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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 216-222

Conventional vs noninvasive upper lid blepharoplasty in upper lid dermatochalasis: a comparative case series study


1 Department of Ophthalmology, Faculty of Medicine, Misr University for Science and Technology, 6th of October City, Egypt
2 Department of Dermatology, Faculty of Medicine, Misr University for Science and Technology, 6th of October City, Egypt
3 Department of Ophthalmology, Research Institute of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt
4 Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission02-Feb-2020
Date of Decision20-Apr-2020
Date of Acceptance23-May-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
MD Ahmed Tharwat
Department of Ophthalmology, Faculty of Medicine, Misr University for Science and Technology, 9A Ramu Buildings, Almotamayez District, 6th of October City 12568, Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_10_20

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  Abstract 


Purpose The aim of this study was to compare the efficiency of fractional plasma with conventional surgical upper lid blepharoplasty in the management of upper lid dermatochalasis.
Patients and methods This is a prospective, comparative, interventional case series study that included 10 patients with bilateral upper lid dermatochalasis. Surgical upper eyelid blepharoplasty was performed on one side and fractional plasma (Blepharoplasma, Plasmage) was performed on the other side for each patient. The outcome was compared between both sides of each patient in terms of the amount of residual excess skin, patient satisfaction with lid contour, scar line, and pretarsal platform, in addition to the duration of the procedure and postoperative complications.
Results No statistically significant difference was found in terms of patient satisfaction between the two techniques. Lid edema was noted in both groups. However, ecchymosis was significantly more obvious in the eyelid that underwent surgical blepharoplasty compared with the lid that underwent fractional plasma, but it resolved within the first week.
Conclusion Fractional plasma may offer a less invasive alternative to surgical upper lid blepharoplasty in mild to moderate cases with some limitations regarding fat prolapse and the severity of dermatochalasis.

Keywords: blepharoplasma, blepharoplasty, dermatochalasis, fractional plasma, plasmage


How to cite this article:
Tharwat A, Saudi WM, Solyman O, Elessawy KB. Conventional vs noninvasive upper lid blepharoplasty in upper lid dermatochalasis: a comparative case series study. Delta J Ophthalmol 2020;21:216-22

How to cite this URL:
Tharwat A, Saudi WM, Solyman O, Elessawy KB. Conventional vs noninvasive upper lid blepharoplasty in upper lid dermatochalasis: a comparative case series study. Delta J Ophthalmol [serial online] 2020 [cited 2020 Oct 30];21:216-22. Available from: http://www.djo.eg.net/text.asp?2020/21/3/216/295873




  Introduction Top


Upper lid dermatochalasis is an involutional change that has cosmetic and functional impact. It may be associated with fat prolapse commonly from the medial pocket [1]. Other involutional changes such as blepharoptosis and brow ptosis may accompany upper eyelid dermatochalasis worsening its functional and aesthetic impact [2]. Surgical upper eyelid blepharoplasty is the classic treatment option of upper eyelid dermatochalasis. It involves excision of excess skin and prolapsed fat. In addition to being a surgical procedure, blepharoplasty may leave a noticeable scar [3].

The use of nonsurgical options such as Botulinum toxin A and dermal fillers are limited in the management of excess lid skin. Plasma exeresis and fractional plasma are new nonsurgical methods, which may provide a less invasive treatment option of upper eyelid dermatochalasis with faster rehabilitation [4],[5]. Fractional plasma delivers energy to the desired tissue, raising the temperature in the superficial part of the skin, stimulating skin contraction, and tightening without causing skin burn [4],[5]. Clinical studies proved that, after 1 month, collagen type 3 is formed (baby collagen). Through this procedure, potential skin harm is decreased in contradiction to traditional lasers. It securely helps the patient who does not wish surgery and helps the doctor to support a high-end service at a low cost and a good outcome [6].

The aim of this study was to compare the efficiency of fractional plasma with conventional surgical upper lid blepharoplasty in the management of upper lid dermatochalasis.


  Patients and methods Top


This is a prospective, comparative, interventional case series that included 20 eyes of 10 patients suffering from upper lid dermatochalasis. It took place between November 2018 and July 2019. Patients were recruited from the Oculoplastic Clinic at Misr University for Science and Technology, Giza, Egypt. The study was approved by the Local Medical Ethics Committee of Misr University for Science and Technology, with adherence to the guidelines of the Declaration of Helsinki. Before the procedure, all patients signed a written informed consent to participate in the study and for publication of data. Patients were free to withdraw from the study at any time.

Surgical upper eyelid blepharoplasty was performed on one side and fractional plasma (blepharoplasma, Plasmage; Brera Medical Technologies, Ogliastro Cilento, Italy) was performed on the other side of each patient. The side choice was randomized by using coin randomization method.

