Eyelid Research Articles

A Neurological Disease, Vathatvartma (Ptosis), Managed with Integrated Management of Modern Science and Ayurveda – A Case Report

ABSTRACT Introduction: Ptosis is when the upper eyelid droops downward. However, a droopy eyelid can cover the pupil and reduce vision in some cases. Causative factors may be congenital, injury or stretching of eyelid muscles or ligaments damage to the nerve controlling the eyelid muscles, aging, a complication of eye surgery, a complication of Botox injections. Aim and objectives: To study case of ptosis with integrated treatment of neurologist along with Ayurveda treatment. Methodology: Case Description - This is a 34year old female patient complaining that she is unable to open her right eye since11 days. She visited to local ophthalmologist, then they have consulted neurologist, MRI done, treatment started, at the same time patient wants to take Ayurveda treatment also. After 7th day visit to neurologist, she has stopped his medicine and told to continue alternative treatment So she consulted at MGACH&RC Salod on 4/3/2022. Her V/A right eye after uplifting upper lid by doctors hand is 6/6 and lt eye v/A is 6/6. Fundus of both was within normal limit. No diplopia, Acute onset with fronto orbital pain, pupil NSRL, conjugate left downgaze movement restricted. Result and Discussion: treatment prescribedshirodhara with brahmi and til tail, netratarpan with triphalaghruta, Tab Palsineuron 2 bd, Tab Ekangvirras 2 bd. - vatashamak Chikitasa is done as ptosis is neurological disease.after 7th day visit to neurologist, he has stopped his medicine and told to continue alternative treatment. Conclusion: The results were enthusiastic photographic depiction were taken. This case may be fruitful for further research on Nimesh/ Ptosis.

Asymptomatic parasitic worm thelazia callipaeda infection found during phacoemulsification: A case report

Introduction:We report a case of asymptomatic thelazia callipaeda infection discovered incidentally during phacoemulsification cataract surgery in March 2024. Case presentation: A 77-year-old male patient presented with complaints of blurred vision. During a slit-lamp examination, trichiasis was observed, but the patient had no foreign body sensation or itching. He was diagnosed with cataract and underwent phacoemulsification cataract surgery. During the surgery, a white, wriggling worm was discovered in the conjunctival sac and removed. It was later identified as thelazia callipaeda. The surgical eye was thoroughly washed and received anti-inflammatory medication postoperatively. No recurrence or new symptoms were reported during the 3-month follow-up period. Conclusions: Thelazia callipaeda infection can be asymptomatic and incidentally discovered. A detailed preoperative examination, such as turning over the upper and lower eyelids to check the conjunctival sac, is necessary before the surgery. When a worm is discovered during surgery, it is crucial to remove it completely and thoroughly clean and disinfect the conjunctival sac.

Morphological and Histological Changes Following Triamcinolone Injection Alone or Mixed Injection of Triamcinolone and Botulinum Toxin in Upper Eyelid

