Development of Clinician-Reported Outcome (ClinRO) and Patient-Reported Outcome (PRO) Measures for Eyebrow, Eyelash and Nail Assessment in Alopecia Areata.

BACKGROUND: Eyebrow and eyelash hair loss and nail damage-in addition to scalp hair loss-are important signs/symptoms of alopecia areata (AA) to patients and deserve assessment in AA clinical trials. OBJECTIVES: Our objective was to develop clinician-reported outcome (ClinRO) and patient-reported outcome (PRO) measures and accompanying photoguides to aid in the assessment of AA-related eyebrow, eyelash and nail signs/symptoms. METHODS: Iterative rounds of qualitative, semi-structured interviews were conducted with US expert dermatologists and North American patients with AA. Patients with eyebrow, eyelash and nail involvement were purposefully sampled. Interview transcripts were qualitatively analyzed. RESULTS: Dermatologists (n = 10) described eyebrow and eyelash loss as concerning for affected patients and, along with nail appearance, as deserving assessment. Dermatologist data informed the development of single item, 4-point Likert-type ClinRO and PRO measures of current eyebrow loss, eyelash loss and nail appearance and a PRO measure of eye irritation. Patients (n = 45, age 15-72 years) confirmed the importance and relevance of these signs/symptoms. Interim revision resulted in measures that were understood by and relevant to patients. Dermatologists (n = 5) and patients (n = 10, age 21-54 years) participated in the development of the eyebrow, eyelash and nail photoguides and confirmed that they included photos that appropriately represented different severity levels and were helpful to derive and standardize ratings across raters. CONCLUSIONS: The ClinRO and PRO measures for eyebrow, eyelash and nail appearance, with their accompanying photoguides and the PRO Measure for Eye Irritation provide clear and meaningful assessments of outcomes important to patients with AA.

Comparison of the efficacy and safety of using 0.01% versus 0.03% bimatoprost for the treatment of eyebrow hypotrichosis: A randomized, double-blind, split-face, comparative study.

BACKGROUND: Previous studies have proven the efficacy and safety of 0.01% and 0.03% bimatoprost for the treatment of eyebrow hypotrichosis; however, there is no comparison study between both concentrations. AIMS: To compare the efficacy and safety between 0.01% and 0.03% bimatoprost for the treatment of eyebrow hypotrichosis. PATIENTS/METHODS: This prospective, randomized, double-blind, split-face clinical study was conducted in 30 patients with eyebrow hypotrichosis. Each side of eyebrow of individual patients was randomly assigned for 0.01% and 0.03% bimatoprost, applied on each eyebrow once daily. Eyebrow density, diameter, the Global Eyebrow Assessment scale, 7-point rating scale, and patient satisfaction were evaluated. Side effects were also recorded. RESULTS: Both 0.01% and 0.03% bimatoprost significantly improved eyebrow density and diameter (P < .05), although there were no statistically significant differences in changes in eyebrow density and diameter from baseline between both concentrations (P = .96 and .84, respectively). Additionally, patients significantly preferred 0.03% bimatoprost in terms of clinical improvement and satisfaction (P = .04 and .003, respectively). CONCLUSIONS: Both 0.01% and 0.03% bimatoprost are effective and safe for the treatment of eyebrow hypotrichosis. Bimatoprost 0.03% is superior to its 0.01% counterpart, albeit without statistical significance.

Three-Dimensional Territory and Depth of the Corrugator Supercilii: Application to Botulinum Neurotoxin Injection.

