Minibleph, A Non-Incisional Blepharoplasty Technique For Skin Tightening Of Eyelids With The Use Of Fractional CO2 Laser

doi:10.21203/rs.3.rs-4107538/v1

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Minibleph, A Non-Incisional Blepharoplasty Technique For Skin Tightening Of Eyelids With The Use Of Fractional CO2 Laser

https://doi.org/10.21203/rs.3.rs-4107538/v1

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Purpose

To measure the efficacy of “Minibleph,” a minimally invasive, non-incisional technique that utilizes a fractional CO2 laser for periocular rejuvenation.

Methods

3-month case series of 22 eyes with eyelid skin laxity, periocular wrinkles and dermatochalasis treated with a CO2 laser with a fractional ablative resurfacing scanner. Included data were pre/post procedure ocular skin laxity, texture and pigmentation, lid measurements, dermatochalasis grade and satisfaction questionnaires.

Results

At 3 months post-treatment, all patients had improved skin laxity and texture where 54.5% of eyelids were in the 4th quartile (75–100% improvement). No signs of postreatment hyperpigmentation. Moreover, there was significant improvement in Eyelid Fold (p-value 0.048), MRD1 (p-value 0.008) and Palpebral Fissure (p-value 0.008) values. There was significant improvement of dermatochalasis (p-value 0.034) where 11 eyelids (50%) improved in dermatochalasis grade. FACE-Q questionnaire showed significant decrease of Upper/ Lower Eyelid Rasch scores (p-value 0.03). Recovery Early Symptoms mean value was low (25.55/100), while means of the Satisfaction with Outcome was high (78.82/100).

Conclusion

“Minibleph” is a safe technique for periocular rejuvenation, improving skin laxity, texture and wrinkles. It may also improve mild dermatochalasis and palpebral fissure opening, However, it is not suitable for correcting moderate to severe dermatochalasis that requires surgical intervention.

Health sciences/Diseases/Eye diseases/Eyelid diseases

Health sciences/Signs and symptoms/Eye manifestations

blepharoplasty

minimal invasive

eyelid

ablative fractional CO2 laser

skin tightening

dermatochalasis

Due to aging, laxity and dermatochalasis that occur around the area of the eyes significantly affect the periocular region. For management these periocular issues, surgical blepharoplasty is one of the choice surgical procedures. In fact, it is the most common surgical procedure performed to rejuvenate eyelids and facial appearance and still the gold standard.¹ This incisional procedure consists of the removal of excess skin of the eyelids. An additional excision of orbicularis muscle or preaponeurotic fat can be performed to address excess volume and/or fat prolapse. For experienced surgeons, blepharoplasty is a safe procedure. As with any surgical intervention, it requires a sterile setup, such as an operating room, and local anesthesia or even general anesthesia for some cases. Also, there are potential complications that should be considered. These include overcorrection (e.g. lagophthalmos), undercorrection, asymmetry, and hypertrophic/hypopigmented scars among others.² Although exceptional, severe complications like orbital hemorrhage can lead to decreased visual function or even blindness.^{2, 3}

Treatment for the early stages of dermatochalasis has been a recent trend with high demand from patients and of interest of oculoplastic surgeons dedicated to the aesthetic aspect of the practice. Although periocular early dermatochalasis usually does not affect the quality of both life and vision, especially the younger population seek correction for cosmetic reasons, while opting for more minimally invasive methods to correct this periocular region. Several non-surgical skin tightening procedures have been proposed already in oculoplastics as well as dermatology and aesthetic medicine.^4–9 Of note is the use of CO₂ lasers for periorbital rejuvenation, which utilizes a minimally invasive technique with fewer complications than traditional incisional surgery. These may be performed in a clinic setting and usually with local anesthesia. This procedure has been in practice for many years, addressing signs of periorbital aging such as those involving mainly the upper eyelids such as dermatochalasis ^4–5 as well as lateral canthal lines/crow’s feet, age spots and dyschromia. The periocular fractional CO₂ laser treatments have also shown to improve the outcome of incisional blepharoplasties by reducing signs of aging such wrinkles and hyperpigmentation, further rejuvenating the face.¹⁰ However, to the best of our knowledge, there are no generally established and accepted parameters and ablative patterns by the oculoplastic practice for the skin resurfacing of the eyelids as well as the periocular area. We had specifically designed the technique for the particular characteristics and behavior of eyelid skin which are thin due to the lack of subcutaneous fat tissue as well as the rest of the periorbital skin. Moreover, this skin region is close to a critical structure, the eye globe, requiring special attention and corneal protection.¹¹

