Pretarsal Skin Research Articles

Modified Anterior Lamellar Recession for All Grades of Upper Eyelid Trachomatous Cicatricial Entropion.

This study aims to assess the combination of anterior lamellar recession (ALR) with blepharoplasty, suprasternal fixation, and internal eyelash bulb extirpation of aberrant lashes posteriorly located in patients with any grade of upper eyelid trachomatous cicatricial entropion. We reviewed the clinical data of eighty-six patients (143 eyelids) including age, gender, systemic medical illnesses, and comprehensive ophthalmological assessment. Eyelid evaluation was recorded, including laterality, previous surgical technique used, possible trichiasis etiology, abnormality of the lid margin, tarsal plate consistency (shrinkage or loosening), skin fold overhanging, laxity of the pretarsal skin, margin reflex distance 1 (MRD1), lagophthalmos, and lid retraction. The success rate was assessed at 3, 6, 9, and 12 months postoperative. The success rate was 97.2% in the third month, which decreased significantly to 92.3% in the 6th month and 90.2% in the 9th month (P = 0.01, and 0.001 respectively). In the 9th month, we had fourteen failed cases. All of them were submitted for a second intervention. Three underwent electrolysis, four cases underwent re-internal bulb extirpation, four cases underwent the same procedure, and three cases underwent epilation. The success of the failed cases after the second intervention was significantly associated with the type of reintervention (P = 0.03), in which all of them succeed except two cases that underwent epilation. Kaplan-Meier analysis showed that the mean recurrence time in our study was 6.8 months (95% CI = 5.8-7.7 months). This study showed the combination of ALR with blepharoplasty, suprasternal fixation, and cauterization or internal bulb extirpation of posteriorly located lashes procedure resulted in a high success rate in patients with any form of UCE with no increase in incidence or degree of lagophthalmos associated with UCE.

The Adherence of Skin and Levator Palpebrae Superior Is Not Necessary in Blepharoplasty of Asian Patients.

Formation of the double eyelid involves insertion of the levator aponeurosis to the pretarsal skin of the upper eyelid. In single eyelids, this structure is absent.1 In upper blepharoplasty, doctors try to rebuild the connection of skin to the levator palpebrae superior,2–5 making the procedure a “physiological reconstruction.” However, some phenomena cannot be explained by theories that exist. First, sagging skin may also appear like a double-fold eyelid. Second, the use of a double eyelid patch (consisting of viscous membranes derived from soft plastics) can also form a double eyelid appearance. (See Video 1 [online], which displays the usage of a double eyelid patch to form a double eyelid appearance.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"displays the usage of a double eyelid patch to form a double eyelid appearance.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_hx4pc6xo"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Third, in the method used by Park and Park,2 the skin and levator aponeurosis were not directly sutured, yet double eyelids could still be formed. Fourth, incision sutures were removed 5–7 days postoperatively, at which time no reliable connection was formed between the skin and levator. Therefore, although the levator is the motor system of lid crease formation, we speculate that a direct connection between the skin and levator is unnecessary for double lid formation. During the past 2 years, 126 patients received upper blepharoplasty without suturing of the skin to the levator palpebrae superior. The incision is about 5–7 mm above the upper eyelid margin. During this procedure, a proportion of skin, the orbicularis oculi, and pretarsal tissues are removed. After stretching the skin and orbicularis oculi muscles and maintaining a certain tension, a 7-0 prolene or premilene suture was used to fix these skins and muscles to the pretarsal tissue. (See Video 2 [online], which displays the procedure of blepharoplasty.) As a result, the skin and orbicularis oculi can move as a unit. More extensive scar adherence can provide stable fixation.2 All patients were satisfied with the outcome of upper blepharoplasty. Figure 1 shows a patient who received blepharoplasty. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"displays the procedure of blepharoplasty.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_neffrl80"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Photographs of a 21-year-old female patient who recieved blepharoplasty. A, Preoperation. B, Six months after blepharoplasty.Based on these doubts and results, stable blepharoplasty relies on two conditions. First, the tissue below the incision must be kept moving, as a unit. If the aponeurosis of the levator is loose, suturing the skin to the aponeurosis can easily cause narrow lid crease width and a puffy appearance after surgery. Keeping the skin-orbicularis oculi-tarsal plate as a unit can solve this problem. Second, when the upper eyelid rises to a certain height, the skin, together with tarsal, moves posterosuperiorly and the tissues on both sides of the incision move in different directions, under the action of the incision suture or scar. In patients with severe depression of the upper eyelid, it is difficult to produce this difference in direction, so the double eyelid is also difficult to form. These two conditions are indispensable for the formation of double eyelids. Although these views still need theoretical support, the causes of lid crease formation need to be further discussed. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT Patients provided written consent for the use of their images.

