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Purpose: The effect of transconjunctival blepharoplasty alone compared with transconjunctival blepharoplasty and CO(2) laser skin resurfacing on lower lid bulging and wrinkles was examined., Design: Randomized clinical trial., Participants: Forty-four subjects, including 13 men and 31 women., Methods: Subjects were prospectively randomly assigned into two groups: (1) transconjunctival blepharoplasty with immediate CO(2) laser resurfacing or (2) transconjunctival blepharoplasty with CO(2) laser resurfacing 2 months later. Standardized photographs were taken before and 2 months after each procedure. A trained, masked observer graded the photographs., Main Outcome Measures: Bulging and wrinkles of the medial, central, and lateral portions of the lower lid were scored and compared at specified end points., Results: Transconjunctival blepharoplasty alone resulted in an improvement in lower lid bulging in 92% of subjects, whereas lower lid wrinkling worsened in 46%. When transconjunctival blepharoplasty was performed with simultaneous CO(2) laser resurfacing, or with CO(2) laser resurfacing 2 months later, a statistically significant improvement in wrinkles occurred (chi square = 20.625; P < 0.0005). The timing of the procedures had no statistically significant effect on final outcome. No subject had lower lid retraction develop., Conclusions: Transconjunctival blepharoplasty and adjunctive CO(2) laser resurfacing represents an excellent alternative to transcutaneous lower blepharoplasty. The procedure addresses lower lid wrinkles, skin redundancy, and fat herniation without a scar and with little risk of lower lid retraction.

This article reviews the etiology and classification of ectropion and entropion, two of the more common eyelid conditions seen by the ophthalmologist. The preoperative evaluation is important in determining the etiology of the lid malposition. Surgical correction should be directed to the anatomic changes present. A detailed discussion of the more useful surgical procedures to correct ectropion and entropion is presented.

Patients with facial paralysis may develop ophthalmic complications. Poor eyelid closure and lagophthalmos place the patient at increased risk for the development of corneal problems such as epithelial defects, stromal thinning, bacterial infection, and even perforation. Initial treatment should be conservative and include the use of ocular lubricants, moisture chambers, and taping of the lower eyelid into proper position. Surgical intervention may be required in patients who have failed medical therapy or in whom the facial paralysis is not expected to improve. Gold weight implantation in the upper eyelid has become a popular procedure to correct upper eyelid retraction and to improve corneal coverage. Previous descriptions of gold weight placement in the upper eyelid have focused on Caucasian eyelid anatomy. However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which dictate the overlying aesthetic differences. We describe our technique for placement of a gold weight in the Asian upper lid, with attention to the maintenance of symmetric eyelid creases. We reviewed the charts of six Asian patients with facial paralysis who underwent gold weight placement in the upper eyelid for the correction of lid retraction. All patients did well functionally and aesthetically, and none developed an extrusion of the implant with this approach.

Purpose: A clinical observation showed that involutional entropion of the lower eyelid in Asians may occur more commonly than ectropion. A review of surgical cases was performed to examine this hypothesis., Methods: A retrospective review of the number of Asian lower lid involutional ectropion and entropion repairs was performed in three different clinical practice settings. These data were compared and statistically analyzed with similar data for non-Asian patients., Results: The frequency of ectropion among Asians was significantly less than in non-Asians (chi-square, p < 0.001). Asian entropion repair represented 11.4% of the 604 eyelid operations performed on Asians, whereas Asian ectropion repair made up only 1.5% of cases. Non-Asian entropion and ectropion repairs were 3.7% and 6.2%, respectively, of the 1,849 eyelid procedures performed on non-Asians., Conclusions: Because of the normal anteriorly protruding position of the orbital fat within the Asian lower eyelid, Asians may be more predisposed than whites to the development of involutional entropion rather than ectropion. Removal of lower eyelid fat should be considered in entropion repair of the Asian lower eyelid.

Purpose: To report the efficacy of tarsal margin rotation with posterior lamella superadvancement in the management of cicatricial entropion of the upper eyelid., Methods: In 15 consecutive patients, 22 eyelids with cicatricial entropion were managed with tarsal margin rotation and posterior lamella superadvancement. In a retrospective study, the technique and results were evaluated., Results: In all 22 upper eyelids, the normal eyelashes rotated away from the surface of the eye. Mean follow-up was 12.9 +/- 12.4 months (range, 1 to 48 months). One eyelid developed buckling of the tarsus. Three eyelids needed electrolysis to treat isolated metaplastic cilia posterior to the normal lash line., Conclusions: Tarsal margin rotation with posterior lamella superadvancement appears to be effective in managing cicatricial entropion of the upper lid.

