Levator Muscle Function Research Articles

Decrease in Levator Function in the Anophthalmic Orbit

Background/Aims: It has been argued that levator function in anophthalmic patients is reduced, but no detailed report on this topic has been issued. This study was undertaken to investigate measured levator function in anophthalmic patients, and to determine how measured values are related to prosthesis size. Methods: Unilateral anophthalmic patients with no significant ptosis, and no history of trauma or surgery to orbit or eyelid were recruited. Levator function was measured with patients wearing their prosthesis, test prosthesis of different heights, and no prosthesis. Results: Thirty-two patients were recruited. Levator function was found to be lower in anophthalmic orbits (10.43 ± 1.48 mm) than in contralateral normal orbits (12.74 ± 1.81 mm). Levator function was lower in anophthalmic orbits with any height or type of prosthesis than in contralateral normal orbits (paired t-test, p < 0.05). In the anophthalmic orbits, the levator functions were highest when patients wore a prosthesis of the proper height, and these functions reduced as the prostheses height reduced (linear regression, p < 0.05). Conclusion: Diminished levator function in an anophthalmic orbit doesn’t necessarily mean that levator muscle function is abnormal. When levator function is measured in an anophthalmic orbit, the fact that it is often underestimated should be taken into account.

Comparative study of Botox® injection treatment for upper eyelid retraction with 6-month follow-up in patients with thyroid eye disease in the congestive or fibrotic stage

To compare morphometric data of the eyelid fissure and the levator muscle function (LF) before and up to 6 months after transcutaneous injection with five units of Botox in patients with upper lid retraction (ULR) from congestive or fibrotic thyroid eye disease (TED). Twenty-four patients with ULR from TED were submitted to transcutaneous injection of 5 units (0.1 ml) of Botox in one eye only. Patients were divided into two groups: 12 with congestive-stage TED (CG), and 12 with fibrotic-stage TED (FG). Bilateral lid fissure measurements using digital imaging and computer-aided analysis were taken at baseline and at regular intervals 2 weeks, 1 month, 3 months and 6 months after unilateral Botox injection. Mean values taken at different follow-up points were compared for the two groups. Most patients experienced marked improvement in ULR, with a mean reduction of 3.81 mm in FG and 3.05 mm in CG. The upper eyelid margin reflex distance, fissure height and total area of exposed interpalpebral fissure were significantly smaller during 1 month in CG and during 3 months in FG. Reduction in LF and in the difference between lateral and medial lid fissure measurements was observed in both groups. The treatment lasted significantly longer in FG than in CG. A single 5-unit Botox injection improved ULR, reduced LF and produced an adequate lid contour in patients with congestive or fibrotic TED. The effect lasts longer in patients with fibrotic orbitopathy than in patients with congestive orbitopathy.

Anthropometric Analysis of Levator Muscle Function

Measurement of levator muscle function is very important in the evaluation and choice of surgical methods for blepharoptosis. In addition, the functional values of levator muscles are very helpful in cases of bilateral ptosis surgery. The normal values of levator muscle function vary according to race, sex, and age. Unfortunately, there are few articles concerning this function in Asians, so the authors have been forced to use Caucasian statistical data in conducting blepharoptosis surgery, until now. There are two commonly used methods for measuring levator muscle function: Berke's method and margin limbal distance. The authors have measured levator muscle function by both of these methods, and have statistically analyzed the function of 498 individuals (234 males and 264 females). The mean levator muscle function values were 11.9 +/- 1.6 mm in males and 11.9 +/- 1.6 mm in females through Berke's method, and 6.5 +/- 1.0 mm in males and 6.6 +/- 1.0 mm in females by margin limbal distance. There was no statistical difference between male and female subjects in left and right levator muscle function. Levator function reached a peak level during the high teen years and twenties among a large percentage of subjects. After peaking, the pattern of change in levator function became stationary or decreased gradually. The results are very different from the reports of Putterman on his Caucasian subjects. Therefore, they should be applied as the standard in cosmetic surgery on Asian eyelids.

