Postoperative Lagophthalmos Research Articles

Journey of frontalis muscle advancement in severe blepharoptosis: Review of the techniques, modifications, and outcomes.

We aimed to review the degree of standardization of frontalis muscle (FM)-orbicularis muscle advancement techniques in the management of severe congenital blepharoptosis and also study the evidence which supports the procedure correcting blepharoptosis. The undisputed rationale of all types of brow suspension in the management of severe blepharoptosis is based on the concept that slings are the conventional way to simultaneously suspend a ptotic eyelid and transmit the contractile action of the FM to the tarsal plate. Traditionally, frontalis suspension using sling has been used to treat patients with severe congenital blepharoptosis with poor levator function; however, postoperative lagophthalmos, forehead scarring, and recurrence remain major concerns. Since the early 80s, a significant number of consecutive articles have suggested that the eyelid can be effectively suspended by directly suturing FM to the tarsal plate. This review article intends to evaluate the level of standardization of FM advancement techniques in the management of severe blepharoptosis. 'In addition, to determine if the procedure should be performed in a standard manner, and is there enough evidence available to recommend FM advancement as a useful surgical technique.

Evaluating the Correlation between Ptosis Improvement and Immediate Postoperative Lagophthalmos following Blepharoptosis Surgery under General Anesthesia in Pediatric Patients.

Background: The objective of this study is to establish a potential correlation between postoperative improvement in upper eyelid ptosis, measured by the marginal reflex distance 1 (MRD1), and the immediate postoperative degrees of lagophthalmos (IPDL). The established correlation is then used to assess whether IPDL can be used as a reliable indicator of successful treatment of eyelid ptosis. Methods: This retrospective study involved 19 patients, aged 1 to 11, with a total of 28 eyes affected by ptosis, who underwent surgery under general anesthesia at Seoul National University Bundang Hospital from January 2018 to December 2022. We monitored the MRD1 of the patients for over six months postoperatively and measured the IPDL. Results: After ptosis correction surgery, no statistically significant correlation was observed between the improvement in MRD1 and IPDL. Furthermore, the degree of postoperative eyelid ptosis improvement was found to vary and was not consistently sustained, attributable to a range of factors. Conclusions: Our study did not establish a statistically significant correlation between IPDL and ptosis improvement as measured by MRD1. Further research is needed to draw definitive conclusions about their correlation.

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

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

Eyelid Blink Lagophthalmos and Blinking Velocity Changes After External Transcutaneous Dacrocystorhinostomy: A Prospective Study

To investigate the changes in eyelid blinking dynamics after external dacryocystorhinostomy (DCR). Prospective before-and-after study with follow-up. Patients undergoing external DCR surgery for primary acquired nasolacrimal duct obstruction were observed using high-speed videography that recorded eyelid blinking of both eyes for a total duration of 4 minutes at a rate of 120 frames per second. These recordings were taken before the surgical procedure, on postoperative day 3, and then at 1 week, 1 month, and 3 months after the DCR surgery. A total of 3 random blinks were selected and isolated from each video recording for data analysis. For each blink, lagophthalmos and eyelid blinking velocity were calculated for the operated eye, and their values were then compared with those calculated for the contralateral, nonoperated eye. Data were obtained for 22 patients. Operated eyes showed large postoperative lagophthalmos on postoperative day 3, with a mean of 56.58% ± 52.63% of the palpebral fissure height. Gradual improvement of the lagophthalmos occurred over the next follow-up visits, and reached a mean of 31.24% ± 36.71% at follow-up visit 3 months postoperatively. The velocity of eyelid blinking showed a significant reduction for the operated eyes, with gradual improvement over 3 months. Postexternal DCR eyelid blinking changes included significant blink lagophthalmos with decreased velocity of eyelid blinking which gradually improved over the 3-month follow-up period. A longer follow-up period may be required to confirm if eyelid blinking lagophthalmos and velocity will return to baseline levels.

