Pretarsal orbicularis oculi muscle tightening with skin flap excision in the treatment of lower eyelid involutional entropion

Background To evaluate a modified technique for involutional entropion correction in a retrospective cohort study. Methods The patients with involutional entropion eyelid were corrected by tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid. The patients received correction surgery from April 2013 to March 2019 were followed up for more than 6 months postoperatively. The outcome measures included the complications and the recurrence rates. Results Total 152 patients (169 eyes) were included. The mean follow-up period was 29.6 months (range: 6–36 months). Postoperative ectropion (over-correction) was observed in 1 patient with 1 eyelid (0.59%); yet, no further surgery was needed for this patient. Recurrence of entropion was found in 1 patient (0.59%). The patient with recurrent entropion received repeated surgery with the same method and achieved a good eyelid position. Conclusions This study demonstrated that tightening the pretarsal orbicularis oculi muscle and excising the excess skin of the lower eyelid could be an effective surgical method to correct lower eyelid involutional entropion. This method is technically easy with a low recurrence rate and not associated with significant complications in Asians.

Bulbar-Predominant Weakness

A 61-year-old man sought care for recurrent episodes of dysarthria for about 1 year. This symptom was more common after prolonged speaking. Six months before his evaluation he had significant slurring of his speech after talking for 3½ hours at work about a new project. This led to emergency evaluation and his symptoms were thought to represent a transient ischemic attack; he started aspirin and a statin. The episodes continued to recur. He also experienced intermittent binocular double vision, which did not improve with new eyeglasses, and a sensation that chewing and swallowing was more effortful. He noted that his arms and legs felt “heavy” at times. All these symptoms tended to occur later in the day or after exertion. Neurologic examination was remarkable for binocular double vision with prolonged gaze upward or to the far right. He could squat and rise 5 times but with difficulty by the 5th attempt. The patient’s symptoms suggested myasthenia gravis. The differential diagnosis for autoimmune myasthenia gravis, particularly with prominent ocular and facial muscle involvement, can include central nervous system disorders, motor neuron disease, and myopathy. Serologic evaluation showed positivity for acetylcholine receptor-binding antibody and acetylcholine receptor-modulating antibody. Striated muscle antibody was also positive. Thiopurine S-methyltransferase activity was low. Repetitive stimulation studies showed a decrement in the right facial nerve, which partially improved after exercise. Routine needle examination showed motor unit variation in the right orbicularis oculi. Single-fiber electromyography showed increased jitter in the right orbicularis oculi. Chest computed tomography showed scattered tiny pulmonary nodules but no evidence of thymoma or other neoplasm. The clinical diagnosis was autoimmune generalized myasthenia gravis, seropositive for acetylcholine receptor antibody, without evident thymoma or other neoplasm. The patient was initially treated with oral pyridostigmine with some symptomatic benefit. Oral prednisone was then initiated; symptoms resolved when the dose was titrated. Calcium and vitamin D supplements, as well as Pneumocystis prophylactic therapy, were initiated concurrently. Mycophenolate mofetil was added as a steroid-sparing agent. On thoracic surgery consultation, thymectomy was recommended. Autoimmune myasthenia gravis is a disorder of impaired neuromuscular transmission caused by immunoglobulin G-mediated attack on a critical component of the acetylcholine receptor signaling complex in the muscle’s postsynaptic membrane. The most commonly identified antibodies, target the nicotinic acetylcholine receptor.

Mask wearing increases eye involvement during smiling: a facial EMG study

The use of face masks has become ubiquitous. Although mask wearing is a convenient way to reduce the spread of disease, it is important to know how the mask affects our communication via facial expression. For example, when we are wearing the mask and meet a friend, are our facial expressions different compared to when we are not? We investigated the effect of face mask wearing on facial expression, including the area around the eyes. We measured surface electromyography from zygomaticus major, orbicularis oculi, and depressor anguli oris muscles, when people smiled and talked with or without a mask. Only the actions of the orbicularis oculi were facilitated by wearing the mask. We thus concluded that mask wearing may increase the recruitment of the eyes during smiling. In other words, we can express joy and happiness even when wearing a face mask.

