A Modified Subbrow Blepharoplasty for Correction of Severe Upper Eyelid Skin Laxity

BACKGROUND

Periorbital aging is characterized by dermatochalasis, lateral hooding and malformation of multiple eyelid creases. Rejuvenation of periorbital region is of great concern in aging Asians, especially for the females. However, the conventional subbrow blepharoplasty was indicated for mild or moderate skin laxity. For severe laxity, double-eyelid incision is necessarily to be involved. This study aims to improve the severe upper eyelid dermatochalasis through an extended subbrow single-incision approach with desirable outcomes.

METHODS

Patients underwent this surgical method from October 2020 to April 2022 were retrospectively reviewed. The redundant skin and orbicularis oculi muscle were excised through a spindle-like subbrow incision delicately designed in the sitting position. Surgical outcomes were evaluated by heights of designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC), and lateral canthus (HPLC) at different follow-ups. The overall satisfaction score of cosmetic outcomes was assessed by an independent surgeon and patients themselves based on the evaluation of: subbrow scar, eyelid symmetry, lateral hooding lifting, visual block improvement and brow shape.

RESULTS

A total of 75 cases were reviewed, including 3 men and 72 women. The preoperative HPPC, HPMC, and HPLC were 4.27 ± 0.40, 4.72 ± 0.45 and 3.41 ± 0.35 mm. The values were postoperatively improved to 7.01 ± 0.46, 6.57 ± 0.34 and 5.69 ± 0.26 mm, respectively, presenting significantly different (p < 0.05). The mean surgeon satisfaction scores were 3.6 ± 0.6 (range, 2.0-4.0), and patient satisfaction scores were 3.5 ± 0.6 (range, 2.0-4.0). No hypertrophic scar, sunken upper eyelids or other complications was found.

CONCLUSIONS

The modified subbrow blepharoplasty method is an effective and safe alternative for correcting severe upper eyelid skin laxity, which can achieve both good cosmetic outcomes and functional improvement.

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 .

Clinical Benefits of Baricitinib Therapy According to Scalp Hair Regrowth in Patients with Severe Alopecia Areata

OBJECTIVES

The present analyses report integrated results from BRAVE-AA1 (NCT03570749) and BRAVE-AA2 (NCT03899259) on the clinical benefits of baricitinib treatment on the basis of the amount of scalp hair regrowth through 52 weeks of treatment.

METHODS

This post hoc analysis was conducted with data from patients who were treated continuously for 52 weeks with baricitinib 4 mg or 2 mg. Clinical outcomes were assessed using the Severity of Alopecia Tool (SALT) and Clinician-Reported Outcome (ClinRO) for Eyebrow (EB) and Eyelash (EL) hair. Secondary measures included the Hospital Anxiety and Depression Scale and Skindex-16 adapted for alopecia areata. At week 52, patients were classified into three subgroups: SALT ≤ 20 response, intermediate response (achieved a 30% improvement from baseline (SALT30) without a SALT score ≤ 20), or nonresponse (never achieved SALT30). The criterion of SALT30 approximates a minimal clinical meaningful response to therapy.

RESULTS

At week 52, with baricitinib 4 mg treatment, the greatest (70%) improvement in EB and EL was observed in responders, but approximately 50% of patients with intermediate response and 20% of nonresponders experienced complete/nearly complete EB and EL regrowth. Improvement in emotional distress was directionally related to improvements in scalp hair regrowth, while impact on quality of life was proportionately greater for the responder subgroup.

CONCLUSIONS

Clinically meaningful regrowth in eyebrow and eyelash hair can occur in the absence of complete scalp hair regrowth after treatment with baricitinib. Emotional distress and quality of life improvement is most associated with obtaining a clinical meaningful improvement in scalp hair.

TRIAL REGISTRATION NUMBER

BRAVE-AA1, ClinicalTrials.gov number, NCT03570749, start date, 24 September 2018; BRAVE-AA2, ClinicalTrials.gov number, NCT03899259, start date, 8 July 2019.

Successful treatment of eyebrow intradermal nevi by shearing combined with electrocautery and curettage: Two case reports

BACKGROUND

An intradermal nevus is a common skin tumour, and the classical method of removal has a risk of recurrence and scarring. It is a challenge for dermatologists to treat eyebrow intradermal nevi quickly and efficiently. This study focused on investigating the efficacy and safety of shearing combined with electrocautery and curettage in the treatment of eyebrow intradermal nevi.

CASE SUMMARY

We describe two adult patients with eyebrow intradermal nevi treated by shearing combined with electrocautery and curettage. Both patients were followed up regularly after surgery. At follow-up, no recurrence of eyebrow intradermal nevus and no obvious scars or hypopigmentation were found in either patient. The results indicated that shearing combined with electrocautery and curettage could remove eyebrow intradermal nevus without side effects and confirmed the efficacy and safety of this modality for treating these skin lesions.

CONCLUSION

Shearing combined with electrocautery and curettage has superior merits, including simple operation, good cosmetic effects, and high patient satisfaction, presenting great application potential for treating intracutaneous nevus.

Gender-Affirmation Hair Transplantation Techniques

Hair restoration can play an important role for transgender patients seeking gender-affirmation procedures. In our clinic, we have seen an increase in transgender patients seeking hair restoration. The most common hair restoration procedures performed in our clinic for the transgender patient are hairline lowering procedures, facial hair restoration procedures including eyebrow and beard transplantation, and body hair transplantation.