In the current study, we aim to show the efficacy and safety with detailed parameters and ablation patterns of a modern CO₂ resurfacing laser technique applied to eyelids and the periocular area. We termed the technique as “Minibleph”, since it provides a minimally invasive, non-incisional and non-surgical blepharoplasty technique that consists of tightening the skin of the eyelids and rejuvenation of the periocular area, by using a fractional ablative CO₂ laser. It can be performed under topical anesthesia in a clinical setting. Utilizing fractional photothermolysis (FP),^12–13 it works by targeting both the epidermis and dermis, where collagen remodeling and new collagen formation occur.

Twenty-two eyes of 11 patients were included in this investigation. All patients recruited for this study were women. All were followed up for the full period of three months. Subjects were in the range of 45 to 70 years old with a mean age of 52.4 ± 7.5 years. Figure 2 shows the outcome of one of the patients included in the study.

In Figs. 2A and 2B there are changes grossly visible after treatment demonstrated in Figs. 2C and 2D specifically in skin laxity and texture, eyelid measurements and dermatochalasis.

Skin Hyperpigmentation and Laxity and Texture

Table 1 shows the results of post-treatment skin hyperpigmentation at 3 months. All eyes (100%) were without post inflammatory hyperpigmentation (PIH). Table 3 also shows results of skin laxity and texture in a quartile grading scale, where the higher grade represents more improvement from pre-procedure laxity and texture. After treatment, all patients (100%) had improvements in laxity and texture: 2 eyes (9.1%) had a grade of 1, 8 eyes (36.4%) had a grade of 3 and 12 eyes (54.5%) had a grade of 4.

Table 1

Treatment protocol and settings depending on skin phototype in AcuPulse CO2 laser.
Combo mode	Deep Parameters		Superficial Parameters
Fitzpatrick Skin Type	Energy (mJ)	Density	Energy (mJ)	Density
I or II	12.5–15	5–15%	60–80	40–60%
III	12.5	5–10%	60	40%

Lid Measurements

The lid measurements of each patient are shown in Table 2. There was improvement in the variables of Eyelid Fold, MRD1 and Palpebral Fissure, where the aforementioned had values that were statistically significant. The variables of MRD2, Eyelid Fold Asymmetry, MRD1 Asymmetry and Palpebral Fold Asymmetry did not show significant changes in their values (Table 2).

Table 2

Number of subjects (n), percentage (%) of Post-procedure Skin Hyperpigmentation and Skin Laxity and Texture Quartile Grading.
	POST
	n	%
Skin Hyperpigmentation
None (0)	22	100
Mild (1)	0	0.0
Moderate (2)	0	0.0
Severe (3)	0	0.0
Skin Laxity and Texture Quartile Grading
0	0	0.0
1	2	9.1
2	0	0.0
3	8	36.4
4	12	54.5

Dermatochalasis

Table 3 outlines the variables of dermatochalasis observed in our sample. Regarding the degree of dermatochalasis, before treatment 2 eyes (9.1%) had grade of 0, 6 eyes (27.3%) had grade 1, 9 eyes (40.9%) had grade 2 and 5 eyes (22.7%) had grade 3. After treatment, 6 eyes (27.3%) had grade 0, 6 eyes (27.3%) had grade 1, 7 eyes (31.8%) had grade 2, while 3 eyes (13.6%) had grade 3. In the pretreatment phase, 36.36% had grade 0 and 1, whereas in the post-treatment phase, this value increased to 54.6% with these low degrees of dermatochalasis. Overall, 11 eyes (50%) improved their grade of dermatochalasis, where the degree of improvement was found to be significant (p-value 0.034).

