Case Study: Contouring the Lower Eyelid

include a variety of conditions affecting the Case Study: Contouring skin such as ichthyosis, chronic dermatitis, burns and skin tumours. 5 In specialised oculoplastic aesthetic practice there is a the Lower Eyelid significant number of patients with postblepharoplasty retraction, a complication as prevalent as up 20% in some studies. 6 Consultant oculoplastic surgeon Mr Daniel Ezra Thyroid eye disease and other forms of inflammatory orbital conditions can also details his approach to treating ‘almond eyes’ cause this. Lower lid skin shortage can also be congenital, in the form of euryblepharon. 7 Appearance has enormous influence on psychosocial functioning 1 The majority of patients with constitutional lower lid sag are typically and the eyes in particular play an important role in perceived seen in context of myopia (short sightedness). Myopic eyes have a attractiveness and communication. 2 larger diameter and tend to protrude forward in what is described as There is a wide range of physiological and constitutional variability in a ‘negative vector’ eye configuration. In these settings, the lower lids the contours of the eyelids. The spectrum of different eye shapes are have less support and often appear to be sagging. If also associated only partly due to the nature of the eyelids themselves. Eye shapes with a canthal dystopia (drooping outer corner of the eye), this can are often determined by the morphology of the mid-face, the depth give rise to a lethargic or sad appearance. 8 of the eye sockets and importantly, the size of the globes (eyeballs). Treatments of pathological lower lid elevation generally require spacer There have been many morphometric studies demonstrating the grafts to be placed within the lower lid. Treatments like this date back importance of eye shapes in different ethnic groups, establishing to the 1940s, when cartilage grafts and other similar spacers have this as an important indicator of attractiveness. 3 A more reductionist been used to elevate the lower lid, but due to their thickness give an analysis has identified several parameters as being important, such as unsightly appearance. 9 eyelid length and ‘canthal tilt’, describing the angle formed between There are only sparse reports in the literature of lower lid contour the inner/outer corners of the eye and the horizontal meridien. 4 reshaping in healthy individuals undertaken for aesthetic reasons. Lower lid sag is a common feature in many individuals and this can This article reports on the experience of a patient undergoing almond give a tired and drawn appearance. This article describes ‘almond eye surgery to address lower lid droop and canthal dystopia using a eye’ surgery, which is a technique using novel biocompatible implants mucograft as a novel spacer implant. Mucograft is normally used for to address this particular feature. Conventional blepharoplasty is soft tissue augmentation in dental reconstructions. 10 effective at reducing excess tissue, but is not able to correct changes in the shape of the lid contours. Many patients are seeking specialist aesthetic treatments focusing on shape change, rather than reduction Many patients are seeking of skin and bags. This is particularly the case for younger patients. There are a variety of eyelid shape parameters that can be changed specialist aesthetic using established treatments such as: ptosis correction, to raise the upper lid position; canthoplasty, to lengthen the eyelid in selected treatments focusing on cases; and levator recession to lower the upper lid and reduce the palpebral fissure height. However, one of the most difficult features shape change, rather than to treat is lower lid sag, which often requires lower lid elevation and change in canthal tilt. reduction of skin and bags There are many causes for lower lid sag and retraction which can either be pathological of physiological (constitutional). The pathological causes of lower lid retraction are beyond the scope of this article, but Patient background A 27-year-old gentleman presented to clinic to seek advice regarding improving lower lid sag which had been present as a constitutional feature since childhood (Figure 2). The lower lids were retracted, Posterior lamella causing the white of the eye to show between the cornea and the lower lid. The feature is referred to as ‘scleral show’, meaning that Anterior lamella there is white of the eye showing between the lower lid and the iris. He felt that this gave a somewhat tired appearance and droopy look to the eyes and he was keen to explore treatments to improve the lower lid position and eliminate the scleral show. Orbital septum The patient was clear that he did not want a significant change in his overall appearance, but rather wanted only to reduce the scleral show Middle lamella and improve the canthal tilt. We discussed the possibility of performing almond eye surgery. The risks were discussed and would include chronic chemosis, failure of the procedure to elevate the eyelid, eye Figure 1: The multiple layers of the lower lid. The anterior lamella is made discomfort and asymmetry. These risks were all very low and the up of skin and muscle. patient opted to proceed with the treatment.

not work for all patients. This individual had several factors in his favour Post-surgical recovery is usually between two to three weeks, although chemosis (conjunctival oedema) can take longer to settle, particularly in myopic patients. Until the mucograft epithelialised and integrates into the lower lid tissues, it maintains a hard and roughened surface. Bandage contact lenses are used in the meantime to allow for comfort, along with prophylactic antibiotics.

