Male brow ptosis is a common condition that is challenging to treat. Multiple treatment options exist, but many traditional options result in either a significant scar or minimal improvement in brow position. Endoscopic brow lift in male patients is effective, well-supported in literature and should be considered for patients needing significant brow lift but wanting to avoid significant scarring.

Purpose: The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure. Methods: A retrospective chart review was performed of three surgeons' charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement. Results: A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm(2) with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures. Conclusion: The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.

Botulinum toxin type A (Onabotulinumtoxin A, Incobotulinumtoxin A, Abobotulinumtoxin A) has been successfully used in the treatment of lateral canthal rhytid (crow’s feet) reduction. Prabotulinumtoxin A is a newer medication that has been shown to have efficacy for the treatment of upper limb spasticity and improvement in moderate to severe glabellar lines. This study evaluated the onset of action, maximal effect, duration of action, and side effect profile for Prabotulinumtoxin A compared with Onabotulinumtoxin A in the treatment of crow’s feet. A total of 18 subjects aged 25 to 60 without a previous history of neuromuscular disorders, eyelid surgery, or botulinum toxin type A injections were included. Patients received 3 injections of botulinum toxin in the crow’s feet area on each side. Each side received 4U/.1cc of Prabotulinumtoxin A or Onabotulinumtoxin A at each site for a total of 12U/.3cc. The surgeon was masked to the serotype injected. The subjects had their lateral canthal areas photographed in relaxed and smiling positions preoperatively, daily from postinjection days 1 to 4, and weekly thereafter for a total of 12 weeks. Two masked oculoplastic surgeons were given the preoperative photos and postinjection photos and graded them on a scale of 0 to 3 (0 = no wrinkles, 1 = minimal wrinkles, 2 = moderate wrinkles, 3 = significant wrinkles). All subjects tolerated the injections well with no significant side effects or complications. The average onset of action was 3.47 days (1-14) for Onabotulinumtoxin A and 3.81 (1-14) for Prabotulinumtoxin A. The average time to peak effect was 11.11 days (1-56) for Onabotulinumtoxin A and 9.58 days (2-42) for Prabotulinumtoxin A. The average duration of action with improvement compared with baseline crow’s feet was 11.22 weeks (7-12) for Onabotulinumtoxin A and 11.11 weeks (6-12) for Prabotulinumtoxin A. Treatment of crow’s feet lines with Prabotulinumtoxin A achieves a comparable efficacy and safety profile compared with Onabotulinumtoxin A at a 1:1 dose. Therefore, Prabotulinumtoxin A can be used as another option in the treatment of crow’s feet.

Brow lifting is an integral part of facial rejuvenation. Forehead rejuvenation is able to restore a more youthful and aesthetically pleasing brow position and facial harmony. Currently, there are many well-described approaches available for forehead rejuvenation. Here, we describe the coronal pretrichial lift to elevate the eyebrow and enhance the upper face by addressing forehead rhytids and improving the brow to trichion distance.

Background A novel medical device that has been approved by the Food and Drug Administration is available for treatment of postsurgical edema. The device emits a low‐level, pulsed electromagnetic energy field, which modulates resting cell membrane potential, allowing a return to physiologic resting membrane potential. Objective To investigate the benefits of electromagnetic energy in eyelid wound healing. Methods Fifty‐seven individuals participated in this randomized, double‐blinded study. All patients underwent upper blepharoplasty. At the postoperative visit, patients rated pain, edema, and ecchymosis, and the physician rated edema, ecchymosis, and erythema. Results There was no difference (p = .76) in patient pain rating when comparing placebo (1.6) with the patch (1.3). Patients reported 6% less edema (p = .11) and 10% less ecchymosis (p = .17) with the active patch eye than in control eye. The physician‐graded edema, ecchymosis, and erythema had a mean Likert‐type scale difference between placebo and active eyes of −0.3 (p = .12), −0.3 (p = .17), and −0.2 (p = .004) respectively. Conclusion The use of pulsed electromagnetic energy did not have an effect on postoperative pain, edema, or ecchymosis as rated by patients and physicians. There was a statistically significant reduction in physician‐graded erythema for active patch eyes versus placebo.