Table 3

Results of the variables studied before and after treatment, and results of the FACE-Q questionnaire. (MRD: Margin to Reflex Distance 1 and 2; SD: Standard deviation; Min: Minimum; Max: Maximum).
	PRE				POST
	Mean	SD	Min	Max	Mean	SD	Min	Max	p-value
Eyelid Fold	8.93	2.16	5	14	7.80	2.53	4	12.5	0.048
MRD1	2.93	1.18	1	5	3.50	1.15	1.5	6	0.008
MRD2	4.91	0.67	3.5	6.5	5.00	0.77	3	6	0.572
Palpebral Fissure	7.84	1.20	6.5	10	8.50	1.37	5.5	11	0.008
Eyelid Fold Asymmetry	0.86	0.62	0	2	0.68	0.39	0	1.5	0.255
MRD1 Asymmetry	0.50	0.53	0	1.5	0.73	0.59	0	2	0.121
Palpebral Fissure Asymmetry	0.50	0.44	0	1	0.64	0.62	0	2	0.422
FACE-Q Upper Rasch	54.09	16.05	26	83	16.64	11.75	0	38	0.003
FACE-Q Lower Rasch	47.18	14.80	28	82	19.09	10.98	0	39	0.003
FACE-Q Psychological function					79.73	10.34	62	93
FACE-Q Recover early symptoms					25.55	5.18	21	40
FACE-Q Satisfaction with outcome					78.82	15.95	45	100

Table 4

Number of subjects (n), percentage (%), median and interquartile range (IQR) with dermatochalasis grades, skin hyperpigmentation and skin texture.
			PRE				POST		p-value
	Median	IQR	n	%	Median	IQR	n	%
Dermatochalasis Grade	2	1			1	2			0.034
0			2	9.1			6	27.3
1			6	27.3			6	27.3
2			9	40.9			7	31.8
3			5	22.7			3	13.6
Dermatochalasis Grade Change
1 to 0 2 to 1 3 to 2							4 5 2	18.2 22.7 9.1

Patient Satisfaction

Table 2 also shows that patients were highly satisfied based on the questionnaires. According to the scores of the FACE-Q questionnaire for Upper Eyelids and Lower Eyelids, there was a decrease in the total score in the last follow-up. This means that there was a subjective perceived improvement by the patient. This decrease was statistically significant. For psychological function, patients scored an average of 79.73 out of 100, indicating that they were satisfied with the appearance of their face. For the Recovery Early symptoms questionnaire, a mean score of 25.55 out of 100 was obtained, indicating that subjects had little symptomatology after treatment, such as mild edema, palpebral hyperemia and burning sensation immediately after the treatment. Finally, for the Satisfaction with Outcome questionnaire, subjects scored 78.82 out of 100, indicating that subjects were generally satisfied with the outcome obtained.

Minibleph is an effective technique for rejuvenation of the periocular area, improving skin laxity, texture, pigmentation, dyschromia, and even for some degrees of dermatochalasis (Figs. 2A and 2B). In our case series we have not found any complication in the form of postoperative wounding, hypo- or hyperpigmentation, inflammation and scarring. The improvements of the aesthetic appearance of the eyelids were satisfactory according not only to the post-treatment eyelid measurements but also according to the patient satisfaction questionnaires.

Although the use of lasers for the treatment of eyelids is not new, there is a lack of standardized protocols to safely treat this region, taking in consideration that the thickness of the eyelid skin is very different from the rest of the facial area. The skin of the eyelid region is thin and there is no subcutaneous fat tissue, being the orbicularis muscle, just below the dermis.