Correction of Congenital Ptosis by Suspension of the Frontalis Muscle Flap Overlapped with the Inferior-Based Orbital Septum Flap

Congenital ptosis of the upper eyelid presents a challenging and complex medical problem in ocular plastic surgery. The type of procedure selected to correct congenital ptosis usually is determined by the amount of ptosis and the functional integrity of the levator muscle. Many patients, both pediatric and adult, with congenital ptosis will have depressed or poor levator muscle function. This presents inherent difficulty for the reliability and efficacy of standard procedures such as levator resection or muellerectomy. Left untreated, this condition can result in amblyopia (due to astigmatism or occlusion) and cosmetic concerns. The standard procedure for congenital ptosis with poor levator muscle function involves using frontalis suspension techniques to recruit frontalis muscle and surrounding tissues to aid in elevation of the eyelid. This procedure, although often successful, has many significant side effects or complications. These include morbidity of the donor site, use of foreign materials in suspension of the lid, lagophthalmos and less than natural appearance, and movement of the eyelid. This article represents a straightforward and local approach to this complex and difficult problem. The surgical approach used has the benefit of modifying an already well-established surgical procedure (frontalis suspension) while using the frontalis muscle itself and the orbital septum to provide elevation to the eyelid. The technique is totally local in nature and avoids the associated morbidity of second-site surgery to obtain donor tissue. The surgical technique also uses the patient’s own tissues and avoids problems associated with foreign bodies and grafted materials. Incorporating a blepharoplasty into the surgery improved the cosmetic effect. The article describes in detail the technical steps involved in the procedure and incorporates drawings to facilitate understanding of the technique. A good series of preand postoperative photos demonstrating results and improved cosmetic appearance are provided. The photos demonstrate good postoperative lid positions without the eyebrow strained into severe elevation. The connection of the frontalis flap and the orbital septum/levator can be adjusted to set the lid at the best possible position. Very few if any complications occurred, and the procedure seems to be generally safe and predictable. No patients experienced postoperative problems with keratitis or corneal exposure. It is important in the preoperative evaluation to assess the patient for tear production via a Schirmer’s test and for a Bell’s response. It is prudent to discuss with the patient preoperatively the possibility of corneal exposure/dry eye and to treat it as indicated. This series, although not a large, demonstrated good longevity of results and easy management of all complications. The problem of reduced eyelid excursion in up/ down gaze would be expected due to the fibrotic nature of the levator muscle in congenital ptosis. Further study of this disorder would involve use of the described procedure for pediatric patients because the most common age at pediatric repair is about 5 to 6 years. I believe this technique would be helpful for other ‘‘poor levator muscle function’’ types of ptosis including Marcus Gunn jaw winking syndrome, chronic progressive external ophthalmoplegia, double elevator palsy, and traumatic ptosis. M. N. Longo (&) Ophthalmic Plastic Surgeons of Texas, 7500 San Felipe #200, Houston, TX 77063, USA e-mail: mlongomd@pleasingtotheeye.com

Surgical Correction of Blepharoptosis Using the Levator Aponeurosis–Müller’s Muscle Complex Readaptation Technique: A 15-Year Experience

Palpebral ptosis is defined as abnormal drooping of the upper lid, caused by partial or total reduction in levator muscle function. It may be caused by various abnormalities, both congenital and acquired. The aim of this article is to report the long-term follow-up of results obtained with the levator aponeurosis-Müller's muscle complex readaptation technique. In a clinical study, 144 eyelids (102 patients) affected by congenital or acquired blepharoptosis were treated using the levator aponeurosis-Müller's muscle complex readaptation technique. Degree of ptosis and levator function were measured preoperatively and postoperatively. All patients were followed up for 1 year, 54 of them for 3 years, 22 for 5 years, and 12 for 10 years. Complete correction or mild residual ptosis was achieved in over 83 percent. All ptosis with preoperative levator function greater than 8 mm was completely corrected, whereas eyelids with poor or absent levator function showed a variable degree of postoperative correction and a statistically significant difference. Ptosis correction between eyelids with levator function greater than 8 mm or less than 8 mm was analyzed statistically using the McNemar test for paired data. This surgical technique is effective in both acquired and congenital ptosis. In particular, the authors obtained better results in those with fair to good (> 8 mm) levator function than in those with poor or absent (< or = 8 mm) levator function.