Orbicularis-Tarsus-Orbital Septum Fixation Technique in Asian Double-Eyelid Blepharoplasty: a Retrospective Study.

The skin-tarsus-skin and orbicularis-levator fixation approaches are the 2 most applied techniques for double-eyelid blepharoplasty in China. However, both approaches have their own disadvantages. To achieve stable and dynamic upper eyelid creases, we take the merits of the 2 techniques. In this study, our orbicularis-tarsus-orbital septum fixation technique is introduced and evaluated. By transversely opening and turning down the anterior orbital septum, we created the septum roll anchored to the tarsus and the pretarsal muscular flap. As the motion transmitter, the roll could receive the pulling power of the levator aponeurosis transmitted to the tarsus and the septum respectively. With the help of the skin-septum roll-skin sutures, the roll passed on the pulling power directly to the pretarsal skin and thus the upper eyelid crease was formed. This study identified 105 Chinese patients (210 eyes) who underwent this technique in our department between September 2020 and May 2021. The follow-up ranged from 7 to 15 months. 90, 6, and 7 patients were satisfied, somewhat satisfied, and somewhat unsatisfied with the postoperative outcome, respectively. The satisfaction rate was 91.43% (96/105). Two patients were unsatisfied with the outcome, including 1 case of bilateral crease disappearance and 1 case of sunken upper eyelid. The orbicularis-tarsus-orbital septum fixation technique is safe and effective for double-eyelid blepharoplasty. This technique helps to form stable upper eyelid creases. Meanwhile, it is easy to achieve ideal curve and symmetry. By preserving the pretarsal tissue and using the orbital septum, sunken scar formation can be avoided.

Patient satisfaction and surgical outcomes after upper eyelid blepharoplasty in Turkish population

This retrospective study was conducted to review the patient satisfaction and surgical outcomes in Turkish patients with dermatochalasis who underwent upper eyelid blepharoplasty alone or in combination with orbital fat pads removal or browpexy, by comparing them with the outcomes of the previous landmark studies on upper eyelid blepharoplasty. One hundred and sixteen eyes of 58 patients were included in this study. The mean age and the mean follow-up time were 60.1±10.4 (38-77) years and 2.4±1.8(1-6) months, respectively. Of 58 patients, 27 had blepharoplasty alone, 18 had blepharoplasty with orbital fat pads removal, and the remaining 13 had combined blepharoplasty and browpexy surgery. The female ratio (88.9%) was significantly higher in the upper eyelid blepharoplasty with orbital fat pad removal group compared to the other groups (p=.024). From baseline to final visit, margin-reflex distance increased from 2.1±0.8 mm to 3.7±0.8 mm, and blepharoplasty outcomes evaluation (BOE) score from 28.9±6.2 to 76.8±14.1 (both p<.001). Change in BOE score between pre- and post-surgery was significantly higher in patients undergoing combined blepharoplasty and browpexy surgery compared to the other groups. The mean final pretarsal skin height and brow-lid crease distance were 6.8±1.2 mm and 11.1±1.3 mm, respectively. In conclusion, upper eyelid blepharoplasty had favorable anatomical outcomes when performed as single procedure or in combination with other procedures. However, patients became more satisfied after combined blepharoplasty and browpexy compared to the other surgical procedures.

