Frontalis muscle flap advancement for correction of severe ptosis under general anesthesia: modified surgical design with 162 cases in China

The Aesthetic Evaluation of the Brow-Eye Continuum After Correction of Severe Congenital Ptosis in Children With Extended Frontalis Muscle Advancement Technique

BACKGROUND

Severe congenital ptosis is a common ocular deformity in pediatric patients that can significantly impact visual development and aesthetic appearance, leading to negative psychosocial outcomes. The frontalis muscle advancement technique is a well-established surgical treatment for severe congenital ptosis. Aesthetic changes of the brow-eye continuum often plays an important role in ptosis surgery.

METHODS

We conducted a single-center retrospective case series study of patients with severe congenital ptosis who underwent the frontalis muscle advancement technique at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University between April 2020 and June 2021. The study aimed to evaluate the aesthetic changes of the eyebrow-eyelid continuum after surgery. The main outcome measurements included marginal reflex distance 1, palpebral fissure height, eyebrow position, upper eyelid to lower eyebrow distance, lower eyelid to upper eyebrow distance, and nasal base to lower eyelid distance.

RESULTS

The study included 48 patients (66 eyelids), with 30 unilateral and 18 bilateral patients. Our analysis found that eyebrow height decreased by an average of 4.8% postoperatively relative to preoperatively in all patients.

CONCLUSIONS

The frontalis muscle advancement technique has demonstrated effectiveness in achieving aesthetically pleasing outcomes in children with severe ptosis. It is crucial to pay careful attention to the brow-eye continuum during the correction process, as its harmony can greatly impact the final result.

Combined levator and frontalis muscle advancement flaps for recurrent severe congenital ptosis

BACKGROUND

To evaluate the outcomes of combined levator resection and frontalis muscle advancement for surgical management of recurrent severe congenital ptosis.

DESIGN

Retrospective, nonrandomized interventional case series.

METHODS

A retrospective review was performed of patients who underwent combined levator resection and frontalis muscle advancement for recurrent congenital ptosis between 2017 and 2020. Inclusion criteria were levator function of 4 mm or less and margin reflex distance 1 (MRD1) of 0 mm or less. Main outcome measures were postoperative MRD 1, lagophthalmos, lash angle, and grades of eyelid contour and crease. The outcomes were assessed by reviewing medical charts and photographs.

RESULTS

Thirty-one patients (35 eyelids) met the inclusion criteria. The mean preoperative MRD1 was -1.14 ± 1.56 mm, which improved to 3.93 ± 0.52 mm with an average lagophthalmos of 0.91 ± 0.74 mm at the last follow-up. A total of 91.4% of eyelids had excellent eyelid contour, crease, and eyelash angle at the final follow-up. One eyelid required revision surgery. There were no other significant complications.

CONCLUSIONS

For poor function recurrent congenital ptosis, combining levator resection and frontalis muscle advancement is an effective method that results in long-term correction with cosmetically pleasing outcomes and minimal complications.

Modified Maximal Levator Palpebrae Superioris Shortening in Correcting Congenital Severe Ptosis in Children

OBJECTIVE

This study aims to evaluate the clinical effect of modified maximal levator palpebrae superioris shortening method for severe congenital ptosis.

METHODS

A retrospective case series was performed including 66 eyes from 62 patients who underwent modified maximal levator palpebrae superioris shortening surgery to treat severe congenital ptosis between February 2015 and November 2018. Preoperative and postoperative margin reflex distance 1 and levator muscle function were recorded. The surgical results were graded as good, satisfied, and poor for functional and cosmetic improvement of the eyelids, and the incidence of complications was also documented.

RESULTS

The mean patient age at the time of surgery was 4.6 ± 1.8 years (2-9 years), and the mean follow-up time was 36.3 ± 14.1 (12-55 months). A mean significant improvement in margin reflex distance 1 and levator function after operation was noted (P < 0.01). The eyelid height and symmetry were satisfied in 59 patients, with success rate of 95.2%. For the patients in the levator function (≤2 mm) group, the success rate was 87.5%. Moreover, the levator function (≤2 mm) group had a higher rate of poor results than levator function (2-4 mm) group (12.5% vs 2.2%). Overcorrection (6.5%) and eyelid fold deformity (11.3%) were the most frequent postoperative complications.

