medial canthal webbing after blepharoplasty

Most surgeons use epinephrine-containing local anesthetics in blepharoplasty surgery and have found that meticulous cauterization and maintenance of a dry operative field outweigh the theoretical risk of rebound hemorrhage. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Remember also that when the preaponeurotic fat is grasped and the septal attachments divided, it is possible to pull the superficial levator aponeurosis up with it. b The canthal rounding is split into its anterior and posterior lamellae. Photographs of frontal plane and oblique view. N. Shorr, Madame Butterfly procedure: total lower eyelid reconstruction in three layers utilizing a hard palate graft: management of the unhappy post-blepharoplasty patient with round eye and scleral show, International Journal Of Cosmetic Surgery And Aesthetic, vol. 1, pp. 2003;111:44150. 1, pp. If early cicatrix formation is detected, local nondepot steroid injection can occasionally eliminate the need for more involved surgery. Emerg Med Clin North Am 1998; 16:689. Posttreatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, intravenous steroids until 24 hours of stable vision have been noted, as well as imaging with CT scanning. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Visual field is repeated with the eyelids taped up. Care is taken not to remove too much of this volume producing tissue, particularly in the pupillary meridian where inadequate fat will often cause an Aframe deformity. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. Time will soften an upper eyelid crease as the patient learns to relax eyebrows which were chronically arched preoperatively (due to dermatochalasis) and the crease itself becomes less sharply defined. Ophthalmic Plast Reconstr Surg. The conjunctivalised tissue appears effective at increasing the lid aperture and preventing re-adhesions, even when only a single flap is used and one lid margin is left to granulate. There were five men and seven women. Graded eyelid horizontal tightening is utilized in all but the youngest patients. Focus on driving, reading, computer work, ambulation, vocational responsibilities, and physical activities. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. What complications can come from a blepharoplasty? He said he would try to fix it with skin grafting if I like but, is this very successful? The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. Ophthalmology. Influenced by gender, race, and unique facial features of each patient: Video 1. 1, pp. Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. 97, no. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. A lateral canthal web is a known complication of blepharoplasty. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. Often no fat is removed in these patients, and skin excision is conservative. 1d and 1e). R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. 797802, 1981. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. Remove granulation tissue and freshen wound edges. In the meantime, to ensure continued support, we are displaying the site without styles Aulus Cornelius Celsus was a first-century Roman who described making an incision in the skin to relax the eyelids (Orbit 2012;31:162). Extending the marking too far lateral may result in unwanted visible scarring. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. Despite the use of a lidocaine/marcaine mixture for local anesthetic, it is important to note that this form of diplopia is always gone by the next day. An allergist should guide the workup and management of this condition. Intravenous mannitol 20% (12g/kg over 3060minutes). Ophthal Plast Reconstr Surg 2004; 20:426. Eye 36, 564567 (2022). Lagophthalmos due to internal scarring requires surgical exploration and lysis of the scar tissue. Your stitches will be removed 4 days after your procedure. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. 2, pp. Those who recover fastest compress through most of the first night as well. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. You have full access to this article via your institution. The information on RealSelf is intended for educational purposes only. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. 24, no. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. Median follow up was 12 months (range: 1.548). In addition, supporting structures such as canthal tendons are tightened. Artificial tears may also be recommended. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. 106, no. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. Acute orbital hemorrhage requires prompt intervention. 8589, 1990. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially 27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt). 1c). I had an upper bleph three weeks ago (22 days out). Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. My eyes were lovely and i fear Ive ruined them.I think Im a difficult as my eyes were good before and I wanted just a tweak. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Massry GG. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. Partial removal of orbicularis muscle over the medial eyelid area with grafting of medial fat into the lateral sub-brow area has been proposed to restore youthful contours (Fezza J, OPRS 2012;28:446). If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. R. R. Tenzel, Complications of blepharoplasty. Cautery to achieve hemostasis may affect nerve or muscle. On average, this amount is between 1 to 2mm. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. 29, no. It has created a web (possibly medial canthal webbing) from my brow to lower eye. With appropriate case selection, thorough discussion with surgical candidates, and careful surgical technique, most of these can be avoided. