Key Roles of Conjunctiva Fornix-Bulbar Conjunctiva-Tenon Capsule in Conjoint Fascial Sheath Suspension.

BACKGROUND: Bulbar conjunctival prolapse is one of the complications of conjoint fascial sheath (CFS) suspension and has a negative impact on surgical results. To explore the prevention methods of this complication, the authors compared the incidence of it between the below-conjunctiva fornix-bulbar conjunctiva-Tenon capsule (CBT) approach and the above-CBT approach to dissecting CFS in CFS suspension and shared their experience in the treatment of bulbar conjunctival prolapse. METHODS: From January of 2020 to August of 2021, 81 patients with severe congenital ptosis who underwent CFS suspension were enrolled and divided into two groups. Forty-five patients' (group A) CFS was dissected by means of the below-CBT approach and 36 patients' (group B) CFS was dissected by means of the above-CBT approach. Data regarding the incidence and outcomes of bulbar conjunctival prolapse and the postoperative condition were collected and analyzed. RESULTS: The incidence of bulbar conjunctival prolapse was 24.44% in group A and 2.78% in group B. Of the 12 bulbar conjunctival prolapse patients, seven patients' conditions improved after conservative treatment, and five did not. All of them underwent bulbar conjunctiva resection within 1 year and were cured. No recurrent prolapse was observed within 3 months postoperatively. At the last follow-up, the mean marginal reflex distance 1 and palpebral fissure height were 4.09 ± 0.19 mm and 9.85 ± 0.62 mm, respectively. There were no complications except lagophthalmos (16 eyelids), asymmetric eyelid contour (one patient), and trichiasis (two eyelids). CONCLUSIONS: The incidence of bulbar conjunctival prolapse decreased significantly by dissecting CFS by means of the above-CBT approach. For patients with bulbar conjunctival prolapse after CFS suspension, bulbar conjunctiva resection could provide satisfactory results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon.

BACKGROUND: Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos. METHODS: We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes. RESULTS: Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment. CONCLUSION: We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tape Tarsorrhaphy in the Management of Lagophthalmos Caused by Severe Congenital Blepharoptosis Procedures.

BACKGROUND: Lagophthalmos, a common complication after blepharoptosis correction, has plagued oculoplastic surgeons. The goal of this study was to investigate the effect of tape eyelid closure on reducing the occurrence of lagophthalmos after blepharoptosis correction. METHODS: From April 2020 to June 2021, a total of 112 patients with severe congenital ptosis received corrective surgery at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University. Of these, 48 underwent frontalis muscle advancement technique and 64 underwent conjoint fascial sheath suspension. Preoperative data collected included demographics, levator function, Bell's phenomenon, and marginal reflex distance 1 (MRD1). Postoperative data included surgery type, MRD1, eyelid closure function, aesthetic outcomes (including eyelid contour, eyelid symmetry, and eyelid crease), keratitis, and other complications. RESULTS: Frontalis muscle advancement technique group: the median of safe eye closure time was 7.3 months (positive Bell's phenomenon; interquartile range [IQR], 3.8-10.8 months) and 13.9 months (poor Bell's phenomenon; IQR, 11.6-16.1 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.52 ± 0.82 vs 3.85 ± 0.58 mm, P < 0.05). Conjoint fascial sheath suspension group: the median of safe eye closure time was 5.7 months (positive Bell's phenomenon; IQR, 2.9-8.5 months) and 12.4 months (poor Bell's phenomenon; IQR, 8.1-16.7 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.02 ± 0.91 vs 4.15 ± 1.03 mm, P < 0.05). All patients/guardians were satisfied with the aesthetic outcomes. CONCLUSIONS: Tape tarsorrhaphy is a safe, easy-to-learn method for treating lagophthalmos with a good aesthetic outcome.

The Aesthetic Evaluation of the Brow-Eye Continuum After Correction of Severe Congenital Ptosis in Children With Extended Frontalis Muscle Advancement Technique.

