Complications of the Superior Eyelid Endoscopic Transorbital Approach to the Skull Base: Preliminary Experience With Specific Focus on Orbital Outcome.

BACKGROUND: The endoscopic superior eyelid approach is a relatively novel mini-invasive technique that is currently investigating for skull base cancers. However, questions remain regarding specific approach-related complications when treating different skull base tumors. This study aims to analyze any surgical complications that occurred in our preliminary consecutive experience, with specific focus on orbital outcome. METHODS: A retrospective and consecutive cohort of patients treated via a superior eyelid endoscopic transorbital approach at the Division of Neurosurgery of the Hospital Clinic in Barcelona was analyzed. Patients features were described in detail. Complications were divided into 2 groups to analyze separately the approach-related complications, and those resulting from tumor removal. The ocular complications were subdivided into early ocular status (<3 weeks), late ocular status (3-8 weeks), and persistent ocular complications. The "Park questionnaire" was used to determine patient's satisfaction related to the transorbital approach. RESULTS: A total of 20 patients (5 spheno-orbital meningiomas, 1 intradiploic Meningioma, 2 intraconal lesions, 1 temporal pole lesion, 2 trigeminal schwannoma, 3 cavernous sinus lesions, and 6 petroclival lesions) were included in the period 2017-2022. Regarding early ocular status, upper eyelid edema was detected in all cases (100%) associated with diplopia in the lateral gaze in 30% of cases, and periorbital edema in 15% of cases. These aspects tend to resolve at late ocular follow-up (3-8 weeks) in most cases. Regarding persistent ocular complications, in one case of intraconal lesion, a limitation of eye abduction was detected (5%). In another patient with intraconal lesion, an ocular neuropathic pain was reported (5%). In 2 cases of petroclival menigioma, who were also treated with a ventriculo-peritoneal shunt, slight enophthalmus was observed as a persistent complication (10%). According to the Park questionnaire, no cosmetic complaints, no head pain, no palpable cranial irregularities, and no limited mouth opening were reported, and an average of 89% of general satisfaction was encountered. CONCLUSIONS: The superior eyelid endoscopic transorbital approach is a safe and satisfactory technique for a diversity of skull base tumors. At late follow-up, upper eyelid edema, diplopia, and periorbital edema tend to resolve. Persistent ocular complications are more frequent after treating intraconal lesions. Enophthalmus may occur in patients with associated ventriculo-peritoneal shunt. According to patient's satisfaction, fairly acceptable results are attained.

Customized Reconstruction of Lower Eyelid Defects.

BACKGROUND: A lower eyelid defect is a loss of skin, muscle, and underlying structures that can occur due to trauma, malignant or benign tumors, burns, or other causes. The conventional surgical treatment of lower lid defects has several limitations, including visible scarring, narrowing of the eye, and ectropion. Here, we combined the use of a customized mid-face lift with a free mucochondral graft to overcome the disadvantages of existing methods. METHODS: Forty patients underwent reconstructive surgery using a customized mid-face lift with or without a free mucochondral graft for a lower lid defect between April 2013 and October 2020. Patients were discharged shortly after surgery and were expected to visit the outpatient clinic periodically for 12 months. RESULTS: The causes of lower eyelid defects were malignancy, trauma, foreign body granuloma, and other causes. Four patients reported complications, including 2 cases of chemosis, 1 case of a hematoma, and 1 case of corneal abrasion, who reportedly performed well after 2 weeks of conservative therapy. No patient required revision during the average follow-up period. CONCLUSIONS: Customized reconstruction demonstrated a better aesthetic reconstruction of the lower eyelid. This method represents a good option for reconstructing lower lid defects.

An Experimental Design to Compare the Compatibility of Absorbable and Nonabsorbable Suture Materials in the Lateral Canthus Area.

