Stabilization of eyelid height after aponeurotic ptosis repair

Müller Muscle-Conjunctival Resection for Treatment of Contralateral Ptosis following Unilateral External Levator Advancement

BACKGROUND

One of the main causes of unsatisfactory outcomes after unilateral blepharoptosis surgery is asymmetry of the upper eyelid height, which occurs as a result of a contralateral eyelid droop. Therefore, the authors evaluated the efficacy of Müller muscle-conjunctival resection (MMCR) for the treatment of contralateral ptosis following unilateral external levator advancement (ELA).

METHODS

This study analyzed 26 eyelids of 26 patients with upper eyelid height asymmetry following unilateral ELA who underwent contralateral MMCR retrospectively. The phenylephrine test was performed before ELA and before MMCR. The main outcome measures were symmetry outcomes and clinical outcomes.

RESULTS

The mean patient age was 55.81 ± 7.98 years (range, 44 to 70 years); 15 were female (57.7%). The Hering dependency was observed in 13 of the patients (50%) before ELA. An adequate response to phenylephrine was observed before MMCR but not before ELA. Symmetry outcomes after MMCR were perfect (<0.5 mm), good (≥0.5 mm and <1 mm), and fair (≥1 mm) in seven, 17, and two patients, respectively. An optimal upper eyelid height was noted in 47 of the 52 eyelids after the MMCR, whereas three of the 52 eyelids had minimal overcorrection, and two eyelids had undercorrection. The mean change in marginal reflex distance 1 of the contralateral eyelid droop was greater for patients with than without the Hering dependency ( P < 0.0001) after ELA but not after MMCR. Two patients (7.6%) underwent revision ELA surgery.

CONCLUSION

MMCR and use of the phenylephrine test to predict the eyelid position may represent an alternative approach in patients who require management of contralateral ptosis following unilateral ELA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Septum-sparing minimally invasive technique for levator advancement surgery in aponeurotic ptosis

PURPOSE

To evaluate the outcome of small incision levator advancement with septum-sparing technique and compare it with standard levator advancement.

METHODS

The surgical findings and clinical data of patients with aponeurotic ptosis who underwent small incision or standard levator advancement surgery in our clinic between 2018 and 2020 were analyzed retrospectively. For both groups; age, gender, systemic and ophthalmic comorbidities, levator function, preoperative and postoperative margin-reflex distance, change in margin-reflex distance after surgery, symmetry between the eyes, follow-up time, perioperative and postoperative complications (under/overcorrection, contour irregularity, lagophthalmos) were all evaluated and recorded.

RESULTS

The study included 82 eyes, 46 from 31 patients in Group I who had small incision surgery, and 36 from 26 patients in Group II who had standard levator surgery. There was no statistically significant difference in surgical success between the two groups (80% and 81% respectively, p = 0.692). The levator function and preoperative margin-reflex distance correlated positively with surgical success.

CONCLUSION

Small incision levator advancement is a less invasive procedure than standard levator advancement because of the smaller skin incision and preservation of orbital septum integrity, but it requires good knowledge of eyelid anatomy and experience in eyelid surgery. In patients with aponeurotic ptosis, this surgery can be performed as a safe and effective surgical technique with a similar success rate as standard levator advancement.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Eyelid Surgery for Upper Visual Field Improvement

BACKGROUND

A group of experts from different disciplines was convened to develop guidelines for the management of upper visual field impairments related to eyelid ptosis and dermatochalasis. The goal was to provide evidence-based recommendations to improve patient care.

METHODS

A multidisciplinary group of experts representing their specialty organizations was selected. A systematic literature review was performed including topics regarding documentation of the underlying cause for visual field impairment, selection of an appropriate surgical repair, assessment of the type of anesthesia, the use of adjunctive brow procedures, and follow-up assessments. The Grading of Recommendations, Assessment, Development, and Evaluation methodology process was used to evaluate the relevant studies. Clinical practice recommendations were developed using BRIDGE-Wiz (Building Recommendations In a Developers' Guideline Editor) software.

RESULTS

Each topic area was assessed. A clinical recommendation was made, and the relevant literature was discussed.

