Eyelid Asymmetry Research Articles

Association of Eyelid Position and Facial Nerve Palsy With Unresolved Weakness.

Understanding the prevalence and clinical features of eyelid malpositions in facial nerve palsy (FNP) may inform proper management of patients with FNP and supplement our knowledge of eyelid physiology. To describe eyelid malposition in FNP. In this retrospective cohort study, patients with FNP seen at the Center for Advanced Facial Plastic Surgery and Jules Stein Eye Institute between January 1, 1999, and June 1, 2014, were reviewed for study inclusion. Data collection was performed between June 1, 2014, to August 1, 2014, and data analysis was performed between June 15, 2014, to September 1, 2015. The distances from the center of the pupil to the upper eyelid margin (marginal reflex distance 1 [MRD1]) and to the lower eyelid margin (marginal reflex distance 2 [MRD2]) were measured on photographs of patients in the primary position and with full smile. Eyelid asymmetry, retraction, ptosis, synkinesis, and severity and duration of FNP were assessed. Eligible participants were adults with FNP at a private tertiary care clinic with primary position photographs. Exclusion criteria included prior history of procedures or medical conditions that could alter eyelid position. The 52 included patients were predominantly female (38 [73%]), with a mean (SD) age of 44.1 (13.8) years. Of this group, 34 patients (65%) were white, 8 (15%) were Asian, 8 (15%) were Hispanic, and 2 (4%) were African American. Retraction (MRD1, >5.0 mm) was present in 8 patients (15%), 3 of whom had eyelid asymmetry (MRD1, >1.0 mm). Overall, total asymmetry of greater than 1.0 mm was present in 14 patients (27%), with the FNP side higher in 12 (23%). Compared with those without asymmetry, patients with eyelid asymmetry were significantly more likely to have contralateral ptosis (42% vs 2.5%, P < .001) but did not have a significantly shorter duration of FNP (12.3 months vs 13.8 months, P = .82). Ptosis was noted in 4 patients and was also unrelated to duration of FNP (9.6 months in patients with ptosis vs 13.6 months in those without, P = .60). Synkinesis was found in 24 patients (46%), but none had concomitant ptosis. Severe FNP (House-Brackmann score, ≥4) was present in 28 patients (54%), and these patients were 20 times more likely to have asymmetry greater than 1.0 mm, often with the FNP side higher. Upper eyelid asymmetry is common in FNP. In most of the patients in this study, the FNP side was higher without demonstrating retraction, and the contralateral side was ptotic. Thus, contralateral ptosis surgery may benefit these patients. Furthermore, patients with severe facial weakness were more likely to have eyelid asymmetry, suggesting that the ability of the eyelid position maintenance system to adapt to weakness of eyelid protractors may be limited by the severity of this weakness. 3.

Surgical treatment for medically refractory myasthenic blepharoptosis.

PurposeCurrently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis.Patients and methodsEight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients.ResultsSeven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period.ConclusionOur results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

Comparison of Blepharoptosis Correction Using Müller-aponeurosis Composite Flap Advancement and Frontalis Muscle Transfer.

Treatments for severe blepharoptosis are well documented and include the most common operations for restoring upper eyelid ptosis, which are levator surgery and frontal muscle transfers; however, the choice of treatment is still controversial. There are different approaches to the restoration of upper eyelid ptosis, and the choice will be based on ptosis severity and the surgeon's skill and experience. Two hundred and fourteen patients presenting with a levator function of between 2 and 4 mm received ptosis correction between 1991 and 2010 at our clinic. Of these, 71 patients underwent Müller aponeurosis composite flap advancement for correction of 89 eyelids, and frontalis muscle transfer was performed on 143 patients (217 eyelids). Postoperative results were evaluated with an average follow-up period of 23 months. The preoperative average for marginal reflex distance (MRD1) in the Müller aponeurosis composite flap advancement group was 1.25 mm, and in the frontal muscle transfer group, it was 0.59 mm. The area of corneal exposure (ACE) was 57.2% in the Müller aponeurosis composite flap advancement group and 53.6% in the frontal muscle transfer group. The postoperative average distance was not significantly different for the 2 techniques. In the Müller aponeurosis composite flap advancement group, MRD1 was 2.7 mm and ACE was improved to 73.5%. In the frontal muscle transfer group, MRD1 was 2.3 mm and ACE was 71.2%. Undercorrection and eyelid asymmetry were the most frequently observed postoperative complications for both techniques. In our study, we confirmed that Müller aponeurosis composite flap advancement and the frontalis transfer technique are both effective in the correction of severe blepharoptosis; our results showed no significant differences between the 2 techniques.

