Aponeurotic Repair Research Articles

Usefulness of mirror image processing software for creating images of expected appearance after blepharoptosis surgery

PurposeThis study aims to evaluate the usefulness of creating images of expected appearance after blepharoptosis surgery using mirror image processing software.MethodsThis prospective, observational study included 60 sides from 30 patients with bilateral aponeurotic blepharoptosis who underwent levator resection or aponeurotic repair on both sides. Before surgery, facial photographs were taken after the eyelid on one side was lifted with a curved hook. The mirror images were created from these photographs and were merged with the original photographs for making the whole facial images, which were shown to each patient at the preoperative counseling. At 1 month postoperatively, we asked patients about the usefulness of the mirror images to predict the postoperative appearance at the preoperative counseling and the similarity between the expected and the resultant postoperative appearance using questionnaires. Margin reflex distance-1, eyebrow height, and pretarsal skin height measured on predictive images were compared with those measured at 1 month postoperatively.ResultsTwenty-nine patients (96.7%) favorably responded to the usefulness of the mirror images to predict the postoperative appearance, and twenty-five patients (83.3%) accepted the similarity between the expected appearance and the actual postoperative appearance. The predictive images showed significantly lower margin reflex distance-1, higher eyebrow height, and higher pretarsal skin height than the postoperative results (P < 0.001).ConclusionThe creation of expected postoperative images was a useful simulation procedure before blepharoptosis surgery for patients to predict the probable postoperative appearance.

Influence of epinephrine contained in local anesthetics on upper eyelid height in transconjunctival blepharoptosis surgery

To examine the influence of epinephrine contained in local anesthetic on upper eyelid height in transconjunctival aponeurotic repair for aponeurotic blepharoptosis. This retrospective study included 164 eyelids from 94 patients with aponeurotic blepharoptosis. Patients were divided according to the use of local anesthetic with (group A, n = 108) or without 1:100000 epinephrine (group B, n = 56). Margin reflex distance-1 (MRD-1) was measured before and after local anesthesia, and before, during, and 3months after surgery. Change in MRD-1a (∆MRD-1a) was calculated by subtracting the postanesthetic MRD-1 value from the preanesthetic value, and we defined ∆MRD-1b by subtracting the postoperative 3-month MRD-1 value from the intraoperative value. ∆MRD-1a was positive in group A (0.57 ± 0.63mm) and negative in group B (- 0.50 ± 0.45mm; p < 0.001). Postoperative MRD-1 decreased significantly from intraoperative MRD-1 in group A (P < 0.001), although there was no significant difference between intraoperative and postoperative MRD-1 in group B (p = 0.255). The magnitude of ∆MRD-1b in group A (- 0.86 ± 0.63) was larger than that in group B (- 0.23 ± 0.26; p < 0.001). Epinephrine stimulates Müller's muscle during surgery, which leads to postoperative upper eyelid droop after the disappearance of the epinephrine effect. Using local anesthetics without epinephrine may allow more accurate estimation of postoperative eyelid height in transconjunctival aponeurotic repair.

Influence of fatty deposits in the levator aponeurosis/levator palpebrae superioris muscle on outcomes of aponeurotic repair in a Japanese population.

To examine a part of the levator aponeurosis/levator palpebrae superioris (LPS) muscle that did not have fatty deposits in patients with aponeurotic blepharoptosis. We also analysed the relation between this length and surgical outcome after transcutaneous aponeurotic repair. We measured the vertical length from the distal end of the anterior layer of the levator aponeurosis to the most distal point of fatty deposits in the levator aponeurosis/LPS muscle (non-fatty-deposit length) in 94 eyelids. Surgical success was defined as a postoperative margin reflex distance-1 (MRD-1) of 2.0-5.0 mm at 3 months postoperatively. The eyelids were classified into two groups: a surgical success group (group A, 76 eyelids) and an undercorrected group (group B, 18 eyelids). Group A was subdivided according to the evidence of a fatty deposit (group A1, fat present, 70 eyelids; group A2, fat absent, 6 eyelids). The non-fatty-deposit measurement was significantly longer in group A1 than in group B (p = 0.035). The levator aponeurosis was less advanced in groups A1 and A2 than in group B (both, p < 0.001), and the eyelids in groups A1 and A2 obtained a higher MRD-1 than those in group B (both, p < 0.001). Eyelids with less fat deposit required less advancement of the levator aponeurosis and obtained more favourable surgical results. Intraoperative findings of eyelids with and without fatty deposits and measuring the non-fatty-deposit length may be useful predictive parameters for outcomes of transcutaneous aponeurotic repair.

Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients

To examine the surgical outcomes of a modified transcutaneous aponeurotic repair for aponeurotic blepharoptosis in a Japanese population. This retrospective study included 75 eyelids of 45 patients with aponeurotic blepharoptosis who had undergone a modified transcutaneous aponeurotic repair. This procedure included a long skin incision for securing a wide surgical field, creation of a double eyelid crease, and a small extent of detachment of the levator aponeurosis from the tarsal surface. Functional success was defined as a postoperative margin reflex distance-1 of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was judged by achieving a ≤ 1-mm laterality of eyelid height, a ≤ 2-mm laterality of pretarsal show, and symmetry of the eyelid contour at 3 months postoperatively. The functional success rate was 70.7% among all patients, with 84.4%, 86.7%, and 88.9% of patients showing cosmetic success regarding symmetry of eyelid height, pretarsal show, and eyelid contour, respectively. After applying functional and all 3 cosmetic criteria simultaneously, 28 patients (62.2%) were satisfied in this study. No serious complications occurred during the follow-up period. This modified procedure provided good functional and cosmetic outcomes for aponeurotic blepharoptosis, indicating an acceptable blepharoptosis repair for East Asian patients.

Assessing outcome following levatorplasty: When East meets West: Editorial on paper “Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients”

Assessing outcome following levatorplasty: When East meets West: Editorial on paper “Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients”

Relationship between the phenylephrine test and eyelid droop after aponeurotic repair with the use of an epinephrine-containing local anaesthetic.

PurposeTo analyse the relationship between the results of the phenylephrine test and postoperative eyelid droop in transcutaneous aponeurotic repair using epinephrine-containing local anaesthetic for aponeurotic blepharoptosis.Patients and methodsWe retrospectively reviewed the medical records of 66 eyelids from 40 patients who underwent transcutaneous aponeurotic repair. A positive phenylephrine test result was defined as an increase in margin reflex distance-1 (MRD-1) ≥0.5 mm after application of phenylephrine eye drops. The patients were divided into a positive phenylephrine response group (Group A, 16 patients) and a negative phenylephrine response group (Group B, 24 patients). The ΔMRD-1 was calculated by subtracting the 3-month postoperative value from the intraoperative value. Patient age, sex, pre- and intraoperative MRD-1s, levator function, and phenylephrine response were investigated as factors potentially influencing the ΔMRD-1. The relationship between these factors and ΔMRD-1 was analysed using single and multiple regression analysis.ResultsThe ΔMRD-1 in Group A (0.68±0.52 mm) was significantly greater than that in Group B (0.17±0.56 mm; P=0.004). A moderate correlation was found between phenylephrine response and ΔMRD-1 in the total patient group (YΔMRD-1=0.441 Xphenylephrine+0.358; r=0.462; r2=0.213; P=0.002).ConclusionsAlthough the ΔMRD-1 in Group B was quite small, the ΔMRD-1 in Group A was considerable, and there was a moderate positive correlation between phenylephrine response and the ΔMRD-1 overall. This indicates that the degree of postoperative eyelid droop can be estimated by the phenylephrine test results in transcutaneous aponeurotic repair.

Modified visual field test for ptosis surgery (Leicester Peripheral Field Test)

There is lack of consensus among Primary Health Care Trusts (PCTs) and health insurers on how to reimburse ptosis surgery and upper lid blepharoplasty, as these procedures can be regarded as cosmetic. Standardised photographs are expensive and difficult to achieve, whilst the routine 24-2 visual field lacks the range to detect visually significant superior field defects.AimTo introduce a modified visual field designed to assess the functional disability associated with ptosis and dermatochalasis and to demonstrate the effectiveness of surgery in improving the visual field. Patients who had surgery for ptosis or dermatochalasis between January 2006 and December 2009 were prospectively invited to perform a modified visual field test pre- and post-operatively. In total, 97 patients amounting to 194 eyes were included in the study. Ninety five eyes had aponeurotic repair with or without blepharoplasty and 77 eyes had blepharoplasty alone. This modified test has a sensitivity of 98.8% of detecting ptosis. For patients who underwent ptosis surgery with or without blepharoplasty, 84.2% recorded an improvement in points seen with the test and 81% recorded an improvement in visual field height. For those who had blepharoplasty alone, 90.9% recorded an improvement in points seen in the modified visual field test and 80.6% had improvement in visual field height. Our modified visual field assessment is a quick and easy way to assess patient disability associated with ptosis and dermatochalasis. Surgery improves the demonstrated defect, confirming that ptosis and dermatochalasis can be considered a functional rather than cosmetic issue.

