Ophthalmic Plastic Surgery of the Upper Face: Eyelid Ptosis, Dermatochalasis, and Eyebrow Ptosis

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MedOne Information Title Page Copyright Dedication Contents Foreword Preface Acknowledgements Contributors Section I Introduction 1 Ptosis Classification 1.1 Introduction 1.2 Ptosis Classification 1.3 Preoperative Assessment 1.3.1 History of Present Illness 1.3.2 Physical Examination 1.4 Upper Eyelid Ptosis Classification 1.4.1 Aponeurotic Ptosis 1.4.2 Myogenic Ptosis 1.4.3 Mechanical Ptosis 1.4.4 Neurogenic Ptosis 1.4.5 Pseudoptosis 1.5 Eyebrow Ptosis Classification 1.6 Clinical Decision-Making 1.7 Photographing the Patient 1.8 Informed Consent 1.9 Principles of Surgical Correction 1.10 When Not to Operate 1.11 Postoperative Complications 1.12 Aesthetic Concerns for Upper Eyelid and Eyebrow Rejuvenation References 2 Aesthetic Anatomy of the Upper Face 2.1 Introduction 2.2 Skin 2.3 Subcutaneous Tissue and Fat Compartments 2.4 Superficial Musculoaponeurotic System 2.5 Retaining Ligaments, Canthal Tendons, and Orbital Septum 2.6 Mimetic Muscles and Eyelid Retractors 2.7 Deep Fat Compartments 2.8 Nervous Innervation to the Upper Eyelid and Forehead 2.8.1 Sensory 2.8.2 Motor 2.9 Blood Supply 2.9.1 Forehead 2.9.2 Eyelid 2.10 Lymphatic Drainage 2.10.1 Forehead 2.10.2 Eyelid 2.11 Unique Considerations for the Upper Facial Surgeon: Facial Danger Zones 2.12 Unique Anatomical Considerations for the Eyelid Surgeon 2.12.1 Anterior Lamella 2.12.2 Middle Lamella 2.12.3 Posterior Lamella 2.12.4 Eye Protective Mechanisms References 3 Anatomic Considerations in the Aesthetic Surgery of the Upper Face 3.1 Introduction 3.2 Racial Differences 3.2.1 Eyelid Skin 3.2.2 Upper Eyelid Crease 3.2.3 Epicanthal Fold 3.2.4 Tarsal Plate 3.2.5 Eyebrow Height and Contour 3.3 Gender Differences 3.3.1 Eyelid Skin 3.3.2 Eyelid Dimensions 3.3.3 Eyebrow Height and Contour 3.4 Conclusions References Section II Mechanical Ptosis 4 Mechanical Ptosis: Etiology and Management 4.1 Introduction 4.2 Benign Eyelid Lesions 4.3 Malignant Eyelid Lesions 4.4 Orbital Lesions 4.5 Periorbital Infections and Inflammation 4.6 Other Considerations 4.7 Summary References 5 Upper Blepharoplasty 5.1 Introduction 5.2 Goals of Treatment 5.3 Risks 5.4 Benefits 5.5 Informed Consent 5.6 Indications 5.7 Contraindications 5.8 The Procedure 5.8.1 Preoperative Checklist 5.8.2 Instruments Needed 5.8.3 Sutures Used 5.8.4 Operative Technique: Step by Step 5.8.5 Expert Tips/Pearls/Suggestions 5.8.6 Postoperative Care Checklist 5.9 Complications and Their Management References 6 Double Eyelid Surgery 6.1 Introduction 6.2 Anatomical Considerations 6.2.1 The Eyelid Crease and Fold 6.2.2 The Medical Canthal Area 6.2.3 The Lateral Canthal Area 6.3 Goals of Intervention/Indications 6.4 Risks of the Procedure 6.5 Benefits of the Procedure 6.6 Informed Consent 6.7 Contraindications 6.8 The Procedure 6.8.1 Instruments Needed 6.8.2 Preoperative Checklist 6.8.3 The Operative Technique 6.8.4 Expert Tips/Pearls/Suggestions 6.8.5 Postoperative Care Checklist 6.9 Complications and Their Management 6.10 Alternative Approaches to Double Eyelid Surgery References 7 A Guide to Eyebrow Contouring Options 7.1 Introduction 7.2 Evolving Trends in Brow Beauty 7.2.1 History of Eyebrow Aesthetics 7.2.2 Volume and Facial Aging 7.2.3 Eyebrow Height and Proportions 7.3 Patient