先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

Advances in the diagnosis and treatment of ptosis

PURPOSE OF REVIEW: The surgical correction of blepharoptosis, both congenital and acquired, has been intensively examined and reported on for many years. This paper reviews recent publications on basic science, evaluation, technique modifications, and innovative materials in the care of ptosis patients. RECENT FINDINGS: The frontalis suspension technique is a commonly performed surgical correction of congenital blepharoptosis, used widely in the repair of ptosis with poor levator function. The repair typically includes using either tissue such as autologous or banked fascia lata or permanent suture material. The procedure involves connecting the motor unit (frontalis muscle) and the upper eyelid. Authors have recently reintroduced the technique of a dynamic frontalis muscle flap tunneled into the eyelid that directly attaches to the tarsal plate.Patients presenting with symptomatic blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. Multiple groups have tended toward a minimally invasive approach directed specifically at the levator aponeurotic defect. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results. SUMMARY: Surgical correction of congenital blepharoptosis may be performed with autologous fascia lata, cadaveric allograft, or permanent suture material. The use of a frontalis muscle advancement flap is elegantly designed; however, its role in clinical practice remains to be defined. Advancement of the levator aponeurosis for senile blepharoptosis may be preformed via a minimally invasive small incision approach. Patients benefit with decreased operative time, edema, ecchymosis, and recovery times.     

重度先天性上睑下垂的手术治疗

目的分析额肌筋膜瓣悬吊术和异体阔筋膜悬吊术矫正重度先天性上睑下垂的优缺点。方法对重度先天性上睑下垂66例87眼进行手术治疗,其中额肌筋膜瓣悬吊术30例45眼,异体阔筋膜悬吊术36例42眼,分析术后上睑下垂矫正效果、上睑弧度、双重睑成形及暴露性角膜炎发生情况。结果额肌筋膜瓣悬吊术取材方便、复发率较低、上睑弧度匀称;阔筋膜悬吊手术简单、重睑形成良好,但取材困难、复发率稍较高。结论额肌筋膜瓣悬吊术和阔筋膜悬吊术均能有效治疗重度先天性上睑下垂,前者无需特殊材料,术后效果较稳定。     

Blepharoptosis repair by fascia lata suspension with direct tarsal and frontalis fixation

Nine patients with blepharoptosis and no levator palpebrae superioris muscle function were treated by fixating irradiated fascia lata to the tarsus and frontalis muscles under direct visualization. No recurrences were noted on follow-up, which ranged from four to 24 months. There were no postoperative infections or granuloma reactions. Cosmetically, the height, contour, and symmetry of the eyelid margin and eyelid crease were predictable and satisfactory. This modified method of frontalis suspension may provide a more predictable and cosmetically pleasing result in the treatment of blepharoptosis when minimal or no levator muscle function is present.     

Broad fascia fixation enhances frontalis suspension

PURPOSE: To report the use of a modified frontalis suspension procedure for congenital ptosis patients with minimal to no levator function. METHODS: Retrospective, non-comparative case series of frontalis suspension by 2 surgeons over a 21-year period. RESULTS: Frontalis suspension with broad fascia fixation was performed on 48 eyelids of 25 patients. All patients had visual obscuration due to blepharoptosis with only 0 mm to 2 mm of measurable levator function. Age ranged from 3 to 13 years. Minimum length of follow-up was 6 months (range, 6-174 months). The palpebral fissure was increased in all patients, improving their head position and unmasking their visual axis in primary gaze. Postoperatively, all patients developed transient exposure symptoms. There were no migrations, extrusions, infections, or granulomas. All patients achieved a satisfactory postoperative result based on eyelid position, function, and contour. CONCLUSIONS: This modified frontalis suspension procedure maximizes frontalis muscle recruitment, creating powerful eyelid elevation with stable effect over time. The technique minimizes other procedures' pitfalls and advances in cosmesis are achieved with enhanced eyelid crease formation and adjustable eyelid contour.     