Asian upper and lower eyelids are typically characterized by a fuller appearance than the lids of whites. Inferior extension of preaponeurotic fat and brow fat into the Asian upper lid explain the upper lid fullness and its difference from the upper lid of whites. Analogous structures in the Asian lower lid may exist to explain its full appearance. High-resolution magnetic resonance imaging (MRI) of 24 normal Asian and white lower lids was performed to evaluate differences in Asian and white lower lid anatomy. Magnetic resonance images revealed two major differences. First, the orbital fat projected further anteriorly with respect to the orbital rim in all Asian lower lids studied. No analogy with the upper lid exists for this difference. Second, the orbital fat extended further superiorly, to the inferior border of tarsus, in those Asian lower lids that did not have well defined creases. This was analogous to the preaponeurotic fat location of the Asian upper lid and different from the white lower lid. The suborbicularis oculi fat in the lower lid, the analogous structure of the brow fat pad in the upper lid, was not different in location in Asian and white lower lids. Therefore, the Asian lower lid appearance is explained by the difference in orbital fat location, which is only partly analogous to the anatomical differences between the Asian and white upper lids.

Purpose: To determine the efficacy of silicone rod frontalis sling ptosis repair in selected patients., Methods: The authors retrospectively studied 35 consecutive patients who underwent silicone sling ptosis repairs in 6 lids at the University of California, San Francisco., Results: Preoperative diagnoses included congenital ptosis causing developmental delay or possible amblyopia in children younger than 3 years of age, chronic progressive external ophthalmoplegia, third-nerve palsy, myasthenia gravis, and ocular restriction secondary to glaucoma filtering valves. With a mean follow-up of 22 months, good-to excellent final lid height was achieved in all 61 lids. Recurrence of the ptosis occurred in four lids (7%), requiring replacement of the silicone rod in two lids and revision of the original sling in two lids to reach the final lid height. Chronic exposure keratopathy without corneal infection occurred postoperatively in 9 (15%) of 61 eyes, all in patients with an inadequate or absent Bell phenomenon. Chronic corneal problems did not develop in any of the children. Extrusion of the sling with or without infection occurred in three foreheads (5%) in two patients younger than 15 years of age., Conclusion: Silicone rod is an effective material for use in frontalis suspension in treating severe ptosis with poor levator function. Children younger than 3 years of age with congenital ptosis and developmental delay or possible amblyopia can undergo silicone frontalis suspension to achieve good visual results. The elasticity and ease of adjustment of the silicone rod are ideal characteristics for a suspensory material used to correct severe ptosis associated with a minimal or absent Bell phenomenon, such as in chronic progressive external ophthalmoplegia, myasthenia gravis, or third-nerve palsy.

Purpose: Because ocular exposure is a major complication of facial paralysis, an external gold eyelid load weight was evaluated for effectiveness in the treatment of this problem., Methods: We prospectively studied 12 patients with unilateral facial paralysis who were treated with the external eyelid weights. Follow-up examinations included corneal exposure, amount of artificial tear usage, patient comfort, and complications associated with the weights. Treatment end points were the patient's decision to undergo a canthoplasty or placement of an implanted weight or resolution of the facial paresis to better than House's grade IV/VI., Results: Of the 12 patients studied, ten had decreased corneal exposure on the affected side, with a coincident decrease in artificial tear drop use and increased comfort. One patient had no improvement in a corneal defect, and one was unable to apply the weight. Five patients had some difficulty in positioning the weight, which was related to upper eyelid dermatochalasis in four of the five. Only two weights were lost in over two years of total wearing time., Conclusions: External eyelid weights are useful in the treatment of ocular exposure associated with facial paralysis. The weights decreased corneal exposure, decreased reliance on artificial tear drops, and increased patient comfort. The weights were helpful as a trial before implantation of eyelid weights and as a longer-term treatment for ocular exposure in patients with temporary facial paralysis. Loose upper eyelid skin may limit their usefulness in some patients.