Extended Suprabrow Lift with Relief of Glabellar Wrinkles

BACKGROUND

Eyebrows define one's facial appearance; brow ptosis, which can occur with aging, can convey a negative expression. Various methods have been used to correct eyebrow position and shape. We endeavored to repair brow ptosis and glabellar wrinkles and present the outcome.

METHODS

This retrospective study reviewed 40 patients who underwent extended suprabrow lift accompanied by relief of glabellar wrinkles between January 2018 and August 2020. The procedure was considered when patients exhibited brow ptosis, glabellar wrinkles, and a wide forehead. Fat graft was implemented after glabellar muscle division. The results were assessed based on measurements performed preoperatively and at 6 and 18 months postoperatively.

RESULTS

Overall, patients were satisfied with the outcomes. To assess glabellar wrinkles, the Modified Fitzpatrick Wrinkle Assessment score revealed adequate correction during neutral and furrowed gazes (P < 0.05). The forehead and brow heights were also analyzed after repair, exhibiting decreased forehead height and elevated brow position (P < 0.05). At 6 and 18 months after surgery, adequate maintenance of the repair was evident (P < 0.05). A visible scar was observed in two patients, which was managed using a fractional ablative laser procedure.

CONCLUSION

Extended suprabrow lift, when based on preoperative measurements, led to the correction of brow ptosis, glabellar wrinkles, and a wide forehead. For periorbital rejuvenation, it is imperative to decide locations where the skin and soft tissues should be preserved or removed. The use of fat grafts for wrinkle repair effectively maintains the repair postoperatively.

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 .

Supraorbital eyebrow approach: A single-center experience

Background

Keyhole neurosurgery is the notion of safely removing brain and skull base lesions through smaller and more precise openings that lessen collateral damage to the surrounding scalp, brain, blood vessels, and nerves. The traditional frontal and pterional approaches require large craniotomies and this predisposes patients to significant and avoidable morbidity. With the growing expectation for minimally invasive surgery, we present our experience with the supraorbital keyhole craniotomy for surgical lesions in the anterior cranial fossa and parasellar regions.

Methods

We retrospectively analyzed and evaluated all cases of neoplastic, vascular, trauma, and infective pathologies of the anterior fossa and parasellar regions treated using a keyhole approach, the supraorbital eyebrow (SOE) approach from January 2018 to June 2022. Treatment outcomes were evaluated based on pathology.

Results

A total of 50 patients underwent a SOE craniotomy during the study period (28 females and 22 males). Their average age ranged from 12 to 86 years, with a mean age of 47.4 years. All patients had anterior skull base and/or anterior frontal lobe pathologies: (23 tumors, 17 ruptured aneurysms, five traumatic frontal hematomas, three extradural empyema, one cerebral cavernous malformation, and one traumatic frontal skull base fracture with dural tear and CSF leak). Gross total tumor resection was achieved in 87% of cases (13 meningiomas of which six were giant, three gliomas, two craniopharyngiomas, and two cerebral metastases). Clip ligation occlusion rate for our aneurysm cases was 100% and intraoperative rerupture was observed in three cases. Mean ICU stay was 2.2 days for the entire series. The overall 30-day mortality rate for our series was 16% (eight deaths). This was highest in the ruptured aneurysm subgroup, with all 5 mortality cases in the aneurysmal subgroup presenting as World Federation of Neurological Surgeons (WFNS) grades ≥ III. 4 of the deaths were in WFNS IV and V patients. The most frequent perioperative complication was transient periorbital swelling which resolved within 7 days. It was observed in 18 of the 50 patients. The next common complications in descending frequency were eyebrow alopecia (three cases), supraorbital hypoesthesia (two cases), CSF leak (two cases), and surgical site infection (one case). There was one approach-related intraoperative complication secondary to carotid injury in a giant meningioma redo case. Conversion to a larger craniotomy was never necessary. Clinical outcome for our cases was evaluated according to the Modified Rankin Scale (mRS) at 3-month postsurgery. A good clinical outcome (mRS ≤ 2) was achieved for 78% of our patients.

Conclusion

The SOE approach craniotomy is an effective minimally invasive approach for various pathologies of the anterior cranial base and parasellar regions. With experience, giant tumors and complex vascular pathology can be addressed with this keyhole approach.

The application of electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia

BACKGROUND

Leukotrichia is one of the difficulties of vitiligo treatment. Hair follicle transplantation is an efficient method to treat vitiligo-associated leukotrichia. A trichiasis electrolyzer, commonly used for treating trichiasis, can be used to damage and remove the depigmented hair follicles.

OBJECTIVE

To evaluate the efficacy of the electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia.

METHODS

A total of 15 patients with stable vitiligo-associated eyebrow and eyelash leukotrichia were enrolled from Department of Dermatology, Hangzhou Third People's Hospital between January 2020 and January 2021. All patients were treated using a trichiasis electrolyzer combined with single hair follicle transplantation. The patients were followed up at the first week, the first month, the third month, and the sixth month after surgery. The texture and growth state of the transplanted hair were observed, and the number of surviving transplanted follicles and regenerating depigmented follicles were recorded.

RESULTS

The transplanted hair grew as expected with natural shape. No local infection or obvious scar were observed. Most of the depigmented hair in the lesion area re-pigmented and only a few depigmented hairs regenerated. The average survival rate of the transplanted hair follicles was 71.6%, and the average regeneration rate of the depigmented hair was 11.6%.