Eyelid and brow asymmetry in patients evaluated for upper lid blepharoplasty.

IntroductionIn evaluation for blepharoplasty, patients often desire improved cosmesis and/or correction of visual field deficits. However, patients are usually unaware of eyelid or brow asymmetry. Furthermore, the prevalence of eyelid and brow asymmetry is infrequently reported in the medical literature.PurposeTo determine the prevalence of brow and eyelid asymmetry in patients evaluated for upper lid blepharoplasty.MethodsOne hundred consecutive patients evaluated for upper lid blepharoplasty were included in the study. Standard pre-operative photographs were taken of all patients using consistent background and photographic equipment. Two of the authors (KM & AM) independently recorded the margin pupil (MPD), central eyebrow (CED), nasal eyebrow (NED) and temporal eyebrow (TED) distances. To test the inter-observer reliability, the senior author (SMT) recorded the same measurements for 10% of randomly selected patients. We calculated 95% confidence intervals to compare symmetry between the right and left sides.ResultsOne hundred patients (94 female, mean age 57.7) were included in the study. The average MPD, CED, NED and TED distances were 0.55 mm (95% CI 0.45-0.65), 1.77 mm (95% CI 1.47-2.07), 1.34 mm (95% CI 1.14-1.54), and 1.78 mm (95% CI 1.50-2.06), respectively. Ninety-three percent of patients had at least one asymmetric measurement of greater than 1 mm. Seventy-five percent of patients studied had at least one measurement greater than 2 mm while 37 percent had at least one greater than 3 mm.ConclusionBrow and eyelid asymmetry is common in patients being evaluated for upper lid blepharoplasty. The facial plastic surgeon should identify and document facial asymmetry pre-operatively, and discuss it with prospective blepharoplasty patients. This will improve informed consent and patient expectations.

Eyelid and brow asymmetry in patients evaluated for upper lid blepharoplasty

In evaluation for blepharoplasty, patients often desire improved cosmesis and/or correction of visual field deficits. However, patients are usually unaware of eyelid or brow asymmetry. Furthermore, the prevalence of eyelid and brow asymmetry is infrequently reported in the medical literature. To determine the prevalence of brow and eyelid asymmetry in patients evaluated for upper lid blepharoplasty. One hundred consecutive patients evaluated for upper lid blepharoplasty were included in the study. Standard pre-operative photographs were taken of all patients using consistent background and photographic equipment. Two of the authors (KM & AM) independently recorded the margin pupil (MPD), central eyebrow (CED), nasal eyebrow (NED) and temporal eyebrow (TED) distances. To test the inter-observer reliability, the senior author (SMT) recorded the same measurements for 10% of randomly selected patients. We calculated 95% confidence intervals to compare symmetry between the right and left sides. One hundred patients (94 female, mean age 57.7) were included in the study. The average MPD, CED, NED and TED distances were 0.55 mm (95% CI 0.45-0.65), 1.77 mm (95% CI 1.47-2.07), 1.34 mm (95% CI 1.14-1.54), and 1.78 mm (95% CI 1.50-2.06), respectively. Ninety-three percent of patients had at least one asymmetric measurement of greater than 1 mm. Seventy-five percent of patients studied had at least one measurement greater than 2 mm while 37 percent had at least one greater than 3 mm. Brow and eyelid asymmetry is common in patients being evaluated for upper lid blepharoplasty. The facial plastic surgeon should identify and document facial asymmetry pre-operatively, and discuss it with prospective blepharoplasty patients. This will improve informed consent and patient expectations.

