Use of the Levator Muscle as a Frontalis Sling

Marcus-Gunn jaw winking syndrome: case series study and management algorithm

PURPOSE

To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS).

METHODS

Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL).

RESULTS

Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia.

CONCLUSIONS

Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

Phenotype, genotype, and management of congenital fibrosis of extraocular muscles type 1 in 16 Chinese families

PURPOSE

Congenital fibrosis of extraocular muscles type 1 (CFEOM1), a classical subtype of CFEOM, is characterized by restrictive ophthalmoplegia and ptosis. It is mainly caused by aberrant neural innervation of the extraocular muscles. This study aimed to investigate the genetic characteristics and clinical manifestations of CFEOM1 in Chinese families.

METHODS

The clinical data, including ocular examinations, magnetic resonance imaging (MRI), and surgical procedures of affected individuals from 16 Chinese CFEOM1 families, were collected. The genomic DNA of 16 probands and their family members were sequenced for causative KIF21A gene mutations. Linkage analysis using microsatellite markers across KIF21A was also conducted.

RESULTS

Affected individuals were presented with bilateral non-progressive ptosis, restricted horizontal eye movement, fixed infraduction of both eyes, compensatory chin-up head position, and neuromuscular abnormalities. Three heterozygous KIF21A mutations, c.2860C > T (p.R954W) (in eight families), c.2861G > T (p.R954L) (in two families), and c.2861G > A (p.R954Q) (in two families) were identified, which implied that hotspot mutations were common in Chinese CFEOM1 families. Germline Mosaicism was likely to be the cause of affected individuals with asymptomatic parents without KIF21A mutations presented in the eight families. Two affected individuals underwent modified levator muscle complex suspension surgery and achieved a good result without any complications.

CONCLUSION

Instead of evaluating the whole CFEOM1 gene variant, hotspot mutations could be given priority for screening. The occurrence of germline mosaicism has to be taken into account in genetic counseling. Patients with CFEOM1 who have ptosis may benefit from an innovative surgical procedure called modified levator muscle complex suspension.

[Management of blepharophimosis, ptosis, epicanthus inversus syndrome at a referral center in Tunisia]

INTRODUCTION

Blepharophimosis ptosis epicanthus inversus syndrome (BPES) is a rare congenital hereditary abnormality. It includes complex orbital-palpebral malformations, causing aesthetic and functional ramifications. Management of BPES requires two steps : diagnosis and treatment.

PATIENTS AND METHODS

We performed a retrospective descriptive study of 44 patients (88 eyelids) with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). In our series, we opted for two-stage surgery in 28 cases : epicanthus-telecanthus surgery followed by ptosis surgery. Simultaneous surgery was performed in 5 cases.

RESULTS

The mean age at the first visit was 6 years (6.1±6.4). The mean age of our patients at the time of the first surgery was 6.6 years. Epicanthus surgery was performed in 35 cases. The two techniques used to correct epicanthus were Y-V plasty in 30 cases (85.7%, n=35) and Y-V+double Z plasty in 5 cases (14.3%, n=35). Correction of the telecanthus was performed at the same time by a medial canthal tendon plication in 31 cases (88.6%, n=35) or transnasal canthopexy in 4 cases (11.4%, n=35). The mean age at the time of ptosis surgery was 7.23 years (±6.25), ranging from 8 months to 27 years. Ptosis surgery was performed in 41 cases (79 eyelids), of which 3 patients underwent unilateral ptosis surgery due to asymmetrical ptosis. The techniques used were levator resection in 64 eyelids and frontal suspension in 15 eyelids.

CONCLUSION

BPES is often clinically diagnosed. The difficulty in management lies in the complex surgery required. There is no established consensus regarding surgical techniques or the timing of the surgeries.

A New Surgical Technique Used for Correction of Congenital Blepharoptosis

BACKGROUND

Blepharoptosis is defined as the drooping or lower displacement of the upper eyelids. Various kinds of surgical techniques and modifications have been introduced to improve the surgical outcomes, but the high recurrence rate and unsatisfying cosmetic results remain as a common problem.

PURPOSE

To solve the problem mentioned above, we came up with our new surgical technique and conducted a retrospective review to verify its effectiveness.

PATIENTS AND METHODS

A retrospective review was conducted among the patients diagnosed as genuine congenital blepharoptosis and receiving the surgical treatments where our unique technique was used between January 2016 and January 2019. The clinical records and preoperative and postoperative photographs were collected and evaluated.