Reconstructive Upper Lid Blepharoplasty

Cosmetic upper eyelid blepharoplasty is not a procedure comprising skin and fat resection only. Efficient and effective functional repair of the upper lid requires brow stabilization or elevation, levator aponeurotic repair, lacrimal gland suspension, and cutaneous laser resurfacing when necessary.

The effect of division of the transverse carpal ligament on flexor tendon excursion

The effect of the transverse carpal ligament (TCL) as a pulley was evaluated by measuring flexor tendon excursion after ligament division and by changing wrist position through a range of flexion and extension. Eight fresh cadaver upper extremities were mounted in a device and tendon excursions from full extension to fingertip-palm contact were measured for each flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendon. Measurements were performed with the wrist at 30 degrees extension, neutral, 30 degrees flexion, and 60 degrees flexion. The TCL was then sectioned, the skin was sutured, and the measurements were repeated. Two forms of carpal ligament repair were then done--transposition flap and aponeurotic repairs--and measurements were again repeated. With increasing wrist flexion, greater excursion differences were noted. Analysis of variance revealed that for both FDS and FDP, a significant difference in excursion occurred at 60 degrees wrist flexion and 30 degrees wrist extension with no ligament reconstruction or aponeurotic repair, compared to values prior to carpal tunnel release (p < .05) and to transposition ligament repair (p < .05).

Levator Aponeurosis Surgery: A Retrospective Review

A review of all cases of aponeurotic repair done since 1980 by the author identified 140 patients and 174 eyelids. An acceptable result at 6 weeks was defined as a lid level within 1 mm of the desired level achieved in 74% of lids with acquired ptosis. The amount of ptosis present preoperatively was the major factor in our study; levator function and type of anesthesia did not affect the success rate. The most significant finding was a lower long-term success rate due to a drop in lid level clustered at the 2- to 4-month period postoperatively. The authors speculate on the cause for this finding.

Anatomy and surgery of the levator aponeurosis in senile ptosis

The authors performed an anatomical and histological study on eight eyelids to define the lower insertions of the levator muscle. Twenty-nine cases of senile ptosis are presented in which levator aponeurosis surgery was successful. All patients were operated under local anesthesia. The authors used an aponeurotic repair when an aponeurosis dehiscence was identified during surgery (12 cases). The preoperative clinical appearance of all of these patients was typical and suggested the presence of a defect in the aponeurosis. In the 17 other cases the authors used aponeurosis tucking. This technique is easy and rapid and can be performed on very old patients. Histological anomalies of the aponeurosis were found out from biopsies. There is an anatomical analogy between the upper and the lower lid, and equally between senile ptosis and senile entropion, characterized by laxity or disinsertion of the lower lid retractor. One patient with a disinsertion of the aponeurosis and of the lower lid retractor is presented.

Aponeurotic Defects in Congenital Ptosis

Levator aponeurosis disinsertion is an accepted etiologic factor in some acquired ptosis cases, but it has not previously been reported as a cause of congenital ptosis. Forty-six congenitally ptotic eyelids in 36 patients with no history of birth trauma were surgically explored and three eyelids were found to have levator disinsertions. All three cases were treated by aponeurotic repair with excellent results. These cases and suggestions that help to preoperatively identify congenitally ptotic eyelids with levator disinsertions are presented. We feel the aponeurotic approach to ptosis correction is applicable to cases of congenital ptosis with at least 5 mm of function.

The Cure of Ptosis by Aponeurotic Repair

Indications for the procedure of aponeurotic repair are nearly all of the ptoses that have 8 mm or more of elevation from downward to upward gaze. Such cases have a levator with an adequate striated part, an inadequate superior tarsal (Müller) muscle, and an aponeurosis that has involutional changes such as a dehiscence or disinsertion. Local anesthesia is advised. The incision is made 7 mm above the lash-line, through the skin and pretarsal muscle only. Blunt dissection upward is used until the preaponeurotic fat pad is uncovered. The upper part of the aponeurosis is picked up under the fat pad and sutured to the lower part of the aponeurosis with 5-0 chromic gut. Fifty-seven eyelids in thirty-four patients have been operated on, with excellent results and minimal trauma.