Assessment 7.3.1 History 7.3.2 Physical Exam Checklist 7.4 Risks of Surgery 7.5 Choosing the Best Procedure/Physician Decision-Making 7.6 Expert Tips/Pearls/Suggestions 7.6.1 Upper Eyelid Considerations 7.6.2 The Role of Nonsurgical Adjuncts 7.6.3 Managing Asymmetry 7.6.4 Minimizing Hair Loss 8 Direct Eyebrow Elevation 8.1 Introduction 8.2 Relevant Anatomy 8.3 Goals of Intervention, Indications, and Benefits of the Procedure 8.4 Risks of the Procedure 8.5 Preoperative Considerations and Patient Selection 8.6 Informed Consent 8.7 Relative Contraindications 8.8 Procedure 8.8.1 Instrumentation 8.8.2 Preoperative Checklist 8.8.3 Operative Technique 8.8.4 Expert Tips/Pearls/Suggestions 8.8.5 Postoperative Care 8.9 Complications and Their Management References 9 Internal Eyebrow Lift 9.1 Introduction 9.2 Anatomic Considerations of the Upper Facial Continuum 9.3 Goals of Intervention 9.4 Risks 9.5 Benefits 9.6 Informed Consent 9.7 Indications 9.8 Contraindications 9.9 Patient Assessment 9.9.1 Medical History 9.9.2 Ophthalmic History 9.9.3 Ophthalmic Examination 9.9.4 Anatomic Evaluation: The Eyelid and Eyebrow Subunits 9.10 Preoperative Checklist 9.11 The Procedure 9.11.1 Instrumentation Needed 9.11.2 Sutures 9.11.3 Operative Technique 9.12 Expert Tips/Pearls/Suggestions 9.13 Postoperative Care Checklist 9.14 Complications and Their management 9.14.1 Bleeding 9.14.2 Infection 9.14.3 Nerve Damage 9.14.4 Postoperative Lagophthalmos and Dry Eye 9.14.5 Residual Aesthetic Deformity 9.14.6 Skin Dimpling 9.15 Summary References 10 Midforehead Browlift Technique 10.1 Introduction 10.2 Goals of Intervention/Indications 10.3 Risks of the Procedure 10.4 Benefits of the Procedure 10.5 Informed Consent 10.6 Contraindications 10.7 Preoperative Assessment 10.8 The Procedure 10.8.1 Instruments Needed 10.8.2 Operative Technique 10.9 Expert Tips/Pearls/Suggestions 10.10 Postoperative Care Checklist 10.11 Complications and Their Management 10.12 Conclusion References 11 Open Coronal Pretrichial Browlift Surgery 11.1 Introduction 11.2 Unique Anatomical Considerations in Coronal Brow Lifting 11.2.1 The Eyebrow 11.2.2 The Anatomic Layers 11.2.3 The Muscles of Elevation and Depression 11.2.4 The Sensory Supply 11.2.5 The Facial Nerve 11.2.6 The Vascular Supply 11.3 Patient Evaluation 11.3.1 Forehead Length and Contour 11.3.2 Eyebrow Shape and Contour 11.3.3 Forehead Rhytids 11.3.4 Nasal Root 11.4 Goals of Intervention/Indications 11.5 Risks of the Procedure 11.6 Benefits of the Procedure 11.7 Contraindications 11.8 Informed Consent 11.9 The Procedure 11.9.1 Instruments Needed 11.9.2 Sutures Used 11.9.3 Preoperative Checklist 11.9.4 The Operative Technique 11.10 Expert Tips/Pearls/Suggestions 11.11 Postoperative Care Checklist 11.12 Complications and Their Management 11.12.1 Expanding Hematoma 11.12.2 Scarring 11.12.3 Postoperative Brow Asymmetry 11.12.4 Facial Nerve Damage 11.12.5 Scalp and Forehead Numbness 11.12.6 Alopecia 11.13 Alternative Approaches to the Open Browlift References Bibliography 12 Pretrichial Temporal Browlift 12.1 Introduction 12.2 Goals of Intervention/Indications 12.3 Risks of Procedure 12.4 Benefits of Procedure 12.5 Contraindications 12.6 Informed Consent 12.7 Preoperative Evaluation 12.8 The Procedure 12.8.1 Instrumentation 12.8.2 Preoperative Checklist 12.8.3 Surgical Technique 12.9 Expert Tips/Pearls/Suggestions 12.10 Postoperative