CONCLUSIONS

The review of the literature revealed varied complication rates and diverse treatment modalities for the correction of upper visual field deficit. Strong recommendations could not be made in most topic areas because of a paucity of methodologically sound studies in the literature. More rigorously designed studies are needed to measure outcomes of interest, with fewer sources of potential error or bias.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Efficacy of tarsoconjunctivomullerectomy in adults with acquired aponeurogenic blepharoptosis: a large single-surgeon case-series

PURPOSE

To evaluate the reoperation rate and symmetry after uni- or bilateral tarsoconjunctivomullerectomy (TCM) in a large, consecutive series of adult patients suffering from mild to moderate acquired aponeurogenic blepharoptosis.

METHODS

Patients who underwent TCM because of mild to moderate acquired aponeurogenic blepharoptosis between January 2005 and September 2016 were analysed. Main outcome was reoperation rate. Secondary outcomes were eyelid symmetry and the effects of uni- or bilateral surgery, and in unilateral cases contralateral ptosis surgery. MRD-1 (Margin to Reflex Distance) similarity within 1 mm and contour of the eyelid were used for grading eyelid symmetry.

RESULTS

We analysed the data of 243 patients, of whom 178 underwent unilateral, and 65 bilateral TCM. Previous ptosis surgery of the same eyelid had been performed (by another surgeon) in 44 patients. Reoperation was performed in four patients after unilateral (2.2%) and in 1 patient after bilateral surgery (1.5%) (p = 1.00). After unilateral surgery, contralateral ptosis surgery due to increased contralateral ptosis was performed in 16 patients (9.0%). We found no difference in reoperation rate between patients in whom ptosis surgery had been performed previously versus primary surgery (p = .22). Symmetry was good in 44%, acceptable in 44% and poor in 12% of the patients.

CONCLUSIONS

After TCM, the reoperation rate was about 2% with good or acceptable eyelid symmetry in most cases. There was no difference in reoperation results between uni- and bilateral cases. However, if we include secondary ptosis surgery of the contralateral eyelid in unilateral cases, results were better after bilateral surgery.

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.

The Effect of Early Postoperative Swelling on Change in Upper Eyelid Position After External Levator Resection and Blepharoplasty

PURPOSE

To determine if early postoperative swelling has an effect on change in the upper eyelid position after external levator resection (ELR) or blepharoplasty.

METHODS

In this observational cohort study, patients >18 years old who underwent ELR or upper blepharoplasty were identified. Digital photographs in primary position were obtained at the preoperative, early postoperative week one, and late postoperative month 3 visits. Marginal reflex distance 1 (MRD1) was measured digitally. Swelling was graded on a previously validated scale from 0 to 3. Photographs were evaluated by 26 experts/professional image graders. Primary outcome measure was changed in MRD1 from preoperative to late postoperative visits. Secondary outcome measure was change in MRD1 from early to late postoperative visits. The effect of early postoperative swelling on each outcome was assessed using linear regression models.

RESULTS

The sample contained 54 patients (25 ELR and 29 blepharoplasty). The model regressing change in MRD1 from preoperative to late postoperative visits with early postoperative swelling as the predictor was significant for ELR (R2 = 0.165, p = 0.044) but not blepharoplasty (R2 = 0.016, p = 0.515). However, the model controlling for preoperative MRD1 was not significant for ELR (B = 0.423, p = 0.354). The model regressing change in MRD1 from early to late postoperative follow up utilizing early postoperative swelling as the sole predictor was not significant for ELR (R2 = 0.010, p = 0.627) but was significant for blepharoplasty (R2 = 0.207, p = 0.013), with increased swelling associated with greater change in MRD1.

CONCLUSIONS

Early postoperative swelling does not affect the final MRD1 outcome of ELR or upper blepharoplasty; however, blepharoplasty patients with early postoperative swelling may experience greater increase in MRD1 over follow up.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Influence of epinephrine contained in local anesthetics on upper eyelid height in transconjunctival blepharoptosis surgery

PURPOSE

To examine the influence of epinephrine contained in local anesthetic on upper eyelid height in transconjunctival aponeurotic repair for aponeurotic blepharoptosis.