Usefulness of mirror image processing software for creating images of expected appearance after blepharoptosis surgery

PurposeThis study aims to evaluate the usefulness of creating images of expected appearance after blepharoptosis surgery using mirror image processing software.MethodsThis prospective, observational study included 60 sides from 30 patients with bilateral aponeurotic blepharoptosis who underwent levator resection or aponeurotic repair on both sides. Before surgery, facial photographs were taken after the eyelid on one side was lifted with a curved hook. The mirror images were created from these photographs and were merged with the original photographs for making the whole facial images, which were shown to each patient at the preoperative counseling. At 1 month postoperatively, we asked patients about the usefulness of the mirror images to predict the postoperative appearance at the preoperative counseling and the similarity between the expected and the resultant postoperative appearance using questionnaires. Margin reflex distance-1, eyebrow height, and pretarsal skin height measured on predictive images were compared with those measured at 1 month postoperatively.ResultsTwenty-nine patients (96.7%) favorably responded to the usefulness of the mirror images to predict the postoperative appearance, and twenty-five patients (83.3%) accepted the similarity between the expected appearance and the actual postoperative appearance. The predictive images showed significantly lower margin reflex distance-1, higher eyebrow height, and higher pretarsal skin height than the postoperative results (P < 0.001).ConclusionThe creation of expected postoperative images was a useful simulation procedure before blepharoptosis surgery for patients to predict the probable postoperative appearance.

Photogrammetric Analysis of Eyebrow and Eyelid Dimensions in Indian American Adults.

In cosmetic surgery, knowledge of the average dimensions of periorbital features based on gender and ethnicity is essential to improve the patient appearance and maintain the ethnicity. The aim the study was to establish gender-specific periorbital anthropometric and anthroposcopic data for Indian Americans (IA) and to assess the statistically ethnic differences by comparing with published data of Malaysian Indians (MI). Evaluation of periorbital features was done on the standardized frontal photographs of 400 IA, aged 18 to 26 years. The measured values were evaluated by an independent t-test. Sexual dimorphism was found in all 15 measurements. The eyebrow height, combined height of the orbit and eyebrow, eyebrow apex inclination, apex to lateral canthus distance, medial end of brow to medial canthus distance, lateral end of brow to lateral canthus distance; pretarsal skin height, palpebral fissure height, palpebral fissure inclination (PFI), and medial canthus tilt were significantly greater in female than the males. In males, eyebrow apex hairline distance, apex to lateral limbus distance, eyebrow apex angle (EAA), lower eyelid height, and interpupillary distance was significantly greater than the females. Significant ethnic difference was found between IA and MI for eyebrow height, apex to lateral limbus distance, EAA, palpebral fissure height, and PFI in male group. In female group, EAA, medial canthus tilt, and PFI were significantly greater in MI. Four types of epicanthus were observed and the brow apex between lateral limbus and lateral canthus was the most common position. The generated normative data may be useful during diagnosis and treatment planning.

Supraciliary Incision as a New Double-Eyelid Approach for Asian Patients: Clinical Experience of 528 Cases.

The double-eyelid operation is the most requested cosmetic surgery in Asians. The incision is usually located at the pretarsal skin 6mm to 8mm above palpebral margin. The purpose of this paper is to report a novel approach of double-eyelid operation through a supraciliary incision (SCI). Three transverse curved lines were drawn on the upper lid skin. The location of line 1 (SCI) was 1.5mm above the eyelash, line 2 according to the amount of redundant skin excised and line 3 at 3mm to 4mm above line 2. After the incisions were made between line 1 and line 2, the subcutaneous dissection is carried out over 5mm the line 3. Then, the redundant skin and a strip orbicularis oculi muscle were removed to open the orbital septum and to explore underside levator aponeurosis. Along the line 3, the internal buried fixation sutures between dermal tissue and the fusion line of the orbital septum and levator aponeurosis were placed. Finally, the wounds were closed between line 2 and line 1. There were 528 patients who underwent the double-eyelid operation through the supraciliary approach. In long-term follow-up, 288 patients were evaluated at 6months to 78months postoperatively. Of those, 266 patients were satisfactory for the result (92.36%) with natural shape and invisible surgical scar. In another 22 patients (7.63%), a revised blepharoplasty was performed in 22 eyelids. The double-eyelid surgery using the SCI has several advantages including less visibility of the incision, the protected subdermal vascular network, the intact continuity of the upper eyelid skin, the combination of the SCI and internal dermal buried suture method. The approach can be considered an efficient technique for Asian patients. 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 .

Dual-plane epicanthoplasty in Chinese blepharoplasty.

