A Novel 3-Point Injection Technique for OnabotulinumtoxinA in the Upper Depressor Anguli Oris.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and safety of onabotulinumtoxinA (ONA) injections to the depressor anguli oris (DAO) to improve downturned mouth. PATIENTS AND METHODS/MATERIALS: This prospective, placebo-controlled, study enrolled subjects aged 18 to 65 years. Injections were performed using a novel 3-point technique in the upper DAO (1.5 U/injection site). The primary end point was a DAO contraction scale 1-grade improvement. Subjective evaluation was performed using the Global Aesthetic Improvement Scale (GAIS). RESULTS: Ten subjects received ONA and 10 placebo (saline) injections. In ONA-treated subjects, DAO scores showed significant improvements at Weeks 4 and 12 ( p < .001) compared with baseline. No significant difference between visits was observed for placebo-injected subjects. Global Aesthetic Improvement Scale scores showed that 100% of subjects were improved compared with baseline at Week 4% and 90% at Week 12. By contrast, 90% and 80% of placebo-treated subjects had "no change" in their DAO appearance at Weeks 4 and 12. Subject GAIS assessments matched the live evaluator at Week 4; 60% continued to report improvement at Week 12. Treatment was well tolerated. CONCLUSION: OnabotulinumtoxinA injections to the DAO using a 3-point technique provide clinically meaningful improvements in appearance. Treatment was well tolerated and in most individuals lasted at least 12 weeks. IDENTIFIER: ClinicalTrials.gov NCT04240535.

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study.

BACKGROUND: Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit. OBJECTIVES: The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA). METHODS: Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months. RESULTS: Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications. CONCLUSIONS: The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members.

BACKGROUND: Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society. OBJECTIVES: The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society. METHODS: A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses. RESULTS: In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique. CONCLUSIONS: High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.

Pushing the Limits in Cheek Reconstruction: The Sub-Superficial Musculo-Aponeurotic System "Deep Plane" Cervicofacial Flap for Reconstruction of Large Eyelid-Cheek Junction Defects.

The cervicofacial flap is a workhorse flap for reconstruction of moderate to large sized defects of the cheek. Defects that involve the eyelid-cheek junction are often the most challenging of these. While the ideal plane of dissection has been debated, it is our belief that dissection in the sub-superficial musculo-aponeurotic system (SMAS) plane provides better aesthetic and functional outcomes due to enhanced vascularity, fascial support, and additional bulk of the flap itself. The authors present a series of 9 patients who presented with heterogeneous defects of the eyelid-cheek junction after cancer resection and underwent reconstruction using a sub-SMAS cervicofacial flap. At a mean follow-up time of 20 months, the cohort had 2 patients who developed lower lid retraction requiring revision and 2 other minor complications. This series lends support to the versatility and reliability of the sub-SMAS cervicofacial flap for large defects of the eyelid-cheek junction.

Identifying Aesthetically Appealing Upper Eyelid Topographic Proportions.

BACKGROUND: The goal of upper eyelid procedures is to restore or create the ideal proportions between the pretarsal space and the upper lid fold. OBJECTIVES: The aim of this study was to define the topographic features of the attractive upper lid. METHODS: Caucasian female frontal facial photographs were obtained from public media and periorbital areas were cropped. A total of 294 photographs of eyes were rated by 6 evaluators using a 4-point Likert scale. Eyes rating an average ≥3.5 were defined as "attractive," whereas those rated ≤2.0 were defined as "unattractive" and analyzed using Adobe Illustrator. RESULTS: Fifty-one and 19 eyes were included in the attractive and unattractive cohorts, respectively. (Upper lid foldPretarsal) shows ratios averaged between 1.8 and 3.0 among attractive eyes, and larger ratios were observed laterally. These ratios were significantly larger laterally among attractive vs unattractive eyes (P ≤ 0.003). The lash line peak (P < 10-4), lid crease peak (P < 10-3), and brow peak (P < 0.05) were significantly more lateralized in attractive eyes. CONCLUSIONS: Attractive eyes tend to exhibit decreased pretarsal show. However, there is pronounced variability in these ratios among attractive eyes, suggesting the importance of other features. Interestingly, progressive lateralization of the lash line, lid crease, and brow peaks appears to be an undescribed feature common to attractive eyes. Knowledge of attractive eyelid features may be an important consideration for planning and optimization of upper lid rejuvenation procedures.

