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ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 3  |  Page : 97-101

Small incision versus conventional transcutaneous levator resection in the management of ptosis with good and excellent levator action


Department of Ophthalmology, Ophthalmic Center, Mansoura University, Mansoura, Egypt

Date of Submission11-Sep-2014
Date of Acceptance29-Apr-2015
Date of Web Publication30-Oct-2015

Correspondence Address:
Ayman Abd El Ghafar
Department of Ophthalmology, Ophthalmology Center, Faculty of Medicine, Mansoura University, 35516 Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.168658

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  Abstract 

Purpose
The aim of this study is to compare small incision levator and conventional transcutaneous levator resection in the management of cases of ptosis with good and excellent levator action.
Patients and methods
This is a prospective comparative study that included 30 patients with unilateral ptosis, 16 cases with congenital, and 14 cases with aponeurotic ptosis. Levator action was good (>10 mm levator excurtion) in 20 cases and excellent (>15 mm levator excurtion) in 10 cases. Fifteen cases (group B) were operated through a small (8 mm) upper lid crease incision through which sutures were passed from the tarsal border to the levator muscle at the target distance and 15 cases (group A) were operated through a conventional transcutaneous levator resection.
Results
This study included 30 cases of unilateral ptosis. They were divided into two groups: group A was operated by a conventional technique and group B was operated by a small incision technique. In group A, 80% of cases were fully corrected, 13.3% were undercorrected, and 6.7% were over corrected; however, in group B, 86.7% were fully corrected and 13.3% were undercorrected. The mean surgical time in group A was 49.5 ± 5.9 and that in group B was 28.1 ± 5.2.
Conclusion
This study shows that small incision levator muscle resection is equally effective as the conventional transcutaneous levator resection for the management of ptosis, with good and excellent levator action, with better lid contour and quicker time.

Keywords: Ptosis surgery, ptosis with good levator action, small incision levator resection


How to cite this article:
El Ghafar AA. Small incision versus conventional transcutaneous levator resection in the management of ptosis with good and excellent levator action. J Egypt Ophthalmol Soc 2015;108:97-101

How to cite this URL:
El Ghafar AA. Small incision versus conventional transcutaneous levator resection in the management of ptosis with good and excellent levator action. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2022 Sep 28];108:97-101. Available from: http://www.jeos.eg.net/text.asp?2015/108/3/97/168658


  Introduction Top


Blepharoptosis can be classified according to various criteria such as age of onset (congenital or acquired), etiology, severity, and levator function. Acquired blepharoptosis may be further subdivided into myogenic, neurogenic, aponeurotic, mechanical, or traumatic [1]. On the basis of severity, it may be minimal or mild (1-2 mm), moderate (3-4 mm), or severe (>4 mm) [2]. When considering levator function, it can be poor (0-4 mm), moderate (5-10 mm), or good (>10 mm) [3].

The surgical correction of blepharoptosis must thus be individualized on the basis of degree of ptosis, levator function, and the need for concomitant blepharoplasty or brow surgery. Fundamental understanding of the underlying anatomical cause of the blepharoptosis can considerably aid in selecting the appropriate surgical procedure [4].

Levator resection is the most common procedure that can be used in children who have congenital ptosis or in adults who have acquired ptosis. The amount of levator resected is determined preoperatively by the levator function and the level of ptosis. Dissection is often extensive and involves dissecting the levator from the underlying Muller's muscle and the conjunctiva, as well as disruption of the medial and lateral horns of the levator [5].

In line with the current trend in surgery to progressively shift toward minimally invasive procedures, various modifications of levator advancement have been described. The current trend started with the initial description of the use of a single suture for aponeurotic ptosis correction by Liu in 1993 [6].

Meltzer et al. [7] modified this by combining the simplicity of a single suture technique with the flexibility of an adjustable suture and reported excellent results in their retrospective series of 51 patients.