CONCLUSION

The electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation was an effective and safe method to treat vitiligo-associated leukotrichia.

Hyaluronic Acid Fillers Enriched with Glycine and Proline in Eyebrow Augmentation Procedure

Background

The eyebrow area is a clinically critical district due to the anatomical complexity and the propensity to aging-related atrophy. Hyaluronic acid fillers have been proposed to recover the dermal volume of the facial and lips regions.

Aim

The aim of the present investigation was to evaluate hyaluronic acid fillers enriched with glycine and proline for the treatment of eyebrow augmentation.

Methods

A total of 15 healthy patients were treated with eyebrow augmentation procedure. The distance between mid-bipupil to lateral eyebrow and mid-eyebrow to the medial eyebrow was measured before, immediately after treatment and at follow-up of 6 months.

Results

The healing period was uneventful, and no evidence of inflammation or swelling associated with the treatment was reported. No macroscopical alteration was reported in the surrounding tissues with no evidences of visible wheals or lumps in the treated sites at the follow-up. Before treatment, the angle was equal to 9.32 ± 0.2°, while after treatment it was 11.21 ± 0.4° (p < 0.01); after three and 6 weeks, it was, respectively, 10.66 ± 0.2° (p<0.05) and 10.02 ± 0.3°(p > 0.05).

Conclusions

The study results suggest that the hyaluronic acid fillers enriched with glycine and proline treatment resulted as being a useful procedure for augmentation, contour and volume definition and elevation of the eyebrow region with a high-level aesthetic result.

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.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Hair Transplant for Eyebrow Restoration

Eyebrow restoration can be best done with individual single hair follicles grafts harvested by FUE. Understanding the male and female eyebrow allows us to plan an aesthetic reconstruction, requiring 70 to 120 grafts. Selection of donor hair, angle of placement, alignment and direction within the rows influences the results, as does scarring and perfusion of the skin. Details of planning, technique, anesthesia and postoperative care, as well as drawbacks of older methods, are discussed in the article.

Head and Neck Restoration in Scar Alopecia: Hair Transplantation in Scalp, Eyebrows, Beard and Mustache

BACKGROUND

Surgical management of hair loss has become an increasingly challenging procedure, when dealing with scar alopecia. We investigated the efficacy of hair transplantation in patients with head and neck scar alopecia.

METHODS

From 2016 to 2018 in Shiraz, Iran, all patients with scar alopecia in head and neck were evaluated for efficacy of follicular unit extraction (FUE), follicular unit transplantation (FUT) or a combination of two methods from donor sites in scalp and beard various hair-grafts were compared.

RESULTS

Fifty-six patients were enrolled. Most of them were between 31 and 40 yr old (48.3%) and male (71.4%). Trauma, burn, surgical excision of adjacent skin, radiotherapy and leishmaniasis were the registered causes. Scars were visible in scalp (39.3%), beard (28.6%), eyebrow (21.4%), and moustache (10.7%) regions. FUE (87.5%), FUT (10.7%) and a combination (1.8%) were the used methods. One-hair-grafts were used in eyebrows (100%), moustache (100%), beard (88%) and scalp (7.9%), while 2-hair-grafts in beard (6%) and scalp (47.4%) and 3-haired grafts in beard (6%) and scalp (44.7%) transplantations.

CONCLUSION

In head and neck scar alopecia, hair transplantation was selected based on type and depth of scar. FUE was targeted when huge grafts were not needed, including beard, moustache, and eyebrow, while FIT was used when extensive scars were present in scalp. One-hair-grafts were mostly applied for eyebrow, moustache and beard, 2-hair- and 3-hair- grafts for beard and scalp transplantation. These findings can be added to the literature when FUE, FIT, or their combination are targeted in hair restoration of scar alopecia in head and neck.

Incisional Blepharoplasty for the Asian Eye

The goal of Asian blepharoplasty is to create a lid crease configuration that resembles the natural-appearing crease found in other Asians. Because the Asian upper eyelid contains more prominent preseptal fat resulting in greater lid fullness, soft tissue work in blepharoplasty of the Asian eye is even more diverse and essential than that of whites in order for there to be the sustainability of the eyelid crease. Hence, Asian blepharoplasty should be performed specifically following the orbital anatomy of Asians. This article details the incisional method of blepharoplasty to create natural-appearing creases for Asians with single eyelids.

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 .

The endoscopic supraorbital translaminar approach: a technical note

OBJECT

Resection of lesions located within the third ventricle presents a surgical challenge. Several approaches have been developed in an attempt to obtain maximal resection, while minimizing brain retraction. In this work, we assess the surgical exposure and maneuverability of the endoscopic supraorbital translaminar approach (ESTA), a potential alternative to fenestrate the lamina terminalis and approach the third ventricle by using the endoscope through a keyhole supraorbital-eyebrow craniotomy.

METHODS

Five cadaveric heads were used to assess the corridor depth, area of exposure, and viewing angles offered by the ESTA. One additional utilized specimen provided a stepwise dissection of the approach.

RESULTS

The ESTA was successfully performed in all specimens. Depth of the surgical corridor from the craniotomy to the ipsilateral internal carotid artery (ICA), lamina terminalis, and contralateral carotid were 70.7 ± 2.9 mm, 73.2 ± 2.9 mm, and 78.9 ± 4.1 mm, respectively. Viewing angle referenced to the ipsilateral ICA was 6.5 ± 4.2°, while the viewing angle for the lamina terminalis was 25.8 ± 4.3°. The surgical exposure provided by the ESTA was 1655 ± 255 mm².