METHODS

This retrospective study included 164 eyelids from 94 patients with aponeurotic blepharoptosis. Patients were divided according to the use of local anesthetic with (group A, n = 108) or without 1:100000 epinephrine (group B, n = 56). Margin reflex distance-1 (MRD-1) was measured before and after local anesthesia, and before, during, and 3 months after surgery. Change in MRD-1_a (∆MRD-1_a) was calculated by subtracting the postanesthetic MRD-1 value from the preanesthetic value, and we defined ∆MRD-1_b by subtracting the postoperative 3-month MRD-1 value from the intraoperative value.

RESULTS

∆MRD-1_a was positive in group A (0.57 ± 0.63 mm) and negative in group B (- 0.50 ± 0.45 mm; p < 0.001). Postoperative MRD-1 decreased significantly from intraoperative MRD-1 in group A (P < 0.001), although there was no significant difference between intraoperative and postoperative MRD-1 in group B (p = 0.255). The magnitude of ∆MRD-1_b in group A (- 0.86 ± 0.63) was larger than that in group B (- 0.23 ± 0.26; p < 0.001).

CONCLUSIONS

Epinephrine stimulates Müller's muscle during surgery, which leads to postoperative upper eyelid droop after the disappearance of the epinephrine effect. Using local anesthetics without epinephrine may allow more accurate estimation of postoperative eyelid height in transconjunctival aponeurotic repair.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery

PURPOSE

The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery.

METHODS

An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain.

RESULTS

The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity.

CONCLUSIONS

The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

The Effect of Upper Aging Blepharoplasty on Upper and Lower Eyelid Position

PURPOSE

Change in eyelid position after upper blepharoplasty is an important factor that can affect postoperative patient satisfaction. However, no one has investigated eyelid changes during follow-up for upper eyelid surgery. Thus, the purpose of this study was to investigate position changes in the upper and lower eyelids during the follow-up period after upper blepharoplasty in Korean.

METHODS

The authors retrospectively reviewed the clinical records of patients who underwent upper blepharoplasty for uncomplicated upper eyelid dermatochalasis. Digital photographs were taken preoperatively, immediately after surgery, and at 1 week postoperative, 1 month postoperative, and 3 months postoperative. Our main-effect variables were marginal reflex distance (MRD) 1 and 2 and palpebral fissure height (PFH), which were measured from digital photographs using ImageJ software.

RESULTS

We enrolled 180 eyes from 90 patients (M: 35 and F: 55) with a mean age of 63.8 ± 10.3 years. The eyelid measurements (MRD1, MRD2, PFH) taken preoperatively, immediately after surgery, and 1 week, 1 month, and 3 months postoperative were, respectively: MRD1 (mm): 2.56 ± 1.08, 1.91 ± 0.86, 2.21 ± 1.02, 2.66 ± 1.01, 2.75 ± 0.99; MRD2 (mm): 4.91 ± 0.93, 4.62 ± 0.87, 4.68 ± 0.90, 4.87 ± 0.86, 4.91 ± 0.83; and PFH (mm): 7.48 ± 1.64, 6.53 ± 1.46, 6.89 ± 1.53, 7.52 ± 1.51, 7.65 ± 1.49. All postoperative measurements for MRD1 and PFH were significantly different from the preoperative measurement, except for measurements taken 1 month postoperative. MRD2 measurements differed significantly from the preoperative measurements immediately after surgery and 1 week postoperative. Among age, preoperative PFH, and amount of skin-muscle resection, only preoperative PFH significantly affected PFH changes immediately after surgery and at 3 months postoperative (OR 0.636, 95% CI 0.478-0.847, OR 0.506, 95% CI 0.386-0.663).

CONCLUSION

All eyelid measurements (MRD1, MRD2, and PFH) decreased 1 week postoperatively from values immediately after surgery, but MRD1 and PFH increased slightly 3 months postoperative. We note that postoperative changes in PFH may be large in patients with large PFH before blepharoplasty. It should also be noted that reverse ptosis of the lower eyelid occurs immediately after upper eyelid surgery.

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.

Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases

PURPOSE

To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques.

METHODS

This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate.

RESULTS

A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002).

CONCLUSIONS

The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.

Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Importance

External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies.

Objective

To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function.

