Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients

Three-Point Vertical Mattress Suture: A Simple Technique for Mild Blepharoptosis Correction in Partial-Incision Double-Eyelid Surgery

The aim of this study was to introduce a simple technique for mild blepharoptosis correction using a three-point vertical mattress suture in partial-incision double-eyelid surgery. The medical records and preoperative and postoperative images of 57 patients who underwent simultaneous mild blepharoptosis correction and partial-incision double-eyelid surgery from January 2018 to July 2021 were retrospectively reviewed. The surgical procedure mainly involves three small incisions in the proper eyelid crease, levator aponeurosis exposure by conservative dissection, and three-point vertical mattress suture to plicate levator aponeurosis and fix the orbicularis muscle with the plicated levator aponeurosis. All patients underwent bilateral partial-incision double-eyelid surgery: 10 unilateral and 47 bilateral blepharoptosis corrective surgeries. The average age was 25.3 ± 7.4 years. The mean operative and follow-up duration were 50 minutes and 13 months, respectively. The pre- and postoperative mean marginal reflex distance was 3.04 ± 0.27 and 3.75 ± 0.35 mm, respectively. The overall surgical success rate was 93%. Complications including undercorrection (5.3%), asymmetry (7.0%), and double-eyelid crease disappearance (5.3%) were reported. Three-point vertical mattress suture is considered an effective, safe, and simple technique for mild blepharoptosis correction in partial-incision double-eyelid surgery.

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula

BACKGROUND

The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes.

OBJECTIVES

The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented.

METHODS

Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance.

RESULTS

A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.

CONCLUSIONS

This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

LEVEL OF EVIDENCE: 4

Factors that influence the postoperative upper eyelid position following surgery for involutional blepharoptosis

External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r = 0.49) and intraoperative (r = 0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.

Surgical outcomes of the anterior versus posterior approach for advancement of the levator aponeurosis in Japanese patients

PURPOSE

To compare the surgical outcomes of the anterior and posterior approaches for advancement of the levator aponeurosis for aponeurotic blepharoptosis in relation to levator function (LF).

METHODS

This retrospective study included 223 eyelids from 125 patients with aponeurotic blepharoptosis. The anterior approach was used for 115 eyelids from 65 patients (anterior group), while the posterior approach was used in 108 eyelids from 60 patients (posterior group). Patients were subdivided into two groups in accordance with their LF (fair: 5-10 mm; good: > 10 mm). Functional success was defined as a margin reflex distance of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was defined as the achievement of ≤ 1 mm laterality of the upper eyelid height, ≤ 2 mm laterality of the pretarsal show, and eyelid contour symmetry at 3 months postoperatively.

RESULTS

The functional success rates of the anterior and posterior groups were comparable for patients with good LF (78.9% vs 87.7%, p = 0.228), whereas it was better in the posterior group (85.7%) than the anterior group (64.1%) in the total group (p = 0.022) and in patients with fair LF (p = 0.031). The posterior group achieved better cosmetic success than the anterior group regarding upper eyelid height symmetry (p = 0.042) and pretarsal show (p = 0.012). No serious complications occurred during follow-up.

CONCLUSIONS

The posterior approach achieved better functional and cosmetic outcomes than the anterior approach, indicating that the posterior approach is more useful in patients with aponeurotic blepharoptosis, particularly for those with only fair LF.

Influence of fatty deposits in the levator aponeurosis/levator palpebrae superioris muscle on outcomes of aponeurotic repair in a Japanese population

PURPOSE

To examine a part of the levator aponeurosis/levator palpebrae superioris (LPS) muscle that did not have fatty deposits in patients with aponeurotic blepharoptosis. We also analysed the relation between this length and surgical outcome after transcutaneous aponeurotic repair.

METHODS

We measured the vertical length from the distal end of the anterior layer of the levator aponeurosis to the most distal point of fatty deposits in the levator aponeurosis/LPS muscle (non-fatty-deposit length) in 94 eyelids. Surgical success was defined as a postoperative margin reflex distance-1 (MRD-1) of 2.0-5.0 mm at 3 months postoperatively. The eyelids were classified into two groups: a surgical success group (group A, 76 eyelids) and an undercorrected group (group B, 18 eyelids). Group A was subdivided according to the evidence of a fatty deposit (group A1, fat present, 70 eyelids; group A2, fat absent, 6 eyelids).

RESULTS

The non-fatty-deposit measurement was significantly longer in group A1 than in group B (p = 0.035). The levator aponeurosis was less advanced in groups A1 and A2 than in group B (both, p < 0.001), and the eyelids in groups A1 and A2 obtained a higher MRD-1 than those in group B (both, p < 0.001).

CONCLUSIONS

Eyelids with less fat deposit required less advancement of the levator aponeurosis and obtained more favourable surgical results. Intraoperative findings of eyelids with and without fatty deposits and measuring the non-fatty-deposit length may be useful predictive parameters for outcomes of transcutaneous aponeurotic repair.