Anatomical study of the extraocular check ligament system.

AIM: To clarify the gross anatomy structure of the check ligament of the palpebra superior in relation to congenital blepharoptosis operation. METHOD: Seven fixed and three fresh cadavers of Chinese adults (between 53 and 76 years old; 5 males and 5 females) were used. Gross dissection was performed on fourteen eyes in seven cadavers. In three fixed cadavers, six bulbus oculi received histological sections for immunohistochemical tests. RESULT: Below the levator upon the superior rectus, the check ligament described by Lockwood is found. It extends bilaterally and attaches to the orbital wall behind the inner and lateral canthus tendon. Between the inferior obliquus and the inferior rectus, we also found a sheath structure similar to the check ligament extending bilaterally to the orbital wall. These two structures form an annular fascial system surrounding the eyeball. The medial half of the fascial sheath is tenacious, and the immunohistochemical test proves that smooth muscle cells are found in this part. CONCLUSION: We call this whole fascial sheath surrounding the circumocular muscle the Extraocular Check Ligament System (ECLS), and it plays a restricting and checking role in the movement of the eyeball. Surgeons should be aware of the ECLS when performing ptosis or other blepharal surgery.

Transconjunctival Müller's muscle Tucking Method for Non-incisional Correction of Mild Ptosis: The Effectiveness and Maintenance.

BACKGROUND: In patients with a mild degree ptosis who undergo non-incisional double-eyelid blepharoplasty, simultaneous correction of ptosis is needed to prevent loosening. The transconjunctival Müller's muscle tucking (TMMT) method may be useful in these cases. OBJECTIVES: The authors performed this study to present the details of the current use of the TMMT method and to provide objective evidence for ptosis correction and its sustained effect. METHODS: A total of 322 eyelids in 161 patients who underwent mild ptosis correction with the TMMT method from July 2012 to December 2017 were retrospectively examined. The continuous suture method using a single stitch was used for double-fold formation, and the TMMT method was used for ptosis correction for the other incision. The margin to reflex distance (MRD) 1 was evaluated at pre-operation, immediate post-operation, and at 2, 6 months post-operation. RESULTS: A total of 34 patients who had more than 6 months of follow-up were included. Right-side MRD1 values were 2.08 (± 0.19) mm before the surgery, 3.49 (± 0.16) mm immediately after the surgery, 3.33 (± 0.14) mm at postoperative 2 months, and 3.22 (± 0.17) mm at postoperative 6 months (p < 0.001). The difference of MRD1 between immediate post-operation and at 6 months was 0.25 mm without statistical significance (p > 0.05). Complications (fold loosening, asymmetry, and ptosis recurrence) occurred in three cases (8.8%), all of which were re-corrected by applying the TMMT method. CONCLUSIONS: The TMMT method was useful for correction of mild ptosis, showed little recurrence, and prevented loss of fold by giving a vertical force to the double-fold. 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 .

Physiological correction of mild to moderate congenital blepharoptosis: A retrospective cohort study involving 97 Eastern Asian patients.

BACKGROUND: Conventional blepharoptosis repair methods distort the normal anatomy of levator aponeurosis and often cause a visible depressed scar in the upper eyelid. METHODS: The levator aponeurosis was dissected as a flap from the pretarsal tissue in mono-eyelid Asian patients who had mild to moderate congenital blepharoptosis. The flap base was advanced and repositioned on the tarsus. The margin of the distal flap was interposed and fused with orbicularis oculi muscles. Postoperative evaluation included ptosis correction, symmetry, and overall cosmetic outcomes. RESULTS: A total of 162 eyes on 97 patients were corrected using our method. Follow-up time ranged from 8 to 24 months (mean 12.4). In mild ptosis eyelids, out of 58 eyelids, 36.2% (21 eyelids), 56.9% (33), and 6.9% (4) required adequate correction, normal correction, and undercorrection, respectively, whereas in moderate ptosis, the results were 34.6% (36 eyelids), 53.9% (56), and 11.5% (12), respectively. For symmetry, 58.8% (57 cases), 32.0% (31), and 9.2% (9) resulted in good, fair, and poor outcomes, respectively. For cosmetic outcomes, 82.8% (48 eyelids), 15.5% (9), and 1.7% (1) of mild ptosis cases achieved good, moderate, and poor results in mild ptosis cases, whereas the results were 77.9% (81 eyes), 20.2% (21), and 1.9% (2), respectively, in moderate ptosis cases. The only complication among all cases was postoperative swelling. CONCLUSIONS: We presented a new blepharoplasty for ptosis repair that allows both satisfactory ptosis correction and cosmetic outcomes in mild to moderate congenital blepharoptosis.