Modified levator muscle complex suspension on treating pediatric blepharoptosis with poor Bell’s phenomenon

To evaluate the surgical outcomes of pediatric congenital blepharoptosis with poor Bell's phenomenon (BP) treated with modified levator muscle complex suspension. Forty-two pediatric congenital blepharoptosis patients with poor BP were treated with modified levator muscle complex suspension, and their major surgical outcomes such as marginal reflex distance1 (MRD1), palpebral fissure height (PFH), and postoperative lagophthalmos were retrospectively reviewed. The mean follow-up was 10.28 ± 9.89months (range 3-32 Months). Surgical success was achieved in 54 (87.1%) of 62 eyelids at the final visit, including excellent results in 46 (74.2%) eyelids, good results in 8 (12.9%) eyelids, and poor results in 8 (12.9%) eyelids, respectively. The postoperative PFH of affected eyes (7.97 ± 1.47mm) was significantly improved compared with that before surgery (3.58 ± 1.31mm). The mean MRD1 was improved from - 1.48 ± 1.36mm before surgery to 2.94 ± 1.46mm after surgery. The postoperative MRD1 was ≥ 3mm in 46 eyelids and < 3mm in 16 eyelids. The mean lagophthalmos was 1.42 ± 1.20mm 3months after surgery. All of the patients presented complete blink postoperatively. Postoperative complications were rarely observed during follow-up. No patient had exposure keratitis, but blepharoptosis recurred in 6 patients (8 eyelids). All patients had satisfactory eyelid symmetry and contour. No complications were observed until the last visit. The modified method results complete blink, mild, and quick recovery of lagophthalmos, flexible eyelid motility, stable ocular surface, and it is simple to perform with few complications and a low recurrence rate at 12.9%, which is worth to wide application on poor Bell's phenomenon blepharoptosis.

Bilateral levator muscle myotomy and frontalis muscle advancement flap in treatment of unilateral Marcus-Gunn jaw winking ptosis

Aim The aim of this study was to report the experience of performing bilateral levator disinsertion followed by bilateral frontalis sling among patients having unilateral Marcus-Gunn jaw winking and ptosis (MGJWP). Setting and design This is a retrospective study that was conducted at Elsafwa Eye Centre, Alexandria, Egypt. Patients and methods The medical records of 24 patients with significant unilateral MGJWP were retrospectively reviewed. Full ophthalmological examination included external eye examination, extraocular muscle motility testing, best-corrected visual acuity, margin reflex distance (MRD) in mm, levator muscle excursion in mm, and amount of jaw winking in mm. All patients in the study had significant winking phenomenon. Bilateral levator disinsertion followed by bilateral frontalis sling was performed. Postoperatively, the patients were examined for MRD in both eyelids, amount of wink, degree of lagophthalmos, eyelid contour, patient satisfaction, and presence of complications or undercorrection. Results More than 2 mm of winking was considered cosmetically unacceptable to the patient and/or the parents. Postoperative follow-up periods ranged from 6 to 52 months, with an average of 16.9 months. After bilateral levator myotomy and bilateral frontalis advancement flap, 22 eyelids (91.66%) showed complete resolution of jaw winking and 2 eyelids (8.33%) showed mild winking (2 mm or less). Surgery was redone in two patients (8.33%) for undercorrected ptosis after 6 months of follow-up, whereas two patients (8.33%) had contour problem in the operated ptotic eyelid. All patients had immediate postoperative lagophthalmos that totally resolved in all patients after 6-month follow-up. Conclusion Bilateral levator muscle disinsertion followed by bilateral frontalis suspension using frontalis muscle advancement flap is an effective surgical technique for the treatment of unilateral MGJWP, resulting in satisfactory symmetrical outcome and resolution of jaw winking and ptosis in most of the cases.

Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function.

