A New Classification of the Lateral Dermatochalasis of Upper Eyelids.

INTRODUCTION
Eyelid dermatochalasis is an abnormal distention of the upper eyelid skin.1 Its etiopathogenesis is secondary to aging, gravity pull and chronic descent, and inflammatory processes.2,3 Dermatochalasis can overlap the upper eyelid and, by gravity, leads to mechanical ptosis of the upper eyelid and reduces the upper and lateral visual fields associated with other clinical manifestations.4 The aging face presents skin relaxation and atrophy of the adipose tissue, with a downward displacement of the eyebrows and upper eyelids. This dermatochalasis may be laterally prolonged to the periorbital and temporal regions outside the eyelid.5–9 Temporal dermatochalasis has been described as lateral hooding, lateral heaviness, and lateral drooping.10–15 In this context, dermatochalasis can be classified generically as primary, due to intrinsic factors, and secondary, due to disorders in the adjacent tissues.5
The frontal region, the eyebrows, and the upper eyelids have a particular interaction with changes in their structure. The passive and active rise of the frontal region and the eyebrows may result in a minor rise of the upper eyelid in the presence of dermatochalasis, which can improve the visual field.16 Therefore, eyelid dermatochalasis must be considered with its lateral extension in the temporal region as an aesthetic and functional unit.5,7–9
Surgical treatment of the eyelids includes the aging elastosis with drooping of muscles due to their hypotrophy. Herniation and hypotrophy of the fatty pockets enhance the eyelids and lead to skin ptosis and ectropium with a lessening in ligaments.17
The first attempt to classify this region was subjective.17 Guinot proposed a classification of the aging of the face, in which dermatochalasis, which he called “drooping eyelids,” did not consider its intensity.18 Other authors classify eyelid dermatochalasis as moderate and severe, without specifying any parameter.10,19 Laville et al studied the genes associated with dermatochalasis using visual patterns in photographic images, but they did not classify them.20 Dermatochalasis of the periorbital region is difficult to measure because it is not an anatomical structure with defined limits.21–24
Jacobs et al assessed 7764 patients with eyelid dermatochalasis and classified this disorder specifically for the eyelid (JEC) as follows: A—normal, eyelid skin does not touch the eyelashes; B—mild, touches the eyelashes; C—moderate, covers the eyelashes; D—severe, covers the eye.25 However, this classification is not applied to the dermatochalasis prolonged laterally to the frontal region and does not evaluate the entire dysmorphia.

OBJECTIVE
Based on the gap in the classification of dermatochalasis, which extends laterally to the eyelids, and the absence of exact anatomical references for anthropometric studies before and after surgical treatment of this disorder, a new classification of dermatochalasis of the upper eyelid and its lateral region (LDC) is presented here.

METHOD
This study was approved by the research ethics committee (no. 3.300.231), was included in the Platform Brazil (no. 10115318.1.0000.5125), and all participants have signed the free and informed consent.
Digital photographs of 100 eyelids of 50 patients (nine men and 41 women; age 39–79 years; average age 59.3 years) were studied before and after blepharoplasty of the upper eyelid due to bilateral dermatochalasis (Tables 1, 2).
The LDC classification includes four degrees:
Grade 0—absence of dermatochalasis, in the lateral region of the orbit.

Grade 1—lower edge of dermatochalasis (LED) is located above the intersection of the lacrimal caruncle with the edge of the upper eyelid.

Grade 2—between the intersection of the lacrimal caruncle with the edge of the upper eyelid and the lower edge of the iris at the pupillary midpoint, even when the LED is at the same level of the intersection of the lacrimal caruncle with the edge of the upper eyelid.

Grade 3—LED below the lower edge of the iris, even when it is at the same level of it.

This classification uses well-defined references of anatomical points (Table 3), and may be assessed in frontal digital photographs, using horizontal lines as parameters to certify the correct anatomical points (Figs. 1–2). In specific cases, where dermatochalasis reaches the limit between two  degrees, generating doubts, one should opt for the highest degree. Existing wrinkles in the periorbital region that do not originate from the fold of dermatochalasis were not considered in the classification. When the lower eyelid overlaps the lower edge of the iris, a small digital circle to define the place of the iris has been placed in the photograph to allow for the classification to be conducted properly (Fig. 3).
The LDC and JEC results were analyzed using statistical tests. The absolute (n = sample size) and relative (percentages) frequencies were described as categorical variables (Tables 2, 4). The correlation of the LDC and JEC categorizations were assessed using the Cramer’s V statistical test (Table 5). The association between two categorical variables were considered “weak” for a degree less than 0.40; “moderate,” between 0.40 and 0.70; and “strong” for greater than 0.70. The pre- and post-blepharoplasty sizes were compared based on the intensity of dermatochalasis by the JEC and LDC methods, using nonparametric tests (Tables 6, 7). All results were considered significant for a P value less than 0.05.

