonsurgical) interventions with natural and aesthetically pleasing results. It is critical for aesthetic facial surgeons to familiarize themselves with these procedures because they are in high demand by patients. This article outlines current concepts of nonsurgical management options for brow and upper eyelid aging. The anatomy and age-related changes in these structures are reviewed, and minimally invasive techniques to address these changes are detailed.