Physical appearance perfectionism in blepharoplasty patients: A prospective observational study.

BACKGROUND: Evaluation of physical appearance perfectionism (PAP) in individuals seeking blepharoplasty would be meaningful. This study aimed to explore the relationship of demographic and psychological variables with PAP in blepharoplasty patients and further investigate the impact of blepharoplasty on PAP in these patients. METHODS: This prospective observational study included 153 patients undergoing blepharoplasty between October 2017 and June 2019. Demographic and psychological variables, and PAP, were collected preoperatively. Postoperative satisfaction with eye appearance and PAP was collected with a 6-month follow-up. RESULTS: Partial correlations analyses revealed that hope for perfection was positively associated with self-esteem (r = 0.246; P < 0.01) in 153 blepharoplasty patients. Worry about imperfection was positively related to facial appearance concern (r = 0.703; P < 0.001) and negatively related to satisfaction with eye appearance (r = -0.242; P < 0.01) and self-esteem (r = -0.533; P < 0.001). After blepharoplasty, the mean± standard deviation of satisfaction with eye appearance increased (preoperatively vs. postoperatively: 5.1 ± 2.2 vs. 7.4 ± 2.2; P < 0.001), and worry about imperfection decreased (17.0 ± 4.2 vs. 15.9 ± 4.6; P < 0.001). Whereas hope for perfection remained unchanged (23.9 ± 3.9 vs. 23.6 ± 3.9; P > 0.05). CONCLUSIONS: Appearance perfectionism was related to psychological variables rather than demographic variables in blepharoplasty patients. Preoperative evaluation of appearance perfectionism could be helpful for oculoplastic surgeons to screen for perfectionistic patients. Although some improvement in perfectionism has been observed after blepharoplasty, long-term follow-up is needed in the future.

Observer-Reported Outcomes and Cosmetic Procedures: A Systematic Review.

BACKGROUND: Cosmetic procedures have demonstrated beneficial effects on physical appearance based on anatomic markers as well as patient-perceived self-image and quality of life. Recent studies of observer-reported outcomes (OROs) suggest an additional benefit from aesthetic interventions. OBJECTIVE: The authors aimed to review the evidence of OROs from cosmetic procedures performed on the head and neck. PATIENTS, METHODS AND MATERIALS: PubMed, Embase, and Cochrane Library databases were searched for relevant studies, yielding 24 included original investigations. RESULTS: These studies captured 686 total patients, 8,257 observer evaluations, and a variety of interventions including face-lifts, blepharoplasty, rhinoplasty, and minimally invasive treatments including botulinum toxins and hyaluronic acid fillers. Forty-one distinct reported OROs were grouped into 12 descriptive domains. Domains were further grouped into 3 higher-order categories: aesthetics and wellness, social capacities, and skills and competencies. Improved perception after cosmetic intervention is most reproducibly demonstrated for the following ORO domains: age, attractiveness, sociability, relationship success, and occupational and financial competency. CONCLUSION: The synthesized findings imply a tertiary layer of benefit for cosmetic intervention beyond anatomical and patient-centered outcomes through enhanced perceptions of others. These findings may inform the pre-procedure risk-benefit discussion with patients of cosmetic medicine and drive future research into longitudinal outcomes.

The Effect of Blepharoplasty on Our Patient's Quality of Life, Emotional Stability, and Self-Esteem.

BACKGROUND: Several studies have been conducted evaluating psychological effects following aesthetic surgery, however few of them following blepharoplasty! PURPOSE: To determine whether blepharoplasty affects quality of life and satisfaction as well as, emotional stability and self-esteem in patients who underwent only blepharoplasty. DESIGN: A retrospective study including transdermal blepharoplasty operations between the years 1995 and 2008. METHODS: A self-developed and indication-specific questionnaire especially for blepharoplasty, as well as the standardized testing instruments FLZM, FPI-R, and RSES, concerning quality of life, body image, personality, and self-esteem was utilized. PARTICIPANTS: A total of 123 patients were included in the study. Forty-six patients participated in the study. MAIN OUTCOMES AND MEASURES: Results were compared with the existing representative norm data from the German speaking countries. RESULTS: In the indication-specific questionnaire, 44 patients reported a positive influence on their personal wellbeing, and 33 were more satisfied with their appearance (follow-up 3-95 months; average 48.5 months); 20 felt more self-confident, and 25 felt more attractive.Statistically significant increased values in quality of life (FLZM) were found in the aspects work (P = 0.02), mobility (P < 0.001) and independence from assistance or help (P < 0.001).Higher scores concerning personality and self-esteem compared with the respective random sample were found in the questionnaires FPI-R (P = 0.02) and RSES (P < 0.001). CONCLUSION AND RELEVANCE: Among plastic surgical interventions, blepharoplasty is a minimal invasive operation, which is very well tolerated by patients. Patients take advantage in personal wellbeing, self-esteem, and different aspects of their daily life.

