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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 1  |  Page : 32-36

Posterior approach levator aponeurosis advancement in aponeurotic ptosis repair


Oculoplasty Unit, Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Web Publication29-May-2015

Correspondence Address:
Molham A Elbakary
Oculoplasty Unit, Department of Ophthalmology, Faculty of Medicine, Tanta University, 31527, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.157787

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  Abstract 

Purpose
The aim of the study was to investigate the efficiency, advantages, and disadvantages of posterior approach advancement of the levator aponeurosis in the repair of aponeurotic ptosis.
Patients and methods
This is a prospective interventional study, which included 27 eyelids of 20 patients with aponeurotic ptosis. The study included only cases with good levator function of 11 mm or more. Patients with significant dermatochalasis were excluded from the study. All patients were treated by posterior approach levator aponeurosis advancement under local anesthesia. Patients were evaluated 1 week, 1 month, 3 months, and 6 months postoperatively for margin reflex distance 1 (MRD1), eyelid symmetry, and eyelid crease and contour.
Results
The study included 27 eyelids of 20 patients with aponeurotic ptosis. The patients' mean age was 44.36 ± 14.47 years. The mean preoperative MRD1 was 1.6 ± 0.5 mm, whereas the mean levator function was 12.6 ± 1.1 mm. The mean operative time was 32.6 ± 5.4 min. The postoperative MRD1 showed significant improvement to 3.7 ± 0.6 mm (P < 0.001). Eighty-five percent showed successful outcome with postoperative MRD1 within 1 mm symmetry with the other eye in unilateral cases or 3.5-4.5 mm in bilateral cases. All cases showed postoperative good natural-looking eyelid crease and contour. Success of the procedure showed no correlation to the results of the phenylephrine test (P = 0.762). Conjunctival granuloma was recorded in 3.7% of patients.
Conclusion
Posterior approach aponeurotic advancement is an effective procedure for correction of aponeurotic ptosis. It has the advantages of high success rate, good natural-looking eyelid contour, and short operative time, and the results are independent of the response to phenylephrine.

Keywords: aponeurotic advancement, apneurotic ptosis, posterior approach


How to cite this article:
Elbakary MA. Posterior approach levator aponeurosis advancement in aponeurotic ptosis repair. Delta J Ophthalmol 2015;16:32-6

How to cite this URL:
Elbakary MA. Posterior approach levator aponeurosis advancement in aponeurotic ptosis repair. Delta J Ophthalmol [serial online] 2015 [cited 2017 Oct 23];16:32-6. Available from: http://www.djo.eg.net/text.asp?2015/16/1/32/157787


  Introduction Top


Aponeurotic ptosis results from an attenuation or disinsertion of the levator aponeurosis from its attachment to the anterior border of the tarsus [1] . Characteristics of aponeurotic ptosis include normal levator function, an elevated eyelid crease, and a deep superior sulcus [2] . Conventional ptosis surgery in the presence of a good functioning levator muscle is predominantly designed to shorten the elongated levator aponeurosis through an anterior approach. Although this technique has a reported success rate ranging from 60 to 95%, there are some concerns regarding the predictability of lid height and, perhaps more so, the postoperative eyelid contour with this procedure [3],[4],[5],[6] .

Alternatively, resection of Müller's muscle together with the overlying conjunctiva (MMCR) was first reported by Putterman and Urist [7] . It was shown to be safe and effective with 90% of eyelids achieving symmetry with the fellow eye without disturbing the eyelid crease and contour. This technique with many modifications that have since been described was predominantly popularized for patients with good levator function and a positive response to the phenylephrine test [6],[7],[8] .

Another available alternative is the transconjunctival advancement of levator aponeurosis, which preserves the advantages of posterior approach surgery with a predictable natural-looking eyelid contour and absence of cutaneous scars, yet avoids the need to excise any tissues with its possible impact on tear production [9] .


  Patients and methods Top


This was a prospective interventional study that included patients suffering from aponeurotic ptosis with good levator function who presented to the Oculoplasty Unit in Tanta University Eye Hospital. The patients were subjected to a thorough ophthalmic evaluation, which included the following:

  1. Onset and duration of ptosis.
  2. Degree of ptosis evaluated by margin reflex distance 1 (MRD1).
  3. Levator muscle function evaluated by eyelid excursion from extreme downgaze to upgaze with the frontalis muscle fixed.
  4. Eyelid crease distance measured in mm.
  5. Tear film evaluated by Schirmer's test and tear breakup time.
  6. Examination of the tarsus and conjunctiva.
  7. Phenylephrine test for both phenylephrine-positive and phenylephrine-negative patients.
  8. Other tests such as evaluation of extraocular movements, Bell's phenomenon, and detection of contralateral hidden ptosis.