Polyglactin 910 (Vicryl) and polypropylene (Prolene) are common suture materials used in ophthalmic surgical procedures. However, there are limited studies assessing tissue reactions to different sutures in eyelid areas. In this study, these suture materials were used subcutaneously in 10 lateral canthi of 5 pigs. Clinical reactive score (CRS) was assessed 14 days and 60 days after surgery. On histology, subcutaneous tissue reactions were assessed by the presence of different inflammatory cells, and the aggregate tissue irritation score was calculated. CRS and the histology score did not differ between these sutures. None of the suture materials used were superior for use in the lateral canthi of pig eyes. Therefore, we recommend both of these sutures for use in the subcutaneous tissue of the eyelid area in animal experiments or clinical practice.

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.

Lower Blepharoplasty with Mid-Face Elevation: A Polydioxanone (PDO) Barbed Suture Loop for Lid-Cheek Junction Blending.

BACKGROUND: Anti-aging in the lower eyelid-cheek junction area has always been the most widely sought cosmetic surgery. However, orbital fat removal or a midcheek fat pad lift alone does not achieve the best results. This study describes a new technique of lower blepharoplasty combined with a midcheek lift performed using a polydioxanone barbed suture loop based on the entire anatomy of the lower eyelid-cheek junction area. METHODS: We report our experience with lower blepharoplasty combined with a midcheek lift, covering 38 procedures performed over the past 3 years. We reviewed the technique and results and described the various indications for which the new technique is suitable. The efficacy of the surgeries was delineated using both 3D volume calculation and graphic pictures. RESULTS: All patients demonstrated significant rejuvenation of the lower eyelid with the elimination of the eyebags, elevation of the lid-cheek junction, and improvement of the nasolabial folds. All the patients were satisfied with the procedure. Complication rates were low, and lower lid retraction temporarily occurred in 3% of patients. CONCLUSIONS: This new method of lower blepharoplasty with midcheek elevation is safe, effective, convenient, and long-lasting. The technique is more doctor-friendly, recovery is quick, and complications are minimized. 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 .

Marcus-Gunn jaw winking syndrome: case series study and management algorithm.

PURPOSE: To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). METHODS: Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). RESULTS: Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. CONCLUSIONS: Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery.

PURPOSE: This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). METHODS: This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. RESULTS: Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. CONCLUSION: An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series.

BACKGROUND: As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area. METHODS: Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic. RESULTS: The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery. CONCLUSIONS: Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Silicone Granulomas of the Eyelids-A Case Series Illustrating a Distant Migratory Phenomenon.

PURPOSE: Exogenous silicone has been reported to migrate to anatomic sights far from an initial injection or implantation site; this phenomenon has been rarely described in the ocular adnexa, especially in the eyelids. We document 3 additional cases of distant migration of silicone implanted elsewhere in the body to the eyelids and review the prior literature on this uncommon event. METHODS: A retrospective chart review of 3 patients was conducted along with analysis of diagnostic histopathology. A comprehensive review of the literature regarding dissemination or migration of silicone to the eyelids in patients with either silicone breast implants or silicone facial filler use was performed. RESULTS: Cases of silicone migrating to the eyelids from silicone breast implants and silicone-based facial filler are outlined in Tables 1 and 2, respectively. There are 4 total reports of women with silicone breast implants, including the 2 described here, with evidence of migration of silicone to the eyelid. Similarly, 5 cases of silicone-based facial filler with resultant migration of filler to the eyelids were identified, including 2 of the cases presented in this report (1 patient had both silicone breast implants and silicone facial filler). CONCLUSION: Silicone is chemically inert, but is known to travel throughout the body, causing a resultant foreign body response in tissue that can adversely affect even the eyelids. Silicone has a relatively characteristic histologic appearance and diagnosis of silicone granuloma highlights the importance of obtaining a thorough clinical history, particularly regarding prior cosmetic injections or breast enhancement surgery. Foreign material/foreign body granuloma is important to consider in patients with deep eyelid nodules of unclear etiology.

How Do the Faces of Kyrgyz Beauties Look? A Photogrammetric Analysis of Beauty Pageant Winners.

