The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function.

BACKGROUND: Severe blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported. OBJECTIVES: The aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed. METHODS: This retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded. RESULTS: A total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted. CONCLUSIONS: The function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.

Myotomy In Situ for Essential Blepharospasm Refractory to Botulinum Toxin.

BACKGROUND: Full myectomy is recommended for benign essential blepharospasm (BEB) refractory to botulinum toxin (BT) treatment, but long-term swelling, scar contracture, hollow appearance, and unnatural contour of the eyelids are common postoperative complications. We present myotomy in situ to minimize these adverse outcomes. METHODS: The redundant eyelid skin with its underlying muscle is resected first, and myotomy in situ is performed by completely cutting the residual orbicularis oculi muscles into multiple cubes and down to the subcutaneous layer, and then cutting the procerus and corrugator muscles down to the periosteum. Patient demographics, medical treatment history, BT injection history, blepharoptosis correction techniques, associated surgical procedures, and aesthetic outcomes were analyzed. Preoperative and postoperative BT injection dosage and frequency, as well as modified disability scores, were compared using paired Student t tests. RESULTS: Twenty-five patients underwent this technique. Their average ± SD age was 64.4 ± 8.9 years, with average postoperative follow-up occurring 17.0 ± 8.0 months. Associated diseases included blepharoptosis (88%) and apraxia of lid opening (44%). There were no postoperative hematoma, seroma, scar contracture, and depressed hollow eyelid contours. Preoperative to postoperative assessments revealed improvements in mean BT injection interval (10.4 ± 2.1 to 14.6 ± 2.9 weeks, P < 0.001), BT injection dosage (44.4 ± 13.3 to 28.1 ± 6.7 units, P < 0.001), and modified disability score (15.3 ± 3.0 to 2.8 ± 2.2, P < 0.001). All patients were highly satisfied with functional and aesthetic surgical outcomes (4.5 ± 0.6 on Likert scale). CONCLUSIONS: Myotomy in situ is effective for patients with BEB who are refractory to BT treatment, with therapeutic benefits similar to that of full myectomy with the ability to maintain favorable cosmetic results. Relative high incidence of blepharoptosis and apraxia of lid opening in patients with refractory BEB was reported. Simultaneous correction of the ptosis can further optimize outcomes.

The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population.

BACKGROUND: Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype. MATERIALS AND METHODS: The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity. RESULTS: During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88 years were enrolled in the research (mean = 57.73 ± 13.41 years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40 years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40 years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction. CONCLUSIONS: Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40 years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD1 reduction among all subtypes of blepharoptosis. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Floppy Eyelid Syndrome: An Unfamiliar Entity for Plastic Surgeons.

BACKGROUND: Floppy eyelid syndrome (FES) is typically characterized by chronic eye irritation and an increased laxity of the upper eyelid that can be easily everted by applying minimal upward traction. However, it is a clinical entity that is less known to most plastic surgeons. Blepharoptosis is one of the most common features, which links to FES, for which a thorough differential diagnosis has become important in directing proper medical treatment. PURPOSE: This review aims to discuss current understanding about FES in a broader spectrum, encompassing the clinical features and evaluation of FES, the underlying etiologies, systemic associations, and surgical procedures for upper eyelid tightening. METHODS: The literature search was conducted in Endnote interface using the keyword "floppy eyelid" through March 2017. All search abstracts were reviewed without language restriction. Citations of identifiable articles were also examined. RESULTS: Despite the exact definition of FES remains ambiguous, patients with FES often demonstrate unresolvable blepharoptosis, dermatochalasis, eyelash ptosis, entropion, or ectropion of the lower eyelid. The pathological course of FES can be worrisome because it is often associated with both ocular and systemic morbidities, most notably papillary conjunctivitis, keratoconus, and obstructive sleep apnea (OSA). Decades of research into the pathogenesis has lent further recognition linking the eyelid floppiness with a loss of elastic fibers, an increased expression of matrix metalloproteinases, and possible collagen gene mutations. Surgery is usually prompted if conservative measures give limited responses. High surgical success rates with different follow-up time have been reported. CONCLUSIONS: For plastic surgeons, early recognition of FES is important because of its chronic, distressing course and the associated morbidities. We believe that surgical intervention is the most effective treatment of choice. The indication for embarking on surgery is based on the clinical severity of the condition. A variety of blepharoplasty techniques for FES have been proposed, including full-thickness wedge excision of the tarsus, medial and lateral canthal ligament ligation, conchal cartilage graft, lateral tarsal strip with flap, and lateral tarsorrhaphy. Most of the procedures have provided excellent visual and aesthetic outcomes; therefore, early surgical intervention is encouraged if early diagnosis can be made.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

