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 .

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years.

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Asian Upper Blepharoplasty with the Hinge Technique.

Asian upper blepharoplasty is one of the most commonly requested procedures in Asian patients. Many incisional and suture methods have been described in the literature. While the suture method is advantageous for its simplicity and quick recovery, the incision method is more versatile and able to deliver predictable and reproducible results for Asian patients presenting with a diverse range of anatomy and requests. Accordingly, the incision method remains the preferred approach for many surgeons performing Asian upper blepharoplasty. In this paper, we detail our open incision hinge upper blepharoplasty technique to create dynamic upper eyelid creases in Asian patients. The surgical videos associated with this paper present our surgical technique in detail, highlighting technical refinements and surgical nuances to perform the surgery precisely and predictably. The conceptual core of our approach is the use of a vascularized orbital septum as a flap to create a fibrous extension from the levator aponeurosis to the dermis at the location of eyelid crease. This vascularized flap securely connects the posterior lamella with the anterior lamella to securely form the eyelid crease with eye opening. This most accurately recreates the anatomy that is present in attractive Asian patients with naturally occurring double eyelid and predictably creates a dynamic and crisp upper eyelid crease. 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 Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula.

BACKGROUND: The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes. OBJECTIVES: The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented. METHODS: Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance. RESULTS: A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%. CONCLUSIONS: This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation.

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.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 .

Asian Cleft Rhinoplasty: The Open Structural Approach.

BACKGROUND: Asian cleft rhinoplasty is a unique procedure with specific challenges. OBJECTIVES: This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach. METHODS: An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated. RESULTS: From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low. CONCLUSIONS: The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients. LEVEL OF EVIDENCE: 4.

Medial Epicanthoplasty with the Skin Re-Draping Technique: Technical Refinements for Predictable outcomes.

The epicanthus is a common feature of the Asian eyes. A prominent medial epicanthal fold gives the impression of a blunted affect and the procedure for its removal, the medial epicanthoplasty, is a very commonly requested by Asian patients. This may be performed as an isolated procedure or more commonly in combination with the upper blepharoplasty. Many conventional medial epicanthoplasty techniques are based on skin flaps transposition and excisions, usually variations of the V-Y, W or Z-plasties (1-4). While these have been variably successful at correcting the epicanthal fold, the common problem is significant scarring in the medial canthal and lower eyelid regions (5-8). This is particularly problematic in Asian patients with greater tendencies for hypertrophic scarring and scar hypo or hyper-pigmentation (9). Recently, the skin re-draping method, designed with incisions limited within the margins of the medial canthus and precise and targeted disruption of the underlying fibromuscular tissues, has emerged as the preferred surgical technique for many Asian surgeons because of its effectiveness and superior aesthetic outcomes(6, 10-12). This technique delivers the most inconspicuous incisions and is advantageous because it is effective in eliminating epicanthal folds of various severities. Precise execution of this technique is difficult, given the complex 3-dimensional anatomy of the epicanthus. This paper presents a detailed explanation of surgical concepts of the skin re-draping epicanthoplasty and provide a step-by-step guide to performing this procedure in a safe and effective manner.

Revisiting vascular supply of the rectus femoris and its relevance in the harvest of the anterolateral thigh flap.

INTRODUCTION: The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus femoris is dominantly supplied by the vascular pedicle which takes off from the same source artery that is harvested with the anterolateral thigh flap. Therefore, the blood supply of the rectus femoris may potentially be compromised when harvesting the anterolateral thigh flap. This study revisits the blood supply of the rectus femoris in the light of recent advances in the understanding of the vascular anatomy of the anterolateral thigh. MATERIALS AND METHODS: From January 2010 to June 2011, a prospective intraoperative observational study was performed in 50 consecutive anterolateral thigh flaps, noting the dimensions and locations of (1) the descending branch, (2) the presence of the oblique branch of the lateral circumflex femoral artery, and (3) the number and size of the muscle branches supplying the rectus femoris. Temporary selective occlusion with microvascular clamps was performed to evaluate the dominance of the blood supply to the muscle. Flap harvest was then completed as planned. RESULTS: The oblique branch was noted to be present in 23 (46%) of 50 patients. Of these, 21 (91%) of 23 of oblique branches supplied a large muscle branch to the rectus femoris. When the descending branch alone was present, occluding the dominant pedicle will usually compromise the blood supply to the muscle. In situations where 2 large muscle branches arise from the descending and oblique branches, occlusion of either pedicle did not affect the circulation of the rectus femoris, demonstrating codominance in this situation. CONCLUSIONS: The vascularity of the rectus femoris can be classified as either a type A or B. Type A rectus femoris is the classic pattern with a single dominant pedicle from the descending branch. Type B rectus femoris is seen when an oblique branch supplies a codominant pedicle to the muscle. The implication of this anatomy is that in a type B rectus femoris, one of the 2 muscle branches can be safely ligated to increase the pedicle length when harvesting of the anterolateral thigh flap, without compromising the vascularity of the muscle.

The anterolateral thigh perforator flap for reconstruction of knee defects.

INTRODUCTION: Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively. METHODS AND MATERIALS: Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a "propeller" distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel. RESULTS: Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel. CONCLUSION: The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.