The small incision approach was then formally described by Lucarelli and Lemke; however, their dissection technique is similar to the traditional approach with less dissection and smaller incision [8].

The aim of this study is to compare traditional transcutaneous levator resection and small incision transcutaneous levator resection in cases of ptosis with good and excellent levator function.


  Patients and methods Top


This study was carried out in Mansoura Ophthalmic Center, Mansoura, Egypt, from February 2013 to June 2013 on 30 patients with ptosis. They were divided into two groups, A and B, each with 15 cases. The cases included had good levator action (levator excurtion >10 mm) and excellent levator action (levator excurtion >15 mm). Cases with poor and fair levator function were excluded. Also, those with dry eye, negative Bell's phenomenon, Marcus Gunn phenomenon, and those operated before for ptosis were excluded. Ethical approaval from Mansoura medical ethics committee (MMEC) and a written consent from all patients were taken.

Operative techniques

Traditional approach (group A)

0In the traditional approach, after obtaining written consent, marking was performed at the proposed lid crease and the upper eyelid was infiltrated with 1 to 1.5 ml of 1-2% lidocaine mixed with epinephrine 1: 200 000 in a subcutaneous plane. The anesthetic paralyzes the orbicularis oculi muscle and the epinephrine can stimulate the Muller's muscle, rendering the intraoperative eyelid position higher than what is expected postoperatively. To avoid this, we set the eyelid height 1 to 1.5 mm higher than the desired postoperative position. A 20 to 22 mm long lid crease skin incision was then typically made using No. 15 blade. Through the skin incision, dissection was carried out superiorly under the orbicularis oculi muscle across the width of the incision. When the orbital septum was identified, it was opened wide to expose the preaponeurotic fat. This was then carefully dissected free of the underlying levator aponeurosis and the aponeurosis was disinserted from the upper edge of the tarsus. Medial and lateral horns were divided. Horizontal mattress sutures were then used to advance and reapproximate the levator aponeurosis to the upper edge of the tarsus and its level was determined and adjusted intraoperatively, where the patient was allowed to sit up and the level was adjusted. The first and central suture was typically placed immediately nasal to the pupil aiming to create a natural eyelid contour. Additional sutures, typically medially and laterally, were placed to further adjust eyelid contour and excess levator aponeurosis was excised. An eyelid crease can then be created through placement of absorbable polygalactin 5/0 sutures that include deep bite through the levator aponeurosis and the skin was closed with black silk 5/0 sutures. Surgical time was recorded.

Postoperative topical eye ointment at bed time was used for 1 week and silk sutures were removed after 5 days. Cases were followed for 6 months for undercorrection and overcorrection and eyelid contour.

Small incision approach (group B)

Local anesthesia was used as in the conventional approach [Figure 1]a, an 8-10 mm long incision was performed in the center of the lid crease [Figure 1]b, and dissection was performed through the pretarsal orbicularis muscle until the tarsal plate was seen through the semitransparent levator aponeurosis. The aponeurosis was then incised with a sharp scissors [Figure 1]c. Blunt dissection was carried out up under the cut aponeurosis until it was free from the underlying tarsal plate and Muller's muscle to a distance of ∼12-15 mm [Figure 1]d. A nonabsorbable double-armed polygalactin 5/0 suture was passed through the undersurface of the aponeurosis as high as possible and brought out of the upper edge of the incision just posterior to the orbicularis oculi muscle [Figure 1]e. The two ends of the suture were grasped and held inferiorly and the patient was asked to sit up and open his or her eyes and look straight ahead and the level of the lid was evaluated and the tension of the suture was adjusted until lid height and contour were optimal, then sutures were passed through the central part of the tarsus, and additional medial and lateral sutures were added, and excess levator aponeurosis was excised [Figure 1]f. The wound was then closed with black silk 5/0 sutures. Surgical time was recorded.
Figure 1: Intraoperative photos of a small incision levator resection. (a) Subcutaneous injection of local anesthesia (lidocaine mixed with epinephrine 1 : 200 000). (b) Marking the site of incision with horizontal 8 mm incision and a vertical incision just nasal to the pupil. (c) Separation of the levator aponeurosis from the tarsus and from the underlying conjunctiva and Muller´s muscle. (d) Application of double-armed polygalactin 5/0 sutures at the desired distance. (e) Placement of the lid at a higher level to compensate for the effect of epinephr ine.