Eye Dominance and Hering’s Law Effect on Bilateral Blepharotosis Repair

Eye dominance and Hering's law dependence are postulated to influence eyelid position, and thus affect surgical outcomes following blepharoptosis surgery. Pseudoretraction of the contralateral eyelid, usually observed in the nondominant eye, is a well-recognized occurrence in the ophthalmic literature. In this article, these 2 phenomena were assessed preoperatively in blepharoptosis patients to evaluate their effect on postoperative outcomes. In this retrospective cohort study, postoperative eyelid position and rates of reoperation were investigated in 38 patients with bilateral involutional ptosis, who underwent bilateral ptosis repair. Institutional Review Board approval was obtained. In addition to the standard ptosis preoperative evaluation, patients were tested for Hering's law dependence and eye dominance. None of the patients included in the study had significant postoperative eyelid asymmetry or required reoperation. Eye dominance and Hering's law dependence did not affect the surgical outcomes of the patients included in this study who had bilateral ptosis repair performed. It was postulated that this may be due to the balancing of these 2 factors intraoperatively, thus negating their effect on eyelid position postoperatively.

Incidence of Lower Eyelid Asymmetry

To avoid complications and improve patient satisfaction with lower lid blepharoplasty, a precise assessment of any preoperative eyelid asymmetry is essential. The authors describe a method of assessing preoperative eyelid asymmetry through readily available software and classifying the resulting measurements. Digital images of 204 patients were analyzed using Photoshop CS3 Extended software (Adobe Systems, San Jose, California). The left eye was superimposed over the right eye using layers in the software program, and the lower eyelid margin and axis were outlined to obtain a diagram with the superimposed outlines of both eyes. Several measurements (ie, lateral canthal height, lower eyelid margin length and axis angle, and lower palpebral fissure surface area) were obtained for each patient. Differences between the right and left eyelids were recorded, and these data were compared between patients. Of the 204 patients studied, 184 (90.2%) had some degree of asymmetry. Most (118; 64.13%) presented with the right lower eyelid at a more inferior position than the left (R-), while 66 (35.87%) presented with the right lower eyelid at a higher position than the left (R+), a difference that was highly significant (P < .001). This software is a powerful and precise tool to evaluate and measure eyelid asymmetries. The use of this method showed a large degree of eyelid asymmetry preoperatively (more than 90%), which proves the importance of detecting and adequately analyzing this condition prior to surgery. The authors' simple method may be an important adjunct to obtaining optimal results in patients who seek eyelid surgery.

Medical elective research – eyelid asymmetry amongst Malaysians: a study of two racial groups

Facial asymmetry is a common condition and only becomes a problem if there is a significant difference between both sides. In the Asian community, the difference between the height and width of the palpebral fissures and the skin creases is usually the most apparent on photographs. There has not been any reports on the prevalence of such differences between the various racial groups in Malaysia. This study looks at the incidence of asymmetry of the palpebral fissue and upper eyelid crease in young Malaysians of Malay and Chinese origins of which form the biggest racial groups in Malaysia. Data obtained from such studies would be useful for reconstructive and aesthetic surgery as well as for counselling patients with dysmorphophobia.

The association of refractive error, strabismus, and amblyopia with congenital ptosis

To determine the frequency of amblyopia and its associations among children with congenital ptosis. A retrospective chart review of 92 active patients with congenital ptosis in the practices of 2 of the authors. The main outcome measures were relative eyelid ptosis severity, presence and type of strabismus, refractive error, and amblyopia. Amblyopia was identified in 22 of 92 patients (23.9%), in almost every case occurring in the context of coexisting anisometropia or strabismus and affecting the eye with the more severe ptosis (P = 0.0001). Amblyopia was more likely to occur in cases with greater relative eyelid asymmetry and did not develop in children with symmetric ptosis. In several cases, anisometropia and amblyopia were not initially apparent but progressively developed during follow-up. Children with congenital ptosis are at risk of anisometropic and strabismic amblyopia, which may progress during early development. Patients should be examined at regular intervals to evaluate and treat these potential complications.