Previous studies have demonstrated other similar noninvasive treatment such as radiofrequency (RF), to correct eyelid laxity, skin surface and palpebral fissure height²². This method modifies dermal collagen and shortens fibrous septae. Ruiz-Esparza attributed cosmetic improvement of the lower eyelids to skin contraction²². In this study, all 11 patients showed cosmetic improvement within 12 weeks, along with high patient satisfaction. There were also no complications due to the procedure. Biesman²³ also used RF energy and a 0.25 cm² shallow treatment tip designed to be specifically suitable and safe for eyelids. Their results were similar to our quartile grading of improvement from baseline through reduction of hooding of the upper eyelids and the improvement of eyelid skin tightening. Hooding was improved in 86% of patients. Upper eyelid tightening was achieved in 88% of subjects and lower eyelid tightening was achieved in 71–74% of patients. Most patients obtained at least 25% improvement.

With the advent of carbon dioxide lasers, other authors have published improvements in the treatment of the periocular area. In a previous study using a non-fractionated laser⁶, periorbital wrinkles were reduced by at least 70%, 3 to 6 months after treatment in 65% of cases, and improvement continued for up to 6 months. Adverse effects included erythema that resolved in 4 weeks in 80% of patients as well as edema that resolved after 4 to 6 weeks, indicating quite a long recovery period, probably due to the fact that non-fractionated laser technology was used. A study by Bonan et al ¹⁹ with the SmartXide DOT (DEKA-M.E.L.A., Calenzano, Italy) fractional CO2 laser focused on the results of eyelid tightening. In their study, 35.6% achieved marked to excellent improvements of laxity and texture (75–100% improvement). Side effects such as erythema disappeared within 24–48 hours of treatment. The studies of Balzani and Toyos also used fractionated lasers on the upper eyelids and the side effects from the laser resolved in a range of 4–10 days^4–5.

With regard to skin laxity and texture in our study, all patients had improvement (reduction of skin laxity and rugosity) of at least 25% from baseline; 54% of all eyes had improved their skin laxity and texture 75–90% from baseline in the 4th quartile range. Skin hyperpigmentation after our treatment was not observed. Eyelid hyperemia and swelling were not persistent and stayed on an average of 2 to 4 weeks post-treatment. In the last follow-up, all patients had all hyperemia resolved which was originally observed in the immediate post-treatment period.

With regard to specific eyelid measurements, several studies have shown effectiveness with the use of CO2 lasers^4–5. Balzani reported using a similar fractional ultrapulse CO2 laser (MX-7000 MICROXEL, Dae Shin Enterprise, Seoul, Korea), where settings and ablation patterns of their technique were described. The study had focus on upper eyelid and brow treatment where, compared to pretreatment measurements, average elevation of eyelid crease and brow position were 1.62 ± 0.69 and 2.110 ± 0.66 mm at 3 months and 1.63 ± 0.68 and 2.300 ± 0.67 mm at 6 months, respectively. The improvements were statistically significant (p value < 0.001). Toyos utilized MIXTO fractional CO2 laser (MIXTO Pro Slim Evolution II) delivered in a continuous wave with lower laser energies to decrease heat buildup leading to less pain and side effects and unwanted damage to skin. The MRD of the upper lid had an increased mean from 0.7 to 2.2 mm ( p = 0.09), while the palpebral fissure distance had an increase from 5.6 to 7.4 mm ( p = 0.2). Bonan¹⁸ reported a widened palpebral fissure in 82.2% of patients after one year treatment with the SmartXide DOT (DEKA-M.E.L.A., Calenzano, Italy) fractional CO2 laser.

Our study agrees with the former studies, since we observed a significant improvement in each of the mean values of eyelid fold, MRD1 and palpebral fissure before and after the treatment (p-value < 0.05). This change in the palpebral aperture was also described using non-fractional lasers by other authors²⁴. We had included asymmetry as a measurement of success before and after Minibleph, and there were no significant changes, thus this technique can maintain the symmetry between both eyes. Dermatochalasis improved (p-value < 0.05) overall in 50% of the eyes, with a change in their grading from a higher to a lower grade, which is considerable, not being an incisional technique. In the last follow-up, 54.6% of the patients had grade 0 to grade 1 of dermatochalasis.