CONCLUSIONS

The ESTA provides a wide surgical view of the lamina terminalis and may be potentially used to approach lesions located in the anterior third of the third ventricle. As a pure endoscopic approach, the ESTA requires minimal brain retraction, while affords good visualization of targeted lesions around the lamina terminalis. The ESTA uses an anterolateral approach and so provides a short and straightforward approach to these structures.

The extradural extended eyebrow approach: A cadaveric feasibility study

INTRODUCTION

Extradural anterior clinoidectomy (eAC) is key to expose the paraclinoid region. Several authors have pointed limitations of performing an eAC through a supraorbital craniotomy. In this article, we aim to provide educational material and discuss the technical nuances to successfully perform an eAC throughout a modification of the supraorbital approach, the extradural extended eyebrow approach (xEBA+eAC).

METHODS

Four embalmed heads were used for anatomic dissection and perform the xEBA+eAC. Additionally, one head was used for a video demonstration of the surgical approach.

RESULTS

The anterior clinoid process was successfully removed, and the ophthalmic artery and paraclinoid region were exposed in all specimens. Drilling the sphenoid wing until exposing the meningo-orbital band and further interdural dissection are vital steps to expose the anterior clinoid process. Removal of the anterior clinoid process can be simplified in 3 osteotomies, including the optic canal unroofing, detachment from the lateral pillar, and drilling of the optic strut. Sectioning of the distal dural ring facilitates the mobilization of the internal carotid artery and the surgical exposure of the ophthalmic artery.

CONCLUSIONS

xEBA+eAC is a technically feasible approach that provides exposure to the paraclinoid region, along with anterior and middle cranial fossa.

Eyebrow Regrowth in Patients with Frontal Fibrosing Alopecia Treated with Low-Dose Oral Minoxidil

Introduction

The eyebrows are an important facial feature that shape one's physical appearance and play a role in non-verbal communication. Partial or complete eyebrow loss is seen in most patients with frontal fibrosing alopecia (FFA). Despite the scarring nature of FFA, eyebrow hair regrowth has been previously reported. Nevertheless, treatment options and supporting evidence remain scarce.

Case Presentation

We report eyebrow regrowth in 7 patients with FFA treated with low-dose oral minoxidil (OM).

Conclusion

Low-dose OM could be a promising adjunctive therapy for treatment of the eyebrows in patients with FFA, particularly in early disease.

Staged excision of basal cell carcinoma arising from a tattooed eyebrow

Side effects of tattoos can occur due to unexpected body responses. Concerns about the side effects of tattoos are growing concomitantly with the increasing number of tattooed individuals. We report a rare case of basal cell carcinoma (BCC) on a tattooed eyebrow. A 48-year-old woman with no family history or occupational risk of skin cancer had her eyebrows tattooed 6 years prior, and she noticed a black mass on her right eyebrow 1 year before presentation. Staged excision was planned due to the patient’s reluctance regarding the possibility of a wide scar. After the first surgical procedure, a histopathological examination confirmed BCC. Wide excision and primary closure were performed for remnant BCC, and no recurrence was observed. The mechanism of skin neoplasms involving tattoos has not been clearly identified. Unapproved tattoo inks contain carcinogenic substances, and previous case reports indicate that skin neoplasms may differ depending on the tattoo color. Therefore, the carcinogenic effects of these unknown components of tattoo ink might cause skin neoplasms. Accurate component analysis and systematic management of tattoo ink is necessary, and medical practitioners must also pay attention to this possibility because it is easy to overlook tattoos as a causal factor contributing to cancer.

An Eyebrow, Supracarotid Triangle Approach for Lesions at the Ventral Thalamopeduncular Junction: A Technical Report

BACKGROUND

Lesions arising at the ventral thalamopeduncular junction are difficult to resect. In addition to being relatively inaccessible, these lesions are located in one of the most sensitive areas of the brain. A critical question is whether new approaches could be developed to allow surgeons to adequately resect these lesions with reasonable outcomes. In the present report, we describe our approach to resect lesions in this region of the brain using an eyebrow craniotomy approach with a trajectory through the supracarotid triangle.

METHODS

Through retrospective data collection, we present a small series of patients who had undergone an eyebrow, supracarotid triangle approach to resect lesions located at the thalamopeduncular junction. We describe our surgical technique and report patient outcomes using this approach.

RESULTS

Three patients had undergone an eyebrow, supracarotid approach for resection of a lesion arising at the ventral thalamopeduncular junction. Two patients had presented with a cavernoma and one with a pilocytic astrocytoma. Complete resection of all 3 lesions was achieved during surgery without any intraoperative complications. No patient developed permanent contralateral weakness despite entering the peduncle during surgery. One patient developed permanent paresthesia in his left hand.

CONCLUSIONS

Lesions arising at the ventral thalamopeduncular junction can be adequately resected with reasonable outcomes using an eyebrow, supracarotid triangle approach. This operative technique establishes another potential operative corridor by which neurosurgeons can resect lesions arising within this relatively inaccessible part of the brain.

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).

Parallel-excision infrabrow blepharoplasty with extensive excision of the orbicularis oculi muscle in an Asian population

Background

Infrabrow blepharoplasty has become a common surgical method used to rejuvenate aged upper eyelids in Asians. In this paper, we describe the parallel excision method for infrabrow blepharoplasty as a useful alternative to the conventional elliptical excision method. The authors’ experience over a 3-year period is presented and reviewed.

