Poor Levator Function Research Articles

The Use of a Pleated Strip of Autogenous Temporalis Fascia Graft for Frontalis Suspension in Recurrent Poor Levator Function Ptosis in Adult Patients

Purpose: Poor levator function (LF) blepharoptosis can be corrected surgically using frontalis muscle suspension with a variety of materials. Autogenous grafts such as fascia lata are commonly used. The need for a remote surgical site and the risk of an unattractive leg scar makes the use of an autogenous temporalis fascia (ATF) graft appealing as the scar is concealed in the hair. We describe the use of a pleated, lengthened ATF graft that is easy to prepare and insert, and provides a cosmetically acceptable outcome.Methods: Prospective case series describing six patients with previous multiple failed lid surgeries and recurrent poor (≤5 mm) LF (mean 2.87 ± 1.72 mm) ptosis. The pleated graft technique was used to yield a strip of ATF up to 18-cm long from a short 2-cm temporal incision. Eight eyelids then underwent ATF graft frontalis suspension surgery using the modified Fox pentagon technique. Outcomes included eyelid measurements with 4.5-year follow-up.Results: All patients achieved good functional and esthetic outcome. The mean central palpebral aperture 6 weeks postsurgery was 7.14 ± 1.67 mm, equating to a mean increase of 3.27 mm (p < 0.05 using the paired t-test). The improvement in eyelid height was maintained at the 4.5-year follow-up in all patients, except one who died of unrelated cause.Conclusion: A pleated strip of ATF graft provides a simpler alternative to fascia lata grafting for frontalis suspension in poor LF ptosis in adult patients with good long-term results.

Direct Frontalis Flap with and without Levator Pulley for Correction of Severe Ptosis with Poor Levator Function in the Same Patient

Purpose: To compare two techniques of frontalis muscle flap suspension in different eyelids of the same patient for correction of severe ptosis with minimal levator function.Material and methods: A prospective study of four patients with severe bilateral ptosis and poor levator function, who underwent direct frontalis muscle flap on the right eyelid and frontalis muscle flap with levator pulley on the left eyelid was conducted. Eyelid studies measurements were taken at baseline, 2 months, one year and 5 years after surgery. The presence of complications, flap function and palpebral contour were evaluated.Results: Despite the surgical technique performed, good results in terms of functionality, contour and aesthetics were observed. In the eyes that underwent frontalis muscle flap (FMF)-direct, there were 2 cases with moderate anteriorization of eyelid margin in extreme upgaze and all patients showed eyelash ptosis that persisted one year after surgery, but improved after 5 years. In the eyes that underwent FMF-pulley, no upgaze anteriorization of eyelid margin was observed and three patients had eyelash ptosis of lesser extent than the fellow eye, improving after 1 year follow-up. FMF-pulley showed more long-term stability in eyelid height, compared with FMF-direct.Conclusions: Frontalis muscle flap with a pulley in the levator aponeurosis prevents some complications caused by the excessive vertical component of the direct frontalis muscle flap, especially in deep-set eye patients, with better stability of the eyelid height and contour over time.

Frontalis sling procedure for ocular myasthenia gravis

A 39-year-old woman was diagnosed with myasthenia gravis when she was 8 years old. Although many treatments – such as cholinesterase inhibitors and steroids – had been given to the patient, her condition did not improve sufficiently. As she demonstrated bilateral 3 mm levator function without any eye movement disturbances, bilateral frontalis sling procedures were performed with an autologous fascia lata. One year after the operation, the operated upper eyelids showed symmetrically appropriate heights with good functional outcome. A sling procedure with an autologous fascia lata was suitable for correcting poor levator function of an ocular myasthenia gravis case.

Direct Tarsus to Frontalis Muscle Sling without Flap Creation for Correction of Blepharoptosis with Poor Levator Function

