Levator Excision Research Articles

Marcus-Gunn jaw winking syndrome: case series study and management algorithm

ABSTRACT Purpose To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). Methods Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). Results Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. Conclusions Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

Management of Marcus Gunn jaw wink syndrome with tarsofrontalis sling vis a vis levator excision and frontalis sling: a comparative study

ABSTRACT Purpose To compare the results between tarsofrontalis sling (TFS) and levator palpebrae superioris (LPS) excision with TFS in cases of ptosis with Marcus Gunn jaw winking syndrome (MGJWS). Method A retrospective review of records of all patients undergoing either TFS (group A) or LPS excision along with TFS (group B) in cases of ptosis with MGJWS was done over the past 10 years and their results were compared. Results The study included 73 patients (75 eyes). There were 36 patients (36 eyes) in group A and 37 patients (39 eyes) in group B. There was a significant reduction in the excursion due to MGJWS from 4.7 ± 1.49 to 1.91 ± 1.04 mm in group A (p = .001) and 4.65 ± 1.34 to 1.79 ± 0.98 mm in group B (p < .05). The reduction in excursion due to MGJWS and lagophthalmos were comparable in both groups. The mean follow-up in group A was 5.62 ± 6.94 (Range: 1–24) months and group B was 19.15 ± 29.16 (Range: 1–96) months (p = .01). Conclusion Both TFS and LPS excision with TFS is equally effective in dampening the eyelid excursion in MGJWS. Tarsofrontalis sling is a safe, easy and effective technique for MGJWS with lesser complication.

Unilateral Versus Bilateral Frontalis Suspension Sling Surgery for Correction of Severe Unilateral Congenital Ptosis.

Background: To compare the surgical outcome of unilateral silicone sling with bilateral fascia latafrontalis suspension surgery for severe unilateral congenital ptosis.Subjects and Methods:This prospective, interventional and comparative study examined 30 patients of severe unilateral congenital ptosis. 30 patients were divided in to 2 groups, group 1 included 15 patients who underwent unilateral silicone sling frontalis suspension surgery and group 2 included 15 patients who underwent contralateral levator excision with bilateral fascia latafrontalis sling surgery.Results:Mean improvement in MRD1 after surgery in group 1 who underwent unilateral silicone sling surgery was 3.9+1.18 mm and in group 2 who underwent bilateral fascia lata it was 4.9+0.89 mm (p value 0.0001). Excellent results (difference of lid height &lt;1 mm) were seen in 93.3% patients who underwent bilateral fascia latafrontalis sling while in 73.3% patients of unilateral silicone sling. All patients who underwent bilateral fascia lata showed excellent lid crease (symmetric without obliteration) and 80% of the patients who underwent unilateral silicone sling surgery (p value 0.032).Conclusion: Functional and cosmetic outcomes regarding MRD1, symmetry of lid height, lid crease were noted better in group 2 patients who underwent contralateral levator excision with bilateral fascia latafrontalis suspension surgery as compared to group 1 patients who underwent unilateral silicone sling surgery.

Surgical management of jaw-winking synkinesis and ptosis in Marcus Gunn syndrome: a systematic outcomes analysis

Aim: Marcus Gunn jaw-winking synkinesis (MGJWS) is characterized by congenital ptosis in conjunction with rapid and involuntary elevation of the affected upper eyelid upon contraction of the ipsilateral external pterygoid muscle. Selecting an approach to the surgical management of eyelid malposition in this syndrome is challenging and requires careful discussion with each patient’s family. In this systematic review, we describe reported surgical approaches, assess outcomes data, and attempt to identify areas of consensus in the management of MGJWS. Methods: Twenty-seven peer-reviewed studies were identified, describing a variety of interventions. Results: The most commonly-used surgical techniques included: bilateral levator excision with bilateral frontalis sling, unilateral levator excision with bilateral or unilateral frontalis sling, the Neuhaus/Lemagne method, and levator plication surgery. However, no clear outcomes-based consensus regarding choice of surgical approach was identified, highlighting the ongoing role of surgeon and family preference in the selection of management strategy. Further, there was considerable variability in the literature for reporting outcome measures, including grading schemes for ptosis and jaw-wink. Conclusion: The existing literature on management of MGJWS does not enable the development of an evidence-based consensus algorithm regarding the selection of an appropriate surgical technique. The disorder is treated according to a case-by-case approach governed by surgeon and family preference. Standardization of nomenclature and outcome measures is crucial for obtaining higher-quality, generalizable data in futures studies.

