The Long-Term Effect on Dry Eye of Posterior Approach Ptosis Surgery Vs. Upper Eyelid Blepharoplasty

PURPOSE

To examine the long-term effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome.

METHODS

This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining.

RESULTS

The participants included 25 post-MMCR patients with a mean follow-up of 4.94 ± 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 ± 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p < .01 and p < .01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p = .044). Those parameters were not significant in the blepharoplasty group.

CONCLUSIONS

Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye.

Transconjunctival Fat Repositioning Blepharoplasty: Is Excess Fat Herniation a Prerequisite?

BACKGROUND

The fat repositioning technique has been widely used for the treatment of tear trough deformity, and there is a strong belief that excess fat herniation is a prerequisite for the procedure. The purpose of this study was to evaluate its effect in patients with minimal or no excess fat herniation.

METHODS

A total of 232 patients underwent the procedure and met the inclusion criteria. Of them, 198 were primary cases, and 34 had a hisory of fat removal for blepharoplasty. The amount of infraorbital fat was evaluated preoperatively by palpation. Release of the tear trough ligament and fat redistribution were sequentially performed as described previously. Surgical outcome was assessed based on the Hirmand grading system and the FACE-Q scales.

RESULTS

Tear trough deformities were eliminated in more than 85% of cases. Aesthetic results were comparable between the primary and secondary surgery groups. The percentage of patients who complained of extremely or moderately severe tear trough deformities decreased from 86.3% preoperatively to 34.0% postoperatively. The scores of the lower eyelid FACE-Q decreased significantly ( P < 0.05). Patients were satisfied with their decision to undergo blepharoplasty (78.2 ± 18.7). Undercorrection of the tear trough occurred in 30 patients. Other complications included 12 cases of transient conjunctiva bleeding, two cases of eyelid numbness, and six cases of dry eye. These resolved spontaneously.

CONCLUSION

Fat repositioning is a feasible and effective technique for the treatment of tear trough deformities in patients with minimal or no excess orbital fat herniation, provided that a fat pad is palpable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical correction of sunken upper eyelid with upper arcus marginalis release and precision fat distribution technique

BACKGROUND

Sunken upper eyelids, characterized by hollowing in the upper orbital region, can contribute to an aged or fatigued appearance. We aim to report on the surgical technique and its effects, involving the release of the arcus marginalis of the upper eyelid and the precise distribution of orbital fat.

METHODS

From December 2021 to March 2023, a total of 84 eyelids from 42 patients who underwent surgical correction for sunken upper eyelids, utilizing the upper arcus marginalis release and precision fat distribution technique, were included in this study. Preoperative and postoperative sunken depths were measured and statistically analyzed. Aesthetic satisfaction was assessed through patient questionnaires.

RESULTS

Preoperative and postoperative sunken depths measured 9.2 ± 2.2 mm and 5.9 ± 2.3 mm, respectively. The mean improvement was 3.3 mm, a change of statistical significance. Aesthetic outcomes and patient satisfaction yielded favorable results. No major complications were observed during the follow-up period.

CONCLUSION

The upper arcus marginalis release and orbital fat distribution technique demonstrated favorable outcomes in correcting sunken upper eyelids. This procedure ensures stable placement of orbital fat at the deepest sunken point, resulting in aesthetically pleasing and enduring results. This technique serves as a valuable alternative for patients with moderate to severe sunken eyelids.

Effects of Midcheek Lift According to Dissection Plane and Range: An Anatomical Study

BACKGROUND

Midcheek lift has been performed for cosmetic or reconstructive surgery of the lower eyelid. For midcheek lift through the subciliary incision, preperiosteal and subperiosteal dissections are the most often implemented, with good clinical outcomes. However, a comparative assessment of the effects of these 2 methods had not been conducted.

OBJECTIVES

In this study we compared the effects of midcheek lift according to preperiosteal or subperiosteal plane and range of midfacial dissection.

METHODS

Forty hemifaces of 20 fresh cadavers were dissected. One side of the hemiface underwent preperiosteal dissection, and the other side underwent subperiosteal dissection. After dissections of 5, 10, 15, 20, and 30 mm and all of the midcheek area from the inferior orbital rim, the length of the elevated lid-cheek junction was measured by placing upward traction on the lateral portion of the lower lid.

RESULTS

In both methods, the length of the midcheek lift increased as the dissection progressed, and the length of the lift on the lateral side was greater than that on the medial side. The length of the pulled skin in the preperiosteal group was the greatest in most cases. However, in the full dissection cases, the midcheek lift length was not statistically different between the 2 surgical methods, especially on the lateral side.

CONCLUSIONS

Flap elevation in lower blepharoplasty surgery can be predicted based on the surgical method and dissection range. Implementing a surgical plan that takes this into account can enhance both reconstruction and aesthetic surgery outcomes in the midcheek area.

Defining Ideal Double Eyelids With a Morphometric Analysis in Asians

BACKGROUND

Double eyelids are always considered crucial aesthetic symbols. Despite numerous studies conducted on the attractiveness of double eyelids, there remains a dearth of research on quantitative and morphological evaluation of ideal double eyelids.

OBJECTIVES

In this we study aimed to investigate the optimal height and morphological characteristics of ideal double eyelids.

METHODS

Participants were presented with a total of 9 images, consisting of 1 single eyelid image and 8 double eyelid images, featuring 2 distinct shapes and 4 varied pretarsal shows. Respondents were instructed to assign scores ranging from 1 (least attractive) to 5 (most attractive) for each image. Subsequently, the scores for each image were analyzed based on population demographics, followed by the calculation of aesthetic metrics.

RESULTS

The whole cohort deemed images with a 2-mm fold to be more attractive than 1 mm (P < .001), followed by 3 mm and 0 mm (single eyelid), and finally, 4 mm. Morphologically, significant differences were found between images with the same pretarsal shows of 3 mm (P < .001) and 4 mm (P = .026). Most subgroup analysis results were aligned with those of the cohort, with gender being the most significant factor in distinguishing double eyelid aesthetics. Additionally, aesthetic characteristics of 2-mm folds were found to be comparable to appealing double eyelids in previous studies.

CONCLUSIONS

In this study we validated the optimal heights and morphology of double eyelids, thereby addressing the existing gap in aesthetic studies on double eyelids. These findings hold significant implications for surgical planning, effect assessment, and other periocular procedures related to upper blepharoplasty.

LEVEL OF EVIDENCE: 4

Long-Term Improvement of Crow's Feet Wrinkles in Combination With Cervicofacial and Temporal Lifting: Review of the Literature

BACKGROUND

The lateral orbital crow's feet area is one for which rejuvenation is most frequently requested by patients. Moreover, lateral canthal wrinkles are a common source of dissatisfaction after rhytidoplasty. Botulinum toxin injection has emerged as a most popular, easy, and effective solution; nevertheless, repeated injections are required periodically for long-term effect. Other nonsurgical options have also been described to have some demonstrable advantages. Orbicularis oculi surgical manipulations have been described as well.

