Discussion: Objective Outcome Measurement After Upper Blepharoplasty: An Analysis of Different Operative Techniques

We read with great interest the article entitled ‘‘Objective outcome measurement after upper blepharoplasty: an analysis of different operative techniques’’ by Ki-soo Parkand David Dae-Hwan Park [1]. We conducted a study to analyze the dislocation of the eyelid position after lower blepharoplasty. Using Adobe Photoshop 7.0.1 (Adobe Systems Inc, San Jose California) software, pre- and,postoperative photos of patients were used to measure the Marginal Reflex Distance2 (MRD2), namely the distance between the center of the pupil and upper border of the lower eyelid [2]. The variations in the lower eyelid positions were calculated and compared pre- and postoperatively for each individual eye. We fully agree with the authors regarding the importance of an objective evaluation of blepharoplasty outcomes. As suggested by the authors, we also maintain that the analysis of digital images provides more accurate results than those obtained by using an handled ruler because inter-observer variability is very low in the former. The use of fixed points, as the distance between the palpebral rim and the center of the pupil, allows an objective measurement. The white-to-white corneal diameter compensates for the differences in scale inherent in patient photographs since its value remains unchanged by blepharoplasty. In our study, to obtain more reliable information, data, collected from digital photos,were performed by three different clinicians and the differences in the mean were statistically compared and were considered as fixed effects in a linear mixed model. To convert in millimeters, the variation of the Margin Reflex Index values, we also applied the average white-to-white corneal diameter of the European population (11.71 mm)[3]. We applied the same criteria based on MRD1 to evaluate long-term results after aponeurotic blepharoptosis correction with external levator muscle complex advancement [4]. Despite the authors, we also considered the symmetry among both eyes (Fig. 1). As suggested by the British Oculoplasty Surgery Society [5], a key point for successful symmetric urgical correction included the differences between the postoperative upper MRD between the two eyes (interlid MRD1 difference), the postoperative difference of the distance between the upper lid margin and the upper lid fold (interlid crease difference) and the postoperative difference in the gap between the upper and lower palpebral rim between the eyes (interlid show difference).