Correlation of single-fiber electromyography studies and functional status in patients with amyotrophic lateral sclerosis.

Objective: Our aim was to examine the significance of single-fiber electromyography (SFEMG) in patients diagnosed with amyotrophic lateral sclerosis (ALS) and determine the best correlating parameter with SFEMG parameters and clinical scales across different muscles including facial muscles. Methods: SFEMG examinations were conducted on the extensor digitorum (ED), frontalis, and orbicularis oculi muscles. Mean jitter, percentage of increased jitter, fiber density (FD), and impulse blocking percentage were compared to reference values and functional scales. Results: Significant differences (p < 0.001) were observed between the patients' SFEMG results and reference values in all muscles. Significant correlations were found between SFEMG parameters and clinical scales, particularly when considering both FD and jitter. A notable value of the ALS Functional Rating Scale Revised (ALSFRS-R) was detected in all muscles: 31 points in the ED muscle, 30 in the orbicularis oculi muscle, and 31 in the frontalis muscle. Below this ALSFRS-R threshold, the percentage of increased jitter was higher, while FD remained relatively low. Conclusion: SFEMG examination emerges as a valuable tool for better understanding ALS and holds potential for assessing prognosis. Combined jitter and FD analysis showed the strongest correlation with clinical scales. In addition to the ED muscle, the orbicularis oculi muscle may be important in the assessment.

Stretching of Putative Mechanoreceptors in the Inferior Tarsal Muscle Regulates Tonic and Clonic Reflex Contractions of Slow-Twitch Fibers in the Palpebral Orbicularis Oculi Muscle Causing Apraxia of Eyelid Opening: A Case Series.

The levator palpebrae superioris muscle (LPSM) and facial muscles comprise both fast-twitch fibers (FTFs) and slow-twitch fibers (STFs). Still, they lack the muscle spindles to induce reflex contractions of STFs. Because reflex contractions of STFs in the LPSM and frontalis muscle, which are the major eyelid opening muscles, are induced by stretching of mechanoreceptors in the superior tarsal muscle, those in the palpebral orbicularis oculi muscle (POOM), which is the major eyelid closing muscle, should not be induced by stretching of the same proprioceptors but instead induced by the proprioceptors in the vicinity of the POOM. Apraxia of eyelid opening (AEO) after eyelid closure might be caused by prolonged POOM contraction. Most patients with AEO tend to stretch the upper and lower eyelids by applying contact lenses and eyedrops to disinsert the aponeurosis and retractor from the tarsi. They taught us that pulling down or raising the lower eyelid decreased or increased involuntary contraction of the POOM, which relieved or worsened AEO, respectively. Then, they asked us to have the lower eyelid lowered and the upper eyelid raised surgically. Whenever the upper eyelid is opened by contractions of the LPSM with the global layer of superior rectus muscle (GLSRM), the lower eyelid is concomitantly opened by contractions of the global layer of inferior rectus muscle (GLIRM), which counteracts the contraction of the GLSRM to maintain the visual axis. We hypothesized that patients with retractor disinsertion raise the lower eyelid by eyelid closure to stretch putative mechanoreceptors in the inferior tarsal muscle (ITM), which induces prolonged tonic and clonic reflex contractions of STFs in the POOM, resulting in AEO. To retrospectively verify the hypothesis, we report five cases with AEO. In the first case, AEO was induced by tight eyelid closure but was prevented by pulling down the lower eyelid during eyelid closure. Surgery to reinsert retractors into the tarsi cured AEO. In the second case, the patient sustained both severe aponeurosis-disinserted blepharoptosis and AEO. In this patient, the first surgery to reinsert aponeuroses to the the tarsi cured AEO, but a tight eyelid closure induced prolonged POOM contraction. The second surgery conducted to reinsert the retractors to the tarsi cured AEO. In the third case, with the entire eyelid AEO, surgery done to reinsert the retractors to the tarsi almost cured the entire eyelid AEO. In the fourth case, an increased clonic contraction of the POOM on the right eyelid after a tight eyelid closure was relieved by 4% lidocaine instillation to anesthetize the ITM. In the fifth case, downgaze induced clonic reflex contraction of the right POOM because of the right retractor disinsertion. Thus, prolonged tonic and clonic reflex contractions of STFs in the POOM appeared to be regulated by enhanced stretching of putative mechanoreceptors in the ITM in patients with retractor disinsertion due to increased contractions and microsaccades of FTFs in the GLIRM. Because reflex contractions of STFs in the POOM by stretching of putative mechanoreceptors in the ITM might essentially attach the upper and lower eyelids to the globe, AEO might simply be the increased reflex contraction of the POOM.