The Role of the Orbicularis Oculi Muscle and the Eyelid Crease in Optimizing Results in Aesthetic Upper Blepharoplasty: A New Look at the Surgical Treatment of Mild Upper Eyelid Fissure and Fold Asymmetries

One of the most common aesthetic and rejuvenative facial plastic surgical procedures performed is upper blepharoplasty. The traditional approaches to this procedure have been conceptually related to the removal of apparent "excess" tissue to enhance the visibility of the pretarsal region and reduce the upper eyelid irregularities and changes that occur with age. Many times, surgery has been performed both bilaterally and similarly on each side without extensive preoperative planning irrespective of the patient presentation and has commonly incorporated the removal of skin, orbicularis oculi muscle, and upper periorbital fat. The orbicularis oculi muscle is excised for a variety of reasons and has, in general, not been considered as an important component that mandates preservation or a potential means with which to further enhance outcomes by manipulation. If upper eyelid ptosis is also present, it may be treated by traditional methods of blepharoptosis repair. Despite this, patients are more often generally pleased with the obvious improvements after surgery with these traditional surgical procedures, yet the changes do not necessarily approach the youthful configuration in some individuals, the asymmetries that they had presented with may persist, and changes might occur that were not anticipated that may detract from the overall aesthetic result. A simple yet comprehensive approach to upper blepharoplasty that considers both the youthful or desired appearance and the management of upper eyelid asymmetries by preservation or selective treatment of the orbicularis oculi muscle and placement of the upper eyelid crease to improve aesthetic outcomes is presented in this article.

Early Postoperative Adjustment of the Fasanella-Servat Procedure: Review of 102 Consecutive Cases

To describe and evaluate an office-based technique to adjust the Fasanella-Servat procedure in the first postoperative week. This retrospective case series reviewed all consecutive eyelids undergoing the Fasanella-Servat procedure between July 1, 2006, and July 1, 2007, by a single surgeon (R.D.L.). Charts were reviewed to determine the frequency, timing, safety, and efficacy of postoperative adjustment. Postadjustment photographs were reviewed by a blinded ophthalmic plastic surgeon for eyelid contour, height, symmetry, overall cosmesis, and picture quality as excellent, satisfactory, or poor. The Fasanella-Servat procedure was performed on a total of 102 eyelids in 54 patients over the 12-month interval. Postoperative adjustments at the time of suture removal were performed to improve mild eyelid asymmetries for 22 eyelids (22%) in 19 patients. Postadjustment photographs, available for 17 patients, showed excellent eyelid contour (53%), height (88%), symmetry (82%), and cosmesis (65%). Satisfactory results were obtained in all remaining photographed eyelids. The Fasanella-Servat procedure should be viewed as an adjustable ptosis correction with the adjustment as a standard component of postoperative suture removal. This manipulation takes only a few moments with minimal to no patient discomfort. It allows for improvements in eyelid height and contour. This series demonstrates a procedure that is simple, highly successful, and safe.

Asymmetry of Blinking

Too investigate asymmetry in eyelid movements with blinking, the stability of the asymmetry, and its modifiability in normal humans. Differences in the start time and amplitude between the two eyelids were assessed for voluntary blinks and reflex blinks evoked by supraorbital trigeminal nerve stimulation. These variables were also measured before and up to 18 months after 2 hours of unilateral upper lid restraint. With voluntary blinks, one eyelid consistently began to close earlier and made a larger eyelid movement than the other eyelid. Stimulation of the supraorbital branch of the trigeminal nerve evoked relatively larger amplitude blinks in one eyelid that correlated with the asymmetries of voluntary blinks. There was a continuum of eyelid asymmetry across all subjects that was stable and independent of other biological asymmetries, such as handedness. Briefly reducing eyelid mobility created a long-lasting change in eyelid asymmetry with blinking. Eyelid asymmetry results from differences in the excitability of motoneurons in the left and right facial motor nuclei and does not appear to involve asymmetries in cortical inputs to the brain stem. Because adaptive processes modify the motoneuron excitability that creates eyelid asymmetry, these processes may underlie changes in blinking associated with facial palsy and may play a role in the development of disorders that affect one side of the face, such as hemifacial spasm.