Surgical Duration Impacts Venous Thromboembolism Risk in Microsurgical Breast Reconstruction.

BACKGROUND: Increased surgical duration can impact patient outcomes and operative efficiency metrics. In particular, there are studies suggesting that increased surgical duration can increase the risk of venous thromboembolism (VTE). One of the longer duration plastic surgery procedures commonly performed is microsurgical breast reconstruction. With the widening indications for multiple and "stacked" free flaps to reconstruct breasts, we endeavored to assess (1) the relationship between duration of microsurgical breast reconstruction and VTE; and (2) determine if a threshold operative time exists that connotes VTE higher risk. METHODS: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2014 who underwent microsurgical breast reconstruction were identified by Current Procedural Terminology code. Three models of multivariate logistic regression were used to characterize the adjusted risk for VTE by operative duration, bilaterality, the length of stay, and patient demographics. RESULTS: A total of 4,782 patients who underwent microsurgical breast reconstruction were identified. Overall VTE incidence was 1.13%. The mean operative duration was 8:31 hours:minutes (standard deviation: 2:59). Operative duration was statistically associated with VTE in continuous, quintile, and dichotomized risk models. Beyond an operative duration of 11 hours, adjusted VTE risk increases fourfold corresponding to a number needed to harm of 45.8. CONCLUSIONS: Increasing surgical duration heightens the risk of VTE in microsurgical breast reconstruction. Increasing body mass index and age enhances this VTE risk. Moreover, limiting surgical duration to 11 hours or less can decrease VTE risk by fourfold vis-à-vis baseline. LEVEL OF EVIDENCE: Risk, II.

Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review.

BACKGROUND: Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to increase eyelid height and improve symptoms has been described for a long time, but the optimal choice of spacer graft material is unknown. OBJECTIVES: The authors reviewed the currently available evidence to determine the best available spacer graft material in terms of efficacy and complications. METHODS: A systematic review of all available literature published between 1985 and the present was performed using the Pubmed, Ovid MEDLINE, and Cochrane library databases. Inclusion criteria were that the studies contain original content assessing the treatment of lower eyelid retraction in humans using a spacer graft and provide quantitative outcomes data. RESULTS: One hundred and twelve articles were reviewed following an initial screen using titles, and 19 articles were chosen for inclusion in this systematic review. Analysis of these articles revealed no spacer graft material that is clearly superior to others. CONCLUSIONS: Due to a lack of high quality evidence, this review did not reveal one spacer graft material that is clearly superior to others. However, a narrative summary of the available evidence reveals unique sets of advantages and disadvantages associated with the various materials currently available. Further research in the form of well-designed studies will be necessary to further clarify advantages of certain spacer graft materials over others. LEVEL OF EVIDENCE: 5.

A comparative analysis of readmission rates after outpatient cosmetic surgery.

BACKGROUND: Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. OBJECTIVES: The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. METHODS: The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. RESULTS: The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010). CONCLUSIONS: Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.

Creating Harmonious Arcs: The Importance of Brow Shape in Determining Upper Lid Aesthetics.

Brow lifting, when indicated, can significantly improve upper eyelid aesthetics. Brow lifting is a powerful maneuver to shape and lateralize the curvature of the brow arc and directly influences the upper eyelid fold height and the curvature of the upper eyelid crease. This article reviews the importance of upper periorbital aesthetic assessment because it lays the foundation to tailor the appropriate operative intervention. Highlighted are the authors' preferred approach to aesthetically shape the brow along with other complimentary upper eyelid aesthetic procedures including upper blepharoplasty, blepharoptosis repair, fat grafting, and upper periorbital fat shifting to optimize brow lifting outcomes.

The Influence of Sagittal Head Tilt on Periorbital Appearance: Implications for Clinical Photography and the Evaluation of Postoperative Results.