RESULTS

A total of 83 patients were included in our study, 78 (94%) of them acquired good surgical outcomes, while 4 (4.8%) of them got fair results, and 1 (1.2%) of them got a poor result. No long-term lagophthalmos, ectropion, entropion and fornix conjunctival prolapse were noted.

CONCLUSIONS

Our surgical technique introduced here is effective in the management of genuine congenital blepharoptosis.

LEVEL OF EVIDENCE III

For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The use of Whitnall's ligament for sling redirection in frontalis suspension ptosis surgery

PURPOSE

To evaluate the cosmetic and functional outcome of a modified frontalis suspension technique when the sling force vector is redirected through Whitnall's ligament.

METHODS

Non-comparative retrospective study. Twenty-nine eyes of 23 patients with poor levator function of 4 mm or less. Patients underwent frontalis suspension with polytetrafluoroethylene (Gore-Tex) (PTFE). The sling was inserted in a single circular fashion through 3 brow incisions. An additional eyelid crease incision was created to allow the passage of the sling beneath Whitnalls' ligament, to permit securing the sling to the tarsus, to perform a limited blepharoplasty, and to reform the eyelid crease. Postoperatively, patients were followed up for at least 24 months.

RESULTS

All cases achieved elevation of the ptotic eyelid in the primary position. Three eyes of 2 patients had under correction in the primary gaze. Twenty-eight of 29 eyes retained the same level of eyelid elevation after 2 years of follow up. Symmetry in the primary gaze was achieved in 4 of 6 (67%) patients with bilateral ptosis and in 12 of 17 (71%) patients with unilateral ptosis. One patient had sling infection with granuloma formation. Lagophthalmos was common, but none developed exposure keratitis.

CONCLUSIONS

Frontalis suspention technique modified with redirecting the sling pulling force vector by passing beneath Whitnall's ligament can achieve a natural-looking eyelid in primary gaze and does not interfere with functional outcome.

Early frontalis flap surgery as first option to correct congenital ptosis with poor levator function

In congenital blepharoptosis the upper eyelid cannot be lifted normally because of congenital impairment in the levator function. The descended eyelid margin partially or completely obstructs of the visual axis with the consequent risk of amblyopia. Frontalis suspension is the surgery of choice for ptosis with poor levator function creating a linkage between the frontalis muscle and the tarsus; the frontalis muscle is used to elevate the eyelid. Direct transplantation of frontalis muscle to the upper eyelid has been widely described. We report our experience using frontalis flap in congenital ptosis with poor levator function in children.

METHODS

Retrospective study of 30 eyes with severe congenital ptosis and poor levator function treated by means of direct frontalis flap. Mean age 2 years. Eyelid measurements were taken at baseline, 1, 3, 12 months postoperatively and last visit. Mean ptosis degree was 5 mm (3-8 mm) and levator function 2 mm (1-5 mm). The presence of complications, flap function and palpebral contour were evaluated. Mean follow up time was 27 months. At last visit, ptosis degree ranged from 0 to 3 mm.

DISCUSSION

Direct advancement of the frontalis muscle to treat severe eyelid ptosis is effective and stable in the long term avoiding the use of a linking structure, therefore the risk of foreign-body reaction, absorption, granuloma and late exposure, as well as the need for a second visible incision in the forehead. Patients learn how to control the lid height by means of the frontalis muscle achieving more symmetry.

Direct frontalis flap with and without levator pulley for correction of severe ptosis with poor levator function in the same patient

PURPOSE

To compare two techniques of frontalis muscle flap suspension in different eyelids of the same patient for correction of severe ptosis with minimal levator function.

MATERIAL AND METHODS

A prospective study of four patients with severe bilateral ptosis and poor levator function, who underwent direct frontalis muscle flap on the right eyelid and frontalis muscle flap with levator pulley on the left eyelid was conducted. Eyelid studies measurements were taken at baseline, 2 months, one year and 5 years after surgery. The presence of complications, flap function and palpebral contour were evaluated.

RESULTS

Despite the surgical technique performed, good results in terms of functionality, contour and aesthetics were observed. In the eyes that underwent frontalis muscle flap (FMF)-direct, there were 2 cases with moderate anteriorization of eyelid margin in extreme upgaze and all patients showed eyelash ptosis that persisted one year after surgery, but improved after 5 years. In the eyes that underwent FMF-pulley, no upgaze anteriorization of eyelid margin was observed and three patients had eyelash ptosis of lesser extent than the fellow eye, improving after 1 year follow-up. FMF-pulley showed more long-term stability in eyelid height, compared with FMF-direct.