The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population.

BACKGROUND: Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype. MATERIALS AND METHODS: The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity. RESULTS: During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88 years were enrolled in the research (mean = 57.73 ± 13.41 years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40 years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40 years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction. CONCLUSIONS: Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40 years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD1 reduction among all subtypes of blepharoptosis. 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 .

Lowering of the High Eyelid Crease in Revision Upper Eyelid Surgery.

BACKGROUND: High placement of the lid crease is a common complication in upper eyelid surgery. Correction of the high crease by revision surgery is challenging and has not been well-reported. METHODS: This is a retrospective interventional study of patients who underwent revision eyelid surgery with lowering of the lid crease from 2008 to 2016 at a tertiary institution. Main outcome measures were pretarsal show (PTS) distance, lid crease symmetry, margin reflex distance 1 (MRD1), and lid height symmetry. Lid crease symmetry was graded as symmetrical, mild asymmetry (PTS difference ≤ 0.5 mm), moderate asymmetry (PTS difference > 0.5 mm but ≤ 1 mm), or obvious asymmetry (PTS difference > 1 mm). Lid height symmetry was graded as symmetrical, mild asymmetry (MRD1 difference ≤ 1 mm), moderate asymmetry (MRD1 difference > 1 mm but ≤ 2 mm), or obvious asymmetry (MRD1 difference > 2 mm). RESULTS: There were a total of 69 patients and 100 eyes. The majority (n = 42, 60.9%) of patients were females. The mean age was 38.3 ± 17.3 years, and mean follow-up was 16 months. Mean PTS decreased from 3.1 mm pre-surgery to 2.0 mm 2 years post-surgery. The proportion of patients with moderate or severe lid crease asymmetry decreased from 81.1% pre-surgery to 6.7% 2 years post-surgery. The mean MRD1 difference decreased from 1.54 mm pre-surgery to 0.23 mm 1 year post-surgery. The proportion of patients with moderate or severe lid height asymmetry improved from 64.5% preoperatively to 4.5% 1 year postoperatively. CONCLUSION: Revision eyelid surgery to correct a high crease is a challenging procedure. We present a technique that is effective in correcting the high lid crease, while simultaneously improving the lid height and lid crease symmetry. 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 .

Incisional Ptosis Correction with Hidden Double Fold in Asian Patients.

BACKGROUND: Korean males and a few females desire to have larger eyes; however, they often wish to enlarge their eyes and conceal their double eyelids. This paper attempts to describe how to make the eyes bigger and brighter without showing double-fold eyelids. METHODS: The authors performed cosmetic ptosis correction in 121 cases from April 2013 to December 2017. All patients enrolled in this retrospective study underwent surgical procedures at the author's institutions. Patients were included that had mild-to-moderate degrees of ptosis and levator function greater than 5 mm, ages greater than 16 years, and no prior ptosis surgery. RESULTS: A successful outcome was achieved with this surgical approach in 113 (93.4%) patients. Complications potentially associated with ptosis surgery were not observed. DISCUSSION: A refined method of preoperative evaluation for incisional ptosis correction to conceal a double fold with no visible signs of surgery is described. Ptosis correction without the formation of double eyelids will result in skin hooding and visible scarring, and thus, it is recommended to lower the height of the double eyelids. The lower height of double eyelids can cover the incisional scar and make it appear there are no double eyelids. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasound biomicroscopy image patterns in normal upper eyelid and congenital ptosis in the Indian population.