This study aimed to determine the three-dimensional (3D) territory and depth of the corrugator supercilii muscle (CSM) using a 3D structured-light scanner. Thirty-two hemifaces from Korean and Thai embalmed cadavers were used in this study, and 35 healthy young Korean subjects also participated. A 3D analysis of the CSM territory and depth was performed using a structured-light 3D scanner. The most frequently observed locations of the CSM identified in the cadaver were confirmed in healthy young subjects using a real-time two-dimensional B-mode ultrasonography system. The CSM was present in all of the cadavers and healthy young subjects at the intersection point between the vertical line passing through the medial canthus and the horizontal line passing through the glabella (Point #6). The CSM was located on the medial side of the lateral limbus in most cases. The most-medial and most-lateral origin points were at depths of 5.7 ± 1.4 mm (mean ± SD) and 6.6 ± 1.4 mm, respectively; the corresponding depths of the insertion points were 5.4 ± 1.4 mm and 5.6 ± 2.1 mm, respectively. The origin and insertion points of the CSM were at similar depths. The injection depth should be around 4 mm for botulinum neurotoxin (BoNT) injections into the CSM. Point #6 could be regarded as an effective target point for managing the glabellar frown line and preventing palpebral ptosis when injecting BoNT into the CSM. Clin. Anat., 33:795-803, 2020. © 2019 Wiley Periodicals, Inc.

A morphometric study of age- and sex-dependent changes in eyebrow height and shape✰.

BACKGROUND: Rejuvenation procedures of the periorbital region and the forehead, with the eyebrow as a key structure, are often performed in plastic surgery. There is no common consent on the changes of aging in this region and the consecutive treatment options. This study was designed to support the body of literature with a broader data basis about the natural changes of eyebrow position and its shape. METHODS: The brow shape, the lid axis, and the distance between both medial canthi (DMC) were analyzed retrospectively on randomly selected standardized photographs of healthy Caucasian females and males. Six defined heights of the upper brow border, including the position and height of the highest brow point (HBP) and the angle of the upper brow line, were measured. RESULTS: A total of 244 Caucasian females and males in two groups (<34 years and >55 years) were analyzed. The data showed a difference between brow shapes of young females and males, especially relating to the HBP, which is located medially in young females. The brow shape of females assimilates toward a male shape with aging. The eyebrow moves upward, the DMC widens, and the lid axis drops laterally in both sexes with aging. CONCLUSIONS: Our data suggest that rejuvenation procedures should focus on not only lifting the brow but also reshaping and stabilizing the brow, especially the HBP, which plays an important role in defining the upper brow line. Our findings can explain why lifting the brow can create not only an undesired surprise but also an older look.

The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia.

INTRODUCTION: Alopecia areata and frontal fibrosing alopecia are common causes of eyebrow loss (madarosis). OBJECTIVE: Assessment of trichoscopic markers of eyebrow loss in alopecia areata and frontal fibrosing alopecia. MATERIALS AND METHODS: The analysis included 50 patients with scalp alopecia areata with madarosis, 50 patients with scalp frontal fibrosing alopecia with madarosis and 50 healthy controls. In every case, trichoscopy of the eyebrow area was performed. RESULTS: Empty follicular and eccrine duct openings were observed in all patients and presented predominantly as yellow dots. Exclamation mark hairs were only detected in patients with alopecia areata (30%). Tapered hairs, broken hair, black dots and Pohl-Pinkus constrictions were observed in 14%, 36%, 26% and 4% of patients with alopecia areata, respectively, 4%, 16%, 2% and 0% of patients with frontal fibrosing alopecia, respectively, and they were not present in healthy controls. Dystrophic hairs and whitish areas were observed only in patients with frontal fibrosing alopecia (28% and 32%, respectively). Eyebrow regrowth in distinct directions was present in 32% of patients with frontal fibrosing alopecia, 8% of patients with alopecia areata and 4% of healthy controls. Diffuse erythema was detected in 60% of patients with alopecia areata and frontal fibrosing alopecia and 56% of healthy controls. Vellus hairs and upright regrowing hairs were observed in patients with alopecia areata (62% and 58%, respectively), frontal fibrosing alopecia (60% and 84%, respectively) and healthy controls (100% and 100%, respectively). CONCLUSION: Trichoscopy of the eyebrow area is useful in diagnosing patients with isolated eyebrow loss. The most characteristic trichoscopic features of eyebrow loss in alopecia areata include exclamation mark hairs, tapered hairs, broken hairs and black dots. Frontal fibrosing alopecia of the eyebrows is characterized by the presence of dystrophic hairs, white areas and eyebrow regrowth in distinct directions.