For the FACE-Q questionnaires of our study, which comprises the patient focused results, satisfaction was found to be excellent. With regard to overall satisfaction of the outcome, the scores had a mean of 79.73 out of 100, indication a favorable response. The Rasch scores of the questionnaires pertaining to the upper and lower eyelids had also significantly decreased post-treatment, which means that patient perception of their eyelids had improved. Lastly, Recovery Early symptoms questionnaires obtained 25.55 as the mean (out of 100), which shows that patients reported less adverse events post-treatment. Consistently with other reports such as that of the UltraPulse CO2 laser (Microxel MX 7000)⁴ patient satisfaction was high where 60% of patients showed good satisfaction, 20% reported excellent and fair satisfactory results while there was no reported poor satisfaction.

This publication prescribes an innovative upper and lower eyelid tightening protocol to rejuvenate the periocular area using the AcuPulse™ fractional ablative CO2 laser. Clinical results and patient satisfaction were satisfactory. Other authors have concluded that fractional ablative CO2 laser remains an excellent alternative to traditional blepharoplasty for mild cases²⁵

We also agree that only minor degrees of dermatochalasis can be treated with Minibleph, and more studies should be conducted to combine this technique with the traditional incisional procedures, due to the fact that incisional blepharoplasties have limitations regarding the complete rejuvenation of the skin, not fully treating periocular lines, texture and pigmentation that are better treated with the use of a fractional laser.

The fractional modality of the laser improves the appearance of the eyelids in the early post-treatment period, with a quick recovery and without relevant complications, compared to previous studies using non-fractionated technologies. Further studies are being conducted in our center, in order to determine the rate of patient satisfaction, efficacy and safety in a longer term observation.

This prospective case series study was performed at Vissum (Miranza Group). We conducted a study on a clinical sample of 11 consecutive patients between January and March 2023. The study followed the tenets of the Declaration of Helsinki. This prospective study was approved by the Ethical Board Committee of our institution. Written and informed consent was obtained from all patients involved regarding the study and the photographs taken before treatment and the study was started. Patients were followed up for a period of three months. Study variables were obtained using physical examinations done pretreatment, and 3 months post-treatment.

Inclusion criteria of patients were as follows: presence of periorbital skin rugosity/wrinkling and skin laxity, no to some degree of dermatochalasis (categorized with grades 0, 1, 2, 3), and skin phototypes I, II or III of Fitzpatrick scale¹⁴. Exclusion criteria was previous surgery involving the eyelids, Fitzpatrick skin phototypes IV, V and VI due to higher risk of hyperpigmentation, severe dermatochalasis affecting visual function with or without brow ptosis, fat prolapse, hypertrophic retroorbicularis oculi fat (ROOF excess), eyelid pathologies such as ectropion or entropion, blepharitis or severe meibomian gland disease, any type of dermatological allergy, and any sign of suspected skin atypia or malignancy. No patient was lost to follow-up.

Intervention: MINIBLEPH TECHNIQUE

Preparation of the eyelid skin

Anesthetic ointment (lidocaine base 7%, prilocaine base 7%, tetracaine hydrochloride 7% and benzyl alcohol 7%) was applied on the patient’s skin and left for 30 minutes before the session to prevent pain and discomfort. After which, the anesthetic ointment was completely removed, followed by skin asepsis/antisepsis with aqueous Chlorhexidine 2% solution. Due to the high-water absorption of ablative CO₂ lasers¹⁴, complete drying of the skin is required, done properly with operative sponge. Finally, to protect both corneas and eye globes from damage from the laser, non-reflecting titanium laser eye shields (Cox II, Oculoplastik inc, Canada) were placed after applying anesthetic eye drops, (Tetracaine hydrochloride 1 mg/ml and oxibuprocaine hydrochlorid 4 mg/ml, Colircusí anestésico doble, Alcon, Switzerland).