MATERIAL AND METHODS

A systematic PubMed literature search was conducted to identify clinical cohort studies including more than 10 patients describing surgical approaches for improvement of crows' feet wrinkles in combination with face and/or temporal lifts. The search was complemented by Embase, Medline, and Cochrane searches in addition to screening of reference lists of selected studies and simple term searches about surgical treatment of crow's feet.

RESULTS

Fourteen studies satisfied the inclusion criteria and were included in this review describing various muscle excision techniques including vertical strip excision, lateral partial resection, wedge resection, muscle resection in "C" pattern, and enlarged myectomy of about one-third of the whole orbital extension in addition to muscle manipulation modalities, including muscle splaying, muscle division, muscle division and splaying, muscle undermining with partial denervation, and muscle suspension. Interposition of fascia between orbicularis muscle and overlying skin was also reported.

CONCLUSION

View the few studies retrieved and the wide spectrum of reported techniques, it is not possible to determine from this review the most effective modality. Nevertheless, it seems that subcutaneous undermining of the lateral canthal area combined with splaying and traction of the orbicularis oculi muscle and fixation to the temporalis fascia with or without muscle division would yield the best long-term results. This review indicates also that surgical correction of crow's feet during rhytidectomy or temporal lift could be a positive complement to improve aesthetic outcome. Unfortunately, if not underreported, it is definitely neglected. We believe that this review may be an eye-opener for surgeons.

Sling for the sling: a new technique for long-term correction of severe congenital ptosis

INTRODUCTION

Severe congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect.

PURPOSE

This retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place "sling for the sling".

METHODS

The medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new "sling for sling" technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months.

RESULTS

Preliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence.

CONCLUSION

This study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

Supraciliary Incision as a Modified Approach for Asian Blepharoptosis Patients

BACKGROUND

Blepharoptosis may result in an unattractive appearance and vision problems. According to the severity of ptosis, patients may undergo correction surgery using upper eyelid retractors. The conventional incision for surgical procedures was the double-eyelid incision, potentially resulting in an obvious and unnatural scar or long-lasting edema and prolonged recovery time.

OBJECTIVES

The aim of this study was to introduce a supraciliary incision as an alternative to the double-eyelid incision for blepharoptosis correction that creates a scarless, natural appearance with a quick recovery time.

METHODS

From June 2019 to June 2021, 32 patients (36 eyelids) underwent blepharoptosis correction through a supraciliary incision. MRD1, the height of the eyelid fissure, and the patient's satisfaction with the shape and scar as well as postoperative complications (eyelid insufficiency, conjunctival prolapse, inadequate correction of ptosis, and excessive correction of ptosis).

RESULTS

All 32 patients (36 eyelids) were followed up for 6 to 18 months, with an average follow-up of 11.6 months. The postoperative satisfaction rate was 96.43%. There was no overcorrection, but one patient (1 eyelid, 2.8%) was under correction that required secondary correction. One patient (1 eyelid, 2.8%) experienced conjunctival prolapse. Sixteen patients showed lagophthalmos early after surgery, in which one patient experienced early-stage keratitis and completely recovered within two months.

CONCLUSION

Blepharoptosis correction via supraciliary incision allows for broader indications and fewer surgical scars without disrupting eyelid integrity, resulting in quick recovery after surgery.

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 .

Application of Fixation of Orbicularis Oculi Muscle and Orbital Septal Tissue Flap at the Upper Edge of Incision in Double Eyelid Plasty

PURPOSE

In order to make the postoperative effect of open double eyelid more close to the physiological and anatomical structure of double eyelid, we improved the traditional open double eyelid operation according to the anatomical characteristics of the upper eyelid. We fixed part of the orbicularis oculi muscle above the incisal margin with the orbital septum flap to make the double eyelid formed after surgery more natural and beautiful.

MATERIALS AND METHODS

A total of 76 patients who received open double blepharoplasty in department of plastic surgery from February 2019 to May 2022 were selected as this study objects, all of whom were female. Their ages ranged from 18 to 32 years, with a mean of (23.6 ± 5.2) years. The surgical method is open double blepharoplasty by fixing part of the orbicularis oculi muscle above the incisal margin with the flap of the orbital septum.

RESULTS

In this study, all 76 patients underwent successful surgery, with an average operation time of (1.5 ± 0.2) h. The postoperative double eyelid curvature was smooth and the double eyelid width was basically symmetrical. In terms of the doctors' satisfaction evaluation of the postoperative effect, 64 cases were very satisfied and 12 cases were satisfied. In terms of patients' satisfaction evaluation of the postoperative effect, 60 patients were very satisfied, 15 patients were satisfied and 1 patient was dissatisfied.

CONCLUSIONS

Through this study, we found that this surgical method invented by us has short operation time, good operation effect, few postoperative complications and high patient satisfaction, which is worthy of promotion and application in plastic surgery clinical practice.

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 www.springer.com/00266 .

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients

BACKGROUND

With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty.

METHODS

Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction.

RESULTS

Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome.

CONCLUSIONS

The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision

BACKGROUND

Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids.

METHODS

We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months).

RESULTS

The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations.

CONCLUSIONS

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids.

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 .

Comparisons of the Fusion Point of Orbital Septum and Levator Aponeurosis in Patients with and Without Mild Ptosis

OBJECTIVE

By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis.

METHODS

In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed.

RESULTS

The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001).

CONCLUSION

The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis.

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 .

Digital analysis of unilateral ptosis repair: external levator advancement vs. Müller's muscle conjunctival resection

PURPOSE

Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Müller's muscle conjunctival resection surgery in unilateral ptosis.

METHODS

We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Müller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid.

RESULTS

Sixteen patients underwent external levator advancement and 16 patients had Müller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Müller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11).

CONCLUSIONS

Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.

A new technique to prevent conjunctival prolapse in Asian patients for correcting severe blepharoptosis

BACKGROUND

In Asian patients with severe ptosis,the use of conjoint fascia sheath (CFS) suspension or levator aponeurosis fascia complex shortening surgery can correct the ptosis. During these surgery, a significant amount of levator aponeurosis fascia shortening is performed, which often leads to serious complications such as conjunctival prolapse.This study compares two surgical approaches for correcting severe blepharoptosis:Conjoint fascial sheath (CFS) + levator aponeurosis and muller's muscle complex (LM complex) suspension and conjoint fascial sheath (CFS) + LM complex+conjunctival suspension.The postoperative efficacy and the incidence of complications such as conjunctival prolapse are investigated for both procedures.

METHODS

This study retrospectively analyzed 70 patients (77eyes) with severe blepharoptosis from January 2019 to December 2021. The patients were divided into the experimental group (34 cases, 38 eyes) and the control group (36 cases, 39 eyes). The experimental group was treated with CFS+LM complex + conjunctival suspension, and the control group was treated with CFS+LM complex suspension.The curative effect of blepharoptosis, the incidence of complications such as conjunctival prolapse and patient satisfaction were compared between the two different surgical methods.