PURPOSE: To study the features of upper eyelid in healthy individual and different types of congenital ptosis in the Indian population using ultrasound biomicroscopy (UBM). METHODS: This was a prospective observational study at a tertiary care center. Eyelid structure of healthy individuals with no eyelid abnormalities (n = 19); simple congenital ptosis (n = 33) cases; Marcus Gunn jaw-winking ptosis (MGJWP, n = 7) cases, and blepharophimosis-ptosis-epicanthus inversus syndrome (BPES, n = 20) cases were studied on a vertical UBM scan using 50-MHz probe. Lid-thickness, tarsal-thickness, orbicularis oculi and levator-Muller-orbital septum-conjunctival (LMSC) complex were measured in primary gaze. Comparison was made between four groups and results were statistically analyzed using ANOVA test. In normal individuals, LMSC measurements were repeated in down-gaze imaging. RESULTS: Skin with subcutaneous tissue, LMSC complex and pre-aponeurotic fat-pad appeared echodense while orbicularis oculi and tarsus appeared echolucent. In primary gaze, mean thickness (± standard deviation) of the eyelid, tarsus, orbicularis oculi and LMSC, respectively, were: 1.612 ± 0.205, 0.907 ± 0.098, 0.336 ± 0.083, and 0.785 ± 0.135 mm in normal individual. LMSC showed 46.64% increase in thickness on down-gaze. The mean eyelid thickness and LMSC were thicker in MGJWP and BPES as compared to normal. In different types of congenital ptosis cases, various patterns of UBM imaging were observed. CONCLUSION: UBM allows noninvasive imaging of eyelid structures with good anatomical correspondence in normal eyelids and study the structural alterations of eyelids in different types of congenital ptosis. UBM can be used to highlight the anatomical difference in normal eyelids that may help modify the surgery for better cosmetic outcomes. Furthermore, it has the potential to be used in preoperative evaluation and operative planning in certain types of acquired ptosis, which needs to be evaluated.

Measurement of the Area of Corneal Exposure Using Digital Image and Its Application During Assessment for Blepharoplasty.

BACKGROUND: The normal morphological and functional values of orbits vary according to race, sex, and age. We measured the palpebral fissure using the marginal reflex distance (MRD1), marginal limbal distance (MLD), and vertical height of the palpebral fissure (VHPF). Unfortunately, these measurements are all one-dimensional figures that measure the distance between two points; they have limitations when it comes to measuring the three-dimensional ocular surface. Therefore, this study used the area of corneal exposure (ACE), which shows a two-dimensional area, to measure changes between the sizes of eyes according to age. MATERIALS AND METHODS: This study was conducted using preoperative photographs of Koreans in Daegu city, Korea, who underwent plastic surgery in our department except for eyelid surgery. We divided the subjects into eight groups, including ten males and ten females in each decade of age, from age 10 to over 80 years. A total of 160 people were recruited who were followed up for photograph analysis using Adobe Photoshop 7.0 software. RESULTS: In terms of the mean value, the ACEs were 73.3 ± 2% in male subjects and 77.1 ± 2% in female subjects, and values for female subjects were greater than those for male subjects (p < 0.05). Significant differences in ACEs were observed according to age. The peak level of growth in the ACE was reached between 20 and 29 years of age. After the 20 s, a gradual decrease was observed (p < 0.05). CONCLUSION: The peak level of growth in the ACE was reached between 20 and 29 years of age. The growth pattern can be classified as continuously decreasing after reaching the peak level. The data from this study are significant in that they can be used as comprehensive data for normal eyelid values according to age. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Measurement of Palpebral Fissure Height Using the Intersection Angle (the Réal Angle) Between the Meeting Points of the Upper Eyelid and the Edge of the Cornea.

BACKGROUND: We evaluated a new palpebral fissure height measurement to evaluate medial, lateral, and overall ptosis. METHODS: We photographed 250 Koreans (44 males, 206 females) and evaluated their Réal 1 angle (angle between the meeting points of the upper eyelid and the corneal edge), Réal 2 angle (angle between the meeting point of the upper eyelid, medial corneal edge and a vertical line through the center of the pupil), Réal 3 angle (angle between the meeting point of the upper eyelid, lateral corneal edge and a vertical line through the center of the pupil), and Réal 4 angle (Réal 2-Réal 3). Angles were compared between sexes and age groups. We then evaluated the Réal angles of 13 Korean actresses. RESULTS: Mean age was 31.85 ± 14.60 years; Réal 1 was 129.01° ± 14.23°, Réal 2 was 68.20° ± 7.49°, Réal 3 was 60.80° ± 9.65°. There was no significant difference between the sexes in Réal 1, Réal 2, and Réal 3 angles. Réal 1 increased with age, and Réal 4 decreased with age. All Réal angles were significantly different between age groups. The actresses' mean age was 30.66 ± 8.01 years; Réal 1 was 102.84° ± 10.16°, Réal 2 was 57.87° ± 6.10°, and Réal 3 was 44.97° ± 8.74°. CONCLUSION: This simple measurement of palpebral fissure height using Réal angles consistently evaluated the amount of medial, lateral, and general ptosis. For average Korean eyes, the lateral portion of the upper eyelid is slightly higher than the medial portion; however, this lateral portion droops with age. Korean actresses have vertically higher eyes than average Korean women. 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 .