The study included only patients with good levator function of 11 mm or more. Patients with levator function of 10 mm or less were excluded from the study. Patients with a significant degree of dermatochalasis were also excluded from the study, as these cases are better addressed through an anterior approach combined with blepharoplasty. All patients were treated by posterior approach levator aponeurosis advancement. The operation was performed under local anesthesia in all cases with subcutaneous infiltration, both along the skin crease and in the mid-pupil pretarsal region and subconjunctival infiltration upon eyelid eversion using 2% mepivacaine hydrochloride with 1 : 20 000 levonordefrin. The desired skin crease was marked, and a 4-0 silk traction suture was placed in the gray line of the upper eyelid, which was then everted over a Desmarres retractor. A conjunctival incision was made along and above the superior border of the tarsus. The Müller's muscle and conjunctiva were dissected off as a composite flap until the disinserted aponeurosis (the white line) was identified. A double-armed 6-0 Vicryl suture was placed centrally through the white line and was then passed through the tarsal plate, 1 mm below its superior border, and then through to the skin [Figure 1]. The eyelid height and contour was assessed after tying this first suture in a bow, and care was taken to ensure there was no slippage of the suture. If the eyelid position was deemed satisfactory, the suture was relaxed and a second suture was placed within 2-3 mm lateral to the first in the method described above. Both sutures were then tied. If the eyelid height was too low after the first suture, a second suture was passed higher through the white line and again through the tarsal plate and skin. Finally, the conjunctival incision was closed by inverted 8-0 Vicryl sutures.
Figure 1: Steps of posterior approach levator aponeurosis advancement. (a) Subconjunctival injection of local anesthesia. (b) Conjunctival incision and dissection deep to Müller's muscle. (c) Identifi cation of disinserted aponeurosis (white line). (d) Advancement suture passed through the aponeurosis. (e) Advancement suture passed through the upper edge of the tarsus. (f) Suture exteriorization to the skin side.

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The patients received systemic antibiotics and topical combined antibiotics-steroids for 1 week postoperatively. The absorbable sutures were not removed and were left to dissolve spontaneously. Patients were evaluated during the postoperative period for the eyelid height (MRD1), symmetry of both eyelids, and eyelid crease and contour. This was done 1 week, 1 month, 3 months, and 6 months postoperatively.


  Results Top


The study included 27 eyelids of 20 patients with aponeurotic ptosis. Twelve (60%) patients were female and eight (40%) were male. The age of the patients ranged between 17 and 58 years with a mean of 44.36 ± 14.47 years. Fourteen patients (21 eyelids, 77.8%) had involutional aponeurotic ptosis, whereas six (22.2%) eyelids of six patients suffered congenital aponeurotic ptosis. Seven eyelids had mild ptosis, 16 had moderate ptosis, and four had severe ptosis. Preoperative MRD1 ranged between 0 and 2 mm with a mean of 1.6 ± 0.5 mm. All patients had good levator function, which ranged between 11 and 14 mm, with a mean of 12.6 ± 1.1 mm. Twelve (44.4%) eyelids showed a positive phenylephrine test and 15 (55.6%) were negative.

All patients were treated by posterior approach advancement of the levator aponeurosis. The mean operative time was 32.6 ± 5.4 min. By the end of the follow-up period, 23 (85.2%) eyelids showed successful outcome with postoperative MRD1 within 1 mm symmetry with the other eye in unilateral cases or 3.5-4.5 mm in bilateral cases. MRD1 showed significant improvement from a mean of 1.6 ± 0.5 mm to 3.7 ± 0.6 mm postoperatively (P < 0.001). All cases showed good natural-looking eyelid crease and contour [Figure 2] and [Figure 3]. The success of the procedure showed no correlation to the results of the phenylephrine test (P = 0.762).{Figure 1}
Figure 2: Patient with right involutional aponeurotic ptosis. (a) Preoperative. (b) 6 months postoperatively.

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Figure 3: Patient with left congenital aponeurotic ptosis. (a) Preoperative. (b) 6 months postoperative.

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Four (14.8%) eyelids showed undercorrection, which required reoperation in three eyelids. This was done through the anterior approach. One patient with 1 mm undercorrection was satisfied with the result and refused reoperation [Figure 4]. One (3.7%) eyelid showed conjunctival granuloma related to conjunctival stitches, which was treated by means of simple excision. Overcorrection was not recorded in any case of the study.
Figure 4: (a) Preoperative left aponeurotic ptosis. (b) 6 monthspostoperative with 1 mm undercorrection, but showing good natural looking eyelid crease and contour.