Female eye attractiveness - Where beauty meets science.

INTRODUCTION: While periorbital and -ocular surgery ranks amongst the most frequently performed plastic surgical procedures, only scarce information exists regarding the contributing factors of aging and its systematic anatomic assessment. The presented study, based on measuring distinct physical landmarks, aimed to gather data to provide a foundation of in-depth periorbital analysis in order to more clearly define female eye attractiveness. METHODS: 80 probands (age range: 30-50 years, M = 38.4 ± 6.5 years) were asked to judge 60 standardized high-resolution digital pictures of female eye regions in respect to the perceived age (in years) and attractiveness (7-point Likert scale). All photographs were objectively evaluated and measured utilizing a total of 38 distinct landmarks. The data was analyzed by calculating correlations between relevant measured eye area parameters and mean attractiveness ratings including age estimations. RESULTS: Overall, it was found that several specific eye shape features correlate with attractiveness and perceived age. For instance, large visible height of the iris and large upward and lateral inclination of both eye axis and eyebrows correlated moderately to strongly with attractiveness (p < 0.05). CONCLUSION: Regarding the female eye, there exist distinct periorbital anatomic features and landmarks which contribute to a youthful appearance and attractiveness. Knowledge regarding these facts may serve as an important guideline for pre- and post-operative patient analysis.

Sonographic Diagnosis of Periorbital Dermoid Cyst.

Periorbital dermoid cysts occur mainly in children. Sonography is useful for the noninvasive, nonionizing evaluation of soft tissue lesions in infants and children without requiring sedation or anesthesia. We report the sonographic appearance of 25 periorbital dermoid cysts and identified that all are avascular oval lesions located below the aponeurotic plane. Nonaggressive bone remodeling was present in 52% of the cases. These finding in pediatric periorbital lesions are highly suspicious of a periorbital dermoid cyst.

A Rapidly Enlarging Recurrent Eyebrow Pilomatrixoma in a Nonagenarian.

A rapidly growing, large (horizontal diameter of 3.1 cm) eyebrow lesion in a nonagenarian patient was found on pathologic examination to demonstrate an admixture of islands of anucleated, washed out eosinophilic "ghost" cells with surrounding nucleated, small germinal basaloid cells. Further analysis disclosed adipophilin granular positivity in the necrotic zones, negative nuclear staining for androgen receptor and strong nuclear positivity for Ki67 in the basaloid cells (proliferation index of 50%). These findings are consistent with a highly mitotically active pilomatrixoma. The lesion recurred after initial resection but returned the same histopathologic features as the primary. Several clinical features were notably atypical for pilomatrixoma-specifically, the age of the patient, rapid lesion growth and recurrence, and clinical appearance and large size of the mass. The immunohistochemical findings can help to distinguish this tumor from other skin neoplasms, especially sebaceous carcinoma in an older individual.

Long-Term Evaluation of Eyebrow Soft Tissue Expansion in Thyroid Eye Disease.

PURPOSE: To evaluate the long-term transformation of lateral eyebrow soft tissue in a group of patients with known thyroid eye disease. METHODS: A retrospective review of all patients with a known diagnosis of thyroid eye disease with clinical photos available from both their initial diagnosis visit and at least 7 years following their initial visit was performed. Age at diagnosis, sex, disease activity, previous orbital, and eyelid surgery were noted, as was history of treatment with radioactive iodine, steroids, and external beam radiation. The area between the upper eyebrow and upper eyelid crease was evaluated in standardized photographs by a panel of 4 expert, independent, masked observers utilizing a previously published visual grading key. RESULTS: One hundred and four patients met inclusion criteria. Fifteen participants were male and 89 were female. The mean patient age was 50.6 years (±1.21 years), and the mean follow up duration was 10.0 years (±0.23 years). The mean initial photo grade (1.24) was significantly higher than the mean follow up photo grade (1.00; p < 0.01). In logistic regression analyses, only the initial photograph grade was significantly associated with improvement in eyebrow soft tissue appearance (p < 0.01). Medical and surgical treatments were not significantly associated with changes in eyebrow soft tissue appearance (all p > 0.05). CONCLUSIONS: Expansion of eyebrow soft tissue may improve over time in patients with thyroid eye disease. This change was not affected by age, sex, disease activity, surgery, or medical therapy.

