Blepharoptosis Repair Research Articles

Impact of COVID-19 on facial plastic surgery volumes: A large database analysis of pre- and post-pandemic trends.

During the COVID-19 pandemic, elective surgeries faced cancelations due to quarantine measures. The objective of this study was to assess facial plastic and reconstructive surgery (FPRS) volume before, during, and after the height of the pandemic on a national scale. The TriNetX Research Network identified 68,101,098 individuals aged 18+ with healthcare interactions from 2017 to 2022. Rates of common FPRS surgeries and procedures were compared during March-August of each year, aligning with the pandemic lockdown. Compared to immediately before the pandemic in 2019, the 2020 pandemic peak saw an overall surgical volume reduction of -36.8%, with specific surgeries decreasing significantly: rhinoplasty (-28.6%), septoplasty (-34.0%), rhytidectomy (-54.9%), blepharoplasty (-40.7%), brow lift (-43.8%), ectropion/entropion repair (-35.6%), repair of blepharoptosis (-45.6%), correction of lagophthalmos (-29.9%), correction of lid retraction (-36.8%), and lipectomy (-41.8%) (p < .001). The procedural volume also decreased by 28.6%, encompassing reductions in various procedures: botulinum toxin A (-18.7%), facial filler (-40.7%), dermabrasion (-62.3%), chemical peel (-36.6%), and intralesional injection (-33.3%) (p < .001). In contrast to 2020, 2021 witnessed an increase of +75.0% in total surgical and +61.3% procedural volume: rhinoplasty (+81.0%), septoplasty (+74.7%), rhytidectomy (+143.4%), blepharoplasty (+81.7%), brow lift (+64.5%), ectropion/entropion repair (+55.2%), repair of blepharoptosis (+62.7%), correction of lagophthalmos (+39.0%), correction of lid retraction (+73.0%), lipectomy (+121.2%), botulinum toxin A (+52.4%), filler (+59.6%), dermabrasion (+91.8%), chemical peel (+78.8%), and intralesional injection (+67.3%) (p < .001). In 2022, rates of total surgeries (+8.5%) and procedures (+12.8%) surpassed pre-pandemic levels from 2019 (p < .001). FPRS experienced significant pandemic-induced decreases, followed by a notable recovery in subsequent years, with certain surgeries and procedures surpassing pre-pandemic levels. 4.

"Blue Scrub Lid Retraction": Changes in Eyelid Position on the Day of Surgery.

The aim of this study is to test the hypothesis that margin-reflex distance 1 (MRD1) on the day of surgery will be higher than the MRD1 measured at the in-clinic consult visit among patients undergoing blepharoptosis repair due to an increased sympathetic drive. Patients evaluated for involutional blepharoptosis repair were prospectively enrolled over a 12-month period in this single-center, self-controlled study. Three investigators independently determined MRD1 using cropped photos taken of patients at the in-clinic consult visit and on the day of surgery. A difference in height was tested for by using the 2-tailed Wilcoxon signed rank test. Evaluated in this study were 76 eyelids from 38 patients. Over 3-quarters of study participants had a higher MRD1 in the right and OSs on the day of surgery than at their in-clinic consultation visit (p < 0.001). The mean increase in MRD1 for the right eyelid and left eyelid was 1.0 mm (range: 0-3.15 mm) and 1.1 mm (range: 0-2.7 mm), respectively. In patients with involutional blepharoptosis, we conclude that MRD1 is higher on the day of surgery as compared with the in-clinic consult visit. This may be secondary to the stress of surgery and an associated increase in sympathetic drive. In some cases, this change in eyelid position led to resolution of apparent involutional ptosis altogether. Caution should be used when considering deferral of ptosis repair on the basis of exam findings present on the day of surgery.

Symmetry of upper eyelid after unilateral blepharoptosis repair with minimally invasive conjoint fascial sheath suspension technique.