Care Checklist 12.11 Complications 12.11.1 Scarring 12.11.2 Suture Granuloma 12.11.3 Undercorrection 12.11.4 Overcorrection 12.12 Conclusion References 13 Minimally Invasive Su-Por–Suture Temporal Brow Suspension: The Lift and Fill Technique 13.1 Introduction 13.2 Goals of Intervention/Indications 13.2.1 Risks of the Procedure 13.2.2 Benefits of the Procedure 13.2.3 Informed Consent 13.3 Contraindications 13.4 The Procedure 13.4.1 Instruments Needed 13.4.2 Preoperative Checklist 13.4.3 Operative Technique 13.5 Expert Tips/Pearls/Suggestions 13.6 Postoperative Care Checklist 13.7 Complications and Their Management References 14 Endoscopic Upper Face and Eyebrow Lifting 14.1 Introduction 14.2 Goals of Intervention 14.3 Risks 14.4 Informed Consent 14.5 Indications 14.6 Contraindications 14.7 The Procedure 14.7.1 Preoperative Checklist 14.7.2 Instruments Needed 14.7.3 Closure 14.7.4 Local Anesthetic 14.7.5 Fat Grafting 14.7.6 Incision Placement 14.7.7 Operative Technique 14.8 Postoperative Care Checklist 14.9 Expert Tips/Pearls/Suggestions 14.10 Complications and Their Management 14.11 Conclusions References 15 Nonsurgical Management Techniques: Fillers and Neuromodulators 15.1 Introduction 15.2 Properties of Botulinum Toxins and Periocular Fillers 15.2.1 Botulinum Toxin Properties 15.2.2 Periocular Fillers Properties 15.3 Single Therapy and Combination Treatments in the Upper Face 15.3.1 Glabellar Frown Lines 15.3.2 Crow’s-Feet 15.3.3 Horizontal Forehead Lines 15.3.4 Brow Lifting and Shaping 15.3.5 Hypertrophic Orbicularis Oculi 15.3.6 Midface 15.3.7 Temple 15.4 Conclusion References 16 Fat Augmentation of the Brow 16.1 Introduction 16.2 Goals of Intervention 16.3 Risks of Fat Grafting 16.4 Benefits of Fat Grafting 16.5 Informed Consent 16.6 Indications 16.7 Contraindications 16.8 Preoperative Checklist 16.8.1 Instrumentation 16.8.2 Operative Technique: Step by Step 16.9 Expert Tips/Pearls/Suggestions 16.10 Postoperative Care Checklist 16.11 Complications and Their Management 16.12 Conclusion References Section III Involutional Ptosis 17 Involutional Ptosis: Etiology and Management 17.1 Introduction 17.2 Etiology 17.3 Clinical Presentation 17.4 Evaluation 17.4.1 Evaluation of Eyelid 17.5 Management References 18 External Levator Advancement with Orbicularis-Sparing Technique 18.1 Introduction/Goals of Intervention 18.2 Risks 18.3 Benefits 18.4 Informed Consent 18.5 Indications 18.6 Relative Contraindications 18.7 The Procedure 18.7.1 Preoperative Checklist 18.7.2 Instruments Needed 18.7.3 Sutures Used 18.7.4 The Operative Technique: Step by Step 18.8 Postoperative Care Checklist 18.9 Expert Tips/Pearls/Suggestions 18.10 Complications and Their Management 18.10.1 Undercorrection 18.10.2 Overcorrection 18.10.3 Lagophthalmos 18.10.4 Unsatisfactory Eyelid Contour or Eyelid Crease Asymmetry 18.10.5 Wound Infection 18.10.6 Retrobulbar Hemorrhage 18.11 Conclusion References 19 Small Incision Anterior Levator Advancement 19.1 Introduction 19.2 Goals/Indications 19.3 Risks of the Procedure 19.4 Benefits of the Procedure 19.5 Contraindications 19.5.1 Absolute Contraindications 19.5.2 Relative Contraindications 19.6 Informed Consent 19.7 The Procedure 19.7.1 Instruments Needed 19.7.2 Preoperative Checklist 19.7.3 Operative Technique 19.8 Expert Tips/Pearls/Suggestions 19.9 Postoperative Care Checklist 19.10 Complications and Their