Objective: The purpose of this experiment was to evaluate the functional and histologic changes in the upper eyelid muscles after injection of triamcinolone acetonide (TA) alone or TA combined with botulinum toxin A (Botox or BTXA) in the cynomolgus monkey model. Methods: Twenty eyes of 10 cynomolgus monkeys were divided into 4 groups: 3 experimental groups (1, 2, and 3) and the control group (group 4) based on the injection type. In group 1, 0.5 mL of TA (Kenalog 40 mg/mL) was administered subconjunctivally (between the conjunctiva and the Müller muscle) with a 26 G needle to the inverted upper eyelid of one eye. In group 2, the same procedure was done with 0.5 mL TA injected into the other upper eyelid. After that, 5 UI/0.1 mL Botox was injected transcutaneously into the suborbicularis oculi space in the middle third of the upper eyelid 3 mm above the center of the superior tarsal border. In group 3, a subconjunctival of 0.5 mL TA was administered to the inverted upper eyelid of one eye 3 times: the injection day, 2 weeks, and 6 weeks after the first injection, whereas a normal saline injection of the same volume was administered one time to the other eye at the injection day in group 4 (control group). Follow-up was done to evaluate the clinical changes in eyelid position at 2, 6, and 12 weeks after injection. Hematoxylin-eosin and Masson trichrome were used to assess the levator or Muller muscle histology and measure the fiber diameter. Results: During the clinical follow-up, there were no major complications observed in any monkeys. The macroscopic appearance of the upper lid on the biopsy day did not differ among groups 1, 2, and 4. There were no cases in these groups that had subconjunctival TA deposit 3 months after injection. Conversely, in group 3, there were 3/5 eyes showing the subconjunctival TA deposit at the last examination. No specific changes in the marginal reflex distance 1, marginal reflex distance 2 (MRD2), and lid crease were noted in either TA alone injection groups 1, 3, and 4. In contrast, there was a significant decrease in marginal reflex distance 1 at 2 weeks (P = 0.003) and 6 weeks (P = 0.005) after TA injection in group 2 in comparison to the baseline. In terms of MRD2, while in group 2, there were significant differences between the pre-MRD2 and the post-MRD2 till the 2 weeks after injection (P = 0.006), then it became insignificant from the sixth week afterward. In contrast, at 2 weeks after injection, MRD2 was reduced in both TA-injected groups 1 and 3, but the observed difference was not significant in both groups. At 6 and 12 weeks, MRD2 fluctuation was not remarkable in these 2 groups and there were no significant differences in comparison to the baseline (P > 0.05). Histological evaluation showed that Müller muscle does not attach directly to the superior border of the tarsus, but it changes to the tendon before attaching to the tarsal plate. In addition, there were no statistical differences in levator muscle fiber diameter and Müller muscle fiber diameter between the 4 groups, with P = 0. 621 and P = 0.695, respectively. Conclusion: Triamcinolone acetonide combined with BTXA showed better results in decreasing upper eyelid height than TA alone in normal monkey eyelids due to its predictable effect. In addition, there were no differences between the side effects and the histology results between the 4 groups. Therefore, TA combined with BTXA may become a promising treatment for selective thyroid eyelid retraction and could offer an alternative to surgery and its complications.

Assessment of meibomian gland morphology and tear‐film lipid layer using noncontact infrared meibography and meibometry, respectively, and tear‐film osmolarity in healthy dogs

AbstractObjectiveTo further investigate quantitative and qualitative tear‐film dynamics through tear‐film osmolarity, meibometry, meibography, and non‐invasive tear‐film break‐up time and to describe a survey of parameters in normal eyes of healthy non‐brachycephalic dogs.Animals StudiedThirty‐two veterinary hospital staff and student owned dogs between 1 and 7 years with no known comorbidities or ocular disease.ProcedureComplete ophthalmic examination, tear‐film osmolarity (I‐PEN® VET), meibometry (Meibometer MB560), meibography, and non‐invasive tear‐film break‐up time (handheld Ocular Surface Analyzer) were performed. Significance threshold was 0.05. Q‐Q plots and histograms were used to assess normality of measurements. Data were summarized descriptively with mean, standard deviation, median, and interquartile range (IQR). Pearson and Spearman's correlations were used to test for correlations between diagnostics with each other and tear‐film break‐up times.ResultsThirty‐two dogs (64 eyes) met the inclusion criteria. Mean tear‐film osmolarity level was 293.6 ± 14.1 mOsm/L (IQR 282.5–302.3). Median meibomian lipid level was 30.4 Meibometry Units (MU) (IQR 11.5–59.1). Median percent loss of meibomian glands in the upper eyelids was 25.3% (IQR 13.5–26.8). Median percent loss of meibomian glands in the lower eyelids was 26.0% (IQR 13.5–52.3). Automatic assessment of meibomian gland loss showed that grade 0 was present in 4/128 (3.1%) eyelids, grade 1 in 78/128 (60.9%) eyelids, grade 2 in 30/128 (23.4%) eyelids, and grade 3 in 16/128 (12.5%) eyelids.ConclusionsTear‐film osmolarity, meibometry, meibography, and non‐invasive tear break‐up time can easily be incorporated into routine ophthalmic examinations to provide clinical information about meibomian gland morphology and function.

Orbital Septum in Lateral Canthus

ABSTRACT Purpose To disclose the precise attachment site of the orbital septum in the lateral canthus. Methods Nine specimens of 7 Japanese cadavers aged 66 to 85 years at death were included. The attachment site of the orbital septum in the lateral canthus was grossly dissected. Two of the 9 specimens were exenterated and used to explore the anatomy from lateral and superior aspects, respectively. Results The orbital septum in the lateral canthus attached slightly lateral to the outer edge of the lateral commissure with the levator aponeurosis and the lower eyelid retractors in the upper and lower regions, respectively. In addition, the orbital septum attached to the arcus marginalis with regard to the orbital bone. Fat tissue occupied the space between the orbital septum and the lateral retinaculum. Conclusion The orbital septum in the lateral canthus attached around the lateral commissure and the orbital rim.