All patients were subjected to complete ophthalmological examination including slit-lamp evaluation and best corrected visual acuity using logMAR. The upper lids were evaluated for the degree of redundant skin and the amount of fat prolapse.

Measuring the amount of excess lid skin

A double-check method was used to measure the amount of excess skin:
  1. Step 1: preoperatively, the redundant skin was measured in millimeters while the patient was sitting and lightly closing her eyes using a surgical caliper. Three successive measurements were taken by the first investigator (A.T.).
  2. Step 2: rechecking the measurements was done by the fourth investigator (K.E.) by taking another three measurements while the patient was in the lying position on the surgical table (directly before the start of the operation).


The amount of excess lid skin recorded was the average result of these six readings taken by these two different investigators. These measurements were done from the center of the upper mark to the center of the lower mark, which has the widest diameter of the skin area to be excised. A grading system of dermatochalasis was given (0, −1, −2, −3, [Table 1]).
Table 1 Grading of dermatochalasis

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Upper lid fat pockets were evaluated and a grading system for steatoblepharon was given (0, −1, [Table 2]). Documented photos were captured in anteroposterior (A.P.) and lateral views after taking the patients’ permission.
Table 2 Grading of steatoblepharon

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Patients included in this study had dermatochalasis (grade −1 or −2) and/or steatoblepharon (grade 0 or −1). Patients suffering from dermatochalasis grade −3, lid, or brow ptosis as well as patients with lagophthalmos, weak orbicularis function, history of lid surgery, or trauma were excluded from the study.

Postoperatively, patient satisfaction was assessed using a score of 10 after 1 month of the last intervention in each eye regarding lid contour, scar, and outcome compared with the preintervention expectation. Eyelid edema and ecchymosis were assessed the second day after the intervention using the Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) questionnaire. This scoring system rates the degree of edema by giving a score according to coverage of iris by the swollen lid (grade 1–4), and rates the degree of lid ecchymosis according to its extent, whether on the inner third only, the inner 2/3, or the whole lid extent (grade 0, −3) [7].

Surgical upper eyelid blepharoplasty

Preoperative markings were made while the patient was sitting upright in the neutral gaze with the brow properly positioned. Markings were made using a surgical skin marker pen (VISCOT surgical marker 1451-200, fine tip Ns; Viscot Medical Llc., East Hanover, New Jersey, USA). The eyelid crease was situated above the lid margin at ∼8–10 mm. The lower limit of excision was along the eyelid crease, and the lateral extent of the marking was limited by an imaginary line joining the lateral end of the brow to the lateral canthus. The amount of skin to be excised was determined by using the pinching technique, marked and measured in millimeters. A minimum of 20 mm of vertical lid height was preserved for normal eye closure. Local anesthesia was achieved by using a combination of 2% lidocaine (SigmaTec Pharmaceutical Industries, Giza, Egypt) and adrenaline 1/200 000 solution.

Skin incision was done using #15 Bard-Parker blade. Excess skin was excised using the blade and Wescott scissors. Hemostasis was achieved as needed using a bipolar cautery. Prolapsed medial fat pocket was clamped, cauterized, and excised when necessary. The wound was then closed by continuous 6-0 Prolene sutures. Topical combined antibiotic/corticosteroid ointment was prescribed postoperatively. Systemic chymotrypsin tablets were given three times daily for 1 week and cold compresses were encouraged for 2 days. The patient returned after 1 week for suture removal.

Noninvasive upper eyelid blepharoplasty (Blepharoplasma, Plasmage)

This was done on outpatient basis. Topical anesthesia was performed using Lidocaine Prilocane combination (EMLA cream 5%; AstraZeneca UK Limited, Macclesfield, Cheshire, UK) that was applied to the skin 30 min before the start of the procedure. The excess cream was then removed and the lid was sterilized with povidone iodine 10%, and then washed with saline.

Preintervention marking was performed in a similar manner as described above in the technique of surgical blepharoplasty. The area of the skin to be treated was determined with the surgical mark in the form of equidistant spots 1 mm apart in horizontal curvilinear lines following the curve of the upper lid crease. The fractioned plasma device (Plasmage, Brera Medical Technologies; Ogliastro Cilento, Italy) setting was adjusted to the automated module designed for blepharoplasma (power 155 J and frequency 3 Hz) ([Figure 1]).
Figure 1 Blepharoplasma module (original).

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Under a foot switch control, fractional plasma was delivered to the treated area using a special needle. The needle tip was brought close enough to each marked spot without touching the skin to form a plasma arc ([Figure 2]). The released plasma energy that is formed by gas ionization from the air between the skin spot and the needle tip stimulated skin contraction and shrinkage. The end point was reached when the desired shrinkage of the treated skin spot was observed, approximately after 2 s of plasmage application.
Figure 2 Fractional plasma session in the right eye (scar of surgical upper blepharoplasty noted in the left eye) (original).