To investigate the symmetry of upper eyelid in patients with unilateral mild and moderate blepharoptosis who underwent unilateral minimally invasive combined fascia sheath (CFS) suspension. A retrospective study of patients who underwent unilateral minimally invasive CFS suspension surgery between January 2018 and December 2021. Inclusion criteria included unilateral mild and moderate ptosis, good levator muscle function (>9 mm) and follow-up of at least 6mo. Pre- and post-operative symmetry was graded subjectively for marginal reflex distance 1 (MRD1), tarsal platform show (TPS) and eyebrow fat span (BFS). A t-test was used to evaluate MRD1, TPS and BFS asymmetry by calculating delta values. The Bézier curve tool of the Image J software was used to extract the upper eyelid contours, where the symmetry was measured by the percentage of overlapping curvatures (POC). Totally 105 patients (105 eyelids) were included (mild group, n=84; moderate group, n=21). Postoperatively, all patients increased MRD1 and decreased TPS in the ptotic eye while maintaining unchanged BFS. The asymmetric delta value for MRD1 was measured to be 1.48±0.86 preoperatively, and it decreased to 0.58±0.67 postoperatively in all cases (P=0.0004). In patients with mild ptosis, the asymmetry value of TPS fell significantly from 1.15±0.62 to 0.68±0.38 (P=0.0187). The symmetry of the upper eyelid contour increased in all subgroups of patients, with a POC of 59.39%±13.45% preoperatively and POC of 78.29%±13.80% postoperatively. Minimally invasive CFS suspension is proved to be an effective means of improving the symmetry of unilateral ptosis in terms of MRD1 (all subgroups), POC (all subgroups) and TPS (only mild group), whereas BFS is unaffected.

Lower eyelid position before and after blepharoptosis repair

ABSTRACT Purpose This study aimed to examine the changes in lower eyelid position after blepharoptosis surgery and the factors that influence the outcome. Methods We conducted a retrospective study of 155 eyes of 89 patients who underwent blepharoptosis surgery between June 2019 and October 2022. The margin reflex distance (MRD)-1 and MRD-2 were examined preoperatively and 3 months postoperatively in two groups: one with lower scleral show (LSS) (n = 37) and one without LSS (n = 118). The clinical characteristics of the two groups were compared. Results Both the LSS and non-LSS groups showed significant postoperative improvement in MRD-1 scores (p < .01, p < .01, respectively). MRD-2 was significantly reduced in the LSS group, while it remained unchanged in the non-LSS group (p < .01, p = .27, respectively). There were no significant differences between the two groups in age, sex, history of hard contact lens use, preoperative levator function, use of topical steroids, history of endophthalmic surgery, or history of filtration surgery; however, the LSS group significantly used prostaglandin analogs (PGAs) (p = .03). Postoperatively, MRD-2 decreased in 13 eyes (35.1%) and was maintained in 24 eyes (64.9%) in the LSS group and was maintained in all eyes in the non-LSS group. In the LSS group, we also examined the association between postoperative MRD-2 reduction and the use of PGAs and found that more patients with MRD-2 reduction used PGAs (p = .02). Conclusion Lower scleral show in PGAs-associated blepharoptosis is expected to improve after blepharoptosis surgery.

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using many a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: ‘good’ (improvement of palpebral fissure height without laterality, MRD-1Margin reflex distance-1 gap between right and left side < 0.5mm), ‘fair’ (improvement of palpebral fissure height with laterality) or ‘poor’ (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity or recurrence of ptosis recurrence. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This graft technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.

Research progress of iatrogenic blepharoptosis repair after double eyelid surgery

To summarize the etiology mechanism and treatment of iatrogenic blepharoptosis after double eyelid surgery in Asia. To extensively review the literature related to iatrogenic blepharoptosis after double eyelid surgery, and to summarize and analyze the related anatomical mechanism, existing treatment options, and indications. Iatrogenic blepharoptosis is a relatively common complication after double eyelid surgery, sometimes it is combined with other eyelid deformities such as sunken upper eyelid and wide double eyelid, which makes it difficult to repair. The etiology is mainly caused by improper adhesion of tissues and scars, improper removal of upper eyelid tissue, and injury of a link of levator muscle power system. Whether blepharoptosis occurs after double eyelid surgery by incision or suture, it should be repaired by incision. The principles of repair include surgical loosening of tissue adhesion, anatomical reduction, and repair of damaged tissues. The key is to use surrounding tissues or transplanted fat to prevent adhesion. When repairing iatrogenic blepharoptosis clinically, appropriate surgical methods should be selected based on the causes and severity of the blepharoptosis, combined with treatment principles, in order to achieve better repair results.