Methods

A retrospective review of parallel excision infrabrow blepharoplasty cases at our hospital between 2014 and 2017 was performed. Three oculoplastic surgeons compared preoperative and postoperative photographs using the Strasser grading system.

Results

From the medical records of 123 patients, a total of 93 patients with moderate-to-severe bilateral dermatochalasis were selected as subjects. The exclusion criterion was levator function less than 8 mm. The total mean follow-up period was 2 years (range, 0.5–3.5 years). The mean skin excision height and width were 9.75 mm (range, 5–16 mm) and 58.51 mm (range, 42–75 mm), respectively. All patients who underwent surgery recovered without major complications, and all patients had high levels of satisfaction and improvements in their visual field. In the Strasser evaluation performed by the oculoplastic surgeons, most patients were found to have excellent results.

Conclusions

The parallel excision method for infrabrow blepharoplasty is a safe and effective technique that yields more natural- and youthful-looking eyelids than the conventional elliptical excision method. In our method, more effective manipulation of the orbicularis oculi muscle led to a reduction in frontalis compensation, resolution of sunken eyelids, and correction of lateral hooding.

Peripheral osteoma on the medial eyebrow successfully extracted while preserving supratrochlear nerve

Osteomas are benign, slow-growing osteogenic lesions frequently found in the craniomaxillofacial region. They can be classified as peripheral, central, or extraskeletal. Reactive mechanisms to trauma or infection, as well as muscle traction, are thought to play a major role in the development of peripheral osteomas. In the present report, a 41-year-old woman presented with a slowgrowing, painless mass on her left eyebrow. She had suffered trauma 15 years prior. In the computed tomography scan, a 2.5 × 2 × 0.7-cm radio-opaque tumor was detected just medial to the left supraorbital foramen, and a peripheral osteoma was clinically diagnosed. An elective operation under general anesthesia was planned. Following a suprabrow incision, subcutaneous and intramuscular dissection was performed. In the surgical plane deep to the corrugator muscles and superficial to periosteum, a branch of the supratrochlear nerve was encountered and preserved using a vessel loop. The osteoma beneath the periosteum was extracted in multiple fragments using a chisel and mallet to minimize trauma to the nerve. Contour and facial symmetry were corrected. To use a suprabrow incision, the surgeon must understand neighboring anatomical structures, including the course of the supratrochlear and supraorbital neurovascular bundles. When these structures are located adjacent to tumor lesions, careful surgical maneuvers should be performed to preserve them.

Optic perineuritis secondary to hyaluronic acid injections: a case report

BACKGROUND

Although a safe, excellent administration method for hyaluronic acid derivatives has been documented; improper injections can lead to devastating and irreversible consequences. Here, we present the first known case of optic perineuritis caused by hyaluronic acid.

CASE PRESENTATION

A young female experienced sudden orbital pain in the right eye after receiving hyaluronic acid injections to the eyebrows. She presented to the eye clinic two weeks later, after developing blurred vision in the right eye. Visual acuity was reduced significantly in the right eye. Automated visual field examination showed defects in both eyes. Fundus examination revealed bilateral swelling of optic discs. Magnetic resonance imaging of the brain demonstrated bilateral perineural enhancement consistent with optic perineuritis. The patient was treated with retrobulbar injection of hyaluronidase and oral prednisolone. Her vision improved with treatment.

CONCLUSIONS

The prognosis for visual outcomes in patients with optic perineuritis is generally excellent. However, a poor prognosis is associated with delays to the initiation of treatment. Recognizing this condition is important, and treatment with corticosteroids should be initiated early.

Brow height asymmetry before and after eyelid ptosis surgery

BACKGROUND

In the setting of upper eyelid ptosis, asymmetric eyebrow position may be observed and may contribute to overall facial asymmetry. In this study, the authors aim to elucidate the prevalence and predictors of brow height asymmetry in the setting of ptosis and to determine the effect of eyelid surgery on brow height asymmetry to guide preoperative evaluation and informed consent.

METHODS

In this cohort study, patients undergoing posterior approach ptosis surgery, unilateral or bilateral, with or without blepharoplasty, were included. Exclusion criteria included heterotropia, history of brow surgery, and history of previous ptosis surgery. Clinically significant eyelid asymmetry was defined as a difference greater than or equal to 1 mm between right and left margin reflex distance 1 (MRD₁) values. Brow asymmetry was defined as difference in pupil-to-brow (PTB) distance of greater than or equal to 3.5 mm.

RESULTS

The sample included 228 patients. Preoperative brow asymmetry was found in 17.1% of the sample. Notably, half of the patients with preoperative brow asymmetry were found to have postoperative brow asymmetry. Logistic regression indicated that preoperative brow asymmetry was a predictor of postoperative brow asymmetry (odds ratio = 17.03, p < 0.01). In subgroup analysis of those with preoperative brow asymmetry, postoperative eyelid asymmetry was a predictor of postoperative brow asymmetry (odds ratio = 5.58, p < 0.01). No variables in the current investigation were found to predict brow symmetry in those with preoperative brow asymmetry.

CONCLUSION

Understanding the limitations of ptosis surgery in altering brow symmetry helps manage patient expectations, prepare informed consent, and guide surgical and postsurgical planning.

Trans-eyebrow supraorbital keyhole approach in suprasellar and third ventricular craniopharyngioma surgery: the experience of 27 cases and a literature review

BACKGROUND

The trans-eyebrow supraorbital keyhole approach, a minimal transcranial approach, has been widely used in different types of surgery for sellar and parasellar lesions. In this study, we investigated the outcome of this approach in the surgical treatment of suprasellar and third ventricular craniopharyngioma.