Figure 2: Demonstrating 3mm reduction in Figure 3: A different patient with a very similar Outcomes and satisfaction scleral show (white below the cornea). There is also an associated reversal of canthal tilt, making set of issues demonstrating 3mm of lower lid elevation at six months. There is also an The primary outcome measured was elevation the eyes look less droopy. Please note that the accentuation in canthal tilt postoperatively. of the lower lid. The elevation of the lateral lump on the outer part of the lower lid in the postoperative image is a coincidental chalazion and was not related to the surgery. and central parts was 2.5mm after six months. Although this seems like a small amount, the Patient selection considerations so this change represents a dramatic improvement. The patient When counselling a patient for this surgery, a meticulous examination reported significant satisfaction with the outcome of the procedure of the eyelids and eyes is required. The almond eye procedure will with no residual discomfort reported (Figure 2). normal palpebral aperture is between 8-9mm, for a positive outcome: Conclusion Blepharoplasty alone is an effective procedure to reduce excess • The patient was, somewhat unusually, not myopic, with a positive tissue and tighten skin, but is not able to change the shape and vector eye configuration. In my experience, patients with a contour of lids. Treatment trends mean that patients are increasingly negative vector eye configuration are less likely to maintain the looking to consider reshaping of the eyelid contours, in terms of post-surgical elevation due to limitation in lateral support of the lengthening, changing angles and raising or lowering the curvatures new eyelid position. of the lids. These are complex procedures with very narrow margins • The eyelid is a complex multi-layered structure (Figure 1). The of error and require meticulous planning and examination of the almond eye procedure is undertaken through internal incisions eyes themselves. As with all eyelid surgery, this procedure requires to recess the middle and posterior (orbital septum and retractors) a detailed biomicroscopic assessment of the ocular surface before layers of the eyelid. However, if skin and muscle shortage (anterior proceeding. This type of procedure should only be performed lamella) is the critical factor mediating the retraction, this procedure by an oculoplastic surgeon with training in ophthalmology and an is less likely to work. Raising the lower lid in the context of skin appropriate subspecialist fellowship training. shortage is more complex, requiring mid-face elevation and is Almond eye surgery represents another step in the ongoing evolution generally not recommended as a primary aesthetic procedure. of aesthetic eyelid surgery, with this report demonstrating that it can be

A careful examination of this patient suggested that there was carried out effectively and safely. enough skin to allow for the elevation created by the almond eye procedure. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital and honorary associate professor • No signs of dry eye. In my experience, patients with existing at the UCL Institute of Ophthalmology in central London. ocular surface disease, particularly blepharitis or dry eye, can have He is also the head of department and service director of significant long-term discomfort after this surgery. The patient had Oculoplastic Surgery. Mr Ezra has published widely on no such ophthalmic issues. eyelid movement disorders and runs a busy private practice based on Harley Street and at Moorfields, focusing on aesthetic eye and facial treatments. He also has a special interest in revision surgery and Treatment managing filler complications. The patient underwent a combined lower lid septo-retractor Qual: MA (Cantab), MMedEd, MD (Cantab), FRCS (G) FRCOphth, FHEA recession, with mucograft implantation and lateral canthoplasty. REFERENCES The precise details of the surgery are beyond the scope of this article but, essentially, the surgery is performed through the inside 1. 2. T. Pruzinsky, ‘Psychological factors in cosmetic plastic surgery: recent developments in patient care’, Plas Surg Nurs, 13 (1993), pp.64-69. A. Clarke, N. Rumsey, J.R.O. Collin, et al. ‘Psychosocial distress associated with disfiguring eye of the eyelid leaving no discernible scars. Through the conjunctival 3. conditions’, Eye, 17 (2003), pp.35-40. Rhee SC, Woo KS, Kwon B., ‘Biometric study of eyelid shape and dimensions of different races with incision, the natural retractor bands within the eyelid itself are released, and then the spacer graft is sutured in to elevate 4. references to beauty’, Aesthetic Plast Surg, 2012 Oct;36(5):1236-45. Bashour M 1 , Geist C., ‘Is medial canthal tilt a powerful cue for facial attractiveness?’ Reconstr Surg. 2007 Jan-Feb;23(1):52-6. Ophthalmic Plast the eyelid and prevent retractor re-attachment. A canthoplasty 5. Samuel Hahn, Shaun C Desai, ‘Lower Lid Malposition: Causes and Correction’, North Am, 2016 May;24(2):163-71. Facial Plast Surg Clin procedure resets the lateral canthal position, to provide further support for the eyelid and ensure that the canthal tilt (angle 6. D.B. Rosenberg, J. Lattman and A.R. Shah, ‘Prevention of lower eyelid malposition after blepharoplasty:anatomic and technical considerations of the inside-out blepharoplasty’ Arch Facial Plast Surg, 9 (6) (2007), pp. 434-438. between medial and lateral canthi) is improved. 7. 8. J A Keipert, ‘Euryblepharon’, Br J Ophthalmol. (197)5 Jan;59(1):57-8. NHS, Short Sightedness <https://www.nhs.uk/conditions/short-sightedness/> Mucograft is an animal-derived acellular collagen matrix commonly used in dental reconstruction. Mucograft is a highly versatile 9. Park E, MD; Lewis K, BA; and Mohammed S. Alghoul M, MD, ‘Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review’, Aesthet Surg J (2017) pp.743-754. component allowing for epithelialisation of the compacted part and 10. Geistlich Pharma, product-range/> Geistlich Mucograft <https://www.geistlich.co.uk/en/dental/matrices/mucograft/ full integration into the inner eyelid. 11 This lower eyelid procedure represents a novel application for this material. 11. Roberto Rotundo , Giovanpaolo Pini-Prato, ‘Use of a New Collagen Matrix (Mucograft) for the Treatment of Multiple Gingival Recessions: Case Reports’., Int J Periodontics Restorative Dent, Aug;32(4):413-9. 2012