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  Discussion Top


Aponeurotic ptosis is secondary to stretching or dehiscence of the levator aponeurosis typically acquired with repetitive traction or involutional changes of the tissues. Thus, it is expected to be seen in the elderly population [10],[11],[12] . It is not common to be encountered in children or young adults. Lee et al. [13] studied the etiology of childhood ptosis under the age of 16 years, and they found that 5% of their cases had aponeurotic ptosis, 75% of them had congenital aponeurotic ptosis, and 25% had post-traumatic form. In this study, six (22.2%) eyelids of six patients had the congenital form of aponeurotic ptosis.

The concepts of aponeurotic ptosis and aponeurotic surgery to correct it were introduced by Jones et al. [14] . A subsequent study by Dortzbach and Sutula [11] confirmed histologically the presence of a disinserted levator aponeurosis in involutional ptosis. Consequently, Beard's original classification of acquired ptosis was modified to include an aponeurotic category [11] .

External levator advancement for aponeurotic ptosis was described as an effective procedure in establishing good eyelid position with reported success rates of 60-95% [3],[15],[16],[17] . Various modifications were introduced in the technique of anterior approach aponeurotic surgery originally described by Jones and colleagues. One of these modifications is the small incision minimal dissection technique described by Frueh et al. [18] . Instead of a 20-22 mm crease incision, they performed an 8-10 mm central crease incision and advanced the central part of the aponeurosis with minimal eyelid tissue dissection. They reported a similar success rate compared with traditional surgery, with a significantly higher rate of good eyelid contour outcome (97.6 compared with 78.4%), which may be explained by more preservation of orbital septum integrity. They also reported significantly shorter operative time (26.3 compared with 56.6 min) [18] .

Although anterior approach aponeurotic surgery is not complex, many patients choose not to undergo surgery because of the eyelid skin incision. Although the eyelid scar tends to become inconspicuous, it may still be quite visible for several weeks or months after surgery [19] .

Posterior approach ptosis surgery was probably the first method of surgery adopted to shorten the levator muscle. In 1923, Blaskovicz [9] first described his technique of levator muscle resection. An important development in posterior approach ptosis surgery was the introduction of MMCR. It was first described by Putterman and Urist [7] . It was traditionally performed in patients with mild ptosis who showed eyelid elevation following instillation of topical phenylephrine [7] . Subsequent modifications to the MMCR technique describe a wide variety of algorithms to determine the appropriate amount of tissue resection to correct a given degree of ptosis [20],[21] . Peter and Khooshabeh [6] described the open sky isolated subtotal Müller's muscle resection. Their modification aimed to preserve the conjunctiva to avoid any potential risk on tear production [6] . Techniques involving Müller's muscle resection has been shown to be effective, with success rates ranging between 90 and 95%, with better results for eyelid contour and avoidance of cutaneous scars [6],[20],[21],[22] .

The anatomical reasons for the success of MMCR have been a matter of debate. Several mechanisms have been suggested as the reason for the success of this technique, including vertical posterior lamellar shortening and secondary contractile cicatrization of the wound. It has been postulated that the success of the procedure is due to advancement of the levator muscle itself, along with the aponeurosis. The mechanism by which MMCR alleviates ptosis may be explained by transmitting the contraction force of the levator muscle directly to the tarsal plate instead of through its aponeurotic attachment [6],[23] . Although MMCR is a simple procedure and yields good results, it does not address the primary cause of aponeurotic ptosis, which is the dehiscence in the attachment of the levator aponeurosis to the tarsal plate. Therefore, resecting a normal Müller's muscle and ignoring the levator aponeurosis would seem an illogical solution for correcting aponeurotic ptosis [19] .

More recently, the transconjunctival levator aponeurosis advancement (white line advancement) was described for correction of aponeurotic ptosis [9],[19] . This technique was used in this study with a success rate of 85.2%, which is comparable to the 87% success rate reported by Petal and Malhotra [9] . All cases had postoperative good natural-looking eyelid contour, which is the most important advantage of posterior approach ptosis surgery, which was also reported by many authors [6],[9],[19] . Also the operative time was reduced to a mean of 32.6 ± 5.4 min. Another advantage of transconjunctival aponeurotic advancement is that it can be performed irrespective of the response to phenylephrine as it does not involve Müller's muscle resection. It was found that the success of the procedure in this series was not related to the results of the phenylephrine test.