Laser Parameters: Energy and Density

The Minibleph technique utilizes a CO₂ laser (AcuPulse™ system, Lumenis, Inc., Yokneam, Israel) using a fractional scanner (AcuScan 120, Lumenis, Inc., Yokneam, Israel) delivering high power pulses within a fraction of a second (superpulses), instead of a continuous wave emission. A superpulse allows ablation without significant peripheral heating. The Combo™ mode treatment is also used to combine deep (dermal) and superficial (epidermal) treatment of the skin simultaneously (Fig. 1A). The first scan on the skin of the Combo™ mode creates deep ablative dermal microcolumns, leading to a shrinkage of the skin, collagen remodeling and formation, while the second scan creates superficial ablative epidermal spirals to renew skin texture, color and quality (Fig. 1A). The treatment utilizes fractional photothermolysis (FP) resulting into targeted microthermal treatment zones (MTZs) in the periorbital skin, which are small microcolumns into which the laser beam is delivered, where surrounding tissue around each column remains intact and unaffected.^12–13 A faster healing process is the result of the fractional scanner.

Minibleph is used with precise calibrated laser parameters dependent on the Fritzpatrick skin type of the patient.¹⁴ For treatment of Fritzpatrick skin type I or II an energy setting of 12.5–15 mJ and density between 5–15% is used for the deep ablation, while the setting of 60–80 mJ and the density of 40–60% is selected for the superficial ablation. When treating Fritzpatrick skin type III, lower energies should be selected to avoid the risk of hyperpigmentation after the session. For example, energy of 12.5 mJ and density between 5–10% is used for deep ablation, and energy of 60 mJ and density of 40% is selected for superficial ablation in these type III cases. Table 1 summarizes these settings.

Laser patterns and area of treatment

When applying the laser onto the skin, different shapes and sizes of the treatment area can be selected. We find that the largest hexagon shape to be the best pattern for the treatment of the periocular area.³ While applying this laser pattern, every hexagon is applied directly next to each other without overlap nor gaps (Fig. 1B). When treating the upper eyelid, the area under the eyelid crease is spared from any laser treatment to protect the meibomian glands, and treatment is directed upwards with as many rows as necessary for enough skin tightening (Fig. 1C). For the lower eyelid, the hexagon pattern is applied 2–4 mm below the eyelash line in rows until the nasojugal groove medially, and orbitomalar groove laterally is reached (Fig. 1D). To provide a smooth transition zone, another peripheral row of hexagon patterns can be drawn with lower densities and energies.

After finishing the procedure, the corneal eye shield is removed, and the treated skin is cleaned with saline solution. To complete the procedure, antibiotics and antinflammatory ointments are applied topically on the skin (30 mg Oxytetracyclin with 10 mg Hydrocortison; Terracortril, Farmasierra Lab SL, Spain). Drops are also applied topically onto the eyes (3mg/ml Tobramycin with 1mg/ml Dexamethasone eye drops; Tobradex, Alcon, Spain).

Post-treatment care

After the session, patients are instructed to use Oxytetracyclin-Hydrocortisone ointment (Terracortril, Farmasierra Lab SL, Spain) twice a day onto the treated skin for 7 days, and not to rub their eyes and avoid make up for the following 10 days. Cooling the treated area with ice packs immediately after the session is recommended.

Physical Examination and Patient Centered Outcomes

Physical examinations were done by two independent observers (B.C. and M.A.). Photographs of patients were taken at each visit with equivalent ambient conditions using the Canon Rebel XTi DSLR Camera with EF-S 18-55mm f/3.5–5.6 Lens.