The aim of this study was to assess how the eyes of Kyrgyz beauties look through an anthropometric analysis of beauty pageant winners. Eleven winners of the Miss Kyrgyzstan contest (2011-2021) were included. Ten other beauty contest winners were added, resulting in a total of 21 beauties who were included. The horizontal corneal diameter, which is 11.75 mm, was used as a standard distance. Other distances were calculated in millimeters based on the proportions of the pixels measured. Twenty-six distances (face: 10, eyebrows: 2, eyes: 4, nose: 4, lips: 4, and chin: 2) and 9 angles (forehead-brow, cantal tilt, 5 face angles, the mandible angle, and the chin angle) were measured. Thereafter, 16 indices (forehead: 1, eyes: 5, nose: 4, lips and chin: 3, and contours 3) were calculated. The forehead-brow angle was 82.2±7.2 degrees. The canthal tilt was 9.0±2.0 degrees. The overall face angles 1 and 2 were 108.6±4.1 degrees and 69.6±2.3 degrees, respectively. The midface angles 1 and 2 were 129.9±3.8 degrees and 125.1±3.9 degrees, respectively. The lower face angle was 139.6±4.1 degrees. The mandible angle and chin angle were 136.9±4.0 degrees and 106.0±4.0 degrees, respectively. The ratio of forehead height to total face height was 0.33±0.03. The ratio of nose height to total face height was 0.25±0.02. The lower face width/face width ratio was 0.82±0.05. The ratio of face width to total face height was 0.72±0.03. The ratio of midface height to total face height was 0.34±0.02. The data from this study might serve as the recommended esthetic proportions for performing plastic surgical procedures.

A Novel Preoperative Design to Address Dermatochalasis in Asian Upper Blepharoplasty.

BACKGROUND: The preoperative design for the amount of skin excision of the upper eyelid is a common procedure in Asian blepharoplasty, but there lack of an effective method addressing dermatochalasis to acquire esthetically pleasing results. Our aim was to propose an alternative technique to determine the skin excision combined with the esthetics of eyes for correcting skin laxity and therefore to create attractive double eyelids. MATERIALS AND METHODS: The preoperative invaginating-simulating design combined with esthetic criteria for determining the amount of excised skin were performed during blepharoplasty. The Strasser grading system and the Global Aesthetic Improvement Scale were evaluated by analyzing the preoperative and 6-month-postoperative photographs. RESULTS: One hundred forty-two patients were included. The general outline of the "optimal incision" took on a knife in shape with a mean of 2.2±3.32 points of Strasser grading score. A total of 130 of 142 patients (91.5%) were judged as "good results" and 12 of 142 patients (8.5%) were judged as "mediocre". The Global Aesthetic Improvement Scale showed a significant cosmetic improvement with the result of 89.4%(127 of 142 patients) for "very much improved", 7.8% for "much improved" and other patients for "improved". No severe complications were observed. CONCLUSIONS: This preoperative design approach has been proven to be effective to address dermatochalasis (especially for lateral hooding) by simulating the expected appearance of a double eyelid combined with esthetic criteria of eyes simultaneously, which can contribute to achieving upper-lid rejuvenation and beautiful and natural outcomes.

A Novel Strategy to Achieve Stable and Lasting Double Eyelids in Upper Blepharoplasty.

BACKGROUND: Incision blepharoplasty is very common among aesthetic surgery, but the effect of it varies considerably. The quality of incision blepharoplasty is mainly defined by operator's ability, which will result in the uncertainty of operation result. We are committed to seeking a principle to guide every operator to achieve optimum success. MATERIALS AND METHODS: A retrospective study of 150 patients experienced the new method from January 2020 to May 2022. This method was mainly divided into 4 steps. Firstly, released adhesion between the orbital septum and the levator aponeurosis and the connection between the orbital septum and the pretarsal fascia. Then, dealt with the epicanthus to reduce the resistance. Third, improve the lifting force of opening eyes or decrease the resistance of opening eyes to keep the balance of biomechanics in the upper eyelid. Last, sutured and closed the incision. The postoperative outcomes were assessed by "Global Aesthetic Improvement Scale." RESULT: The follow-up period at last for 3 months.-The results showed that the rate of "Very much improve" was 88% (132 patients); that of "Much improve" was 9.3% (14 patients); that of "Not change" was 0.6% (1 patient); and that of "Worse" was 2% (3 patients). The recovery time of patients varied from 2 weeks to 1 month. And the complications of the narrowing and lightening of the double-eyelid line decreased. CONCLUSION: Applying the biomechanical balance principle to incision blepharoplasty can generate a more beautiful double-eyelid line and is less likely to trigger off complications.