Obesity as a Potential Risk Factor for Blepharoptosis: The Korea National Health and Nutrition Examination Survey 2008-2010.

PURPOSE: To examine obesity parameters as potential risk factors associated with blepharoptosis in a representative Korean population. METHODS: We analyzed the Korea National Health and Nutrition Examination Survey (KNHANES), conducted between 2008 and 2010. 10,285 Korean adults (4,441 men and 5,844 women) aged 40 years or older was enrolled. We compared body mass index (BMI), waist circumference (WC) and percentage body fat (BF), according to the severity of blepharoptosis. Multiple logistic regression analysis was conducted to examine the associations of each obesity parameter with blepharoptosis. RESULTS: The overall prevalence of age-related blepharoptosis was 14.8 % in South Korea. There were significant and graded associations between increasing blepharoptosis severity and the mean value of obesity parameters (P for trend < 0.05). As marginal reflex distance 1 (MRD1) decreased, the prevalence of general obesity and overweight status increased (P for trend=0.121 in men and < 0.001 in women); the prevalence of abdominal obesity increased (P for trend < 0.001 for both genders); the prevalence of highest quartile of percentage BF increased (P for trend ≤0.001 for both genders). Blepharoptosis was significantly associated with general obesity in women (adjusted odds ratio (aOR), 2.14; 95% confidence intervals (CI), 1.32-3.47); and with the highest quartile of percentage BF in men (aOR, 2.01; 95% CI, 1.34-2.97) and in women (aOR, 1.52; 95% CI, 1.06-2.3317, after adjusting for age, smoking exercise, drinking alcohol, total energy intake, fat intake, total cholesterol, and high density lipoprotein cholesterol, diabetes, hypertension, and family history of eye disease. CONCLUSIONS: The etiology of age-related blepharoptosis may be multifactorial and is unclear. Our results suggest that obesity parameters such as BMI, WC and percentage BF might be potential risk factors for age-related blepharoptosis in a representative Korean population.

Distinct features in Koreans with involutional blepharoptosis.

BACKGROUND: The authors intended to present the distinct characteristics in Korean patients with involutional ptosis that deviate from typically defined features. METHODS: This is a prospective observational study of 162 Korean patients with involutional ptosis. The patients underwent levator aponeurosis advancement surgery from January of 2006 to June of 2013. Patient characteristics including eyelid crease, palpebral fissure width, levator function, and the shape and condition of the levator muscle and aponeurosis were assessed. RESULTS: Of 279 total eyes in 162 patients, high eyelid crease and levator aponeurosis disinsertion from the tarsal plate were observed in 19.7 percent and 13 percent of the eyes, respectively. Moderate to severe fat tissue infiltration on the levator muscle was noted in 90.6 percent of the eyes. Patients were older (p = 0.002) and the eyelid drooping was more severe (p < 0.001) in cases with more fat infiltration. Levator function was inversely proportional to the degree of fat tissue infiltration (p = 0.037). CONCLUSION: Slightly decreased levator function, infrequent high eyelid crease occurrence, thick and puffy eyelids, low incidence of levator aponeurosis disinsertion from the tarsal plate, and prominent fatty infiltration on the levator muscle are distinct and unique characteristics of involutional ptosis in Korean patients.

Oxidative stress in the levator aponeurosis in Asian involutional blepharoptosis.

PURPOSE: To analyze the histopathology and expression of 8-hydroxydeoxyguanosine (OHdG), a marker of oxidative stress, in the levator aponeurosis tissues of involutional aponeurotic and congenital blepharoptosis patients, and adult subjects with no history of blepharoptosis. METHODS: Fourteen and 4 levator aponeurosis tissues obtained from Asian patients with involutional and congenital blepharoptosis and 3 normal adult tissues were examined. All tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and then submitted for hematoxylin and eosin staining and immunohistochemistry with anti-8-OHdG antibody. RESULTS: The levator aponeurosis tissues contained spindle smooth muscle fibers and striated muscles. Nuclear immunoreactivity for 8-OHdG was noted in striated and smooth muscle cells in all the tissues. The 8-OHdG-positive rate was significantly lower in congenital blepharoptosis than involutional blepharoptosis (p < 0.05). Moreover, the number of 8-OHdG-positive striated muscle cells was significantly higher in the involutional blepharoptosis than normal tissues (p < 0.05). In contrast, there was a rare positive 8-OHdG-immunoreactivity of smooth muscle cells in the aponeurotic tissues of the involutional blepharoptosis patients. CONCLUSIONS: Levator aponeurosis in involutional aponeurotic blepharoptosis tissues showed oxidative stress in the muscle, indicating that oxidative stress plays a potential role in the pathologic study of the disease.