A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty.

IMPORTANCE: Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions. OBJECTIVES: To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions. DESIGN, SETTING, AND PARTICIPANTS: A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected. MAIN OUTCOMES AND MEASURES: A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status. RESULTS: A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (-1.04 years; 95% CI, -1.70 to -0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty. CONCLUSIONS AND RELEVANCE: This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty. LEVEL OF EVIDENCE: NA.

Assessment of self-esteem and psychological aspects in patients undergoing upper blepharoplasty / Avaliação da autoestima e aspectos psicológicos em pacientes submetidos à blefaroplastia superior

Abstract Objective: To evaluate the self-esteem and quality-of-life outcomes in patients undergoing upper blepharoplasty. Methods: A cross-sectional study was performed at Federal University of São Paulo. The self-esteem and quality-of-life of 29 patients undergoing upper blepharoplasty were compared with 20 age-matched volunteers from the general population. During preoperative assessment, the patients and volunteers underwent complete ophthalmological examinations and answered two questionnaires: the Rosenberg self-esteem scale (RSES) and the World Health Organization quality of life assessment (WHOQOL-BREF). The RSES is a ten-item questionnaire developed to measure self-esteem that are answered using a four-point scale. The scores range from 0 to 30, and lower scores indicate higher self-esteem. The WHOQOL-BREF is composed of 26 questions divided into four domains. Mean values greater than 5 are considered indicative of very good quality-of-life. Data from the RSES and quality-of-life scores were compared between the two groups using an unpaired t- test. Results: The mean self-esteem scores for the patients and volunteers were 10.31 ± 0.71 and 6.9 ± 0.99, respectively (p < 0.001). The mean response scores for the WHOQOL-BREF questionnaire for the patients and volunteers were 3.67 ± 0.08 and 3.76 ± 0.08, respectively (p = 0.449). For the psychological subscale of the WHOQOL-BREF questionnaire, the results for the patients and volunteers were 3.52 ± 0.09 and 3.78 ± 0.08, respectively (p = 0.041). Conclusions: Subjects who underwent upper blepharoplasty exhibited worse self-esteem based on the RSES. Regarding quality-of-life, as assessed using the WHOQOL-BREF questionnaire, significant differences between the groups were evident in the psychological aspects subscale. Our study confirms the importance of subjecting patients to psychological evaluation prior to upper blepharoplasty.

Resumo Objetivo: Avaliar os resultados de autoestima e qualidade de vida em pacientes submetidos à blefaroplastia superior. Métodos: Um estudo transversal foi realizado na Universidade Federal de São Paulo. A autoestima e a qualidade de vida de 29 pacientes submetidos à blefaroplastia superior foram comparadas com 20 voluntários pareados para idade. Durante a avaliação pré-operatória, os pacientes e voluntários foram submetidos a exames oftalmológicos completos e responderam a dois questionários: a escala de autoestima de Rosenberg (RSES) e a avaliação da qualidade de vida da Organização Mundial de Saúde (WHOQOL-BREF). O RSES é um questionário de dez itens desenvolvido para medir a autoestima que são respondidos usando uma escala de quatro pontos. Os escores variam de 0 a 30, e os escores mais baixos indicam maior autoestima. O WHOQOL-BREF é composto por 26 questões divididas em quatro domínios. Os valores médios acima de 5 são considerados indicativos de uma boa qualidade de vida. Os dados da RSES e os escores de qualidade de vida foram comparados entre os dois grupos usando um teste de t-teste não pareado. Resultados: Os escores médios de autoestima para pacientes e voluntários foram de 10,31 ± 0,71 e 6,9 ± 0,99, respectivamente (p <0,001). Os escores de resposta média para o questionário WHOQOL-BREF para pacientes e voluntários foram de 3,67 ± 0,08 e 3,76 ± 0,08, respectivamente (p = 0,449). Para a subescala psicológica do questionário WHOQOL-BREF, os resultados para pacientes e voluntários foram 3,52 ± 0,09 e 3,78 ± 0,08, respectivamente (p = 0,041). Conclusões: Aqueles submetidos à blefaroplastia superior apresentaram menor autoestima com base na RSES. Quanto à qualidade de vida, avaliada utilizando o questionário WHOQOL-BREF, diferenças significativas entre os grupos foram evidentes na subescala de aspectos psicológicos. Nosso estudo confirma a importância de submeter os pacientes à avaliação psicológica antes da blefaroplastia superior.