BACKGROUND: Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. METHODS: In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. RESULTS: All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. CONCLUSIONS: The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Analysis of Levator Function and Ptosis Severity in Involutional Blepharoptosis.

BACKGROUND: Involutional blepharoptosis is the most common type of acquired blepharoptosis. The etiology is believed to be the degeneration of the levator aponeurosis, and levator superioris muscle function was believed to be normal. However, there are a few studies analyzing levator function (LF) in involutional blepharoptosis. Our study aimed to access the LF abnormality in involutional blepharoptosis and analyze the correlation between LF and ptosis severity in involutional blepharoptosis in Taiwan. METHODS: We reviewed the medical records of patients who underwent ptosis correction surgery between October 2011 and December 2015 after receiving a diagnosis of involutional blepharoptosis. This study examined patient sex and age, preoperative LF, margin reflex distance of the upper eyelid (MRD1), and ptosis severity. Linear regression was performed for statistical analysis. Levator muscle specimen was sent for pathologic examination. RESULTS: We analyzed 231 eyelids of 126 patients. Average MRD1 was 0.43 ± 2.15 mm. Average LF was 14.30 ± 2.51 mm. Overall, 77.1% (178/231) of involutional blepharoptotic eyelids had normal LF (more than 12 mm). Forty-three (18.6%) of 231 were good (10-12 mm), and 10 (4.3%) of 231 were fair (6-9 mm). No patients with poor levator function (≤5 mm) were observed in our case series. A positive correlation between LF and MRD1 was observed after statistical analysis. On average, a 0.6-mm reduction in LF was observed for each 1.0-mm decrease in MRD1. Fat infiltration in levator muscle is observed both grossly and microscopically in most cases with varied degrees. CONCLUSIONS: Levator function and MRD1 were positively correlated in patients with involutional blepharoptosis. In our study, 77.1% (178/231) of eyelids had normal levator function, which meant there was 23.0% (53/231) of eyelids had abnormal LF, in contrast to current literature. Fat infiltration was common in our series. In Asian involutional blepharoptosis, LF was not always excellent and it had positive correlation with ptosis severity.

Composite grafting with pulp adipofascial advancement flaps for treating non-replantable fingertip amputations.

BACKGROUND: Non-replantable fingertip amputation is still a clinical challenge. We performed modified composite grafting with pulp adipofascial advancement flap for Hirase IIA fingertip amputations. Results from a series of patients are presented and achieved better outcome than traditional composite grafting. PATIENTS AND METHODS: From September 2012 to April 2014, fourteen patients with sixteen digits were included in our study. Mean age of patients was 43.9 years (20-71 years). All of our patients underwent this procedure under digital block anesthesia. We performed pulp adipofascial advancement flap for better soft tissue coverage of bone exposure stump first. The amputated parts were defatted, trimming, and reattached as composite graft. Age and gender of patients, injured finger, Hirase classification, mechanism of trauma, overall graft survival area, two-point discrimination (2PD) (mm) at six-month, length of shortening of digit, The average disabilities of the arm, shoulder, and hand (DASH) score and subjective self-evaluation questionnaire at 6 month were recorded. RESULTS: Average graft survival area was 89% (75-100%). Average length of shortening was 2.2 mm (1.8-3.5 mm). 2PD at six-month after surgery was 6.3 mm in average (5-8 mm). Average DASH score at 6 month was 1.45 (0.83-2.5). The self-evaluated aesthetic results showed twelve patients (85.7%) were very satisfied, and no patient was completely unsatisfied. CONCLUSIONS: In Hirase zone IIA traumatic fingertip amputation where replantation is difficult, our modified technique of composite grafting with pulp adipofascial advancement flap provided an alternative choice with high successful rate, acceptable functional and aesthetic outcomes. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016. © 2015 Wiley Periodicals, Inc. Microsurgery 36:651-657, 2016.