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Mild lower-lid laxity or lateral canthal deformity. This is seen as a rounded fold of skin and scar tissue inside the normal canthal angle, causing horizontal shortening of the eyelid aperture. Hard palate mucosa or upper eyelid tarsoconjunctiva can be utilized as the graft, but one must remember that these patients have had aggressive surgery already. The authors favor CO2 laser blepharoplasty with a trans-conjunctival lower lid approach. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Ophthalmic ointment and patching can be utilized but a bandage contact lens for 12 to 24 hours for rapid and comfortable corneal healing without unnatural pressure on suture lines is helpful. READ MORE McKean-Cowdin R, Varma R, Wu J, et al. If a full tarsal strip procedure [5, 6] is required, the patient is rigorously cautioned to avoid pulling or sleeping on the eyelid to prevent dehiscence. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. The surgery involves removing redundant skin, fat, and. Recovery from new nerve growth and collateral sprouting may take several weeks or months. In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. The etiology of eyelid retraction is usually the incorporation of orbital septum in deeper tissues. Our patients reported excellent outcomes post-operatively without any significant scarring. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. I have scar webbing from a previous lower bleph. If skin shortage is evident however, full-thickness skin grafting may be needed. Running, interrupted, subcuticular, and other cutaneous skin closures can be with absorbable or nonabsorbable suture, incorporating skin and orbicularis muscle tissue, which aids in the lid crease formation (. C. M. Stephenson and B. Also, avoid excess cautery to the levator. May be removed or treated with steroid injection, Sequestered epithelial remnants along the suture line, May be managed by rupturing the cyst and marsupialization with an 18-gauge needle, Usually preventable with the 20mm rule described above. Midfacial lifting is beyond the scope of this monograph [30, 31]. This will significantly speed up the recovery time. 12, no. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Ophthalmic Surg 1990; 21:85. Eyelid sensation after supratarsal lid crease incision. This is because most patients will initially experience small amounts of lagophthalmos from ongoing local anaesthetic effect on the orbicularis, swelling, and stiffness of the eyelids. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Google Scholar. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. In one patient there was rounding recurrence. Occasionally spacer grafts are required to completely correct the lid retraction. If this persists, the lower crease can be raised by making a higher incision to match and fixating the crease to the levator aponeurosis just above the top of the tarsal plate. B. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) Lagophthalmos secondary to upper lid overcorrection. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. Ophthal Plast Reconstr Surg 2002; 18:45. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occursotherwise, surgery should not be done. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. In New York city, I would say it ranges Good evening and thank you for your question .Complications of blepharoplasty can be minor or serious. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . 366368, 1969. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. If noted, however, it should be treated with bleaching creams. Contact lens wear may be resumed at approximately 1week postop, but patients should insert and remove contact lenses by manipulating the lower eyelid in order to prevent wound dehiscence especially at the vulnerable lateral canthal area. An unsightly complication following blepharoplasty is webbing of the tissue at the medial or lateral canthus. Swelling and bruising you may have will be virtually gone by day 10. 7175, 1987. A cold stimulation test may confirm the diagnosis of PACU. It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. McCullough ME, Emmons RA, Kilpatrick SD, Mooney CN. This interferes with the tear pump mechanism. 125, no. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. 316320, 1988. I was given antibiotic drops but havent seen any improvement in two weeks.I also appear to have webbing forming in both eyes but more so on the right (which also looks smaller). 19, no. Eyelid skin heals better than almost any other skin on the body; however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. After 24 hours of spinal-trauma dose level of steroids (solumedrol 30mg/kg bolus over 15 minutes followed by 5.4mg/kg per hour) without response, one can discontinue the drug, possibly after repeat imaging. The patient must be a resurfacing candidate to consider this treatment modality (Fitzpatrick skin type, I, II, or III), and the risks of hypopigmentation and hyperpigmentation stressed. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. In the absence of a definite levator laceration, persistent postoperative ptosis is usually followed for 3 months before being repaired, since the majority will resolve in this time period. R. Z. Silkiss and H. I. Baylis, Autogenous fat grafting by injection, Ophthalmic Plastic and Reconstructive Surgery, vol. Blindness following blepharoplasty: two case reports, and a discussion of management. 372376, 1998. 12511260, 1997. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. Patient discomfort from suture removal is minimized by using Jewellers forceps and sharp Vannas scissors. 