The ethnically characteristic upper eyelids of many Chinese individuals include medial epicanthal folds, substantial fatty tissue, a laxity of pretarsal skin, and a lack of superior palpebral folds. Different epicanthoplasty techniques have been described in the literature. However, postoperative medial canthal scarring remains a concern. This article introduces a novel technique that minimizes the risk of postoperative canthal scarring. Dual-plane epicanthoplasty involves an advanced skin flap and a rotation skin flap, which are, respectively, distributed on the outer skin lining and inner skin lining and belong to the different three-dimensional planes of the epicanthus. The dense connective fibers located between the skin and the orbicularis oculi muscle were completely released. In the final steps, the upper advanced triangle flap was anchored in the direction of the lacrimal caruncle and the lower rotation triangular flap was anchored to the nasal skin. From January 2016 to September 2018, 216 patients were enrolled in the cohort undergoing dual-plane epicanthoplasty, with 172 patients undergoing the concomitant double eyelidplasty. For 206 of the cases, follow-up lasted for over 6months, with a median time of 11months. Except for one patient (0.49%) who may need a revision procedure for a prominent scar, all other patients (99.51%) achieved natural and cosmetically desirable appearances with adequate lacrimal caruncle exposure and minimal postoperative medial canthal scaring. Dual-plane epicanthoplasty, with or without double eyelidplasty, is a novel and effective surgical technique modified for Chinese patients with good esthetic outcomes.

Upper Eyelid Filling Approach [U.E.F.A.] Technique: State of the Art After 500 Consecutive Patients.

Lately, it has become evident that eye physical aging is mainly due to depletion of the upper eyelid fat causing laxity and wrinkles of the eyelid skin, and new therapeutic strategies aimed at solving the volume loss have appeared in the literature. The aim of this study is to provide a clear classification of upper eyelid aging after 500 consecutive cases and to present a standardization of the therapeutic approach to be adopted when using hyaluronic acid (HA) as fillers or a surgical approach. The upper eyelid aging process of a total of 500 patients was classified based on the measurement of the pre-tarsal skin show m and the pre-septal skin show N. A total of 382 patients were treated exclusively with HA injections in the upper eyelid, 45 patients both with blepharoplasty surgery and HA filling, whereas only 73 patients underwent blepharoplasty only. Patient satisfaction and at least 1-year clinical follow-up were used to evaluate the results. Pre-treatment and post-treatment photographic assessment was considered as well. A total of 447 patients were women, whereas 53 were men. The correct ratio between m and N was restored in all cases. HA filling can be used as either the only volumization procedure or together with blepharoplasty to restore upper eyelid volume loss. The correct strategy has to be selected on the basis of a clear classification. The upper eyelid filling approach is a safe, manageable, lasting and low-cost technique providing excellent results when the correct procedure is followed. 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 .

Pretarsal skin height changes in children receiving topical prostaglandin analogue therapy for primary congenital glaucoma

To compare pretarsal skin height (PTSH), as proxy indicator of deepening of the upper eyelid sulcus, in children with primary congenital glaucoma (PCG) treated with topical prostaglandin analogues (PGAs) with PTSH in healthy children (control group 1) and children with PCG but not using PGAs (control group 2). We recruited children with PCG who had been using PGAs for at least 6months (PCG/PGA group). PTSH in all participants was measured using ImageJ software from photographs taken in a standardized manner. The PTSH was compared for the PCG group and both control groups. A total of 34 children with PCG and 41 controls (31 in group 1; 10 in group 2) were included. The difference in PTSH between children in the PCG/PGA group and both control groups was statistically significant (mean difference, ≥1.7mm [P<0.01]). The PTSH was significantly greater in children with PCG using PGAs compared to children with PCG not using PGAs and healthy children. Children and their parents should be counseled about lid abnormalities prior to commencing treatment with PGAs.

Modifications of Z-Epicanthoplasty Combined with Double-Eyelid Blepharoplasty in Asians.