Pre-operative experiences and post-operative benefits of ptosis surgery: A qualitative study.

This qualitative study sought to explore the experiences of patients who had undergone successful ptosis correction surgery. Participants were recruited from Bristol Eye Hospital. Nine participants were interviewed using a semi-structured interview schedule and open ended questions. Data were analysed using inductive thematic analysis. Four major themes were identified from patient accounts. Patients described the psychosocial and functional difficulties they experienced living with ptosis, and the subsequent benefits of surgery. Patients reported experiencing appearance related anxiety pre-operatively due to their condition and engaging in behaviours to avoid social encounters. Gender differences were noted in the internalization of perceived negative reactions from others, with men describing fewer adverse impacts. Patients described perceived barriers to seeking surgery including a lack of awareness of ptosis as a treatable condition, the perception that being concerned with their appearance could be seen as vain and the view that ptosis surgery is synonymous with cosmetic surgery. Following successful surgery patients outlined positive impacts on their vision, appearance and psychosocial well-being after successful surgery. This qualitative study highlights the complexities of the factors and processes contributing to the psychosocial impacts of ptosis and the potential benefits of surgery and/or psychosocial support. An increased awareness amongst people with ptosis of the potential positive impacts of surgery and an enhanced understanding of the reasons why patients may not seek treatment amongst health care professionals are likely to benefit this often overlooked patient group.

Association Between Facial Rejuvenation and Observer Ratings of Youth, Attractiveness, Success, and Health.

IMPORTANCE: Surgical procedures for the aging face-including face-lift, blepharoplasty, and brow-lift-consistently rank among the most popular cosmetic services sought by patients. Although these surgical procedures are broadly classified as procedures that restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face. OBJECTIVES: To determine if face-lift and upper facial rejuvenation surgery improve observer ratings of age, attractiveness, success, and health and to quantify the effect of facial rejuvenation surgery on each individual domain. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical experiment was performed from August 30 to September 18, 2016, using web-based surveys featuring photographs of patients before and after facial rejuvenation surgery. Observers were randomly shown independent images of the 12 patients; within a given survey, observers saw either the preoperative or postoperative photograph of each patient to reduce the possibility of priming. Observers evaluated patient age using a slider bar ranging from 30 to 80 years that could be moved up or down in 1-year increments, and they ranked perceived attractiveness, success, and health using a 100-point visual analog scale. The bar on the 100-point scale began at 50; moving the bar to the right corresponded to a more positive rating in these measures and moving the bar to the left, a more negative rating. MAIN OUTCOMES AND MEASURES: A multivariate mixed-effects regression model was used to understand the effect of face-lift and upper facial rejuvenation surgery on observer perceptions while accounting for individual biases of the participants. Ordinal rank change was calculated to understand the clinical effect size of changes across the various domains after surgery. RESULTS: A total of 504 participants (333 women, 165 men, and 6 unspecified; mean age, 29 [range, 18-70] years) successfully completed the survey. A multivariate mixed-effects regression model revealed a statistically significant change in age (-4.61 years; 95% CI, -4.97 to -4.25) and attractiveness (6.72; 95% CI, 5.96-7.47) following facial rejuvenation surgery. Observer-perceived success (3.85; 95% CI, 3.12-4.57) and health (7.65; 95% CI; 6.87-8.42) also increased significantly as a result of facial rejuvenation surgery. CONCLUSIONS AND RELEVANCE: The data presented in this study demonstrate that patients are perceived as younger and more attractive by the casual observer after undergoing face-lift and upper facial rejuvenation surgery. These procedures also improved ratings of perceived success and health in our patient population. These findings suggest that facial rejuvenation surgery conveys an even larger societal benefit than merely restoring a youthful appearance to the face. LEVEL OF EVIDENCE: NA.