Adjunctive techniques to traditional advancement procedures for treating severe blepharoptosis.

BACKGROUND: To create a more physiologic eyelid opening in patients with severe blepharoptosis, the authors used lamina propria mucosa of conjunctiva, which continues to the check ligament of the superior fornix, in addition to levator aponeurosis and Müller's muscle as a composite flap. In patients with epicanthal folds with associated telecanthus, the authors also performed epicanthoplasty with medial canthal tendon shortening. METHODS: Fifty blepharoptosis patients (85 eyelids) with a degree of ptosis of greater than 4 mm underwent the advancement technique using the levator aponeurosis-Müller's muscle-lamina propria mucosa of conjunctiva as a composite flap. Twenty-one (42 percent) of those patients also underwent split V-W epicanthoplasty and plication of the medial canthal tendon for epicanthal folds with associated telecanthus. Degree of ptosis and levator function were measured preoperatively and postoperatively. RESULTS: Complete or near-complete correction of ptosis (degree of ptosis, <1 mm) was achieved in 54 eyelids (63.5 percent) and mild residual ptosis (degree of ptosis, 1 to 2 mm) was observed in 22 eyelids (25.9 percent) in postoperative follow-up after 6 months. The most common complication was reoperation, which was done in 15 eyelids (17.6 percent) because of incomplete correction. CONCLUSIONS: The advancement technique using the levator aponeurosis- Müller's muscle-lamina propria mucosa of conjunctiva composite was effective in the treatment of severe blepharoptosis with levator function of 2 to 7 mm. The technique produced elevating motion of the physiologic eyelid in a superior-posterior direction. There were no serious complications, such as long-term lagophthalmos or lid lag. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ten years' experience with unilateral conjunctival mullerectomy in the Asian eyelid.

BACKGROUND: The purpose of this study was to report 10 years of experience with unilateral conjunctival mullerectomy in the Asian eyelid. METHODS: Medical records of patients with unilateral ptosis who underwent conjunctival mullerectomy performed by a single surgeon from January of 2001 to December of 2011 were reviewed. The following factors were investigated: preoperative marginal reflex distance-1 of the ptotic and contralateral normal eyelids, levator function, and preoperative marginal reflex distance-1 after instillation of 2.5% phenylephrine of the ptotic eye. Main outcome measures were the surgical success rate of conjunctival mullerectomy, comparison of preoperative factors according to surgical results, and the results of univariate and multiple logistic regression analyses to identify the factors associated with undercorrection of conjunctival mullerectomy. RESULTS: Of a total of 64 eyes (64 patients), 53 eyes (82.8 percent) showed surgical success, two eyes (3.1 percent) showed overcorrection, and nine eyes (14.1 percent) showed undercorrection. The mean preoperative marginal reflex distance-1 difference between both eyes was 2.20 mm in the undercorrection group and 1.40 mm in the surgical success group (p = 0.001). The percentage of patients in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid was 88.9 percent (eight of nine eyes) in the undercorrection group, and 28.3 percent (15 of 53 eyes) and 0 percent (zero of two eyes) in the surgical success and overcorrection groups, respectively (p = 0.001). Multiple logistic regression analysis showed that patients in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid were associated with an increased risk of undercorrection after conjunctival mullerectomy (OR, 10.740; 95 percent confidence interval, 1.098 to 15.431; p = 0.041). We observed 0.18 ± 0.08-mm lid elevation per 1 mm of conjunctival mullerectomy. CONCLUSIONS: Conjunctival mullerectomy can be successfully performed to correct unilateral ptosis in the Asian eyelid in 82.8 percent of patients. Patients with greater degrees of preoperative ptosis and those in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid have a higher possibility of undercorrection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Combined epicanthoplasty and blepharoptosis correction in Asian patients.