Design, Setting, and Participants

This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic.

Interventions

The technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations.

Main Outcomes and Measures

Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1).

Results

Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, -0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments.

Conclusions and Relevance

In correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed.

Level of Evidence

3.

Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis

PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.

The Effect of Hering's Law on Different Ptosis Repair Methods

BACKGROUND

The Hering's law effect has significant importance in surgical planning and outcomes of eyelid surgery.

OBJECTIVES

The current study examined the preoperative and intraoperative effect of Hering's law in Mullerectomy and levator aponeurosis advancement.

METHODS

A retrospective analysis was conducted of 52 patients with unilateral ptosis who underwent surgical repair from January 2011 through June 2013. Patients underwent levator aponeurosis advancement or Mullerectomy with or without tarsectomy. Preoperative and postoperative clinical documentation and photographs were evaluated. Preoperative Hering's dependency and postoperative changes in positioning of the non-operated eyelid were measured. The decision to operate on the ptotic eye alone or on both eyelids was based on preoperative Hering's dependence and intraoperative changes in the contralateral eyelid.

RESULTS

Fifty-two patients with unilateral ptosis were included. Average age was 63.3 ± 20.1 years (range, 22-88 years; median, 61 years); 34 (65.4%) were female. The 14 cases that were not aponeurotic (either congenital, secondary to trauma, or due to postoperative ptosis) did not need contralateral repair (p = .000). In 4 (19%) cases of Mullerectomy and in 9 (52.9%) cases of levator advancement, both eyelids required surgery (p = .029). Hering's law effect was significantly more apparent in the levator advancement approach than in Mullerectomy.

CONCLUSIONS

Levator surgery resulted in a higher incidence of combined intraoperative and postoperative Hering's law effect than did Mullerectomy. Cases with poor levator function or congenital ptosis can be repaired unilaterally with no need for contralateral surgery. The fibrotic levator palpebrae muscle and its special innervations probably explain this phenomenon. This should be considered in surgical planning.

What Is the Best Way to Handle the Involutional Blepharoptosis Repair?

There are many different operations to correct involutional blepharoptosis (IB); however, the outcome of the corrective surgery is rather unpredictable, regardless of the procedure employed. A reasonably predictable outcome can be achieved with careful intraoperative evaluation of the condition, with measuring of the margin reflex distance-1 (MRD-1) in supine position of the patients. With these prepositions, we collected data that indicated that our approach can achieve a predictable outcome. This was a prospective study of 21 consecutive patients (8 men and 13 women) involving 42 eyelids with IB. IB was defined as an MRD-1 of <2  mm. All 21 patients were informed of the purposes of the study, and underwent levator aponeurosis advancement. The MRD-1 was measured intraoperatively with the patients in a supine position and in the 3-month postoperative inspection with the patients in a sitting position. Statistical analyses using paired t-tests were performed. From intraoperative measurement, mean MRD-1 values were 4.31  mm on the right side (range 3.0-4.5) and 4.29  mm on the left side (range 3.5-5.0). Three months after the operations, mean MRD-1 values were 3.07  mm on the right side (range 1.5-4.0) and 3.07  mm on the left side (range 2.0-4.0). Compared with the intraoperative MRD-1 measurements, those of the postoperatives were significantly 1.2  mm reduced (right: P < 0.01, left: P < 0.01). The intraoperative measurement of MRD-1 without changing position of patients could result in successful outcome of the operation.

The role of frontalis orbicularis oculi muscle flap for correction of blepharoptosis with poor levator function