Functional benefits and patient satisfaction with upper blepharoplasty - evaluated by objective and subjective outcome measures.

PURPOSE: To investigate the functional benefits and patient satisfaction with upper blepharoplasty in patients meeting the Danish visitation guidelines for upper blepharoplasty from the Danish Health and Medicines Authority (Sundhedsstyrelsen). METHODS: Before and 3 months after upper blepharoplasty, the following investigations were made: (i) a standard eye examination, (ii) photographic documentation with a normal camera and the infrared camera of a Spectralis Optical Coherence Tomograph and (iii) measurements of the upper visual fields using the blepharoptosis test of Octopus 900. Along with the pre- and postoperative examinations, the patients completed a questionnaire concerning the functional and psychosocial impact of their eyelids. RESULTS: Ninety eyelids of 45 patients were studied, 34 females and 11 males. The mean age was 56.9 years (SD: 12.8). The mean change in the distance between the upper eyelid skin fold and the visual axis or the marginal reflex distance (MRD), depending on which was lowest, was 1.6 mm (SD: 0.8 mm) for the right eyelids and 1.2 (SD: 0.9 mm) for the left eyelids. The mean improvement in the upper visual field was 31.3% points for the right eyelids (SD: 21.4% points) and 28.3% points for the left eyelids (SD: 24.9% points). A statistically significant correlation between the preoperative distance from skin fold to visual axis/MRD and the pre- and postoperative visual field was found. The patients reported an improvement in their symptoms postoperatively. All subjects were satisfied with the postoperative result and would undergo the surgery again if they had to make the choice again. CONCLUSION: Patients meeting the Danish visitation guidelines for upper blepharoplasty experience a measurable improvement in function and alleviation of symptoms after blepharoplasty.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics.

IMPORTANCE: Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented. OBJECTIVE: To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD. DESIGN, SETTING, AND PARTICIPANTS: This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016. METHODS: All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE). RESULTS: Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE. CONCLUSIONS AND RELEVANCE: Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care. LEVEL OF EVIDENCE: NA.

FACE-Q Eye Module for Measuring Patient-Reported Outcomes Following Cosmetic Eye Treatments.

IMPORTANCE: Aesthetic eye treatments can dramatically change a person's appearance, but outcomes are rarely measured from the patient perspective. The patient perspective could be measured using an eye-specific patient-reported outcome measure. OBJECTIVE: To describe the development and psychometric evaluation of FACE-Q scales and an adverse effect checklist designed to measure outcomes following cosmetic eye treatments. DESIGN, SETTING, AND PARTICIPANTS: Pretreatment and posttreatment patients 18 years and older who had undergone facial aesthetic procedures were recruited from plastic surgery clinics in United States and Canada and completed FACE-Q scales between June 6, 2010, and July 14, 2014. We used Rasch Measurement Theory, a modern psychometric approach, to refine the scales and to examine psychometric properties. MAIN OUTCOMES AND MEASURES: The FACE-Q Eye Module, which has 4 scales that measure appearance of the eyes, upper and lower eyelids, and eyelashes. Scale scores range from 0 (worst) to 100 (best). The module also includes a checklist measuring postblepharoplasty adverse effects. RESULTS: Overall, 233 patients (81% response rate) 18 years and older participated. Adverse effects included being bothered by eyelid scars, dry eyes, and eye irritation. In Rasch Measurement Theory analysis, each scale's items had ordered thresholds and good item fit. Person Separation Index and Cronbach α were greater than or equal to 0.83. Higher scores on the eye scales correlated with fewer adverse effects (range, -0.26 to -0.36). In the pretreatment group, older age correlated with lower scores (range, -0.42 to -0.51) on the scales measure appearance of the eyes and upper and lower eyelids. Compared with the pretreatment group, posttreatment participants reported significantly better scores on the scales measuring appearance of eyes overall, as well as upper and lower eyelids. CONCLUSIONS AND RELEVANCE: The FACE-Q Eye Module can be used in clinical practice, research and quality improvement to collect evidence-based outcomes data. LEVEL OF EVIDENCE: NA.