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma.

OBJECTIVES: We determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma. METHODS: We performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture. RESULTS: Our study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k=0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054-8.849) for superior wall fractures, 0.459 (95% CI: 0.152-1.389) for inferior wall fractures, 2.286 (95% CI: 1.062-4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215-1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR)=12.01, P=0.011), and medial or inferior wall fracture was a protective factor (adjusted OR=0.14, P=0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%). CONCLUSION: Among patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.

The Impact of Hering's Law in Blepharoptosis: Literature Review.

The aim of this literature review is to examine Hering's law, a well-documented phenomenon in blepharoptosis patients, with 10% to 20% noted in cases of unilateral ptosis. Predominantly presenting as contralateral eyelid drop postoperatively, it poses a challenge for eyelid surgeons in the pursuit of symmetry and appropriate eyelid height. Proper preoperative evaluation is of utmost importance, consisting of one of either lifting test, covering test, or phenylephrine test. A deeper understanding of Hering's law further provides adequate information for optimal management of ptosis. In regard to ptosis etiology, congenital ptosis does not appear to have a distinct relation to positive Hering's law, commonly associated with a low incidence, when compared with acquired ptosis. Ptosis in the dominant eye seems to be related to a higher incidence of the phenomenon than ptosis in the nondominant eye, with statistical significance in studies ranging from P < 0.001 to P = 0.09. This can be explained as an innate response for increased innervation to regain the field of vision. Both ptosis severity and levator function appear to be of lesser importance than ptosis etiology, with minimal incidence of Hering's law in congenital ptosis regardless of these factors. It is, however, noted that ptosis severity has direct association with contralateral eyelid position in acquired ptosis, whereas there is a lack of studies for levator function. In the event of preoperative contralateral eyelid drop, surgeons should consider simultaneous surgery instead of delayed surgery for bilateral ptosis (P = 0.002). For unilateral ptosis, although reoperation is done per patient request, it may be more appropriate to first wait for roughly 2 weeks and reassess for self-regulation to a normal eyelid position.

The role of frontalis orbicularis oculi muscle flap for correction of blepharoptosis with poor levator function.

On the basis of the close anatomical interdigitation between the longitudinal-oriented frontalis muscle and the horizontal-oriented orbicularis oculi muscle (OOM), frontalis OOM (FOOM) flap was developed to treat blepharoptosis. Retrospective study during an 11-year period, 66 patients with 81 poor levator function ptotic eyelids accepted FOOM flap shortening (65 lids; 80.2%) or double-breasted FOOM flap advancement (16 lids; 19.8%) to correct blepharoptosis. There were 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Severity of blepharoptosis included severe type in 72 (88.9%) lids, moderate type in 5 (6.2%) lids, and mild type in 4 (4.9%) lids. The underlying etiology included congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and neurologic origin in 4 (6.1%) patients. Marginal reflex distance 1 and lid slit distance improved from -1.6 (2.0) to 3.3 (1.2) and 3.2 (2.0) to 7.2 (1.4) mm, respectively, after operation. The postoperative outcome includes good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. The undercorrection or recurrence rate is 14.8%, and secondary revision rate is 11.1%. Positive Hering law is 17.6% among patients with unilateral ptosis. Overall patients' satisfaction rate is 95.1%. Both FOOM flap shortening and double-breasted FOOM flap advancement are effective to treat poor levator function blepharoptosis. Double-breasted FOOM flap advancement is highly recommended because of the more natural contour and minimal lagophthalmos postoperatively, because of the maximal preservation of OOM.