Epicanthoplasty combined with double-eyelid blepharoplasty is one of the most popular cosmetic procedures in Asians. However, the postoperative medial canthal scar is a concerned issue. Here the authors adopted some modifications of Z-epicanthoplasty to minimize the canthal scar. Modifications of Z-epicanthoplasty were mainly in three aspects. First, supratarsal creases were created before epicanthoplasty to prevent the impact of tension variation on epicanthal incisions, caused by elevating and tightening of the upper eyelid skin. Second, one triangle flap was determined according to the transposition of another one in Z-plasty, and hence, it can be guaranteed that the incisions were closed free of tension with more accuracy and less injury to surrounding tissues. Third, linear scar contracture was avoided by adopting discontinuous incisions, and the resulting skin bulge was eliminated by making an additional stitch to anchor the pretarsal skin on the tarsal plate. The follow-up interval was 1month to 2years, with a median of 6.5months. From January 2012 to December 2015, 237 female and 4 male patients received the surgery. Except five (2.07%) patients, who were not satisfied with the color of incision scars in medial canthal area, none complained about scars 6months after surgery. The appearance of the supratarsal crease was natural, and the medial canthal scar was inconspicuous in close observation at 2years. The modifications of Z-epicanthoplasty are safe and effective. It is potentially helpful to minimize postoperative medial canthal scars. 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 Prevalence of Double Eyelid and the 3D Measurement of Orbital Soft Tissue in Malays and Chinese

This study aimed to determine the prevalence of double eyelid among two main Mongoloid ethnicities, the Malays and Chinese who reside in Malaysia. We also measured their periorbital tissue parameters for application in anthropology, optometry, ophthalmology, oculoplastic surgery and maxillofacial trauma surgery. The images of the 103 Malay and 97 Chinese volunteers were captured using indirect 3D photogrammetry, and quantitative measurement was obtained using the software provided by the manufacturer. All Malays and 70.1% of Chinese in this cross section population had double eyelid on both eyes. The mean pretarsal skin height was 3.99 mm for the Malays and 2.29 mm for the Chinese. The Malays appeared to have shorter eyebrow height (11.10 mm) compared to the Chinese (11.79 mm). An opposite pattern could be seen in the measurement of upper eyelid crease height between the Malays (8.33 mm) and the Chinese (4.91 mm). Of note, the intercanthal distance of the Chinese (IDC = 35.85 mm) was wider and their interpupillary distance was narrower (IPD = 62.85 mm) compared to the Malays’ (ICD = 34.21 mm; IPD = 64.04 mm). In conclusion, there were significant differences in the prevalence of double eyelid and periorbital tissue measurements between the Malays and Chinese.

Periorbital Soft Tissue Anthropometric Analysis of Young Adults.

The authors aim to determine the periorbital soft tissue anthropometric norms for Turkish young adults for right and left eyes using a noninvasive two-dimensional photogrammetric analysis. Anthropometric measurements of the periorbital soft tissue were taken from 172 female and 56 male Turkish adults aged between 18 and 24 years. The periorbital soft tissue profiles (ocular and palpebral) for males and females were digitally analyzed using linear measurements made with standardized photographic records, taken in a natural head position. Statistically significant differences were found for ocular soft tissue measurements according to gender except inner intercanthal distance (P = 0.125) and right horizontal palpebral aperture (P = 0.240). Statistically significant differences were found for palpebral soft tissue measurements according to gender except right pretarsal skin height (P = 0.112) and left pretarsal skin height (P = 0.056). Results were compared with other ethnic groups. Normal periorbital soft tissue measurements are fundamental anatomical parameters utilized in ophthalmology, optometry, ophthalmic industry, oculoplastic surgery, clinical genetics, dermatocosmetology. Further, normal anthropometric measurements generate reference data for studies in craniofacial dysmorphology, oculoplastic surgery, dermatocosmetology, and comparative physical anthropology.

Infrabrow Skin Excision Associated With Upper Blepharoplasty to Address Significant Dermatochalasis With Lateral Hooding in Select Asian Patients.

In Asian patients, lateral hooding in the aging upper eyelid is prominent and frequently seen. Removal of the redundant skin of this region during classic blepharoplasty tends to produce a resultant prolonged scar. Furthermore, as the height of the eyelid skin excision increases, suturing of the thick upper skin to the thin pretarsal skin can result in upper lid fullness. This study documents the combination of infrabrow skin excision and upper blepharoplasty to address lateral hooding in select patients of Asian ancestry. This study is a retrospective chart review of patients who underwent infrabrow skin excision associated with upper blepharoplasty. The inclusion criteria were moderate and severe upper eyelid dermatochalasis in patients with high eyebrows and lateral hooding; residual lateral hooding following previous blepharoplasty. Thirty-two eyelids of 16 female patients of Japanese ancestry underwent infrabrow skin excision associated with upper blepharoplasty. The mean age of patients was 68.87 ± 7.88 years (57-82 years). Mean follow up was 37.25 ± 18.96 months (9-72 months). Patients were evaluated at 1, 3, 6, and 9 months at least. The Strasser system for evaluation of surgical results was applied at 3 months. All patients had scores indicating good results and were satisfied with the cosmetic outcome and improvement of visual field after surgery. No complications related to wound dehiscence, lagophthalmos, hypertrophic scars, or sensory changes were observed. The combination of infrabrow skin excision and upper blepharoplasty was effective to address moderate and severe dermatochalasis with lateral hooding in select patients of Japanese ancestry.