A New Method of Orbital Septal Fat Flap in Transconjunctival Approach.

Orbital fat release is critical in blepharoplasty for correcting tear trough deformities, but traditional transconjunctival approaches often face limitations due to restricted fat volume and pedicle length. This study introduces an innovative technique by reconstructing the orbital fat flap, aiming to improve tear trough coverage and optimize Aesthet outcomes. The technique is achieved by reconstructing the orbital fat flap. To enhance fat survival, meticulous preservation of the pedicle's vascular supply was ensured during surgery. Microsurgical techniques were employed to precisely dissect and position the fat flap, ensuring full coverage of the tear trough area while maintaining facial symmetry. Postoperative follow-up was conducted to evaluate functional and Aesthet outcomes. The modified technique resulted in complete tear trough coverage and significant reduction in postoperative retraction. Patients reported improved Aesthet outcomes, with natural restoration of the lower eyelid contour and preservation of the culturally significant "Lower-lid Pretarsal Roll" appearance. No major complications such as fat atrophy or eyelid retraction were observed. This new technique for extending the orbital fat flap in blepharoplasty offers better coverage of tear trough deformities, reduces the risk of postoperative complications, and improves patient satisfaction, making it an important advancement in eye contour surgery. 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 .

“Floating Island Flap”—A New Technique for the Reconstruction of Full-Thickness Lower Eyelid Defects with Spontaneous Healing (Folded V-Y Island Flap with Orbicularis Oculi Muscle)

Background: Due to the high incidence of malignant tumors of the lower eyelids and the widespread use of surgery for their treatment, the reconstruction of tissues in this area is a frequent task for surgeons. Methods for restoring full-thickness lower eyelid defects are often invasive, pose a significant risk of complications, and do not provide optimal results. Methods: The authors developed a simple technique for the reconstruction of full-wall defects of the lower eyelids. It is a V-Y-type musculocutaneous island flap from the lower eyelid, with the orbicularis oculi muscle folded in the upper part and partially left for spontaneous healing, called by the authors a “floating island flap”. Between 2012 and 2023, 39 patients were operated on using this method. Results: Surgical procedures performed under local anesthesia were well tolerated by the patients. The healing process was quick and well accepted. Complications were rare. The most common were: eye irritation and temporary swelling of the flap. In 37 patients, proper protection of the eyeball and good esthetic results were achieved; only in two cases was the cosmetic result assessed as poor. Corneal defects occurred in two cases and healed after conservative treatment. In no cases was reoperation necessary. Conclusions: The developed method is simple and effective. It can be widely used in the reconstruction of full-thickness defects of the lower eyelids.

Commentary on: The Role of Nasal Fat Preservation in Upper Lid Surgery and Assessment With the Face-Q Questionnaire: Innovations in Upper Blepharoplasty

Commentary on: The Role of Nasal Fat Preservation in Upper Lid Surgery and Assessment With the Face-Q Questionnaire: Innovations in Upper Blepharoplasty

Approaches to Cheek Reconstruction following Mohs Surgery

AbstractThe native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Superior Eyelid Coloboma as A Manifestation of Triple X Syndrome

Superior Eyelid Coloboma as A Manifestation of Triple X Syndrome

Effect of smoking on meibomian gland among Nepalese population

Purpose of study: To investigate the effects of cigarette smoking on meibomian gland and tear function test. Methods: It was a hospital-based cross-sectional study, which enrolled examined 30 subjects with a smoking history of at least 1 year (study group) alongside 25 healthy non-smokers (control group). Each participant’s symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire. A comprehensive ophthalmological evaluation followed, which included the non-invasive tear breakup time (NITBUT) and Schirmer test (with anesthesia). Additionally, we conducted a detailed analysis of the meibomian glands in both the upper and lower eyelids using meibography, employing the advanced Sirius anterior segment analysis system. Results: Participants in the study group averaged a smoking history of 6.94 ± 6.73 pack years. The mean OSDI score was 36.45 ± 10.60 in the study group, compared to 31.41 ± 8.12 in the control group (P = 0.05). For the NITBUT and Schirmer test, the study group recorded values of 9.54 ± 5.89 seconds and 14.77 ± 9.39 mm, respectively, while the control group showed 9.95 ± 6.15 seconds and 19.08 ± 7.08 mm (P = 0.85 and P = 0.03, respectively). Upper lid meibography revealed a 55.40 ± 10.10% gland loss in the study group, significantly higher than the 46.33 ± 14.70% observed in the control group (P = 0.01). However, no statistically significant difference was found in lower lid meibomian gland loss between the groups, with the study group at 54.08 ± 9.71% and the control group at 51.41 ± 17.24% (P = 0.49). Conclusion: Smoking results in meibomian gland damage which may be a risk factor for dry eye. In cases of ocular surface disorders related to chronic smoking, meibomian gland damage should be taken into consideration.