BACKGROUND: Consistency in standardized periorbital photography-specifically, controlling for sagittal head tilt-is challenging yet critical for accurate assessment of preoperative and postoperative images. OBJECTIVES: To systematically assess differences in topographic measurements and perceived periorbital attractiveness at varying degrees of sagittal head tilt. METHODS: Standardized frontal photographs were obtained from 12 female volunteers (mean age 27.5 years) with the Frankfort plane between -15° and +15°. Unilateral periorbital areas were cropped, and topographic measurements were obtained. The images of each individual eye, at varying head tilt, were ranked in order of attractiveness by 11 blinded evaluators. RESULTS: Inter-rater and intra-rater reliability was excellent (intraclass correlation > 0.9). Downward sagittal head tilt was linearly associated with an improved aesthetic rating (Spearman's correlation; ρ = 0.901, P < 0.001). However, on subgroup analysis, eyes with lower lid bags received the highest aesthetic score at neutral head tilt. Pretarsal show and upper lid fold heights progressively decreased (P < 0.001), positive intercanthal tilt became more pronounced (P < 0.001), and the apex of the brow (P < 0.001) and lid crease (P = 0.036) arcs lateralized with downward sagittal head tilt, contributing to a more angular appearance of the eye. Marginal reflex distance (MRD) 1 was maintained, while MRD2 progressively increased (P < 0.001) with downward head tilt. CONCLUSIONS: Negative sagittal head tilt significantly improves periorbital aesthetics; however, in the presence of lower eyelid bags, this also increases demarcation of the eyelid cheek junction which may be aesthetically detrimental. Controlling for sagittal head tilt is critical to reliably compare preoperative and postoperative clinical photographs.

The Asian Eye: Anthropometric Eye Measurements of Attractiveness in Young East Asian Women.

BACKGROUND: Because of the high volume of Asian eyelid operations performed and the complexity of the Asian eye, there is a need to define exactly what anthropometric measurements determine attractiveness. METHODS: Eye photographs of young East Asian women were collected from publicly available sources online. Photographs were evaluated on a Likert scale ranging from 1 to 5 for attractiveness. Thirty-seven anthropometric measurements were collected using ImageJ from the most attractive and least attractive eyes to discover which features play the most important role in attractiveness. RESULTS: A total of 322 right eye photographs were evaluated for attractiveness. Sixty-six eyes received a median score of greater than or equal to 4.0 and were included in the attractive cohort. Forty-three eyes received a score of less than or equal to 2.0 and were included in the unattractive cohort. The superior brow peak was more lateralized compared to the upper lid crease and upper lash line peaks in attractive eyes. A greater palpebral aperture height-to-upper lid show ratio was found to be more associated with attractive eyes than with unattractive eyes. At the midpupillary line, the ratio was on average 1.58 ± 0.32 in attractive eyes and 1.22 ± 0.43 in unattractive eyes ( p < 0.001). Eyes with convergence of the upper lid crease with the upper lash line were more likely to be deemed unattractive ( p < 0.001). CONCLUSIONS: East Asian eyes have specific anthropometric measurements that are more associated with attractiveness. These ideal measurements are different from those in Caucasians, suggesting ethnic variability in features defining attractiveness and a need to tailor surgical care appropriately.

From simple interrupted to complex spiral: a systematic review of various suture techniques for microvascular anastomoses.

Accomplishing successful microvascular anastomoses is undoubtedly one of the most critical steps in performing free tissue transfer. However, the ideal technique has often been a subject of debate. Therefore, our objective was to review the current literature in an attempt to find objective evidence supporting the superiority of one particular technique. A PubMed and OVID on-line search was performed in November 2007 using the following keywords: microvascular anastomoses, microsurgical anastomosis, continuous suture, interrupted suture, mattress suture, and sleeve anastomosis. Our literature review found no difference in short- and/or long-term patency rates between the six main published techniques, which includes continuous suture, interrupted suture, locking continuous, continuous horizontal, horizontal interrupted with eversion, and sleeve anastomoses. These findings were consistent for each technique as long as the microsurgeon maintained standard microsurgical principles and practice, including suture line eversion, minimized tension, and direct intima-to-intima contact. Current literature supports no overall statistical difference in short- and/or long-term patency rates between any of the various techniques. The choice to perform one suture technique over another ultimately depends on the plastic surgeon's preference and microsurgical experience. To date, there are no human randomized, controlled clinical trials comparing the efficacy and clinical outcomes of each of the various suture techniques, and therefore one's comfort and familiarity should dictate his or her microsurgical technique. However, "exposure to many and mastery of one" simply provides the plastic surgery resident, fellow, or staff the technical flexibility needed for less-complicated surgical planning when performing free tissue transfer.

