BOPSS Brighton
We are grateful to the following speakers to taking time to answer some of the questions asked throughout the conference
Upper eyelid retraction in TED – Rebecca Ford, Bristol
What is the technique for using Botox in lid retraction, and what are the criteria for selecting patients?
Can be done through everted lid injecting subconjunctivally through conj or transcutaneously eg through skin crease aiming towards orbital roof to inject above levator. Evidence suggests both are effective but trans conj may have lower risk of side effects such as diplopia. Risks include overcorrection and diplopia but are transient (eg 1-3 weeks duration)
Paper on algorithm for dose is Ozturk Karabulut G, Fazil K, Saracoglu Yilmaz B, Ozturker C, Gü naydın ZK, Taskapili M, Kaynak P. An algorithm for Botulinum toxin A injection for upper eyelid retraction associated with thyroid eye disease: long-term results. Orbit. 2021 Oct;40(5):381-388. doi: 10.1080/01676830.2020.1814351. Epub 2020 Sep 4. PMID: 32885692.
There is a meta-analysis here Zong AM, Giannakakos VP, Delbourgo Patton C, Barmettler A. Botulinum Toxin Treatment in Thyroid Eye Disease: A Systematic Review and Metaanalysis. Ophthalmic Plast Reconstr Surg. 2025 May-Jun 01;41(3):250-257. doi: 10.1097/IOP.0000000000002852. Epub 2024 Dec 19. PMID: 39700405.
And a review article here Young, Stephanie Ming1; Kim, Yoon-Duck2; Woo, Kyung In3,*. Nonsurgical management of upper eyelid retraction in thyroid eye disease. Taiwan Journal of Ophthalmology 14(4):p 548-553, Oct–Dec 2024. | DOI: 10.4103/tjo.TJO-D-23- 00043
Full thickness lid excision good for post lowering ptosis.
I’m not sure if this is a question or a suggestion. I assume they mean excising a portion of skin and tissue above the tarsus to shorten the overcorrection and I suppose this could be successful in cases where you are sure there is sufficient anterior lamella remaining. I have never tried it myself so have no experience of its efficacy.
Any place for conservative lid stretch?
-I couldn’t find any evidence for its efficacy whilst reviewing literature for this talk. However, it seems unlikely that it would cause harm and might be worth trying early in the condition.
Avoiding flat lid with mullerectomy
To be honest I done this often enough to have detailed experience as I primarily do anterior approaches. However, I consider the shape of the lid pre-op and would consider leaving the medial portion of Muller’s intact. If the patient is awake I would do it in sections starting laterally and check the height and contour as I go. I generally only opt for this approach for those needing 1-2mm only of change and don’t have experience with levator recession via the posterior approach personally.
Tamsulosin
Works by relaxing smooth muscle. I have no personal experience but included it for completeness due to reading a recent publication. I’m not sure I would use a systemic treatment fora localised problem – see study Arnon R, Goldberg H, Ben-Simon GJ, Priel A, Zloto O, Landau-Prat D, Cukierman-Yaffe T, Agmon-Levin N, Sagiv O. Alpha-1 antagonist treatment for eyelid retraction in patients with thyroid eye disease-a prospective pilot study. Eye (Lond). 2025 Jan;39(1):175-178. doi: 10.1038/s41433-024-03403-8. Epub 2024 Oct 21. PMID: 39428445; PMCID: PMC11733210.
How does Mullerectomy work for retraction?
This is not exactly the same mullerectomy as for ptosis. The Muller’s is excised but conj must be left intact, and the cut edge of Mullers is not sutured to the tarsus. Hence the lids ends up in the ‘Muller’s relaxed’ position rather than the ‘Muller’s contracted’ position.
Is there a time window for injecting the botox for retraction?
No, this treatment does seem to work in all phases of disease. It may become less effective if the levator muscle becomes very fibrotic and can’t relax.
How do you measure the ULR? Do you have the patient looking at a near or far point?