CONCLUSION

Modified maximal levator palpebrae superioris shortening was effective and endurable in the treatment of severe congenital ptosis with poor levator function, including in patients whose levator function was less than 2 mm.

Three Different Anesthesia Approaches in Blepharoptosis Surgery

Background

Despite the many methods of anesthesia for blepharoptosis, there is little documentation in the literature. When using the Müller aponeurosis composite flap advancement approach, one of the 3 anesthesia methods is chosen: general, local, and sedative anesthesia. On the other hand, the choice of anesthesia method is controversial.

Methods

A total of 101 patients (48 female and 53 male) admitted to hospital for treatment were selected: 38 (37.6%) patients (49 eyes) with local anesthesia, 34 (33.7%) patients (60 eyes) with general anesthesia, and 29 (28.7%) patients (42 eyes) with sedative anesthesia.

Results

The preoperative average marginal reflex distance (MRD1) in the local, general, and sedative anesthesia groups was 0.90, 0.35, and 0.47 mm, respectively. The corneal exposure area (CEA) in the local, general, and sedative approach groups was 63.2%, 57.8%, and 55.9%, respectively. The postoperative average distance for the MRD1 was significantly different among the 3 anesthesia approaches. The postoperative MRD1 in the local approach group was 3.28 mm and the CEA improved to 75.4%. In the general anesthesia approach group, the MRD1 was 3.01 mm and the CEA was 73.4%. In the sedative anesthesia approach group, the MRD1 and CEA were 3.62 mm and 74.0%, respectively. The MRD1 in the general, local, and sedative groups was 2.65 ± 1.48, 2.39 ± 1.65, and 3.17 ± 1.77, respectively; the difference was not significant (P > 0.05).

Conclusions

The general, local, and sedative anesthesia approaches are all effective in the correction of blepharoptosis; the results were similar regardless of the anesthesia approach. On the other hand, the patients felt more comfortable and surgeons could control the process more easily using the sedative approach.

The Frontalis Muscle Flap: As a Salvage Procedure for Upper Eyelid in a Burn Patient

The ugly face of civil war shows itself in the desperate patients and their extreme sequellae. The options for reconstruction of patients with late-term serious sequellae decrease and their treatments also become more difficult. A 31-year-old male patient was injured 18 months ago due to a bomb explosion and received long-term treatment through local wound care in his country. A patient who is referred to us with such late-term ectropion and lagophthalmos is likely to have both morphologic and functional deterioration. A frontal muscle flap was planned for this patient. The frontal muscle flap has been used for a long time in ptosis surgery and was used in the treatment of the patient to repair both lagophthalmos and ptosis. Satisfactory results were obtained at the end of a 6-month period during which the patient was monitored.

The inflammation influence on corneal surface after frontalis suspension surgery

AIM

To study the influence of frontalis muscle flap suspension on ocular surface by analyzing the clinical features and inflammatory cytokines.

METHODS

A prospective, observational case series. Thirty-one eyes of 25 patients with severe congenital blepharoptosis who underwent frontalis muscle flap suspension surgery with at least 6mo of follow-up were included in the study. The main outcome measures were margin reflex distance 1 (MRD₁), degree of lagophthalmos, ocular surface disease index (OSDI), fluorescein staining (Fl), tear break-up time (BUT), Schirmer I test, and inflammatory cytokine assay.