The Effect of Eyelid Laxity on Corneal Mapping and Corneal Topography

Purpose To evaluate the effect of eyelid laxity on the structure of the cornea. Methods This was a retrospective study performed in one institution. Patients with and without upper and lower eyelid laxity, which were determined using the snap-back test (SBT) and the upper eyelid distraction test (LDT), were evaluated for corneal structural changes with Scheimpflug imaging corneal tomography for the keratometric readings, and cor-neal spectral domain optical coherence tomography for the epithelial thickness (ET) measurements. The ET values were obtained using the statistics report for the superior quadrant (SET), the inferior quadrant (IET) within the 2- to 7-mm region, and central thickness (CET) within the 2-mm region. The minimum corneal thickness values within the central 5-mm region (MinCT) were also included in the study. Keratometric readings (in diopters), horizontal white-to-white (HWTW) measurements, pachymetry, and ET measurements were assessed along with the presence or absence of eyelid laxity. Results A total of 170 eyes from 85 patients were evaluated (50.6% with eyelid laxity, and 49.4% without eyelid laxity). There was no significant difference between the mean keratometric readings, HWTW, and the mean IET and CET values ( P > .05); however, the difference was significant for the MinCT and SET ( P < .05). A statistically significant negative correlation was found between the SET values and age, LDT, and SBT measurements ( P < .05). Conclusions A strong association was found between decreased SET and MinCT values and eyelid laxity. The possible reason for these decreases may be inflammation, which plays a role in the pathophysiology of eyelid laxity. [ J Refract Surg . 2024;40(11):e783–e791.]

A comparative study on the lipid layer thickness analysis of medical staff before and after work.

To study the change of the lipid layer thickness analysis in medical staff (MS) before and after work, and to explore the significance of measuring lipid layer thickness (LLT) respectively in four quadrants. Ocular Surface Disease Index (OSDI) questionnaire and video display terminal using time for 55 MS were collected (the informed consent was obtained from all patients). Noninvasive tear break-up time, LLT, tear meniscus height (TMH), meibomian glands (MG) dropout, and blink pattern before and after work (worked for more than 4 h) of 110 eyes were measured by Gaush iDea Ocular surface analyzer. Lid margin abnormalities were evaluated by the slit-lamp microscopy. The average OSDI score of 55 MS was 25.68 ± 14.91. The average LLT of 110 eyes after work (65.12 ± 3.63 nm) was significantly reduced compared to before work (66.54 ± 4.16 nm), p < 0.05. The LLT in the superior quadrant was significantly thinner than that in the other three quadrants, p < 0.01. The average LLT was positively correlated with the LLT in the inferior (r = 0.822, p < 0.001), nasal (r = 0.261, p < 0.001), and temporal quadrant (r = 0.372, p < 0.001), while was negatively correlated with the MG dropout in lower lid (r = -0.209, p = 0.002). There was a significant correlation between the LLT in the inferior quadrant and the VDTt (r = -0.173, p = 0.01). The LLT of inferior quadrant were positively related to the TMH (r = 0.149, p = 0.027) and negatively related to MG dropout in lower lid (r = -0.162, p = 0.017). The LLT significantly decreases after work in MS. The distribution of the lipid layer on the ocular surface is uneven. It is unreasonable for current detection instruments to measure the inferior quadrant LLT alone to represent average LLT.

Foreign-body granuloma formation in the lower eyelid after injection of poly-D,L-lactic acid as a collagen stimulator: a case report

Poly-D,L-lactic acid (PDLLA) is widely used in facial rejuvenation as a collagen stimulator, with a lower risk of granuloma formation compared to poly-L-lactic acid (PLLA). However, granulomas may still occur. In this case, a 58-year-old woman developed firm, non-tender, bilateral infraorbital granulomas 2 months after her third PDLLA injection for infraorbital hollowing. The lesions were unresponsive to intralesional trichloroacetic acid (TCA) and intense pulsed light therapy, necessitating surgical removal. Histopathological analysis confirmed foreign-body granulomas caused by the PDLLA filler. This case highlights the need for caution when injecting PDLLA into thin-skinned areas like the infraorbital region, where granulomas can be more visible due to limited tissue volume. Although PDLLA fillers are generally safe, granuloma formation remains a potential complication. Early diagnosis and treatment with non-surgical methods, such as intralesional TCA, should be prioritized. If these methods fail, surgical excision, aimed at preserving as much normal tissue as possible, may be necessary for optimal outcomes.