Anatomical considerations of medial eye wrinkles: Guidelines for botulinum neurotoxin injections.

Crow's feet lines in the lateral canthal region are a common concern among aging patients, initially appearing as dynamic wrinkles during facial expressions and becoming more pronounced with age. Botulinum neurotoxin temporarily paralyzes muscles by inhibiting acetylcholine release, smoothing wrinkles and enhancing skin's youthful appearance. Effective treatment requires tailored approaches considering individual anatomy and muscle activity. Recent cadaveric studies identified the tear trough muscle, emphasizing its role in infraorbital support and aging. Clinically, patients often present medial eye wrinkles after BoNT treatment for crow's feet, prompting exploration of underlying mechanisms and management strategies. Three cases demonstrated that medial BoNT injections in the orbicularis oculi muscle significantly improve medial eye wrinkles and tear trough appearance. The study underscores the importance of understanding muscle hyperactivity and anatomical variations for precise treatment. Enhanced injection techniques targeting specific areas can achieve better outcomes and minimize complications, particularly in culturally sensitive regions where facial expressions are valued. This research highlights the necessity for comprehensive anatomical knowledge and patient-specific treatment strategies to address medial eye wrinkles effectively.

Orbicularis oculi muscle activity during computer reading under different degrees of artificially-induced aniseikonia.

Background: Aniseikonia is a binocular vision disorder that has been associated with asthenopic symptoms. However, asthenopia has been evaluated with subjective tests that make difficult to determine the level of aniseikonia. This study aims to objectively evaluate the impact of induced aniseikonia at different levels on visual fatigue by measuring the orbicularis oculi muscle activity in the dominant and non-dominant eyes while performing a reading task. Methods: Twenty-four collegiate students (24.00 ± 3.86 years) participated in this study. Participants read a passage for 7 minutes under four degrees of aniseikonia (0%, 3%, 5% and 10%) at 50 cm. Orbicularis oculi muscle activity of the dominant and non-dominant eye was recorded by surface electromyography. In addition, visual discomfort was assessed after each task by completing a questionnaire. Results: Orbicularis oculi muscle activity increased under induced aniseikonia (i.e., greater values for the 10% condition in comparison to 0%, and 3% conditions (p = 0.034 and p = 0.023, respectively)). No statistically significant differences were observed in orbicularis oculi muscle activity for the time on task and between the dominant and non-dominant eyes. Additionally, higher levels of subjective visual discomfort were observed for lower degrees of induced aniseikonia. Conclusion: Induced aniseikonia increases visual fatigue at high aniseikonia degrees as measured by the orbicularis oculi muscle activity, and at low degrees as measured with subjective questionnaires. These findings may be of relevance to better understand the visual symptomatology of aniseikonia.

The Orbicularis Oculi Muscle Sparing Full-Incision Double-Eyelid Blepharoplasty.

BACKGROUND: Double-eyelid blepharoplasty was the most prevailing cosmetic procedures in China. To reduce the visible scar and unnatural crease after the removal of the OOM in the traditional full-incision double-eyelid technique. This research tried to introduce and promote the orbicularis oculi muscle sparing full-incision double-eyelid blepharoplasty with more conservative resection of upper eyelid soft tissue. METHODS: The orbicularis oculi muscle sparing full-incision double-eyelid blepharoplasty was operated and evaluated in 227 patients (454 eyes), and the esthetic results, the satisfaction of patients and complications were scored and analyzed at 6-12 months postoperative. RESULTS: Of the 227 patient, 164 (72.25%) patients were very satisfied, and 49 (21.59%) patients were satisfied, 14 (6.17%) patients were unsatisfied mainly because of the loss of palpebral fold or shallow folds. The average subjective scar score was 4.92 with 209 (92.1%) patients scored very satisfied, 18 patients scored satisfied. No patients experienced the eyelid numbness, dry eyes, and stitch abscess. 8 patients (3.52%) developed mild eye irritation in early postoperative period, however the symptoms resolved spontaneously in 2 weeks. CONCLUSION: The orbiculars oculi muscle sparing full-incision double-eyelid blepharoplasty contributes to the conservation of the physiology of the eyelid structure, producing a reliable, nature, dynamic double-eyelid crease with a light scar and less complication. LEVEL OF EVIDENCE IV: 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 .