BACKGROUND: Severe congenital ptosis is a common ocular deformity in pediatric patients that can significantly impact visual development and aesthetic appearance, leading to negative psychosocial outcomes. The frontalis muscle advancement technique is a well-established surgical treatment for severe congenital ptosis. Aesthetic changes of the brow-eye continuum often plays an important role in ptosis surgery. METHODS: We conducted a single-center retrospective case series study of patients with severe congenital ptosis who underwent the frontalis muscle advancement technique at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University between April 2020 and June 2021. The study aimed to evaluate the aesthetic changes of the eyebrow-eyelid continuum after surgery. The main outcome measurements included marginal reflex distance 1, palpebral fissure height, eyebrow position, upper eyelid to lower eyebrow distance, lower eyelid to upper eyebrow distance, and nasal base to lower eyelid distance. RESULTS: The study included 48 patients (66 eyelids), with 30 unilateral and 18 bilateral patients. Our analysis found that eyebrow height decreased by an average of 4.8% postoperatively relative to preoperatively in all patients. CONCLUSIONS: The frontalis muscle advancement technique has demonstrated effectiveness in achieving aesthetically pleasing outcomes in children with severe ptosis. It is crucial to pay careful attention to the brow-eye continuum during the correction process, as its harmony can greatly impact the final result.

Modified Levator Resection Technique for Moderate Congenital Blepharoptosis.

BACKGROUND: For moderate ptosis associated with fair levator function (LF), the levator resection is the most commonly used procedure. However, the levator resection technique still has some disadvantages, such as residual lagophthalmos (RL), undercorrection, conjunctival prolapse, and eyelid contour abnormality. To solve the above problems, our team have made modifications to the levator resection technique in three aspects: releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. METHODS: Fifty-seven patients (81 eyes) underwent the modified levator resection technique and were enrolled in the study. Preoperative data collected included age, sex, margin reflex distance 1 (MRD1), and LF. Postoperative data collected included MRD1, RL, patient satisfaction, complications, and length of follow-up. RESULTS: Mean MRD1 significantly increased from 1.45 ± 0.65 mm preoperatively to 3.57 ± 0.51 mm postoperatively. Mean LF significantly increased from 6.49 ± 1.12 mm preoperatively to 9.48 ± 1.39 mm postoperatively. Successful correction was obtained in 77 eyes (95.1%). Mean RL was 1.09 ± 0.57 and 72 eyes (88.9%) showed excellent or good eyelid closure function. Fifty-four patients (94.7%) were completely satisfied with the final result. Complications such as hematoma, infection, conjunctival prolapse, suture exposure, corneal abrasion, and keratitis were not found in any cases during follow-up. CONCLUSION: This modified levator resection technique introduced in this study is effective in correcting moderate congenital blepharoptosis, while minimizing RL, undercorrection, conjunctival prolapse, eyelid contour abnormality by releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. LEVEL OF EVIDENCE IV: This journal requires that authors 42 assign a level of evidence to each article. For a full 43 description of these Evidence-Based Medicine ratings, 44 please refer to the Table of Contents or the online 45 Instructions to Authors www.springer.com/00266 .

Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis.

BACKGROUND: The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and undercorrection. This article describes the authors' extended frontalis muscle advancement technique, which takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis. METHODS: A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1, levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, and cosmetic result was performed at the last follow-up. RESULTS: From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative margin reflex distance 1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0%) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7%) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2%) had an excellent or good cosmetic result. CONCLUSIONS: Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, and minimizes undercorrection, residual lagophthalmos, eyelid contour abnormality, and eyebrow ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Simultaneous Double Eyelid Blepharoplasty and Blepharoptosis Correction With Levator Aponeurosis Plication Technique: Clinical Experience of 108 Cases.

