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Minimal Incision Posterior Approach Levator Plication for Aponeurotic Ptosis

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Minimal Incision Posterior Approach Levator Plication for Aponeurotic Ptosis Eye (2015) 29, 483–491 & 2015 Macmillan Publishers Limited All rights reserved 0950-222X/15 www.nature.com/eye Minimal incision DS Ng, E Chan and ST Ko CLINICAL STUDY posterior approach levator plication for aponeurotic ptosis Abstract Purpose To assess the efficacy and Nevertheless, a survey of members of the predictability of a minimal incision posterior American Society of Ophthalmic Plastic and approach levator plication technique for Reconstructive Surgery published in 2011 correction of involutional ptosis. revealed that 74% of surgeons performed Method Retrospective chart review of posterior approach ptosis surgery.1 Muller’s patients with involutional aponeurotic ptosis muscle-conjunctival resection (MMCR), in underwent minimal incision posterior particular, was found to attain better cosmetic approach levator plication technique between results as compared with patients who August 2013 and June 2014 by a single underwent anterior approach levator surgeon. The upper lid was double everted, advancement, and predictable outcomes and the conjunctiva and Muller’s muscle without the need for intraoperative cooperation layers were incised vertically until the levator of the patient or adjustment. A comparative aponeurosis could be identified. The study of anterior levator advancement vs incision(s) was similar to performing incision MMCR reported a 22% lower revision rate for and curettage of chalazion, except that the MMCR and a statistically better outcome.2 site was above the tarsal plate and extended On the basis of the theory that the towards the fornix. Then insertion of aponeurosis is the main transmitter of aponeurosis was dissected away from the contraction of the levator to tarsus, techniques anterior tarsal surface, and the more for levator aponeurosis advancement through superiorly located levator was plicated on it posterior approach have been previously with double arm suture(s). No tissue was described.3–7 These techniques avoid resection excised in this procedure. Surgical success of conjunctiva which prevents dry eyes, and was defined as a postoperative margin reflex may be more effective in patients with negative distance (MRD)42 mm ando4.5 mm, interlid response to phenylephrine test as well as Department of heighto1 mm and satisfactory contour. correcting severe ptosis. Some surgeons may Ophthalmology, Tung Wah Results Forty-four lids of 27 patients were prefer intraoperative adjustment of lid height Eastern Hospital, Hong Kong included. Preoperative mean MRD was 0.48 instead of using a preoperative algorithm to þ / À 0.56 mm. Severe ptosis of MRDo1mm determine the amount of tissue resection. Correspondence: was present in 34/44 patients (77.3%). The Less invasive, yet effective, surgical techniques DS Ng, Department of postoperative mean MRD was 2.49 þ / À are of interest to both patients and surgeons. This Ophthalmology, 9/F, Tung 0.53 mm, and mean improvement was 2.02 study describes a technique of posterior approach Wah Eastern Hospital, 19 þ / À 0.61 mm, which was statistically to levator plication through minimal incision(s) Eastern Hospital Road, Causeway Bay, Hong Kong, significant (Po0.001). The overall success rate near the fornix without resection of conjunctiva Hong Kong was 38/44 (86.4%). and Muller’s muscle. No suture is required to Tel: +852 21626901. Conclusions Minimal incision posterior close the small incision site(s). This study aims to E-mail: dr.dannyng@ approach to levator plication was effective evaluate the effectiveness of this technique for gmail.com for the correction of aponeurotic ptosis with correction of adult involutional ptosis under local moderate to good levator function. anesthesia which allows intraoperative Received: 15 September 2014 Eye (2015) 29, 483–491; doi:10.1038/eye.2014.318; adjustments of lid height and contour. Accepted in revised form: published online 23 January 2015 25 November 2014 Published online: Introduction Methods 23 January 2015 The popularity of posterior approach ptosis Surgical records from a single surgeon (DSN) The work has not been repair has waxed and waned over the years. were reviewed to identify all patients previously presented Minimally invasive internal ptosis surgery DS Ng et al 484 undergoing minimal incision posterior levator plication plate to double evert the upper lid (Figure 1a and b). The for ptosis repair between August 2013 and June 2014. free ends of tractions sutures were clamped to the drape Institutional Review Board approval was obtained for a when the upper lid fornix was adequately exposed. retrospective chart review of these patients. Inclusion Figure 3a is a schematic diagram that illustrates the criteria included patients’ age greater than 18 years, essential upper lid anatomy after double eversion. A acquired aponeurotic ptosis, levator function (LF) equal or monopolar diathermy (Erbe USA Incorporated, Marietta, above 6 mm and surgery performed under