Management References 20 Müller’s Muscle–Conjunctival Resection 20.1 Introduction 20.2 Special Preoperative Considerations 20.2.1 Margin Reflex Distance 1 20.2.2 Phenylephrine Test 20.2.3 Determining the Amount of Müller’s Muscle–Conjunctival Resection 20.3 Risks 20.4 Benefits 20.5 Informed Consent 20.6 Contraindications 20.7 Instrumentation 20.8 Preoperative Checklist 20.9 Operative Technique 20.10 Expert Tips/Pearls/Suggestions 20.11 Postoperative Management 20.12 Complications and Their Management 20.13 Acknowledgment References 21 Dresner’s Modification of Müller’s Muscle–Conjunctival Resection 21.1 Introduction 21.2 Indications 21.3 Risks 21.4 Benefits 21.5 Informed Consent 21.6 Contraindications 21.7 Instrumentation 21.8 Preoperative Checklist 21.9 Operative Technique 21.10 Expert Tips/Pearls/Suggestions 21.11 Results 21.12 Complications and Their Management 21.13 Conclusion References 22 Posterior White Line Advancement 22.1 Introduction 22.2 Relevant Anatomy 22.3 Indications 22.4 Risks 22.5 Benefits 22.6 Informed Consent 22.7 Contraindications 22.8 Instrumentation 22.9 Preoperative Checklist 22.10 Operative Technique 22.10.1 The White Line Advancement for Aponeurotic Ptosis 22.10.2 Levatorpexy for Congenital Ptosis 22.11 Expert Tips/Pearls/Suggestions 22.12 Complications and Their Management 22.13 Conclusions References 23 The Fasanella–Servat Procedure 23.1 Introduction 23.2 Indications 23.3 Risks 23.4 Benefits 23.5 Informed Consent 23.6 Contraindications 23.7 Instruments Needed 23.8 Preoperative Checklist 23.9 Operative Technique 23.10 Expert Tips/Pearls/Suggestions 23.11 Results 23.12 Complications and Their Management 23.13 Conclusion References 24 Combined Upper Blepharoplasty and Ptosis Repair 24.1 Introduction 24.2 Clinical Evaluation and Indications for Surgery 24.3 Combined Müller’s Muscle–Conjunctival Resection and Blepharoplasty 24.4 Combined Fasanella–Servat and Blepharoplasty 24.5 Combined Levator Aponeurotic Advancement and Blepharoplasty 24.5.1 Indications 24.5.2 Contraindications 24.5.3 Instrumentation 24.5.4 Preoperative Checklist 24.5.5 Operative Technique 24.6 Expert Tips/Pearls/Suggestions 24.7 Postoperative Management 24.8 Complications and Their Management 25 Floppy Eyelid Syndrome Repair with Concomitant Ptosis Repair 25.1 Introduction 25.2 Goals of Intervention/Indications 25.2.1 Risks of the Procedure 25.2.2 Benefits of the Procedure 25.3 Informed Consent 25.4 Contraindications 25.5 Preoperative Assessment 25.6 Operative Technique 25.6.1 Instruments Needed 25.6.2 Surgical Technique 25.7 Expert Tips/Pearls/Suggestions 25.8 Postoperative Care Checklist 25.9 Complications References 26 Management of Lacrimal Gland Prolapse 26.1 Introduction and Anatomy 26.2 Goals of Intervention 26.3 Risks 26.4 Benefits 26.5 Contraindications 26.5.1 Surgical Procedure 26.5.2 Instruments Needed 26.5.3 Operative Technique: Step by Step 26.6 Expert Tips/Pearls/Suggestions 26.7 Postoperative Management and Complications References Section IV Myogenic Ptosis 27 Myogenic Ptosis: Etiology and Management 27.1 Introduction 27.2 Static Myogenic Ptosis 27.3 Progressive Myogenic Ptosis References 28 Static Myogenic Ptosis: Evaluation and Management 28.1 Introduction 28.2 Causes and Syndromic Associations of Static Myopathic Ptosis 28.2.1 Isolated Congenital Ptosis 28.2.2 Static Myopathic Ptosis with Associated Periocular Anomalies 