Comments on "Simplified Muscle-Suspension Lower Blepharoplasty by Orbicularis Hitch".

We would like to comment on the publication by Drs Little and Hartstein.[1] The authors present a very useful technique to support the lid and to improve its contour, and they conclude that “orbicularis hitch is a safe, simple, and effective procedure for suspension based rejuvenation of the lower eyelid region. The technique allows the safe reversal of significant orbicularis oculi descent.”

We agree with the usefulness and the simplicity of the technique proposed, but we feel the need to highlight the following points.

Lack of Standardization of the Adjunctive Techniques Among the Two Surgeons at Every Level

Adjunctive Eyelid Tightening

They state that orbicularis hitch “nearly eliminates the need for horizontal lid-tightening procedures at the lateral canthus.” However, some patients underwent “tarsopexy,” canthoplasty, and canthopexy. We could not find any references for the tarsopexy as “a simplified version of a common lid-stabilizing maneuver.” Tarsopexy was indicated when lid distraction was above 10 mm, but the author stated that this occurred rarely; in the results it is stated that tarsopexy was performed in two patients. A second group of patients, those with an eyelid distraction test between 5 and 10 mm, underwent another unreferenced technique of “nasal lid-margin shift,” but we don’t get to know how many patients underwent this adjunctive technique. In the oculoplastic group we learn that the surgeon added canthopexy or lateral tarsal strip canthoplasty if particular lid laxity was diagnosed, but no measures as to the amount of eyelid laxity indicated what technique was used and when.

Associated Procedures

Ninety-five percent of the patients of the plastic surgeon underwent CO2 laser resurfacing. This adjunctive procedure may as well be the main responsible for the skin tightening effect.

Eyelid Volume

Eyelid volume was addressed by means of fat removal in only three patients and fat grafting in 100% in the plastic series; the fat pads were repositioned in 40% and removed in 60% of patients by the oculoplastic surgeon. In the oculoplastic technique it is stated elsewhere that the fat was also added with either deep traditional fat implant and superficial enhanced fluid fat injection (SEFFI).

Follow-Up

We were also surprised to read that the series of the plastic surgeon included patients with 3 week and 3 month follow ups, with self-reported long term positive outcome. The oculoplastic group included patients with a follow up of three months. We feel that results with less than 6 month follow up should not be included in the study, even if evaluated by expert plastic surgeon. Some journals have a specific policy of 1 year follow up only, and we thought ASJ was among them.

Study Design

There are no objective measurements, no masked evaluation, no patient self-assessment, just the opinion of the authors. There are numerous published reports of eyelid procedures evaluated with the ImageJ software (National Institute of Health, Bethesda, MD), giving objective measurements to compare.[2] We believe the use of such software could have enhanced this report.

Complications

In the combined series there was one case only of eyelid malposition. Again there are no objective measures to substantiate this conclusion; the only clinical example of pre and postoperative result in the manuscript, which supposedly conveys the best example, shows significant descent of the lower lids, right more than left, especially noticeable in the temporal aspect. It also shows medial displacement of the lateral canthal angle of the right lid, which therefore displays a shortened horizontal fissure compared to preoperative. We do not want to criticize the author’s perspective on their result, and we agree that most patients should and would be happy with such a result. We want to highlight the fact that the only pre and post of the printed version of the paper, being the one most viewed by the readers, shows how the lack of objective measurements can affect the conclusions. We can deduct that either the authors failed to recognize eyelid malposition or they have different goals in eyelid rejuvenation.

Conclusions Drawn

The conclusion “The authors’ separate experiences confirm that orbicularis hitch is a safe, simple, and effective procedure for suspension-based rejuvenation of the lower eyelid region” is never supported by the data they present.

We like the orbicularis hitch and the authors should be commended for publishing this original technique, but we believe that ASJ should have a stricter peer review process, to favor higher evidence-based manuscripts.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.