Radiographic evidence of prominent retro and suborbicularis oculi fat in thyroid-associated orbitopathy.

PURPOSE: To compare the radiological differences in retro-orbicularis oculi fat (ROOF) and suborbiculars oculi fat (SOOF) among patients with thyroid-associated orbitopathy (TAO) and normal subjects using computed tomography (CT). METHODS: A retrospective analysis of orbital CTs was performed in 39 consecutive patients, who were imaged between October 2005 and June 2009. Bilateral orbital CTs of 16 patients with a final report significant for thyroid orbitopathy and 23 normal subjects were evaluated. All of the CTs consisted of 0.75 mm thick axial slices with 1.5 mm coronal reconstructions. Using the axial soft tissue windows, the ROOF and SOOF tissues were identified. The maximum ROOF thickness was measured perpendicular to the frontal bone, immediately superior to the supraorbital rim. Similarly, the maximum SOOF thickness was measured perpendicular to the zygomatic bone, immediately inferolateral to the infraorbital rim. The radiologist was blinded to the CT reports while conducting the measurements. Multivariable analysis of the two groups was then performed for comparison. RESULTS: Seventy-eight ROOF and SOOF measurements were obtained from 16 TAO patients with and 23 patients without TAO. The female-to-male ratio was 6:1 in the TAO group and only 3:2 among the normal subjects. The mean axial ROOF thicknesses was 3.8 ± 1.9 for TAO patients and 2.8 ± 1.0 mm in patients without TAO, while the SOOF thickness was 4.4 ± 1.0 and 3.4 ± 1.0 mm in the 2 groups, respectively. To account for bilateral measurements, the mixed model analysis was used. After controlling for age, gender, and ethnicity, the mean TAO ROOF and SOOF thicknesses were 1.0 mm (p = 0.04) and 0.9 mm (p < 0.01) greater than the control group, respectively. CONCLUSION: Retro-orbicularis oculi fat (ROOF) and suborbicularis oculi fat (SOOF) hypertrophy are two additional radiologic CT measurements that may be valuable in establishing the diagnosis of thyroid-associated orbitopathy.

The supraorbital keyhole approach via an eyebrow incision applied to obtain the olfactory bulb as a source of olfactory ensheathing cells--radiological feasibility study.

BACKGROUND. The purpose of the study was to test the suitability of supraorbital keyhole craniotomy with an eyebrow incision for obtaining olfactory bulb for therapeutic purposes. METHODS. Fifty three high-resolution axial head computed tomography images of patients with a mean age of 55 ± 15 years were used. The exclusion criterion was a pathology of the anterior skull base. The virtual keyhole supraorbital craniotomy was placed on each side of a three-dimensional skull model with respect to the anatomical landmarks. Trajectories of neurosurgical instrument transitions to the anterior and posterior aspects of olfactory grooves (OGs) were subsequently designed with the use of a neuronavigation planning station and measured with correction allowing the avoidance of collisions with skull base structures. Three types of anatomical configuration were divided, reflecting the extent of the correction needed to reach the bottom of OG. RESULTS. Simulation of the surgical access and consequent metrological analysis was performed on 97 skull sides - 9 (8.5%) sides were excluded due to the large frontal sinus. The mean length of the craniotomy basis was 30.71 mm, lengths of the anterior and posterior trajectories were 53.25 and 58.24 mm, respectively (p < 0.0001). In 37% of cases the value of the corrections exceeded the depth of OG. CONCLUSIONS. The supraorbital keyhole approach via an eyebrow incision may be applied to obtain the olfactory bulb as a source of olfactory ensheathing cells in over 60% of cases. Further verification and evaluation of the surgical handiness based on cadaver specimens is justifiable.

