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.     

Unilateral frontalis sling for the surgical correction of unilateral poor-function ptosis

PURPOSE: To evaluate the functional and cosmetic results after frontalis sling repair for unilateral ptosis associated with either poor levator function or synkinesis. METHODS: Preoperative and postoperative photographs and records of 127 patients who underwent unilateral frontalis sling ptosis repair were retrospectively reviewed. An eyelid crease incision was used in all cases, with suturing of the sling material directly to tarsus. RESULTS: Preoperative diagnosis for all patients was either unilateral poor-function blepharoptosis or ptosis associated with levator synkinesis. Underlying causes included 75 congenital, 13 posttraumatic, 11 congenital "jaw-winking," 10 cranial nerve III palsies, 9 myasthenia gravis, 5 chronic progressive external ophthalmoplegia, and 4 congenital "double-elevator" palsies. There was a mean follow-up of 11.6 months. Twenty-eight eyelids required reoperation: 11 for undercorrection, 6 for overcorrection with keratopathy, 2 for upper eyelid crease revision, 7 for correction of poor contour, 1 for a broken sling, and 1 for removal of an infected exposed polytetraflouroethylene sling. Lagophthalmos of greater than 2 mm was noted in 18 patients, 5 of whom had persistent keratopathy requiring reoperation. No other complications were reported, except for 1 suture granuloma. Good to excellent final postoperative eyelid height was achieved in 121 patients (95%) after all surgeries and with conscious recruitment of the frontalis muscle. A large majority of patients and/or parents expressed satisfaction with the final cosmetic result and were not bothered by any asymmetric lagophthalmos in downgaze or lack of a synchronous blink. However, 19 of 25 amblyopic patients were less satisfied with passive eyelid height as they failed to recruit the ipsilateral frontalis muscle to activate the sling during binocular viewing. In 17 of these 19 patients, good to excellent eyelid height could be achieved with conscious active brow elevation. CONCLUSIONS: Unilateral sling provides good to excellent functional and cosmetic results in unilateral poor-function ptosis. However, patients with amblyopia usually require conscious effort to activate the frontalis muscle to achieve satisfactory eyelid height.     

Frontalis muscle flap advancement for correction of blepharoptosis

PURPOSE: To describe a technique of frontalis muscle flap advancement to repair myogenic ptosis in lieu of a graft or suture material. METHODS: Ten ptotic eyelids in eight patients were repaired using the frontalis flap technique. Patients were selected at random by two separate surgeons; all patients had eyelid excursion measured as poor (or less than 6 mm). RESULTS: Nine of 10 ptotic eyelids were adequately corrected by the frontalis flap technique, with follow-up intervals ranging from 18 to 42 months. Adequate correction was defined as ptosis corrected within 1 mm of the fellow eyelid. Complications of frontalis advancement were few and primarily transient. CONCLUSIONS: Frontalis flap advancement is a technically simple, safe, and effective technique for the repair of myogenic ptosis. The primary advantage of frontalis muscle flap advancement over a graft or suture material that it elevates the eyelid directly by moving the insertion of the frontalis muscle into the eyelid, rather than by graft or suture material.     

Frontalis muscle flap advancement for jaw-winking ptosis

PURPOSE: To describe the technique and results of frontalis muscle flap advancement for correction of ptosis associated with jaw-winking. METHODS: Four cases of unilateral jaw-winking ptosis were corrected with frontalis muscle flap advancement after excision of levator muscle on the affected side. RESULTS: Three of the 4 patients achieved good results with the correction within 1 mm of the opposite eyelid. The residual asymmetry on downgaze after follow-up of 4 to 18 months ranged from 1 to 5 mm. The main complication was mild forehead hypoesthesia in 2 patients, which resolved over a period of 1 month. CONCLUSIONS: Frontalis muscle flap advancement is an effective procedure when performed unilaterally for jaw-winking ptosis. It is simple, safe, and involves a single surgical field. Eyelid lag on downgaze improves considerably over time, and the remaining asymmetry between the two eyelids is cosmetically acceptable to most patients.     

Direct Tarsus to Frontalis Muscle Sling without Flap Creation for Correction of Blepharoptosis with Poor Levator Function

Purpose: To report the outcomes of ptosis surgery in patients with weak levator function utilizing the direct tarsus to frontalis muscle sling technique without creation of a flap.

