Growth of muscles and nerves in the upper eyelid: a morphometrical and immunohistochemical study using term human fetuses.

BACKGROUND: There is no information about muscle growth in eyelids with infrequent blinking in fetuses. METHODS: To examine the muscle and nerve morphology, we morphometrically and immunohistochemically examined sagittal sections of unilateral upper eyelids obtained from 21 term fetuses (approximately 30-42 weeks of gestation) and, for the comparison, those from 10 midterm fetuses (12-15 weeks). RESULTS: The approximation margin of the upper eyelid always corresponded to the entire free margin in midterm fetuses, whereas it was often (18/21) restricted in the posterior part in term fetuses. Thus, in the latter, the thickness at the approximation site to the lower lid often ranged from 0.8 to 1.6 mm and corresponded to 18-56% of the nearly maximum thickness of the lid. In the lower part of the upper eyelid, a layer of the orbicularis oculi muscles often (14/21) provided posterior flexion at 90-120° to extend posteriorly. Nerve fibers running along the mediolateral axis were rich along the approximation surface at term, but they might not be reported in the upper eyelid of adults. CONCLUSION: Being different from adult morphologies, the term eyelid was much thicker than the approximation surface and it carried a flexed muscle layer and transversely-running nerve. The infrequent blinking in fetuses seemed to provide a specific condition for the muscle-nerve growth. Plastic and pediatric surgeons should pay attention to a fact that infants' upper eyelid was unlikely to be a mini-version of the adult morphology.

Development of a neural network-based automated eyelid measurement system.

The purpose of this study was to assess the clinical utility and reliability of an automated eyelid measurement system utilizing neural network (NN) technology. Digital images of the eyelids were taken from a total of 300 subjects, comprising 100 patients with Graves' orbitopathy (GO), 100 patients with ptosis, and 100 controls. An automated measurement system based on NNs was developed to measure margin-reflex distance 1 and 2 (MRD1 and MRD2), as well as the lengths of the upper and lower eyelids. The results were then compared with values measured using the manual technique. Automated measurements of MRD1, MRD2, upper eyelid length, and lower eyelid length yielded values of 3.2 ± 1.7 mm, 6.0 ± 1.4 mm, 32.9 ± 6.1 mm, and 29.0 ± 5.6 mm, respectively, showing a high level of agreement with manual measurements. To evaluate the morphometry of curved eyelids, the distance from the midpoint of the intercanthal line to the eyelid margin was measured. The minimum number of divisions for detecting eyelid abnormalities was determined to be 24 partitions (15-degree intervals). In conclusion, an automated NN-based measurement system could provide a straightforward and precise method for measuring MRD1 and MRD2, as well as detecting morphological abnormalities in the eyelids.

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

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

Routine eyelid care for those without dermatitis.

The eye is a unique structural and functional anatomic unit of the face and requires specific care and attention. Often, dermatologists are not familiar with the routine needs of the eyelid area. Despite evidence showing that lid hygiene may serve as an important supplement to therapeutic management of eyelid disorders, lid hygiene is often overlooked. Ophthalmologists and dermatologists have an important role to play in educating patients on the importance of proper eyelid hygiene and ensuring patient compliance. We review eyelid anatomy and function to better understand how these structures relate to potential disease processes. We also review current recommendations for routine eyelid care and discuss the need for further advancements in promoting eyelid health.

Photo-Assisted Anthropometric Analysis of Double Eyelid Blepharoplasty in Young Chinese.