BACKGROUND:Treating congenital blepharoptosis is often mandatory to clear the visual access and avoid amblyopia; however, when the levator function is poor, achieving a satisfactory long-term outcome is challenging. This study aimed to compare the outcomes of maximal levator resection (MLR) with those of frontalis suspension (FS) using Gore-Tex ®, in the treatment of congenital blepharoptosis with poor levator function.PATIENTS AND METHODS:The study included 102 eyelids of 66 patients of mean age 4.3 ± 1.6 standard deviation (SD) years, randomly divided into two groups (51 eyes each). Group A: FS using Gore-Tex ®, Group B: MLR. Postoperative outcomes were evaluated at 1, 6 and 12 months. Patients' ophthalmic examination including margin-reflex distance (MRD1) before and after surgery and postoperative complications were recorded.RESULTS:At the end of the follow-up, the mean MRD1 increased from 0.3 ± 0.7 SD mm in Group A, 0.4 ± 0.8 SD mm in Group B preoperatively, to 2.7 ± 0.5 SD mm and 2.9 ± 0.7 SD mm, respectively (P < 0.001 in both groups). Results of Group B were significantly higher than Group A (P = 0.047). Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B. The total recurrence rate was 6.9% (seven eyes), while other complications were recorded in 23 eyes (22.5%).CONCLUSION:MLR, compared to FS with Gore-Tex® sling, can be a more efficient surgical option to correct congenital blepharoptosis with poor levator excursion. Prominent postoperative lagophthalmos warrants close ocular surface observation in early follow-up weeks.

Safety and Efficacy of the Under-Corrected Frontalis Sling in Myogenic Ptosis Accompanying Extraocular Muscle Paralysis.

The surgical treatment of myogenic ptosis accompanying extraocular muscle paralysis is an intractable problem in the field of oculoplastic surgery due to the severe complications such as exposure keratopathy. It is promising to find an appropriate procedure to treat this kind of patients, which is able to ensure the safety and efficacy. The authors retrospectively reviewed 12 eyes of 6 patients who underwent the under-corrected "double V-Loop" frontalis suspension sling procedure for myogenic ptosis accompanying extraocular muscle paralysis and access the safety and efficacy of this kind of surgery. All the patients underwent corneal fluorescein staining and confocal microscopy before and after the surgery to inspect the corneal condition. The density of central corneal epithelial cells and endothelial cells were observed. After the surgery, the eyelids contour was natural, and the symmetry was achieved in these cases. The average palpebral fissures height changed from 2.75 ± 1.41 mm to 4.50 ± 0.35 mm (P = 0.0007) and margin reflex distance 1 changed from -1.25 ± 1.22 mm to +0.50 ± 0.35 mm (P = 0.0002). Out of 12 operated eyes, mild postoperative lagophthalmos was present in 4 cases but without exposure keratopathy during the follow-up, the confocal microscopy showed that there were no significant differences in central corneal superficial epithelial cells (P = 0.93) and endothelial cells (P = 0.90) before and after the surgery. The under-corrected "double V-Loop" frontalis suspension sling is a proper surgery in myogenic ptosis accompanying extraocular muscle paralysis, which leads to a low occurrence of exposure keratopathy, maintains the integrity of the cornea, and remains the patients' vision function.

Lagophthalmos after congenital ptosis surgery: comparison between maximal levator resection and frontalis sling operation.