local anesthesia GA, USA) was applied to the conjunctiva immediately without sedation. LF of less than 6 mm, inadequate follow- above the superior tarsal border for a 3–5 mm vertical up (less than 3 months postoperatively), required skin or incision towards the fornix, similar to performing fat blepharoplasty, those who underwent concurrent brow incision and curettage of a chalazion, except that the surgery, presence of a superior filtering bleb, previous incision site was above the tarsal plate (Figure 1c). The history of trauma and ptosis of congenital, myogenic and incision depth was through the thin layer of Muller’s neurogenic etiologies were excluded. muscle until the appearance of levator aponeurosis, Preoperative data collected include age, sex, previous which could be directly visualized as a whitish tissue history of ptosis surgery and types, upper eyelid margin layer, or identified by its movement when the patient reflex distance (MRD), and LF. MRD is defined as the looks up and down. A pair of Stevens scissors was used distance between the central corneal light reflection and the for blunt dissection to further undermine the conjunctiva upper eyelid margin. Using the examiner’s hand to fixate the and Muller’s muscle layer from the posterior belly of the brow, eyelid excursion from extreme downgaze to upgaze levator aponeurosis. At the superior edge of tarsus, sharp was measured and recorded as LF. Response to 2.5% scissors entered the plane just superficial to the anterior phenylephrine instillation was also documented, with surface of tarsal plate to dissect the insertion of elevation of lid height 1 mm or more deemed a positive result. aponeurosis away from the anterior tarsal surface until Duration of surgery for each ptotic eyelid was collected. 2–3 mm below the superior tarsus edge (Figures 2a and Patients were followed up within 1 week postoperatively. 3b). A double-armed 6-0 vicryl suture was placed MRD and LF were measured in each follow-up visits. through the posterior belly of the levator aponeurosis Measurements at the last follow-up visit were used for and passed through partial thickness of the tarsal plate at comparison. Surgical success was defined as postoperative its anterior surface (Figure 2b and c and Figure 3c). The MRD of Z2mmand r4.5 mm, and an interlid height traction sutures were released, and then the sutures were difference of r1 mm. Any complications and recurrence of externalized through skin at the level of lid crease. A ptosis necessitating surgery were recorded. All patients knot was tied if the eyelid position was deemed to be had pre- and post-operative photographs taken, the latter satisfactory (Figure 2d). Figure 3d illustrates the location being performed 1–3 months postoperatively. Statistical of the levator plication suture when the upper lid returns analysis, including Wilcoxon signed-rank test was to its primary position. Lid height and contour were conducted by JMP statistical software (V7.0 for Windows, assessed with the patient seated upright (Figure 4b, Left). SAS Institute Inc, Cary, NC, USA). If the lid was too low after the first suture, a second suture was placed just next to the first suture, passing higher through the levator aponeurosis and again Surgical technique through the tarsal plate and skin to avoid the undue Topical anesthetic (proparacaine, 0.5% solution) was delay of removing the first suture. If the upper eyelid applied to the eye 5 min before the procedure was contour appeared peaked after the first suture, then this performed. The skin crease was marked at a matching was relaxed and a second suture was placed. If the lid height to the fellow eye. If bilateral ptosis was present, appeared low medially or laterally, additional sites for the crease height was based on central tarsal height, levator plication was performed by the same method which averages 6.5–8.0 mm (slightly lower in Asians). accordingly until satisfactory lid contour was achieved. The involved upper eyelid was everted over a Desmarres The incision(s) wound through the conjunctiva and retractor. To avoid distorting upper lid tissue and Muller’s muscle were left to heal by primary intention. contour, a small amount of local anesthesia of 0.5–1 ml of The absorbable sutures were not removed and were left 2% lidocaine with 1:80 000 adrenaline was injected into to dissolve spontaneously in the postoperative period. the subconjuctival layer at the start of the procedure. Patients remained fully alert throughout the procedure Results without sedation. If the patient complained of pain at any time during the operation, small bolus of local anesthetic The minimal incision posterior approach for levator was injected. Two 5-0 silk traction sutures were placed at plication technique was performed on 44 lids of 27 the lateral and medial sides at the superior edge of tarsal patients. All patients were of Asian ethnicity. Twenty-five Eye Minimally invasive internal ptosis surgery DS Ng et al 485 Figure 1 (a) Upon lid eversion, two 5-0 silk traction sutures were placed at the lateral and medial sides at the superior edge of tarsal plate.
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