额肌筋膜瓣悬吊术矫正完全性上睑下垂

目的：重庆探讨及证明对于完全性的上睑下垂治疗,额肌筋膜瓣悬吊术的可行性和可靠性。方法：对我院眼科1997年3月－1999年4月住院的41例,完全性上睑下垂患者,施行额肌筋膜瓣悬吊术,随访约2年,对全部患者进行观察及分析。结果：额肌筋膜瓣悬吊术对于治疗完全性的上睑下垂,可作为上睑下垂矫正术众多选择方法之一。结论：额肌筋膜瓣悬吊术治疗完全性上睑下垂,效果肯定,并有其独特的优势,特别对需要特殊材料支持的手术,尤其如此。     

Transconjunctival frontalis suspension: a clinical evaluation.

PURPOSE: To determine the effectiveness of transconjunctival frontalis suspension in patients with blepharoptosis and poor levator function (eyelid excursion less then 5 mm). METHODS: The medical records of 29 patients (50 ptotic eyelids) were reviewed. RESULTS: Four patients (eight eyelids) had blepharophimosis syndrome, ten patients (27 eyelids) had congenital ptosis, seven patients (14 eyelids) had myogenic ptosis, and one patient (one eyelid) had neurogenic ptosis. Surgical results were good and complications were minimal during follow-up intervals ranging from six months to seven years. CONCLUSIONS: Transconjunctival frontalis suspension is technically simpler than traditional external frontalis suspension and yields satisfactory functional and cosmetic results in patients with poor levator function.     

额肌悬吊术治疗重度先天性上睑下垂的效果分析

目的 探讨在额肌筋膜瓣悬吊术中,行否睑轮匝肌桥瓣对手术效果的影响.方法 分析2003～2006年接受手术治疗的重度先天性上睑下垂患者,随机分为A组(术中做睑轮匝肌桥瓣)与B组(术中未做睑轮匝肌桥瓣),比较两组术后远期效果.结果 术后6个月比较,A组矫正满意42只眼,矫正良好7只眼,矫正不良2只眼;B组矫正满意51只眼,矫正良好6只眼,矫正不良0只眼,经Ridit检验两组差异有统计学意义(P＜0.01).结论 在额肌筋膜瓣悬吊术中,睑轮匝肌桥瓣对手术效果并无至关重要的作用,相反因其术后较多的产生局部粘连,可能使额肌筋膜瓣的活动性受到一定程度的限制.因此,不主张在该手术中采用睑轮匝肌桥瓣的做法.     

One medial triangular Tutoplast sling as a frontalis suspension for adult myogenic blepharoptosis

PURPOSE: The treatment of choice for medium to severe blepharoptosis with minimal or no levator function is frontalis suspension with a sling, using a rectangular or rhomboid sling placement technique. We describe the short-term, follow-up results of frontalis suspension surgery for adult myogenic blepharoptosis using Tutoplast, a commercially available fascia lata allograft. METHODS: We conducted a consecutive, interventional case study. All adult (>25 years of age) patients operated for non-traumatic myogenic ptosis during a 1-year period were included. All underwent frontalis suspension using one medial triangular Tutoplast sling. Success was judged according to lid position and complications. RESULTS: Successful surgical results were judged by lid level, lid symmetry and lid contour. During a mean follow-up of 9 months, the success rate was 91% in all three criteria and 100% in at least two out of three. No major complications were observed. The most prevalent minor complication was the need for lubrication treatment in 26% of the operated patients. CONCLUSION: The use of Tutoplast for frontalis suspension in cases of adult myogenic ptosis is safe and has a high success rate in the early postoperative period. Further large-scale studies are necessary to ascertain the longterm results and the applicability of this material to other indications.     

Maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function

From 1994 to 1999, 1121 operations for blepharoptosis were performed in our department on 987 patients. In 44 cases we found a moderate to severe congenital ptosis with a levator function of less than 2 mm. Until today, in such cases, it is recommended to use a frontalis suspension in order to elevate the upper eyelid. Unsatisfactory cosmetic results in facial expression and lack of skin-fold are only a few of the disadvantages of this technique. In 1994, therefore, we decided to perform a maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function. All children included in our study were younger than six years of age. The ptosis was moderate (2-4 mm) in 36/44 and severe (>4 mm) in 8/44 cases. The levator function was less than 2 mm. Complete transsection of the medial and lateral horn of the levator aponeurosis under preservation of the Whitnall ligament is the most important surgical step in mobilizing the levator muscle. A satisfactory eyelid elevation (generally considered to be a difference of less than 1 mm between both eyelid fissures) was achieved in 36/44 cases. Our results indicate that, in contrast to established practice, maximal levator resection is the treatment of choice for congenital ptosis with poor levator function.     

Suspending of blepharoptosis on temporalis fascia slings: our own experience

There are many procedures providing treatment of ptosis. In cases with palpebrae levator palsy, procedures involving mechanical suspension of palpebrae are used. Artificial and natural materials are used to suspend the lid. We describe surgical treatment of blepharoptosis using autogenous temporalis fascia sling. The sling is attached to the tarsus and spreads to the frontalis muscle. We have used this procedure in 12 cases. Full effect of functional elevation of palpebrae was achieved in 14 to 30 days after procedure. We did not encounter any significant complications due to this material. These operative modifications make this procedure more closely parallel to the normal eyelid dynamics and provide consistently good results for this difficult problem.     

Suspension of the eyelid to the frontal muscle in the surgery of ptosis. Technic and indications

Twenty seven frontalis sling procedures were performed with use of autogenous fascia-lata. The choice of this procedure was performed sometimes at the first stage for severe ptosis with poor levator function: isolated congenital ptosis, blepharophimosis syndrome, Marcus Gunn Jaw-Winking ptosis, ptosis with severe myopathy, some traumatic ptosis. This procedure was also performed in a second stage after failure of the useful procedures (levator resection) and after verification that the levator was not exploitable. Sometimes the choice of the procedure is done during the exploration of the eyelid and the levator because there is not always "parallelism" between the levator function and his anatomy. So operative technique must always be performed by a complete anterior palpebral approach, the surgeon can passed the suspensory material from the tarsus to the roof of the orbit, just anterior to the levator aponeurosis, and then out above the eyebrow. The pulley this created by the periosteum of the superior orbital margin prevents vertical traction lines. The skin crease is created with sutures which pick up the tarsus and the lid retractors. If, during the explorations the levator is "exploitable", a super maximum levator resection will be performed at the first stage, the frontalis suspension will be maintained in case of failure of the levator resection.     

Ultrasound biomicroscopy of the levator aponeurosis in congenital and aponeurotic blepharoptosis

PURPOSE: To evaluate and measure the thickness of the levator aponeurosis by ultrasound biomicroscopy in congenital dysmyogenic and aponeurotic blepharoptosis. METHODS: Forty-four upper eyelids of 22 patients who had unilateral blepharoptosis were evaluated by ultrasound biomicroscopy. The patients ranged in age from 13 to 69 years (mean, 35.4 +/- 20.2 years). Fourteen patients were male and 8 patients were female. Seven patients had congenital dysmyogenic blepharoptosis and 15 patients had aponeurotic blepharoptosis. Imaging was performed with a 50-MHz transducer. The thickness of the levator aponeurosis was measured centrally at the upper border of the tarsus. RESULTS: The levator aponeurosis was imaged in all eyelids except for one eyelid with aponeurotic blepharoptosis. The mean thickness of the levator aponeurosis was 0.39 +/- 0.10 mm in the ptotic eyelid and 0.42 +/- 0.09 mm in the control eyelid of the patients with congenital dysmyogenic blepharoptosis (p = 0.043). The mean thickness of the levator aponeurosis was 0.26 +/- 0.05 mm in the ptotic eyelid and 0.36 +/- 0.04 mm in the control eyelid of the patients with aponeurotic blepharoptosis (p = 0.001). The thickness of the levator aponeurosis was correlated with the palpebral fissure height (p = 0.013, r = 0.644) in aponeurotic blepharoptosis. The thickness of the levator aponeurosis was correlated with the levator function (p = 0.033, r = 0.795) in congenital dysmyogenic blepharoptosis. CONCLUSIONS: The thickness of the levator aponeurosis can be measured with ultrasound biomicroscopy. The most common pathology in aponeurotic blepharoptosis is thinned-out aponeurosis. The levator aponeurosis of the ptotic eyelid is thinner than the normal eyelid in congenital ptosis.     