Transconjunctival Müller Muscle Recession With Levator Disinsertion for Correction of Eyelid Retraction Associated with Thyroid-Related Orbitopathy

To evaluate the efficacy of transconjunctival Müller muscle recession and graded levator disinsertion for eyelid retraction in patients with thyroid-related orbitopathy (TRO). Retrospective consecutive case series. Medical record review of 78 TRO patients (107 eyelids) who underwent surgery for upper eyelid retraction in a 5-year period was performed. Main outcome measures were anatomic and functional success, minimal reflex distance (MRD), lagophthalmos, eyelid asymmetry, and patient discomfort. One hundred seven eyelid retraction surgeries were performed on 78 TRO patients (63 women, mean age 49 years); mean follow-up time was 16.7 months. Upper eyelid position, lagophthalmos, exposure keratopathy, and patients' discomfort markedly improved after surgery (P < .001). Marginal reflex distance (MRD1) decreased an average of 2.6 mm from 6 mm pre-operatively to 3.4 mm post-operatively (P < .001); lagophthalmos decreased an average of 0.6 mm from 1.3 mm pre-operatively to 0.4 mm post-operatively (P = .006) Failure rate was 8.4%, most improved with a second surgery. Overcorrection was noticed in three cases (2.8%). Eyelid asymmetry improved from a mean of 1.0 mm pre-operatively to 0.4 mm post-operatively (P = .001); more than 80% of patients showed eyelid asymmetry of 1 mm or less. Transconjunctival Müller muscle and levator recession is safe and effective in correction of mild, moderate, or severe eyelid retraction in TRO patients. The failure rate is less than 10% and may be addressed by a second surgery.

The aponeurotic approach for the correction of blepharoptosis.

Blepharoptosis results from underaction of the eyelid protractors relative to the eyelid retractors causing the eyelid to be lower than its normal anatomic position. The lowering of the upper eyelid obstructs the superior visual field. Patients suffering from ptosis complain of eyelid asymmetry, fatigue, and difficulty reading. Ptosis is classified into categories based on the underlying anatomic abnormality. The categories: myogenic, aponeurotic, neurogenic, and mechanical may be differentiated based upon the levator function and the clinical examination. The type of ptosis and the degree of levator function determine which surgical interventions may be considered in an individual patient. The aponeurotic approach to the correction of blepharoptosis provides versatility and may be used for all degrees of ptosis provided the levator function is adequate. The aponeurotic approach allows for concomitant correction of associated dermatochalasis and eyelid crease abnormalities. Eyelid height and contour may be adjusted intraoperatively to obtain the most consistently favorable post-operative results. Early postoperative adjustment enables revision of the eyelid with minimal additional surgical trauma.

Ocular Asymmetry Measuring Device

An instrument that measures ocular, eyebrow, canthal, and lower eyelid asymmetries accurately is useful for evaluating various deformities before oculoplastic surgery is performed. The ocular asymmetry measuring device comprises a headband, a ruler, and a T-shaped crosspiece. When the band is placed around the patient's head at forehead level, it fixes the ruler vertically over the midforehead. The metal rod is aligned with whatever eyelid, eyebrow, eye, or canthus is lower and is then elevated until it transects a similar structure on the opposite side. The degree of asymmetry is measured in millimeters. The device is useful in determining the degree of correction needed in various conditions that result from orbital fracture, facial paralysis, and congenital anomalies.