Müller's Muscle–Conjunctival Resection for Correction of Upper Eyelid Ptosis

To evaluate the outcome of Müller's muscle-conjunctival resection (MMCR) for correction of upper eyelid ptosis and to explore the relationship between phenylephrine testing, muscle resection, and surgical outcome. Medical records were reviewed for all patients who underwent MMCR at the Jules Stein Eye Institute, Los Angeles, California, from January 1, 1999, through June 30, 2005. Outcome measures were margin reflex distance-1, ptosis correction after instillation of phenylephrine drops, extent of MMCR, ptosis correction, and eyelid symmetry. In 80 patients who underwent 131 MMCR procedures for correction of upper eyelid ptosis, margin reflex distance-1 increased on average by 1.6 mm (P < .001). In 106 patients (81%), eyelid symmetry equal to or less than 1 mm was achieved (P = .02). Phenylephrine testing underestimated the extent of ptosis correction achieved with MMCR. A weak correlation was found between the extent of MMCR and ptosis correction (r = 0.2; P = .04). Müller's muscle-conjunctival resection is effective for ptosis correction in patients with good levator muscle function; good eyelid symmetry is achieved in most patients. Phenylephrine testing underestimated the ptosis correction achieved with MMCR by 40%. The relationship between MMCR and ptosis correction is complex.

Strategies for Simultaneous Double Eyelid Blepharoplasty in Asian Patients With Congenital Blepharoptosis

Most patients with blepharoptosis prefer to undergo a double eyelid operation and a ptosis repair simultaneously to achieve the optimal cosmetic and functional result. However, it is difficult to achieve symmetry in patients with blepharoptosis. Surgery was performed on the levator aponeurosis or frontalis muscle to correct blepharoptosis while double eyelid surgery was simultaneously performed to correct blephroptosis in 264 patients over the past 15 years. This report describes 39 representative cases of unilateral congenital blepharoptosis and 30 representative cases of bilateral congenital blepharoptosis. In cases of unilateral ptosis with good or fair levator function, a levator resection or plication was performed, and the position of the lid margin was adjusted to 1 to 2 mm below the upper limbus. Cases of severe unilateral blepharoptosis were corrected by frontalis muscle flap, orbicularis oculi muscle flap, or frontalis myofacial flap, and the height of the double eyelid was created to be 1 to 2 mm less than the height on the normal side. The position of the lid margin was adjusted to the level of the superior limbus, and the height of the lid crease of the ptotic eye was determined to be according to that on the nonptotic side. For bilateral ptosis patients with equal levator function, the height of the double eyelid was designed symmetrically. Bilateral blepharoptosis patients with unequal levator muscle function should have the double eyelids on both sides created the same as in normal cases, and they must be grafted in proportion to the severity of the blepharoptosis. If the results are unpredictable, the two-stage operation should be performed. Only 30% of the eyelids in this study were perfectly symmetric after the blepharoptosis operation, with 70% asymmetric. These 70% showed good symmetry immediately after surgery, but asymmetry occurred 6 months after the operation. In blepharoptosis surgery, different techniques for double eyelids must be applied according to the method of ptosis correction used. Usually, the height of the double eyelid on the ptotic side should be a little less than the normal double eyelid height on the nonptotic side. However, it is difficult to achieve symmetric double eyelids in blepharoptosis patients.

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.

Neurofibromatosis type 2: a case of ptosis

Neurofibromatosis type 2 (NF2) is a disorder usually diagnosed later in life since the features are subtle in children. The hallmark is bilateral vestibular schwannomas, which may not appear until after the second decade. Other cranial nerve schwannomas occur as well. In addition, there may be schwannomas of spinal nerve roots or peripheral nerves, as well as meningiomas, gliomas, and ependymomas. Here is described a rare case of NF2 associated with a superior rectus muscle paralysis and severe ptosis. A complex surgical procedure, which achieved satisfactory results, is also described. A 17-year-old patient with NF2 was referred to us with diagnosis of left-eye superior rectus muscle paralysis, with a later onset of unilateral severe ptosis. Best-corrected visual acuity was 20/20 in both eyes; pupillary reflexes to light and near vision were normal, and subcapsular posterior opacity of the lens was detected. Eye motility examination confirmed a left-eye superior rectus paralysis and a severe ptosis with almost absent palpebral levator muscle function. The patient showed positive familiar history for NF (the father was affected), bilateral involvement of the acoustic nerves (schwannoma), multiple neurofibromas, and bilateral posterior subcapsular lens opacity. Magnetic resonance imaging (MRI) showed bilateral acoustic neuromas in the left temporal region close to the cavernous sinus; since neurological examination and ocular motility problems had remained stationary over time, surgical correction of ptosis and strabismus was suggested. Palpebral ptosis has rarely been reported in NF2. In the case described, ptosis associated with rectus superior palsy was caused by expansive processes in the temporal region close to the cavernous sinus. In order to resolve ptosis and vertical diplopia, we performed a complex surgery that achieved satisfactory results.