A well-recognized drawback of the transconjunctival approaches, whether MMCR or aponeurotic advancement, is the fact that redundant skin in the upper eyelid could not be removed during the same operation [19] . Patients with excessive dermatochalasis were not included in the study as these patients are better addressed through anterior approach aponeurotic advancement combined with blepharoplasty. Another potential disadvantage of posterior approach ptosis surgery is related to the presence of suture material on the palpebral conjunctiva. Complications that may arise from this condition include keratopathy, suture granulomas, and the need for suture removal [6] . This was avoided by exteriorization of the aponeurotic advancement sutures having knots on the skin side and closing the conjunctival incision with inverted sutures. Suture granuloma was recorded in only one (3.7%) eyelid and was treated by simple excision.

In conclusion, transconjunctival aponeurotic advancement is an effective procedure for correction of aponeurotic ptosis. It has the advantages of high success rate, good natural-looking eyelid contour, and short operative time, and the results are independent of the response to phenylephrine.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Freuh BR, Musch DC. Evaluation of levator muscle integrity in ptosis with levator force measurement. Ophthalmology 1996; 103:244-250.  Back to cited text no. 1
    
2.
Waqar S, McMurray C, Madge S. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J 2010; 4:76-80.  Back to cited text no. 2
    
3.
Berlin A, Vestal K. Levator aponeurosis surgery: a retrospective review. Ophthalmology 1989; 96:1033-1037.  Back to cited text no. 3
    
4.
McCulley T, Kersten R, Kulwin D, Feuer W. Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis. Ophthalmic Plast Reconst Surg 2003; 19:388-393.  Back to cited text no. 4
    
5.
Scoppettulol E, Chadha V, Bunce C, et al. British Oculoplastic Surgery Society (BOPSS) national ptosis survey. Br J Ophthalmol 2008; 92:1134-1138.  Back to cited text no. 5
    
6.
Peter NM, Khooshabeh R. Open-sky isolated subtotal Müller's muscle resection for ptosis surgery: a review of over 300 cases and assessment of long-term outcome. Eye 2013; 27:519-524.  Back to cited text no. 6
    
7.
Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Arch Ophthalmol 1975; 93:619-623.  Back to cited text no. 7
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8.
Putterman AM, Fett DR. Müller's muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg 1986; 17:354-360.  Back to cited text no. 8
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9.
Patel V, Malhotra R. Transconjunctival blepharoptosis surgery: a review of posterior approach ptosis surgery and posterior approach white-line advancement. Open Ophthalmol J 2010; 4:81-84.  Back to cited text no. 9
    
10.
Anderson RL, Beard C. The levator aponeurosis: attachments and their clinical significance. Arch Ophthalmol 1977; 95:1437-1441.  Back to cited text no. 10
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11.
Dortzbach RK, Sutula FC. Involutional blepharoptosis: a histopathological study. Arch Ophthalmol 1980; 98:2045-2049.  Back to cited text no. 11
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12.
Lim JM, Hou JH, Singa RM, et al. Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center. Orbit 2013; 32:231-234.  Back to cited text no. 12
    
13.
Lee V, Konrad H, Bunce C, et al. Aetiology and surgical treatment of childhood blepharoptosis. Br J Ophthalmol 2002; 86:1282-1286.  Back to cited text no. 13
    
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Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975; 93:629-634.  Back to cited text no. 14
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Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis: analysis of 113 procedures. Ophthalmology 1983; 90:1056-1059.  Back to cited text no. 16
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Shore JW, Bergin DJ, Garrett SN. Results of blepharoptosis surgery with early postoperative adjustment. Ophthalmology 1990; 97:1502-1511.  Back to cited text no. 17
    
18.
Frueh BR, Musch DC, McDonald H. Efficacy and efficiency of a new involutional ptosis correction procedure compared to a traditional aponeurotic approach. Trans Am Ophthalmol Soc 2004; 102:199-207.  Back to cited text no. 18
    
19.
Ichinose A, Leibovitch I. Transconjunctival levator aponeurosis advancement without resection of Müller's muscle in aponeurotic ptosis repair. Open Ophthalmol J 2010; 4:85-90.  Back to cited text no. 19
    
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Weinstein GS, Buerger GF Jr. Modification of the Müller's muscle conjunctival resection operation for blepharoptosis. Am J Ophthalmol 1982; 93:647-651.  Back to cited text no. 20
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Dresner SC. Further modifications of the Müller's muscle conjunctival resection procedure for blepharoptosis. Ophthal Plast Reconstr Surg 1991; 7:114-122.  Back to cited text no. 21
    
22.
Ben Simon GJ, Lee S, Sshwarcz RM, et al. External levator advancement vs Müller's muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol 2005; 140:426-432.  Back to cited text no. 22
    
23.
Mercandetti M, Putterman AM, Cohen ME, et al. Internal levator advancement by Müller's muscle-conjunctival resection. Arch Facial Plast Surg 2001; 3:104-110.  Back to cited text no. 23
    


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