BACKGROUND: Double eyelid blepharoplasty has gained popularity over decades among Asians. Quantitative assessment of the morphologic changes after double eyelid blepharoplasty remains obscure. A photo-assisted digital method was introduced to measure the outcomes of double eyelid surgery in young Chinese. METHODS: A total of 168 Chinese patients who underwent esthetic upper blepharoplasty were recruited from October 2018 to October 2020. The participants were divided into mini-incision, full-incision, and full-incision double with epicanthoplasty (FIDE) groups. Changes in the eyeball exposure area (EEA), brow eyelid margin distance [brow eyelid distance (BED)], and palpebral crease height after surgery were analyzed using ImageJ software. RESULTS: There was an overall increase in EEA in the 3 groups after upper blepharoplasty surgery. The FIDE group showed the most increase in EEA among these groups. Furthermore, BED was significantly decreased in each group after upper eyelid blepharoplasty; however, the mini-incision double group showed the least BED reduction. The palpebral crease height at 90 days was significantly lower than that at 7 days after surgery. CONCLUSIONS: The photo-assisted anthropometric analysis offers a simple and objective measurement for double eyelid blepharoplasty. The eyes appear larger because of the increase in EEA and decrease in BED after double eyelid blepharoplasty. Distinct results were produced by different surgical techniques. The FIDE group showed the maximum increase in EEA and a decrease in BED. These findings provide important references for preoperative planning and postoperative measurement.

Accessory Muscles Associated With the Levator Palpebrae Superioris Muscle in 100 Cadavers.

PURPOSE: This study aimed to determine the variations of the levator palpebrae superioris muscle and to reveal its morphological features. METHODS: This study conducted on 100 adult orbit cadavers in the Department of Anatomy, Istanbul University, used an exploratory, descriptive research design. The anatomical and morphological variations of the levator palpebrae superioris muscle and its relationship with the superior ophthalmic vein were evaluated. RESULTS: Variations of levator palpebrae superioris muscle were discovered in 11 of 100 orbits. Single (9%), double (1%), and triple (1%) accessory muscle slips were observed. The origin of accessory muscle slips showed variation as the accessory muscle slips originated either from the proximal or distal half of the levator palpebrae superioris muscle. Also, the insertions of accessory muscle slips were variable, as they were inserted into levator aponeurosis, trochlea, lacrimal gland, lateral orbital wall, or the fascia of the superior ophthalmic vein. CONCLUSIONS: Accessory muscles associated with levator aponeurosis were found in a significant proportion of cadavers. These muscles may cause confusion in orbital surgery and should be taken into account during surgical planning and orientation in the superior orbit.

Normal palpebral anthropometric measurements in Uygur population： A cross-sectional study.

OBJECTIVE: To provide a normative palpebral database for the Uygur subjects to determine norms that may contribute to the diagnosis and prognosis of eyelid diseases. Methods: The cross-sectional study was conducted from March to May 2021 at the First People's Hospital of Kashi, China, and comprised Uygur subjects of either gender aged 18-70 years. The slant, height and width of the palpebral fissure, vertical brow-upper lid distance, intercanthal distance, pupillary distance, brow height, crease height and levator function were measured. Data was analysed using SPSS 22. RESULTS: Of the 335 subjects having mean age 41.41±14.53 years, 165(49.3%) were males with mean age 41.08±14.23 years and 170(50.7%) were females with mean age 41.74±14.85 years. There were 107(31.9%) subjects aged 18-30 years, 115(34.3%) aged 31-50 years and 113(33.7%) aged 51-70 years. Mean palpebral fissure width and margin reflex distance of the palpebrae were significantly different in terms of gender (p<0.05). Age was also a significant factor on several counts (p<0.05). Conclusion: Anthropometric measurements of eyelid in Uygur subjects indicated certain peculiarities.

Anatomic and Magnetic Resonance Imaging-Based Correction of Upper-Eyelid Depression and Blepharoptosis in Senile Patients.

In senile patients with sunken superior sulcus, involutional ptosis, and higher eyelid crease, a single operation to correct depression or ptosis cannot achieve good results. We demonstrated the anatomy of periorbital septum fibers, which may contribute to the levator muscle's volume depletion and dynamic power transmission disorder, and described a procedure for correcting upper-eyelid depression and blepharoptosis in senile patients. The fibrous webs in these patients connected the posterior aspect of the orbicularis and the orbital septum and extended to the orbital fat and levator aponeurosis. These fibers were dissected to release the periorbital septal fibers, and the orbital septal fat flap was transferred to the depressed region. Advancement or plication of the levator aponeurosis was performed in patients with uncorrected blepharoptosis after the procedures described above. The technique was applied to 13 Chinese patients (25 eyes) between May 2021 and April 2022. Postoperative magnetic resonance imaging revealed that the preaponeurotic fat was displaced forward and down to the upper margin of the tarsus, and the curvature of the upper-eyelid depression was significantly improved. Moreover, the superior sulcus deformity improved, the ptosis was corrected, and the uppermost crease decreased in all patients. No recurrence of ptosis or abnormal adhesion was observed. We believe this is the first study using magnetic resonance imaging to evaluate eyelid anatomy and the effects of surgery in this patient group. Releasing periorbital septum fibers is crucial for correcting a portion of the sunken eyelid and ptosis in Asians.

