Tarsal switch using an anterior approach to correct severe ptosis

BACKGROUND: To present the outcomes of the tarsal switch procedure using an anterior approach to correct severe ptosis with poor levator muscle function ( < 4 mm) with absent or poor Bell’s phenomenon. METHODS: This retrospective case series included 11 patients with severe neurogenic or acquired myogenic palpebral ptosis. All patients underwent the tarsal switch procedure through an anterior approach from 2012 to 2015. Margin reflex distance (MRD1 and MRD2) and the palpebral fissure were evaluated preoperatively and postoperatively. Data were compared using the Wilcoxon signed-rank test. P-values < 0.05 were considered to indicate statistical significance. RESULTS: Surgery was performed on 18 eyelids (11 patients). The median age at surgery was 57 years (range, 29-86 years). Four patients had unilateral ptosis and seven had bilateral ptosis. Nine patients had myogenic ptosis and two had neurogenic ptosis. Postoperatively, the chin-up position improved in all patients. The MRD1 increased statistically significantly, from 0 mm preoperatively to 1.0 mm postoperatively (P=0.001). The MRD2 decreased statistically significantly, from 4.5 mm preoperatively to 3.0 mm postoperatively (P=0.001). The palpebral fissure did not change (4.0 mm preoperatively to 4.0 mm postoperatively) (P=0.13). CONCLUSIONS: The tarsal switch procedure through an anterior approach is an effective alternative for correcting severe ptosis, especially neurogenic or acquired myogenic ptosis. This procedure can be performed with minimal risk of ocular surface exposure and provides stable outcomes.

Complicações da blefaroplastia superior / Superior eyelid blepharoplasty and complications

A blefaroplastia tem sido realizada com grande frequência devido à valorização da cirurgia estética. As complicações relacionadas a este procedimento são raras. Este relato de caso tem como objetivo enfatizar um tipo de complicação que pode ocorrer. T.J.S.P., 45 anos de idade, sexo feminino, branca, procedente de Botucatu, apresentava dermatocálase bilateral. Optou-se pela realização de blefaroplastia superior bilateral, realizada removendo-se pele e gordura da pálpebra superior. No pós-operatório foi observado ptose palpebral à esquerda. Optou-se pela cirurgia para reinserção do músculo levantador da pálpebra superior à esquerda. Um mês após a reinserção, observou-se retração palpebral superior nos dois olhos. A paciente foi, então, submetida à cirurgia para a correção de retração palpebral por desinserção do músculo de Müller. Dois meses após esta última cirurgia, a paciente apresentava ptose palpebral à direita e piora da retração palpebral à esquerda. Nova cirurgia para correção da retração palpebral foi feita, colocando-se enxerto livre de esclera para alongamento do levantador da pálpebra superior esquerda, com bom resultado. Foi apresentada uma paciente submetida à blefaroplastia e que desenvolveu no pós-operatório quadro de ptose, seguida de retração palpebral. Estes dois quadros podem ocorrer como complicação de blefaroplastia e o cirurgião deve estar atento para manejar de forma apropriada, a fim de obter o resultado que a paciente espera ter.

The blepharoplasty has been performed with great frequency due to the appreciation of aesthetic surgery. The complications related to this procedure are rare. This case report aims to emphasize complications that can occur. T.J.S.P., 45 years old, female, white, resident of Botucatu City, presented dermatocalase bilaterally. We opted to perform upper blepharoplasty bilateral, by removing skin and fat of the upper eyelid. In the postoperative period was observed left eyelid ptosis. We decided to reinsert the levator muscle of the left upper eyelid. One month after the ptosis correction, retraction was observed in both upper eyelid. The patient was then submitted to surgery for the correction of eyelid retraction by disinsertion of the muscle of Muller. Two months after this last surgery, the patient presented right eyelid ptosis and worsening of eyelid retraction to the left. New surgery for correction of the eyelid retraction was made, using free graft sclera for elongation of the left eyelid levator muscle, with good results. The authors presented a patient who underwent a blepharoplasty and developed ptosis in the post-operative period, followed by eyelid retraction. These two possibilities may occur as a complication of blepharoplasty and the surgeon must be careful to handle in an appropriate way, in order to get the result that the patient expects to have.