RESULTS
Comparing the preoperative dermatochalasis based on the two studied classifications, LDC and JEC, the results were quite different (Tables 2, 4). More than half of the patients were considered to have normal eyelids (A grade), according to JEC; however, all of them presented significantly different degrees (grades 1, 2, and 3) of temporal dermatochalasis, none of which were normal (grade zero) when analyzed by LDC. All patients with B, C, and D grades in JEC had two and three degrees in LDC, with tendency toward a worse degree in LDC than in JEC. There was no statistically significant association (P = 0.583) between the LDC and the JEC methods (Table 5).
However, the comparison of both classifications in the postoperative period showed some similarities (Table 4). Almost all patients presented very good results, which were considered to be A grade in JEC and zero grade in LDC. No patients presented intense dermatochalasis, such as grade D in JEC and grade 3 in LDC, in the postoperative period. According to both classifications, the eyelid dermatochalasis was reduced after blepharoplasty (P < 0.001) (Tables 6, 7).
A difference was observed between JEC and LDC in relation to the detection of changes in the degrees of dermatochalasis after blepharoplasty, with a 100% perception by LDC (Table 2). The degree of improvement of dermatochalasis observed by LDC after blepharoplasty showed a greater specificity, with a more varied distribution among the degrees in the postoperative period. Cases have gone from grade 3 to grades 2, 1, and 0, while cases from grade 2 have moved to 1 and 0, and all cases from grade 1 have gone to 0 (Table 7).

DISCUSSION
The soft tissues of the eyelid and in its neighboring temporal region present a loosening with age, which is earlier and more intense laterally to the eyes, resulting in dermatochalasis. This lateral disorder of the eyelid forming a single crease, may be neglected during blepharoplasty. In fact, all the existing classifications correlate only the intensity of the eyelid dermatochalasis, without observing the lateral dermatochalasis. Therefore, many patients that could be beneficiated by upper blepharoplasty are not operated on if we consider only the specific classification of the eyelid.
Dermatochalasis of the temporal region is well classified by the LDC; however, it is not considered by the JEC (Table 3). Considering that the dermatochalasis lateral to the eyelid is not defined before treatment by any classification, the postoperative assessment of the aesthetic results of the blepharoplasties also fails when revising only the eyelids. In this sense, the LDC is the only method that includes the whole aesthetic result, not only of the eyelid, but also of the temporal region.
Another important characteristic of LDC is the precise anatomical points to define the dermatochalasis that is not present in other classifications. This aspect makes it possible for a uniformity in classifying the eyelid and temporal dermatochalasis. The lines through the anatomical points in the digital images indicate a precise classification of dermatochalasis. The JEC considers only the eyelid and joins the categories “B,” “C,” and “D” in less than a 2-mm border of the upper eyelid.
A limiting difficulty of LDC occurs when the lower eyelid overlaps the edge of the iris, making a grade 3 classification uncertain to be defined. In this case, a small digital circle to specify the place of the iris allows for a correct classification (Fig. 3).
All patients in this study had dermatochalasis in the LDC event, including those 59 eyelids considered normal by the JEC in the preoperative period (Tables 4, 6, 7). Therefore, all patients showed a well-defined improvement and their dermatochalasis after blepharoplasty was classified in greater detail when using LDC. However, according to the JEC, differences after the surgical procedure were pointed out in less than half of the patients (Tables 2, 6).
LDC and JEC classifications are not antagonistic with each other and may even be complementary. The alphabetical scale used in JEC and the numerical scale used in LDC allow for a simultaneous classification of both regions in an alphanumerical manner, specifying the intensity of the eyelid dermatochalasis and laterally to it, such as: A0, A1, A2, A3; B0, B1, B2, B3; C0, C1, C2, C3; and D0, D1, D2, D3.
According to LDC, blepharoplasty is not recommended for patients with grade 0. Surgical treatment becomes necessary at grade 1. A pivotal feature of the blepharoplasty is its extension to the lateral region of the eyelid, until reaching the anatomical point three of the LDC, and the possibility of its association with other treatments, such as the suspension of the eyebrows and facial lifting. However, the relationship between the degrees of dermatochalasis and the recommendation of specific treatment techniques requires further study on the temporal region to reach a more appropriate treatment.

CONCLUSIONS
The new classification presented herein, LDC, evaluates the intensity of lateral dermatochalasis for eyelids, is specific for this medical condition, is based on exact anatomical points, and is easy to understand and perform. This method is effective and specific in detecting changes in dermatochalasis after blepharoplasty and is useful in typifying this dysmorphia. Therefore, LDC presents advantages over other classifications in defining more precisely the aesthetic results of blepharoplasties.

ACKNOWLEDGMENT
The authors gratefully thank the Dean’s Office for Research (Pró-reitoria de Pesquisa) at UFMG.