METHODS

Twenty-seven patients with suprasellar and third ventricular craniopharyngioma underwent surgery via a supraorbital approach between June 2007 and June 2018. The medical data and follow-up results were retrospectively analyzed.

RESULTS

All tumors were located in the suprasellar region and the third ventricle. The mean tumor size was 29.1 mm. The mean follow-up period was 49.6 months. Gross total resection (GTR) was achieved in 23 patients (85.2%). Of 17 patients with preoperative visual impairment, 12 patients (70.6%) showed improvement. Following surgery, 11 patients exhibited new-onset anterior hypopituitarism, ten developed diabetes insipidus, and two became overweight. One residual tumor relapsed 1 year after surgery. No perioperative death, cerebrospinal fluid (CSF) rhinorrhea, or meningitis occurred. All patients exhibited satisfactory cosmetic results. At the last follow-up, the Extended Glasgow Outcome Scale Score was 8 in 25 patients (92.6%).

CONCLUSION

The supraorbital trans-eyebrow keyhole approach is characterized by minimal invasion and a satisfactory cosmetic outcome. According to our experience, craniopharyngiomas located in the suprasellar region and the third ventricle can be safely resected via a trans-eyebrow supraorbital keyhole approach.

Eyebrow Contouring with Hyaluronic Acid Gel Filler Injections

Background: The eyebrow region presents challenges for filling: the skin is thick, the three-dimensional anatomy is complex and there is a predisposition towards fat atrophy and skeletonization with aging. Hyaluronic acid gel fillers are well known for their use in the periorbital region. We report our long-term experience with eyebrow filling over a period of five years. Methods: Twenty cases of periorbital eyebrow filling with hyaluronic acid gel fillers were followed up over a period of five years. The eyebrow filling was customized based on the patient's anatomical features in a three-dimensional plane. Standardized photographs before and after the procedure in standard lighting conditions were evaluated. Results: Hyaluronic acid gel fillers were tolerated well in the eyebrow region. There were no cases with blue-gray dyschromia or prolonged edema as is the case with lower eyelid injections. The eyebrow gained volume and looked fuller immediately after the injection. There were three cases with excessive eyebrow puffiness noted on a long-term follow-up which may be the accumulated filler weighing the eyebrow. No other adverse events were noted. Conclusion: The eyebrow anatomy is a complex three-dimensional structure. Deflation in the eyebrow area along with the superior sulcus occurs with aging. Filling the eyebrow with hyaluronic acid gel fillers is a useful tool in the armamentarium of the cosmetic facial surgeon and can be used in isolation in select patients or as an adjunct to surgical rehabilitation. We believe the fillers last longer and are well tolerated in the eyebrow region due to the complex anatomy specific to this region.

Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas. A systematic review

OBJECTIVE

To review current management strategies for olfactory groove meningioma (OGM)s and the recent literature comparing endoscopic endonasal (EEA) with traditional transcranial (TCA) approaches.

METHODS

A PubMed search of the recent literature (2011-2016) was performed to examine outcomes following EEA and TCA for OGM. The extent of resection, visual outcome, postoperative complications and recurrence rates were analyzed using percentages and proportions, the Fischer exact test and the Student's t-test using Graphpad PRISM 7.0Aa (San Diego, CA) software.

RESULTS

There were 444 patients in the TCA group with a mean diameter of 4.61 (±1.17) cm and 101 patients in the EEA group with a mean diameter of 3.55 (± 0.58) cm (p = 0.0589). GTR was achieved in 90.9% (404/444) in the TCA group and 70.2% (71/101) in the EEA group (p < 0.0001). Of the patients with preoperative visual disturbances, 80.7% (21/26) of patients in the EEA cohort had an improvement in vision compared to 12.83%(29/226) in the TCA group (p < 0.0001). Olfaction was lost in 61% of TCA and in 100% of EEA patients. CSF leaks and meningitis occurred in 25.7% and 4.95% of EEA patients and 6.3% and 1.12% of TCA patients, respectively (p < 0.0001; p = 0.023).

CONCLUSIONS

Our updated literature review demonstrates that despite more experience with endoscopic resection and skull base reconstruction, the literature still supports TCA over EEA with respect to the extent of resection and complications. EEA may be an option in selected cases where visual improvement is the main goal of surgery and postoperative anosmia is acceptable to the patient or in medium-sized tumors with existing preoperative anosmia. Nevertheless, based on our results, it seems more prudent at this time to use TCA for the majority of OGMs.

[Clinical analysis before surgery in facial and neck rejuvenation]

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. A thorough understanding of the anatomy and the natural history of ageing will facilitate the analysis of the face. Not only the degree of ptosis but also the degree of volume loss will need to be assessed, as well as the influence of the facial muscles, the skin quality, and the different causes of rythids. The comprehensive age-related anatomical changes are often perceived and described as tiredness or sadness. Patients very commonly only point out a single anatomical region. During the consultation, the surgeon should provide the patient with the information of the comprehensive interplay of the different anatomical regions and their individual ageing process. Obtaining a harmonious, natural appearing outcome is the result of excellent surgical skills and applied knowledge. The clinical exam should also find out traps and technical difficulties. Although standardized photographs allow a static evaluation of one's result, video may deliver additional information about the postoperative result, and may contribute to the understanding of the technique used. Spending the additional time by performing a thorough facial analysis and preoperative planning is well-invested time. Having a good understanding of the possible surgical improvements and limitations will be beneficial for both, the patient and the surgeon. Managing the expectations of the patient and careful preoperative planning will increase patient's satisfaction. At the same time, the surgeon will able to critically assess his/her own result and taking pleasure improving their own technique.