Upper Eyelid Fractional CO2 Laser Resurfacing With Incisional Blepharoplasty.

Laser resurfacing, performed at the same time as blepharoplasty, has most commonly been applied to the lower eyelid skin but can effectively be used on the upper eyelid to reduce rhytidosis and improve skin quality. The authors evaluate the safety and efficacy of this procedure. Fractional CO2 laser resurfacing was performed in conjunction with incisional upper blepharoplasty. The ultrapulsed laser energy was applied to the sub-brow skin, the upper medial canthal skin, and the pretarsal skin in 30 patients. Photos were obtained preoperatively and at 3 months. All patients demonstrated reduction in upper eyelid rhytidosis without any serious complications. Independent rhytidosis grading (0-4) showed a mean improvement of 42%. One patient experienced wound dehiscence that satisfactorily resolved without intervention. Upper eyelid laser resurfacing is effective and can be safely performed at the same time as upper blepharoplasty. This approach reduces or eliminates the need for medial incisions to address medial canthal skin redundancy and rhytidosis and it directly treats upper eyelid wrinkles on residual eyelid and infra-brow skin during blepharoplasty.

Combined Subbrow Excision with Upper Blepharoplasty Using a Tadpole Shaped Excision for Blepharochalasis

Background In efforts to solve blepharochalasis, induced by aging process, various surgical methods have been developed over the years. Among them, classical upper blepharoplasty has a problem that severe lateral hooding may be restricted in making correction, cause of difference in thickness between the pretarsal skin and subbrow skin. And also subbrow excision (SE) blepharoplasty cannot be easily corrected in severe drooping of the medial skin. In an effort to make up for the disadvantages of these methods, we attempted SE-tadpole shaped excision blepharoplasty (TSEB). Methods Fifteen patients underwent SE-TSEB from January 2013 to November 2014. SE-TSEB was performed the following cases: 1) patients who showed moderate to severe blepharochasis with severe lateral wrinkles; 2) patients with a history of pre-existent SE blepharoplasty; 3) patients with a tattoo on the eyebrows, who want to make revision; and 4) patients with eyelid skins that are thick or have overly protuberant fat pads of the retro-orbicularis oculi fat (ROOF), and have a plan to extirpate them. Results During the follow-up observation period, most patients showed amicable correction of visibility difficulty and were aesthetically satisfied with the postoperative results with respect to correction of the lateral wrinkles. Scars formed in the subbrow incision line were within the scope of management. Conclusions SE-TSEB is a treatment modality that overcomes the disadvantages and limitations of classical upper blepharoplasty and SE blepharoplasty. Furthermore, maximizing the advantage of each surgical approach is another innovative approach for correction of changes in the upper eyelid, induced by aging. Keywords: Blepharochalasis, Blepharoplasty, Eyelids

Photogrammetric Analysis of Eyebrow and Upper Eyelid Dimensions in South Indians and Malaysian South Indians

The eyebrow and eyelid are important sexually dimorphic and ethnic features of the face. In cosmetic surgery, maintenance of these landmarks is important to obtaining satisfactory results. The authors quantify the dimension and position of the eyebrow and eyelid in South Indians and Malaysian South Indians and assess whether significant differences exist between the sexes and ethnic groups. Evaluation of eyebrow and upper eyelid was performed on standardized photographs of 200 South Indian and 200 Malaysian South Indian subjects, aged 18 to 26 years. We measured eyebrow thickness, apex to lateral limbus distance, apex to lateral canthus distance, interbrow distance, medial end of the eyebrow to medial canthus, lateral end of the eyebrow to lateral canthus, eyebrow height, eyebrow apex inclination, and pretarsal skin height. The measured values were evaluated by an independent t test. We also assessed the prevalence of double lid crease and types of epicanthus and eyebrow apex positions. A significant difference was found between women in the South Indian and Malaysian South Indian groups for eyebrow apex to lateral limbus distance, medial end to medial canthus, pretarsal skin height, eyebrow height, and eyebrow apex inclination. Male groups showed significant ethnic difference for eyebrow apex to lateral limbus distance. Sexual dimorphism was found for all measurement categories. A double crease fold appeared in 99% of the subjects. Only epicanthus tarsalis (95%) and epicanthus superciliaris (5%) appeared in the subjects. Four types of eyebrow apex position were found. Ethnic and sex differences exist for eyebrow and eyelid dimensions in the 2 groups we studied. Knowledge of these trends is significant during surgical planning to obtain ideal outcomes.