Quantidade de gordura no músculo levantador da pálpebra de portadores de ptose congênita

To quantify the fat in the levator muscle of patients with congenital ptosis, as related to clinical and epidemiological aspects of this disease. Twenty-two levator muscle samples of the superior eyelid from patients with congenital ptosis were morphometrically evaluated with aim of establishing a relationship between the fat quantity and age, sex, ptosis degree and levator muscle function. According to our results the fat in the levator muscle of patients with congenital ptosis is not related to gender or epidemiologic aspects. Fat amount in the levator muscle from congenital ptosis is not related to age, sex, ptosis degree or levator muscle function. Other studies will be necessary to show the real alterations in the levator muscle related to eyelid ptosis.

Technique for Blepharoptosis Correction Using Double-Breasted Orbicularis Oculi Muscle Flaps

The technique that uses the orbicularis oculi muscle flap to elevate the upper eyelid has become a popular surgical alternative for blepharoptosis. This method is especially effective in cases of severe blepharoptosis with poor levator muscle function. In this technique, the superiorly based orbicularis oculi muscle flap (which is connected to the frontalis muscle anatomically) is advanced and attached to the tarsal plate, thus enabling dynamic elevation of the upper eyelid. However, a temporary period of lagophthalmos occurs with the original method. Although the problem is temporary, it typically lasts 2 to 6 months and may lead to serious eye emergencies. We describe a modification that eliminates lagophthalmos, which is the main drawback of the original technique. Two orbicularis oculi muscle flaps are created, one superiorly based and one inferiorly based. The inferiorly based flap corresponds to the strip of pretarsal orbicularis oculi that is considered "excess" and is discarded in other methods. Our aim with this modified technique is to preserve as much of the pretarsal part of the orbicularis oculi muscle as possible, and thus enable immediate tight eyelid closure postoperatively and achieve dynamic, powerful eyelid-opening action. We have used this technique in 7 patients (11 eyelids total) during the past 5 years and have achieved favorable results. All 11 operated eyelids showed immediate tight closure postoperatively, as well as dynamic, powerful eyelid-opening action. This operation is a good alternative for patients with severe ptosis who have insufficient levator function and for cases that have recurred after operations with other methods. Local native tissues are used and dynamic correction is achieved with a single incision. The need for intensive eye care is eliminated and there is less risk of corneal damage in the early postoperative period. Above all, this technique yields predictable eyelid-opening action.

Ptosis as an Initial Manifestation of Orbital Lymphoma: A Case Report

Ptosis on its own is an infrequent initial manifestation of orbital lymphoma. Orbital lymphoma usually presents as a palpable mass with proptosis, diplopia, and conjunctival ("salmon-pink") swelling. We report here a 62-year-old female patient who presented with right eye ptosis. The initial imaging study showed an indistinct enlargement of the superior rectus-levator muscle complex. After 3-4 months, ptosis and upward gazing movement were further restricted. The imaging study revealed a definite soft-tissue mass in the superior orbit surrounding the superior rectus-levator muscle complex. A tumor biopsy through anterior orbitotomy revealed a large diffuse B-cell lymphoma. With the experience of this case, we suggest that orbital lymphoma should be included in the differential diagnosis of ptosis accompanied by impairment of levator muscle function.