Restoration of the Lateral Canthus and Stabilization of the Lower Eyelid After Failed Esthetic Lateral Canthoplasty.

BACKGROUND: An improper procedure of esthetic lateral canthoplasty can lead to lateral canthal deformity with other complications. To ensure proper canthal contour and eyelid function, the lateral canthus must be restored and the lower eyelid must be stabilized. METHODS: This was a retrospective study that included a group of consecutive patients who had failed esthetical lateral canthoplasty between 2020 and 2022. All patients underwent the modified lateral tarsal strip procedure to restore the normal anatomy of the lateral canthus and stabilize the lower eyelid. Clinical data (age, sex, laterality, follow-up, ocular symptoms, previous medical history, and lateral canthal deformity) were collected. Preoperative and postoperative photographs were analyzed for cosmetic outcomes. RESULTS: Among the 15 female patients, 25 eyelids were treated, including both eyes in 10 patients and only the left eye in 5 others. The mean age was 32.6 years. The mean follow-up was 13.34 months. All the patients had undergone esthetic lateral canthoplasty with other esthetic surgeries. Lateral canthus deformities include canthal webbing, rounding canthus, eyelid margin defect, remnant raw surface, mucosal exposure, lower eyelid retraction, sclera show, ectropion, symblepharon, and lagophthalmos. All the patients exhibited esthetically satisfactory results with improved ocular symptoms. In statistical analysis, horizontal palpebral aperture, vertical palpebral aperture, MRD2, and lateral canthus angle were statistically different pre to postprocedure (paired t test, P < 0.001). CONCLUSIONS: Restoration of the lateral canthus and stabilization of the lower eyelid using the modified lateral tarsal strip procedure showed good functional and cosmetic outcomes in patients who had failed lateral canthoplasty.

Sunken Upper Eyelid Deformity Correction by Orbital Fat Pad Repositioning and Orbicularis Oculi Muscle Folding in Blepharoplasty.

BACKGROUND: Sunken upper eyelid deformity results in an aged and unnatural appearance and is common among Asians along with the single eyelid. The upper eyelid volume restoration is as important as the creation of a supratarsal fold for patients with sunken eyelids. In the present study, the combination of orbital fat pad repositioning and orbicularis oculi muscle flap folding was established to correct the upper eyelid depression during blepharoplasty. METHODS: A retrospective study was conducted on patients who underwent the orbital fat pad repositioning and orbicularis oculi muscle flap folding to correct the upper eyelid depression between July 2020 and October 2021. The preoperative and postoperative sunken depths were calculated and compared, and overall patient satisfaction was performed to evaluate the operation efficiency. RESULTS: There were 40 patients, including 39 females and 1 male, who underwent surgery with an average age of 25.4 years. During the mean follow-up period of 12.7 months, the sunken depth improved from 3.2 mm preoperatively to 1.5 mm postoperatively with a statistical significance. Satisfactory results were achieved without major complication. CONCLUSIONS: For patients with mild to moderate sunken upper eyelids, the combination of orbital fat pad repositioning and orbicularis oculi muscle folding has been proved efficient and consistent to restore the upper eyelid volume and helpful to build esthetic double eyelids.

Use of the Acellular Dermal Matrix (ADM) to Reconstruct Full-thickness Eyelid Defects.