Methods: In a prospective nonrandomized case series over a 3-year period, patients with ptosis and weak (less than 4?mm) levator function underwent direct sling of the tarsus to frontalis muscle without creating any flap. Success was defined as upper lid margin to central corneal reflex distance of at least 3?mm in bilateral cases and a difference of less than 1?mm in unilateral cases.

Results: Overall, 26 eyes of 22 patients with mean age of 15.4?±?9.4 years were operated and followed up for 13.5?±?8.4 months. The ptosis was congenital in 15 patients (68.2%) and acquired in 7 patients (31.8%). Twelve patients (54.5%) had a history of ptosis surgery. The procedure was judged as successful in 77.3% of patients after initial surgery and in 100% after reoperation. Surgical success after initial surgery was directly correlated with the amount of levator function (P?=?0.02). However, success was not associated with age (P?=?0.9) or history of surgery (P?=?0.9). None of the patients developed eyelid hematoma, lagophthalmus or dry eye.

Conclusions: Direct sling of the upper tarsus to the frontalis muscle without creation of flap is an effective procedure for correction of ptosis in patients with weak levator function. Minimal dissection and preservation of the orbicularis oculi prevents lagophthalmus and its consequences.     

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.     

改进的额肌瓣悬吊术矫正儿童先天性上睑下垂

目的评价改进的额肌筋膜瓣悬吊术治疗儿童先天性上睑下垂。方法对35例中重度先天性上睑下垂采用改进的额肌瓣悬吊术。术后观察3～6月。结果眼睑高度正常，上睑弧度自然，无并发症发生。结论改良型额肌瓣悬吊术适用于儿童先天性上睑下垂，其效果优于上睑提肌缩短术及传统额肌瓣悬吊术，能达到矫正畸形及改善外观的效果。     

Early Frontalis Flap Surgery as First Option to Correct Congenital Ptosis with Poor Levator Function

Abstract

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.     

Double-bridged flap procedure for nonmarginal, full-thickness, upper eyelid reconstruction

PURPOSE: To describe the technique and results of double-bridged flap reconstruction of full-thickness upper eyelid defects that spares the upper eyelid margin. METHODS: The surgical technique is described and illustrated in 2 patients who underwent this procedure. RESULTS: The 2 patients presented in this study achieved excellent functional and cosmetic results following the procedure. One patient subsequently underwent a frontalis sling procedure to correct residual ptosis. CONCLUSIONS: Double-bridged flap reconstruction of the upper eyelid that spares the eyelid margin can provide excellent functional and cosmetic results, particularly in cases of nonmarginal eyelid tumor excision, severe upper eyelid scarring, and severe cicatricial retraction.     

Management of ptosis in chronic progressive external ophthalmoplegia

Patients with chronic progressive external ophthalmoplegia (CPEO) are often disabled by ptosis; however, conventional ptosis surgery may induce lagophthalmos and exposure keratitis. Ten patients with CPEO underwent ptosis correction via bilateral frontalis suspensions, using monofilament synthetic material. Three of these patients were also treated with lower eyelid horizontal tightening. The frontalis sling was adjusted to provide a firm linkage between the eyebrow and eyelid, but was loose enough to allow eyelid closure when the frontalis muscle is relaxed. All patients experienced lessening of ptosis and relief from visual obstruction. One patient required reoperation of one eyelid for undercorrection. No lagophthalmos or corneal complications occurred. The rationale for treatment, preoperative evaluation, and operative procedure in CPEO is discussed herein.     

复发性先天性上睑下垂的发病原因和疗效分析

目的:分析先天性上睑下垂复发的原因,指导再次手术方式的选择。方法:术前了解前次手术方式,分析失败原因,根据提上睑肌肌力结合病史确定再次手术方式。以提上睑肌肌力为依据,考虑前次手术的手术方式,对于提上睑肌肌力≤4mm者均采用额肌瓣悬吊术,对于提上睑肌肌力≥6mm者,均选择提上睑肌缩短术,对于提上睑肌肌力4～6mm之间者,若前次手术是利用额肌的手术,可行提上睑肌缩短术或额肌瓣悬吊术,我们采用了额肌瓣悬吊术。结果:患者26例30眼术眼睑缘弧度无畸形,双重睑自然,上睑缘位于上方角膜缘下1～2mm,或与健眼基本对称。结论:复发性先天性上睑下垂再次手术要根据提上睑肌肌力结合病史确定再次手术方式。     