SK Forceps: New Monopolar Electrosurgical Forceps Designed Specifically for Blepharoptosis Surgery.

The electrode tips of conventional monopolar forceps are relatively blunt, complicating the delicate detachment manipulations required for blepharoptosis repair. This study describes the SK forceps, which is a new monopolar electrosurgical forceps we specifically designed for blepharoptosis surgery. The electrode tips in our design were engineered to be as fine as possible. The SK forceps can cut tissues with the electrode tips in contact in the closed position and coagulate bleeding while clasping the blood vessels. When inactivated, the SK forceps can perform similar manipulations to regular surgical forceps. Surgeons holding the nonactivated SK forceps in one hand and regular forceps in the other benefit from greatly improved maneuverability at every step of the procedure. Incision and dissection procedures performed with the SK forceps result in a surgical field with minimal bleeding because the forceps can simultaneously perform hemostasis and incision, which is a characteristic of a high-frequency electrosurgical unit. However, when unexpected bleeding is encountered in the operative field, the SK forceps can clamp the injured vessels and coagulate the bleeding more rapidly and confidently compared with the needle-type monopolar electrodes without switching instruments. Our design allows surgeons to perform successive procedural steps without switching instruments. This characteristic makes the SK forceps a beneficial instrument for blepharoptosis surgery.

Conjunctival Müllerectomy With or Without Tarsectomy Using Absorbable Versus Nonabsorbable Suture.

To compare the outcomes of blepharoptosis repair using conjunctival Müllerectomy with or without tarsectomy (CM±T) using absorbable suture versus nonabsorbable suture. Retrospective case-series of all consecutive cases of CM±T ptosis repair between January 1, 2019, and August 31, 2021. Patients were placed in groups based on whether they had absorbable or nonabsorbable suture used during their procedure. Preoperative and postoperative measurements of MRD1 were gathered in both groups, and information on patient satisfaction, symmetry, complications, and reoperations. Ninety-two patients had surgery using nonabsorbable suture and 96 patients had surgery using absorbable suture, with average age of 72.0 and 70.9 years, respectively ( p = 0.488). When comparing nonabsorbable to absorbable suture, the groups did not differ on average preoperative MRD1 (1.11 mm [±0.96] vs. 0.96 mm [±0.86]; p = 0.161), average postoperative MRD1 (3.18 mm [±0.54] vs. 3.20 mm (±0.51); p = 0.736) or average MRD1 improvement (2.09 mm (±0.86) vs. 2.25 mm (±0.79); p = 0.089). Goal MRD1 was achieved in 85.3% of nonabsorbable cases and 82.8% of absorbable cases ( p = 0.562) and the rate of reoperation between groups was not significant ( p = 0.63). Good postoperative symmetry was noted in 91.6% of nonabsorbable and 91.0% absorbable suture cases ( p = 0.83). No difference in the number of complications was noted between groups ( p = 0.88), including need for contact lens placement (2.7% nonabsorbable, 1.3% absorbable; p = 0.37). The use of absorbable suture was found to have predictable and effective outcomes similar to cases using nonabsorbable suture for CM±T without an increase in complications or rate or reoperation.

Comparison of Postoperative Infection Rates After Office-based Oculoplastic Procedures Using Sterile and Clean Gloves.