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The patient was instructed to use a nonsteroidal anti-inflammatory cream on the treated area twice daily for 1 week with the use of systemic chymotrypsin tablets three times daily for 1 week. The procedure was repeated after 3 weeks.

Postoperative assessment:

Patients were followed up 1 day, 1 week, and 1 month after each intervention. Patient satisfaction was assessed using a score of 10 after 1 month of the last intervention in each eye regarding lid contour, scar, and outcome compared with her preintervention expectation. Eyelid edema and ecchymosis were assessed the second day after intervention using the SPREE questionnaire [7]. The amount of residual excess skin was measured in millimeters 1 month after the last intervention in both eyes using a caliper while the patient was sitting with light eye closure.

Statistical analysis

Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS computer software package, version 20.0, 2006; Echo Soft Corporation, IBM, Armonk, New York, USA). Qualitative data were expressed as frequencies and percentages. Quantitative data were expressed as mean± SD for parametric data and median±interquartile range for nonparametric data. Differences between groups were assessed through one-way analysis of variance for parametric data and Kruskal–Wallis test for nonparametric data. All tests were tailed and considered significant at P less than 0.05 and highly significant at P less than 0.01.


  Results Top


All patients were women in the age range from 44 to 57 years. The indication for surgery was cosmetic with no functional impairment in all patients. Preoperative and postoperative data of all patients included in the study are illustrated in [Table 3]. [Figure 3],[Figure 4],[Figure 5] show the preoperative appearance of some patients, as well as the postoperative results of both techniques.
Table 3 Preoperative and postoperative data in both techniques

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Figure 3 Patient no. 1–upper left: before any intervention; upper right: second day after surgery in the left eye; lower left: second day after second blepharoplasma in the right eye; lower right: after 1 month of last intervention (original).

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Figure 4 Patient no. 4–upper left: before any intervention; upper right: second day after surgery in the right eye; lower left: second day after second blepharoplasma in the left eye; lower right: after 1 month of last intervention (original).

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Figure 5 Patient no. 8–upper left: before any intervention; upper right: second day after surgery in the right eye; lower left: second day after second blepharoplasma in the left eye; lower right: After 1 month of last intervention (original).

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Five patients with grade −1 dermatochalasis and five patients with grade −2 dermatochalasis were included in this study. Grade 0 steatoblepharon was found in eight patients with grade −1 being present in only two patients with medial fat pocket prolapse in both eyes.

The amount of excess skin planned to be managed was measured in all patients before intervention (mean=8.9±1.73 mm), with no significant difference between the two eyes in the 10 patients (P=1.00).

The patient satisfaction with the eyelid contour was excellent in both eyes in all patients with no statistically significant difference between the two groups (P=1.00).

The patient satisfaction with the scar was excellent in both eyes in all patients, except one patient with skin dimple at the lateral side of skin incision after surgical blepharoplasty, which was smoothened with one blepharoplasma session, with no statistically significant difference between the two groups (P=0.30).

The patient satisfaction with the final outcome compared with the patient preintervention expectation showed a slight difference between the two eyes with slightly more satisfaction in the surgical blepharoplasty side, but the difference between the two groups was not statistically significant (P=0.14).

Lid edema was present in both eyes according to the SPREE score with no statistically significant difference between the two groups (P=0.276). It completely resolved within the first week.

Periocular ecchymosis was significantly more obvious in the surgical blepharoplasty side according to the SPREE score (P=0.000). However, it completely resolved within the first week.

The amount of residual excess skin was measured after 1 month of the last intervention in both eyes using a ruler and caliper with the patient sitting and closing her eyes. There was no statistically significant difference between the two groups (P=0.15).

The amount of skin removed using each technique was statistically significant (P=0.05), yet there was no statistically significant difference between the two techniques in terms of skin removal (P=0.158).


  Discussion Top


Upper lid dermatochalasis is typically managed by blepharoplasty for functional and cosmetic purposes. However, new nonsurgical techniques have evolved to achieve the required aesthetic outcome [8].

Surgical upper lid blepharoplasty offers a better option for severe dermatochalasis with excess skin, not amenable to nonsurgical treatment options. In addition, surgical blepharoplasty is more favorable in cases associated with significant steatoblepharon, brow ptosis, lacrimal gland prolapse, or lash disorders [3].

Surgical intervention can leave a scar at the site of incision. However, scar complications as wound dehiscence, infections, granuloma formation, keloid formation, and disfigurement are rare nowadays, but are still present. With proper surgical technique scarring with its associated complications is rarely a problem. Additionally, lid edema and ecchymosis usually improve within 1–2 weeks, especially if there is no bleeding tendency or if the patient is not on blood thinners [9],[10].