Purpose: To report the outcomes of ptosis surgery in patients with weak levator function utilizing the direct tarsus to frontalis muscle sling technique without creation of a flap.Methods: In a prospective nonrandomized case series over a 3-year period, patients with ptosis and weak (less than 4 mm) levator function underwent direct sling of the tarsus to frontalis muscle without creating any flap. Success was defined as upper lid margin to central corneal reflex distance of at least 3 mm in bilateral cases and a difference of less than 1 mm in unilateral cases.Results: Overall, 26 eyes of 22 patients with mean age of 15.4 ± 9.4 years were operated and followed up for 13.5 ± 8.4 months. The ptosis was congenital in 15 patients (68.2%) and acquired in 7 patients (31.8%). Twelve patients (54.5%) had a history of ptosis surgery. The procedure was judged as successful in 77.3% of patients after initial surgery and in 100% after reoperation. Surgical success after initial surgery was directly correlated with the amount of levator function (P = 0.02). However, success was not associated with age (P = 0.9) or history of surgery (P = 0.9). None of the patients developed eyelid hematoma, lagophthalmus or dry eye.Conclusions: Direct sling of the upper tarsus to the frontalis muscle without creation of flap is an effective procedure for correction of ptosis in patients with weak levator function. Minimal dissection and preservation of the orbicularis oculi prevents lagophthalmus and its consequences.

Open loop fascial sling for severe congenital blepharoptosis

Purpose Severe congenital eyelid ptosis present as a functional and aesthetic problem. The choices of procedures depend mainly on providing an additional elevator force to the upper lid to elevate it, and maintain a reasonable eye opening and vision. We describe a simple open loop fascia lata suspension sling to the frontalis muscle to treat patients with sever eyelid ptosis and poor levator function. Methods Sixty nine lids in 51 patients, were enrolled in this study, all had sever eyelid ptosis and had autogenous fascial sling used for the correction of the ptosis. Results The final lid level and contour was evaluated after the follow-up period and showed that the results were satisfactory in 77% of the patients. The unsatisfactory results were due to under correction in 10%, poor lid crease in 6%, lid notch in 4%, and entropion in 3% of the operated lids. Conclusions The accurate evaluation and implementation of this technique can correct the problem of ptosis provided that the patients exercises the frontalis muscle in order to accomplish the desired lid level.

Increased Levator Muscle Function by Supramaximal Resection in Patients With Blepharophimosis-Ptosis–Epicanthus Inversus Syndrome

To study the efficacy and clinical and anatomical results of supramaximal levator resection in patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) with severe congenital ptosis with poor levator function (LF). Eleven patients with molecularly proven BPES underwent supramaximal levator resection. Palpebral fissure height and LF were measured preoperatively and postoperatively. All patients showed an excellent reduction in ptosis with a single intervention resulting in a clear visual axis. Palpebral fissure height improved from mean (SD) 3.3 (0.7) mm preoperatively to 7.1 (0.9) mm postoperatively (P value <.001). Four patients underwent additional surgery because of cosmetic issues with eyelid height asymmetry. All patients showed a marked, consistent, and lasting improvement in LF, going from mean (SD) 1.9 (0.9) mm preoperatively to 7.4 (1.1) mm postoperatively (P value <.001). This improvement could be attributed to the presence of a very long and thin tendon, as well as a striated muscle belly. This elongated aponeurosis inhibits the levator muscle from having sufficient impact on the vertical eyelid excursion. We demonstrated that supramaximal levator resection performed in patients with BPES not only results in good cosmetic appearance in terms of ptosis reduction in the majority of cases but also in a significant increase of the levator palpebrae superioris function. An anatomical substrate was found to explain these findings. To our knowledge, this is the first study to provide evidence of a marked increase in LF in BPES due to resection of the elongated tendon with reinsertion of the muscle belly.

Prolene frontalis suspension in paediatric ptosis

The aim of this study was to assess the efficacy of frontalis suspension using 4-0 prolene sutures for paediatric ptosis with poor levator function. A retrospective chart review was performed on children who underwent 4-0 prolene frontalis suspension from 2000 to 2008 with a minimum of 6 months' follow-up. Functional success was defined when three criteria were met: (a) satisfactory lid height (defined as margin-to-reflex distance ≥3 mm with minimal frontalis muscle tone); (b) satisfactory lid symmetry (≤2 mm asymmetry in margin-to-reflex distance); and (c) satisfactory cosmesis. Recurrence was defined by a drop in lid height of ≥3 mm from the initial post-operative level. A total of 23 patients (30 eyelids) were included. The mean follow-up duration was 28.7 months (range 6.3 to 100 months). The functional success rate was 74% (17/23 patients). Ptosis recurred in 22% (5/23) of patients. Only one patient (4%) developed a complication: a case of minor wound infection. In paediatric ptosis with poor levator function, prolene frontalis suspension has good efficacy and an excellent safety profile. The results of prolene frontalis suspension are comparable to those of other non-autogenous materials.