To compare postoperative infection (PI) rates using sterile and clean-boxed gloves in office-based oculoplastic procedures. Prospective, comparative study of patients undergoing oculoplastic procedures by a single surgeon (RS) in an office-based procedure room between October 2018 and September 2020. Participants included were 18 years or older. Excluded were patients on oral antibiotics within 2 weeks before the procedure, had a follow-up period of less than 1 week, had a contaminated wound, had complex reconstructions, or had multiple simultaneous procedures performed. Oculoplastic procedures were performed using either sterile or clean-boxed gloves. The main outcome measure was the frequency of postoperative infection. Three thousand one hundred twenty-nine patients, 1,815 (58%) of whom were women, with a mean age of 60 (18-102) years were included. One thousand five hundred seventy procedures were performed with sterile gloves, while 1,559 were performed with clean-boxed gloves. The patients in the 2 groups were similar in age, gender, and number of high-risk individuals. One patient in the sterile glove group who underwent upper blepharoplasty (0.064%) and one patient (0.064%) in the clean-boxed glove group who had an external levator advancement blepharoptosis repair developed PI. Neither patient had risk factors for infection, and both infections resolved after 1 week of oral amoxicillin-clavulanate 875/125 mg twice daily. In minimally complex in-office oculoplastic procedures, using sterile versus clean-boxed gloves resulted in similar low infection rates in this large cohort. The healthcare benefits may not outweigh the costs of using sterile gloves universally for office-based oculoplastic procedures.

Effects of Upper Eyelid Surgery on the Ocular Surface and Corneal Topography

Objectives:To evaluate the effect of upper eyelid surgery on ocular surface and corneal topography.Materials and Methods:Patients who underwent upper eyelid blepharoplasty and/or blepharoptosis repair were evaluated prospectively. Tear film break-up time (TBUT), Schirmer tests, corneal staining pattern, Ocular Surface Disease Index questionnaire, corneal topography, and autorefractor parameters were measured preoperatively and at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively.Results:Thirty-two eyes of 20 patients (9 male, 11 female) were included in the study. The mean age was 44.8±18.9 years (range: 8-74). Patients were divided into the following 3 groups according to the type of surgery performed: upper eyelid blepharoplasty (group 1), upper eyelid blepharoplasty and levator advancement ptosis surgery (group 2), and levator advancement ptosis surgery (group 3). There was a significant decrease in Schirmer test results at 6 months in groups 1 and 2 but no change in group 3. TBUT values were decreased at 1 week in group 3 (p=0.028) and returned to baseline at 1 month. Corneal punctate staining was detected at 1 day and 1 week in all groups. On corneal topography, group 3 showed a significant change in K2 values (0.3 diopters) at 1 month (p=0.006). There was no statistically significant change in autorefractor measurements postoperatively compared to preoperative values (p>0.05).Conclusion:Depending on the type of surgical procedure performed, blepharoptosis repair and upper eyelid blepharoplasty can lead to dry eye of varying severity that may persist at postoperative 6 months.

Telemedicine for Preoperative Evaluation of Upper Eyelid Malposition: Reliability of Diagnosis and Surgical Plan.

Outpatient visits and surgeries for nonurgent indications in ophthalmology have intermittently been restricted during the COVID-19 pandemic. Telemedicine services have rapidly gained acceptance during this period, and could improve patient access for routine oculoplastic evaluations in the future. The objective of this study is to investigate interobserver and intraobserver reliability of eyelid and brow position assessment and surgical plan when comparing photography-based and face-to-face evaluation. This was an observational study conducted at a single academic center. Thirty randomly selected patients who had completed an in-office evaluation for chief complaint of "drooping eyelids" between June 2019 and March 2020 were included. Virtual assessment of brow position, dermatochalasis, blepharoptosis, and margin-reflex distance 1 was performed by 2 oculoplastic surgeons based on external photographs, and a surgical plan was formulated. Fraction of agreement and Cohen's κ were determined to evaluate reliability of the virtual assessment compared to face-to-face examination. For 60 eyes from 30 study subjects, diagnostic reliability for observer A was near perfect for brow ptosis, substantial for blepharoptosis and moderate for dermatochalasis (κ = 0.86, 0.67, and 0.57, respectively); for observer B, reliability was moderate for brow and blepharoptosis and substantial for dermatochalasis (0.47, 0.59, and 0.79). Fraction of agreement for blepharoptosis was 94% in eyes where the eyelid margin was visible, and 66% in eyes where the eyelid margin was obscured by overhanging skin. Virtual margin-reflex distance 1 measurements were highly correlated with those obtained face to face (r = 0.77, p < 0.01). Fraction of agreement for surgical plan after virtual examination by observer A/B, respectively, was 100%/94% for brow lift, 90%/87% for blepharoptosis repair and 83%/83% for functional upper blepharoplasty. Virtual evaluation of upper eyelid and brow malposition can be performed with acceptable reliability. Co-existing dermatochalasis or brow ptosis may require special photographic technique or video examination to ensure an appropriate diagnosis. A photography-based preliminary surgical plan offers a viable alternative to face-to-face encounters.

