Anatomical Injection Guidelines for Glabellar Frown Lines Based on Ultrasonographic Evaluation

When botulinum neurotoxin (BoNT) is injected to treat glabellar frown lines, the corrugator supercilia muscle (CSM) and procerus muscles are the main targets. Although there have been many studies on the treatment of glabellar frown lines, no study has confirmed the dynamic movement under ultrasonography (US). This study examined and evaluated dynamic muscle movements under US, thereby providing more effective BoNT injection guidelines for glabellar frowning. Glabellar frowning was categorized as either Type A or B. Type A is the general frowning pattern in which vertical wrinkles are made by contracting the CSM and procerus muscles (81%, n = 13). On US images, the procerus muscle thickens and the bilateral CSMs contract. Type B is an upward frowning pattern demonstrating upward elevation of vertical wrinkles due to hyperactive contraction of the frontalis muscle during frowning (19%, n = 3). On US images, the hypoechoic frontalis muscle thickens, forming horizontal forehead lines. After BoNT injection into the CSM and frontalis muscle but not the procerus muscle, Type B patterns showed improvements in the vertical crease and horizontal forehead line. Both types showed improvement in glabellar frown lines after conventional injection, but the horizontal forehead line did not improve in Type B. Type B wrinkles improved after additional injections into the frontalis muscle. This study provided novel anatomical findings related to the injection of glabellar frown lines with BoNT. Preliminary analysis and optimized procedures using US will enable more effective and safer injections.

The Influence of Neuroticism on the Muscle Response in the Trapezius and Frontalis Muscles to Anticipatory Stress

Objective quantification of mental stress in the workplace would be beneficial for designing work tasks to avoid the negative consequences of mental stress. Methods such as surface electromyography have proven to be sensitive to mental demands. However, there is little knowledge about the muscle response and moderating factors during anticipatory stress paradigms. This study examined whether the personality dimension neuroticism moderates the muscle response to the expectation of an unpredictable electrical shock. Forty-seven subjects underwent three expectation phases, in which they could expect a pleasant audio signal (NoShock) or an electric shock in two conditions (anticipation of the first: Shock1, and second electric shock: Shock2) at an unpredictable moment. The frontalis muscle activity and the upper and upper/middle parts of the trapezius muscle were recorded using surface electromyography. Neuroticism was surveyed using the Big Five Inventory to assign the subjects to a group with lower or higher neuroticism. Shock1 only induced higher trapezius muscle activity in the higher neuroticism group, which vanished during Shock2, while the frontalis muscle showed no significant effects. The results suggest that neuroticism should be considered a moderating factor in assessing anticipatory stress using surface electromyography at the trapezius muscle.

EFFICACY OF FRONTALIS MUSCLE FLAP SUSPENSION IN TREATING MODERATE TO SEVERE BLEPHAROPTOSIS

Purpose: This study aims to evaluate the efficacy of frontalis muscle flap suspension in treating moderate to severe blepharoptosis. Study subjects: 54 eyes of 47 moderate to severe blepharoptosis patients (aged 17.34 ± 9.17 years, 18 males, 29 females). Study design: Prospective uncontrolled clinical trial. Results: Following frontalis muscle flap suspension surgery, there was a statistically significant improvement (p<0.001) in margin reflex distance 1 (MRD1) and palpebral fissure height (PFH), from 0.009 ± 0.60 mm and 5.59 ± 0.68 mm (pre-operation) to 2.68 ± 1.10 mm and 8.26 ± 1.14 mm (1 week after operation), 3.63 ± 0.77 mm and 9.24 ± 0.85 mm (6 months after operation), 3.45 ± 0.80 mm and 9.02 ± 0.89 mm (12 months after operation). At the 12th month after operation, it was found that severe lagophthalmos, lid lag on down-gaze and forehead hypoesthesia were present in 7.4%, 9.3% and 14.0% of all treated eyes, respectively. Excellent functional results were determined in 66,0% of procedures postoperatively, with 31,9% and 2,1% rated as good and unsatisfactory. In terms of cosmetic results, 78,7%, 19,1% and 2,1% of cases were rated as excellent, good and unsatisfactory, respectively. Conclusion: Majority of case results were excellent (78,7%) and good (19,1%), unsatisfactory cases 2,1%.

Comparative evaluation of conventional and modified frontalis muscle flap advancement techniques in the treatment of severe congenital ptosis: A retrospective cohort study

Purpose To introduce a modified frontalis muscle (FM) flap for use in FM flap advancement surgery and compare it with the conventional flap for correcting severe congenital ptosis. Methods This retrospective cohort study included 200 patients (278 eyes) with severe congenital ptosis treated with FM flap advancement at Tianjin Eye Hospital from April 2018 to October 2019. The patients were divided into two groups: 100 patients (138 eyes) in the conventional group and 100 patients (140 eyes) in the modified group. The success and complication rates were evaluated. Results The final success rate was 77.5% (107/138) in the conventional group and 90.0% (126/140) in the modified group (p = 0.005). Undercorrection was observed in 31 eyes (22.5%) in the conventional group and 14 eyes (10%) in the modified group (p = 0.005). In the conventional group, angular deformity of the upper eyelid was observed in 29 eyes (21.0%), FM paralysis in 11 (8.0%), frontal hypoesthesia in 10 (7.2%), severe hematoma in 12 (8.7%), and exposure keratitis in 8 (5.8%); these complications were not observed in the modified group (p <0.001, p <0.001, p = 0.004, p <0.001, p = 0.011, respectively). There were no cases of overcorrection, entropion or ectropion in either group. Conclusion Compared with the conventional FM flap, the modified FM flap in this study yielded a higher success rate with a clear field of vision, mild trauma, and few complications. This technique is simple and convenient for correcting severe congenital ptosis.

Pronounced Ptosis in Myasthenia Gravis—A New Bedside Clinical Sign

We report three cases of myasthenia gravis in whom the asymmetrical ptosis at presentation became more pronounced with the described bedside technique. Pronounced ptosis could be elicited by making the patient speak continuously for up to 2 minutes. Pauses for breathing and natural blinking were allowed. The sign is best elicited in newly diagnosed and treatment-naive patients. The loss of compensation for ptosis by frontalis muscle due to speech-induced fatigue may be responsible for the observed effect. Patients’ symptoms abated on treatment with acetylcholine esterase inhibitors, steroids, and steroid-sparing agents.