Analysis of Facial Muscle Depths to Guide Botulinum Toxin Therapy of the Periocular Region

Purpose: Botulinum toxin (BTX) injections are used in cosmetic surgery to efface facial wrinkles. Botulinum toxin relaxes the muscle by preventing the release of the neurotransmitter acetylcholine at the neuromuscular junction located at the posterior muscle surface causing local muscle paralysis. The purpose of this study is to provide anatomic knowledge of muscle belly depths of the frontalis, corrugator supercilii, procerus, and orbicularis oculi muscles in an attempt to improve the efficacy of BTX treatment of glabellar, forehead, and lateral eyelid rhytides. Methods: Six-millimeter punch biopsies were obtained from 7 fresh cadavers. Biopsies were taken from the corrugator supercilii, frontalis, procerus, and orbicularis oculi muscles at the sites of routine BTX injection. Specimens were fixed in formalin, and representative H&E-stained sections were used to measure muscle surface depths by light microscopy equipped with digital camera that includes a digital micrometer. One-way analysis of variance test analyses were used to identify statistical differences between measured muscle depths. Results: The measured anterior muscle depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 4.2 ± 0.6, 3.9 ± 0.6, 2.9 ± 0.4, and 2.3 ± 0.7 mm, respectively. The anterior muscle surface of the corrugator supercilii and frontalis was found to be deeper than that of the procerus and orbicularis oculi ( P < .001). The posterior surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 6.6 ± 0.8, 5.1 ± 0.7, 4.9 ± 0.7, and 3.8 ± 1.0 mm, respectively. The posterior surface depth of the corrugator supercilii was found to be significantly deeper than that of the frontalis, procerus, and orbicularis oculi ( P < .001); the posterior surface depth of the frontalis and procerus was deeper than that of the orbicularis oculi ( P < .001). The muscle belly width of the corrugator supercilii, frontalis, procerus, and orbicularis oculi measured 2.5 ± 0.9, 1.1 ± 0.4, 2.0 ± 0.6, and 1.5 ± 0.5 mm, respectively. The corrugator supercilii was found to be thicker than the frontalis and orbicularis oculi, while the procerus was found to be thicker than the frontalis ( P < .001). Conclusion: The findings above demonstrate statistical differences in the posterior muscle surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi which can be used clinically to improve BTX injection efficacy when used to efface facial rhytides.

Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned from Functional Anatomy

Background The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying fascial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments. Objectives To evaluate the location and function of the angular vein in the tear trough in three different facial expressions: repose, smiling, and max. orbicularis oculi contraction. Methods Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m 2 were investigated via functional ultrasound imaging. The diameter of the angular vein, the velocity, and direction of venous blood flow were analyzed in repose, smiling and during max. orbicularis oculi contraction. Results The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (= intra-muscular course) within the tear trough whereas the angular artery was not identified in this location. The distance between the angular vein the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/sec and was 7.3 cm/sec at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling. Conclusions The diameter and the venous blood flow of the angular vein varied between the three tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein

High Therapeutic and Esthetic Properties of Extracellular Vesicles Produced from the Stem Cells and Their Spheroids Cultured from Ocular Surgery-Derived Waste Orbicularis Oculi Muscle Tissues

Extracellular vesicles (EVs) are paracrine factors that mediate stem cell therapeutics. We aimed at evaluating the possible therapeutic and esthetic applications of EVs prepared from the waste human facial tissue-derived orbicularis oculi muscle stem cells (OOM-SCs). OOM-SCs were isolated from the ocular tissues (from elders and youngsters) after upper eyelid blepharoplasty or epiblepharon surgeries. EVs were prepared from the OOM-SCs (OOM-SC-EVs) and their three-dimensional spheroids. OOM-SCs showed a spindle-like morphology with trilineage differentiation capacity, positive expression of CD105, CD 90, and CD73, and negative expression of CD45 and CD34, and their stem cell properties were compared with other adult mesenchymal stem cells. OOM-SC-EVs showed a high inhibitory effect on melanin synthesis in B16F10 cells by blocking tyrosinase activity. OOM-SC-EVs treatment led to a significant attenuation of senescence-associated changes, a decrease in reactive oxygen species generation, and an upregulation of antioxidant genes. We demonstrated the regeneration activity of OOM-SC-EVs in in vitro wound healing of normal human dermal fibroblasts and upregulation of anti-wrinkle-related genes and confirmed the therapeutic potential of OOM-SC-EVs in the healing of the in vivo wound model. Our study provides promising therapeutic and esthetic applications of OOM-SC-EVs, which can be obtained from the ocular surgery-derived waste human facial tissues.

Intolerance of uncertainty and physiological responses during instructed uncertain threat: a multi-lab investigation

Individuals with high self-reported Intolerance of uncertainty (IU) tend to interpret uncertainty negatively. Recent research has been inconclusive on evidence of an association between IU and physiological responses during instructed uncertain threat. To address this gap, we conducted secondary analyses of IU and physiology data recorded during instructed uncertain threat tasks from two lab sites (Wisconsin-Madison; n = 128; Yale, n = 103). Higher IU was associated with: (1) greater corrugator supercilii activity to predictable and unpredictable threat of shock, compared to the safety from shock, and (2) poorer discriminatory skin conductance response between the unpredictable threat of shock, relative to the safety from shock. No IU-related effects were observed for the orbicularis oculi. These findings suggest that IU-related biases may be captured differently depending on the physiological measure during instructed uncertain threat. Implications of these findings for neurobiological models of uncertainty and anticipation in anxiety are discussed.