To compare postoperative lagophthalmos after maximal levator resection (MLR) and frontalis suspension (FS) in congenital ptosis patients with poor levator function (LF). A cross-sectional study was performed to compare postoperative outcomes in patients with preoperative LF ≤ 4 mm who had undergone MLR or FS at a single tertiary institution, and who had visited the outpatient clinic between February 2017 and August 2018. Main outcome measures were as follows: (1) Preoperative LF and margin reflex distance 1 (MRD1), (2) Postoperative MRD1, lagophthalmos and grade of superficial punctate keratopathy (SPK). Our study comprised 152 eyelids of 122 patients. There were 71 eyelids in the MLR group and 81 eyelids in the FS group. The MLR group had comparable mean postoperative MRD1 (2.8 ± 0.8 mm) to the FS with autogenous fascia lata (AFL) group (3.0 ± 0.7 mm), while the FS with preserved fascia lata (PFL) group had the lowest mean postoperative MRD1 (2.2 ± 1.0 mm). The PFL group had significantly less lagophthalmos (0.6 ± 1.0 mm) than the AFL (1.9 ± 1.4 mm) and maximal levator resection (1.9 ± 1.7 mm) groups. In the MLR group, there was no significant difference in postoperative surgical measurements between the LF 0-2 mm group and LF 2.5-4 mm group in terms of exposure keratopathy, degree of lagophthalmos and MRD1. MLR is an effective alternative to FS in congenital ptosis patients with poor levator function, with the risk of postoperative lagophthalmos related to postoperative MRD1 rather than preoperative LF.

Frontalis Linkage Without Intraoperative Eyelid Elevation for the Management of Myopathic Ptosis.

To report the effect of frontalis linkage without intraoperative eyelid elevation for the management of myopathic ptosis. Retrospective analysis of 21 (42 eyelids) myopathic patients with bilateral ptosis who were operated between 1999 and 2017. All patients had orbicularis weakness and poor or absent Bell's phenomenon. Surgery consisted of using an autogenous fascia sling to link the tarsal plate to the frontalis muscle without any degree of intraoperative eyelid elevation. The main outcome measures were margin reflex distance, brow height and degree of brow excursion and degree of lagophthalmos, and exposure keratitis. After surgery, there were significant changes (p <0.0001) in both margin reflex distance and brow position. Mean margin reflex distance increased to 1.4 mm ± 1.34 DP and with full frontalis contraction, it reached 3.0 mm ± 1.73 DP, while mean brow position decreased 1.6 mm ± 1.59 SD, p < 0.0001. Postoperative lagophthalmos was not detected in 31 (74%) eyes. In the remaining 11 eyes (26%), lagophthalmos ranged from 1.2 to 5.2 mm (mean = 1.7 mm ± 0.74 DP). Mild inferior superficial keratitis was detected in 14 eyes (33.3%) of 7 patients only 3 of which had lagophthalmos. One patient needed additional surgery to correct unilateral eyelid retraction. Overall, 81.81% of the patients were pleased with the procedure. Myopathic ptosis can be alleviated with a minimal amount of lagophthalmos by just linking the tarsal plate to the frontalis muscle without lifting the eyelid margin intraoperatively.

A Modified Levator Resection to Improve Postoperative Lagophthalmos and Eyelid Lag.

To assess the effect of releasing the central attachment between the Whitnall's ligament (WL) and the levator palpebrae superioris muscle on the postoperative levator function (LF), eyelid lag, and degree of lagophthalmos. This retrospective case-control study included patients with moderate and severe simple congenital ptosis who underwent skin approach levator aponeurosis resection (LR) as a primary procedure with a minimum of 6-month follow up. Patients were divided into 2 groups; the first group underwent LR without WL release (control group) while the second group underwent LR with WL release. Preoperative demographics and clinical data were reviewed. Postoperative LF, eyelid lag, and degree of lagophthalmos as well as surgical outcomes were compared and analyzed in both groups. A total of 81 patients (88 eyelids) were included in this study. There were 50 males (61.7%). The mean age was ±SD 12.0 ± 9.5 years. The first group included 43 eyelids while the second had 45 eyelids. There was no statistical difference in demographics and preoperative data between both groups. The postoperative LF was higher in the second group (10.7 ± 2.1 mm) with less consecutive eyelid lag compared with the control group (7.8 ± 1.9 mm) (p < 0.001). The control group had acquired more postoperative lagophthalmos compared with the second group (p < 0.001). Complete surgical success was achieved in 82.2% in the second group compared with 60.5% in the control group (p = 0.024). Releasing the central attachment between WL and levator palpebrae superioris muscle has achieved an improvement in LF with minimal postoperative eyelid lag, lagophthalmos, and corneal complications.Releasing the central attachment between levator palpebrae superioris muscle and Whitnall's ligament during levator aponeurosis resection allows better levator excursion and minimizes postoperative lagophthalmos, eyelid lag, and corneal complications.