28.2.3 Congenital Ptosis with Aberrant Innervation 28.2.4 Trauma 28.3 History 28.3.1 Personal History of Ptosis 28.3.2 Family History of Ptosis 28.4 The Physical Examination 28.4.1 The Eyelid and Adnexal Examination 28.4.2 The Eye Examination 28.5 Management 28.5.1 Observation 28.5.2 Timing of Surgical Intervention 28.5.3 The Surgical Approach 28.6 Conclusions References 29 Surgical Management of Levator Function Less Than 4 mm 29.1 Introduction 29.2 History of Frontalis Sling 29.2.1 Patterns of Sling 29.2.2 Sling Materials 29.2.3 Fixation of Sling to Eyelid Tarsus 29.3 Indications 29.4 Consequences 29.5 Unique Considerations in Frontalis Suspension 29.5.1 Congenital Cases 29.5.2 Acquired Cases 29.6 Risks of the Procedure 29.7 Benefits of the Procedure 29.8 Relative Contraindications 29.9 Informed Consent 29.10 The Procedure 29.10.1 Surgical Supplies and Equipment 29.10.2 Preoperative Checklist 29.10.3 Operative Technique 29.11 Expert Tips/Pearls/Suggestions 29.12 Postoperative Care Checklist 29.13 Complications and Their Management 29.13.1 Early Complications 29.13.2 Late Complications References 30 Surgical Management of Static Congenital Ptosis with Levator Function between 4 and 10 mm 30.1 Introduction 30.2 The Anatomy of the Eyelid Crease 30.3 Preoperative Assessment 30.3.1 Indications 30.3.2 Consequences of Levator Resection 30.3.3 Risks of the Procedure 30.3.4 Benefits of the Procedure 30.3.5 Relative Contraindications 30.3.6 Alternatives 30.4 Informed Consent 30.5 Instrumentation 30.6 The Levator Resection Procedure 30.7 Expert Tips/Pearls/Suggestions 30.8 Postoperative Care 30.9 Complications and Their Management 30.10 Conclusion References 31 Progressive Myogenic Ptosis: Evaluation and Management 31.1 Introduction 31.2 Causes of Progressive Myopathic Ptosis 31.2.1 Oculopharyngeal Muscular Dystrophy 31.2.2 Chronic Progressive External Ophthalmoplegia 31.2.3 Myotonic Dystrophies 31.2.4 The Masquerader of Progressive Myopathic Ptosis 31.3 History and Physical Examination 31.3.1 The History 31.3.2 Physical Examination 31.4 Management of Progressive Myopathic Ptosis 31.4.1 Timing of Repair 31.4.2 Our Workhorse Procedure 31.5 Conclusions References 32 Syndromic Blepharoptoses 32.1 Introduction 32.2 Aberrant Innervation Syndromes 32.3 Static Myopathic Ptoses Involving the Extraocular Muscles 32.4 Progressive Myopathic Ptoses that Affect the Levator and Other Muscle Groups Presenting in Childhood 32.5 Progressive Myopathic Ptoses Seen in Adulthood 32.6 Management and Conclusions References Section V Neurogenic Ptosis 33 Neurogenic Ptosis: Diagnosis and Management 33.1 Introduction 33.2 Neuroanatomic Considerations 33.2.1 Cortical and Supranuclear Pathways 33.2.2 Oculomotor Nerve 33.2.3 Oculosympathetic Pathway 33.2.4 Neuromuscular Junction 33.3 Localization 33.3.1 Supranuclear/Cortical Localization 33.3.2 Brainstem Localization 33.3.3 Spinal Cord and Paravertebral Ganglia Localization 33.3.4 Carotid Artery and Cavernous Sinus Localization 33.3.5 Nuclear Localization 33.3.6 Infranuclear Localization 33.4 Aberrant Innervation Syndromes 33.4.1 Compressive/Trauma 33.4.2 Marin-Amat’s Syndrome 33.4.3 Synkinesis 33.5 Diseases of the Neuromuscular Junction 33.5.1 Myasthenia Gravis 33.5.2 Lambert–Eaton Syndrome 33.6 Congenital Presentations 33.6.1 Third Nerve Palsy 33.6.2 Congenital Horner’s Syndrome 33.7 Summary References