Patients skin phototypes were based on the Fitzpatrick classification.¹⁴
Pretreatment and post-treatment ocular skin laxity and texture improvement were also recorded. This was based on a quartile grading scale similar to the system used by Rongthong et al¹⁶ and Bonan¹⁷. Briefly: 0 = no improvement, 1 = 1–25% improvement, 2 = 26–50% improvement, 3 = 51–75% improvement, and 4 = 76–100% improvement compared to baseline.
The presence of post-treatment hyperpigmentation/dyschromia (grade 1 – mild, 2 – moderate, 3 – severe) was noted.
Lid measurements pretreatment and 3 months post-treatment included: measurement of the Margin to Reflex Distance (MRD) 1 and 2, Eyelid Fold, and Palpebral Fissure. Asymmetry was measured by taking the absolute value of MRD1 and the Eyelid Folds between the two eyes at pretreatment and 3 months post-treatment, in the same manner as previously performed by Pool et al.¹⁸
Grading of dermatochalasis was based on the Lateral Dermatochalasis Classification (LDC) system by Santos Silva et al¹⁹ which described four degrees: grade zero—absence of dermatochalasis; grade 1—lower edge of dermatochalasis above the imaginary line intersecting the lacrimal caruncle and the edge of the upper eyelid; grade 2—lower edge of dermatochalasis located between two imaginary lines: one line intersecting the lacrimal caruncle and the edge of the upper eyelid, and another parallel to the previous line located at the inferior limbus; and grade 3—lower edge of dermatochalasis below the inferior limbus.

The FACE-Q Aesthetic Module was used as a validated questionnaire for patient-reported outcome measures (PROMs).^20–21 The questionnaires included in the study were the Psychological Function, Appraisal of Upper Eyelids and Lower Eyelids, Recovery of Early Symptoms and Satisfaction with Outcome. The only questionnaires taken both prior and after treatment were the Appraisal of Upper and Lower Eyelids.

Statistical Analysis

Statistical analysis was performed by SPSS 26.0.0 (IBM Statistics). Descriptive statistics were expressed as means, standard deviations, minimum and maximum. The Kolmogorov-Smirnov test determined that the parameters met the criteria for normality, so non-parametric tests were used. Wilcoxon signed rank test was used for nonnormally distributed data. Spearman’s Rho correlation coefficient was calculated to assess the relationships among the quantitative variables. For all statistical tests, the same level of significance was used (p < 0.05).

Author contributions statement

M.A. conceived the study and conducted the treatments, R.S.M. collected and tabulated the data. M.C. analyzed the results. L.B. made the initial parts of the study. M.A. and R.S.M. wrote and finished the main paper. J.B. proofread and gave comments to the article. All authors reviewed the manuscript.

Competing interests

María A. Amesty is a medical advisor of L’Acuité, a local distributor of Lumenis in Spain.

Ronald S. Medalle II, Lena Beckers, Mario Cantó-Cerdán, and Jorge L. Alió del Barrio declare no potential conflict of interest.