Periorbital facial rejuvenation; applied anatomy and pre-operative assessment

PURPOSE

Since different subspecialties are currently performing a variety of upper facial rejuvenation procedures, and the level of knowledge on the ocular and periocular anatomy and physiology is different, this review aims to highlight the most important preoperative examinations and tests with special attention to the eye and periocular adnexal structures for general ophthalmologist and specialties other than oculo-facial surgeons in order to inform them about the fine and important points that should be considered before surgery to have both cosmetic and functional improvement.

METHODS

English literature review was performed using PubMed with the different keywords of "periorbital rejuvenation", "blepharoptosis", "eyebrow ptosis", "blepharoplasty", "eyelid examination", "facial assessment", and "lifting". Initial screening was performed by the senior author to include the most pertinent articles. The full text of the selected articles was reviewed, and some articles were added based upon the references of the initial articles. Included articles were then reviewed with special attention to the preoperative assessment of the periorbital facial rejuvenation procedures.

RESULTS

There were 254 articles in the initial screening from which 84 articles were found to be mostly related to the topic of this review. The number finally increased to 112 articles after adding the pertinent references of the initial articles.

CONCLUSION

Static and dynamic aging changes of the periorbital area should be assessed as an eyelid-eyebrow unit paying more attention to the anthropometric landmarks. Assessing the facial asymmetry, performing comprehensive and detailed ocular examination, and asking about patients' expectation are three key elements in this regard. Furthermore, taking standard facial pictures, obtaining special consent form, and finally getting feedback are also indispensable tools toward a better outcome.

[Temporal rejuvenation]

The temporal region has imprecise limits in the young patient. During the aging process, it becomes individualized with the appearance of a temporal fossa, the temporal, orbital and zygomatic bone margins, the ptosis of the lateral part of the brow and the appearance of the wrinkles of the crow's foot. As this area frame the look, it should be taken into consideration during the clinical examination as well as the facial and cervical stages. The rejuvenation techniques are numerous, nuanced and gradual. As long as the eyebrow ptosis is not evident and the distance of the eyebrows unaltered, the volumizing techniques and the botulinum toxin can respond effectively and harmoniously to the patients' demand. Then the surgical techniques of temporal and brow liftings must be considered and coupled with the techniques of lipostructure that are more and more practiced. It should be noted that the demand for temporal rejuvenation is increasing and precedes the demand of cervicofacial rejuvenation. This underlines the importance of this region both in terms of preventing or at least slowing down the process than in terms of curing the stigma of aging.

Eyebrow reconstruction

This is a systematic review of eyebrow reconstruction options, using the PubMed database, as well as dermatology and plastic surgery texts. Eyebrow reconstruction options in various clinical scenarios (small, large, medial, lateral, and total defects) are presented. The goals of eyebrow reconstruction are to provide structural, functional, and aesthetic restoration. A good understanding of various eyebrow reconstruction techniques is essential for plastic, dermatologic, and oculoplastic surgeons.

Management of Forehead Scars

This article provides an overview of scar management within the forehead region. It addresses the unique challenges specific to the treatment of forehead wounds. A logical, stepwise approach is used. A subsite based treatment algorithm is provided along with a review of current best practices. Pertinent case examples are included for demonstration purposes.

Changes in Eyebrow Position and Movement with Aging

Background

This study evaluated dynamic changes in eyebrow position related to aging.

Methods

Female participants were recruited and separated into two groups aged 20–30 years (the younger group, n=20; mean age, 24.8 years) and 50–70 years (the older group, n=20; mean age, 55.8 years). Photogrammetry was used to determine the eyebrow position at the medial canthus (MC), lateral limbus, lateral canthus, and lateral end point (EP) for 6 actions: smooth opening (the reference action) and closing of the eye, forward gaze, maximum opening and closing of the eye, and maximum frown. Videos were also recorded.

Results

No differences in eyebrow position were detected at the MC when opening or closing the eyes smoothly, gazing straight ahead, or closing the eyes maximally. For all 6 actions, the position of the lateral EP in the older group was significantly lower than in the younger group (P=0.003), and the smallest degree of vertical movement at this point was found in both age groups (P<0.001). Vertical movement at the 4 landmarks of the eyebrows decreased with aging.

Conclusions

Eyebrow position was unchanged at the MC with aging, except at maximal eye opening and maximal frown. No differences in eyebrow position were observed between the younger and older groups when eyes were maximally closed, except at the EP. It is important to focus on correction of the lateral EP for periorbital rejuvenation.

Unilateral Pleomorphic Lipoma of the Eyebrow

AIM

Epithelial and soft tissue tumours of the eyebrow skin and subcutis are rare occurrences. We describe an unusual eyebrow subcutis mass in a 65-year-old female.

METHODS

A 65-year-old female presented with an 8- to 9-month history of a painless swelling over the right eyebrow that was sausage-shaped. The clinical differential diagnosis included neurofibroma/schwannoma, cyst, prolapsed fat or metastasis. The lesion was excised.