Unilateral Levator Aponeurosis Excision for Marcus Gunn Syndrome and Risk Factors of Residual Jaw Winking.

Purpose To investigate the association of ptosis, levator, and jaw winking in Marcus Gunn jaw-winking synkinesis (MGJWS), and the risk factor of preservation and outcomes of the unilateral levator excision and frontalis suspension. Methods Clinical features of MGJWS case series from 2011 to 2018 were retrospectively reviewed. Association between jaw winking and ptosis/levator function was statistically analyzed. The patients underwent unilateral levator excision and frontalis suspension using silicone rod or autogenous fascia lata. Clinical outcomes were evaluated in operated patients and the independent risk factors of residual jaw winking were investigated after a long follow-up. Results There were 42 MGJWS patients in 2011 to 2018, accounting for 2.87% of all congenital blepharoptosis. 80% of mild jaw winking was accompanied with mild ptosis and fair levator function, and moderate-to-severe jaw winking was often accompanied with moderate-to-severe ptosis and poor levator function (P < 0.05). Ptosis showed a strong association with excursion of jaw winking (R = 0.785, P < 0.01). Jaw winking was resolved in all 34 operated patients with good correction of ptosis. Severity of jaw winking is an independent risk factor for the residual synkinesis after surgery. Severe preoperative jaw winking had an 18.05 times increased risk of postoperative residual synkinesis compared with moderate jaw winking (P < 0.05). Conclusions In MGJWS eyelid excursion of jaw winking has a direct correlation with ptosis and dysfunction of levator muscle. Unilateral levator aponeurosis excision and frontalis suspension is an efficient approach for MGJWS. Severe jaw winking is a risk factor of residual eyelid synkinesis after surgery.

Effect of Eyelid Crease Formation on Aesthetic Outcomes post Frontalis Suspension for Unilateral Ptosis.

Background:The eyelid crease plays a very important role in determining eyelid symmetry. This study was performed to compare the cosmetic results post silicone rod frontalis suspension surgery, performed with and without eyelid crease formation, for correction of unilateral, congenital ptosis.Methods:Prospective, interventional study. One hundred patients with unilateral, congenital ptosis, with poor levator muscle action, operated on by a single facial plastic surgeon, over 5-year duration (2011–2016). Group I had 50 patients, who underwent silicone sling (Bvi Visitec) frontalis suspension surgery. Group II had 50 patients, who underwent frontalis suspension silicone sling (Bvi Visitec) surgery, in combination with eyelid crease formation and levator muscle excision (when required). The cosmetic outcomes were evaluated by the patients themselves and by 3 blinded physician observers and recorded objectively via a 5-point questionnaire, after a 1-year follow-up.Results:Patients in group II were much more satisfied than the patients in group I, as confirmed by the subjective and objective evaluations.Conclusion:The silicone sling frontalis suspension surgery, when combined with eyelid crease creation and levator excision procedure (when required), provides better symmetry, superior cosmesis, and excellent patient satisfaction.

Surgical Outcomes in Cases of Marcus-Gunn Jaw-Winking Phenomenon.

Markus-Gunn Jaw-winking Phenomenon (MGJW) is a congenital ptosis associated with synkinetic movement of upper lid on masticating movements of jaw. It results from aberrant connection between motor division of trigeminal nerve and oculomotor nerve. To investigate the clinical characteristics of MGJW phenomenon and evaluate its surgical outcomes of unilateral levator excision and frontalis suspension. It is a retrospective analysis of nine cases of MGJW phenomenon seen from 2007 to 2013 AD. The clinical features were recorded and analysed. Unilateral levator excision and frontalis suspension for the correction of synkinesis and ptosis was done for all the patients. The result of surgery was analysed. MGJW phenomenon was seen more in males. All the cases had unilateral ptosis with jaw winking phenomenon. Ipsilateral hypotropia and refractive errors were seen in 44%. One week post operative margin reflex distance was good in 67% of cases. Persistent jaw-winking was seen in 3 cases, two underwent repeat surgery to abolish the synkinesis. At one year follow up, 33% had good margin reflex distance of more than 4mm and 22% had fairly good margin reflex distance of 3mm. Patients with Marcus Gunn jaw winking synkinesis can present at a wide age range. There may be an associated vertical muscle imbalance, which should be managed before ptosis surgery to avoid ptosis under correction. Unilateral frontalis flap suspension combined levator excision can correct ptosis very well for patients with Marcus-Gunn syndrome.