Palpebral Ptosis: Clinical Classification, Differential Diagnosis, and Surgical Guidelines

Palpebral ptosis indicates the abnormal drooping of the upper lid, caused by partial or total reduction in levator muscle function. It may be caused by various pathologies, both congenital and acquired. Based on a review of the available literature and on our own clinical experience, a classification is proposed as well as a differential diagnosis between ptosis and pseudoptosis. Some basic surgical guidelines related to age of onset and etiopathogenesis are drawn. Ptosis is divided into neurogenic, myogenic, aponeurotic, and mechanical. The aim of surgery is two fold: functional, to correct the limit in the visual field; and also aesthetic. From January 2000 to January 2004, 42 patients were referred and treated at the Unit of Cranio-Maxillofacial Surgery-Centre for Orbital Pathology and Surgery, Hospital and University, Ferrara, Italy. Of these, 12 cases were congenital and 30 acquired (13 were monolateral and 29 bilateral, for a total of 71 cases). The most widely used surgical techniques were levator muscle recession and frontalis suspension. In congenital forms, these techniques were often associated with techniques to correct oculo-muscular imbalance (i.e., strabismus).Seventy-one upper eyelids were treated, 5 of which were mild, 35 moderate, and 31 severe. Regarding levator muscle function, 60 were fair and 11 poor.Surgical treatment followed the indications and timing with good morphologic and aesthetic results. Complications included two cases of hypocorrection, two asymmetries, and two cases of hypercorrection. Surgical treatment of palpebral ptosis is complex and requires precise diagnosis and indications for surgery related to clinical examination and pathogenesis. Even if these indications are strictly followed, in some cases, the outcomes are unpredictable.

The Search for an Ideal Surgical Procedure for Pediatric Congenital Ptosis With Poor to Absent Levator Muscle Function Continues

&lt;h4&gt;EXCERPT&lt;/h4&gt; &lt;p&gt;The surgical management of severe congenital blepharoptosis in pediatric patients continues to evolve. Results are often less than ideal regardless of the procedure used. This accounts for the numerous reports of proposed improved techniques and modifications of frontalis suspension and maximal levator muscle resection surgical procedures. A recent improvement in the frontalis suspension procedure is the incorporation of tarsal fixation of the suspensory material. This procedure includes an eyelid crease incision with dissection to the tarsus. This technique may preclude slippage of the suspensory material and recurrence of the ptosis. Although this increases surgical time, the improved long-term results make the extra time invested well worth it.&lt;/p&gt;

Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age

Purpose To evaluate the outcome of frontalis suspension surgery for congenital ptosis using autogenous fascia lata for children under 3 years of age. Design Retrospective nonrandomized interventional case series. Methods This study included nine children (14 eyelids) with severe congenital ptosis aged less than 3 years. All patients underwent frontalis suspension surgery using autogenous fascia lata. Postoperative lid level results, ptosis recurrence, and cosmetic appearance of leg scars were evaluated after the operation. Results The mean age of the patients was 15.3 months (range, 6 months to 2.5 years) with a mean follow-up period of 41.6 months (range, 18 to 96 months). All children achieved satisfactory cosmetic and functional results, with no postoperative complications such as wound infection, corneal exposure, eyelid contour abnormalities, or ptosis overcorrection. No recurrence of ptosis was encountered. Harvesting was not difficult, and a sufficient amount of material was achieved. There was one patient (11.1%) with a hypertrophied leg scar. Conclusions Frontalis suspension using autogenous fascia is proposed as a possible procedure for correcting congenital ptosis in children younger than 3 years of age. It appears to be an effective and feasible treatment for children with poor levator muscle function in this age group.

Classification, assessment, and management of childhood ptosis.

Ptosis in childhood may both impair normal visual development and be cosmetically disfiguring. Ptosis may sometimes be a component part of a more extensive disorder involving the extraocular muscles, facial structures, or nervous system. Each patient must receive a thorough ocular examination, as well as careful assessment of the ptosis itself. Optimum outcome following surgical repair depends on the correct choice of operation for the specific type of ptosis and degree of levator muscle function.

Evaluation of bupivacaine-induced muscle regeneration in the treatment of ptosis in patients with chronic progressive external ophthalmoplegia and Kearns-Sayre syndrome.

