Marijke H. J. Hollander

The aim of this study was to assess changes in headaches, eyebrow height, and electromyographic (EMG) outcomes of the frontalis and orbicularis oculi muscles, after an upper blepharoplasty with or without resecting a strip of orbicularis oculi muscle. In a randomized controlled trial, 54 patients received an upper blepharoplasty involving either only removing skin (group A) or removing skin with an additional strip of orbicularis muscle (group B). Preoperative, and 6 and 12 months postoperative headache complaints were assessed using the HIT-6 scores and eyebrow heights were measured on standardised photographs. Surface EMG measurements, i.e., electrical activity and muscle fatigue, were assessed for the frontalis and orbicularis oculi muscles preoperatively and 2, 6, and 12 months postoperatively. Significantly fewer headaches were reported following a blepharoplasty. The eyebrow height had decreased, but did not differ between groups. Regarding the surface EMG measurements, only group A’s frontalis muscle electrical activity had decreased significantly during maximal contraction 12 months after surgery (80 vs. 39 mV, p = 0.026). Fatigue of both the frontalis and the orbicularis oculi muscles did not change significantly postoperatively compared to baseline. EMG differences between groups were minor and clinically insignificant. The eyebrow height decreased and patients reported less headaches after upper blepharoplasty irrespective of the used technique.

Objective: to systematically review the efficacy of microfocused ultrasound (MFU) for facial skin tightening. Methods: A systematic search was performed (Pubmed, Embase) to assess the efficacy of single MFU treatments for facial skin tightening. Eligible studies included randomised controlled trials, controlled trials, cohort studies and case series (n ≥ 10). Objective and subjective outcomes were assessed. Results: A total of 693 studies were identified of which 16 studies were eligible. All the studies involved female patients. MFU is capable of tightening the skin, as observed in studies measuring the results of brow lifts (0.47–1.7 mm) and submental lifts (measured as a 26–45 mm² reduction in the submental area on lateral photographs). Data from the Global Aesthetic Improvement Scale (GAIS) were pooled, and the day 90 pooled subjective investigator reported scores (IGAIS) (n = 337) showed that 92% of the patients demonstrated an improvement in skin tightening and/or in wrinkle reduction which continued up to one year. Longer-term follow-up data are not available. The patient-reported pooled scores (SGAIS) (n = 81) showed that the skin improvements were mild and continued to increase from 42% (90 days) to 53% (360 days) post-treatment. The MFU treatment was moderately painful and caused transient erythema with or without oedema. Other adverse effects were rare (2%), including dysesthesia (numbness or hypersensitivity), bruising and stinging, mandibular burns, striations and contact dermatitis. Various device settings, treatment protocols and energies were applied. Excessive skin laxity and a BMI > 30 were posed as relative contraindications for MFU treatment because positive results declined with an increase in laxity and BMI. Conclusions: MFU treatment is effective in tightening female patients’ mildly to moderately lax facial skin. Future studies should focus on objective treatment outcomes, optimising treatment regimens and male patients.

Background: Different skin excision shapes may result in different aesthetic outcomes after upper blepharoplasty. Methods: Two skin-only excision shapes were evaluated objectively and subjectively in 28 matched patients with laterally extended skin excision (group A) or traditional elliptical skin excision (group B). The pretarsal show, lateral eyebrow height, amount of scarring (evaluated with the Patient and Observer Scar Assessment Scale), and patient-reported aesthetic results (evaluated using FACE-Q) were scored and compared at 6 and 12 months postoperatively. Results: In both groups, pretarsal show improved significantly after blepharoplasty. The homogeneity of pretarsal show improved significantly in the lateral extension group (group A) together with slightly more pretarsal show (0.5 to 0.8 mm at central pupil region) at 6 and 12 months of follow-up compared with group B (P = 0.004). A trend was observed in the exocanthion 45-degree measurement, in which group A had 0.6 mm greater pretarsal show 6 months postoperatively. Homogeneity of the pretarsal show had improved significantly in group A, but not in group B, at 12 months after blepharoplasty. No other significant differences were observed between the groups regarding pretarsal show measurements or FACE-Q scores. Both groups showed descent of the lateral eyebrow, but this was only significant in group B. Group B showed 1.4 to 2.0 mm more descent compared with group A. Scarring and adverse effects scores were low in both groups and did not differ. Conclusion: Laterally extended skin excision and traditional elliptical skin excision both result in positive aesthetic results, but the laterally extended skin excision technique is accompanied by a slightly more favorable outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Purpose: Upper blepharoplasty may be related to dry eye symptoms since the function of the orbicularis oculi muscle may affect the tear film. We aimed to assess the effect of blepharoplasty with or without the removal of a strip of orbicularis oculi muscle on tear film dynamics and dry eye symptoms.Methods: A double‐blind, randomized, controlled trial comparing upper blepharoplasty without (group A) or with (group B) orbicularis oculi muscle excision was performed on 54 healthy Caucasian patients. Tear film dynamics and dry eye symptoms were evaluated using multiple dry eye parameters, i.e. tear osmolarity, Schirmer test I, corneal/conjunctival staining, tear break‐up time (TBUT), Oxford Scheme, Sicca Ocular Staining Score and Ocular Surface Disease Index questionnaire. All the parameters were assessed preoperatively and 6 and 12 months after upper blepharoplasty. All the groups’ outcomes were compared.Results: The differences were not significant between the two upper blepharoplasty techniques regarding most of the above‐mentioned outcomes. Subjective symptoms of ocular irritation, consistent with dry eye disease and vision‐related impairment, were reduced after upper blepharoplasty independent of the type of the technique applied, while the pre and postoperative outcomes of the objective tear dynamics did not differ 12 months after surgery. However, group B demonstrated a significant increase in tear osmolarity and TBUT at the 6‐month follow‐up visit.Conclusion: An upper blepharoplasty alleviates subjective dry eye complaints in the long term, while not changing the tear dynamics. The improvement was independent of the blepharoplasty technique used.

The reproducibility of scanning in the periorbital region with 3D technology to enable objective evaluations of surgical treatment in the periorbital region was assessed. Facial 3D-scans of 15 volunteers were captured at different time points with a handheld Artec Space Spider structured light scanner. Two scans were made with a one minute interval and repeated after 1 year; for both a natural head position and with the head in a fixation-device. On assessing the area between the eyelashes and eyebrows, the medians of the average deviations between the various cross-sections of the one minute interval 3D-scans ranged from 0.17 to 0.21 mm at baseline, and from 0.10 to 0.11 mm when the minute-interval scanning was repeated one year later. The systematic differences when scanning in a natural head position and fixated position were comparable. The reproducibility of the 3D processing was excellent (intraclass correlation coefficient > 0.9). The repeated scanning deviations (baseline versus one year data) were well within the accepted clinical threshold of 1 mm. Scanning with a hand-held 3D-scanning device (Artec Space Spider) is a promising tool to assess changes in the periorbital region following surgical treatment since the median deviations are well below the clinically accepted 1 mm measuring error, for both the natural head and fixated positions.