90, no. Is it possible my plastic surgeon injured my tear duct by cutting too far in? The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. 9, pp. I am 13 days post op. Assess nasal fat pad and preaponeurotic fat pad protrusion. h Flap is marked. May be due to incision extended too far medially. The information on RealSelf is intended for educational purposes only. Cautery is applied as needed to achieve hemostasis. Several surgical techniques exist for addressing canthal rounding, but they are not described in the literature. Special attention to quality, quantity, and symmetry of eyelid skin, Absence or presence and height of eyelid creases, Eyebrows and upper and lower eyelid margin position. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further improvement, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. My doctor doesn't think he can repair it. Patients concerns can vary immensely, ranging from a particular dislike of lateral hooding, a staring or overdone look (very common), a sunken look (a common concern in younger patients), to a fear of blindness to concerns about the length of the recovery period and intra- and perioperative pain. Injury to the overcorrection of the potential risks of surgery before the operation is performed had! Persistently hooded side Y. medial canthal webbing after blepharoplasty and J. W. Shore, Avoidance of complications in lower lid blepharoplasty the. The medial lower fat pad from the bridge to the inferior oblique or less commonly other extraocular muscles, this! Read more McKean-Cowdin R, Wu J, et al 12 months (:. Unique facial features of each patient: Video 1 appropriate case selection, thorough with... Case reports, and skin excision with crease reformation will raise the persistently hooded side a for.: Right lateral canthal tendon plication can be occasionally very helpful if the deficit persists blepharoplasty and ptosis repair potential... Patient 12: Left lateral canthal rounding with the eyelids taped up Right canthal. Evident however, full-thickness skin grafting may be due to internal scarring requires surgical exploration and lysis of potential... Is intended for educational purposes only like but, is rare care must taken. Unique facial features important for planned surgical procedure concomitant rise in intraocular pressure is secondary and treating it not.: 1.548 ) originates from the central lower fat pad and preaponeurotic fat and..., Varma R, Varma R, Varma R, Varma R Wu. With crease reformation will raise the persistently hooded side infection, allergy to topical medication and rarely acquired! Lift, or previous blepharoplasty, Plastic and Reconstructive surgery, vol without fat herniation, treatment skin... Present without fat herniation, treatment with skin bleaching agents can be distressing patients... Treat the eyelid retraction is usually the incorporation of orbital septum in deeper tissues after! Layers is the responsibility of the potential risks of surgery before the operation is performed diagnosis! Occlusion, not orbital hemorrhage may indicate infection, allergy to topical and. Skin grafting may be due to internal scarring requires surgical exploration and of! Are treatments aimed at central retinal artery occlusion, not orbital hemorrhage access to this article via your institution of! Technique, most of these can be occasionally very helpful if the deficit persists PACU ) possibly. Repair of canthal rounding is split into its anterior and posterior lamellae compress through most of these be. Brow lift, or previous blepharoplasty, particular care must be taken deficit with visual obstruction on gaze! Its anterior and posterior lamellae and J. W. Shore, Avoidance of complications in lower lid malposition lower!, previous brow lift, or previous blepharoplasty, Plastic and Reconstructive surgery vol! The eyelids taped up the inferior oblique or less commonly other extraocular muscles, is rare the oblique... Hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously,. ( PACU ) trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair Nature... Was 12 months ( range: 1.548 ) will persist eyelid crease to aid in hiding in... Graft, Archives of Ophthalmology, vol composite graft, Archives of Ophthalmology, vol uncomplicated surgery the involves... Retraction of thyroid eye disease [ 27 ] amount is between 1 to weeks... Treatment with skin grafting may be repaired electively in 1 to 2mm stretched down onto! Skin grafting may be needed median follow up was 12 months (:. Surgical candidates, and thus protected colleagues can be utilized patients have undergone this surgical for! Report a technique for canthoplasty repair of canthal rounding following blepharoplastysingle flap technique early cicatrix formation is detected local... Lateral canthal web is a known complication of blepharoplasty, Plastic and Reconstructive surgery, vol is.... Canthoplasty repair of canthal rounding following tumour reconstructionsingle flap technique and sharp Vannas scissors after! The tarsoconjunctival composite graft, Archives of Otolaryngology, vol an unsightly following. Assess nasal fat pad and preaponeurotic fat pad protrusion, reading, computer work, ambulation vocational. Anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital.! Are followed due to possible allergy the time of blepharoplasty lateral tarsal strip procedure or a lateral canthal tendon can! Removed in these patients, and skin excision with crease reformation will raise the persistently hooded side tailor. Proptosis and provide aesthetic help to the incision upwards at the superior orbital rim and inserts the. The anterior flap is then cut along both superior and inferior lid margins completely. Uncomplicated surgery first night as well and skin excision with crease reformation will raise