RESULTS

There was no significant difference in the correction effective rate between the experimental group (84.21%) and the control group (82.05%) (P > 0.05). There was no significant difference in the total incidence of complications between the experimental group (23.68%) and the control group (38.46%) (P > 0.05), but in the complication of conjunctival prolapse, the incidence of conjunctival prolapse in the experimental group was significantly lower than that in the control group. The difference was statistically significant (P < 0.05). In the survey of patient satisfaction rate, the satisfaction rate of the experimental group was significantly higher than that of the control group,which was statistically significant (P < 0.05).

CONCLUSIONS

Compared to CFS+LM complex suspension surgery, the CFS+LM complex + conjunctival suspension has a definite effect in preventing postoperative conjunctival prolapse .The procedure has a high feasibility, good corrective effect, and improves patient satisfaction after surgery.

A simplified technique for correction of complete ptosis secondary to palpebral neurofibromatosis

PURPOSE

To present a simplified technique in management of complete ptosis secondary to neurofibromatosis.

METHODS

This prospective, non-comparative, clinical interventional study included 13 patients with complete ptosis secondary to histologically proved plexiform neurofibromas. It was conducted at the Orbital Unit of Assiut University Hospital, the referral center of Upper Egypt in the period between June 2013 and October 2021. In all cases, a simplified technique of 5 surgical steps was applied: (A) Division of the involved eyelid surgically into three parts by drawing 2 curvilinear lines, the superior line 11 mm below and parallel to the lower eyebrow hairline and the inferior one 10 mm above the lid margin, (B) Resection (full-thickness) of the large middle part which involves the main pathology and lies between the 2 lines, (C) Preservation of the upper part with identification, dissection and clamping of the levator muscle, (D) Refinement of the lower part by removal of any tissue between the skin and the debulked tarsus and (E) Re-suturing of the upper and lower parts in layers; conjunctiva to conjunctiva, levator to tarsus (after resection of a part that corrects the ptosis) and skin to skin.

RESULTS

Ptosis was completely corrected in 8 cases (61.5%) and residual mild ptosis occurred in 5 patients (38.5%). No exposure keratopathy or tumor growth was reported during the follow-up period of minimum 1 year.

CONCLUSIONS

This simplified technique could be considered as a surgical basis for correction of complete ptosis in neurofibromatosis.

Modified lateral canthopexy with upper and lower blepharoplasties for aesthetic refinements: My personal technique

BACKGROUND

Blepharoplasty is a surgical procedure that modifies the shape and structure of the eyelids to restore a more youthful appearance. The procedure comprises the removal of extra muscle, fat, and skin. In order to get the optimum functional and aesthetic result, supporting components like canthal tendons can also be tightened.

AIM

To evaluate the efficacy of canthopexy in conjunction with the upper and lower blepharoplasty technique and its complications.

METHODS

A total of 400 individuals who underwent these procedures between January 2020 and January 2021 had been recruited for this study. The frequency and clinical complications were analyzed.

RESULTS

The complications were found to be 17 (4 %) cases of relapse, 12 (3 %) temporary hematoma formation, 11 (3 %) cases of epiphora, 8 (2 %) cases of unequal eyelid positioning, 5 (1 %) patients developed conjunctivitis and chemosis.

CONCLUSION

This method appears to be effective since it is simple, practicable, and capable of delivering positive functional and aesthetic effects with a minimum of side effects.

Choosing Upper Blepharoplasty, Infra-brow Lift, and Forehead Lift in Asians: An Algorithmic Approach from Personal Experience

BACKGROUND

Eyelid surgery is a cosmetic procedure performed worldwide in the field of plastic surgery. However, achieving optimal outcomes for the upper eyelids presents a challenge, necessitating careful patient selection and appropriate surgical choices.

OBJECTIVES

This article aims to provide recommendations for selecting the most suitable surgical procedure among three commonly performed treatments for aged upper eyelids.

METHODS

A retrospective cohort study was conducted from October 2020 to May 2022, involving 518 patients. Pre- and postoperative photographs were analyzed to evaluate changes in the distance between the eyelids and brows. Notably, patients who habitually use the frontalis muscle to manage upper eyelid redundancy showed significant variations in the lid-brow distance after eyelid surgery.

RESULTS

The study confirmed that addressing skin laxity through upper blepharoplasty or infra-brow excision reduced the stimulus for frontalis activity, resulting in true brow ptosis. However, the degree of compensatory frontalis movement differed among individuals, and changes in the lid-brow distance observed before and after the photos were influenced by various factors. As a result, obtaining clear numerical data regarding the changes in the lid-brow distance following eyelid surgery proved challenging. Nevertheless, after analyzing 518 cases, the author has classified the patients into three groups, which can contribute to more predictable and satisfying outcomes.

CONCLUSION

Based on the analysis of pre- and postoperative results from 518 patients, this study recommends specific strategies to enhance patient satisfaction. The proposed treatment algorithm may assist beginner surgeons in avoiding angry or tired-looking eyes after periorbital rejuvenation.

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 .

Small-Incisional Double Eyelid Blepharoplasty: A Retrospective Study of Our Minimally Invasive Technique with Three Mini Incisions

BACKGROUND

Small-incisional double eyelid surgery has been increasingly performed these years and achieved good aesthetic results, but the techniques vary greatly between literatures. The authors reviewed the cases of three-small-incisional double eyelid surgery performed in the past three years and introduced their surgical technique in detail.

METHODS

A total of 87 patients receiving bilateral three-small-incisional double eyelid surgery were included in this retrospective study. The pretarsal folds were designed meticulously, along which three evenly distributed 2 mm-long incisions were made. A minimal amount of orbicularis oculi muscle and pretarsal soft tissue were removed to expose the pretarsal fascia for further fixation. An appropriate amount of orbital septal fat was removed through the lateral incision if required. The superficial orbicularis oculi muscle and dermis on the lower margin of the incision were fixed onto the pretarsal fascia with some underlying tarsus on the upper margin of the tarsus. The skin was closed by one stitch for each incision.

RESULTS

The average follow-up was 9.9 ± 5.2 months (range: 6-27 months). All the patients were satisfied with the result. None of them experienced loss of the pretarsal fold, bilateral asymmetry, scar hyperplasia, or persistent swelling after surgery.

CONCLUSIONS

Our three-small-incisional technique with minor soft tissue debulking offers a simple, safe, and reproducible approach to double eyelids. It can create a stable and natural-looking pretarsal fold with a short recovery period.

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 .

Late-Onset Traumatic Corneal Conjunctival Epithelial Disorders due to Granular Formation After Cosmetic Suture Blepharoplasty

PURPOSE

The purpose of this study was to report conjunctival granular formation as one of the causative factors of a traumatic corneal conjunctival epithelial disorder after plastic suture blepharoplasty.

METHODS

Clinical charts of 7 patients who had visited Ohshima Eye Hospital with a symptomatic corneal epithelial disorder and history of suture blepharoplasty were reviewed. Clinical evidence of conjunctival granular formations was observed in all patients at the tarsal conjunctiva facing to corneal conjunctival traumatic epithelial disorders. The desired outcome was to alleviate the disorder. The assessment included tabulating results after the placement of a soft contact lens bandage and subsequent partial tarsal plate resection of the granular formation.