Integra Bilayer Matrix Wound Dressing Closure of Large Periorbital Traumatic Wound

We report the first use of the Integra Bilayer Matrix Wound Dressing (Integra LifeSciences Corp), a collagen sheet with glycosaminoglycans and a silicone layer, in an innovative reconstruction approach to devastating traumatic tissue loss in the periocular area. A 36-year-old woman was involved in a motor vehicle crash with a resultant large defect from the medial canthus to the temporal fossa and from the pretarsal skin to the brow. There was denudation of skin and soft tissue to the bone at the superolateral orbital apex. The severity of tissue loss precluded placement of an autograft or allograft; thus, a skin substitute was instead used, with a successful reconstructive outcome. Application of the newer bioengineered skin products for full-thickness skin wounds should be considered for reconstruction of the periocular area.

Lazy S-curve Epicanthoplasty in Asian Blepharoplasty

Ethnic characteristics of the Asian upper eyelid include the lack of a superior palpebral fold, excessive fat, laxity of pretarsal skin, and a medial epicanthal fold. We present the lazy S-curve epicanthoplasty for correction of the medial epicanthal fold. The lazy S-curve incision was made as an entrance step. Then the connective and orbicularis oculi muscle dense fibers underlying the epicanthal folds were released and shifted. To reduce the tension of the new medial canthus, we anchored the canthus by suture fixation of both the subdermal and medial orbital periosteum. Rotation of the S-curve flap was settled as the last step. From December 2005 to December 2009, the authors corrected the epicanthal folds on the eyelids of 156 Asian patients using the lazy S-curve epicanthoplasty. Results were satisfactory in most of the follow-up cases. Lazy S-curve epicanthoplasty is a reliable and effective method to eliminate not only the epicanthal fold but also the undesirable orbicularis oculi muscle.

A Reappraisal of Eyelid Eccrine and Apocrine Hidrocystomas: Microanatomic and Immunohistochemical Studies of 40 Lesions

To establish reliable criteria for diagnosing eyelid eccrine and apocrine hidrocystomas. Retrospective clinicopathologic and immunohistochemical study. Twenty-two specimens of normal portions of eyelids were evaluated to establish the distribution and microanatomy of eccrine and apocrine glands. Immunostaining for cytokeratin 7 (CK7), gross cystic disease fluid protein-15 (GCDFP-15), alpha-smooth muscle actin (α-SMA), epithelial membrane antigen (EMA), and carcinoembryonic antigen (CEA) was performed on these tissues and on 40 lesions in 33 patients diagnosed with eccrine or apocrine hidrocystomas by unaided light microscopy. Eccrine glands were not present in the eyelid margins, the lower half of the upper eyelid pretarsal skin, or the pretarsal lower eyelid skin. Apocrine glands were restricted to the eyelid margins and canthi where the cysts were located. GCDFP-15, CK7, and α-SMA immunoreacted with the eccrine secretory coils but not their ducts; apocrine gland secretory spirals also stained positively for these markers throughout their extended courses, but not their short terminal ducts. Positivity was found in 37 of 40 hidrocystomas for α-SMA and 19 for GCDFP-15; lesions tested for CK7 displayed positivity. Alpha-SMA-, CK7-, and/or GCDFP-15-positive apocrine hidrocystomas were the only type discovered in this series and arose from glandular secretory spirals within the marginal, perimarginal, or canthal skin. Three lesions did not stain for α-SMA, initially suggesting an absent myoepithelium and therefore an eccrine ductal origin; they manifested CK7 positivity, however, another characteristic of the apocrine secretory spiral but not ducts. Our findings disprove the contention that eccrine predominate over apocrine hidrocystomas in the eyelids.