Brow suspension using 3-0 Prolene

Sir, We read with interest your publication of Garrott et al's1 recent case series, highlighting the long-lasting benefit of 2-0 Prolene brow suspension for congenital ptosis. Our experience of ∼10 years of performing suture brow suspension in children and adults, for a number of different indications, echoes these findings. In addition, we found that repeat brow suspension, when necessary, was a more straightforward undertaking using this technique. This technique avoids the sequelae of autologous fascia lata harvesting2 and the soft tissue complications associated with the use of mersilene mesh.3 A retrospective case note review highlighted 41 eyes having undergone brow suspension surgery using 3-0 Prolene over a 9-year period (2001–2009) at our institute. All cases with a levator function of <5 mm were included in the analysis, irrespective of cause of ptosis and age, to provide a realistic clinical picture. Mean age at operation was 23 years (range 1–74 years). Recorded palpebral aperture improved significantly following the surgery (P<0.0005; mean 4 mm pre-operation, 7 mm post-operation). The majority were free from complications, although seven (17%) experienced a recurrence of their ptosis requiring a further operation and five (12%) experienced discomfort or a lump at the site of the suture knot. The Kaplan–Meier plot shows the cumulative survival for the group (Figure 1). Figure 1 Kaplan–Meier plot demonstrating cumulative survival for brow suspensions using 3-0 Prolene. Unfortunately, no randomized controlled trials have been undertaken to determine the optimal material for brow suspension surgery. We commend Garrott et al for publishing their long-term outcomes and agree that fascia lata brow suspension is not a prerequisite for successful, long-lasting brow suspension surgery in children. Indeed fascia lata use is not without its complications, at both the harvesting site2 and through proposed contracture of the fascia lata itself leading to variability in the cosmetic results.4 In addition, we suggest a Prolene sutured brow suspension can be used in a broader group of patients, to provide adults with ptosis and poor levator function, a cosmetically and functionally satisfactory result in the long-term. It is worth noting that we have performed this procedure under local anaesthesia in a small number of adults. It is an easily reversible and repeatable procedure.

Transcutaneous Blepharoptosis Surgery: Simultaneous Advancement of the Levator Aponeurosis and Müller’s Muscle (Levator Resection)

Transcutaneous blepharoptosis surgery with simultaneous advancement of the levator aponeurosis and Müller’s muscle (levator resection) is a popular surgery which is considered effective for all types of blepharoptosis except for the myogenic type. Repair of ptosis cases with good levator function yields excellent results. A good outcome can be also obtained in cases with poor levator function, however, in such cases; a large degree of levator advancement may be required, which may result in postoperative dry eyes, unnatural eyelid curvature and astigmatism. These cases are therefore better treated with sling surgery. With the right patient selection, the levator resection technique is an effective method for ptosis repair.

Outcomes of levator resection in blepharoptosis patients with grafted corneas

To present the surgical results of, and postoperative complications after, resection of the levator aponeurosis as a treatment for aponeurotic blepharoptosis in patients with grafted corneas. Nine eyes with grafted corneas displaying aponeurotic blepharoptosis were investigated. Undercorrective resection of levator aponeurosis was performed on all nine patients. The margin reflex distance 1 (MRD1) values prior to the operation and at 7 days and 6 months after the operation were compared. The postoperative MRD1 values of patients with both poor and fair levator function were also evaluated. Differences in visual acuity and visual field before and after surgery were also assessed. The MRD1 values at 7 days and 6 months after the surgery were higher than before surgery, and there was no difference between the MRD1 values of patients with poor and fair levator function at these time points. Levator function 6 months after surgery improved compared with that before surgery. Neither visual acuity nor the visual field changed after the blepharoptosis surgery. There was no preoperative corneal problem in any patient, and postoperative corneal erosion in some patients resolved with only conservative care. In blepharoptosis patients with grafted corneas, the undercorrection of blepharoptosis by levator resection showed satisfactory surgical results regardless of levator function status (poor or fair), and did not adversely affect the survival of grafted corneas.

Orbital inflammation as a late complication of frontalis silicone elastomer sling operation for congenital ptosis

Frontalis suspension with the use of a silicone elastomer is one of the preferred procedures for correcting moderate-to-severe ptosis with poor levator function. This procedure involves the attachment of the upper eyelid to the frontalis muscle by a silicone sling. Although this surgery has been performed for many years, information regarding long-term outcomes and complications is relatively limited. We report a case of orbital inflammation 15 years after a frontalis silicone sling suspension operation for congenital ptosis.