High-resolution ultrasound as an effective and practical tool to analyze eyebrow profile expansion in thyroid-associated periorbitopathy.

PURPOSE: Clinical, radiographic, and molecular studies have shown that patients with thyroid-associated orbitopathy exhibit volumetric expansion of eyebrow tissues. This clinicopathologic entity has been termed thyroid-associated periorbitopathy. The goal of this study was to determine whether high-resolution ultrasonography could be used to reliably quantify thyroid-associated periorbitopathy. METHODS: Institutional review board approval was obtained. The internal case-control study consisted of 12 subjects with unilateral-asymmetric thyroid-associated orbitopathy. High-resolution ultrasonography using a 15-MHz probe (Logiq p6) was performed by a single operator. Measurements were obtained 0.5 cm cephalad to the superior orbital rim at the midpupillary sagittal level. For each subject and tissue layer thickness (total tissue, dermis fat, retro-orbicularis oculi fat), the measured values on the less affected side were subtracted from those on the more severely diseased side. Summary statistics were used to analyze results. RESULTS: High-resolution ultrasonography effectively demonstrated asymmetric expansion of total eyebrow tissue (p < 0.0001) and retro-orbicularis oculi fat (p = 0.0003). No significant difference in dermis fat thickness was found between the 2 sides (p = 0.2). Hertel exophthalmometry measurements were statistically different between the 2 sides (p = 0.002). CONCLUSIONS: This study demonstrates that high-resolution ultrasonography independently confirms previously published studies of retro-orbicularis oculi fat expansion in patients with thyroid-associated orbitopathy. Compared with CT, MRI, and tissue biopsy, high-resolution ultrasonography is a more practical and cost-effective way to quantify and track thyroid-associated periorbitopathy over time. With its potential for real-time tissue assessment, high-resolution ultrasonography may be best suited for future studies of the dynamic relationship between globe and periorbital structures.

Ptose palpebral: avaliação do posicionamento palpebral por imagens digitais / Palpebral ptosis: evaluation of eyelid positioning using digital images

OBJETIVO: Avaliar a posição palpebral de portadores de ptose congênita e adquirida, procurando identificar diferenças entre elas. MÉTODOS: Foi realizada avaliação retrospectiva de portadores de ptose palpebral atendidos no Ambulatório de Plástica Ocular da Faculdade de Medicina de Botucatu-UNESP, no período de 1995 a 2006, com dados recuperados de fichas de atendimento e de arquivo de imagens digitais. Foram avaliados dados de 87 pacientes, como idade, sexo e dados relativos à ptose. As ptoses foram separadas em dois grandes grupos: congênita e adquirida. Foram realizadas medidas digitais da distância margem-reflexo (DMR), distância margem-sulco palpebral superior (DMSC) e distância margem supercílio (DMSP). A unidade de medida considerada foi o diâmetro corneano de cada um dos indivíduos. Todos os dados foram transferidos para tabela Excel e receberam análise estatística. RESULTADOS: A análise mostrou que não existe associação entre a presença de ptose e sexo, assim como tipo de ptose e sexo. Houve diferença significativa entre pálpebras com ptose e sem ptose para DMR. A DMR não apresentou diferença significativa nas ptoses congênita ou adquirida. No que tange a DMSP e DMSC, a ptose adquirida possui valores superiores aos obtidos para portadores de ptose congênita. CONCLUSÃO: A avaliação do posicionamento palpebral confirmou que a DMR é menor nos portadores de ptose palpebral e que as ptoses congênitas e adquiridas possuem DMR semelhantes. A DMSC e a DMSP apresentam valores superiores em portadores de ptose adquirida.