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Postoperative medications were administered and follow-up was performed as in the conventional approach.


  Results Top


This is a prospective comparative study including 30 cases of ptosis with good levator action (levator excurtion >10 mm) and excellent levator action (levator excurtion >15 mm). They were divided into two groups, A and B, each including 15 cases.

Group A included nine men (60%) and six women (40%); their age ranged from 4 to 48 years, with a mean of 25.2 ± 14.5. Nine of these patients (60%) were congenital and six (40%) were aponeurotic. Seven of these (46.7%) were mild and eight (53.3%) were moderate. Ten of these (66.7%) had good levator action and five (33.3%) had excellent levator action [Table 1].
Table 1: Sex, age, type, and presentation of the two groups

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Group B included 10 men (66.7%) and five women (33.3%); their age ranged from 20 to 50 years, with a mean of 35.1 ± 9.9. Seven of these patients (46.7%) were congenital and eight (53.3%) were aponeurotic. Nine of these (60%) were mild and six (40%) were moderate. Ten of these (66.7%) had good levator action and five (33.3%) had excellent levator action [Table 1].

For group A, we performed conventional transcutaneous levator resection under local anesthesia, except the child aged 4 years, who was operated under general anesthesia; the duration of surgery ranged from 40 to 60 min, with a mean of 49.5 ± 5.9. Full correction of ptosis was achieved in 12 cases (80%); however, two cases (13.3%) were undercorrected by 2 mm and underwent a second intervention within 3 months of the first surgery and one case (6.7%) was over corrected by 2 mm and did not need further intervention.

In terms of postoperative complications, only one case (6.7%) showed an irregular contour of the lid margin; this was mild and did not need further intervention [Table 2].
Table 2: Outcome of the two groups

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For group B, we performed small incision levator resection under local anesthesia. The duration of surgery ranged from 22 to 40 min, with a mean of 28.1 ± 5.2. Full correction of ptosis was achieved in 13 cases (86.7%); however, two cases (13.3%) were undercorrected by 2 mm and underwent a second intervention within 3 months of the first surgery.

In terms of postoperative complications, only one case (6.7%) complained of redundant skin and was corrected by blepharoblasty after 1 month of surgery [Table 2].

The difference in surgical time between the two groups was statistically significant (P < 0.001); the small incision technique was shorter in duration [Table 2].


  Discussion Top


The small incision, minimal dissection ptosis correction procedure is easy to perform and to teach. The minimal dissection required means that the anatomy is less disrupted and probably explains the significantly higher rate of good eyelid contour outcome. It is a procedure that is usable usually only in eyelids that have not been subjected to previous lid surgery or trauma because the anatomy should be in its original state to allow for blunt dissection. It is also suitable in cases with at least good levator action [9].

Lucarelli and Lemke [7] published the first small incision ptosis procedure and used primarily a single suture, adding additional sutures as needed. However, their dissection was similar to the traditional dissection (finding and opening the orbital septum, retracting the fat to identify the levator aponeurosis, cutting the aponeurosis from Müller's muscle, and then attaching it to tarsus). Use of a single suture was introduced by Liu [10]. Meltzer et al. [6] presented excellent results with an adjustable single suture technique.

However, Frueh et al. [9] performed a small incision minimal dissection procedure without opening the orbital septum as described in our study.