Debate and update issues for surgical treatment of mid and lower rectal cancer

Updates and Debate issues form the surgical treatment of middle or low rectal cancer The main goals for the surgical treatment of rectal cancer were the complete removal of the rectal cancer with surrounding lymphatic draining area, which subsequently result in decreasing the rate of local recurrence as well as prolong patient survival. If the tumor located at the near the anal canal, concerning issues will be whether anal sphincter can be preserved or not and furthermore autonomic pelvic nervous system could be saved or not. Multidisciplinary approach for rectal cancer has been more popular and treatment strategy rapidly changing based on more accurate preoperative local staging finding and minimal invasive surgical techniques become popular too. One of the advance technology is the development of transanal local excision techniques such Transanal endoscopic microsurgery technique such as TEM(transendoscopic microsurgery), TEO(transendoscopic operation) and TAMIS (transanal minimal invasive surgery). Those techniques make us be able to excise early rectal cancer with full thickness as well as unfragmented state, also can be approached to the upper rectum, which can not approach with previous conventional transanal approach method. Local excision for early T1 rectal cancer has been regards as good treatment option because patient can avoid complication related to the radial proctotectomy such as anastomoitc leakage, postoperative sexual and voiding dysfunction and dysregulated bowel movements. Neoadjuvant chemoradiation therapy has been recommended for patient with cT3N0 or cT3 N+ rectal cancer because some clinical trials showed us preoperative chemoradiation therapy showed better local control rate and less toxicities than postoperative chemoradiation treatment. Recent clinical trial both retrospective and prospective showed us a promising results about local excision after neoadjuvant chemoradiation selectively in patients with low rectal cancer. Neoadjuvant chemoradiation therapy for cT2N0 followed by local excision reported excellent oncologic outcomes quite comparable to the radical surgery group. In addition to that, there has been some reports which showed clinical complete remission after neoadjuvant chemoradiation therapy could be wait and see. A couple of observational studies showed wait and see can be possible option of treatment in selective patients. Radial surgery for middle and low rectal cancer still remains a cornerstone of surgical treatment Ultralow anterior resection with or without intersphincteric resection became a more standard surgical method for low rectal cancer. Oncologic and functional outcomes has been reported as safe even functional outcomes study was rare. Furthermore, Abdominoperineal resection has been famous for high intraoperative tumor perforation and positive circumferential resection margin, those factors have been contributed to the high rate of local recurrence and poor survival rate compared with sphincter saving procedures for rectal cancer. Recently, there have been great efforts for reducing theses problem and total levator excision or extended abdominoperineal resection concepts emerged. Surgeons who advocated this concept recommended perineal dissection under the Jack-knife position. Surgical management for low rectal cancer should be directed for radically and preserving function based on multimodality approach. We need more high level of evidence based on prospective clinical trials for tailored treatment of rectal cancer patients

Update and Debate Issues in Surgical Treatment of Middle and Low Rectal Cancer

Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.

Results of Levator Excision Followed by Fascia Lata Brow Suspension in Patients with Congenital and Jaw-Winking Ptosis

Aim: The purpose of the study was to examine the results of frontalis brow suspension after levator excision in patients with ptosis, and to determine whether satisfactory cosmetic results can be achieved with this procedure. Methods: A retrospective case notes review of 13 patients (21 lids) undergoing levator weakening and frontalis brow suspension using autogenous fascia lata was performed. Seven patients (14 lids) were affected by the Marcus Gunn jaw-winking phenomenon. These had bilateral levator muscle excision. Five patients (5 lids) had unilateral congenital levator dystrophy (isolated congenital ptosis) with poor levator function. These had levator muscle excision on the normal side only. One patient (2 lids) had congenital aberrant regeneration of the third nerve. This patient had bilateral levator muscle excision. A successful result in terms of lid height was defined as a lid height within 1 mm of the desired height. Results: During the first post-operative month, 11 out of 21 lids were undercorrected by more than 1 mm, whilst 10 achieved a satisfactory lid height. At subsequent follow-up visits, 18 lids were within 1 mm of the desired height and only 3 lids of 2 patients remained undercorrected by more than 1 mm and required further surgery. There were no overcorrections. Conclusions: Excision of the levator muscle followed by brow suspension ptosis correction can reliably produce satisfactory cosmetic results with good symmetry of lid movement and position. It is used selectively in the normal upper lid in congenital ptosis with poor levator function and in both upper lids in synkinetic ptosis.

