Upper Eyelid Ptosis Correction Combined with Facial ...



Title: Aesthetic Correction of Upper Eyelid Ptosis

Authors: Jorge de la Torre, MD; Scot A. Martin, MD; Benoit C. De Cordier, MD;

Mazin S. Al-Hakeem, MD; Sherry S. Collawn, MD, PhD.; Luis O. Vasconez, MD

Introduction:

Patients presenting for surgical rejuvenation on the face often show acquired upper eyelid ptosis. In this population of patients, the ptosis is caused by a thinning, lengthening, or less often, disinsertion of the levator aponeurosis from the tarsal plate. The aesthetic effects include not only the abnormal position of the lid and asymmetry of the eyes, but also the dynamic changes, which occur in the periorbital region affecting both the upper and middle third of the face.

Various procedures have been developed to correct upper lid ptosis from simple skin excision to dynamic suspension techniques. Techniques, which plicate the aponeurosis and use a blepharoplasty approach, have also been described. Anterior approaches to the levator using a blepharoplasty-type incision allow resection of a portion of the levator aponeurosis and tightening.1 Further evolution has led to techniques which use adjustable suture plication either alone or inconjunction with aesthetic blepharoplasty.2,3

Methods:

A retrospective review was performed on the medical records of 74 patients determined to have undergone upper eyelid ptosis correction in conjunction with facial rejuvenation between 1994 and 2000. Clinical information such as prior surgery, concomitant procedures, complications and revision rates were recorded.

Technique:

The surgical technique utilizes a standard blepharoplasty approach to resect the skin and muscle. Once the levator is identified and exposed, a 6-0 clear nylon suture is placed in the mid-pupillary line. This horizontal mattress stitch is used to plicate only the aponeurosis, but avoids the tarsus. The superior portion of the suture is placed in the aponeurosis 4 to 8 mm above the superior tarsus, depending on the severity of the ptosis. The inferior portion of suture is placed in the aponeurosis just above the tarsal plate. The amount of plication used was determined by the elevation of the lid gained with the plication. Approximately 1 mm of lid margin elevation is obtained with 3 mm of plication.

Results:

Of the 74 cases reviewed, 68 patients were female with an average age of 59.3 (range 41 to 80 years), and 6 were male patients with an average age of 63.3 years (range 55 to 72 years). All of the patients underwent other additional facial surgical procedures. The average follow up of patients was 14 months (range 6 to 54 months). Previous periorbital surgery had been performed in 25 patients prior to their aesthetic ptosis correction.

Symmetry was excellent in 50 patients, acceptable in 20 patients and four patients required revision for persistent asymmetry. Thirteen patients had temporary lagopthalomos and seven patients had temporary eye irritation all of which were self-limiting. Difficulty closing the eye was noted in 13 patients. Eye irritation was noted in 10 patients and three patients had contour irregularities. All but four of these complications were minor and resolved with eye lubrication.

The four patients who required revision for asymmetry were corrected by additional plication of the levator on the undercorrected side. The procedures were performed under local anesthesia in the immediate postoperative period. None of the patients demonstrated recurrence of their ptosis once correction was successfully achieved.

Discussion:

Acquired or senile ptosis of the eyelids can have a subtle presentation and may even go unnoticed by the patient. The diagnosis can be made by observing the resting position of the upper eyelid margin. Periorbital signs include a high tarsal fold, persistent wrinkles in the forehead due to contraction of the frontalis muscle, and asymmetric elevation of the eyebrows, greater on the affected side.

The degree of ptosis and levator function should be evaluated when considering surgical options.4 Patients who have good levator function can obtain long-term correction of the ptosis using plication of the distal levator muscle aponeurosis. They can be treated successfully at the time of facial rejuvenation with transpalpebral blepharoplasty plication of the levator aponeurosis. Correction allows opening of the periorbital region and results in a more youthful appearance.

The complication rate of this series included numerous minor problems, which resolved with minimal discomfort to the patient. Management of these patients requires meticulous and constant observation for the possibility of exposure of keratitis. In many patients, particularly if the ptosis correction is combined with endoscopy, there may be some difficulty with closing the eyes at night, and this requires lubrication as well as patching of the eyes for a period of several weeks.

The success rate outside of these minor postoperative problems was 94.6% (70/74), with complete correction of asymmetry achieved in 67.6% (50/74) of the patients. This compares favorably with the success rate reported in other series.5-8 Ultimately, all patients were satisfied with their final results, from both a functional and aesthetic perspective. Long-term results demonstrated permanency of the ptosis correction.

Conclusions:

Levator aponeurosis plication is an effective, safe, and simple procedure to correct upper eyelid ptosis and can easily be combined with many cosmetic surgery procedures on the face. It can be performed to augment periorbital rejuvenation as part of global facial aesthetic improvement, effectively addresses both the functional and aesthetic components of upper lid ptosis. It can be used in patients who have undergone prior periorbital cosmetic surgery and it is a safe and lasting technique with an acceptable revision rate.

References:

[?]. Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol. 1975;93:629–634

2. Borman H. New adjustable suture technique for managing eyelid ptosis. Ann Plast Surg. 2001;47:673-7.

3. Stasior OG, Ballitch HA. Ptosis repair in aesthetic blepharoplasty. Clin Plast Surg 1993; 20:269–273.

4. Signorini M, Baruffaldi-Preis FW, Campiglio GL , Marsili MT. Treatment of congenital and acquired upper eyelid ptosis: report of 131 consecutive cases. Eur J Plast Surg. 2000;23:349–355.

5. Berlin AJ, Vestal K. Levator aponeurosis surgery. A retrospective review. Ophthalmol. 1989; 96:1033-37.

6. Mauriello JA, Abdelsalam A. Modified levator aponeurotic advancement with delayed postoperative office revision. Ophthalmic Plast Reconstr Surg. 1989; 14:266-270.

7. Older JJ. Levator aponeurosis surgery for correction of aquired ptosis: analysis of 113 procedures. Ophthalmol. 1983; 90:1056-9.

8. Smith B, McCord CD, Baylis H. Surgical treatment of blepharoptosis. Am J Ophthalmol.1969; 68:92-99.

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