CONCLUSIONS

Frontalis muscle flap with a pulley in the levator aponeurosis prevents some complications caused by the excessive vertical component of the direct frontalis muscle flap, especially in deep-set eye patients, with better stability of the eyelid height and contour over time.

An alternative frontalis suspension technique: triband suspension--a modified Garcia's procedure

Blepharoptosis surgery is one of the most common oculoplastic procedures, and the aim is to clear the visual axis. Many surgical techniques for the correction of ptosis have been described and performed, but the operative approach is based on the extent of eyelid excursion, the amount of levator function, and the degree of ptosis.In this study, the frontalis sling procedure with triband suspension was performed on 32 eyelids of 23 patients. All the patients had visual loss because of blepharoptosis with only 0 to 3 mm of measurable levator function. Postoperatively, the palpebral fissure was increased in all the patients. The purpose of this study was to report the use of a modified frontalis sling procedure for congenital ptosis patients with minimal to no levator function. In conclusion, this modified frontalis sling technique if used maximizes the frontalis muscle, creating sufficient eyelid elevation, with stable effect over time.

Frontalis suspension using expanded polytetrafluoroethylene: results of different surgical designs

BACKGROUND/PURPOSE

Several surgical designs and materials have been proposed for frontalis suspension for treating congenital ptosis and ptosis with poor levator muscle function. This study evaluated the surgical results of frontalis suspension using expanded polytetrafluoroethylene (ePTFE) with two different surgical designs (open-type and closed-type).

METHODS

We reviewed the medical records of 96 patients (68 children and 28 adults) who underwent frontalis suspension surgery using ePTFE. Postoperative eyelid position, ptosis recurrence, and complications were recorded.

RESULTS

Twenty-eight out of 68 children and all 28 adults underwent closed-type frontalis suspension surgery, and 40 children underwent open-type surgery. The recurrence rate was 20% (8 of 40 eyelids) for children with closed-type surgery, and 2% (1 of 50 eyelids) for those with open-type surgery. There was a statistically significant difference in the recurrence rate between the two surgical methods in children (p = 0.011). The recurrence rate was 5% (2 of 40 eyelids) in adults who underwent the closed-type method. The recurrence rate after closed-type surgery was significantly different between the child and adult groups (p = 0.04).

CONCLUSION

Open-type frontalis suspension surgery using ePTFE is preferable to closed-type surgery for children with upper eyelid ptosis. Closed-type surgery provides more favorable results in adults than in children.

Multistage correction of blepharophimosis: our rationale for 18 cases

BACKGROUND

Due to the complexity of staging order and the number of surgical procedures required to correct blepharophimosis-ptosis-epicanthus inversus (BPES), this study aimed to analyze multistage correction of BPES syndrome objectively.

METHODS

This retrospective study was undertaken with 18 BPES patients who underwent multistage correction from April 2004 to September 2007. Data regarding levator function, horizontal palpebral fissure length (HPFL), vertical interpalpebral fissure height (IPFH), inner intercanthal distance (IICD), and the ratio of IICD to HPFL were recorded and analyzed. Facial photographs were taken both pre- and postoperatively. Any complications were documented.

RESULTS

The Mustardé method was used for 13 patients, and the Y-to-V technique was selected for 5 patients. In addition, seven patients also received lateral canthoplasty. All the patients underwent frontalis aponeurosis suspension. Changes in both IICD and HPFL were statistically significant (P < 0.001). The IPFH also showed statistically significant improvement after surgery. The range in the preoperative ratio of IICD to HPFL was 1.48-2.35 (mean, 2.04 +/- 0.28). Postoperatively, the ratios for all the patients were less than 1.8 (range, 1.1-1.5; mean, 1.28 +/- 0.13). Changes in the ratio of IICD to HPFL were statistically significant (P < 0.001). Mild undercorrection was observed in two patients postoperatively. Although neither keratitis nor overcorrection occurred, conjunctiva prolapse was experienced by one patient 10 days after frontalis aponeurosis suspension.

CONCLUSION

Staged surgery for correction of BPES syndrome is beneficial in terms of improved function and cosmesis.