Silicone Sling Allows Adjustable Ptosis Correction in Children and in Adults at Risk of Corneal Exposure

Background/Aim: Brow suspension is the procedure of choice for ptosis correction in patients with poor levator function. A subgroup of these patients, namely the ocular myopathies, is at risk of progressive muscle weakness and subsequent corneal exposure. We aim to demonstrate that silicone rods can be easily adjusted and therefore allows greater control of lid height in these patients.Method: A retrospective review of 42 consecutive silicone sling brow suspensions in 26 patients performed in Salisbury District Hospital between 1998 and 2007. The recurrence rate and ease of adjustment after silicone slings are compared with published results using monofilament prolene, polyfilament nylon, Mersilene mesh and expanded polytetrafluoroethylene.Results: Children: 12 lids of 10 children had primary brow suspension using silicone slings. Median follow up was 42 months. One lid required adjustment 3.75 years after surgery. Adults: 30 lids of 16 patients had silicone sling brow suspensions. Median follow up was 22 months. Seven lids (19.4%) needed adjustment between 2 and 11 months after surgery (median 8 months).Conclusion: Our results were comparable to alternative materials in respect of recurrence and were superior in respect of both granuloma formation and infection. Silicone is superior to all listed materials in respect of ease of adjustment of the sling in cases where the ideal lid position was not achieved after primary surgery.

Evaluation of Transconjunctival Frontalis Suspension Using Nonabsorbable Suture

To evaluate the transconjunctival frontalis suspension technique using nonabsorbable suture (4/0 polypropylene) in patients with severe blepharoptosis and poor levator function. A total of 22 patients (33 ptotic eyelids) were included in a prospective interventional case series study. All had severe ptosis with poor levator function. Transconjunctival frontalis suspension using 4/0 polypropylene suture was done in all patients. Twelve patients (17 eyelids) had congenital ptosis, 6 patients (12 eyelids) had blepharophimosis, and 4 patients (4 eyelids) had traumatic ptosis. The surgical technique was easy and fast and surgical results in the 3 groups were good functionally and cosmetically. Recurrences in 3 eyelids (9%) happened after 3 years. Follow-up ranged from 1 to 4 years. Transconjunctival frontalis suspension technique is simple and time saving for treatment of severe ptosis with poor levator function. It gives good functional and cosmetic results. Healing was normal with no postoperative swelling or infection. 4/0 Polypropylene exhibits satisfactory results and easy manipulation.

Use of the Levator Muscle as a Frontalis Sling in Monocular Elevation Deficiency

Purpose: For the correction of ptosis in monocular elevation deficiency (MED) patients, levator resection or frontalis sling operation with various materials has been used. The authors present a case of a monocular elevation deficiency patient who was treated for ptosis using the levator muscle as a frontalis sling. Case summary: A six-year-old male patient with left monocular elevation deficiency underwent a frontalis sling operation using a levator muscle. The patient had received left inferior rectus recession, left medial rectus resection and left lateral rectus recession with transposition. An upper eyelid skin crease incision was made, and the anterior surface of the levator muscle was exposed as far as the Whitnall ligament. A levator muscle flap was then formed from aponeurosis by incising the full width of the levator horizontally, just below the Whitnall ligament and anchored to the frontalis muscle. The surgical result was satisfactory as the preoperative MRD1 was 0.5 mm and the postoperative MRD1 was 2.5 mm. There were no complications such as keratitis or wound problems. Conclusions: The levator muscle flap can be an effective frontalis suspension material to correct ptosis in an MED patient with poor levator function.

Total levator aponeurosis resection for primary congenital ptosis with very poor levator function

Aim:This study was designed to evaluate the effectiveness of total levator aponeurosis resection in patients with very poor levator function secondary to primary congenital ptosis.Design:A retrospective, noncomparative single-institutional study was designed.Participants:Seven patients with very poor levator function secondary to primary congenital ptosis operated between May 2008 and May 2010 by one surgeon (AM).Materials and Methods:A retrospective study of seven patients with congenital ptosis evaluating eyelid elevation following total levator aponeurosis resection. End result is improvement of the eyelid elevation.Conclusion:Total levator aponeurosis resection is easy and effective tool in elevating the eyelid in patients with very poor levator function secondary to primary congenital ptosis.