Nonsurgical techniques have been introduced in a trial to achieve an acceptable aesthetic outcome without the need for surgical intervention. Fractional plasma is a type of energy based on the fourth state of matter. It delivers plasma energy on the desired tissue, formed by the gas ionization from the air. The generated plasma is used to raise the temperature in a certain part of the skin using specific electrode by the creation of a series of small dots on the skin. The rise of temperature stimulates skin contraction and tightening through sublimation of the superficial layers only down to a depth of 0.1 mm at the level of the stratum corneum, without any ablative effect on the skin [4],[5],[6].

The main advantage of fractional plasma compared with laser or radiofrequency is thought to be the high precision with no affection of the surrounding skin. It can be used in the management of acne scars, wrinkles as crow’s feet or smoker’s lines, skin tags, milia, syringoma, and dermatochalasis (blepharoplasma) [5],[6].

On the basis of results of this study, fractional plasma offered a good alternative to surgical blepharoplasty for skin shrinkage especially in mild and moderate cases of dermatochalasis. It can be used in moderate bilateral cases of dermatochalasis to achieve the symmetrical acceptable outcome without the need for surgical intervention.

Fractional plasma is a minimally invasive outpatient procedure. However, at least two sessions may be required to achieve the desired outcome, usually 3 weeks apart. The need for more than one session and the interval between the sessions may be a disadvantage for those who want to achieve the desired aesthetic outcome rapidly with the least possible visits. In addition, it is associated with mild lid edema and spark effect that resolves within 1–2 weeks.

The limitations for blepharoplasma are severe dermatochalasis with much excess skin and fat pocket prolapse as fractional plasma only works on the superficial layers down to the level of the stratum corneum. So, it has a minimal or no effect on the orbital fat. However, it represents a good alternative to surgical blepharoplasty in certain patients. Good patient selection with preintervention counseling is important to achieve the expected aesthetic outcome with the use of blepharoplasma.

To our knowledge, this is the first work to compare a nonsurgical technique using plasma energy with surgical blepharoplasty. Performing the two techniques in both eyes of the same patient minimized the effect of other factors as skin texture and tissue response and ensured effective comparison of the outcome of the two techniques.


  Conclusion Top


Fractional plasma is a good alternative to surgical blepharoplasty in mild and moderate dermatochalasis with certain limitations regarding fat prolapse and severity of dermatochalasis. No statistically significant difference in the results was noticed between the two techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Brown MS, Siegel IM, Lisman RD. Prospective analysis in changes in corneal topography after upper lid surgery. Ophthalmic Plast Reconstr Surg 1999; 15:378–383.  Back to cited text no. 1
    
2.
Nagi KS, Carlson JA, Wladis EJ. Histologic assessment of dermatochalasis: elastolysis and lymphostasis are fundamental and interrelated findings. Ophthalmology 2011; 118:1205–1210.  Back to cited text no. 2
    
3.
McCord CD. Upper blepharoplasty and eyebrow surgery. In: Chen WP, editor. Oculoplastic Surgery. New York, NY:Thieme 2001. 125–145  Back to cited text no. 3
    
4.
Tsioumas GS, Georgiadis N, Georgiadou I. The gas ionization by plasma technology for noninvasive techniques in oculoplastic. JOJ Ophthal 2017; 2:555584.  Back to cited text no. 4
    
5.
Tsioumas GS, Georgiadis N, Georgiadou I. New treatment with plasma exeresis for non-surgical blepharoplasty. EC Ophthalmol 2017; 5:156–159.  Back to cited text no. 5
    
6.
Sotirios TG, Nantia S. Non-invasive blepharoplasty with plasma exeresis (plexr) pre/post treatments. J Aesthetic Reconstr Surg 2018; 4:6.  Back to cited text no. 6
    
7.
Oliver JD, Menapace D, Younes A, Recker C, Hamilton G, Friedman O. Validation of the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) questionnaire: a prospective analysis of facial plastic and reconstructive surgery procedures. Facial Plast Surg 2018; 34:95–101.  Back to cited text no. 7
    
8.
Tsioumas GS, Georgiadou I, Ntountas I. Noninvasive upper blepharoplasty in relation to surgical blepharoplasty. Pinnacle Med Med Sci 2014; 1:436–440.  Back to cited text no. 8
    
9.
Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg 1999; 15:173–181.  Back to cited text no. 9
    
10.
Goldberg RA. The three periorbital hollows: a paradigm for periorbital rejuvenation. Plast Reconstr Surg 2005; 116:1796–1804.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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