Blepharoptosis in the Setting of an Ocular Prosthesis: A Literature Review and Description of the Novel Use of a Template Prosthesis

Blepharoptosis in acquired anophthalmia is common, yet the best treatment methods remain uncertain. We review the literature for descriptions of pathophysiology or management of blepharoptosis in acquired anophthalmic sockets and describe a technique and results of using a template prosthesis to facilitate intraoperative adjustment during external levator resection ptosis repair. The PubMed database was searched in October 2021 to identify all studies in English describing the pathophysiology or treatment of anophthalmic blepharoptosis. Seventy-one articles were identified; 13 met inclusion criteria and were reviewed. We also reviewed the charts of 12 adult patients with acquired anophthalmia undergoing external levator resection using a limbal templated, non-detailed, customshaped prosthesis. We assessed results (margin to reflex distance 1 [MRD1] and symmetry), as well as the number of eye prosthesis modifications. According to the literature, levator pathophysiology and orbital volume loss are important variables in anophthalmic ptosis. Prosthesis augmentation may be useful to treat ptosis in many instances, but may be limited by decreased motility and a poorer overall prosthesis fit. A variety of blepharoptosis repair surgical techniques have been described with reported success rates of 88–100%. The use of a template prosthesis to facilitate intraoperative lid positioning in ptosis repair was effective in 12 patients. All patients had MRD1 within 1 mm of target and with good facial symmetry. There were no complications or need for revision ptosis repair or redundancy in prosthesis fabrication at 3 years (mean; minimum 6-month) follow-up.

Developing the Aesthetic Postoperative Complication Score for Detecting Major Morbidity in Facial Aesthetic Surgery

INTRODUCTION: Facial aesthetic surgery encompasses a wide variety of procedures with a complication rate that is difficult to estimate. To explore this further, we sought to estimate major complication rates in patients undergoing facial aesthetic procedures and to develop a risk assessment tool to stratify risk. METHODS: We utilized the Tracking Operation and Outcomes for Plastic Surgeons database from 2003 to 2018. The database was evaluated to include major facial aesthetic procedures selected based on CPT codes. All infra-cervical procedures were excluded. Procedures included were blepharoplasty (upper and lower), rhytidectomy (forehead, neck with platysma tightening, glabellar, SMAS flap, cheek, chin, and neck), repair or brow ptosis, repair of blepharoptosis, canthopexy (lateral and medial), genioplasty, augmentation of mandibular body, primary rhinoplasty (minor and major), revision rhinoplasty (minor and major), subcutaneous injection/fat transfer, cervicoplasty, and otoplasty. Demographics, comorbidities, and procedures were analyzed with univariate analysis for initial selection. Clinically relevant cutoff points were used to dichotomize significant continuous variables for the model. A backward stepwise multivariate regression model was developed to determine the risk factors for prediction. Goodness-of-fit was assessed with Hosmer-Lemeshow test. Regression coefficients were multiplied by two and rounded up to the nearest integer, and then summed to create the total score. Area under receiver operating characteristic curves were used to measure performance and choose optimal predictive models. Lastly, sensitivity analysis was performed with a complete case analysis to evaluate robustness of the model. RESULTS: A total of 38,569 patients were identified to have had a facial aesthetic procedure. The major complication rate for this adult population undergoing at least one facial aesthetic procedure was 1.44% (460). From the available demographics and perioperative variables, those statistically significant in univariate analysis included current/former smoker, diabetes mellitus, body mass index, ASA classification, canthoplasty, blepharoptosis repair, rhytidectomy in forehead, rhytidectomy with platysma thickening, rhytidectomy with SMAS flap, rhytidectomy with check/chin/neck, cervicoplasty, subcutaneous injection of filler/fat graft, primary rhinoplasty, lower blepharoplasty, and over three procedures were performed at the same time. In the final stepwise backward regression model undergoing rhytidectomy with platysmal tightening, rhytidectomy of cheek/chin/neck, cervicoplasty, over three surgeries at the same time, BMI ≥ 25, and ASA class ≥ 2 were the variables fit for calculating the risk prediction score [n = 13,349; AUC: 0.70, SE: 0.02, (0.66–0.74)]. The sum of the calculated integers gives a total score of 7 with cervicoplasty counting for two points and the rest of the covariates each given one point. Sensitivity analysis from each level of our score (0–7) showed the cutoff point of ≥2 to best balance sensitivity and specificity, with 58% and 70%, respectively. At this cutoff point, 70% of cases were correctly classified as a major complication (n = 12,764). CONCLUSIONS: Despite low morbidity rates, we were able to develop an acceptable risk prediction score with a cutoff value of ≥2 correctly classifying approximately 70% of major morbidity in adult patients undergoing face and neck aesthetic surgery.