Simultaneous ipsilateral transconjunctival repair of upper and lower eyelid retraction in thyroid-associated ophthalmopathy

ABSTRACTPurpose: To report a simple, highly effective technique of simultaneous transconjunctival repair of upper and lower eyelid retraction in patients with thyroid eye disease (TED).Methods: A retrospective interventional case review was conducted on 22 eyes of 19 TED patients. The lower eyelid was recessed with placement of a tarsoconjunctival spacer graft harvested from the upper eyelid. The upper eyelid was then recessed through the conjunctival incision used to harvest the tarsal graft. A temporary tarsorrhaphy was placed for 5–7 days. The postoperative outcome was assessed by measuring the margin reflex distance of the upper eyelid (MRD1), inferior scleral show (ISS), and lagophthalmos.Results: The absolute change in MRD1 ranged from 0 to 5 mm with an average of 1.86 ± 1.34 mm. The absolute change in ISS ranged from 0 to 2 mm with an average of 1.3 ± 0.49 mm. One patient had postoperative lagophthalmos and 17 of 19 had improvement in their ocular surface exposure symptoms. None of the patients’ grafts were observed to undergo absorption during the postoperative course.Conclusions: This technique of harvesting a free tarsoconjunctival graft from the upper eyelid as a posterior spacer for the lower while simultaneously recessing the upper eyelid through the same incision is an effective and durable method of correcting eyelid retraction in TED.

Long-Term Effects of Frontalis Fascial Slings on the Elastic Properties of the Upper Eyelid

ABSTRACTPurpose: To measure the long-term effects of frontalis slings with fascial tissues on the downward eyelid saccadic movementsMethods: Downward lid saccades for 10, 20, 30, 40, and 50 degrees of downgaze were measured in a sample of 19 patients with congenital ptosis who underwent frontalis slings with fascia lata (autogenous and banked) and temporalis fascia. Mean postoperative time was 10.7 years ± 3.8 SD. Seventeen age-matched normal subjects comprised the control group. Lid movements as well as the magnitude of brow motion were quantified in all participants with an opto-electronic device that automatically corrected any head movement.Results: Most patients (77.4%) displayed lagophthalmos on eyelid closure. The lid saccades of the patients were severely restricted and did not increase beyond 30 degrees of downgaze. The maximum velocity of lid saccades was also abnormally low. Although the pre- and postoperative lid positions did not differ between eyes operated with the three types of slings, interocular analysis of patients who had bilateral surgery showed that the restrictive effect on the saccadic movements was more asymmetrical with banked fascia than with autogenous tissue. Overall, there was a significant negative correlation between the surgical effect with frontalis contraction and maximum saccadic amplitude. While in controls brow motion accounted for about 3.3–9.3% of the lid saccades, it was responsible for more than 43.5–57.4% lid movements in the patients.Conclusion: Fascial slings have a permanent restrictive effect on the elastic properties of the lids. Postoperative lagophthalmos is a natural consequence of any type of fascial sling. Downward saccadic amplitude is negatively correlated with the surgical effect with frontalis contraction.