Treating Cosmetic ‘Tech-Neck’ for Patients Post-lockdown with Thermage FLX ®

With the world working from home, healthcare professionals are now seeing more patients than ever with an interest in their neck and jawline

“The dermis, whose main components are mainly collagen fibres, is very thin, making it more prone to ageing than other parts of the body,” says cosmetic surgeon Dr Angelica Kavouni. 1 And, while cumulative sun exposure over a lifetime has always been the main culprit of premature ageing on the neck, Dr Kavouni has seen a significant increase in patients asking for treatments to tighten the jawline and combat the symptoms of what she terms ‘Tech-Neck – cosmetic’ after a prolonged period of working from home. Proven track record 3. B. D Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device: a pilot study. Arch Dermatol. 2004

New and improved Thermage FLX® is the brainchild of Solta Medical®, one of the world’s most notable names in medical aesthetics and the company that introduced leading noninvasive antiageing treatment Thermage® over 13 years ago. Today, the new generation, Thermage FLX®, promises even faster results.*

Before After

What is the ‘Tech Neck’ – cosmetic? “The changes to the neck and jawline definition that we see as a result of looking down at a screen for a prolonged period include creases, folds, fine lines and wrinkles caused by laxity of muscular support and the cumulative effects of photodamage and gravity. These contribute to the loss of definition of the cervicomental angle, submental sagging and redundancy of the skin, along with an increase in platysmal band visibility,” explains Dr Kavouni. “As a result, the lower facial third may appear loosened and untoned, which can diminish the ‘heart-shaped’ facial shape that is so widely associated with a youthful and desired appearance. The delicate skin of our neck may develop deep etched horizontal and vertical lines. Thermage FLX® offers a great treatment option for patients as it aims to tighten the lower face and neck, as well as tone and improve skin elasticity in the long term,” she adds.

Before and after Thermage FLX ® . Courtesy of Carolyn I Jacob, MD FAAD (Dermatologist, USA)

Featuring innovative AccuREP™ technology, the new Thermage FLX® provides personalised skin tightening by employing the new treatment algorithm that optimises and tailors the radiofrequency energy output to each skin type, for precise and gentle heating.

As well as this, the Comfort Pulse Technology, which intersperses cooling bursts, works with the multidirectional tip vibration to ensure comfort 2 throughout the session.

How it works Targeting the skin’s dermis layer where collagen fibres are found, Thermage FLX® uses patented monopolar radiofrequency that delivers a uniform heating effect that penetrates deep into the collagen-rich layers of the skin. This gentle heating causes existing collagen tissue to tighten, stimulates the production of new collagen, and helps to define contours. Thermage FLX® integrates the Comfort Pulse Technology with the latest AccuREP™ technology that auto-tunes each pulse of energy for an even more and up to 90 minutes for the body depending on the area to be treated.

Thermage FLX ® treatment uses radiofrequency technology to heat the deeper, collagen rich layers of the skin, while the tip vibrates and cools the surface to help aid in patient comfort. 2

All aided by the new ‘Total Tip 4.0’ that offers faster treatment up to 25%* and an even heat distributed over the entire skin area, allowing a multidimensional tightening effect. “The result is an immediate skin tightening 3 and well-defined three dimensional skin contour, all in a single treatment with little to no downtime. The patient’s skin continues to improve for the next six months, 4 with results lasting up to 12 months,”** says Dr Kavouni.

A pioneer in non-invasive skin tightening, CE mark approved and FDA-cleared, Thermage FLX® is known for its ability to reduce the appearance of fine lines, wrinkles and sagging skin and is recognised for its good safety profile, demonstrated in more than 50 published clinical studies. Thermage® has been the go-to choice for many patients concerned with signs of ageing on their face, neck, arms and even buttocks and knees. Over 2 million Thermage® treatments have been performed worldwide, and it’s the only FDA-cleared non-invasive eye skin tightening treatment.

* All comparisons are made with Thermage CPT® and its components. **Recommended by physicians as part of an annual skin rejuvenation maintenance programme.

REFERENCES

1. www.ionkavounilondon.com 2. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100-

GA-T ‘Validation of the Thermage 3.0 cm2 STC and DC Frame

Tips, Comfort Software and Vibration Handpiece on the Face and Thighs’ (#09-019ER). Bothell. precise and consistent treatment. Each treatment takes about 45 minutes for the face

Feb;140(2):204-9. 4. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42.

This advertorial was written and supplied by Solta Medical®

www.thermage.co.uk

®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2020 Bausch & Lomb Incorporated or its affiliates. THR.0027.UK.20