Effective encoder-decoder network for pupil light reflex segmentation in facial photographs of ptosis patients

Accurate segmentation of pupil light reflexes is essential for the reliable assessment of ptosis severity, a condition characterized by the drooping of the upper eyelid. This study introduces a novel encoder-decoder network specialized in reflex segmentation by focusing on addressing issues related to very small regions of interest from an architectural perspective. Specifically, the proposed network is designed to exploit low-level features effectively by integrating a multi-level skip connection and a 1 × 1 convolution-enhanced initial encoding stage. Assessed using a photograph image dataset from Chung-Ang University Hospital, which includes 87 healthy subjects, 64 with ptosis, and 257 with Graves’ orbitopathy (collected between January 2010 and February 2023), the proposed network outperforms five conventional encoder-decoders. Over 30 trials, the proposed network achieved a mean Dice coefficient of 0.767 and an Intersection over Union of 0.653, indicating a statistically significant improvement in the segmentation of reflex. Our findings show that an elaborate design based on the lowest-level skip connection and 1 × 1 convolution at initial stage enhances the segmentation of pupil light reflexes. The source code of the proposed network is available at https://github.com/tkdgur658/ReflexNet.

Human Vision as A Multi-Circuit Mathematical Model of the Automated Control System

Abstract The paper contains a proposal an original, extended mathematical model of an automatic system of human vision reaction to a forcing light pulse. A comprehensive mathematical model of the vision process was proposed in the form of an equation described in the frequency (dynamics) domain. Mathematical modelling of human senses is very important. It enables better integration of automation systems with a human cooperating with them, also as an automation system. This provides the basis for reasoning based on a mathematical model instead of intuitive reasoning about human reactions to visual stimuli. A block diagram of the proposed system with five human reaction paths is given. The following can be distinguished in the scheme: the main track consisting of: the transport delay of the eye reaction, the transport delay of the afferent nerves, the inertia of the brain with a preemptive action, the transport delay of the centrifugal nerves and the inertial and transport delay of the neuromotor system. In addition, the scheme of the system includes four tracks of negative feedback of motor and force reactions: upper eyelid, lower eyelid, pupil and lens. In the proposed model, the components of each path along with their partial mathematical models are given and discussed. For each reaction path, their overall mathematical models are also given. Taking into account the comprehensive models of all five reaction paths, a complete mathematical model of the automatic system of human reaction to a forcing light impulse is proposed. The proposed mathematical model opens up many possibilities for synchronizing it with mathematical models of many mechatronics and automation systems and their research. Optimizing the parameters of this model and its synchronization with specific models of automation systems is difficult and requires many numerical experiments. This approach enables the design of automation systems that are better synchronized with human reactions to existing stimuli and the selection of optimal parameters of their operation already in the design phase. The proposed model allows, for example, accurate determination of difficulty levels in computer games. Another example of the use of the proposed model is the study of human reactions to various situations generated virtually, for example in flight simulators and other similar ones.