On the basis of the close anatomical interdigitation between the longitudinal-oriented frontalis muscle and the horizontal-oriented orbicularis oculi muscle (OOM), frontalis OOM (FOOM) flap was developed to treat blepharoptosis. Retrospective study during an 11-year period, 66 patients with 81 poor levator function ptotic eyelids accepted FOOM flap shortening (65 lids; 80.2%) or double-breasted FOOM flap advancement (16 lids; 19.8%) to correct blepharoptosis. There were 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Severity of blepharoptosis included severe type in 72 (88.9%) lids, moderate type in 5 (6.2%) lids, and mild type in 4 (4.9%) lids. The underlying etiology included congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and neurologic origin in 4 (6.1%) patients. Marginal reflex distance 1 and lid slit distance improved from -1.6 (2.0) to 3.3 (1.2) and 3.2 (2.0) to 7.2 (1.4) mm, respectively, after operation. The postoperative outcome includes good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. The undercorrection or recurrence rate is 14.8%, and secondary revision rate is 11.1%. Positive Hering law is 17.6% among patients with unilateral ptosis. Overall patients' satisfaction rate is 95.1%. Both FOOM flap shortening and double-breasted FOOM flap advancement are effective to treat poor levator function blepharoptosis. Double-breasted FOOM flap advancement is highly recommended because of the more natural contour and minimal lagophthalmos postoperatively, because of the maximal preservation of OOM.

Intraoperative adjustment of eyelid level in aponeurotic blepharoptosis surgery

There have been numerous reports on the use of aponeurotic surgery to correct involutional blepharoptosis. However, it is still difficult to determine optimal eyelid level during operation. Here we present our new method to adjust eyelid level intraoperatively. After the aponeurosis was temporally sutured to the tarsus, while still in the supine position, the patient was asked to look up, and the position of the eyelid margin was confirmed. The margin should be located above the pupil but within the cornea while the patient gazes up. And it is ideal if the eyelid position is located in the upper half of this range. Although 3 of 29 patients were reoperated on in the follow-up period, only 1 patient required readjustment in the perioperative period. Our method is simple, easy and reduces operative time, because it is not necessary to change patient position during the operation.

Assessment of the Predictive Value of Intraoperative Eyelid Height Measurements in Sitting and Supine Positions During Blepharoptosis Repair

PURPOSE

To examine relationships between intraoperative and postoperative eyelid heights in relation to patient postures in blepharoptosis surgery.

METHODS

Thirty eyelids in 15 patients with bilateral aponeurotic ptosis were selected. The margin reflex distance-1 (MRD-1) was measured with the patients in the sitting position preoperatively, intraoperatively, and in the postoperative 6 weeks. MRD-1 also was measured intraoperatively with patients in the supine position. The intraoperative sitting and supine values and the postoperative values were statistically compared using a paired t test, and lateralities in those groups were statistically analyzed using Student's t test.

RESULTS

From the intraoperative measurements, mean MRD-1 values in the sitting position (right: 3.80 mm, left: 3.73 mm) were significantly lower than those in the supine position (right: 4.37 mm, p < 0.001; left: 4.33 mm, p < 0.001). In the postoperative 6 weeks, mean MRD-1 values (right: 3.80 mm, left: 3.63 mm) were not significantly different from intraoperative values in the sitting position (right: p = 1.000, left: p = 0.189), but were significantly lower than intraoperative values in the supine position (right: p < 0.001, left: p < 0.001). There was no significant laterality among the three groups (supine intraoperative: p = 0.890, sitting intraoperative: p = 0.785, postoperative: p = 0.546).

CONCLUSION

Intraoperative measurements in the sitting position more accurately predicted postoperative eyelid height than did measurements with the patient in a supine position.

Comparative study of the subjective and objective grading of ptosis surgery outcomes

AIMS

To assess the results of blepharoptosis surgery in our hospital by subjective and objective grading of the outcome and comparing them to determine their degree of corelation.

METHODS

Retrospective interventional case series report supplemented by postal questionnaires and telephonic patient surveys. The study included 107 eyelids of 78 patients. Using a simple grading system, surgical outcome was objectively graded as good, suboptimal, or poor. Outcome was also defined according to the patients' perspective as good, suboptimal, or poor. Level of agreement between the subjective and objective grading of the outcome was measured using a weighted kappa analysis.

RESULTS

The objective results were classed as good-68/107 (63.5%), suboptimal--18 eyelids (16.8%), and poor--21 eyelids (19.6%). The subjective results were obtainable in 91 eyelids and were good--54/91 (59.3%), suboptimal--8/91 (8.7%), and poor--29/91 (32%). A mismatch between objective and subjective outcomes was seen in 16 eyelids. We saw a statistically significant corelation between the objective grading and the patients' perspective (P<0.001).