Importance of changes in abnormal muscle responses during microvascular decompression for hemifacial spasm.

Objective: To determine if compression sites of the facial nerve correlate with immediate postoperative outcomes in patients with hemifacial spasm (HFS), and if changes in the waveform of abnormal muscle response (AMR) during microvascular decompression (MVD) for HFS can predict the postoperative course. Methods: In this retrospective review, we evaluated 50 patients with HFS who underwent AMR monitoring during MVD. The ratios of amplitude and duration of AMR waveforms were computed by comparing baseline with final examinations. Vascular compression sites were categorized into four portions of the facial nerve. Postoperatively, we classified patients into two groups based on symptom relief as those whose symptoms disappeared immediately (DI group), and those whose symptoms disappeared gradually (DG group). Results: The compression sites significantly correlated with postoperative outcomes at discharge (p < 0.001) but not with outcomes after 6 months of MVD. Lower duration ratios of AMRs from the mentalis muscle were significantly associated with an increased chance of classification into the DI group based on the results of multivariate logistic regression analysis (p = 0.017). Conclusions: Relationship between compression sites and immediate outcomes could provide useful information to surgeons for predicting if symptoms will resolve over long term. Moreover, changes in AMRs recorded from the mentalis muscle could predict the postoperative course of HFS. Significance: These findings can help surgeons evaluate the changes in AMR amplitude and duration during MVD for HFS.

Growth of muscles and nerves in the upper eyelid: a morphometrical and immunohistochemical study using term human fetuses.

BACKGROUND: There is no information about muscle growth in eyelids with infrequent blinking in fetuses. METHODS: To examine the muscle and nerve morphology, we morphometrically and immunohistochemically examined sagittal sections of unilateral upper eyelids obtained from 21 term fetuses (approximately 30-42 weeks of gestation) and, for the comparison, those from 10 midterm fetuses (12-15 weeks). RESULTS: The approximation margin of the upper eyelid always corresponded to the entire free margin in midterm fetuses, whereas it was often (18/21) restricted in the posterior part in term fetuses. Thus, in the latter, the thickness at the approximation site to the lower lid often ranged from 0.8 to 1.6 mm and corresponded to 18-56% of the nearly maximum thickness of the lid. In the lower part of the upper eyelid, a layer of the orbicularis oculi muscles often (14/21) provided posterior flexion at 90-120° to extend posteriorly. Nerve fibers running along the mediolateral axis were rich along the approximation surface at term, but they might not be reported in the upper eyelid of adults. CONCLUSION: Being different from adult morphologies, the term eyelid was much thicker than the approximation surface and it carried a flexed muscle layer and transversely-running nerve. The infrequent blinking in fetuses seemed to provide a specific condition for the muscle-nerve growth. Plastic and pediatric surgeons should pay attention to a fact that infants' upper eyelid was unlikely to be a mini-version of the adult morphology.

Application of Fixation of Orbicularis Oculi Muscle and Orbital Septal Tissue Flap at the Upper Edge of Incision in Double Eyelid Plasty.

PURPOSE: In order to make the postoperative effect of open double eyelid more close to the physiological and anatomical structure of double eyelid, we improved the traditional open double eyelid operation according to the anatomical characteristics of the upper eyelid. We fixed part of the orbicularis oculi muscle above the incisal margin with the orbital septum flap to make the double eyelid formed after surgery more natural and beautiful. MATERIALS AND METHODS: A total of 76 patients who received open double blepharoplasty in department of plastic surgery from February 2019 to May 2022 were selected as this study objects, all of whom were female. Their ages ranged from 18 to 32 years, with a mean of (23.6 ± 5.2) years. The surgical method is open double blepharoplasty by fixing part of the orbicularis oculi muscle above the incisal margin with the flap of the orbital septum. RESULTS: In this study, all 76 patients underwent successful surgery, with an average operation time of (1.5 ± 0.2) h. The postoperative double eyelid curvature was smooth and the double eyelid width was basically symmetrical. In terms of the doctors' satisfaction evaluation of the postoperative effect, 64 cases were very satisfied and 12 cases were satisfied. In terms of patients' satisfaction evaluation of the postoperative effect, 60 patients were very satisfied, 15 patients were satisfied and 1 patient was dissatisfied. CONCLUSIONS: Through this study, we found that this surgical method invented by us has short operation time, good operation effect, few postoperative complications and high patient satisfaction, which is worthy of promotion and application in plastic surgery clinical practice. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision.

