Resolving conjunctival prolapse following severe blepharoptosis correction: A simple sutureless direct excision technique and systematic review.

BACKGROUND: Conjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall's ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. OBJECTIVES: This study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. METHODS: Patients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. RESULTS: The comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. CONCLUSION: We proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.

Surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in unilateral congenital ptosis with poor levator function.

PURPOSE: To compare the surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in patients of unilateral congenital ptosis with poor levator function (≤ 4 mm). MATERIALS AND METHODS: This randomized control study was conducted over a period of 18 months. 44 patients were enrolled in the study group. The study population was randomly divided into two groups (22 in each group). In Group A, congenital ptosis was treated with tarsofrontalis sling surgery using silicon rod and supramaximal levator resection was done in the group B. Follow-up examination was done at postoperative day 1, one week, 1 month, 6 months and 12 months. Surgical outcome measures were change in marginal reflex distance-1 (MRD 1), vertical palpebral fissure height (VPFH) and inter-eyelid difference of margin reflex distance 1 and complications in two groups. RESULTS: The mean age of patients in group A was 7.25 ± 6.10 years ranging from 1-18 years and mean age of patients in group B was 5.64 ± 2.44 years ranging from 3 to 11 years. Good surgical outcome was obtained in 73-77% of both groups. MRD1and VPFH increased significantly after surgery from baseline in both the groups (p value < 0.001). Inter-eyelid MRD 1 difference also improved significantly in both groups following ptosis surgery. CONCLUSION: Both supramaximal levator resection and tarsofrontalis sling surgery are equally effective in cases of unilateral ptosis patients with poor levator function and should be part of the surgical armamentarium for treating congenital ptosis.

Evolución de la técnica «avance de colgajo frontal» en la ptosis congénita / Evolution of the «frontal flap advancement» in congenital ptosis

El tratamiento de la ptosis congénita con mala función del elevador se basa habitualmente en una suspensión del párpado superior al músculo frontal mediante diversos tipos de materiales autógenos o aloplásticos. Sin embargo, el empleo de dichos materiales conlleva una serie de complicaciones, lo cual dio lugar a la búsqueda de una técnica quirúrgica mediante la que, sin necesidad de ningún material adicional, se enlazaran músculo frontal y tarso; el avance de colgajo frontal. No obstante, es una técnica menos conocida y que todavía no está estandarizada, por lo que a lo largo del tiempo se han ido describiendo variaciones para mejorar los resultados estéticos y funcionales. El objetivo de esta revisión bibliográfica es repasar en detalle las distintas variaciones de la técnica quirúrgica y obtener la mejor opción con o sin la combinación de las diferentes versiones empleadas hasta el momento. Según los resultados observados, se podría deducir que la cirugía con mejores resultados estéticos y funcionales sería la siguiente; una única incisión en el surco palpebral para realizar una disección suborbicular hasta alcanzar reborde orbitario. Realización de lipectomía si lo precisa. A continuación, disección roma del músculo frontal y formación de colgajo en «U». Avance de la aponeurosis del elevador si se trata de una ptosis grave. Finalmente, sutura sin polea del colgajo frontal al tarso con tres puntos no reabsorbibles tratando de mantener el contorno simétrico al ojo contralateral y con una altura de 1,5mm por encima del limbo corneal (AU)

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improving the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determining which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a “U” shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5mm above the sclero-corneal limbus (AU)

Evolution of the «frontal flap advancement¼ in congenital ptosis.

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

Maximal Levator Resection Beyond Whitnall's Ligament in Severe Simple Congenital Ptosis with Poor Levator Function.

PURPOSE: To evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall's ligament in patients with poor levator function (LF) and severe simple congenital ptosis. METHODS: This retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall's ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed. RESULTS: A total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011). CONCLUSION: Maximal levator resection beyond Whitnall's ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

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.

Surgical treatment of unilateral severe simple congenital ptosis.

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

The Effect of External Levator Resection in Blepharoptosis with Poor Levator Function

The postoperative complications of frontalis sling for severe blepharoptosis with poor levator function have included undercorrection, overcorrection, exposure keratitis due to lagophthalmos, lid lag. upper lid asymmetry etc, External levator resection with aponeurotic approach was performed for 77 blepharoptosis patients (106 eyelids) with poor levator function from October 1987 through April 1996 at the Department of Ophthalmology, Yeungnam University, College of Medicine. Unilateral blepharoptosis were 44 eyelids and bilateral cases included 62 eyelids. Levator function was measured 4nim in 23 eyelids, Slum in 22 eyelids and 0-2iBin in 61 eyelids, After the follow up periods of 12-108 months (mean 36.3 months) , satisfactory resuite have been achieved in 44 eyelids (100%) of unilateral ptosis and in 30 eyelids (90.9%) of bilateral ptosis. All eyelids with 4mm levator function was successful, 22 eyelids (86.4%) with 3mm levator function were satisfactory and 61 eyelids (95. 1%) with 0-2mm levator function revealed satisfactory result. Postoperative complications included entropion (4 cases) , undercorection (2 cases) , corneal opacity (I case) and corneal ulcer (1 case). Based on this study, external levator resection could were one of the ideal techniques for severe ptosis with poor to absent. levator function.

Aponeurotic Ptosis Surgery

Sixty-five levator aponeurotic surgeries were carried out to treat acquired and congenital blepharoptosis including those with very poor levator function. Margin reflex distance(MRD) was measured and postoperative drooping of the upperlid was observed carefully during the follow-up period of 6 months to 1 year. Most of these cases had a stationary level of MRD or less than 1 mm change of MRD but three cases resulted in more than 1.5 mm postoperative fall of the upperlid. This procedure also proved the excellent surgical efficacy in severe congenital ptosis with very poor levator function. In our experience, about 1 mm overcorrection at surgery provided a more satisfactory result.