膨体聚四氟乙烯额肌悬吊术治疗儿童先天性上睑下垂的临床疗效和安全性评价

背景 先天性上睑下垂是一种易引起弱视的儿童眼病,及时进行手术并寻找理想的额肌悬吊材料具有非常重要的意义.目前国际上常采用膨体聚四氟乙烯(e-PTFE)材料作为额肌悬吊材料对低龄儿童的先天性上睑下垂进行治疗,取得了较好的效果,但中国尚缺乏相关的临床资料. 目的 应用e-PTFE材料进行额肌悬吊术治疗先天性上睑下垂儿童,观察其临床治疗效果及其安全性,评价其临床应用价值.方法 采用前瞻性系列病例观察性研究方法,收集2012年7月-2012年8月在北京儿童医院确诊的年龄为2.8 ～6岁的先天性上睑下垂患者36例45眼,所有患儿均行额肌悬吊术,术中采用e-PTFE为额肌悬吊材料.分别于术后1d、1周、1个月、3个月、6个月、1年、1.5年进行复查,观察指标包括上睑缘至角膜光反射点距离(MRD)、睑裂高度、额肌与睑板关联度、眼睑闭合情况以及上睑迟落情况、术后外观评分,记录术后复发率和相关并发症及其处理结果. 结果 术后1.5年患儿的MRD为(2.8±0.8) mm,明显高于术前的(1.8±1.2)mm,差异均有统计学意义(t=4.651,P=0.000);术后眼睑闭合度为(1.3±0.5) mm,与术前的(1.1±0.5) mm比较差异无统计学意义(t=1.897,P=0.061);术后额肌与睑板关联度为75％±20％;术后外观改善满意.本组患者中术后1例1眼欠矫,出现轻度角膜炎者1例1眼,角膜炎患儿系术后护理不当,经指导家长术后正确点用上皮生长因子联合玻璃酸钠滴眼液后痊愈;术后发现额部伤口肉芽肿1例1眼,局麻下将肉芽肿切除,局部注射地塞米松注射液0.2ml,1个月后无复发;眼睑内翻1例1眼,考虑与术中上睑位置过高有关,经观察于术后3个月上睑位置部分地回落,上睑内翻自愈;术后3个月16例20眼可在额部切口缝合部位局部触及皮下小硬结,至随访末自行消失.复发1例1眼,经二次手术治愈.结论 e-PTFE作为额肌悬吊材料对于先天性上睑下垂儿童性额肌悬吊术效果和安全性好,术后患儿上睑功能恢复较好,外观改善满意.     

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.     

Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis

The charts of 10 patients affected by myogenic ptosis who underwent surgical correction by means of a frontalis suspension sling using a silicone rod were reviewed. The patients included in the study were affected by ptosis secondary to myasthenia gravis (MG), chronic progressive external ophthalmoplegia (CPEO) or mitochondrial myopathy (MM). In every patient the ptosis was severe (MRD( 1) < 2 mm), with the eyelid partially or totally occluding the visual axis; levator function was poor (<5 mm), Bell's phenomenon was poor or absent and the orbicularis function was reduced. Final eyelid height, patient satisfaction and the presence of complications were our main outcome measures. Analysis of the results showed that the ptosis was corrected in every patient with a clear visual axis. One patient with absent Bell's and poor levator function had exposure keratopathy resistant to medical treatment and required surgical revision. We believe that the frontalis suspension sling is safe, effective and is the procedure of choice for patients affected by poor-function acquired ptosis. A silicone rod, because of its elasticity, is the material of choice in this selected category of patients.     

先天性上睑下垂经眶隔后隧道额肌瓣悬吊术

目的 观察经眶隔后隧道额肌瓣悬吊术治疗先天性上睑下垂的临床效果.方法 先天性上睑下垂170例,随机分为观察组和对照组,观察组采用经眶隔后隧道额肌瓣悬吊术治疗,对照组采用上睑提肌缩短徙前矫正术治疗.术后观察6个月,统计对比两组治疗效果及满意度.结果 观察组患者矫正满意度为92.05％,对照组者为71.95％,差异具有统计学意义（x2=13.29,P＜0.05）;观察组有效率为96.59％,对照组者为86.59％,差异具有统计学意义（x2=9.28,P＜0.05）.结论 经眶隔后隧道额肌瓣悬吊术治疗先天性上睑下垂效果明显.有较高的临床价值.     

Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material

PURPOSE: To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis. DESIGN: Retrospective, nonrandomized, comparative interventional case series. METHODS: Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated. RESULTS: MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure. CONCLUSION: Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.     

Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis

PURPOSE: To investigate the long-term outcome of using autogenous palmaris longus tendon (PLT) sling for correcting congenital ptosis in children. METHODS: This is an observational case series involving 15 eyelids of 14 consecutive children with congenital ptosis who underwent frontalis suspension surgery using PLT in a university teaching hospital. RESULTS: One child had bilateral ptosis and the other children had unilateral ptosis. The age of patients at the time of surgery ranged from 2 to 7 years, with an average of 4.7 years. At a mean follow-up of 92 months (range, 80-104 months), all eyelids were successfully corrected with good lid height. No recurrence or other postoperative complications were encountered except one patient who developed a small skin fold over the PLT harvest site.CONCLUSION: Long-term lid position is remarkably stable after surgical correction using PLT. PLT sling appears to be a safe and effective treatment for children with congenital ptosis requiring frontalis sling operation. It could be a good alternative to autogenous fascia lata, and further studies, to compare these two sling materials seem warranted.     

超常量提上睑肌缩短及额肌瓣悬吊治疗重度先天性上睑下垂效果比较

目的：比较提上睑肌缩短术与额肌瓣悬吊术治疗重度先天性上睑下垂的疗效与并发症。

方法：对40例58眼重度先天性上睑下垂患者进行手术治疗,其中,20例28眼行额肌腱膜瓣悬吊术,20例30眼行改良的提上睑肌缩短术,术后随访6mo,观察两种手术方式治疗重度先天性上睑下垂的治疗效果及术后并发症的发生情况。

结果：术后随访6mo,提上睑肌缩短术组及额肌瓣悬吊术组治疗重度先天性上睑下垂的正矫率分别为：83%、82%,差异无统计学意义(P>0.05),但术后并发症的发生,如倒睫、闭合不全、暴露性角膜炎、结膜脱垂等,提上睑肌缩短术组少于额肌瓣悬吊术组,且有更好的外观。提上睑肌缩短术后6mo复诊时,眼睑闭合不全15眼,暴露性角膜炎共1眼,结膜脱垂2眼; 额肌瓣悬吊术后6mo随诊,眼睑闭合不全23眼,暴露性角膜炎2眼,上睑倒睫3眼。

结论：提上睑肌缩短术及额肌瓣悬吊术均能有效矫正重度先天性上睑下垂,但前者并发症少,术后外观好。     

Tarsal switch procedure for the surgical rehabilitation of the eyelid and socket deficiencies of the anophthalmic socket.

PURPOSE: To describe a tarsal transfer procedure, which we have named the "tarsal switch," to correct the eyelid malpositions and camouflage the socket defects of acquired anophthalmos. METHODS: The technique consists of an upper eyelid tarsectomy, with transfer of the autologous tarsoconjunctival graft to the posterior lamella of the lower eyelid. RESULTS: The operation was performed in 21 anophthalmic patients. In 16 patients with eyelid malpositions, excellent results (within 1 mm of the fellow eye) were attained in 100% of the patients with ptosis, and in 88% of patients with lower eyelid retraction. In the remaining 5 patients, orbital volume loss with secondary implant migration, inferior prosthetic displacement and eyelid asymmetry predominated. In these patients the anophthalmic orbital defects and eyelid asymmetry were masked well. Patient satisfaction was high and complications were few during an average follow-up interval of 16 months. CONCLUSION: The tarsal switch procedure is useful in managing the eyelid malpositions and masking the orbital deficiencies of the anophthalmic socket.     

Frontalis Sling Using a Silicone Rod for Ptosis in Third Nerve Palsy: Cosmesis versus Safety

PurposeTo evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety.MethodsPatients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance, and corneal status.ResultsTwenty-four eyes of 18 patients (12 male and six female patients) were included. The mean age at the time of surgery was 35.1 years (range, 5–64 years). Twelve patients underwent a unilateral ptosis operation, and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2–87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell’s phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative margin reflex distance, +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments.ConclusionsFrontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.