Brow Position Change and its Potential Risk Factors Following Upper Blepharoplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Eyebrow position affects human facial expression and aesthetic appearance. However, upper-eyelid surgeries may cause brow position changes and affect the function and aesthetics of the eyebrow. The purpose of this review was to assess the influence of upper-eyelid surgeries on brow position and morphology. METHODS: PubMed, Web of Science, Cochrane Library, and EMBASE were searched for clinical trials and observational studies published between 1992 and 2022. The brow height from the center of the pupil is analyzed to show the brow height change. The change in brow morphology is measured by the change in brow height from the lateral palpebral and the medial palpebral. Studies are further divided into subgroups according to different surgical techniques, author locations, and whether to conduct skin excision. RESULTS: Seventeen studies met the inclusion criteria. Nine studies and 13 groups were included in the meta-analysis, indicating that brow height decreased significantly after upper-eyelid surgeries (MD = 1.45, 95% CI [0.87, 2.07], P < 0.0001), and simple blepharoplasty, double-eyelid surgery, and ptosis correction can cause the brow position to drop by 0.67, 2.52, and 2.10 mm, respectively. East Asian authors group had a significant decrease in brow height compared with the non-East Asian authors group (28 groups, p = 0.001). Skin excision during blepharoplasty does not affect brow height. CONCLUSIONS: Brow position changes significantly following upper blepharoplasty according to the decrease in brow-pupil distance. The morphology of the brow showed no significant postoperative change. Different techniques and authors locations may result in different levels of postoperative brow descent. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Male Eyebrow and Eyelid: An Anthropometric Analysis of White Professional Models.

BACKGROUND: Surgical lift of eyebrows is one of the most efficient facial rejuvenation methods. Although the popularity of those procedures seems to be increasing among men, little is known about aesthetically pleasant male eyebrow shape and position. METHODS: Semiautomatic photogrammetric analysis of 300 professional White male models of assumed age (18 to 39 years old) was performed. The assessment was conducted in two sessions, using A.I.D. software. A set of linear, angular, and surface area morphometric parameters of the periorbital region was measured. RESULTS: A total of 600 periorbital regions were quantitatively evaluated. Statistical analysis showed high interrater reliability for all three types of measurements. The mean width of the eyebrow was found to be 47.28 ± 4.55 mm. The male eyebrow was flat and low-located, overlying the orbital rim. The apex was located at the lateral two-thirds of the brow's width. The vertical distance between the eyebrow's peak and the hairline was 51.3 ± 7.15 mm. In addition, averaged body contours were generated using the A.I.D. software, enabling graphic summarization of facial outline and periorbital contours of all analyzed subjects in the form of a single figure. CONCLUSIONS: Based on the aesthetic preferences of several leading modeling agencies, a concept of the ideal eyebrow for White men was created. The collected morphometric data on the periorbital region may guide the surgical rejuvenation attempts of achieving youthful and natural brow contours. It may also aid its reconstruction using hair transplant techniques.

Age-related changes of the periocular morphology: a two- and three-dimensional anthropometry study in Caucasians.