This study aimed to introduce the use of an acellular dermal matrix (ADM) as a posterior lamellar substitution for full-thickness eyelid reconstruction after malignant tumor excision. After resection of the malignant eyelid tumors, anterior lamellar defects were repaired using direct sutures and pedicled flaps in 20 patients (15 men and 5 women). ADM was used to replace the tarsal plate and the conjunctiva. All patients were followed up for 6 months or more to assess the functional and esthetic outcomes of the procedure. The flaps survived in all but 2 cases, wherein they necrosed due to insufficient blood supply. The functionality and esthetic outcomes were excellent in 10 and 9 patients, respectively. There were no changes in visual acuity or corneal epithelial damage after the surgery. The eyeball movement was good. Corneal irritation no longer appeared, and patient comfort was maintained. Furthermore, no tumor recurrence occurred in any patient. ADM is a valuable posterior lamellar material for the full-thickness reconstruction of eyelid defects after the resection of malignant tumors on the eyelids.

A Surgeon's Armamentarium for Ocular Management in Facial Paralysis: A Comprehensive Review.

OBJECTIVE: To review the current management paradigm of the eye in patients with facial paralysis. METHODS: A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "ocular," "facial," "synkinesis," "palsy," "neurotization," and various combinations of the terms. A total of 65 articles were included. RESULTS: Facial paralysis may result in devastating ocular sequelae. Therefore, assessment of the eye in facial paralysis is a critical component of patient management. Although the management should be individualized to the patient, the primary objective should include an ophthalmologic evaluation to implement measures to protect the ocular surface and preserve visual acuity. The degree of facial paralysis, lacrimal secretion, corneal sensation, and position of the eyelids should be assessed thoroughly. Patients with the anticipated recovery of facial nerve function may respond to more conservative temporizing measures to protect the ocular surface. Conversely, patients with expected prolonged paralysis should be appropriately identified as they will benefit from surgical reconstruction and rehabilitation of the periorbital complex. The majority of reconstructive measures within a facial surgeon's armamentarium augment coverage of the eye but are unable to restore blink. Eyelid reanimation restores the esthetic proportionality of the eye with blinking and reestablishes protective functions necessary for ocular preservation and function. CONCLUSIONS: Ocular preservation is the primary priority in the initial management of the patient with facial paralysis. An accurate assessment is a critical component in identifying the type of paralysis and developing an individualized treatment plan.

Long-Term Aesthetic Cicatrization Analysis of Lower Eyelid Incision for Orbital Floor Fracture Approach.

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches.

Patient-Reported Outcome Analysis after Resident Performed Upper Blepharoplasty: A Suitable Procedure for Young Surgeons.

Upper blepharoplasty is one of the most frequently performed aesthetic surgeries worldwide. While it is considered a low risk procedure, patients have high expectations regarding the outcome of elective surgery of the face and the majority of residents usually have little exposure to cosmetic surgeries in the early years of their training. All eligible patients who had undergone bilateral upper blepharoplasty at the senior author's institution between January 2016 and August 2019 were invited to participate in an online questionnaire. Our study used a 27-item questionnaire to evaluate postoperative patient satisfaction and compared the patient reported outcome between operations conducted by surgeons with more than 3 years of experience and less than 3 years. In total, 102 patients returned the completed questionnaire and were included in our study after further screening. There was no significant difference in patient reported satisfaction concerning the aesthetic outcome (8.75 vs. 8.29, p=0.49), and complications (6.2 vs. 18.6%, p=0.63), related to the experience of the surgeons. Overall patient satisfaction was very high, while the rate of complications was low. Patient reported aesthetic outcomes after blepharoplasty demonstrated no significant difference comparing the experience of the surgeons.

Lower Eyelid Transcutaneous Blepharoplasty, Minimizing Complications and Correction of Lower Eyelid Malposition.

The periocular area is one of the first and most noticeable areas affected by ageing. Common signs of lower lid ageing include rhytids, prominent eye bags caused by prolapse of orbital fat pads, increased lid laxity leading to lid malpositioning, and deepening of tear troughs, all of which give a sunken aged appearance. Lower lid transcutaneous blepharoplasty can correct most of these problems providing excellent long-term aesthetic outcomes with minimal downtime for the patient. However, lower eyelid anatomy is complex, and a thorough understanding of its structure and function is needed to avoid serious complications such as lid malpositioning and blindness. In this review, we present the anatomy of the lower lid and useful surgical techniques to circumvent and avoid such complications.

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.