RESULT

Seven women (mean age 45.0 ± 10.9 years) enrolled in this study had previously undergone suture blepharoplasty (mean 18.3 ± 6.9 years before). Soft contact lens bandages relieved all of the patients' complaints immediately. After resecting the granular formation, the traumatic corneal conjunctival epithelial disorder disappeared, and no recurrence was observed after surgery.

CONCLUSIONS

The conjunctival granular formation within the tarsal conjunctiva after suture blepharoplasty caused the late-onset traumatic corneal conjunctival epithelial disorder. A complete cure was obtained after resection of the granular formation at the tarsal conjunctiva. To the best of our knowledge, this is the first report to identify the removal of granular formations in 7 patients with late-onset traumatic corneal conjunctival disorders many years after blepharoplasty. The resection of these lesions is a promising procedure to treat late-onset ocular epithelial disorder after suture blepharoplasty.

Can Local Infiltration Influence Postoperative Recovery in Upper Blepharoplasty? A Case Series Study on Two Different Infiltration Methods

Upper blepharoplasty is a common aesthetic surgery procedure which is frequently performed wide awake, under local anesthesia. However, advancements concerning the patients' perception during and after the procedure are still needed. This study aimed to evaluate the efficacy of a new method for local anesthetic infiltration in the upper eyelid comparing it to the traditional needle injections.A prospective, randomized, and clinical trial was conducted on 20 patients who underwent upper eyelid blepharoplasty in local anesthesia. After randomization, one eyelid was infiltrated using a Nanosoft technology needle, while on the contralateral side traditional needle injections were performed. Preoperative demographics, Fitzpatrick, and SNAP test were recorded. Postoperative patients visual analog scale (VAS) scores for both infiltration methods and ecchymosis and edema were recorded.Our results showed that the mean VAS scores for perceived pain were significantly lower on the eye infiltrated with Nanosoft technology (p < 0.05). Furthermore, the rate of postoperative ecchymosis and edema were also significantly lower with Nanosoft technology (p = 0.0012 and 0 = 0.0197, respectively). All 20 patients were satisfied with outcomes, and there were no major complications or need for a revision.Our case series study suggests that Nanosoft technology may be a more effective and efficient method for the local anesthetic infiltration in upper eyelid blepharoplasty in reducing discomfort and downtime for the patient.

Comparison of Stab Incision and Eyelid Crease Incision Techniques in Children with Revision Frontalis Sling Surgeries Using Silicone Rods

PURPOSE

To compare stab and eyelid crease incision techniques in revision frontalis sling surgeries using silicone rods.

METHODS

This retrospective study involved 52 eyes in 48 consecutive pediatric patients who underwent revision frontalis sling surgery between 2008 and 2019. All primary surgeries were performed by making eyelid crease incisions and suturing of silicone rods onto the tarsal plates. The revision surgeries were performed by either making stab incisions over the eyelid through which to pass the silicone rods (group A), or by refixing the same or a new silicone rod to the tarsal plate (group B). The surgical results were compared.

RESULTS

The mean follow-up period was 22.4 months (range, 6-62 months) and the mean age of the patients was 6.1 years (range, 1-16 years). There were 28 female and 20 male patients. Surgical success was achieved in 23 of 28 patients (82.1%) in group A, and 12 of 24 patients (50.0%) in group B. The difference between the groups was statistically significant (p = 0.012). Superficial punctate epithelial defects were detected in six group A patients (21.4%) and seven group B patients (29.1%). In group B, lid hematoma occurred in three patients (12.5%) and entropion occurred in three patients (12.5%). The silicone rods were removed from two eyes, and entropion spontaneously resolved in one eye with close follow-up.

CONCLUSIONS

Using the stab incision technique increases revision frontalis sling surgery success rates when primary surgeries are performed using eyelid crease incisions and suturing silicone rods to the tarsal plates in children.

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

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 .

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon

BACKGROUND

Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos.

METHODS

We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes.

RESULTS

Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment.

CONCLUSION

We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos.

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

A new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults

A posterior approach is recommended for the correction of mild to moderate upper eyelid ptosis in adults. The aim of this study is to propose a new algorithm that helps to predict outcomes in the transconjunctival correction of moderate to severe blepharoptosis. This study included adult patients with moderate to severe upper eyelid ptosis treated between 2019 and 2021. Patients meeting inclusion criteria underwent ptosis correction through a posterior approach using an algorithm: 4 mm Mueller's muscle transconjunctival resection to correct 1 mm ptosis (depending on a test with 10% phenylephrine: 3-12 mm) ± tarsal plate resection: 1 mm for every 1 mm of residual ptosis after phenylephrine test, but leaving a minimum of 4 mm upper tarsus intact. Outcomes were ovserved within at least 6-months. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications. Outcomes of 118 procedures in 81 patients (average age 69, range: 47-87) were analyzed. MRD1 changes were statistically significant, from 0.2 ± 1.6 mm before to 4.1 ± 1 mm after surgery. The function of the levator palpebrae superioris muscle was 10.2 ± 3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8 ± 0.7 (range 0-3) mm after the instillation of 10% phenylephrine eyedrops. An average of 8.5 ± 0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2 ± 0.9 (range 1-5) mm of the tarsal plate were resected during the procedure. Inter-eyelid height symmetry within 1 mm was achieved in 95% of outcomes. The algorithm introduced in this study appears to be useful to achieve repeatable satisfactory outcomes in the transconjunctival correction of moderate to severe upper eyelid ptosis in adults with at least "fair" levator function.

Outcomes of a novel algorithm for levator muscle plication surgery in congenital blepharoptosis

AIM

to assess the outcomes of a novel algorithm for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery.

METHODS

this retrospective comparative study included 34 patients with congenital ptosis subjected to levator muscle plication surgery during the period from October 2021 to November 2022. They were divided into two groups. Group A: the amount of levator muscle plication was calculated by a traditional formula [(amount of ptosis x 3) + 9 mm in cases with good levator function or (amount of ptosis x 3) + 11 mm in cases with fair levator function]. Group B: the amount of levator muscle plication was calculated by a novel nomogram [the result of the traditional formula was modified by subtracting 4 mm if the calculated amount was ≥ 15 mm or subtracting 3 mm if the calculated amount was < 15 mm]. Demographic data, baseline ptosis characteristics and postoperative results at 1st week, 1st month, 3rd month and 6th month were compared between the groups. Primary outcome measure was postoperative Marginal Reflex Distance (MRD1). Secondary outcome measures were lid contour, lid crease and any reported complications.