Factors that influence the postoperative upper eyelid position following surgery for involutional blepharoptosis

External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r=0.49) and intraoperative (r=0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.

How to determine the amount of levator resection in congenital ptosis repair

Background and objective: Levator aponeurosis resection is an effective technique to correct blepharoptosis when the levator function is fair to good. This study aimed to determine the amount of levator resection in congenital blepharoptosis repair. Methods: This is a prospective case series study conducted in Rizgary teaching hospital and private hospitals in Erbil city, Kurdistan Region, Iraq, from June 2011 to August 2019. The data of 53 patients (64 eyelids) affected by congenital blepharoptosis with poor to good levator function that underwent unilateral orbilateral levator resection blepharoptosis repair through the standard approach were included. The final outcome measures included postoperative eyelid height, contour, and symmetry. Results: This study includes a total of 53 patients with congenital blepharoptosis (64 eyelids); 20 males and 33 females. The age of the patients ranged from 3 years to 54 years, with a mean age ± SD of 14.11 ± 10.66 years. The ptosis was right sided in 22 patients (41.5%), left sided in 20 patients (37.7%), and bilateral in 11 patients (20.8%). The study showed good patient satisfaction in 66.03% of the cases, suboptimal satisfaction in 22.64% of the cases, and poor satisfaction in 11.32% of the cases. Conclusion: The levator resection for congenital ptosis is effective even with poor levator function and replaced in our practice the traditional fascial sling. We recommend that further studies be done on a larger number of patients to investigate the effectiveness of levator resection in patients with severe ptosis and very poor levator function. Keywords: Congenital blepharoptosis; Levator aponeurosis; Levator resection; Levator resection.

Efficacy and safety of blepharoptosis repair after incisional glaucoma surgery.

There is an increased risk for development of blepharoptosis after incisional glaucoma surgery. Data on safety and efficacy of ptosis repair in this group of patients in limited. The goal of this study is to evaluate outcomes and identify potential risk factors for failure of ptosis repair in eyes with history of incisional glaucoma surgery. A retrospective chart review was performed of all patients who underwent incisional glaucoma surgery, specifically trabeculectomy or implantation of glaucoma drainage device (GDD), and subsequent ptosis repair at a single institution from 2009 to 2019. Ptosis surgery outcomes were compared to a control group who underwent ptosis repair after cataract surgery. Seventy-eight eyes of 64 patients were included in the glaucoma surgery group. The rate of severe ptosis (margin reflex distance 1 ⩽ 0 mm) among glaucoma surgery patients was higher compared to control (35 of 78 (44.9%) vs 23 of 82 (28.6%). Ptosis repair was successful in 59 of 78 eyes (75.6%), which was similar to control. Risk for revision surgery was increased more than five-fold in the GDD group compared to control. There were no cases of early or late bleb-related complications. Ptosis repair can be performed safely in patients after incisional glaucoma surgery. Müller muscle conjunctival resection and external levator advancement are equally effective. Patients with history of GDD should be advised about the potentially increased risk of need for revision surgery.

