A modified technique for levator resection in congenital ptosis

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.

Efficacy and Complications of External and Internal Pediatric Blepharoptosis Repair Techniques: A Systematic Review

PURPOSE

To review and evaluate the efficacy and complication rates of external and internal blepharoptosis repair techniques in pediatric patients.

METHODS

The systematic review protocol was published on PROSPERO (CRD42020197343). Embase, MEDLINE, CENTRAL, and ClinicalTrials.gov were searched without date limitations. Two independent reviewers evaluated the articles for inclusion. Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I tool, respectively.

RESULTS

Of 2,228 articles screened, 23 studies involving 730 patients were included. There were 20 case series and 3 retrospective cohort studies, but no randomized controlled studies. Overall study quality was low with serious risk of bias according to the GRADE and ROBINS-I criteria, respectively. External levator resection was the most studied procedure, evaluated in 18 studies. Seven studies investigated internal approaches including the Fasanella-Servat procedure. There was no standardized evaluation of surgical efficacy. Reoperation rates were 16.6% (range 3.6-50.9%) for external levator resection compared with 22.2% (range 0.0-25.8%) for internal approaches. The commonest postoperative complications were not sight-threatening. The most consistently reported complication was undercorrection, occurring at rates of 8.4% (range 2.4-16.7%) and 15.3% (range 2.7-75.0%) for external levator resection and internal approaches, respectively. There were no consistently applied, validated patient-reported outcomes or cosmetic outcomes.

CONCLUSIONS

External and internal approaches have been successfully employed in pediatric blepharoptosis repair. However, noncomparative designs and risk-of-bias limit existing studies. Thus, prospectively designed studies with standardized outcome measures are required to minimize reporting bias, facilitate evidence synthesis, and support clinical decision making.

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.

Aponeurosis of the levator palpebrae superioris in Chinese subjects: A live gross anatomy and cadaveric histological study

An accurate understanding of the anatomy of the levator palpebrae superioris aponeurosis (LPSA) is critical for successful blepharoplasty of aponeurotic ptosis. We investigated the macroscopic and microscopic anatomy of the LPSA.This prospective live gross anatomy study enrolled 200 adult Chinese patients with bilateral mild ptosis undergoing elective blepharoplasty. Full-thick eyelid tissues and sagittal sections from the eyelid skin to the conjunctiva were examined with Masson trichrome staining or antismooth muscle actin (SMA) immunohistochemistry.Gross anatomy showed that the space between the superficial and deep layers of the LPSA could be accessed after incising the overlying superficial fascia, by retracting the white line. Adipose layers were clearly observed in 195 out of 200 patients with bilateral mild ptosis, among which 180 cases had the superficial layer connected to the uncoated adipose. Fifteen cases had the superficial layer connected to the smoothly coated layer, and 5 cases had the superficial layer directly connected to the deep loose fiber, almost without adipose. In previously untreated patients, the LPSA space was located beneath the intact orbital septum. In those with previous surgeries, it was beneath the superficial layer of the LPSA, underlying the destructed orbital septum. Cadaveric histology showed that the deep layer of the LPSA extended into the anterior layer of the tarsal plate and the superficial layer reflexed upward in continuity with the vertical orbital septum. An occult space existed between the 2 layers of the LPSA, with a smooth lining on the deep layer. The superficial layer of the LPSA was SMA-immunonegative but the deep layer was slightly immunopositive for SMA. An occult anatomic space exists between the superficial and deep layers of the LPSA, in proximity to the superior tarsal plate margin. Recognition of the more anatomically significant LPSA deep layer may help improve the aesthetic outcome of blepharoplasty.