Dacron mesh encasement of gold weight implants in paralytic lagophthalmos

Purpose: The purpose of this study is to evaluate the efficacy of Dacron mesh used as an encasement material for gold weight implantation, which is a new therapeutic technique, in patients with paralytic lagophthalmos. Materials and Methods: Fifteen eyelids of 14 patients with paralytic lagophthalmos, who underwent surgery with Dacron mesh-covered gold implants, were retrospectively reviewed. None of the patients had any eyelid surgery, and none had orbital or any other eyelid disease. All patients had various degrees of preoperative corneal pathology due to lagophthalmos. The patients were followed up for a mean of 17.5 ± 12.4 months (range: 6-36 months), and both postoperative success and complications were reported. Pre- and post-operative lagophthalmos degrees were compared between cases with successful results and cases with complications. Preoperative lagophthalmos degrees of <9 mm versus ≥9 mm were also compared between successful and complicated cases. The Wilcoxon signed test was used to measure mean differences between pre- and post-operative values. Differences were statistically significant when P < 0.05. Results: During final visits, while 13 of 15 operated eyelids had adequate lid closure with no complications, 3 of 15 patients developed inflammation and infection in the early postoperative period. During follow-up, two of complicated patients responded to treatment poorly, and implants were removed. Skin ulceration was observed in the third patient, and the implant was replaced with a new one with no Dacron coverage, achieving adequate lid closure and satisfaction. Conclusions: Dacron mesh may be a good option as a barrier for gold weight implants to prevent implant extrusions; however, the high rate of early postoperative inflammation raises concerns about its use.

Safety and Long-term Outcomes of Congenital Ptosis Surgery: A Population-Based Study.

To report the long-term outcomes of childhood ptosis surgery in a population-based setting over a 46-year period. In this population-based cohort study, the medical records of all patients who were residents of Olmsted County, Minnesota, diagnosed as having blepharoptosis and having undergone surgical management prior to 19 years of age (between January 1, 1965, and December 31, 2010), were retrospectively reviewed. Age at time of surgery, type of surgery, duration of follow-up, number and nature of revisions, degree of amblyopia, and postoperative lagophthalmos and dry eye were documented. Forty-seven children meeting inclusion criteria underwent ptosis surgery. The median age at time of first surgery was 5.6 years (range: 1.5 to 17.7 years). Fifteen of 47 (31.9%) patients required a second procedure. Three of 47 (6.4%) patients underwent three procedures. The median time was 1.1 years (range: 0.03 to 7.8 years) between the first and second surgery and 6.0 years (range: 0.3 to 6.1 years) between the second and third procedure. Seven of 47 (14.9%) patients had amblyopia. Nineteen of 47 (40.4%) patients were noted to have lagophthalmos and 3 of 47 (6.4%) presented for symptomatic dry eye postoperatively. In this population-based setting, more than half of the children with ptosis required only a single surgical procedure, although a significant proportion required two procedures. Postoperative lagophthalmos is common, but symptomatic dry eye is rare. [J Pediatr Ophthalmol Strabismus. 2016;53(4):212-217.].

Nylon Hang Back Sutures in the Repair of Secondary Ptosis Following Overcorrected Dysthyroid Upper Eyelid Retraction.

Repair of blepharoptosis secondary to surgical overcorrection of thyroid related primary upper eyelid retraction (secondary ptosis) can be unpredictable. This study describes the long-term results of "hang-back" nylon sutures, for an anterior approach surgical repair of secondary ptosis. This was a retrospective consecutive case note review of patients referred with secondary ptosis (after prior upper eyelid lowering for thyroid eye disease), under the care of a single surgeon at Moorfields Eye Hospital & subsequently at Barking Havering Redbridge University Hospitals NHS Trust (SSD). In accordance with hospital trust policy, this audit was registered and all patient data was anonymized, ethical approval was not required. Patients with secondary ptosis underwent surgery under local anesthesia through an upper eyelid skin-crease incision. The anterior portion of the levator muscle was freed from all scar tissues and its action re-established on the superior part of the upper tarsal plate, using two 6-0 nylon hang-back sutures placed centrally and medially. The margin reflex distance 1 (MRD1), skin crease height, eyelid contour, symmetry of eyelid position (difference in margin reflex distance 1 <1 mm in both eyes) and degree of lagophthalmos were assessed from clinical notes preoperative and postoperatively at 1, 3, and 12 months. Surgery was undertaken in 14 eyelids in 13 patients (3 males; 23%), with 9/14 (65%) eyelids having undergone attempted repair of ptosis prior to referral; in 7 of the 8 (88%) eyelids with previous failed ptosis repair, the referring surgeon had used soluble hang-back sutures. As compared with an average preoperative margin reflex distance 1 of 0.9 mm (median 1, range: -1 to 2 mm), the average margin reflex distance 1 at 3 months was 3.0 mm (median 3, range: 2.5-4 mm; p < 0.0001) and 2.8 mm at 12-month follow up (median 3, range: 2-4mm; p < 0.0001). The upper eyelid central skin crease height changed from a preoperative mean of 9.8 mm (median 9, range: 5-15 mm) to 8.7 mm at 3 months (median 8, range: 7-12 mm; p = 0.1412) and 8.9 mm at 12-month follow up (median 9, range: 7-11 mm; p = 0.2930). Only 3 patients had postoperative lagophthalmos (one patient 3 mm and two patients 1 mm) at 3 months after surgery, this resolving by the 12-month postoperative visit. Thirteen cases (93%) had a good functional, symmetrical, and aesthetic result at 12 month follow up, with a late recurrence of ptosis in 1 patient (7%). The "hang-back" semi-permanent suture technique for repair of over-corrected upper eyelid lowering in thyroid eye disease appears to provide an excellent and predictable long-term result with a low incidence of late recurrence of ptosis.