CONCLUSION

Our overall ptosis surgery results are comparable with rates previously reported. The subjective and objective outcomes of ptosis surgery may sometimes vary, but nevertheless exhibit substantive agreement when measured by this simple grading system.

Aetiology and surgical treatment of childhood blepharoptosis

AIMS

To describe the aetiology, demography, surgical management, and outcome of a cohort of paediatric ptosis patients in a large tertiary referral oculoplastic centre.

METHODS

A case note review of all patients undergoing ptosis surgery below the age of 16 years in a tertiary referral oculoplastic unit documenting the laterality, aetiology, severity of ptosis, indications for and type of surgery undertaken, the proportion of good, suboptimal, and poor surgical outcomes, re-operations, and level of patient satisfaction.

RESULTS

340 patients (82% (280/340) unilateral, 18% (60/340) bilateral ptosis) with myogenic (79%, 269/340), aponeurotic (5%, 16/340), neurogenic (11%, 37/340), mechanical (2%, 6/340), apparent (1%, 2/340), and syndrome related (3%, 10/340) ptosis underwent anterior (41%, 141/340) and posterior (26%, 90/340) levator resection, frontalis suspension with mersilene (9%, 29/340) and autogenous fascia lata (17%, 59/340), levator transposition (5%, 15/340) and other surgery (1%, 6/340) for visual (43%, 141/333) and cosmetic (57%, 189/333) indications. 77% (260/340) of patients achieved a good outcome, 10% (35/340) a suboptimal outcome, and 13% (45/340) a poor outcome requiring re-operation. There was no statistically significant difference in surgical outcome between patients with mild, moderate, or severe ptosis and with good, moderate, or poor levator function. The level of recorded patient satisfaction with the surgical outcome was 90% (206/229).

CONCLUSIONS

Results suggest that most groups of paediatric ptosis patients, including those with poor levator function and severe ptosis, achieve satisfactory results with the appropriate ptosis surgery.

New adjustable suture technique for managing eyelid ptosis

The challenge of accurately predicting eyelid height after levator surgery for ptosis is a well-known problem even in competent hands. It is always better to correct an unfavorable postoperative result without surgical intervention, and thus spare the patient another involved procedure. The author describes a new adjustable suture technique that ensures a secure connection between the levator muscle and the tarsus, and allows easy postoperative adjustment of lid height. The suture design consists of an inner and an outer loop in a configuration that resembles a paper clip. When the suture is tightened, the inner loop approximates the distal part of the levator muscle to the tarsal plate, bringing the tissues into secure contact. When tightened further, the outer loop is activated and it approximates the more proximal part of the levator muscle to the tarsus as much as desired to achieve the proper eyelid height. When the sutures are tightened, the levator muscle shortens by folding on itself like the pleats of an accordion. Using this method, muscle slack is reduced as the tissue is folded on itself several times.

A simplified technique of ptosis repair using a single adjustable suture

PURPOSE

To describe a simplified technique for ptosis repair using a single adjustable suture.

DESIGN

Retrospective noncomparative series.

PARTICIPANTS

Fifty-one cases of ptosis repair performed or supervised by the same surgeon between 1993 and 1995.

INTERVENTION

The surgical approach consisted of using a single adjustable "hang-back" 5-0 silk suture for plication of the superior portion of the levator aponeurosis. Lid height was then reassessed within the first 4 postoperative days and permanently readjusted by fixating the adjustable suture. Excluded were patients with history of unstable ptosis as a result of systemic disease or congenital, mechanical, and traumatic ptosis resulting from a mass or trauma. The follow-up period ranged from 3 to 31 months.

MAIN OUTCOME MEASURE

Lid position.

RESULTS

All eyelids included in this study were corrected to 1 mm of the desired result. There were no incidents of peaking or recurrence on long-term follow-up. Complications included one case of hematoma and a case of slight tenting of the eyelid margin.

CONCLUSIONS

This procedure combines the physiologic approach of levator aponeurosis surgery with the simplicity and flexibility of a single adjustable "hang-back" type suture. It may readily be combined with other procedures such as blepharoplasty. It is also useful when the "ideal" lid level may not be determined until the postoperative period, such as eyes subject to ptosis by Hering's law, levator dehiscence, or those at increased potential risk for corneal exposure.