PURPOSE:Determine if raising the pH of 2% lidocaine with epinephrine 1:100 000 to a physiologic level decreases pain perception during periocular, subcutaneous anesthesia.DESIGN:Double-blind, prospective, randomized study. Simultaneous unilateral injections of buffered and unbuffered lidocaine solutions were given before surgery to patients having bilateral, periocular surgery.PARTICIPANTS:Fifty-four consecutive patients (27 male and 27 female; mean age, 68 years; standard deviation, 11 years).INTERVENTION:Patients were given simultaneous injections of buffered and unbuffered 2% lidocaine with epinephrine 1:100 000. The needles were inserted simultaneously and the anesthesia was injected for a 20-second count for a total volume of 1.0 ml per injected side.MAIN OUTCOME MEASURES:After the simultaneous injections, the patients were asked to rate the pain on each side on a Likert-type visual analog scale of 0 to 10.RESULTS:Sixty-five percent of patients preferred the buffered lidocaine with a scaled pain reduction of 0.9 (P = 0.0005). Additionally, for the patients who believed that the buffered solution was less painful, the mean decrease in scaled pain rating was 2, for a 51% reduction in pain level (P = 0.001). No gender differences were noted.CONCLUSIONS:Buffering 2% lidocaine with epinephrine 1:100 000 with sodium bicarbonate 8.4% offers a clinically and statistically significant reduction in pain experienced by two-thirds of patients receiving periocular subcutaneous anesthesia.

Background: The purpose of this study was to compare postoperative eyelid position using fibrin sealant versus suture for wound closure in Müller's muscle–conjunctiva resection ptosis repair. Methods: One hundred ninety-six patients (367 eyelids) who underwent Müller's muscle–conjunctiva resection ptosis repair were divided into two groups: wounds closed with suture and those closed with fibrin sealant. Preoperative and postoperative eyelid measurements were compared statistically using appropriate t tests. Complications, eyelid symmetry, and revision rates were analyzed using a two-tailed Fisher's exact test. Results: Suture was used for wound closure on 53 eyelids of 39 patients and fibrin sealant was used on 314 eyelids of 157 patients. There was no statistically significant difference (p = 0.49) when comparing the change from preoperative to postoperative margin-to-reflex distance 1 between the two groups. Postoperative symmetry within 0.5 mm was achieved in 87 percent of patients in the suture group and in 96 percent of patients in the fibrin sealant group (p = 0.06). The percentage of patients requiring additional ptosis adjustment was 2 percent in both groups (p = 1.0). Major complications were more common in the suture group (p = 0.0001). Conclusions: Müller's muscle–conjunctiva resection ptosis repair using fibrin sealant for wound closure offers equivalent lid position and symmetry as compared with suture wound closure. There is also a reduction in major postoperative complications when using fibrin sealant.

Objective: To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.Methods: Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis.Results: The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Muller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty.Conclusions: Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2011; 118: 2510-2517 (C) 2011 by the American Academy of Ophthalmology.

Hematic cyst formation after placement of nonporous alloplastic orbital floor implants is well described. A benefit of porous polyethylene is fibrovascular ingrowth without capsular formation. This ingrowth inhibits hematic cyst formation. In the case presented here, a hematic cyst developed on a screw-fixated porous polyethylene/titanium mesh implant (Medpor Titan B-T-M, Porex Surgical, Newnan, GA, U.S.A.). The risk factor for this patient was the nonporous barrier surface of the implant and inadequate fracture reduction. Proper surgical technique, including implant sizing, placement, and fixation, are factors reported to prevent hematic cyst formation. This patient's symptoms resolved after removal of the implant and cyst and replacement of the orbital implant.

26th Annual Scientific Meeting The American Journal of Cosmetic Surgery Vol.26, No.4, 2009 The 26th Scientific Meeting of the American Academy of Cosmetic Surgery will be held January 28th-31st, 2010 at the Rosen Shingle Creek Resort, Orlando, Florida. This is an overview of the papers to be presented.