Secondary upper lid blepharoplasty: a clinical series using the tarsal fixation technique.

Background:One hundred consecutive secondary upper lid blepharoplasties were reviewed retrospectively to determine the lid characteristics of patients undergoing secondary blepharoplasty and the outcomes of all the procedures, which were performed using a tarsal fixation technique performed by one surgeon.Methods:The median age of the patients was 54 years, and 99 percent of the patients were women. The median time since primary blepharoplasty was 8.7 years (range, 2 to 22 years). At surgery, no additional skin was removed in 37 percent, and the median amount excised in the remainder was only 2 mm. Revision surgery was performed in 13 percent, mainly for incomplete correction of asymmetry (5 percent) or ptosis (4 percent). Nonsurgical complications were mainly ocular (8 percent). There were no cases of persistent postoperative lagophthalmos or dry eyes.Results:The term “postblepharoplasty look” was introduced to describe the different aging changes that follow primary blepharoplasty, mainly dermatochalasis (70 percent), with a high or absent and often poorly defined lid fold, with fat distribution irregularities. The tarsal fixation technique is advantageous in secondary blepharoplasty, as its benefit does not depend on further skin removal, minimizing the risk of lagophthalmos and dry eye syndrome. Lipoinfiltration for volume contouring is another major advance. The higher revision rate in secondary blepharoplasty reflects the incidence of asymmetry, lid ptosis, and scar from the original blepharoplasty, and from ongoing aging.Conclusions:The postblepharoplasty look of patients undergoing secondary upper lid blepharoplasty differs from the lid appearance of patients presenting for primary blepharoplasty. Tarsal fixation and lipoinfiltration are major advances in secondary upper lid blepharoplasty.

Revisiting the Single-Stage Forehead Flap in Nasal Reconstruction

To review the single-stage forehead flap for patient selection, technique, and main outcome measures. Patients undergoing nasal reconstruction between January 1, 1995, and June 30, 2000, were reviewed from medical records, photographs, and personal communication. All work was performed in an academic medical center. Fifty-one patients had a forehead flap for nasal reconstruction, of which 10 (20%) were repaired in a single stage. All patients had no evidence of small vessel disease, eg, hypertension, diabetes mellitus, or tobacco use. Nasal defects were limited to the upper two-thirds of the nose. The technique is modified from the original description by creating a unilateral, subcutaneous pedicle, wide undermining, and partial resection of the procerus muscle. One patient had superficial epidermolysis at the distal tip of the flap. The remaining 9 patients maintained complete viability with satisfactory outcomes. One debulking procedure was performed to the glabellar area for aesthetic reasons. The average interval for returning to work was 6.6 days compared with the minimal 3 weeks for conventional interpolated flaps. In select cases, a single-stage, island midline forehead flap can be used safely as an advantageous alternative to the conventional interpolated forehead flap.