OBJECTIVES: To assess the palpebral position in patients with congenital or acquired ptosis, related to margin, sulcus and eyebrow, trying to identify differences between types of ptosis. METHODS: A retrospective evaluation of patients with palpebral ptosis treated at the Ambulatory of Ophthalmic Plastic Surgery - Faculdade de Medicina de Botucatu (UNESP) was conducted, from 1995 to 2006. Data were recovered from electronic medical charts as well as digital image files. Eighty-seven patients were assessed, according to age, gender and data related to ptosis, such as time of appearance and type of palpebral ptosis. Palpebral ptosis was classified in two groups: congenital and acquired ptosis. Measurements were taken of margin-reflex distance (MRD), margin sulcus distance (MSD) and margin eyebrow distance (MED) using digital measurements of photos obtained. The corneal diameter of each individual patients was the unit of measure used. All data was transferred to an Excel Spreadsheet and received statistical treatment. RESULTS: Statistical analysis revealed there is no association between the presence of ptosis and gender, or the type of ptosis and gender. There was a significant difference between eyelid with and without ptosis for MRD. However, in relation to the type of ptosis (congenital or acquired), MRD did not present any significant difference. The MSD and MED measurements were higher in acquired ptosis when compared to congenital ptosis. CONCLUSION: Assessment of palpebral positioning using digital measures endorse that MRD is smaller in patients with palpebral ptosis and similar in congenital or acquired ptosis, whereas MSD and MED presented higher values in acquired ptosis.

A three-dimensional construct of the aging eyebrow: the illusion of volume loss.

BACKGROUND: The eyebrows and eyebrow fat pads, key structures in upper facial aesthetics, are particularly vulnerable to age-related changes. OBJECTIVES: In this study, the authors compare the impact of aging on the eyebrows and eyebrow fat pad volume in men and women through three-dimensional (3D) volumetric analysis. METHODS: Electronic medical records of patients seen at the Jules Stein Eye Institute in the Division of Orbital and Ophthalmic Plastic Surgery between 2005 and 2010 were reviewed. Patients were included if they had undergone investigative imaging of the orbit for unilateral pathology. Computed tomography (CT) scans of patients with Graves disease diagnosis, extensive orbital trauma, and/or previous eyebrow surgery were excluded. A total of 52 CT scans (24 men and 28 women) were retained for analysis. A 3D reconstruction software was used to analyze the scans and calculate volumes of the retroorbicularis oculi fat (ROOF), galeal fat (ROOF and subcutaneous fat), and soft tissue muscles. RESULTS: Galeal and brow fat volumes showed a significant positive trend toward enlargement in women (P values of .01 and .05, respectively). Although men showed a tendency toward fat enlargement with age, this was not statistically significant. Soft tissue-muscle volume decreased significantly in aging women (9.32 mm(3)/y) (P = .02). Data indicated that soft tissue volume in men tended to increase with age (3.92 mm(3)/y) but not significantly (P = .36). Neither total volume nor brow thickness appeared to change significantly in women (P = .56, P = .73). In men, total volume and brow thickness showed weak evidence of increasing with age (P = .12, P = .22). Linear regressions of Hertel measurements with and without sex interaction showed no statistically significant trend between the amount of proptosis and the galeal or brow fat. CONCLUSIONS: Although overall eyebrow volume does not change with age, the relative contribution of fat and soft tissue to the total volume does seem to change. This pattern also differs between males and females. As women age, the fat volume increases and the soft tissue volume decreases. In men, the shift from soft tissue volume to fat volume is less pronounced. Although many clinicians have been drawn to the concept of fat volume deflation as a key element of facial aging, this study does not support this perspective in the eyebrow fat pad. An increasingly refined understanding of the dynamics of facial aging is mandatory for clinical diagnosis and will likely provide the framework from which to develop more innovative treatment options.