Tarsal resection operation in correction of severe unilateral blepharoptosis with poor levator function

There are many options for surgical repair of congenital unilateral ptosis with poor levator function. We performed resection of tarsus, Muller muscle, and conjunctiva in conjunction with an intraoperative adjustable levator resection. Resection of tarsus, Muller muscle, and conjunctiva in conjunction with levator resection was performed in a prospective series of 17 consecutive patients with unilateral ptosis with poor levator function over a 2-year period. Pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Muller muscle resection, postoperative eyelid symmetry, and postoperative complications were evaluated. Mean preoperative upper eyelid margin to reflex distance was 0.11 mm. Mean postoperative upper eyelid margin to reflex distance was 3.20 mm. Improved postoperative eyelid symmetry within 1.0 and 1.5 mm was demonstrated in most of our cases (58% and 76%, respectively). The major complication has been exposure keratitis. Resection of tarsus, Muller muscle, and conjunctiva combined with adjustable levator resection can correct severe unilateral ptosis with poor levator function.

Outcomes in Silicone Rod Frontalis Suspension Surgery for High-Risk Noncongenital Blepharoptosis

To evaluate the outcomes of silicone rod frontalis suspension for complicated cases of ptosis with poor levator function. A retrospective interventional case series of consecutive patients undergoing silicone rod frontalis suspension by 2 surgeons over 20 years generated records of 51 eyelids (33 patients) with ptosis secondary to cranial nerve III palsy, myasthenia gravis, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy. Outcome measures included postoperative change in eyelid height, lagophthalmos, and corneal fluorescein staining; need for reoperation; patient and physician satisfaction; grading of postoperative photographs; and interobserver agreement. Forty-five percent of patients had preoperative corneal staining. Surgery resulted in a significant increase in eyelid height (+2.8 mm; p < 0.0001), lagophthalmos (+0.4 mm, p < 0.0001), and corneal staining grade (+0.3 units; p = 0.02). Most patients achieved a subjectively acceptable result. Patient and physician agreement with outcome assessment was good (kappa = 0.65, p < 0.0001). Twenty eyelids (39%) required revision of the silicone sling, most often for adjustment of eyelid height. Survival analysis differed by diagnosis (p = 0.0154) and was most favorable for patients with myasthenia gravis. Interobserver agreement on postoperative photographs was marginal. Silicone rod frontalis suspension surgery increases the eyelid height in complicated blepharoptosis patients with minimal eyelid excursion. Patients and physicians concur closely regarding satisfaction; masked assessment of photographic outcome parameters by observers yields marginal agreement. Because most patients undergoing this procedure have a narrow window for appropriate postoperative eyelid height, a relatively high proportion of patients required revision. Silicone rod frontalis suspension surgery is chosen in these challenging cases for the ease of adjustment.

Comparison of Mersilene Mesh and Autogenous Fascia Lata in Correction of Congenital Blepharoptosis: A Randomized Clinical Trial

To asses the functional results and complications of Mersilene mesh as an alternative to autogenous fascia lata in the management of low function ptosis. In a randomized clinical trial, 31 eyelids with poor levator function were operated on. In 16 eyelids Mersilene mesh (Group A) and in 15 eyelids autogenous fascia lata were used for frontalis suspension procedure (Group B). Nine patients with congenital unilateral and 11 patients with bilateral ptosis underwent sling procedure. There were no differences between the two groups with regards to functional (lid fissure height stability) and cosmetic (lid margin contour) results. Eyelid fissure increase was 4.00-/+1.46 mm in Group A and 3.13-/+1.72 mm in Group B. Change in eyelid fissure in both groups was significant (p=0.00, paired t-test), but intergroup difference was not significant (p=0.141, independent sample t-test). Follow-up for Group A was 14.2 (range 6-26) months and for Group B was 15.1 (range 9-29) months. Dermatochalasis was seen more in Group B (B/A = 10/2) and extrusion of Mersilene mesh was seen in two cases of Group A and none of Group B. Early complications such as corneal epithelial defects and entropion and late complications such as undercorrection were comparable in the two groups. Mersilene mesh with long-term functional results and low rate of complications is a suitable alternative to autogenous fascia lata as a suspensory material in ptosis surgery.

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.

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.