BACKGROUND: Fifty percent of Asians are born without a supratarsal fold (also called single eyelid), and double eyelid blepharoplasty is one of the most commonly performed and most popular facial cosmetic surgeries in the Asian population. However, patients with single eyelid frequently present with concomitant mild blepharoptosis (degree of ptosis, ≤2 mm), which often fails to cause the attention of surgeons and misses correction. METHODS: A retrospective study of all patients who underwent double eyelid blepharoplasty and blepharoptosis correction simultaneously with the modified levator aponeurosis plication technique was performed from June of 2017 to June of 2020. RESULTS: A total of 108 patients (155 eyelids) underwent double eyelid blepharoplasty and blepharoptosis correction simultaneously with the modified levator aponeurosis plication technique and were enrolled in the study. The average follow-up period was 11.8 ± 4.5 months. There was a statistically significant difference between the preoperative margin reflex distance 1 (MRD1) and postoperative MRD1 (2.93 ± 0.37 vs 4.21 ± 0.39 mm, P = 0.000), and the mean MRD1 improvement was 1.28 ± 0.50 mm. Sufficient correction was obtained in 148 eyelids (95.5%), whereas undercorrection was observed in 5 eyelids (3.2%) and overcorrection was observed in 2 eyelids (1.3%). One hundred two patients (94.4%) were completely satisfied with the final result.All patients had smooth and elegant upper eyelid margin curve, and no patients complained of distortion of the eyelid margin contour and foreign body sensation.There were no cases of hematoma, infection, suture exposure, corneal abrasion, and keratitis in any patient. CONCLUSIONS: This modified levator aponeurosis plication introduced in this study is a simple and effective method for creating double-eyelid crease and correcting mild blepharoptosis simultaneously, and provides a satisfactory outcome. As such, we recommend this method in treating patients with both single eyelid and mild blepharoptosis.

Aesthetic Changes of Brow-Eyelid Continuum After Correction of Moderate-Severe Blepharoptosis with Conjoint Fascial Sheath Suspension.

BACKGROUND: As periorbital aesthetic commonly improved in blepharoptosis patients after correction surgery, the aim of this study was to elaborate the brow-eyelid continuum changes in moderate-severe ptosis patients who underwent conjoint fascial sheath suspension systematically. METHODS: Patients with moderate-severe ptosis who underwent conjoint fascial sheath suspension were assessed by using pre- and post-operative digital photographs in the primary gaze position of the eye. The main outcome measurements included marginal reflex distance1 (MRD1), palpebral fissure height (PFH), eyebrow position, the symmetry of face and the horizontal forehead lines condition. RESULTS: There were 43 patients (53 eyelids) in our study, including 33 unilateral and 10 bilateral patients. The mean levator function was 3.00 ± 1.07 mm. Before surgery, the mean MRD1 and PFH were 0.60 ± 1.14 mm and 6.75 ± 1.71 mm, respectively. The mean eyebrow height at medial, center, lateral position was 33.16 ± 3.95 mm, 35.99 ± 4.02 mm and 34.35 ± 4.80 mm, respectively. It was found that MRD1 and PFH symmetry both were 23.26% and eyebrow symmetry was 62.79%. For forehead wrinkles, 48.84% of the patients was mild, 34.88% was moderate, and 16.28% was severe. The average follow-up was 12.78 months (ranged from 12 to 18 months). One month after surgery, the mean MRD1 and PFH were 5.68 ± 0.86 mm, 11.61 ± 0.97 mm, respectively, both of which improved significantly (P < 0.0001). The mean eyebrow height at medial, center, lateral position descended to 28.22 ± 4.77 mm (P = 0.017), 31.41 ± 4.58 mm (P = 0.033) and 30.28 ± 3.41 mm (P = 0.018), respectively. The result showed that the rate of patients with MRD1 symmetry was 32.56%, PFH symmetry was 30.23%, and eyebrow symmetry was 90.7%. For forehead wrinkles, 69.77% was mild and 30.23% was moderate. Then, patients' eyebrow gradually elevated, while their upper eyelid dropped. At the last follow-up, the mean MRD1 and PFH were 3.83 ± 0.98 mm and 9.84 ± 1.56 mm, respectively. The mean eyebrow height at medial, center, lateral position improved to 30.52 ± 4.59 mm (P = 0.031), 32.40 ± 4.68 mm (P = 0.033), 31.19 ± 4.16 mm (P = 0.028), respectively. The patients with MRD1 symmetry accounted for 86.05%, PFH symmetry 86.05%, and eyebrow symmetry 90.7%. For forehead wrinkles, 67.44% was mild and 32.56% was moderate. CONCLUSION: CFS suspension can effectively reconstruct moderate-severe ptosis patients' aesthetics of the brow-eyelid continuum by descending elevated eyebrow, improving facial symmetry and reducing forehead rhytids. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Conjoint Fascial Sheath Suspension for Correction of Recurrent Blepharoptosis.