I choose a far point as I think we tend to look down and converge when looking at near targets which would change the lid position eg by putting less fixation stress on inferior rectus. I record MRD1 and scleral show in mm. I note any lateral flare and if MRD1 is maximal lateral to the light reflex I would note both measurements.
Btx for lidretraction – where are the injection sites? Medially directly to the levator or rather divided in two injections on each side of the levator muscle?
I personally just inject sub conj centrally with the lid everted and the botox will inevitably spread
Avoiding asymmetry in upper lid blepharoplasty – Austin McCormick
In cases where you elevate the lid crease asymmetrically on the side with mild relative brow ptosis – do you also remove more skin on that side?
I tend not to as I think creating asymmetry is hard enough to judge when changing only 1 variable so tend to leave them with the same amount of skin in each upper eyelid.
For Austin. If the skin excision alone will improve lid show anyway, how do you predict how much to raise the skin crease when you want to fine-tune lid show?
Although I am aiming / hoping for perfect symmetry I am not expecting it, more looking to reduce the asymmetry as much as possible. I tend to grade it very basically from an incision just at the upper edge of my marking on the low brow side and just at the lower edge of the marking on the higher brow side for subtle brow asymmetry. Then I would raise the low brow side skin crease by 1mm or 2mm if moderate or more severe brow ptosis. I haven’t found a way to quantify or measure what skin crease elevation results in a corresponding increase in lid show.
Minimising complications of lower eyelid blepharoplasty – Pari Shams
How do you manage persistent chemosis following four eyelid blepharoplasty despite normal eyelids position and no lagophthalmos?
If not responding to topical lubrication and a course of topical steroid, One-snip procedure to release accumulating fluid, through the bulbar conjunctiva and penetrate the underlying Tenon’s capsule under topical anaesthesia and povidone-iodine, ideally on slit lamp or under microscope, followed by firm pressure dressing for 24-48 hours or just one side if bilateral problem, followed by Copious (1- 2 hourly) ocular lubrication PF and a course of topical steroid eye drops- monitor for and treat steroid response
Would you do the lower lid transcutaneous bleph under LA or only under GA?
Prefer GA due to good control of BP and reduced need for LA infiltration intra op
What do you do with volume deficit and sunken lower lid( showing the lower orbital rim) following transconjunctival lower lid blepharoplasty? Thanks
Recommend autologous fat transfer to the area
Do you ever redrape the fat?
If the patient is at risk of a sunken or skeletonised look, has a very prominent nasojugal groove and there is the need to smooth out the lid–cheek junction
Which antimetabolite do you use and details how, dose etc
I use MMC, the same protocol as my Glaucoma colleagues at Moorfields. 0.2mg/ml, 0.1 ml on sponges/neurosurgical pattie = total 0.02 mg and place on the area of release scar tissue (Middle lamella/Retractors/septum) and leave for 3mins. Avoid contact with bulbar conjunctiva, then wash out with 50ml of BSS.
If found to be required: Would you advise for mid-face lift before every lower lid Blepharoplasty?
I would perform the mid face lit simultaneously with lower lid bleph
Do u repair transcutaneous post transcend blep
Not sure what this question is asking exactly but if asking about revision of transcutanoues bleph, I would avoid cutting the skin again unless I needed to revise a bad skin scar. Redos usually, but not always, need lid tightening, orbicularis muscle suspension and mid face support and therefore I would take a transconj approach to the lower eyelid if needing to work more on the fat but I would access the lateral canthus and midface via an incision in the lateral canthal skin smile line and down to the periosteum of the malar eminance.
Burning extraocular muscles – Ilse Mombaerts
Any competent of scleritis in these myositis cases?
Possible when the anterior tendon is involved, the latter being affected in approximately 50% of cases
Do you have a routine battery is systemic investigations you carry out on patients with myositis?
Serum IgG4 and thyroid parameters
How often do you see isolated levator myositis?
Exceedingly rare
When switch to immunosuppression and what to give
When high-dose methylprednisolone is unsuccessful, the next choice is Rituximab, followed by Methotrexate
How did you define mild vs severe?
Based on the level of pain and motility defect
Have you ever caused a diplopia with the 4mm punch?