Improvement of the Marginal Reflex Distance-1 in Blepharoptosis Surgeries

The aim of this study was to predict the improvement of the marginal reflex distance (MRD1) in each blepharoptosis surgery.In PubMed and Scopus, the search terms 1. (blepharoptosis) AND 2. (surgery) AND 3. (levator OR outcome OR MRD OR function OR ptosis amount) were used and 1268 titles were found. Among them 28 papers were analyzed: Aponeurotic surgery (A-group, 8), Muller muscle resection (M-group, 10), Levator resection (L-group, 4), and Frontalis suspension (F-group, 6).The preop-MRD1 was greatest in L-group (1.7 ± 1.0 mm) followed by the A-group (1.3 ± 0.5 mm) and the M-group (1.3 ± 0.5 mm). The F-group had the lowest (-0.4 ± 0.7 mm). Age was oldest in the M-group (58.6 ± 11.9 years) followed by the A-group (42.4 ± 18.9 years) and the F-group (27.2 ± 17.9 years). The L-group was the youngest (18.9 ± 11.5 years). The mean improved amount of MRD1 (ΔL) was 2.15 ± 0.90 mm. The ΔL was different among the four operative methods. The F-group was greatest (2.4 ± 1.5 mm) followed by the A-group (2.3 ± 0.5 mm) and the M-group (2.0 ± 0.6 mm). The L-group had the least improved amount of MRD1 (1.8 ± 0.8 mm). There were significant differences between the groups (P < 0.05), except between the F-group and the A-group (P = 0.284). The mean follow-up period was 8.1 ± 7.0 months. In the 3 groups except A-group, the ΔL decreased in follow-up periods, with different degree of decrement. Only in A-group, ΔL increased slightly in follow-up periods. We think this is due to relatively well preserved levator function and short follow-up period (5.4 ± 3.3 months) of A-group patients.The results of this review can be used in choosing blepharoptosis correction methods.

Surgical anatomy of the superior orbit on ultra-high-resolution MRI at 9.4 Tesla

BACKGROUND

A good understanding of the anatomical details is required to ensure optimal results during surgery of the orbit. Several indications for orbital surgery require biopsy, resection, or reconstructive procedures. The intricate relationships between the orbital septum and adjacent structures of the upper orbit can cause difficulties in interpreting the surgical anatomy of this region. The purpose of this study was to acquire further insight into the anatomy of the superior part of the orbit, with special attention paid to the orbital septum.

METHODS

An ex-vivo study was performed using magnetic resonance imaging (MRI) at 9.4 Tesla (isotropic resolution = 20 μm) on six human cadaver specimens to examine the superior-medial half of the orbit. To visualise the posterior layers of the upper orbit, a dissection of three of the orbits was performed prior to the MRI examination, and a flexible PVC sheet was introduced above the levator muscle.

RESULTS

The technique enabled a visualisation of anatomically important landmarks of the anterior and posterior parts of the upper orbit at a resolution near histological levels; to the authors' knowledge, this visualisation has not been reported previously. A posterior continuation of the orbital septum, which forms a distinct anatomical structure, is revealed.

CONCLUSIONS

The posterior aspect of the orbital septum separates the levator muscle and the orbital fat pad. Between these two structures, a surgical corridor is formed using MRI, enabling alternative access to the superior part of the orbit; this alternative access might be less invasive because the orbital septum remains undamaged.

Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair

PURPOSE

We describe a minimally invasive technique and report our experience of posterior approach levator plication ('levatorpexy') for congenital ptosis.

STUDY DESIGN

Retrospective review.

PARTICIPANTS

Consecutive series of 16 patients.

MATERIALS AND METHODS

Posterior approach levatorpexy was performed for congenital ptosis under general anaesthesia. This surgical procedure involves exposing the posterior surface of the levator muscle through a transconjunctival approach. The levator muscle is advanced and plicated using a suture passed through its posterior surface, partial-thickness, to tarsal plate and tied on the skin. No tissue (conjunctiva, Muller's muscle, levator) are excised during this procedure.

MAIN OUTCOME MEASURES

Data collected included margin reflex distance (MRD1), symmetry of eyelid height, contour and complications. Surgery was considered successful if the following three criteria were simultaneously met: A postoperative MRD1 of ≥2 mm and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour.

RESULTS

Mean age was 9.1 years (range 3-26 years). Mean postoperative follow-up was 8.1 months (4-24 months). Preoperative phenylephrine test was positive in 81% of patients. Mean levator function was 11 mm (5-15 mm). Mean preoperative MRD1 was 1.5 mm and the mean postoperative MRD1 was 2.6 mm. Fourteen patients (87%) achieved the desired eyelid height and fulfilled our criteria set for success.

CONCLUSIONS

Posterior approach levatorpexy appears to be a safe and effective procedure for correction of congenital ptosis particularly with moderate or better levator function.