BACKGROUND: Blepharoptosis is defined as an abnormally low-positioned upper eyelid margin in the primary gaze position, which results in cosmetic discomfort and functional visual dysfunction. Recurrence is one of the common complications after ptosis correction and requires further revision. Conjoint fascial sheath (CFS) suspension has become increasingly popular for ptosis. In this article, we described our experience of CFS suspension in the treatment of recurrent blepharoptosis and evaluated the postoperative outcomes so as to guide the clinical application of CFS suspension. METHODS: Thirty-eight patients (48 eyelids) who had recurrent blepharoptosis and received CFS suspension were included in this study. Before the surgery, the degree of ptosis and levator function were assessed. The postoperative evaluation consisted of the correction effect, eyelid symmetry, protective closure function of eyelid, and surgical complications. RESULTS: At the final follow-up, 46 eyelids (95.8%) showed an ideal correction, of which 24 eyelids (50%) showed sufficient correction and 22 eyelids (45.8%) showed normal correction. The remaining 2 eyelids (4.2%) showed under-correction. Among all 38 patients, 26 patients (68.4%) achieved good symmetry, and 10 patients (26.3%) achieved fair symmetry, while only 2 patients (5.3%) showed poor symmetry. Recovery time of eyelid protective closure function was 3.9 ± 1.04 months (range, 2.5-6 months). There were no complications except residual lagophthalmos (9 eyelids) residual conjunctival prolapse (10 eyelids). CONCLUSION: CFS suspension is an effective method for the correction of recurrent blepharoptosis due to its sufficient correction effect, recovery of eyelid protective closure function, and less complication rate. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anterior tibial artery injury is not the contraindication of medial plantar flap: digital subtraction angiography evidence and clinical application.

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.

Application of Digital Subtraction Angiography in Reconstruction of Plantar Forefoot With Reverse Medial Plantar Flap.

ABSTRACT: The reverse medial plantar flap (RMPF) raised from the nonweight-bearing region of the plantar foot represents a viable option for the soft tissue defect in planter forefoot. The anatomical basis of RMPF is the complex anastomotic branches between medial plantar artery (MPA) and deep plantar arch. Those anastomotic branches have high variation rate and may be damaged by trauma such as electric injury. Therefore, it is very important to know whether those anastomotic branches are present and intact before harvesting RMPF. Five patients with soft tissue defect in planter forefoot were enrolled into the study. The digital subtraction angiography (DSA) was performed to evaluate the plantar hemodynamics in the ipsilateral foot. The RMPF was harvested only after the anastomotic connections between MPA and deep plantar arch was confirmed. Anastomosis between superficial branch of MPA and deep plantar arch was observed in all DSA examinations. All 5 patients received the repair of soft tissue defect in plantar forefoot with RMPF. All flaps survived completely. The DSA can effectively evaluate the blood supply basis of RMPF and provide imaging evidence for the design and harvest of the flap. The main anatomical basis of RMPF is the anastomotic connections between superficial branch of MPA and deep plantar arch.

Application of Superficial Temporal Artery Flap in Wound Repairing After the Resection of Craniofacial Malignant Tumors.