Procuring a tissue sample from the enlarged, diseased part of the muscle, either with a punch (for the anterior part of the muscle) or with scissors (for the mid/posterior part of the muscle) does not alter the muscle function.
Immunotherapy in SCC – Guy Ben Simon
What is the definition of locally advanced?
Locally advanced refers to tumors with deep orbital involvement where complete surgical removal cannot be easily achieved, or where surgery is likely to result in high morbidity or carries a high risk of recurrence. This classification typically corresponds to T3 or T4 tumors in AJCC staging and often requires multidisciplinary management, including surgery, radiation therapy, and, in select cases, systemic or immune therapy.
Tarsal ectropion review and management – Raghavan Sampath
Can you elaborate on the mechanism of tarsal ectropion / why it occurs?
Inferior retractor attachment is lost to the lower border of tarsal plate – playing a role in flipping the lid due to loss of this attachment combined with other factors
In the same way ‘closed’ everting sutures for Entropion have a short duration of effect; isn’t it the same with the Leicester suture for Ectropion?
Inverting sutures combined with some form of lateral canthal tightening – similar to everting sutures with canthal tightening
What are long term results of the procedure shown in the video?
Out follow up data at 6 months ( considered a good post op review for recurrence ) show recurrence of less than 20 percent – even less with additional factors like laxity and cicatrisation are addressed
What size and type of suture is used for the inverting sutures?
5’0’ Vicryl double ended
Do you need to use a BCL with Leicester suture technique?
No need for BCL
Contraindicated in reverse bell’s phenomenon?
No
Have you audited the longevity of the outcomes of the Leicester inverting sutures?
Yes – if all factors are addressed recurrence is less than 20 percent – sometimes combined with MS
Do you ever bury the sutures through a stab incision at the inferior rim?
If very inflamed skin better to bury due to risk of infection
What is the Longevity of LEICESTER sutures (eg 12-24 months followup)
Already answered – this pathology is rare and selective use of this procedure helps – but will not correct if significant cicatrisation also present – patient selection important
What do you do when the conjunctiva is hypertrophic
Can use a course of topical steroid if needed – but just by inverting the lid and placing it against tear film does the trick
How long do you leave the Sutures in?
Three weeks – and remove if there is any reaction
Sometimes my inverting sutures pull the lower lid away from the eye. Is this just because I’ve not appreciated horizontal laxity? Or am I doing something wrong
Yes – have to address horizontal shortening – either by LTS or canthopexy after placing the inverting sutures
Why LTS and not lateral shortening?
Any form of lid shortening – if there is horizontal laxity – one is happy with
Peri ocular burns – Bal Dheansa
Any role for dermal substitute grafts such as Pelnac?
I prefer autograft and preferably full thickness skin for upper and lower eyelids.
Where do the full thickness skin grafts come from? And comments on foreskin eyelid skin grafts?
The amount of skin required usually means that full thickness donor sites are usually groin or inner upper arm. Foreskin is a possibility but in practice rarely used
Thoughts on hyperbaric oxygen and negative pressure?
There is very little good quality evidence that shows hyperbaric oxygen is helpful. Negative pressure is not usually a practical solution if there is extensive facial burn but also precludes inspection of the cornea which is often damaged and needs attention
The Changing World of Aesthetics: Moving Beyond Toxins and Fillers – Jenny Doyle
Regarding under eye filler – there seems to be a move away from this due to complications and migration. Are the alternatives better?
The only thing that will really replace volume and correct the concavity of a tear trough deformity is filler. If done conservatively and in the right plane with a good product selected they can be helpful. However assessment of the patient to make sure they are a good candidate (eg. good skin elasticity, no oedema etc) is needed.
Are we expected to believe that ultrasound can lift brow, with little evidence,when sometimes even surg removal of 1/1.5cm skin struggles to give a good lift?