RESULTS

Group A included 20 eyes of 18 patients while Group B included 20 eyes of 16 patients. The mean amount of levator muscle plication was 16.98 ± 2.44 mm and 13.48 ± 2.42 mm in group A and group B respectively. The difference between the two groups was highly statistically significant (p < 0.001). Mean MRD1 at the 1st postoperative week was 4.95 ± 0.37 mm in group A and 4.08 ± 0.64 mm in group B. This difference was highly statistically significant (P < 0.001). Overcorrection was seen in 8 (40%) eyes in group A and 1 (5%) eye in group B. The difference was statistically significant between the two groups (p = 0.008). Undercorrection was seen in only 1 (5%) eye in group B. No other complications were reported. Surgical success was achieved in 12 (60%) eyes in group A versus 18 (90%) eyes in group B. The difference between the two groups was statistically significant (p = 0.03).

CONCLUSION

our novel nomogram for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery is effective in achieving a satisfactory postoperative MRD1.

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for the repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: "good" (improvement of palpebral fissure height without laterality, Margin reflex distance-1 gap between right and left side <0.5 mm), "fair" (improvement of palpebral fissure height with laterality), or "poor" (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity, or recurrence of ptosis. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This grafting technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.

Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic Review

BACKGROUND

Cicatricial lower eyelid retraction is a challenging condition. It involves scarring of the lower eyelid, which causes it to retract and expose the sclera. This can lead to complications such as dry eye syndrome and corneal melting. It can be caused by trauma, burns, or previous eyelid surgery. Detailed assessment and understanding of eyelid anatomy and retraction are critical for successful surgical planning. Dynamic and static examinations of the eyelid including measurements of the lower eyelid margin reflex distance (MRD2) and scleral show are also essential to determine the appropriate treatment approach.

METHODS

A systematic review was conducted using Medline, Scopus, and Cochrane databases with keywords related to cicatricial lower eyelid retraction. The publication language was limited to English after 2000. A total of 29 articles were included for data extraction and analysis.

RESULTS

The main surgical techniques include tarsoconjunctival grafts, spacers, midface lift, and lateral canthal tendon suspension, although no single procedure has been universally recognized as the gold standard. New innovations such as synthetic grafts and xenografts are being explored for their potential in eyelid reconstruction. Severe cases, defined as those with inferior scleral show greater than 2 mm, may require a combination of reconstruction methods.

CONCLUSIONS

Correcting cicatricial lower eyelid retraction is a major challenge in oculoplastic reconstruction. The surgical approach should be individualized, considering the pathologies and etiologies of lid retraction. In-depth knowledge and careful surgical planning are essential for best outcomes. There is no gold standard technique, and postoperative outcomes, complications, and management vary depending on the surgical approach used.

Tape Tarsorrhaphy in the Management of Lagophthalmos Caused by Severe Congenital Blepharoptosis Procedures

BACKGROUND

Lagophthalmos, a common complication after blepharoptosis correction, has plagued oculoplastic surgeons. The goal of this study was to investigate the effect of tape eyelid closure on reducing the occurrence of lagophthalmos after blepharoptosis correction.

METHODS

From April 2020 to June 2021, a total of 112 patients with severe congenital ptosis received corrective surgery at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University. Of these, 48 underwent frontalis muscle advancement technique and 64 underwent conjoint fascial sheath suspension. Preoperative data collected included demographics, levator function, Bell's phenomenon, and marginal reflex distance 1 (MRD1). Postoperative data included surgery type, MRD1, eyelid closure function, aesthetic outcomes (including eyelid contour, eyelid symmetry, and eyelid crease), keratitis, and other complications.

RESULTS

Frontalis muscle advancement technique group: the median of safe eye closure time was 7.3 months (positive Bell's phenomenon; interquartile range [IQR], 3.8-10.8 months) and 13.9 months (poor Bell's phenomenon; IQR, 11.6-16.1 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.52 ± 0.82 vs 3.85 ± 0.58 mm, P < 0.05). Conjoint fascial sheath suspension group: the median of safe eye closure time was 5.7 months (positive Bell's phenomenon; IQR, 2.9-8.5 months) and 12.4 months (poor Bell's phenomenon; IQR, 8.1-16.7 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.02 ± 0.91 vs 4.15 ± 1.03 mm, P < 0.05). All patients/guardians were satisfied with the aesthetic outcomes.

CONCLUSIONS

Tape tarsorrhaphy is a safe, easy-to-learn method for treating lagophthalmos with a good aesthetic outcome.

Ultrasound-based histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method

OBJECTIVE

To observe the changes of pretarsal fat fascia histological structure after double eyelid blepharoplasty with the orbital septum method.

METHODS

From December 2019 to February 2022, the patients with congenital single eyelid who underwent double eyelid blepharoplasty with the orbital septum method at the Plastic and cosmetic surgery department of Hunan provincial people's Hospital and the same number of congenital double eyelid volunteers. Then divided into three groups: preoperative eyelid ultrasound images in Group A, postoperative eyelid ultrasound images in Group B, and congenital double eyelid volunteers in Group C. To study the histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method and congenital double eyelid by ultrasound.

RESULTS

Ninety-eight patients who underwent double eyelid blepharoplasty with the orbital septum method met the inclusion criteria. All 98 patients aged 22.88 ± 3.00 years, including 7 males and 91 females, followed up for 6-12 months. Included 98 volunteers with congenital double eyelid, aged 23.58 ± 2.59 years, including 49 males and 49 females. Ultrasound showed that the pretarsal fat fascia was divided into two layers. The dense layer adhered closely to the surface of the tarsus with no statistically significant differences. There was a statistically significant difference in the thickness of the pretarsal loose fat fascia layer between Group A and B. The points a b c in Group A were significantly thicker than those in Group B and C, and there was no significant difference between Group B and C. Postoperative evaluation: 83 cases were satisfied, 11 cases were basically satisfied and 4 cases were unsatisfied.

CONCLUSION

After double eyelid blepharoplasty using orbital septum, the histological structure of pretarsal fat fascia is similar to that of congenital double eyelid, suggesting that double eyelid blepharoplasty with the orbital septum method can change the structure of pretarsal fat fascia and make it similar to congenital double eyelid, which is one of the anatomical bases for its good clinical effect.

The Aesthetic Evaluation of the Brow-Eye Continuum After Correction of Severe Congenital Ptosis in Children With Extended Frontalis Muscle Advancement Technique

BACKGROUND

Severe congenital ptosis is a common ocular deformity in pediatric patients that can significantly impact visual development and aesthetic appearance, leading to negative psychosocial outcomes. The frontalis muscle advancement technique is a well-established surgical treatment for severe congenital ptosis. Aesthetic changes of the brow-eye continuum often plays an important role in ptosis surgery.

METHODS

We conducted a single-center retrospective case series study of patients with severe congenital ptosis who underwent the frontalis muscle advancement technique at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University between April 2020 and June 2021. The study aimed to evaluate the aesthetic changes of the eyebrow-eyelid continuum after surgery. The main outcome measurements included marginal reflex distance 1, palpebral fissure height, eyebrow position, upper eyelid to lower eyebrow distance, lower eyelid to upper eyebrow distance, and nasal base to lower eyelid distance.