Clinical characteristics of moderate and severe Marcus-Gunn jaw-winking synkinesis and its surgical treatment

To investigate the clinical characteristics of moderate and severe Marcus-Gunn jaw winking synkinesis and it surgical management. Thirty-three patients with Marcus-Gunn syndrome were enrolled from 1997 to 2003 in Zhongshan Ophthalmic Center. The clinical characteristics were analyzed based on the records. Unilateral levator excision and frontalis flap suspension were performed for the correction of ptosis and the results were analyzed. The follow-up period varied from 1 to 6 years. Sixteen patients were male and 17 were female. The left eye was involved in 22 patients and the right eye in 11 patients. There was no family history. The amount of ptosis in each patient was more than 2 mm. At the end of observation, good results were achieved for ptosis correction in 26 (87%) of 30 patients, fair results in 3 (10%) patients. The ptosis of patients with moderate and severe Marcus-Gunn syndrome needs to be treated surgically. Unilateral frontalis flap suspension combined levator excision can correct ptosis very well for patients with moderate and severe Marcus-Gunn syndrome.

Use of the Levator Muscle as a Frontalis Sling

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. 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. Synkinetic muscle movements were completely abolished. All cases had good primary eyelid position, no corneal complications, and effective frontalis action on eyelid elevation. 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.

Management of moderate-to-severe marcus-gunn jaw-winking ptosis

Objective To report the results of levator excision and frontalis suspension for moderate-to-severe Marcus-Gunn jaw-winking ptosis. Design A retrospective noncomparative case series. Participants Twenty-four patients with moderate-to-severe Marcus-Gunn jaw-winking ptosis (21 unilateral and 3 bilateral) were treated surgically between 1978 and 1997 by one surgeon. Intervention Levator excision either in the involved eyelid or in both eyelids, followed by bilateral frontalis suspension, was performed. Main outcome measures Postoperative improvement of jaw-winking was determined. The surgical results of ptosis surgery were assessed as good, fair, or poor based on habitual upper eyelid heights and symmetry. Results Postoperative follow-up periods ranged from 6 months to 153 months, with an average of 36.9 months. After levator excision in a total of 27 eyelids exhibiting jaw-winking, 10 eyelids (37.0%) showed complete resolution of jaw-winking, and 13 eyelids (48.2%) showed mild winking (1 mm or less) on the lateral jaw movement only (functionally and cosmetically not a problem). In four eyelids (14.8%), these results were not recorded. In the group of five patients undergoing bilateral frontalis suspension and levator excision only on the involved side, final results were good in two patients (40%) and poor in three (60%). Of the 19 patients who underwent bilateral levator excision, final results were good in 13 (68.4%) and fair in 6 (31.6%). Conclusions For moderate-to-severe jaw-winking ptosis, bilateral frontalis suspension after bilateral levator excision generally provided satisfactory correction of both jaw-winking and ptosis.

Eye Bobbing Associated with Jaw Movement

Two patients were treated for a previously unreported disorder believed to be related to Marcus Gunn jaw-winking. The first, a 9-month-old infant with left congenital blepharoptosis without jawwinking and with normal ocular motility had an up and down movement of the left globe synchronous with nursing movements of the jaw. The second was a 5-year-old girl with left blepharoptosis, jaw-winking, and left double elevator palsy who had up and down movements of both the left upper lid and the left globe synchronous with chewing. The left globe movements were most prominent in the field of vertical action of the superior rectus muscle and persisted after levator excision and fascia lata sling procedures. The possible etiology of the Marcus Gunn jawwinking phenomenon is discussed and related to our cases of eye bobbing. The eye bobbing probably is caused by abnormal innervation to the superior rectus muscle produced by jaw movements in a manner analogous to the abnormal stimulation of the levator muscle in jawwinking. The similar embryologic development and innervation of the levator and superior rectus muscles add credence to this theory.