Self-esteem, Self-efficacy, and Appearance Assessment of Young Female Patients Undergoing Facial Cosmetic Surgery: A Comparative Study of the Chinese Population.

IMPORTANCE: The psychological traits of cosmetic surgery patients (CSP) are important for selecting patients and postoperative patient satisfaction. A patient's self-esteem, self-efficacy, and self-assessment affect his or her motivation for cosmetic surgery, but the association among these traits remains unclear, especially in the Asian population. OBJECTIVE: To clarify the association of a patient's psychological traits, decision to undergo cosmetic surgery, and the effectiveness of facial cosmetic surgery on the psychological conditions of young, female Chinese patients. DESIGN, SETTING, AND PARTICIPANTS: Three different groups of young women (aged 18-30 years) from the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and 7 universities were enrolled from January 1, 2012, through December 31, 2014: CSPs (n = 161), general population controls (GPCs) (n = 355), and facial appearance raters (FARs) (n = 268). The last date of follow-up was January 20, 2015. Patient data from questionnaires were obtained preoperatively and 6 months postoperatively, and the data from the control groups were obtained immediately after enrollment. Front-view facial images of the study participants were taken and then shown to independent raters to assess the participants' facial appearances on a rating scale. MAIN OUTCOMES AND MEASURES: Evaluation of self-esteem and self-efficacy, subjective and objective assessment of facial appearance, and structural equation models. RESULTS: A total of 163 CSPs and 387 GPCs were recruited for the study, and complete and valid data were obtained from 161 CSPs and 355 GPCs. All responses from the 268 FARs met the criteria for subsequent analysis. Of the questionnaires issued to the CSPs 6 months postoperatively, 126 valid responses were returned (response rate, 78.3%). Self-esteem and self-efficacy decreased significantly in preoperative patients compared with controls (P < .001) (mean [SD] scores, 22.60 [1.80] for CSPs and 27.39 [2.11] for GPCs for self-esteem and 21.50 [2.40] for CSPs and 28.59 [4.23] for GPCs for self-efficacy) and were found to be at nearly normal levels 6 months postoperatively (mean [SD] scores, 25.88 [3.65] and 26.38 [2.45] for self-esteem and self-efficacy, respectively). The patients' objective assessments of facial appearance did not differ significantly from those of the control group participants (mean [SD] scores, 4.51 [0.77] and 4.55 [0.74] for CSPs and GPCs, respectively; P = .86); however, a significant decrease in patient self-assessment was noted (mean [SD scores], 6.45 [1.15] and 7.31 [1.42] for CSPs and GPCs, respectively; P = .01). Moreover, the structural equation models revealed a path from low self-esteem and self-efficacy after decreased self-assessment to decision for cosmetic surgery. CONCLUSIONS AND RELEVANCE: Self-esteem and self-efficacy mediate the negative effects of self-assessment on the decision of young women to undergo facial cosmetic surgery. The impairment of self-esteem and self-efficacy may indicate the need for preoperative psychological intervention. Facial cosmetic surgery can have positive effects on self-esteem and self-efficacy. LEVEL OF EVIDENCE: 2.

Long term patient-reported benefit from ptosis surgery.

PURPOSE: To assess the long term impact of ptosis surgery on health-related quality-of-life using the Glasgow Benefit Inventory (GBI) patient-reported outcome measure. PATIENTS AND METHODS: A retrospective case note review was carried out on all patients who had undergone ptosis surgery (6 November 2008 to 5 December 2010) by one surgeon at Royal Bournemouth Hospital. Patient demographics, surgical technique, and complications were recorded. The GBI questionnaire data was obtained by telephone interview. RESULTS: A total of 62 ptosis operations (33 right, 29 left, of which 18 were bilateral) on 44 patients; 20 male, 24 female were included. Median age 77 years (range: 17-95 years). One wound dehiscence occurred, but no redo ptosis procedures were required. GBI data was obtained on 32 patients (45 ptosis procedures) at a mean follow-up period of 42.8 months postoperatively (range 31-67 months). The mean total GBI score for ptosis surgery was +21.36 (range 0-58.33; 95% confidence interval: 17.28-25.43, P<0.05). CONCLUSION: Patients derived a highly significant benefit to their health-related quality-of-life from ptosis surgery measured by the GBI that was maintained for up to 5 years.