RESULTS

The study included 48 patients (66 eyelids), with 30 unilateral and 18 bilateral patients. Our analysis found that eyebrow height decreased by an average of 4.8% postoperatively relative to preoperatively in all patients.

CONCLUSIONS

The frontalis muscle advancement technique has demonstrated effectiveness in achieving aesthetically pleasing outcomes in children with severe ptosis. It is crucial to pay careful attention to the brow-eye continuum during the correction process, as its harmony can greatly impact the final result.

Effects of Orbicularis Oculi Flap Suspension on Transcutaneous Lower Blepharoplasty

OBJECTIVE

The purpose of this study was to analyze the clinical effects of orbicularis oculi muscle suspension in conjunction with transcutaneous blepharoplasty in patients 60 years of age or older.

METHODS

A retrospective study was conducted on patients aged 60 or older who underwent orbicularis oculi flap suspension in conjunction with transcutaneous blepharoplasty to treat lower lid festoons, lower lid fat prolapse, and lid laxity at Korea University Guro Hospital. The outcomes were surgical success rate, recurrence rate, postoperative complications, and patient satisfaction.

RESULTS

In total, 39 patients (18 males and 21 females) were included, with an average age of 67.5 years (60-86 y) and a follow-up period of 145.7 days (95-195 d). In all patients, eyelid laxity was effectively corrected, and there was no recurrence of eyelid laxity after surgery. Three patients suffered postoperative complications, transient skin edema in 2 patients, and transient ectropion in 1 patient. Subjective satisfaction score following surgery was high, with an average score of 2.56 out of 3 points.

CONCLUSIONS

Orbicularis oculi flap suspension with transcutaneous blepharoplasty can shorten operation time due to surgical ease. It also has the advantage of not involving conjunctival-related complications such as conjunctival edema since it does not pass through the conjunctiva. Finally, it can successfully treat lid laxity and could be used in lower blepharoplasty procedures.

Subclinical Upper Eyelid Ptosis in Asian Patients: The Role of Levator Advancement in Optimizing Outcomes in "Cosmetic" Upper Blepharoplasty

BACKGROUND

Subclinical ptosis is prevalent in Asian patients presenting for aesthetic upper blepharoplasty. To achieve predictable and satisfactory results in these patients, addressing the ptosis component is critical. In this paper, we present a precision levator advancement technique that enabled us to predictably incorporate the levator advancement into our upper blepharoplasty to deliver more predictable results in these patients.

MATERIALS AND METHODS

Asian patients with normal or near normal margin to reflex distance 1 (MRD 1 of ≥ 3.5 mm) and symptoms and signs of straining of the frontalis with eyelid opening were diagnosed with subclinical upper eyelid ptosis and included in this prospective study. The advancement required was estimated pre-operatively using a formula that we developed. Our surgical technique is presented in detail here, and our long-term results were analysed.

RESULTS

From December 2019 to August 2022, 97 patients were included in this study. Sixty-five patients were primary cases and 32 were revision cases. The mean follow-up was 15 months. Of the 192 eyelids analysed, our formula was able to correctly identify the required fixation location in 69% of eyelids. In majority of the eyelids (94%), the correct location of fixation location within +/- 1 mm of the estimated location. All patients (100%) were satisfied with their long-term results. Our revision rate was 3%.

CONCLUSIONS

Incorporating a precisely done levator advancement into the upper blepharoplasty in patients with subclinical ptosis is critical for optimizing the aesthetic and functional outcomes. This approach has enabled us to perform this procedure greater predictably in this group of patients.

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 www.springer.com/00266 .

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty

BACKGROUND

Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks.

OBJECTIVES

The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB.

METHODS

Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared.

RESULTS

There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2).

CONCLUSIONS

The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

LEVEL OF EVIDENCE: 4

How Brow Rotation Affects Emotional Expression Utilizing Artificial Intelligence

BACKGROUND

It is well known that brow position affects emotional expression. However, there is little literature on how and to what degree this change in emotional expression happens. Previous studies on this topic have utilized manual rating; this method of study remains small and labor intensive. Our objective is to correlate manual brow rotations with emotional outcomes using artificial intelligence to objectively determine how specific brow manipulations affected human expression.

METHODS

We included 53 brow-lift patients in this study. Pre-operative patients' brows were rotated to - 20, - 10, +10, and +20 degrees in respect to the central axis of their existing brow using PIXLR, a cloud-based set of image editing tools and utilities. These images were analyzed using FaceReader, a validated software package that uses computer vision technology for facial expression recognition. The primary facial emotion and intensity of facial action units (0 = no action unit detected to 4 = most intense action unit detected) generated by the software were recorded.

RESULTS

265 total images [5 images (pre-operative, - 20 degree brow rotation, - 10, +10, and +20) per patient] were analyzed using FaceReader. The primary emotion detected in the majority of images was neutral. The percentage of disgust in patients' expressions, as detected by FaceReader, increased with increased positive brow rotation (1.76% disgust detected at - 20 degrees, 2.09% at - 10 degrees, 2.65% at neutral, 2.61% at +10 degrees, and 2.95% at +20 degrees). In contrast, the percentage of sadness in patients' expressions decreased with increased positive brow rotation (29.92% sadness detected at - 20 degrees, 21.5% at - 10 degrees, 11.42% at neutral, 15.75% at +10 degrees, and 12.86% at +20 degrees). Our facial action unit analysis corresponded with primary emotion analysis. The intensity of the inner brow raiser decreased with increased positive brow rotation 8.54% at - 20 degrees, 4.21% at - 10 degrees, 1.48% at neutral, 0.84% at +10 degrees, and 0.76% at +20 degrees). The intensity of the outer brow raiser increased with increased positive brow rotation (0.97% at - 20 degrees, 0.45% at - 10 degrees, 1.12% at neutral, 5.45% at +10 degrees, and 11.19% at +20 degrees).

CONCLUSION

We demonstrated that increasing the degree of brow rotation correlated positively with the percentage of disgust and inversely with the percentage of sadness detected by FaceReader. This study demonstrated how different manipulated brow positions affected emotional outcomes using artificial intelligence. Physicians can use these findings to better understand how brow-lifts can affect the perceived emotion of their patients.

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 www.springer.com/00266 .

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.

Sector area index: a novel supporting marker for blepharoptosis screening and grading

PURPOSE

To introduce a new supporting marker for discriminating different grades of ptosis called Sector Area Index (SAI) and a semi-automated technique to calculate it.

METHODS

In this cross-sectional comparative case series, a circle enclosing the intercanthal distance was automatically drawn after choosing two points as the medial and lateral canthus and manually selecting the palpebral fissure region. Finally, 15-degree apart sectors are applied to the enclosed circle. SAI was measured automatically by dividing the area of each 15-degree sector marked with the upper eyelid contour by the total area of the sector marked with the edge of the surrounding circle. SAI values and inter-eye SAI differences were compared between patients with different grades of ptosis as well as normal patients.