Ptosis secondary to anterior segment surgery and its repair in a two-year follow-up study

OBJECTIVE: Aponeurotic blepharoptosis is a postoperative complication of anterior segment surgery with a reported incidence of 1-2% and a variable aetiology. In this 2-year follow-up study, we investigated the incidence of this postoperative complication in our experience of anterior segment surgery and propose a modified technique of aponeurosis advancement for its repair. METHODS: 200 consecutive patients undergoing anterior segment surgery in our eye clinic were enrolled in the study. Patients who developed any other operative or postoperative complication were excluded from the study. In all patients, the following upper lid parameters were calculated to determine whether postoperative blepharoptosis had occurred: margin-reflex distance, upper eyelid crease, use of frontalis muscle and levator function. A questionnaire was submitted to all blepharoptosis patients investigating mainly their subjective judgement of the impact of blepharoptosis on their quality of life and if they had been informed accurately about the incidence of this postoperative complication. RESULTS: 163 patients were included in our study. 11 had postoperative blepharoptosis (6.7%). 9 patients wanted ptosis repair and were operated on with our modified technique. None of the 11 ptosis patients had been informed about the possible occurrence of the blepharoptosis as postoperative complication. Our modified technique shows good, long-lasting results. CONCLUSIONS: Postoperative blepharoptosis is a well-known postoperative complication of anterior segment surgery. It can be successfully treated surgically by aponeurosis advancement. It is our opinion that all patients should be informed of the possibility of postoperative blepharoptosis when consenting for anterior segment surgery.     

改良提上睑肌缩短术矫正上睑下垂

目的:探讨改良提上睑肌缩短术矫正上睑下垂的效果。方法:保留提上睑肌腱膜与上睑的连接方式不变,采用提上睑肌腱膜复合瓣与缩短的提上睑肌腱膜吻合术矫正19例20眼上睑下垂。结果:术后4～10mo随访,治愈18例19眼,欠矫1例1眼,无过矫病例。结论:改良提上睑肌缩短术与常规手术比较有改进,术后的睑缘高度易保持在上方角膜缘,弧度与健侧对称自然,不易形成眼角畸形,能较好提高矫治效果。     

三种术式治疗重度先天性上睑下垂的疗效对比

目的:探讨提上睑肌缩短术、额肌瓣悬吊术、阔筋膜悬吊术治疗重度先天性上睑下垂的效果。方法:手术治疗重度先天性上睑下垂患者42例47眼,其中提上睑肌缩短术25例28眼、额肌瓣悬吊术10例12眼、阔筋膜悬吊术7例7眼,比较手术效果,上睑弧度、双重睑成形情况及手术并发症情况。结果:采用提上睑肌缩短术者,术后外观自然美观,兔眼恢复时间短,效果满意;采用额肌瓣悬吊术者术后外形欠自然、兔眼恢复时间长;采用阔筋膜悬吊术者,上睑迟滞和眼睑闭合不全较明显,易发生矫正不足。结论:三种手术方式均能有效治疗先天性上睑下垂。提上睑肌缩短术更符合生理状态,手术效果最好且并发症少。     