Ocular manifestations in neurofibromatosis: A case series

Background: A collection of inherited diseases known as neurofibromatosis (NF) are distinguished by a broad spectrum of clinical manifestations. A genetic mutation on chromosome 17 (17q11.2) is the cause of NF type 1 (NF1), whereas a mutation on chromosome 22 (22q12.2) is the cause of NF type 2 (NF2). In NF1, ocular symptoms are more frequent. Patients with NF1 commonly appear with globe enlargement, glaucoma, and orbital facial involvement. Palpebral neurofibromas have the potential to grow extensively and, in rare instances, develop into malignant tumors. Optic nerve gliomas can result in strabismus and proptosis. Up to 80% of patients with NF2 may experience early-onset cataracts, optic nerve hamartomas, and mixed pigment retinal and epithelial hamartomas. Case presentation: We present four cases of neurofibromatosis, each displaying typical clinical features of the disorder. · Case 1: A 28-year-old male presented with headaches, reduced vision, and multiple tiny discolorations in both eyes for six months. Examination revealed multiple hyperpigmented skin lesions (2-5 mm) across his body, and ocular assessment showed normal pupillary reactions and distant vision of 6/6 in both eyes. Slit-lamp examination identified multiple dome-shaped lesions on the iris, consistent with Lisch nodules. · Case 2: A 42-year-old female experienced reduced vision for six months and skin lesions for five years. Examination revealed multiple discrete skin-colored papules and café-au-lait macules on her hands. Her vision was 6/12 in both eyes, with normal pupillary reactions. Slit-lamp findings were also consistent with Lisch nodules. o Case 3: A 48-year-old male reported vision loss in both eyes over two months, accompanied by swelling of the right upper eyelid, which was increasing in size. Lisch nodules were found on the iris of the left eye, and he was diagnosed with typical NF. o Case 4: A 38-year-old male presented with diminished vision. Slit-lamp examination revealed multiple dome-shaped lesions on the iris, suggesting Lisch nodules, along with skin lesions on the face and other body areas Conclusion: Managing neurofibromatosis requires a multidisciplinary approach, involving close collaboration between healthcare providers. Monitoring visual prognosis, enrolling patients in clinical trials, and regular disease monitoring are essential steps in managing the condition.

Depictions of Aging in a Self-Portrait by David Bailly (1584-1657).

I present a case involving a portrait of David Bailly, containing 2 images portraying changes over a period of ∼40 years, and I compare the facial features that illustrate the aging process. He was 67 years old when he painted "Self-Portraits With Vanitas Symbols" (1651). By juxtaposing past representations with present reality, the painting suggests that the young artist is contemplating his future aging. The young man, appearing so vividly within the painting's immediate reality, actually symbolizes a bygone era Compared with the young portrait, the older portrait exhibits a slightly drooped eyebrow tail, indicative of brow ptosis. In the young portrait, the lid margin is aligned with the upper border of the iris, whereas in the older portrait, it is aligned with the upper border of the pupil. The margin reflex distance 1 decreases with age. In addition, the older portrait shows baggy lower eyelids. The nasojugal groove is more pronounced, and the nasolabial fold is deeper. The beard and mustache are more extensive, and silver strands are interspersed among the black hairs. Presenting 2 images from a 40-year interval, the older portrait exhibits more pronounced signs of facial aging than the younger portrait. Portraits from that era, whether painted by western or eastern artists, demonstrate that the painters had an understanding of facial skin lines and the aging process. The process of creating portraits provides insights into historical contexts and remains significant in contemporary settings, particularly concerning perceptions and identity.

Asymptomatic, slowly progressing erythematous papules with adult onset.

A 35 year old woman presented with sudden onset of multiple asymptomatic erythematous papules on her dorsal feet followed by a 2 year period of additional lesions appearing on ankles, right forearm and right superior eyelid.

Clinical Practice Patterns and Evidence-Based Medicine in Blepharoplasty: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

The American Board of Plastic Surgery (ABPS) Continuous Certification tracer data on blepharoplasty offers valuable information on national trends in clinical practice. The present study was performed to analyze evolving trends in blepharoplasty and compare practice patterns to Evidence-Based Medicine (EBM) publications within the same timeframe. Tracer data for blepharoplasty procedures performed by ABPS-certified surgeons between 2005 and 2020 was analyzed. Data between two timeframes, 2005-2014 (early cohort, EC) and 2015-2020 (recent cohort, RC), were compared to identify evolving trends in blepharoplasty over time. Results were then compared to EBM-based publications. Of 3,050 blepharoplasties (1,510 EC; 1,540 RC), 82% were performed in female patients and the average age was 56 years. Blepharoplasty was most frequently performed in an ambulatory setting (56%) compared to in hospital (25%); significantly more cases are being performed in the office (p< 0.001) in the RC compared to the EC. Mean surgical duration has decreased by 13 minutes (p< 0.001), and fewer surgeries are being performed with concomitant procedures (p< 0.001). Fewer surgeons use antibiotics (p< 0.001), and fewer surgeons use DVT prophylaxis in the form of sequential compression devices after anesthesia (p< 0.001). More skin resections were performed for upper blepharoplasties (p=0.016), while fewer cases of lower lid blepharoplasty involved either skin-muscle flaps (p=0.038) or transcutaneous fat removal (p=0.004). Most surgeons did not perform canthal tightening during their blepharoplasty (82%). A review of over 15-years of ABPS blepharoplasty tracer data allows surgeons to compare their practice with national trends and EBM. The tracer data illustrates a shift in technique towards shorter and simpler procedures in the office setting.