RESULTS

In the current study, 106 eyes were recruited (30, 25, 27, and 24 in the control, mild, moderate, and severe ptosis groups, respectively). Mean values of SAI in all sectors showed a decreasing trend from normal individuals toward patients with severe ptosis. The mean difference values of SAI between study eyes and fellow eyes in all four groups of patients showed a statistically significant difference (p < 0.05). In a pairwise comparison between groups, mean values of SAI in all nasal sectors from 15° to 60° showed a statistically significant difference between all groups (p < 0.05).

CONCLUSION

The mean difference of SAI between study eyes and fellow eyes, including eyelid curvature, especially in 15°-60° and 120°-165° sectors, can demonstrate differentiating performance for detecting and discriminating varying grades of ptosis.

The Temporal Subcutaneous Brow Lift with Orbicularis Oculi Muscle Elastic Flap: Technical Considerations, Systematic Review, and Terminology Standardization

OBJECTIVES

 As the face ages, cosmetic changes in the periorbital region including eyebrow ptosis, sagging in the lateral temporo-orbital region with superior eyelid hooding, ptosis of orbicularis oculi muscle associated with drooping of the malar area with multiple "crow feets", a deeper lid-cheek junction, and malar festoons also occur. All these periorbital structures should be considered as a single anatomical entity.

METHODS

 Numerous techniques have been described to correct brow aesthetics in facial rejuvenation. We report the senior author's (M.P.) current approach utilizing a temporal subcutaneous brow lift (TSBL) associated with an orbicularis oculi muscle (OOM) elastic flap. Furthermore, a systematic review of the literature was performed comparing the different surgical approaches striving to clarify its terminology. A total of 298 patients underwent this procedure in 4 years period. Of these, 230 patients, with at least 12 months of follow-up, were submitted to subjective and objective methods to evaluate the self-perception of scar and their overall aesthetic satisfaction. A committee of experts, blinded to each other's assessment, evaluated the same outcomes. Total eyebrow's tail lift was measured and recorded for each patients.

RESULTS

 The most satisfying aspect of these techniques is the dramatic periorbital rejuvenation and preservation of the patient's original youthful identity. In fact, the postoperative results appear very natural and do not suffer from an "operated" look. This aspect is noticeable from both the surgeon's and the patient's perceptions. There were no major complications in any of the cases.

CONCLUSIONS

 The proposed TSBL with OOM elastic flap technique, in the hands of senior author (M.P.) has emerged as a reliable, effective, and highly reproducible method to treat sagging and aging of the lateral region of the orbit, even without associated blepharoplasties.

Misdiagnosis and Treatment of Corneal Complications Caused by Suture Exposure After Buried-Suture Double-Eyelid Blepharoplasty

PURPOSE

The purpose of this study was to summarize the misdiagnosis and treatment of corneal complications associated with suture exposure in cases of buried-suture double-eyelid blepharoplasty.

METHODS

This study retrospectively analyzed 14 patients with palpebral conjunctival and corneal complications due to suture exposure after buried-suture double-eyelid blepharoplasty at the First Affiliated Hospital of Harbin Medical University from January 2020 to July 2022. The patients' clinical symptoms included photophobia, lacrimation, pain, foreign body sensation, swelling of the eyelids, conjunctival hyperemia, secretion, etc. We recorded the patient's sex, age, surgical method, length of exposed suture, suture type, number of double-eyelid surgeries, surgical site, timepoint when eye discomfort occurred, misdiagnosed disease and treatment.

RESULTS

Three patients were misdiagnosed with dry eye, nine patients were misdiagnosed with viral keratitis, and two patients were misdiagnosed with allergic conjunctivitis. All 14 patients had manifestations of photophobia, lacrimation, pain, foreign body sensation and conjunctival hyperemia. Eight patients had manifestations of swelling of the eyelids. Five patients had manifestations of eye secretions. There were 8 patients with corneal epithelial injuries and 6 patients with corneal ulcers. All patients underwent suture removal without further progression. Ten patients were treated with artificial tears, and 4 patients were treated with calf serum deproteinized gel after suture removal.

CONCLUSION

If there is postoperative eye discomfort caused by eyelid and corneal complications in patients after buried-suture double-eyelid blepharoplasty, clinicians should carefully check whether there is suture exposure and determine the cause in a timely manner. Suture removal is the best way to treat this complication.

LEVEL OF EVIDENCE IV

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Horizontal eyelid shortening alone versus combined procedures for the correction of involutional lower eyelid entropion

BACKGROUND

Conventionally, management of involutional entropion involves correcting both vertical and horizontal laxity, however the optimal surgical approach is debated.

OBJECTIVE

To compare the recurrence rate of horizontal lower eyelid shortening alone with combined surgical approaches for correction of involutional lower eyelid entropion.

METHODS AND MATERIAL

A retrospective, comparative, consecutive case series of patients undergoing surgery for involutional lower eyelid entropion with both horizontal and vertical laxity. Patients were categorized based on the procedure as: Group 1, horizontal shortening alone, Group 2, horizontal shortening with everting sutures), and Group 3, horizontal shortening with retractor plication.

RESULTS

Of the 249 procedures (31 bilateral) performed on 218 patients, 54 (22%) involved horizontal eyelid shortening alone (Group 1), while 80 (32%) had this combined with everting sutures (Group 2), and 115 (46%) with retractor plication (Group 3). The anatomical success rates for Groups 1, 2, and 3 were 93, 94, and 90% (P = 0.69), respectively. Similarly, reported symptom improvements were 94, 93, and 93% for these groups (P = 0.91). After an average follow-up of 15.7 months (median 10; range 6-81), Group 1 (eyelid shortening alone) had a 7% (4/54) recurrence, compared to 8% (16/195) in Groups 2 and 3 (combined procedures) (P = 1.0). Complications were minor, with no significant difference between groups.

CONCLUSION

Eyelid shortening alone appears to be as effective as combined techniques for involutional entropion with both horizontal and vertical eyelid laxity. Nevertheless, procedure selection should consider primary pathogenic factors.

Periosteal flaps allow for single stage reconstruction of larger full thickness eyelid defects: a retrospective study

Full-thickness lower eyelid defects after Mohs micrographic surgery are frequently referred out to oculoplastic surgery for reconstruction. Reconstructive options include wedge closure with or without canthotomy/cantholysis and tarsoconjunctival sliding flaps. Defects > 50% of the eyelid margin have traditionally required the two-stage Hughes flap, leaving the patient with monocular vision for 3-6 weeks until pedicle division. To demonstrate single-stage periosteal flaps performed by dermatologic surgeons can result in safe, functional, and cosmetically acceptable repairs for large full thickness eyelid defects, an institutional review board-approved retrospective study of repairs performed by two dermatologic surgeons between January 2017 and July 2021 at the University of Minnesota. Patient demographics, operative notes, and follow-up notes were reviewed. Defect and follow-up photographs were scored using a visual analogue scale to assess aesthetic results. Ten cases were included in the analysis. Six patients were male and the average age was 62 years old. 8/10 were basal cell carcinoma and 2/10 were melanoma. The mean defect was 9.5 cm2, with a range of 1-24 cm2. The median cosmetic score was 85.8 ± 10.7. There were no serious complications reported. Mohs micrographic surgeons can safely and successfully reconstruct large, full thickness eyelid defects by periosteal flap.