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

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

A Modified Approach to Transconjunctival Levator Advancement Offering Intraoperative Options.

The transconjunctival technique is an effective approach to mild to moderate blepharoptosis repair that does not involve skin incision. However, accurate surgical manipulation of this method is greatly restricted by poor intraoperative evaluation. The aim of this study was to introduce a modified transconjunctival approach with flexible intraoperative adjustments in order to achieve more accurate ptosis correction. Taking a transconjunctival approach, the levator aponeurosis and Müller's muscle were folded with a square-like mattress suture for flexible adjustment and accurate correction. In 18 mild ptosis eyelids, 94.5% (17 eyelids) achieved adequate or normal correction. In 9 eyelids with moderate ptosis, 88.9% (8 eyelids) achieved adequate or normal correction. Of 24 ptosis patients, 23 (95.8%) achieved a good or fair symmetry result. This study presents a modified transconjunctival technique for repair of mild to moderate ptosis, which is characterized by flexible intraoperative adjustments that produce satisfying functional and aesthetic outcomes.

Changing in a GIF (Graphics Interchange Format): Innovations in Before and After Photography.

Before and after images are an important part of aesthetic counseling, but no studies have examined ways to optimize change detection through the layout of displayed images. This study compares 3 different image layouts to determine which presentation style improves perception of postprocedure changes. In this prospective, randomized study, participants viewed sequential images of patients who either had or had not undergone upper eyelid blepharoptosis repair or blepharoplasty ("change" and "no-change," respectively). These paired images were randomly presented in 1 of 3 formats: side-by-side, up-and-down, or alternation flicker (in which 2 images are superimposed and alternated in a graphics interchange format). Participants were asked if a procedure had been performed based on the 2 photographs. Paired t tests were used to compare response times and change detection rates between individual-level pairs of presentation modes. Of 299 recruited patients, 286 completed the study. Rate of change detection trended toward increased sensitivity for alternation flicker over static images. This became statistically significant for patients less than 45 years old. Detection rates did not differ significantly between the 2 static layouts (side-by-side and up-and down). Enhancing and customizing aesthetics counseling for different ages can improve patient understanding, expectations, and advertising. When using static photography, the layout, whether side-by-side or up-and-down, can be chosen to fit the mode of presentation with no statistically significant difference. To optimize detection of changes in before and after photography in a demographic less than 45 years old, the animated, alternation flicker format was statistically significantly more effective.

Effects of Aspirin on Postoperative Bruising and Bleeding Complications in Upper Eyelid Surgery.

We evaluated the effects of aspirin versus placebo in patients undergoing upper eyelid blepharoplasty and/or levator advancement or plication blepharoptosis repair in this randomized, prospective study. Patients who presented between October 2017 and April 2019 requiring blepharoptosis repair and/or upper eyelid blepharoplasty who were taking 81 mg aspirin were randomized to receive 1 week of aspirin tablets or 1 week of placebo tablets prior to surgery. Postoperative complications, such as bleeding, hematoma, or hemorrhage, were noted as well as perioperative thromboembolic complications. Photos were obtained at the patient's first postoperative visit and later judged on bruising severity. The 2 groups were subsequently compared. A total of 48 patients and 89 eyelids were evaluated in this study. Fifty-two eyelids were included in the aspirin group and 37 eyelids were included in the placebo group. There was no statistically significant difference in bruising rating between groups. There was no statistically significant difference in the number of patients who experienced mild postoperative bleeding. No patients experienced vision loss. No patients experienced a thromboembolic event. There were no patients who experienced hemorrhage, hematoma, or retrobulbar hemorrhage. Continuation of aspirin does not appear to effect outcomes with respect to postoperative bruising in patients undergoing upper eyelid blepharoplasty or blepharoptosis repair. The study was not powered to determine statistical significance with regard to bleeding complications and would require a significantly higher sample size. We suggest changing the current guidelines to recommend routine continuation of low dose 81 mg aspirin before upper eyelid surgery.