Repair of Lower Eyelid Cicatricial Entropion With Midface Lift, Spacer Graft, and Drill-Hole Canthoplasty.

Postoperative cicatricial lower lid retraction is a challenging surgical problem that often disfigures the shape of the eye and has functional consequences. Depending on the severity, more than one surgical procedure may be needed to achieve the desired lower lid shape and position given the recurrent nature of scarring. Concepts of scar release, establishing lower lid vertical height, soft tissue replacement, and midcheek support are discussed in this video.

Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction.

BACKGROUND: Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture. METHODS: The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture. RESULTS: The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix. CONCLUSIONS: The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Upper Blepharoplasty with Endoscopically Assisted Brow Lift to Restore Harmonious Upper Lid Arc Curvatures.

BACKGROUND: Achieving excellent results in upper lid rejuvenation requires a balanced approach to address skin, muscle, fat, upper lid margin position, and brow aging changes. In the appropriately selected patient, brow lifting plays an essential complement to upper blepharoplasty to restore more youthful upper lid fold-to-pretarsal ratios. The goal of this study is to describe a safe and reproducible method to perform brow lifting and upper blepharoplasty. METHODS: Medial to the temporal line of fusion, in-line with the brow peak, a 2-cm scalp incision is oriented parallel to the course of the deep branch of the supraorbital nerve to minimize the risk of nerve injury. The brow vector of pull is maximal in this location and secured to a monocortical bone channel with 3-0 polydioxanone. Lateral to the temporal line of fusion, an ellipse of scalp tissue is excised to gently elevate the brow tail. Upper blepharoplasty is performed in an individualized fashion to achieve a youthful contour of the upper lid fold. RESULTS: The endoscopically assisted technique is designed to achieve tissue release under direct visualization. The brow-lift maximal vector of pull is centered over the brow peak and, to a lesser extent, at the brow tail to improve lateral upper lid fold height and a smooth contour of the pretarsal space. Muscle shaping sutures improve convexity of the lateral upper lid fold. CONCLUSION: In the appropriately selected patient, combined brow lift and upper blepharoplasty with muscle contouring are safe and effective techniques that help improve aesthetic upper lid topographic proportions.

Getting Good Results in Cosmetic Blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately diagnose the cosmetic deformity and thoroughly understand the periorbital surface topography. 2. Develop a preoperative plan and pick the right operation. 3. Master technical tips. 4. Rejuvenate the lateral orbital area. 5. Manage complications. SUMMARY: Getting good results in blepharoplasty requires understanding ideal surface topography, accurate diagnosis of the cosmetic deformity, thorough knowledge of anatomy, and careful technique to change the anatomy. Several approaches have been described; however, the procedure continues to have its shortcomings and share of complications that have both functional and cosmetic consequences. This continuing medical education article focuses on getting good results and maximizing success in upper and lower blepharoplasty through the discussion of five major components: diagnosis and understanding of the cosmetic deformity; preoperative planning; technical tips; rejuvenation of the lateral orbital area; and management of complications.

Neurotized Free Platysma Flap for Functional Eyelid Reconstruction: A Cadaveric Study of Anatomical Feasibility.