BACKGROUND: Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids. METHODS: We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months). RESULTS: The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations. CONCLUSIONS: Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids. LEVEL OF EVIDENCE IV: 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 .

Future treatment options for facial nerve palsy: a review on electrical stimulation devices for the orbicularis oculi muscle.

Facial nerve palsy can cause diminished eyelid closure (lagophthalmos). This occurs due to functional deficits of the orbicularis oculi muscle, potentially leading to sight-threatening complications due to corneal exposure. Current management options range from frequent lubrication with eye drops, to the use of moisture chambers and surgery. However, achieving functional restoration may not always be possible. Recent efforts have been directed towards the support of orbicularis oculi muscle function through electrical stimulation. Electrical stimulation of the orbicularis oculi muscle has been demonstrated as feasible in human subjects. This article offers a comprehensive review of electrical stimulation parameters necessary to achieve full functionality and a natural-looking eye blink in human subjects. At present, readily available portable electrical stimulation devices remain unavailable. This review lays the foundation for advancing knowledge from laboratory research to clinical practice, with the ultimate objective of developing a portable electrical stimulation device. Further research is essential to enhance our understanding of electrical stimulation, establish safety standards, determine optimal current settings, and investigate potential side effects.

Facial nerve neurographies in intensive care unit-acquired weakness.

BACKGROUND: Patients with an intensive care unit-acquired weakness (ICU-AW) often present clinically with severe paresis of the limb and trunk muscles while facial muscles appear less affected. To investigate whether the facial nerves are partially spared from this condition, we performed both peripheral and cranial nerve conduction studies in critically ill patients. METHODS: In patients requiring prolonged ICU therapy, the motor and sensory nerve conduction velocities of the peroneal, ulnar and facial nerves and the muscle action potentials of the associated muscles, as well as the orbicularis oculi reflexes were assessed shortly after admission, and on ICU days 7 and 14. RESULTS: Eighteen patients were included in the final data analysis (average age 54.2 ± 16.8 years, 8 females). The amplitudes of the peroneal nerve compound muscle action potentials (CMAPs) were reduced in all patients at ICU days 7 and 14 (F(1.39; 23.63) = 13.85; p < 0.001). There was no similar decrease in the CMAP amplitudes of the ulnar or facial nerve. Other parameters of nerve function (latencies, sensory and motor nerve conduction velocities, sensory nerve action potentials) remained unchanged. The reproducibility of the orbicularis oculi reflex was reduced during the disease course, while its latencies did not change significantly during the disease course. CONCLUSIONS: There is a relative preservation of CMAPs in facial and hand as opposed to foot muscles. This is compatible with the clinical observation that the facial muscles in patients with ICU-AW are less severely affected. This may be primarily a function of the nerve length, and consequently more robust trophic factors in shorter nerves. Trial registration This study was prospectively registered in the German Clinical Trial Register on April 20th 2020 (DRKS00021467).

Myasthenia gravis patients exhibiting an eyelid myotonia-like phenomenon.

We report here a retrospective case series of 3 MG patients suffering from difficulty opening eyes that appeared together with a diagnosis of MG. All are male patients with late-onset MG who are seropositive for anti-acetylcholine receptor antibodies. The phenomenon was characterized by difficulty opening the eyes after forced closure or reflex eye closure, improving with the ice pack test and with repeated forced eye closure but worsening with pyridostigmine treatment. We provide a detailed clinical, serological, imaging and electrophysiological examination of these patients. Electromyography evaluation did not show spontaneous muscle activity or myotonia at rest in the orbital part of the orbicularis oculi muscle. However, there was sustained muscle activity lasting several seconds in the pre-tarsal and pre-septal parts of this muscle. Videos of those reported symptoms were produced and provided. We discuss the possible neurological pathophysiology of this disorder and suggest to name this rare ocular disorder "myotonia-like disorder of the pre-tarsal and pre-septal parts of the orbicularis oculi". This study expands our knowledge of this rare clinical feature of MG and highlights the need for increased awareness of it and further investigation of this ocular manifestation.

Reconstruction of medial canthal region with orbicularis oculi myocutaneous flap: Our experience.