Frueh et al. [9] reported that the incidence of attaining good eyelid contour was significantly better in the small incision group, in which 41 of 42 lids (97.6%) evaluated by photographs had a good contour compared with 29 of 37 lids (78.4%) in the traditional group. Lucarelli and Lemke [7] reported that the success rate in small incision ptosis surgery was 89.3%; 7.1% were undercorrected and 3.6% were over corrected.

Baroody et al. [8] reported that, of the 118 eyelids corrected by a small incision technique, 109 cases were fully corrected (92.4%); there were four overcorrections, three undercorrections, one failure, one postoperative ptosis procedure of the contralateral upper eyelid secondary to Hering's law ptosis, and four patients requested surgical treatment of dermatochalasis. No symptomatic dry eye, exposure keratopathy, or other complications resulted in association with the overcorrections.

In this study, we found that full correction of the ptotic lid was achieved in 80% of the patients in group A (traditional procedure) and 86.7% in group B (small incision minimal dissection procedure); undercorrection occurred in 13.3% of patients in both groups and one case (6.7%) of overcorrection occurred in group A.

Frueh et al. [9] reported that the mean surgical time was 26.3 min in the small incision minimal dissection procedure and 56.6 min in the traditional procedure (P < 0.0001, statistically significant).

Lucarelli and Lemke [7] reported that the small incision minimal dissection procedure requires shorter operative time than a full-incision external levator repair.

Elabjer et al. [11] reported that the advantages of small incision ptosis surgery include less distortion of the lid because of less bleeding and edema, shorter operation time (on average 15-20 vs. 60 min in classic surgery), less scarring, and shortened recovery time.

In this study, we found that the mean surgical time was 49.5 ± 5.9 min in group A and 28.1 ± 5.2 min in group B (P ≤ 0.001 statistically significant), and this result is in agreement with Frueh et al. [9].

From this study, we can conclude that small incision minimal dissection ptosis surgery represents a good alternative to conventional transcutaneuos levator resection in cases with good and excellent levator action with the advantage of a shorter duration and less disturbance of the anatomy.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dortzbach RK, Sutula FC. Involutional blepharoptosis. A histopathological study. Arch Ophthalmol 1980; 98 :2045-2049.  Back to cited text no. 1
    
2.
Tarbet KJ, Lemke BN. Anatomy of the eyelids and lacrimal drainage system. In: Albert DM, Jakobiec FA, Azar Dt, eds. Principles and practice of ophthalmology. Philadelphia, PA: WB Saunders; 2000: 3318-3332.  Back to cited text no. 2
    
3.
Dresner SC. Ptosis management: a practical approach. In: Chen WP, ed. Oculoplastic surgery: the essentials. New York, NY: Thieme Medical Publishers; 2001: 1-10.  Back to cited text no. 3
    
4.
Shovlin JP. The aponeurotic approach for the correction of blepharoptosis. Int Ophthalmol Clin 1997; 37 :133-150.  Back to cited text no. 4
    
5.
Edmonson BC, Wulc AE. Ptosis evaluation and management. Otolaryngol Clin N Am 2005; 38 :921-946.  Back to cited text no. 5
    
6.
Meltzer MA, Elahi E, Taupeka P, Flores E. A simplified technique of ptosis repair using a single adjustable suture. Ophthalmology 2001; 108 :1889-1892.  Back to cited text no. 6
    
7.
Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol 1999; 127 :637-644.  Back to cited text no. 7
    
8.
Baroody M, Holds JB, Sakamoto DK, Vick VL, Hartstein ME. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg 2004; 52 :558-561.  Back to cited text no. 8
    
9.
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 :199-206 discussion 206-207.  Back to cited text no. 9
    
10.
Liu D. Ptosis repair by single suture aponeurotic tuck. Surgical technique and long-term results. Ophthalmology 1993; 100 :251-259.  Back to cited text no. 10
    
11.
Elabjer K, Bu M, Elabjer E. Microincision ptosis surgery. Coll Antropol. 2009; 3:915-918.  Back to cited text no. 11
    


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