RESULTS

The histology revealed a lesion composed of rope-like collagen, some spindle cells, mature adipocytes and hyperchromatic multi-nucleate floret cells. The spindle and multi-nucleate floret cells showed immunohistochemical positivity for CD34. The features were of a primary pleomorphic lipoma.

CONCLUSIONS

This is the first reported case of a pleomorphic lipoma of the eyebrow subcutis. We discuss the clinical and histological differential diagnosis, especially related to histological conditions with which pleomorphic lipoma can be confused, such as well-differentiated liposarcoma.

Lateral Brow Lift: A Multi-Point Suture Fixation Technique

Background

Descent of the lateral aspect of the brow is one of the earliest signs of aging. The purpose of this study was to describe an open surgical technique for lateral brow lifts, with the goal of achieving reliable, predictable, and long-lasting results.

Methods

An incision was made behind and parallel to the temporal hairline, and then extended deeper through the temporoparietal fascia to the level of the deep temporal fascia. Dissection was continued anteriorly on the surface of the deep temporal fascia and subperiosteally beyond the temporal crest, to the level of the superolateral orbital rim. Fixation of the lateral brow and tightening of the orbicularis oculi muscle was achieved with the placement of sutures that secured the tissue directly to the galea aponeurotica on the lateral aspect of the incision. An additional fixation was made between the temporoparietal fascia and the deep temporal fascia, as well as between the temporoparietal fascia and the galea aponeurotica. The excess skin in the temporal area was excised and the incision was closed.

Results

A total of 519 patients were included in the study. Satisfactory lateral brow elevation was obtained in most of the patients (94.41%). The following complications were observed: total relapse (n=8), partial relapse (n=21), neurapraxia of the frontal branch of the facial nerve (n=5), and limited alopecia in the temporal incision (n=9).

Conclusions

We consider this approach to be a safe and effective procedure, with long-lasting results.

Oncologic Surgery to the Ciliary Region

Dermatologic surgery for tumors affecting only the ciliary region is not very common and it can sometimes be difficult to find published descriptions that deal specifically with surgery to this area. However, reconstruction of the ciliary region is very important, not only because this region is necessary to protect the eye, but also because its position and continuity are of great importance in facial expression, aesthetic appearance, and harmony. We present the cases of patients who have undergone oncologic surgery to the eyebrow region in our department in recent years and review the different techniques proposed for reconstruction of this region.

Eyelid and brow asymmetry in patients evaluated for upper lid blepharoplasty

Introduction

In evaluation for blepharoplasty, patients often desire improved cosmesis and/or correction of visual field deficits. However, patients are usually unaware of eyelid or brow asymmetry. Furthermore, the prevalence of eyelid and brow asymmetry is infrequently reported in the medical literature.

Purpose

To determine the prevalence of brow and eyelid asymmetry in patients evaluated for upper lid blepharoplasty.

Methods

One hundred consecutive patients evaluated for upper lid blepharoplasty were included in the study. Standard pre-operative photographs were taken of all patients using consistent background and photographic equipment. Two of the authors (KM & AM) independently recorded the margin pupil (MPD), central eyebrow (CED), nasal eyebrow (NED) and temporal eyebrow (TED) distances. To test the inter-observer reliability, the senior author (SMT) recorded the same measurements for 10% of randomly selected patients. We calculated 95% confidence intervals to compare symmetry between the right and left sides.

Results

One hundred patients (94 female, mean age 57.7) were included in the study. The average MPD, CED, NED and TED distances were 0.55 mm (95% CI 0.45-0.65), 1.77 mm (95% CI 1.47-2.07), 1.34 mm (95% CI 1.14-1.54), and 1.78 mm (95% CI 1.50-2.06), respectively. Ninety-three percent of patients had at least one asymmetric measurement of greater than 1 mm. Seventy-five percent of patients studied had at least one measurement greater than 2 mm while 37 percent had at least one greater than 3 mm.

Conclusion

Brow and eyelid asymmetry is common in patients being evaluated for upper lid blepharoplasty. The facial plastic surgeon should identify and document facial asymmetry pre-operatively, and discuss it with prospective blepharoplasty patients. This will improve informed consent and patient expectations.

[Eyebrow reconstruction]

The eyebrow is an essential anatomical area, from a social point of view, so its reconstruction, in case of skin defect, must be as meticulous as possible, with the less residual sequela. Capillary density extremely varies from one person to another and the different methods of restoration of this area should absolutely take this into consideration. We are going to review the various techniques of reconstruction, according to the sex and the surface to cover.

Complex nasal and periorbital reconstruction using locoregional flaps: a case report

Facial reconstruction is one of the most challenging problems faced by a reconstructive surgeon. We present a case of complex facial reconstruction with a composite trauma to the nose resulting in near total loss of skin and lining along with complete loss of left eyebrow with exposed frontal bone and partial loss of the left eyelid. We combined a temporoparietal fascial flap for reconstruction of the eyebrows and covering the exposed frontal bone and prefabricated forehead flap with skin graft for nasal reconstruction. Proper planning and staging of the surgical procedures and use of local flaps gave us good aesthetic and functional outcome with a satisfied patient.

Basal cell carcinoma arising in a tattooed eyebrow

Malignant skin tumors, including squamous cell carcinoma and malignant melanoma, have occurred in tattoos. Seven documented cases of basal cell carcinoma associated with tattoos have also been reported in the medical literature. We encountered a patient with basal cell carcinoma in a tattooed eyebrow. We report on this case as the eighth reported case of a patient with basal cell carcinoma arising in a tattooed area.