RESULTS

The degrees of lagophthalmos significantly increased after surgery. The OSDI scores significantly increased 1wk postoperatively and then decreased 4wk after operation. The Fl scores reflected corneal epithelial defects in sixteen patients at early stage postoperatively. The BUT and Schirmer I test values remained stable and did not show change compared to those before surgery. The inflammatory cytokines in conjunctival epithelial cells (including IL-1β, IL-6, IL-8, TNF-α, and IL-17A) significantly increased 1wk after the surgery (P<0.001), then returned to the normal level at 24wk postoperatively. The levels of inflammatory cytokine IL-1β, IL-6, IL-8, TNF-α, and IL-17A elevated significantly and were positively correlated with OSDI and Fl scores.

CONCLUSION

Frontalis muscle flap suspension surgery results in lagophthalmos in early period of post-operation and relieved after months. The elevation of inflammatory cytokines level may participate in the occurrence of corneal epithelial defects at the early postoperative stage.

[Effectiveness of levator muscle resection combined with Mustarde's double Z-plasty for blepharophimosis-ptosis-epicanthus inversus syndrome]

Objective

To investigate the effectiveness of levator muscle resection combined with Mustarde's double Z-plasty to correct blepharophimosis-ptosis-epicanthus inversus syndrome (BPES).

Methods

Between March 2015 and June 2017, one-stage operation of levator muscle resection combined with Mustarde's double Z-plasty were performed on 26 children with bilateral BPES. There were 16 boys and 10 girls with an average age of 7 years (range, 4-14 years). All patients marked the four typical signs of BPES. There were 7 cases accompanied with a low nasal bridge, and 20 cases with amblyopia and strabismus. The length of eye fissure was (19.5±4.5) mm, the width of eye fissure was (2.5±1.6) mm, the diameter of inner canthus was (42.1±6.5) mm, and the muscular strength of levator palpebrae superioris was (5.5±1.3) mm.

Results

All the incisions healed by first intention. Twenty-three patients were followed up 2-12 months, with an average of 10 months. Among which, 2 cases were less corrected, 3 cases were over corrected, 6 cases had poor curvature of the eyelid. No eyelid internal and external pronation or keratitis occurred. Amelioration of blepharoptosis and epicanthus was achieved in the other patients, and the double eyelid fold was naturally smooth. At 7 days after operation, the length of eye fissure was (27.2±1.9) mm, the width of eye fissure was (12.5±1.3) mm, and diameter of inner canthus was (29.4±2.6) mm, which were superior to preoperative values ( t=0.127, P=0.042; t=0.341, P=0.029; t=0.258, P=0.038). There was no angular deformity caused by the width and length regressions of eye fissures.

Conclusion

The levator muscle resection combined with Mustarde's double Z-plasty can effectively correct BPES and obtain good effectiveness.

Ten Years of Results of Modified Frontalis Muscle Transfer for the Correction of Blepharoptosis

Background

Conventional frontalis transfer may cause a range of complications. In order to overcome complications, we made modifications to the surgical technique, and compared the outcomes of patients who underwent conventional frontalis transfer with those of patients who underwent modified frontalis transfer.

Methods

We conducted a retrospective study of 48 patients (78 eyes) who underwent conventional frontalis transfer between 1991 and 2003 (group A) and 67 patients (107 eyes) who underwent modified frontalis transfer between 2004 and 2014 (group B). The frontalis transfer procedures were modified conform to the following principles. The tip of the frontalis muscle flap included soft tissue that was as thick as possible and the soft tissue on the tarsal plate was removed to the greatest extent possible. A double fold was created in cases of unilateral ptosis. In order to evaluate the objective effects of modification, preoperative and postoperative values of the marginal distance reflex 1 (MRD1), the corneal exposure area, and the decrease in eyebrow height were compared between the two groups.

Results

In group A, patients showed an improvement of 1.19 mm in the MRD1, a 6.31% improvement in the corneal exposure area, and a 7.82 mm decrease in eyebrow height. In group B, patients showed an improvement of 2.17 mm in the MRD1, an 8.39% improvement in the corneal exposure area, and an 11.54 mm decrease in eyebrow height. The improvements in group B were significantly greater than those in group A.

Conclusions

Modified frontalis transfer showed better results than the conventional procedure and provided satisfactory outcomes.