Section VI Pseudoptosis 34 Pseudoptosis: Evaluation and Management 34.1 Introduction 34.1.1 Dermatochalasis 34.1.2 Vertical Strabismus 34.1.3 Contralateral Eyelid Retraction 34.1.4 Enophthalmos 34.1.5 Ocular Abnormalities 34.1.6 Eyelid Protractor Overaction References Section VII Additional Considerations in Upper Facial Surgery 35 Eyelash Ptosis Management 35.1 Introduction 35.2 Anatomical Considerations 35.2.1 Eyelash Cilia 35.2.2 Levator Aponeurosis and Eyelid Crease 35.3 Goals of Intervention/Indications 35.4 Risks of the Procedure 35.5 Benefits of the Procedure 35.6 Informed Consent 35.7 Contraindications 35.8 Procedure 35.8.1 Instruments Needed 35.8.2 Preoperative Checklist 35.8.3 Operative Technique 35.8.4 Expert Tips/Pearls/Suggestions 35.8.5 Postoperative Care Checklist 35.9 Complications and Their Management References 36 Blepharoptosis Reoperation 36.1 Introduction 36.2 Anatomical Considerations 36.3 Goals of Intervention/Indications 36.4 Risks of the Procedure 36.5 Benefits of the Procedure 36.6 Informed Consent 36.7 Contraindications 36.8 Procedure 36.8.1 Instruments Needed 36.8.2 Preoperative Checklist 36.8.3 Operative Technique 36.8.4 Expert Tips/Pearls/Suggestions 36.8.5 Postoperative Care Checklist 36.9 Complications and Their Management References 37 Nonsurgical Management of Ptosis 37.1 Introduction 37.2 Mechanical Eyelid Elevation 37.2.1 Eyelid Crutches 37.2.2 Eyelid Taping 37.2.3 Haptic Contact Lens 37.3 Pharmacologic Eyelid Elevation 37.3.1 Topical Therapy 37.3.2 Neurotoxin Injections 37.4 Management of Ptosis in the Anophthalmic Patient 37.5 Management of Pseudoptosis with Filler Injection References 38 Unique Considerations in Upper Facial Surgery 38.1 Introduction 38.2 Perioperative Medications 38.2.1 Blood-Thinner Considerations 38.2.2 Classes of Blood Thinners 38.2.3 Balancing Thrombotic Risks and Bleeding Risks 38.2.4 Time to Stop Blood Thinners Preoperatively 38.2.5 Supplements and Other Considerations 38.3 Perioperative Antibiotic Considerations 38.3.1 Current Practice Patterns in Oculofacial Plastic Surgery 38.3.2 Patterns and Rates of Surgical Site Infection 38.3.3 Preoperative Recommendations 38.3.4 Perioperative Recommendations 38.3.5 Postoperative Recommendations 38.4 Energy Devices 38.4.1 Types of Devices 38.4.2 Fire Risk and the Triad 38.4.3 Effects of the Plume 38.5 Conclusions References 39 Staying Out of Trouble: Strategies Based on Recent OMIC Oculofacial Plastic Surgery Claims 39.1 Introduction 39.2 Particular Problem Areas in the Practice of Upper Facial Plastic Surgery 39.2.1 Blepharoplasty and Ptosis Repair 39.2.2 Brow Lifting 39.2.3 Invasive Skin Treatments 39.3 Fillers and Autologous Fat 39.4 Goals for the Upper Facial Surgeon 39.4.1 Establishing the Correct Diagnosis 39.4.2 Knowing When to Say No to Treatment 39.4.3 Effective Communication 39.4.4 Surgical Plan and Execution 39.4.5 Patient Follow-Up 39.4.6 Actively Manage Complications 39.4.7 Revisit Patient Expectations Frequently 39.5 The Unhappy Patient: Cosmetic Dissatisfaction and Patient Expectations 39.5.1 Refunds 39.5.2 I’m Sorry Laws 39.6 Expert Tips/Pearls/Suggestions 39.7 Coping with the Process of a Malpractice Claim 39.8 Conclusions References 39.9 Appendix A 39.9.1 Informed Consent for Ptosis Surgery (Droopy Eyelid Surgery) 39.10 Appendix B 39.10.1 Patient Cosmetic Surgical Agreement Index Medone Additional Information