Reconstructive surgery of the medial canthus is among one of the most challenging due to its complex anatomy and aesthetic features. In this area even the slightest deformity or asymmetry is noticeable. Reconstructive surgery of this anatomical region aims to restore the tissue defect ensuring an appropriate aesthetic and functional feature, restoring colour, thickness and consistency of the replaced tissue. Orbicularis oculi myocutaneous flap is an option to reconstruct the medial canthal region; in this paper the authors present their experience with orbicularis oculi myocutaneous flap in 10 patients with medial canthal malignant lesions. The patients' postoperative period was uneventful, the flaps usually showed some degree of temporary venous congestion during the first days after surgery, and any donor site morbidity was observed: no lid lag, ectropion, ptosis, or other eyelid deformity. This flap offers a similarity in texture, colour, and thickness to the recipient site and a negligible incidence of donor site morbidity, and it can be easily tailored to fit the shape of the soft tissue defect.

The evaluation of the skin-muscle and only-skin upper blepharoplasty featuring surface electromyography: a single-masked, randomized split-face prospective study.

BACKGROUND: Even though upper blepharoplasty is one of the most commonly performed procedures in esthetic surgery, there is still no consensus regarding the management of the orbicularis oculi muscle (OOM). AIM: To compare outcomes of upper eyelid blepharoplasty with or without OOM excision using surface electromyography in a 12 month follow-up. METHODS: A prospective, randomized, single-blinded comparative split-face study was conducted on 26 patients with dermatochalasis. Skin-only upper blepharoplasty was performed on a randomly selected side, and on the contralateral side, a strip of OOM was resected as well. The functional outcomes were assessed using sEMG, and the esthetics were evaluated independently by the operating surgeon, blinded patients, and three blinded ophthalmic surgeons. RESULTS: The RMS values of maximal contraction of the OOM were statistically significantly lower two weeks after blepharoplasty than the values before surgery in both groups (p < 0,001) and reached the preoperative values after six months. Lagophthalmos occurred in 2 cases in the skin-muscle group (7.69%), and no incidence of lagophthalmos was observed in the skin group. There were comparable esthetic outcomes on both operated sides. CONCLUSIONS: This study is an objective and quantitative report using surface electromyography on upper blepharoplasty with or without a strip of OOM excision. Our results showed that OOM fully recovers after the stripping procedure. The resection of the skin-OOM flap showed no difference in long-term cosmetic results. Therefore, we recommend OOM preservation during upper blepharoplasty unless muscle excision is well-grounded.

Histopathological View of Benign Essential Blepharospasm: Orbicularis Oculi Hormone Receptor Levels.

Objectives: Benign essential blepharospasm (BEB) is a focal dystonia characterized by involuntary contractions of the orbicularis oculi and periocular muscles. We aimed to investigate the effects of muscle receptor levels on the etiopathogenesis of blepharospasm by evaluating the orbicularis oculi estrogen receptor (ER) and androgen receptor (AR) levels. Methods: Four blepharospasm patients (2 females and 2 males) who underwent upper lid blepharoplasty and/or orbicularis myomectomy and 4 healthy cases (2 females, 2 males) that had upper lid blepharoplasty were included. The pretarsal, preseptal, and orbital parts of the orbicularis muscles of the patients who underwent orbicularis myomectomy and the waste muscle tissue materials taken from the preseptal orbicularis muscles of the patients who had only upper blepharoplasty were analyzed. Immunohistochemical staining was performed with estrogen alpha and androgen. Results: In healthy men, the orbicularis oculi muscle was stained with ER at a moderate intensity and with AR at a high intensity. In men with blepharospasm, the orbicularis oculi were not stained with ER at all, but at a high intensity with AR. In healthy women, the orbicularis oculi were stained with ER and AR at a high intensity (>50%). In women with blepharospasm, the staining intensities of both receptors were moderate. Conclusion: We determined a decrease in ER and AR in females and almost the absence of ER in males with BEB. This decrease in ER may be associated with a functional abnormality in mitochondria and the decrease in hormonal receptors may be associated with sarcopenia in orbicularis oculi muscle fibers.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora.

BACKGROUND: The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow. PURPOSE: This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora. MATERIAL AND METHODS: This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit. RESULTS: Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed. CONCLUSION: Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Width of the orbicularis oculi fibers extending to the upper lip with the lateral and inferior lengths of the orbicularis oculi at the lateral canthus level: application to botulinum neurotoxin type A injection for crow's feet.