Self-mutilation by a patient with borderline personality disorder.

UNLABELLED: We present an unusual insatiable aesthetic/plastic surgery patient with borderline personality disorder (BPD) who removed her upper eyelids by herself after we rejected her request for revision blepharoplasty. This impulsive self-injury was attributed to anxiety from what the patient considered to be abandonment by the surgeon. Even after the eyelid defects were successfully treated, the patient requested several other revisions, including tattoo removal. Compared with other mental disorders, including body dysmorphic disorder, preoccupation with appearance in BPD is less profound and shifts from one body part to another. In an aesthetic and plastic surgery practice, a different psychiatric approach should be used for individuals with BPD, and the proper timing for a psychiatric referral should be established. 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 .

Transconjunctival lower blepharoplasty: a 2-sided assessment of results and subjects' satisfaction.

PURPOSE: To assess the results and satisfaction after transconjunctival lower blepharoplasty, evaluate the effect of associated aesthetic procedures on the satisfaction, and compare surgeon versus subjects' perspective on the results. METHODS: In a retrospective cross-sectional study, a chart review was performed on transconjunctival lower blepharoplasty procedures performed by 1 eye plastic surgeon from April 2003 to April 2009. Subjects with less than 6 months follow-up time or reoperation were excluded. Demographic data, associated surgical procedures, intra and postoperative complications, subjects and surgeon's perspectives on postoperative results, photographs (before and after the operation), and satisfaction score (Visual analogue scale score) at last follow-up time were recorded. RESULTS: There were 164 subjects (133 women, 81.1%) with mean age of 50.7 years (standard deviation=11.6, range: 23-80). Mean follow-up time was 22.8 months (standard deviation=11.5, range=6-60 months). Complications, observed by the surgeon and subjects, were undercorrected fat excision (4.9% vs. 3.7%), eyelid retraction (1.2% vs. 1.2%), and tear trough deformity (9.7% vs. 0.6%). Subjects reported less complication rate (5.4%) than surgeon (15.8%). Mean visual analogue scale score was 92.8 (standard deviation=0.36), which was significantly higher in subjects who had simultaneous upper blepharoplasty and lower in subjects with postoperative eyelid retraction. CONCLUSIONS: Transconjunctival lower blepharoplasty is associated with a high satisfaction. Subjects reported less complication rate than surgeon especially for tear trough deformity. Postoperative eyelid retraction significantly decreased and simultaneous upper blepharoplasty procedure significantly increased the satisfaction.

[Faults and failure: aesthetic rhinoplasty plus brow, eyelid and conchal surgery]. / Fehler und Gefahren: Die ästhetische Rhinoplastik sowie Brauen-, Lid- und -Ohrmuschelkorrektur.

Within the last years aesthetic surgery enjoys greater popularity and acceptance. One of the most frequently asked operations has been the aesthetic rhinoplasty. Hardly any other field of surgery is exposed to such a critical analysis than aesthetic rhinoplasty because the results are so obvious. According to the "International Society of Aesthetic Surgery" (ISAPS) over 980 000 cosmetic rhinoplasties have been performed in 2010. This corresponds to 10.4% of all registered aesthetic procedures worldwide. Complications can not be eliminated in such a large number of nasal operations. Up to 15% of all patients re-consult a doctor for a revision because they are dissatisfied with their final rhinoplasty result. Findings of the tip followed by functional problems and irregularities of the nasal dorsum are named most frequently. The responsible rhinosurgeon has to regard all anatomical and physiological details and to consider ethical and psychological aspects in the preselection and postoperative care of the patient. Aesthetic surgeons should be acquainted with terms and definitions like body image, dysmorphophobia or Thersites complex. Acronyms, like "SIMON" or "SYLVIA", support the physician additionally to analyze and assess the patient. The following article describes the most frequent faults, complications and pitfalls after aesthetic rhinoplasty listed by the anatomical structure. Results will be analyzed, strategies and techniques will be suggested to correct the faults and to prevent them in the future. Furthermore psychologic, social and psychiatric aspects will be discussed and handling with aesthetic patients explained.