Ultrasound for skin laxity has been used for several years, Sofwave has optimised the way it is delivered by fixing the depth at 1.5mm and heating the dermis to 60-70 degrees and holding it there for 4 seconds. Trials were carried out for FDA approval which showed up to 4-5mm of lift on the brow. This paper references them: Wang, Jordan V. MD, MBE, MBA; Bajaj, Shirin MD; Kauvar, Arielle MD†,‡; Geronemus, Roy G. MD*,†. Eyebrow Lifting From High-Intensity, High-Frequency, Parallel Ultrasound Beams. Dermatologic Surgery 49(7):p 718-720, July 2023. | DOI: 10.1097/DSS.0000000000003809
What is the specific elastin eye serum you mentioned?
Alastin Restorative Eye Serum
What about Sculptra?
Sculptra you can’t use in the periocular area- skin too thin and high risk of granulomas/ nodules
Opening the Septum in Upper Blepharoplasty – Paul Rosser, New Zealand
Do you think the excision of septum is the key to causing some adhesion at crease or the levator suture?
I am convinced that it is suturing the levator aponeurosis to the orbicularis muscle that creates the skin crease and not purely opening the septum. This is because once I’ve opened the septum, I can choose to change the skin crease position based on where my sutures attach to the levator aponeurosis.
Would you ever combine upper lid blepharoplasty with a brow proxy in patients with brow ptosis who don’t want brow scars?
I used to perform browpexies, but no longer do so, as in my hands they achieve very little. If one attaches the soft tissues beneath the brow to the soft tissues low in the forehead the result does not seem to last and if attached to the periosteum, the lift is better, but the brow relatively immobile. In addition, I’ve found a browpexy can affect the accuracy of skin crease placement.
What sort of brow lift did you offer the males who declined brow lift. Endobrow, internal or transcutaneous?
I assume that the question asks what procedures were discussed with the patient, even though they refused the surgery. If I feel a patient has significant brow ptosis and would benefit from brow lift surgery, I discuss the options of either an endoscopic brow lift or a transcutaneous lift. If I am to perform surgery, I prefer a transcutaneous approach placing the wound in a low mid-forehead crease.
I’ve seen brow descent after ULB in some pts with brow ptosis presumably because drive to raise brows diminished. How often did you see that in your cases?
Looking at our 500 consecutive eyelids we found that the post-operative skin crease was slightly higher than predicted by about 0.5mm on average. I presume this relates to traction following tightening of the upper lid skin and is also probably the reason some studies have found a small amount of brow drop after upper blepharoplasty. This is difficult to accurately assess without accurate and standardized photography – which was not included in our study.
What’s your experience with sub-brow skin removal for Asian bleph with significant redundant upper lid skin? for Mr Rosser
While I am aware of the procedure, having first seen it presented around 10 years ago at the Tokyo World Ophthalmology Congress, I have no experience with it myself. The technique is reported to be both effective and cosmetically acceptable.
Why not just place the suture into the posterior surface of apo and preserve the septum entirely?
Do you mean from a posterior approach? – as this surgery is mainly used in conjunction with skin approach blepharoplasty combining skin and muscle debulking. To adequately access the levator aponeurosis from a skin approach, the septum needs to be opened.
How do you schedule patients Botox injections around upper blepharoplasty? Do you operate after a washout period?
If patients regularly have Botox injections, I don’t ask them to have a toxin holiday. Their ‘new normal’ situation is with Botox and therefore it is reasonable to plan the surgery in a treated state.
Do you use 6.0 vicryl x4 for skin crease reformation? ie what sutures?
Yes, I use 4 x 6.0 vicryl on an S-14 needle to reform the skin crease, and one more lateral suture just closing the orbicularis muscle. When operating on Asian patients I will often place 5 sutures to make the crease as in some cases the crease ‘falls out’ after a couple of years. I feel that using more skin crease reformation sutures will increase the likelihood of the crease being maintained.
Can you do a skin crease reformation without opening the septum?
The way to differentiate between the septum and the aponeurosis is to grasp the structure intra-operatively and have the patient elevate their lid. This demonstrates that the aponeurosis is significantly more mobile than the septum, and why it is useful in skin crease reformation. Although suturing the orbicularis muscle to the septum can result in a skin crease, it is less well formed, less predictable and more likely to fall out over time.