Analysis of treatment results 389 patients with congenital blepharoptosis

PURPOSE: Retrospective analysis of the results in the treatment of congenital blepharoptosis. MATERIAL AND METHODS: We retrospectively reviewed the records of 389 patients with blepharoptosis who underwent surgical treatment in the Hospital of Plastic Surgery in Polanica-Zdrój, from January 1976 to January 2005. The age of patients, degree of malformation and unilateral or bilateral occurrence of ptosis, was analyzed. Moreover, we studied treatment results of patients with blepharoptosis treated in our hospital and patients treated elsewhere, before admission to our hospital. RESULTS: 218 patients from 327 operated in our hospital had levator muscle resections. After 6 months of observation 39 patients were qualified for surgical re-correction. 12 months after surgery 4 patients had recurrence of ptosis. Frontalis suspension technique with using the temporal fascia, was performed in 109 patients. After 6 months observation, 8 patients were qualified for surgical re-correction. CONCLUSIONS: For patients with maintained function of the levator muscle the most effective and physiological procedure, is the muscle shortening. Frontalis suspension technique with use of the temporal fascia should be limited to treat failure cases and patients with poor or absent function of the levator muscle.     

Use of the levator muscle as a frontalis sling

PURPOSE: To investigate the use of the distal portion of levator aponeurosis as a flap for frontalis suspension in patients with severe congenital ptosis and poor levator function. METHODS: Eleven procedures were performed on 8 patients with severe congenital ptosis and poor levator muscle function. Three of the 8 patients had Marcus-Gunn jaw-winking phenomenon. Preoperative evaluation included measurements of the degree of ptosis, levator function, superior rectus action, Bell phenomenon, lagophthalmos, and (if present) synkinetic eyelid movement. Surgery involved fashioning a flap from the distal portion of the levator aponeurosis and anchoring it to the frontalis muscle. Postoperatively, patients were followed for at least 6 months to assess the level of the eyelid in the primary position at rest and when the brow is raised, the degree of eyelid margin excursion on brow elevation, persistence of synkinetic eye movement, presence of complications, lagophthalmos, corneal exposure, and symmetry. RESULTS: Synkinetic muscle movements were completely abolished. All cases had good primary eyelid position, no corneal complications, and effective frontalis action on eyelid elevation. CONCLUSIONS: The distal levator muscle flap is an effective frontalis suspension material to correct ptosis with poor levator function and to abolish synkinetic eyelid movement without compromising corneal protection.     

先天性上睑下垂患者提上睑肌腱膜的病理改变

背景先天性上睑下垂是临床常见的眼睑运动功能障碍性疾病,可导致患者视功能异常。国外研究表明,提上睑肌的发育异常与该病的发生明显相关,但中国人群该病患者提上睑肌的形态研究缺乏。目的对先天性上睑下垂患者提上睑肌腱膜组织进行组织病理学检查,探讨其发育异常的具体表现。方法先天性上睑下垂患者（年龄14～19岁,平均17岁）2l例,根据上睑下垂的程度分为轻度组（3例）、中度组（14例）和重度组（4例）,在提上睑肌缩短术过程中获取所有患眼截除的提上睑肌腱膜组织标本,分别进行苏木精一伊红染色、Masson三色染色、胶原纤维染色,对标本中的Ⅲ型胶原蛋白和肌球蛋白行免疫组织化学染色,患者标本的染色结果与取自北京同仁医院眼库的9例正常供体的新鲜提上睑肌腱膜组织进行对照。结果不同程度先天性上睑下垂患者随着下垂程度的增加,提上睑肌腱膜肌纤维数量减少,间质中结缔组织增加,肌内膜的完整性下降的例数均增加,各组间比较差异均有统计学意义（Z=-0．702,P=0．002;Z=0．738,P‘0．001;Z=0．746,P〈O．001）。4例（占19％）先天性上睑下垂患者标本中发现肌间质中有脂肪细胞增生。免疫组织化学染色发现,先天性上睑下垂患者组提上睑肌腱膜肌纤维中肌球蛋白的表达较正常对照组明显减弱,而Ⅲ型胶原蛋白的表达明显增强。先天性上睑下垂患者组标本中肌动蛋白、肌红蛋白、纤维连接蛋白、Ⅳ型胶原纤维及层黏连蛋白的表达强度与正常对照标本比较差异均无统计学意义（P〉O．05）。结论先天性上睑下垂患者提上睑肌腱膜组织肌纤维、结缔组织及其相关蛋白均有发育异常,其病理改变的程度与症状一致。