PURPOSE: To determine age-and sex-related changes in periocular morphology in Caucasians using a standardized protocol. METHODS: Healthy Caucasian volunteers aged 18-35 and 60-90 years old were recruited from the Department of Ophthalmology, Faculty of Medicine and University Hospital, Cologne, between October 2018 and May 2020. Volunteers with facial asymmetry, facial deformities, history of facial trauma, facial surgery, botox injection, eyelid ptosis, strabismus, or nystagmus, were excluded. Standardized three-dimensional facial photos of 68 young volunteers and 73 old volunteers were taken in this clinical practice. Position changes of endocanthion, pupil center, and exocanthion were analyzed in different age and gender groups, including palpebral fissure width (PFW): distance between endocanthions (En-En), pupil centers (Pu-Pu), exocanthions (Ex-Ex), endocanthion and nasion (En-Na), pupil center and nasion (Pu-Na), exocanthion and nasion (Ex-Na), endocanthion and pupil center (Pu-En), exocanthion and pupil center (Pu-Ex), and palpebral fissure inclination (PFI); angle of endocanthions to nasion (En-Na-En), pupils to nasion (Pu-Na-Pu), exocanthions to nasion (Ex-Na-Ex); endocanthion inclination (EnI), and exocanthion inclination (ExI). RESULTS: PFW, En-En, Ex-Na, Pu-Ex, PFI, ExI, and Ex-Na-Ex were significantly different between the young and old groups (p ≤ 0.004). There were sex-related differences in PFW, Ex-Ex, En-Na, Pu-Na, Ex-Na, Pu-En, PFI, and EnI between both groups (p ≤ 0.041). CONCLUSION: The position change of the pupil is minimal relative to age; it is preferred to establish the reference plane to describe periocular changes. The endocanthion tends to move temporally and inferiorly, while the exocanthion tends to shift nasally and inferiorly with age.

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

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

Unravelling the Complex Anatomy of the Tear Trough and Lower Eyelid Folds: A Review of Cadaveric Studies in the Literature.

The lower eyelid tear trough deformity is a common cosmetic concern which is the result of multiple anatomic changes in the lower eyelid, usually resulting from age. A sound understanding of the underlying anatomy is vital to inform surgeons about the ideal treatment options for rejuvenation of this region and to minimize the risk of complications. Cadaveric studies provide unique insight into underlying anatomic changes. Here we review the relevant published cadaveric studies relating to the tear trough deformity and its treatment.

A Systematic Approach of the Intrauterine Morphogenesis of the Human Palpebral Apparatus.

The human eyelid embodies a vast diversity of functions. Acting as a protective shield for the ocular apparatus and as a light regulator in the sight process, eyelids stand a fascinating - yet omitted - role in facial aesthetics, serving as a racial trait by which humankind succeeded to manifest heterogeneity as a species. These assumptions are precisely forecasted right from in-utero life through intricate processes of growth and cell differentiation. In the Department of Anatomy of "Carol Davila" University of Medicine and Pharmacy, we performed morphological assessments on 41 embryos and fetuses with gestational ages ranging from 6 to 29 weeks. This study aims to illustrate the morphogenesis of eyelids in human embryos and fetuses and highlight macroscopic features which could potentially have significant clinical implications in ophthalmic pathology.

Anthropometric Periocular Soft Tissue Analysis From Preadolescence to Young Adulthood: Photogrammetric Measurements.

ABSTRACT: The periocular region has a central role in the prediction of ethnicity, understanding emotional expression, age, and sex. The aim of this study was to determine the sex-related growth changes in the periocular region of Turkish preadolescents, adolescents, and young adults. The study included a total of 234 individuals (preadolescents: 34 females and 40 males; adolescents: 40 females, 40 males, and young adults: 40 males and 40 females). A total of 7 periocular parameters (3 bilateral, 3 unilateral linear, and 1 angular measurement) were analyzed statistically to determine sex-related differences. The palpebral fissure and canthal indexes were also calculated. Of the 14 periocular measurements, 9 were found to be sexually dimorphic in certain age groups ( P < 0.05). Right-left palpebral fissure width and left palpebral fissure height were significantly different between young adult males and females ( P = 0.018, P = 0.013, and P = 0.027, respectively). A significant sexual dimorphism was observed for outercanthal distance and canthal index in 3 age groups ( P < 0.05). The data collected in this study may serve as a sex-dependent database source for the Turkish population during normal growth from preadolescence to young adulthood. The present study results would be useful for planning and designing aesthetic and post-traumatic surgical interventions in the periocular region as well as personal identification in this population.