Ptosis is common in patients with mitochondrial disease. Whilst surgical shortening of the levator muscle can mechanically elevate the lid, this procedure does not restore normal movement and leaves patients at risk of corneal exposure due to concomitant ophthalmoparesis. Recent studies have shown that bupivacaine-induced muscle regeneration is capable of reversing the molecular genetic and biochemical defect in patients with mitochondrial myopathies. This study was undertaken to assess the potential of this approach in restoring levator muscle function in patients with mitochondrial disease and ptosis. The levator muscle of one eye in five patients with molecularly genetically confirmed mitochondrial DNA disease and ptosis was directly injected with 3 ml of bupivacaine hydrochloride (0.75%). Levator function was compared before and 3 months after the injection. No objective clinical improvement in levator function was detected following bupivacaine administration. The lack of functional recovery seen in our patients is most likely to result from a failure of bupivacaine to induce sufficient regeneration necessary to improve levator muscle function. This result indicates that consideration now needs to be given to the use of alternative and more potent myotoxic agents capable of inducing a more widespread regenerative response from the endogenous muscle satellite cells which contain low or undetectable amounts of mutant mitochondrial DNA.

Fox's Modified Technique Using the Mersilene Mesh Sling in the Management of Blepharoptosis

Frontalis suspension is the best surgical procedure for severe ptosis with poor or absent levator muscle function. In addition to autologous fascia lata, a variety of materials are available for suspension. The authors describe the use of Mersilene mesh slings developed to overcome the problems of failure, slippage, and extrusion commonly associated with various suspensory materials. Brow suspension was performed in 20 ptotic eyelids of 14 patients. All patients had severe ptosis with levator function of 4 mm or less. The surgical technique used was a modified version of the method originally described by Fox using the Mersilene mesh sling. The improvement in lid height was evaluated by preoperative and postoperative vertical aperture measurements and ranged from 2 to 5 mm (average 3.5 mm). The results were maintained in all cases during a follow-up period of 18 months. The good functional and cosmetic results suggest that Fox's modified technique using the Mersilene mesh sling has a definite place in ptosis management.

Unilateral Congenital Ptosis With Ipsilateral Superior Rectus Muscle Overaction

Congenital ptosis may be accompanied by weakness of the ipsilateral superior rectus muscle. We report the finding of a hypertropia of the ipsilateral eye in patients with isolated unilateral congenital ptosis that became manifest only in upgaze. Seventy consecutive patients with congenital ptosis were recalled and 58 reexamined. Examination included assessment of visual acuities, palpebral apertures, levator muscle function, and an orthoptic examination. Particular attention was paid to the assessment of upgaze. Thirty-eight patients had an isolated unilateral congenital ptosis. Four patients had bilateral ptosis, six had upgaze deficits, and ten others had a variety of other syndromes associated with ptosis. Seventeen of the 38 patients with isolated unilateral congenital ptosis were found to have an ipsilateral hypertropia on upgaze. The size of the vertical deviation varied from 5 to 30 prism diopters and, in the more severe cases, produced a cosmetic problem that became more noticeable after successful ptosis surgery. In one of these patients, a superior rectus muscle posterior fixation suture was effective in reducing the hypertropia. Of a number of possible causes for the ipsilateral hypertropia in upgaze in patients with unilateral congenital ptosis that we observed either a misdirection syndrome within the superior division of the oculomotor nerve or an exaggerated Bell's reflex is the most likely.

Use of Gore-Tex sling in brow suspension procedure.

A variety of materials have been employed for brow suspension surgery for ptosis. Gore-Tex (expanded polytetrafluoroethylene ePTFE) has been used as vascular prosthesis. We have used cylinder Gore-Tex in brow suspension surgery for 15 ptotic eyelids (11 patients), including 10 eyes (8 patients) of congenital ptosis, 1 eye of traumatic ptosis in a young male, and 4 eyes (2 patients) of myogenic ptosis in elderly patients. All of the eyelids had minimal or absent levator muscle function, and drooped to cover the visual axes. The surgical technique for the 10 congenital ptotic eyelids was a modified Fox's method. The remaining 5 adult eyelids were operated by a modified Crawford's method, with interlocking of the two suspension bands at the lower apex of each triangle and direct suturing of the bands to the tarsal plate. The use of Gore-Tex in brow suspension makes it easy to adjust the height and contour of the operated eyelids. Patients were followed-up from 2 to 16 months (average 9.1 months) postoperatively. The only complication was granuloma formation at the most upper knot area in 5 patients (6 eyelids), one of which also had granuloma at the ipsilateral fornix with the Gore-Tex band cutting through the conjunctiva. One eyelid drooped due to knot granuloma and infection.(ABSTRACT TRUNCATED AT 250 WORDS)