BACKGROUND: In ptosis surgery, not addressing the epicanthal fold leaves a persistent rounded nasal scleral triangle, which blunts the effect of ptosis repair and leads to patient dissatisfaction. To achieve satisfactory results, epicanthoplasty is usually performed with ptosis correction. Furthermore, surgeons usually choose epicanthoplasty methods based on personal preference, and no guideline exists for selecting optimal methods. The aim of this study was to demonstrate the usefulness of a concomitant procedure (ptosis correction and epicanthoplasty) and to provide recommendations for the selection of epicanthoplasty. METHODS: The medical records of 99 patients that underwent simultaneous ptosis correction and epicanthoplasty from September of 2003 to January of 2011 were reviewed. Differences between preoperative and postoperative interepicanthal distances were analyzed by using patient photographs, and interepicanthal distance changes were evaluated for each epicanthoplasty. RESULTS: Epicanthoplasty was performed in the 99 patients using elliptical excision epicanthoplasty in 24 cases, periciliary epicanthoplasty in 12 cases, half-Z epicanthoplasty in eight cases, and V-W epicanthoplasty in 55 cases. Some changes in interepicanthal distances were observed after epicanthoplasty. Interepicanthal distance changes depended on the method used (elliptical excision epicanthoplasty, 3.1 mm; half-Z epicanthoplasty, 4 mm; periciliary epicanthoplasty, 5.3 mm; and V-W epicanthoplasty, 5.4 mm). The greatest differences between preoperative and postoperative interepicanthal distance values were found for periciliary and V-W epicanthoplasty, and these differences were statistically significant. No revision operations were conducted, and most patients were satisfied with results. CONCLUSIONS: In general, concurrent ptosis and epicanthus should be corrected to provide optimal cosmetic benefit. Periciliary or V-W epicanthoplasty is indicated when epicanthal folds are severe. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ocular surface area changes after double eyelidplasty.

INTRODUCTION: Double eyelidplasty is one of the most common cosmetic surgeries in Asia. Subjective enlargement of the ocular surface area (OSA) after double eyelidplasty was appreciated by patients. Objective measurement of the OSA provides a more scientific result. We introduce a relatively precise method, using iris as a scale combined with the digital photography and software calculation, to measure the OSA before and after double eyelidplasty. MATERIALS AND METHODS: One hundred and nineteen patients (108 females and 11 males) were enrolled in this study. Ninety-two patients received minimally invasive double eyelidplasty without other procedures and 27 patients received medial epicanthoplasty with modified Z-plasty besides double eyelidplasty. Digital photographs of the operative eyes in all patients were obtained preoperatively and postoperatively. The image processing software we used was ImageJ (v1.43, National Institutes of Health, United States). Preoperative and postoperative OSAs were measured. The percentage of difference of the OSA between two eyes in same patient before and after the operation was calculated and compared. RESULTS: The average increase of the OSA among 238 operative eyes was 12.5 ± 8.2%. Preoperative and postoperative OSA differences between two eyes in same patients were significantly decreased after surgery. CONCLUSION: Digital photography using iris as a scale combined with software calculation is an easy and convenient method to measure the OSA; it provides quantitative information for both preoperative and postoperative evaluation. Our study revealed that double eyelidplasty not only increased OSA but also improved ocular asymmetry after surgery.

Histopathologic findings of the orbicularis oculi in upper eyelid aging: total or minimal excision of orbicularis oculi in upper blepharoplasty.

OBJECTIVE: It is well known that gradual loss of elastic fibers and skin relaxation cause the aging process, but whether changes in the orbicularis oculi muscle may contribute to the aging of the upper eyelid is not known. The aim of the present study was to use histopathologic examination to investigate whether the orbicularis oculi contributes to upper eyelid aging. METHODS: Full-thickness upper eyelids, which were removed during blepharoplasty using en bloc resection, were stained with hematoxylin-eosin and examined. Eleven patients with oriental eyelid, 14 patients with bilateral dermatochalasia, and 2 patients with facial nerve palsy and contralateral dermatochalasia were included in this study. RESULTS: Patients ranged in age from 21 to 73 years (median age, 55.8 years). Histologic results revealed that changes in the aging upper eyelid were mainly in the skin and subcutaneous layers with large masses of deranged elastic fibers in the papillary dermis, which was characterized as solar elastosis. CONCLUSIONS: Our study revealed that the entire orbicularis oculi muscle layer remained morphologically intact with aging. Moreover, our findings suggests that a minimally invasive surgical approach with muscle sparing in upper blepharoplasty in selected patients could yield good results in terms of cosmetic outcomes and upper eyelid function while minimizing postoperative complications.