Preoperative phenylephrine testing as a predictor of postoperative eyebrow position

Dear Sir, E yebrow position and contour strongly influences overall facial cosmesis [1-3] and depends on many factors, including age, gender, ethnicity, superior sulcus depth, frontal sinus pneumatization, prior surgery, and cultural trends [3-9]. Repair of blepharoptosis or dermatochalasis may diminish compensatory eyebrow elevation, thereby lowering eyebrow position postoperatively[10-11]. The preoperative blepharoptosis discussion with a patient should include possible effects on eyebrow position [10]. However, to our knowledge, no method exists to predict the amount of eyebrow descent that may occur in order to guide this discussion. We commonly employ preoperative phenylephrine testing in cases of conjunctival-M俟llerectomy with or without tarsectomy (CM依 T) blepharoptosis repair to determine the appropriate amount of tissue resection [12]. In our experience, the ipsilateral eyebrow often descends following a positive phenylephrine test. Given that phenylephrine testing may predict final eyelid position using our algorithm for CM 依T blepharoptosis repair [13], we sought to determine whether such testing predicts postoperative eyebrow position. We retrospectively reviewed the charts of all patients undergoing unilateral CM 依T blepharoptosis repair at the Cole Eye Institute between July 2012 and October 2013. Exclusion criteria included concurrent or previous upper eyelid/eyebrow surgery or trauma; inadequate or missing photographs; known history of Graves' disease, Horner's syndrome, Myasthenia Gravis, 3rd nerve palsy, 7th nerve palsy, or infiltrative blepharoptosis; history of topical alpha-agonist use; concurrent periocular neurotoxin injection; and follow-up interval of less than 6-week duration. All surgeries were performed according to a previously published tissue resection algorithm and technique by one surgeon (Perry JD)[12]. Preoperative, post-phenylephrine, and postoperative digital photographs were analyzed for each patient. ImageJ software (National Institute of Health, Bethesda, MD, USA) was used to measure distances in pixels, and these measurements were converted to millimeters using a previously published technique . Measurements included marginal-reflex distance (MRD1), lateral brow height (LBH), central brow height (CBH), and medial brow height (MBH; Figure 1). Follow-up interval was measured between date of surgery and date of last postoperative photograph used for analysis. Two-tailed paired Student's -test and Pearson product correlation were used for data analysis. Seventy patients underwent unilateral CM依T blepharoptosis repair during the study period; 61 patients were excluded, mostly for inadequate or incomplete photographs (41 patients) and concurrent or prior upper eyelid or brow surgery (15 patients), leaving 9 patients for inclusion in the study. There were 8 female patients and 1 male patient. Average patient age was 58y (range 34-85y). Average follow-up time between preoperative and postoperative photographs was 2.8mo (range 1.3-9.5mo). Table 1 summarizes the average ipsilateral and contralateral MRD1, LBH, CBH and MBH preoperatively, after phenylephrine testing, and after surgery. Linear regression plots between the change in ipsilateral MRD1, LBH, CBH, and MBH after phenylephrine testing and following surgery with respective linear equations are demonstrated in Figure 2.