PURPOSE: The aim of this study was to determine the width of the fibers that extend from the orbicularis oculi muscle (OOc) to the upper lip, and the lateral and inferior lengths of the OOc at the lateral canthus level. METHODS: The OOc was investigated in the 40 hemifaces of 20 Korean cadavers. The lateral fibers of the OOc (OOc lat) were traced to determine whether or not these fibers extended to the upper lip. RESULTS: The OOc lat extended to the upper lip at the lateral canthus level in 31 of the 40 specimens (77.5%), whereas some inferolateral fibers of the OOc that extended to the upper lip were observed near the level of the lower margin of the OOc in the other 9 specimens (22.5%). The mean ± SD and maximum widths of the OOc lat that extended to the upper lip at the lateral canthus level were 6.9 ± 3.3 mm and 14.3 mm, respectively. CONCLUSION: The obtained data will be helpful to distinguish the muscles that underly the wrinkles around the lateral canthus for safer and more-efficient BoNT-A treatments for crow's feet.

Comparison of the cutaneous orbicularis oculi excision treatment with the inferior eyelid margin fixation treatment for congenital lower eyelid entropion.

PURPOSE: To modify the traditional surgical approach to treat patients diagnosed with congenital lower eyelid entropion using inferior eyelid margin fixation of the orbicularis eyelid muscle. METHODS: Ninety-six participants (180 eyes) with congenital lower eyelid entropion diagnosed between January 2019 and April 2021 were included in this study. The patients were divided into Group A (cutaneous orbicularis oculi excision treatment) and Group B (inferior eyelid margin fixation treatment). The efficiency and recurrence rate of treatments were used to compare the two treatments. RESULTS: There was no significant difference in age, sex, and eyes distribution in both groups. And higher efficiency rate was found in Group B (P < 0.05). And Group A had a higher recurrence rate in the follow-up after surgical treatment (P < 0.05). CONCLUSIONS: This modified inferior eyelid margin fixation of the orbicularis eyelid muscle treatment is an ideal procedure with a high degree of efficacy and low recurrence rate in patients with congenital lower eyelid entropion.

A modified Park's technique for creating a natural-looking double eyelid.

Objective: This study aimed to evaluate an improved park's technique to create a natural double eyelid and reduce scar formation. Methods: The levator aponeurosis, orbicularis oculi muscle, and dermis were fixed using subcutaneous intermittent sutures, and then the skin and the levator aponeurosis were sutured. Postoperative evaluation included double-eyelid stability, symmetry, double-eyelid curve, scar formation, and patient satisfaction. Results: Between January 2021 and August 2021, a total of 89 patients (178 eyes) underwent double-eyelid blepharoplasty by the same surgeon using this improved technique. The mean follow-up period was 15.5 months (range 10 to 18 months). Seventy-six patients were very satisfied with this surgical method, six patients were rather satisfied, and seven patients were dissatisfied. The overall satisfaction rate was 92.1%. Conclusion: This new blepharoplasty method generates a stable, natural double-eyelid line with minimal scarring.

Influence of exophthalmos on design of double eyelid incision / 中华医学美学美容杂志

Objective:To compare the postoperative effects of double eyelid surgery with different exophthalmos to find its influence on the surgery and necessary changes in preoperative design and during operation.Methods:A total of 50 female patients with single eyelid seeking beauty from June 2021 to March 2022 were selected from the Department of Plastic Surgery, Affiliated Hospital of Qingdao University. The ocular protrusion was measured by HETEL ophthalmostatometer before surgery. Both eyes at 12-15 mm were taken as normal group ( n=26), both eyes at 16-18 mm as mild protrusion group ( n=14) and both eyes at 19-22 mm as severe protrusion group ( n=10). All the patients were treated with double-eyelid surgery by orbital septum and unified postoperative nursing. Results:After six months of follow-up, there was no difference in eyelid width with closed eyes (all P>0.05). The width of double eyelid with open eyes in normal group was smaller than that in mild protrusion group ( F=23.23, all P<0.05), and the width of double eyelid with open eyes in mild protrusion group was smaller than that in severe protrusion group ( F=47.70, all P<0.05). There was no difference in the improvement rate of facial aesthetics among the three groups ( P>0.05). The " feeling of meet" and scar formation in the normal group were less than those in the mild protrusion group ( F=16.92, F=33.45, all P<0.05), and the " feeling of meet" and scar formation in the mild protrusion group were less than those in the severe protrusion group ( F=27.93, F=28.53, all P<0.05). The improvement rate of normal group was higher than that of mild and severe protrusion group (χ 2=7.25, 7.89, all P<0.05). There was no difference in the improvement rate between the mild and severe protrusion groups ( P>0.05). Conclusions:In clinical practice, it is necessary to make corresponding changes in the preoperative design and operation of double eyelid surgery for patients with high eyeball protrusion.