Double reinsertion including Whitnall\u2019s ligament in aponeurotic ptosis surgery

Nuria Pfeiffer,Nicolas Toledano Fernandez,Markus Pfeiffer,Alberto Reche Sainz

doi:10.1007/s00417-020-05004-z

Abstract

PurposeThe results of a technique with a double reinsertion of the aponeurosis to the tarsus and aponeurosis to Whitnall’s ligament (ATW) were compared with a simple reinsertion of the aponeurosis to the tarsus (AT) in acquired aponeurotic palpebral ptosis surgery.MethodsAnalytical, observational, retrospective, cohort study. Seven hundred and twenty-two consecutive cases with acquired aponeurotic palpebral ptosis have been treated surgically between 2000 and 2012 and have been followed up for 5 years. The cases were divided into two cohorts according to the applied surgical technique (AT vs ATW).ResultsThe mean postoperative MRD after 1 month in cohort AT was 1 mm lower than in ATW (3 ± 0.9 mm vs 4 ± 1 mm). The mean MRD in the long-term follow-up (5 years) was 1 mm lower in cohort AT than in ATW (2.9 ± 1.5 mm vs 3.9 ± 0.9 mm). The rate of long-term recurrence (5 years) was 15% higher in A-T than in A-T-W (20% vs 5%). 70.5% of the eyes studied intra-surgically presented gaps between the Whitnall ligament and the aponeurosis, an anatomical area that we describe as the upper transition zone (UTZ). In an independent analysis, only those patients with open UTZ were evaluated and it was observed that those operated with A-T-W presented elevations greater than 1 mm compared to those operated with the AT technique (4 ± 0.9 mm A-T-W vs 2.8 ± 1 mm A-T) and a much lower recurrence rate (5.4% A-T vs 38.09% A-T-W).ConclusionsIn our study, the A-T-W technique achieved better results in terms of palpebral elevation and fewer recurrences compared to the A-T technique in all cases studied with aponeurotic ptosis. However, it particularly demonstrates its superiority in patients with large gaps in the UTZ.

Highlights

JustificationPalpebral ptosis is a frequent pathology but remains a challenge for the oculoplastic surgeon since it is not easy to achieve satisfactory results that last over time [1].There are different types of palpebral ptosis and the acquired aponeurotic ptosis is the most frequent
We propose an alternative surgical technique based on a double connection of the aponeurosis to the tarsus and to the Whitnall’s ligament (ATW) without any resection of tissue
Not randomized, studying only those patients with upper transition zone (UTZ) gaps, the mean MRD a month after surgery in those patients was greater if they were operated with the aponeurosis to Whitnall’s ligament (ATW) technique (4 mm, of ± 0.975 mm) than if they were operated with AT (2.89 mm of ± 1.084 mm); in terms of recurrence with ATW, this was 5.4%, Multiple techniques have been described over the years to treat palpebral aponeurotic ptosis (Fasannela Servat, Blaskowitz, elevator resection, Müllerectomy) [1] but the most usual to date is the reinsertion of the aponeurosis to the tarsus as it fixes the main cause of ptosis, the disinsertion of the aponeurosis to the tarsus [7]

Summary

Introduction

There are different types of palpebral ptosis and the acquired aponeurotic ptosis is the most frequent. This involutional type of palpebral ptosis is associated with age. The levator system of the upper eyelid is formed by three parallel arcs of fibrous tissue that are basic structures of the levator system: the tarsus, the aponeurosis of the elevator muscle, and Whitnall’s ligament [3]. Between Whitnall’s ligament and the upper aponeurosis, there is a transition with continuous or discontinuous fibrous tissue. Under normal conditions Whitnall’s ligament is connected by fibrous tissue towards the aponeurosis leaving a central gap of 1–3 mm (UTZ). In certain cases, there may be a disinsertion of fibers or a fatty degeneration of the UTZ, producing larger separations between Whitnall’s ligament and the aponeurosis (Fig. 1) [4, 5]

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