BACKGROUND AND OBJECTIVE: Craniofacial malignant tumors require not only extended resection but also appropriate reconstruction to restore appearance, which remains a major challenge. Here the authors introduced the application of superficial temporal artery (STA) flap in wound repairing after the resection of craniofacial malignant tumors. METHODS: From January 2015 to December 2018, 16 patients with craniofacial malignant tumors were enrolled into the study, including squamous cell carcinoma (n = 6), basal cell carcinoma (n = 3), melanoma (n = 4), neuroendocrine carcinoma (n = 2), and dermatofibrosarcoma protuberance (n = 1). All of the tumors underwent extended resection. The defects formed were repaired by flaps pedicled with superior or frontal branch of STA. Donor sites were repaired with skin grafts. Patients were followed up for 6 months to 3 years to monitor the recurrence of tumor. RESULTS: All the flaps survived well. Venous congestion occurred in two cases but resolved after blood-letting and application of drugs promoting venous draining. During the follow-up, no recurrence of tumors was observed and the appearance of flaps was satisfying. But flap donor sites suffered from relatively poor appearance or alopecia deformity. CONCLUSIONS: The STA flap is reliable for wound repairing after resection of craniofacial malignant tumors. The STA parietal branch flap is preferred for repairing scalp defects, while the STA frontal branch flap is preferred for repairing facial defects. However, the STA flap should be used prudently due to its disadvantage of the deformity in scalp donor sites.

Reconstruction of the distal lower leg and foot sole with medial plantar flap: a retrospective study in one center.

Soft tissue reconstruction of the distal lower leg and foot sole is a challenge for surgeons. In this article, we describe our experience and outcomes with distal lower leg and foot sole reconstruction using the medial plantar flap. From January 2007 to December 2017, 29 consecutive patients from our department underwent reconstruction of soft tissue defects over the distal lower leg, heel and plantar forefoot using medial plantar flaps. Of the 29 patients, the defects were located in the distal lower leg (n = 8 [27.6%]), heel (n = 14 [48.3%]) and plantar forefoot (n = 7 [24.1%]). The mean follow-up period was 18.6 months, 28 (96.6%) survived completely. Lateral partial necrosis occurred in one flap. No patient had recurrence of ulcer and two (6.9%) patients died within 1 year post-reconstruction owing to metastatic malignant melanoma. At last follow-up, all survived patients could walk for more than 1 h in normal shoes. All donor sites were covered with a split-thickness skin graft, no early nor late complications were encountered, and no patients complained about the donor site scar. The medial plantar flap may be considered as an effective method for the repair of small to medium soft tissue defects in the distal lower leg, heel and plantar forefoot.

Treatment of Large Scars in Children Using Artificial Dermis and Scalp Skin Grafting.

BACKGROUND AND OBJECTIVES: Large scars formed after burns injury can seriously hamper appearance and function in children. Surgical resection of scars and secondary skin or flap grafting often brings severe damages to donor sites, which may lead to physiological and psychological development disorders in children. Here, we introduce the use of artificial dermis and skin grafts from scalps to treat large scars in children to minimize the donor site morbidity. METHODS: A retrospective char review was performed including 7 children with large scars between January 2016 and December 2017. First, the scars were resected, and artificial dermis was applied to the secondary wounds. Twelve days later, outer silicone membrane was removed. Another 2 days later, scalp skin grafts of 0.3 mm were transplanted to the wounds. Manchester Scar Scale and Visual Analog Scale were used to evaluate scar appearance before and after the treatment respectively. One special patient with extensive scars was treated twice at an interval of 1 year. The first therapy was performed with both conventional method of resection and skin grafting and the new method described above. In the second therapy, 4 samples were taken from 4 different sites-the normal skin, scars, the skin where artificial dermis and scalp skin grafting were performed, and the skin where only scalp skin grafting was performed. H-E staining, Masson staining, Aldehyde fuchsin staining, and scanning electron microscopy were used for histological observation. RESULTS: All skin grafts survived well. The Manchester Scar Scale score of the graft area was significantly reduced (P < 0.01) after the treatment. Histological examination showed obviously better dermis arrangement where artificial dermis and scalp grafting was performed. CONCLUSION: The therapy achieves better appearances and minimizes donor site morbidity. It is beneficial to physical and psychological development of children and provides an alternative to treat children with large scars.