Gentile RD. Upper lid blepharoplasty. Facial Plast Surg Clin North Am 2005;13(4): 511-524, v-vi.
Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int 2012;2012: 252368.
Mack WP. Blepharoplasty complications. Facial Plast Surg 2012;28(3): 273-287.
Balzani A, Chilgar RM, Nicoli M, Sapountzis S, Lazzeri D, Cervelli V, Nicoli F. Novel approach with fractional ultrapulse CO2 laser for the treatment of upper eyelid dermatochalasis and periorbital rejuvenation. Lasers Med Sci. 2013 Nov;28(6):1483-7. doi: 10.1007/s10103-012-1255-4. Epub 2013 Jan 10. PMID: 23307441.
Toyos MM. Continuous Wave Fractional CO2 Laser for the Treatment of Upper Eyelid Dermatochalasis and Periorbital Rejuvenation. Photomed Laser Surg. 2017 May;35(5):278-281. doi: 10.1089/pho.2016.4225. Epub 2017 Jan 12. PMID: 28085575; PMCID: PMC5439434.
Harris DM, Fried D, Reinisch L, et al. Eyelid resurfacing. Lasers Surg Med 1999;25(2): 107-122.
Sukal SA, Chapas AM, Bernstein LJ, et al. Eyelid tightening and improved eyelid aperture through nonablative fractional resurfacing. Dermatol Surg 2008;34(11): 1454-1458.
Kauvar AN. Fractional nonablative laser resurfacing: is there a skin tightening effect? Dermatol Surg 2014;40 Suppl 12: S157-163.
Gold MH, Biron JA. Combined superficial & deep fractional skin treatment for photodamaged skin--a prospective clinical trial. J Cosmet Laser Ther 2012;14(3): 124-132.
Tierney EP, Hanke CW, Watkins L. Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: Case series and review of the literature. J Am Acad Dermatol 2011;64(4): 730-740.
Bucay VW, Day D. Adjunctive skin care of the brow and periorbital region. Clin Plast Surg 2013;40(1): 225-236.
Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004;34(5): 426-438.
Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006;38(3): 169-176.
Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol 1988;124(6): 869-871
Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser Ther 2014;23(1): 49-60
Rongthong, A., Wanitphakdeedecha, R., Maiprasert, M., Cembrano, K. A. G., Voravutinon, N., Rakchart, S., … Koonngam, P. (2023). Efficacy and safety of hyaluronic acid filler on the treatment of horizontal neck lines. Journal of Cosmetic Dermatology, 22(2), 433–438. https://doi.org/10.1111/jocd.15539
Bonan P, Campolmi P, Cannarozzo G, Bruscino N, Bassi A, Betti S, Lotti T. Eyelid skin tightening: a novel 'Niche' for fractional CO₂ rejuvenation. J Eur Acad Dermatol Venereol. 2012 Feb;26(2):186-93. doi: 10.1111/j.1468-3083.2011.04034.x. Epub 2011 Mar 24. PMID: 21435023.
Pool SM, van der Lei B. Asymmetry in upper blepharoplasty: a retrospective evaluation study of 365 bilateral upper blepharoplasties conducted between January 2004 and December 2013. J Plast Reconstr Aesthet Surg 2015;68(4): 464-468.
Rossi Santos Silva K, Cardoso Rossi D, Petroianu A. A New Classification of the Lateral Dermatochalasis of Upper Eyelids. Plast Reconstr Surg Glob Open 2021;9(7): e3711.
Kosowski TR, McCarthy C, Reavey PL, et al. A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg 2009;123(6): 1819-1827.
Klassen AF, Cano SJ, Scott AM, et al. Measuring outcomes that matter to face-lift patients: development and validation of FACE-Q appearance appraisal scales and adverse effects checklist for the lower face and neck. Plast Reconstr Surg 2014;133(1): 21-30.
Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a new technique using nonablative radiofrequency on periorbital skin. Dermatol Surg 2004;30(2 Pt 1): 125-129.
Biesman BS, Baker SS, Carruthers J, et al. Monopolar radiofrequency treatment of human eyelids: a prospective, multicenter, efficacy trial. Lasers Surg Med 2006;38(10): 890-898.
Nilforoushzadeh MA, Heidari-Kharaji M, Behrangi E, et al. Effect of Endolift laser on upper eyelid and eyebrow ptosis treatment. J Cosmet Dermatol. 2022;00:1–6. doi:10.1111/jocd.14798
Bae-Harboe YS, Geronemus RG. Eyelid tightening by CO2 fractional laser, alternative to blepharoplasty. Dermatol Surg 2014;40 Suppl 12: S137-141.

Competing interest reported. María A. Amesty is a medical advisor of L’Acuité, a local distributor of Lumenis in Spain. Ronald S. Medalle II, Lena Beckers, Mario Cantó-Cerdán, and Jorge L. Alió del Barrio declare no potential conflict of interest.

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Minibleph, A Non-Incisional Blepharoplasty Technique For Skin Tightening Of Eyelids With The Use Of Fractional CO2 Laser

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Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Results

Skin Hyperpigmentation and Laxity and Texture

Lid Measurements

Dermatochalasis

Patient Satisfaction

Discussion

Methods

Intervention: MINIBLEPH TECHNIQUE

Preparation of the eyelid skin

Laser Parameters: Energy and Density

Laser patterns and area of treatment

Post-treatment care

Physical Examination and Patient Centered Outcomes

Statistical Analysis

Declarations

References

Additional Declarations

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