Dry Eye Symptoms and Chemosis Following Blepharoplasty

To determine the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis following upper or lower blepharoplasty. To examine the outcomes among long-term blepharoplasty data to better understand the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis, to evaluate the known risk factors for DES in the general population, and to analyze intraoperative procedures (such as forehead-lift, midface-lift, canthopexy, and canthoplasty) to determine their effects on DES and chemosis. A retrospective medical record review was performed among all the cases of upper or lower blepharoplasty performed by the senior author during a 10-year period (January 1999 through December 2009). A self-reported dry eye questionnaire was used to collect baseline and follow-up data. Patients with incomplete medical records, multiple (>1) revision procedures, less than 3 weeks of postoperative follow-up data, or a history of Sjögren syndrome, severe thyroid eye disease, histoplasmosis ocular infection, periocular trauma causing eyelid malposition, or radiotherapy for nasopharyngeal cancer were excluded from the study. Binary logistic regression analyses were performed to analyze the relationship between 13 preoperative and anatomical variables and DES or chemosis. χ2 Tests were performed to analyze the relationship between intraoperative risk factors and DES or chemosis. In total, 892 cases met the study inclusion criteria. Dry eye symptoms and chemosis following blepharoplasty were reported in 26.5% and 26.3% of patients, respectively. The incidences of DES and chemosis were significantly higher in patients who underwent concurrent upper and lower blepharoplasty (P < .001) and in patients who underwent skin-muscle flap blepharoplasty (P = .001). Hormone therapy use and preoperative scleral show were associated with DES after blepharoplasty (P < .05). Male sex, preoperative eyelid laxity, and preoperative DES were associated with an increased incidence of chemosis following blepharoplasty (P < .05). Intraoperative canthopexy significantly increased the risk for developing chemosis (P = .009), and postoperative lagophthalmos significantly increased the risk for DES following blepharoplasty (P < .001). Dry eye symptoms and chemosis are common following blepharoplasty, and the risk for developing these conditions may increase with intraoperative canthopexy, postoperative temporary lagophthalmos, concurrent upper and lower blepharoplasty, and transcutaneous approaches violating the orbicularis oculi muscle. Patients with a preoperative history of DES, eyelid laxity, scleral show, or hormone therapy use may be at greater risk for developing dry eyes or chemosis following surgery.

Clinical Outcome of Surgical Treatment for Periorbital Basal Cell Carcinoma

Basal cell carcinoma (BCC) has a predilection for the periorbital region, which is a special, prominent, cosmetic, functional area to protect the eyeball. For squamous cell carcinoma and melanoma, extensive resection with reconstruction is performed. In contrast, for BCC, resection is often confined to a small to medium-sized area, necessitating higher-quality reconstructive surgery. We analyze the surgical outcomes of treatment for periorbital BCC, and evaluate reconstruction method after resection. Forty-nine patients with periorbital BCC had surgery in our hospital over 20 years. Age, gender of the patients, and size, localization, and histology of the tumor, and surgical procedures, and their early and late complications were analyzed retrospectively. BCC was most frequently occurred in the lower lid (55%), followed by inner canthus (19%), upper lid (17%), and outer canthus (9%). The histologic classifications were solid (80%), morphea (7%), mix (7%), superficial (2%), keratotic (2%), and adenoid (2%). Recurrence of the tumor was observed in 2 advanced cases in patients treated with resection of the tumor including surrounding tissue 5 mm from the margin. A rotation advancement cheek flap procedure was most frequently applied. Horizontal shift of the skin was most effective to prevent postoperative lagophthalmos. BCC occurred most frequently in the lower lid within the periorbital area. Rotation advancement of cheek flap with horizontal shift of the skin is most effective procedure in both appearance and function of the eyelid.