A Quantitative Three-Dimensional Tear Trough Deformity Assessment and Its Application in Orbital Septum Fat Transposition

BACKGROUND

Existing evaluation tools of tear trough deformity are based on subjective impression of clinicians. More accurate quantitative assessment methods are needed. This study aimed to propose a quantitative three-dimensional assessment method for the tear trough deformity in comparison with the Barton's grading system and apply it to the efficacy evaluation of orbital septum fat transposition.

METHODS

117 healthy Chinese adults (234 eyes) were enrolled and divided into four groups according to the Barton's grading system. Three-dimensional facial images were captured using Vectra H1 handheld camera. 6 anthropometric landmarks were identified on each eye and 8 linear measurements were generated accordingly. Intra-observer reliability was determined and measurements were compared between groups. Pre- and post-operative three-dimensional measurements were compared in 19 patients who received lower blepharoplasty with orbital septum fat transposition.

RESULTS

The severity of tear trough was positively correlated with age (P < 0.001) but not BMI (P = 0.145) or gender (P = 0.280). Intra-rater reliability of the 8 linear measurements was excellent except for the vertical distance between the palpebrale inferioris margin and the tear trough below the pupillary center. Intergroup comparison showed that the horizontal distance between the lateral end of tear trough (P < 0.001) and medial canthus and the sagittal vector from tear trough point toward eyelid bag point (P = 0.009) increased with grade, while the vertical distance from mid-pupil to palpebrale inferioris margin decreased gradually (P = 0.001). Orbital septum fat transposition significantly improved the tear trough deformity as assessed by these three-dimensional measurements.

CONCLUSIONS

We demonstrated a novel quantitative evaluation method of the tear trough deformity using three-dimensional stereophotogrammetry and proved it to be valid and reliable. It showed good value of clinical application and might help with periorbital rejuvenation planning and outcome assessment.

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 .

A Modified Double-Eyelid Blepharoplasty: Tarsus Linkage Mechanism

BACKGROUND

Double-eyelid blepharoplasty is the most popular plastic surgery in East Asia. The incisional methods are divided into two schools. The traditional method produces a stable eyelid, but will leave a postoperative scar. The other is represented by "Park," creating dynamic double-eyelid technology. Its advantage is that there is only mild scarring, but its disadvantages are asymmetry, corneal exposure, and loss of the palpebral furrow. Due to these various complications, we here propose an improved incisional blepharoplasty with the tarsus linkage mechanism.

METHODS

This work covers 482 patients who underwent surgery from March 2018 to March 2022. All patients completed 6 months of postoperative follow-up. The basic procedure described here involves removing the pre-tarsal tissue without completely incising the orbicularis and suturing the orbicularis and the tarsus into a unit. This connection provides a more robust and stable eyelid adhesion.

RESULTS

As reported by physicians, 412 patients (85.5%) had satisfactory results, 69 patients (14.3%) had somewhat satisfactory results, and 1 patient (0.2%) had unsatisfactory results. As reported by the patients, 424 patients (88.0%) were satisfied, 57 patients (11.8%) were somewhat satisfied, and 1 patient (0.2%) was unsatisfied.

CONCLUSION

This study proposes a modified double-eyelid blepharoplasty with the tarsus linkage mechanism. It is suitable for most primary eye cases, particularly in patients with lax upper lid skin and high levels of upper orbital fat.

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 technique for small-incision levator resection with a double mattress suture for ptosis correction

PURPOSE

To introduce a novel technique for small-incision levator resection in ptosis surgery and evaluate its efficacy in a pilot study among patients affected by congenital or aponeurotic ptosis.

METHODS

We prospectively enrolled congenital and aponeurotic ptosis patients if their levator function was not poor (≥5 mm) from June 2021 through October 2022. Surgical technique involved a 1-cm lid crease incision, minimal dissection, and creating a loop passing through the tarsus and levator aponeurosis. Success was defined as postoperative MRD-1 ≥3 mm and inter-eyelid MRD-1 difference ≤1 mm. Eyelid contour quality was scored excellent, good, fair, and poor according to its curvature and symmetry.

RESULTS

Sixty-seven eyes (35 congenital and 32 aponeurotic) were included in the study. Mean age was 34±19 years (range, 5-79 years). Mean preoperative levator function and levator resection amount were 9.53 mm and 8.39 mm in the congenital group and 12.34 mm and 4.15 mm in the aponeurotic group, respectively. Mean pre- and postoperative MRD-1 was 1.61 mm and 3.27 mm respectively (P<0.001). The overall success rate was 82.1% (95% C.I: 71.7-89.8%); the result was failure in 12 cases, of which 11 had under-correction. Preoperative MRD-1 was correlated with a success rate (P=0.017).

CONCLUSION

The described technique shows non-inferior results to the previously described surgical methods and also it shows very good lid contour outcome and minimal lag. The findings suggest that the double mattress single suture technique can be used in both congenital and aponeurotic ptosis.

Does Double-Eyelid Blepharoplasty Improve Forehead Wrinkles? A Prospective Study Using FACE-Q Scale and Anthropometric Measurements

BACKGROUND

Single eyelids are common among Asians. It is not uncommon to see people with single eyelids raise their eyebrows to wide open their eyes. This results in frequent compensatory contraction of the frontalis muscle and thus leads to deep forehead wrinkles. Double-eyelid blepharoplasty creates a larger visual field. In theory, patients who receive the surgery will stop overusing the frontalis muscle. Therefore, the forehead wrinkles can be improved.

METHODS

35 patients who underwent double-eyelid blepharoplasty were enrolled. FACE-Q forehead wrinkle assessment scale was adopted to evaluate the forehead wrinkles preoperatively and postoperatively. In addition, anthropometric measurements were taken to indirectly evaluate frontalis muscle contraction in maximum eye-opening position.

RESULTS

According to the FACE-Q scale, forehead wrinkles were improved after double-eyelid blepharoplasty, and the improvement was long-lasting in the 3-month follow-up. This was because the frontalis muscle contraction reduced after the surgery, as shown by the anthropometric measurements.

CONCLUSION

This study used subjective and objective methods to prove that double-eyelid surgery improves forehead wrinkles.

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 .

An Overview of Surgical Approaches for Lower Eyelid Blepharoplasty

Age-related changes in the lower eyelid are noticed by patients as bags or circles under the eye, a tired look, and a flattened face. Lower eyelid blepharoplasty, in which the excess skin and/or orbital fat is excised and repositioned, is mainly performed for aesthetic reasons rather than the correction of functional abnormalities. Favorable outcomes for the combination of these approaches have been reported, but the most suitable surgical technique is still debated. This systematic narrative review deals with the indications, preoperative considerations, operative techniques, and complications of several different surgical approaches to lower eyelid blepharoplasty.

LEVEL OF EVIDENCE: 3