Morphological evaluation of the orbit, eye tunics, eyelids, and orbital glands in young and adult aardvarks Orycteropus afer, Pallas, 1766 (Tubulidentata: Orycteropodidae): Similarities and differences with representatives of the Afrotheria clade.

The Afrotheria clade includes a large group of extant mammals, and the aardvark (Orycteropus afer) is the only representative of the order Tubulidentata in it. Here, we studied the morphological nature of the orbital region, eye tunics, upper and lower eyelids, superficial gland of the third eyelid, the third eyelid, deep gland of the third eyelid, and lacrimal gland in post-mortem specimens obtained from three captive aardvarks, two young and one adult. The obtained samples were analyzed using macroscopic, histological, and histochemical methods. We observed choroidal tapetum lucidum fibrosum in all specimens, which was typical for aardvarks. The superficial gland of the third eyelid was a compound multilobar tubular branched gland of a mucous nature. The deep gland of the third eyelid produced a serous secretion. The seromucous secretion was typical for the lacrimal gland. We compared the morphological data of the O. afer skull with that from other endemic African mammals in the Afrotheria clade. We found that other authors provided different anatomical names for some bones and foramina located within the orbit. The types and function of eyelid glands, as well as eyeball glands of aardvarks, can primarily be connected with their habitat. Our study may constitute an introduction to the ontogenesis of individual eyeball glands in aardvarks.

Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned From Functional Anatomy.

BACKGROUND: The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying facial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments. OBJECTIVES: The authors sought to evaluate the location and function of the angular vein in the tear trough in 3 different facial expressions: repose, smiling, and max. orbicularis oculi contraction. METHODS: Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m2 were investigated via functional ultrasound imaging. The diameter of the angular vein and the velocity and direction of venous blood flow were analyzed in repose, smiling, and during max. orbicularis oculi contraction. RESULTS: The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (intra-muscular course) within the tear trough, whereas the angular artery was not identified in this location. The distance between the angular vein and the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/s and was 7.3 cm/s at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling. CONCLUSIONS: The diameter and the venous blood flow of the angular vein varied between the 3 tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein.

Deep learning-based image analysis for automated measurement of eyelid morphology before and after blepharoptosis surgery.

BACKGROUND AND AIM: Eyelid position and contour abnormality could lead to various diseases, such as blepharoptosis, which is a common eyelid disease. Accurate assessment of eyelid morphology is important in the management of blepharoptosis. We aimed to proposed a novel deep learning-based image analysis to automatically measure eyelid morphological properties before and after blepharoptosis surgery. METHODS: This study included 135 ptotic eyes of 103 patients who underwent blepharoptosis surgery. Facial photographs were taken preoperatively and postoperatively. Margin reflex distance (MRD) 1 and 2 of the operated eyes were manually measured by a senior surgeon. Multiple eyelid morphological parameters, such as MRD1, MRD2, upper eyelid length and corneal area, were automatically measured by our deep learning-based image analysis. Agreement between manual and automated measurements, as well as two repeated automated measurements of MRDs were analysed. Preoperative and postoperative eyelid morphological parameters were compared. Postoperative eyelid contour symmetry was evaluated using multiple mid-pupil lid distances (MPLDs). RESULTS: The intraclass correlation coefficients (ICCs) between manual and automated measurements of MRDs ranged from 0.934 to 0.971 (p < .001), and the bias ranged from 0.09 mm to 0.15 mm. The ICCs between two repeated automated measurements were up to 0.999 (p < .001), and the bias was no more than 0.002 mm. After surgery, MRD1 increased significantly from 0.31 ± 1.17 mm to 2.89 ± 1.06 mm, upper eyelid length from 19.94 ± 3.61 mm to 21.40 ± 2.40 mm, and corneal area from 52.72 ± 15.97 mm2 to 76.31 ± 11.31mm2 (all p < .001). Postoperative binocular MPLDs at different angles (from 0° to 180°) showed no significant differences in the patients. CONCLUSION: This technique had high accuracy and repeatability for automatically measuring eyelid morphology, which allows objective assessment of blepharoptosis surgical outcomes. Using only patients' photographs, this technique has great potential in diagnosis and management of other eyelid-related diseases.