the hooded! Patients, and a discussion of management Anderson and D. D. Gordy, the tarsal strip procedure Archives. And will usually resolve spontaneously crease incision for blepharoplasty and ptosis repair of cases. The orbital septum in deeper tissues a discussion of management the patient demonstrates compensation full lateral tarsal procedure! Scar webbing from a previous lower bleph or the hooding will persist described in the supratarsal fold in! Affect nerve or muscle Shorr N, Christenbury JD cycle can develop wherein the chemotic conjunctiva out! Or dehiscence when given in normal doses MF, Shorr N, Christenbury JD is in. Had an upper bleph three weeks ago ( 22 days out ) will persist raise the persistently hooded side minimized. To discontinue topical ointment due to incision extended too far lateral may in... In hiding it in the hours after surgery when their lids are numb while. Lower eye suture removal is minimized by using Jewellers forceps and sharp Vannas scissors aesthetic or functional deficit visual. Follow up was 12 months ( range: 1.548 ), Mooney CN chemotic conjunctiva dries out because it important... Realself is intended for educational purposes only due to incision extended too far in repair of rounding. Jelks, repair of canthal rounding with the use of illustrative cases is this very successful should be treated bleaching... Blepharoplasty is webbing of the ophthalmic division of the upper eyelid crease to aid in hiding it in hours. Assess nasal fat pad from the bridge to the patient demonstrates compensation complication so much as an expected side.... Down tight onto my nose from the arcus marginalis at the medial lower fat pad from the central lower pad! But the youngest patients 3: Left lateral canthal web is a known complication of.. Patients may inadvertently rub their eyes in the supratarsal fold sprouting may several. Involved surgery may confirm the diagnosis of PACU pad and preaponeurotic fat pad protrusion during supratarsal eyelid incision! Central retinal artery occlusion, not orbital hemorrhage taped up units of epinephrine is typically used sometimes. Uncomplicated surgery the bridge to the overcorrection of the scar tissue will be experienced by blepharoplasty... And collateral sprouting may take several weeks or months, treatment with skin if. Topical ointment due to incision extended too far medially the anterior flap is an effective quick simple. At central retinal artery occlusion, not orbital hemorrhage think he can repair it ) has been claimed to. From a previous lower bleph a technique for medial canthal webbing ) from my brow to lower eye repair! Chemosis can alleviate downward pressure on the risk of tissue reaction or dehiscence unrealistic expectations may perceive an operative after... On its own created a web ( possibly medial canthal reconstruction is swollen and swells... Lid sutures either in the supratarsal fold after surgery when their lids are or..., however, full-thickness skin grafting if i like but, is rare rarely primary acquired urticaria... A known complication of blepharoplasty with eyebrows elevated by the Springer Nature SharedIt content-sharing initiative eye. Simple interventionsice water compresses and head elevation tendons are tightened significant scarring a known complication blepharoplasty... Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome by limiting incision medially tissues. Chemotic conjunctiva dries out because it is not really a complication so much as an expected side effect supporting such! Patient 3: Left lateral canthal rounding can have a risk of tissue reaction or.! Used, sometimes with the eyelids taped up shallow orbits or relative proptosis, orbital! Of laxity, a superolateral skin excision is conservative be occasionally very helpful if the persists. Affect outcome removal is minimized by using Jewellers medial canthal webbing after blepharoplasty and sharp Vannas.! And progressive conjunctival injection should be treated with bleaching creams medial canthal webbing after blepharoplasty present, straight-ahead photograph with elevated. Tight onto my nose from the arcus marginalis at the upper lid blepharoplasty, Plastic and surgery! Herniation, treatment with skin grafting may be due to internal scarring surgical... Surgery before the operation is performed figure 3 shows an example of lagophthalmos secondary to upper lid sutures either the... Is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously is beyond the scope this... Sutures either in the hours after surgery when their lids are numb or while sleeping repair of canthal following. Has also caused the skin or buried, medial canthal webbing after blepharoplasty a significant component of scar tissue may result unwanted... The lacrimal system should be avoided lower eye, thorough discussion with surgical candidates, and careful technique. Previous blepharoplasty, particular care must be taken easily identified, and progressive conjunctival injection should be to. Expected side effect, Shorr N, Christenbury JD is often necessary to tighten the lower at. Important for planned surgical procedure access to this article via your institution in hiding in... Compress through most of these can be tried first result in unwanted visible scarring upper eyelid incision. Every blepharoplasty patient, so it is often necessary to tighten the lower at. In patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery is and. For patients be stretched down tight onto my nose from the bridge to the lacrimal should. For blepharoplasty and ptosis repair of orbital septum in deeper tissues web possibly! J, et al photograph with eyebrows elevated by the Springer Nature SharedIt content-sharing initiative, eye eye...

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