Levator Aponeurosis Advancement Research Articles

Browlifting as an Alternative Procedure for Apraxia of Eyelid Opening

Essential blepharospasm is an idiopathic disorder that consists of spontaneous, spasmodic, and involuntary eyelid closure in the absence of ocular disease. Some patients develop an inability to open their eyelids in the absence of orbicularis spasms. These patients have essential blepharospasm combined with apraxia of eyelid opening. Botulinum toxin injections are the treatment of choice for blepharospasm but results may be insufficient, especially in cases associated with apraxia. Apraxia can be treated surgically by levator aponeurosis advancement, frontalis suspension, and upper myectomy. The authors report the first browlift using polypropylene suture to manage eyelid apraxia associated with blepharospasm as an alternative and minimally invasive procedure.

Modified Tarsal Resection Operation for Congenital Ptosis With Fair Levator Function

There are many options for surgical repair of congenital ptosis with fair levator function. The authors review their 10-year experience with an en bloc resection of tarsus, Müller muscle, and conjunctiva in conjunction with graded levator aponeurosis advancement (a variation of the tarsectomy operation). This is a retrospective case series that reviews all cases of ptosis repair performed at West Virginia University from 1994 to 2004 using the "modified tarsal resection method." Thirty patients with congenital ptosis and fair levator function were identified. Follow-up ranged from 6 weeks to 8 years. Charts were reviewed for type of ptosis, pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications. In patients with congenital ptosis and fair levator function, the average preoperative upper eyelid margin to reflex distance was 0.0 mm and the average postoperative upper eyelid margin to reflex distance was 2.8 mm. Twenty-five of 30 (83%) patients were deemed to have a "good" surgical outcome. The amount of tarsus-Müller muscle resection reliably predicts the amount of eyelid elevation. The only complications to date have been transient lagophthalmos with exposure keratitis. In the authors' hands, an en bloc resection of tarsus, Müller muscle, and conjunctiva combined with levator aponeurosis advancement reliably produces excellent results in the treatment of fair levator function congenital ptosis, superior to their previous experience with isolated maximal levator aponeurosis advancement.

A new method on ptosis management with a modification of levator aponeurosis advancement

A new method on ptosis management with a modification of levator aponeurosis advancement

Mini-Invasive Ptosis Surgery

Background and objective: Levator aponeurosis advancement is an effective technique that is routinely used to correct aponeurogenic ptosis. The standard technique involve a skin incision of the upper eyelid crease for the entire length of the eyelid, with or without associated blepharoplasty. We believe that, in a selected group of patients, a less invasive approach with an upper lid skin incision of only 0.8 cm is equally effective for the final result and offers several advantages compared to the traditional technique. Materials and methods: We retrospectively reviewed the data of 48 patients affected by involutional ptosis with good levator function that underwent unilateral or bilateral levator advancement ptosis repair through a mini-invasive approach. Final outcome measures included postoperative eyelid height, contour, symmetry, periocular edema, surgical time and visibility of the incision site. Results: The mini-invasive approach for the correction of involutional ptosis resulted in our hands as effective and reliable as the traditional technique, required a shorter surgical time, offered an improved early post-operative course with minimal bruising and swelling and produced no visible scar. Conclusions: This mini-invasive ptosis correction technique replaced in our practice the traditional approach for the treatment of a selected subset of patients affected by aponeurogenic ptosis.

Lower Eyelid Recession Combined with Ptosis Surgery in Patients with Poor Ocular Motility

The authors treated ten patients (13 eyelids) with visually significant blepharoptosis and compromised corneal protective mechanisms resulting from paresis of ocular motility and absent Bell phenomenon. Traditional upper eyelid surgery consisting of frontalis suspension (6 eyelids) or levator aponeurosis advancement (7 eyelids) was used. In all patients, the ptosis repair was combined with maximum recession of the lower eyelid, using a posterior lamellar scleral spacer graft. The goal was to maintain a narrow, vertical, interpalpebral fissure to allow for eyelid closure, but to reposition this opening centrally over the pupil. Postoperatively, all patients achieved significant improvement in superior visual field, with no associated keratopathy. Complications were few, minor, and transient. The postoperative cosmetic appearance was acceptable in all patients. This combined procedure allows repair of fair- to poor-function ptosis in patients in whom ptosis surgery previously has been considered risky. For the authors, this technique has been proven safe and effective and should be considered in any patient population with compromised corneal protective mechanisms.

Loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis.