BACKGROUND: Conventional reconstructive options for large full-thickness eyelid defects are limited to static local flaps without replacing the missing orbicularis. The authors' aim is to delineate the platysma neurovascular anatomy for innervated functional eyelid reconstruction. METHODS: Fourteen fresh latex-injected heminecks were dissected. The locations where neurovascular structures entered the platysma muscles were expressed as the percentage distance ± SD from the sternocleidomastoid muscle mastoid insertion to manubrium origin. RESULTS: The superior thyroid, facial, and lingual vessels were the major pedicles in eight of 14 (57.1 percent), four of 14 (28.6 percent), and one of 14 specimens (7.1 percent), respectively. In one specimen (7.1 percent), both the superior thyroid and facial vessels supplied a major pedicle. Venous drainage generally mirrored arterial inflow but was redundant, with 43 percent and 14 percent of flaps also with major contributions from the external jugular and anterior jugular veins, respectively. Neurovascular pedicles entered the platysma 28 to 57 percent caudal to the sternocleidomastoid muscle mastoid insertion, between 0.5 and 4.8 cm anterior to the medial sternocleidomastoid muscle border. CONCLUSION: Although variability exists, platysma neurovascular pedicles enter at predictable locations between 28 and 57 percent of the distance from the mastoid insertion of the sternocleidomastoid muscle, therefore making free platysma transfer a feasible option for eyelid reconstruction.

Rethinking Upper Blepharoplasty: The Impact of Pretarsal Show.

BACKGROUND: Conventional upper blepharoplasty relies on skin, muscle, and fat excision to restore ideal pretarsal space-to-upper lid fold ratios. The purpose of this study was to identify presenting topographic features of upper blepharoplasty patients and their effect on cosmetic outcomes. METHODS: This is a retrospective review of patients who underwent upper blepharoplasty at the authors' institution from 1997 to 2017. Preoperative and postoperative photographs were standardized using Adobe Illustrator to an iris diameter of 11.5 mm. Pretarsal and upper lid fold heights were measured at five locations. Patients were classified into three groups based on preoperative pretarsal show: none, partial, or complete. Photographs were randomized in PowerPoint and given a cosmetic score of 0 to 5 by four independent reviewers. RESULTS: Three hundred sixteen patients were included, 42 men (13 percent) and 274 women (87 percent). Group 1 included 101 eyes (16 percent), group 2 had 159 eyes (25 percent), and group 3 had 372 eyes (59 percent). Mean cosmetic score increased from 1.75 to 2.38 postoperatively (p < 0.001), with a significantly lower improvement in scores in group 3 compared to groups 2 and 1 for both sexes (p < 0.01). For group 3, those with midpupil pretarsal heights greater than 4 mm had a significantly lower postoperative aesthetic score (1.95) compared with those less than or equal to 4 mm (2.50) (p < 0.001). CONCLUSIONS: Many patients presenting for upper blepharoplasty have complete pretarsal show and are at risk for worse cosmetic outcomes using conventional skin excision techniques. Adjunctive procedures such as fat grafting and ptosis repair should be considered in this group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension.

BACKGROUND: Lower eyelid defects are traditionally classified based on depth and 25 percent increments in defect width. The authors propose a new classification system that includes the vertical defect component to predict functional and aesthetic outcomes. METHODS: A retrospective review of patients who underwent lower lid reconstruction performed by a single surgeon was performed. Defects were classified into four categories based on the vertical component: (1) pretarsal; (2) preseptal; (3) eyelid-cheek junction; and (4) complex pretarsal/preseptal. Preoperative and postoperative central and lateral marginal reflex distance-2 values were obtained. Aesthetic outcomes were evaluated by three blinded reviewers. Outcomes were compared using one-way analysis of variance and analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width. RESULTS: Thirty-four patients underwent reconstruction of lower eyelid defects. There were 12 pretarsal defects (type I), nine preseptal defects (type II), nine eyelid-cheek defects (type III), and four complex pretarsal/preseptal defects (type IV). Postoperative retraction was highest in the complex pretarsal/preseptal group at 75 percent, with a significantly greater change from preoperative to postoperative central and lateral marginal reflex distance-2 compared with the other groups (p < 0.01) and worse postoperative mean aesthetic scores (p < 0.001). Type IV patients had significantly more revision operations (mean, 5.5) compared with the other groups (p < 0.001). CONCLUSIONS: The vertical dimension of lower eyelid defects is an important variable. A new classification system is proposed that supplements width-based methods for improved surgical planning and prediction of postoperative outcomes in lower eyelid reconstruction. CLINICAL QUESTION/LEEVL OF EVIDENCE: Therapeutic, IV.