Effect of lower blepharoplasty on self-esteem.

BACKGROUND: Cosmetic surgery is an increasingly common medical procedure whose benefits to patients have not been quantified objectively. Although physicians historically have focused on minimizing side effects and optimizing the physical outcome, a broad spectrum of patient needs also factors in treatment success. Unfortunately, few data are available regarding the effects of cosmetic procedures on patient's self-esteem. OBJECTIVE: To prospectively examine long-term self-esteem outcomes for patients undergoing lower blepharoplasty at São Paulo Federal University between April 2005 and May 2007. METHODS: The self-esteem of 50 patients undergoing blepharoplasty at São Paulo Federal University was compared with that of 25 age-matched volunteers from the general population. The parameters of the Rosenberg Self-Esteem Scale (RSES) were determined preoperatively and at 6-month intervals postoperatively. The data from the instrument were analyzed using the Wilcoxon test. RESULTS: Self-esteem scores improved from a baseline preoperative mean level+/-standard deviation of 5.1+/-4.1 to 3.6+/-3.5 6 months after surgery (p=.001). The self-esteem of 31 (62%) subjects improved after the surgery. CONCLUSION: Marked improvement in self-esteem, evaluated using RSES at 6-month follow-up, was observed in patients undergoing blepharoplasty.

Patients' perspectives on the ocular symptoms of facial paralysis after gold weight implantation.

SUMMARY: Upper lid loading for the treatment of lagophthalmos resulting from facial paralysis is a simple and effective procedure with relatively few side effects and complications. A detailed patient-based self assessment, focusing on subjective complaints after upper lid weight implantation is scarce. In this study, a population of facial palsy patients with lid weights is asked about their subjective complaints in order to find out the patients' point of view. Patients with upper lid weights were asked questions indicating the degree of soreness, tearing, redness, visual acuity, lid closing during the day, lid closing during sleep, aesthetic appearance, artificial tear utilisation and outdoor comfort. All questions were evaluated by an analogue scale in reference to the opposite eye, where a score of '10' corresponds to the best outcome (no symptoms at all or appearance comparable to the contralateral eye) and a score of '1' corresponds to the worst outcome. Thirty patients filled in the questionnaire and 22 of them were seen in the outpatient clinic. The most pleasing result was obtained in the lid closing during the day (score 8.8+/-1.9), during sleep (7.7+/-3.0) and in the aesthetic appearance of the eye (score 7.6+/-2.7), whereas visual acuity received the lowest score (score 5.7+/-1.5). Complication and re-operation rates were 23% and 13%, respectively. In conclusion, upper lid weights solve the problem they are used to address. They provide a satisfactory lid closure and aesthetic appearance in the patients' point of view. However, the ocular symptoms of facial paralysis still persist to some extent and the procedure is not without its complications.

The vertical midface lift. An improved procedure.

We describe a novel procedure for an anatomically-based face lift to correct vertical vectors in the ageing face. It has the advantage of surgical simplicity, minimal tissue removal and minimal risk. It provides an effective readjustment of cheek volume and correction of periorbital hollowness. Natural facial expression is preserved largely because there is no change in the position of the lateral canthus. The cheek is mobilised subperiosteally through a blepharoplasty incision. A second dissection is made via a short temporal incision, to join the infraorbital dissection. A Hagedorn needle is then inserted through a point inferior to the lateral canthus and in line horizontally with the nasal ala. It is passed to the orbital incision, charged with a loop of suture material, and pulled down again to the cheek incision, from where it is pushed back to the orbit to suspend the cheek. The upper border of orbicularis oculi is fixed firmly to the temporalis aponeurosis at the level of the temporal incision. We now frequently use an Endotine Midface device for fixation. Of the first 150 patients, results were excellent or good in 145. This represents a revival of the subperiosteal mask lift, and abandons the use of endoscopic techniques. In spite of its simplicity, the operation involves subperiosteal dissection as well as delicate eyelid surgery that necessitate plastic surgical skill.