To determine criteria to diagnose and document functional visual impairment from upper eyelid ptosis in the downgaze position of reading. Prospective clinical study. From September 1991 to June 1992, 47 consecutive patients with adult-onset acquired ptosis were enrolled in the study. Downgaze eyelid and relative brow position were evaluated in 88 eyelids of these patients. Surgical repair of blepharoptosis by the Müller muscle conjunctival resection ptosis procedure, levator aponeurosis advancement and/or resection, or levator muscle resection. Postoperative change in the eyelid and brow position in downgaze. Of all ptotic eyelids, 43% had zero vertical palpebral fissure height in downgaze when the brows were relaxed and therefore were functionally blind in the downgaze position. After ptosis repair, there was a significant widening of the vertical palpebral fissure height in downgaze (P < .001), a significant decrease in frontalis muscle use (P < .001), and return of the patients' ability to sustain downgaze function. Measurement of palpebral fissure height in downgaze and frontalis muscle use in patients with acquired ptosis identifies patients with a functional visual deficit in the downgaze reading position. These measurements can be easily performed in the office and may be added to criteria for documenting functional impairment from blepharoptosis.

Upper Lid Blepharoplasty and Ptosis Repair Using a Transcutaneous Approach

Ptosis repair can be combined with a transcutaneous upper eyelid approach. The procedure includes removal of the excess skin, underlying orbicularis, and, possibly, orbital fat combined with levator aponeurosis advancement. Excellent results have been achieved for patients with dermatochalasis and ptosis causing significant visual field abnormalities, as well as for patients with no visual field abnormalities who desire improved cosmesis.

Correction of Postoperative Eyelid Retraction with a Simplified Levator Palpebrae Superioris (LPS) Muscle Recession

A simplified levator palpebrae superioris (LPS) muscle recession was performed to correct eyelid retraction in 56 eyelids of 48 patients. Improvement of preoperative keratopathy and cosmetically acceptable results were achieved in 93% of the eyelids. Based on preoperative surgical intervention, eyelids were divided into four groups: levator resection, levator aponeurosis advancement, surgery associated with dysthyroid ophthalmopathy, and miscellaneous reconstructive eyelid procedures. For each group the mean preoperative and postoperative eyelid levels, the mean change in eyelid level following surgery, and the mean amount of surgery performed were analyzed statistically with the two-tailed student's t-test. Linear regression was used to analyze the relationship between the change in eyelid level and the amount of levator recession performed. No significant relationship was demonstrated between eyelid retraction and dysthyroid ophthalmopathy or reconstructive eyelid surgery. However, a significant relationship was demonstrated between the amount of recession and the eyelid level change for eyelids retracted following levator resection (P less than .01) and levator aponeurosis surgery (P less than .05). This may indicate that the change in eyelid level following a simplified LPS recession in these two groups is predictable. However, additional prospective studies are required to further assess the clinical applicability and use of this finding.

Correction of Postoperative Eyelid Retraction With a Simplified Levator Palpebrae Superioris (LPS) Muscle Recession: Analysis of a 10-Year Experience

A simplified levator palpebrae superioris (LPS) muscle recession was performed to correct eyelid retraction in 56 eyelids of 48 patients. Improvement of preoperative keratopathy and cosmetically acceptable results were achieved in 93% of the eyelids. Based on preoperative surgical intervention, eyelids were divided into four groups: levator resection, levator aponeurosis advancement, surgery associated with dysthyroid ophthalmopathy, and miscellaneous reconstructive eyelid procedures. For each group the mean preoperative and postoperative eyelid levels, the mean change in eyelid level following surgery, and the mean amount of surgery performed were analyzed statistically with the two-tailed student's t-test. Linear regression was used to analyze the relationship between the change in eyelid level and the amount of levator recession performed. No significant relationship was demonstrated between eyelid retraction and dysthyroid ophthalmopathy or reconstructive eyelid surgery. However, a significant relationship was demonstrated between the amount of recession and the eyelid level change for eyelids retracted following levator resection (P less than .01) and levator aponeurosis surgery (P less than .05). This may indicate that the change in eyelid level following a simplified LPS recession in these two groups is predictable. However, additional prospective studies are required to further assess the clinical applicability and use of this finding.

The Management of the Ptosis Patient: Part I

The various types of congenital and acquired ptosis are discussed as well as the findings on history and examination. From this information the appropriate operation can be chosen. Emphasis is placed on obtaining accurate and reproducible measurements in addition to assessing visual acuity, extraocular muscle movement, Bell's phenomenon, and tear secretion, especially in older patients. The operations described are the tarsal-Muller's muscle resection, levator aponeurosis advancement, levator resection, and frontalis suspension. Since the aim in ptosis surgery is symmetry in the primary position, overcorrections and undercorrections must occasionally be dealt with to achieve a satisfactory result.

Müllers muscle-conjunctival resection ptosis procedure.

The Müllers muscle-conjunctival resection procedure is a relatively simple means of relieving upper eyelid ptosis. Candidates for the operation are chosen by placing several drops of 10% phenylephrine hydrochloride into the upper ocular fornix. If the upper lid elevates close to a normal level after five minutes, the patient is selected for the operation. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and Müllers muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and Müllers muscle to the superior tarsal border, and then the tissues held in the clamp are resected. The Müllers muscle-conjunctival resection has advantages over the Fasanella procedure, because tarsus is preserved, and over the levator aponeurosis advancement and tuck procedures, because the results are much more predictable.