A Modified Algorithm-Based Levator Aponeurectomy in Mild to Moderate Congenital Blepharoptosis.

BACKGROUND: Levator aponeurectomy is a common operation for mild to moderate blepharoptosis. The accuracy of ptosis correction relied on intraoperative judgement when patients were under local anesthesia. For patients who must receive the operation under general anesthesia, it would be an issue to determine how much length of levator aponeurosis to shorten. To solve this issue, we collected data from patients who underwent the operation under local anesthesia and concluded an algorithm. METHODS: This single-center, prospective bivariate regression study allocated patients of mild to moderate congenital blepharoptosis who received levator aponeurectomy under local anesthesia. Preoperative MRD1 and levator function, intraoperative amount of levator aponeurotic shortening, and postoperative MRD1 were measured. The follow-up period was right after the operation. RESULTS: Twenty-nine patients were included in this trial. Two subjects exited because of not receiving allocated operation and data of the other 27 subjects (including 34 eyelids) were analyzed. A scatter diagram was drawn where x axis referred to levator function and y axis referred to the ratio of the amount of shortening of levator aponeurosis over the height of MRD1 correction. Linear regression showed y = - 0.2717*x + 5.026, R2 = 0.8553. CONCLUSION: A modified algorithm to predict the amount of shortening of levator aponeurosis based on levator function and height of ptosis correction was concluded with better accuracy and clinical feasibility. 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 .

Musculoaponeurotic architecture of the human masseter muscle: an in vivo ultrasonographic study of architectural changes during mandibular protrusion and lateral excursions.

OBJECTIVE: The present study evaluated the in vivo musculoaponeurotic architecture of the superficial head (SH) of the masseter muscle (MM) of asymptomatic participants in excursive mandibular movements compared to the relaxed state as examined with ultrasonography. It was hypothesized that the mean fiber bundle length (FBL) and mean height of the aponeurosis (HA) of the laminae of the SH would differ significantly between the relaxed state and protrusion, ipsilateral excursion, and contralateral excursion. STUDY DESIGN: The MM was studied volumetrically in 12 female and 12 male asymptomatic participants bilaterally by using ultrasound imaging. Mean FBL and HA in protrusion and ipsilateral and contralateral excursion were compared to these values in the relaxed state using paired t tests (P < .05). The intraclass correlation coefficient was used to assess intraexaminer reliability. RESULTS: The SH exhibited multiple laminae. Fiber bundles were found to attach to bone and the superior and inferior aponeuroses. Mean FBL was significantly shorter and mean HA significantly longer in protrusion and the excursions than in the relaxed state although the pattern of altered laminae and aponeuroses differed among the mandibular movements. Intraexaminer reliability was excellent. CONCLUSION: Specific changes in mean FBL and mean HA suggest differential contraction of the SH of the MM based on laminar morphology. These findings provide a baseline to investigate musculoaponeurotic changes in patients with myogenic masseter muscle pain.

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives : Aponeurotic maldevelopment in congenital ptosis.

PURPOSE: Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair. METHODS: This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients' records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs. RESULTS: Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat. CONCLUSION: Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

Mechanical Ptosis by Medial Upper Eyelid Fat Prolapse.

Common symptoms of medial fat pad prolapse may include a noticeable bulge in the inner corner of the upper eyelid, puffiness, and a tired or aged appearance. In some cases, this condition may contribute to mechanical ptosis. However, mechanical ptosis caused by medial upper eyelid fat prolapse has not been reported previously. The purpose of the current study is to report the author's experience of successful treatment of ptosis caused by medial upper eyelid fat prolapse in a 67-year-old woman. The patient complained of slowly aggravating asymmetric upper eyelids starting from 5 years ago. At the time of her visit, she had to use her left forehead to open her eyes, making her left eyebrow upwardly positioned. This condition might be related to medial upper eyelid fat prolapse-related mechanical ptosis. The author explored her left upper eyelid with a 9 mm height incision. The author found a substantial amount of medial fat herniation and levator aponeurosis tear. After fat pad removal, the author fixed the levator aponeurosis tear with nylon 6-0, and transdermal sutures were done. The patient was happy with esthetically pleasing results 2 months after the initial surgery. The author successfully treated this rare condition with basic principles, such as fat removal, levator aponeurosis repair, and transdermal sutures.

Orbital septum attachment site on the levator aponeurosis sling for mild congenital blepharoptosis.

PURPOSE: This study aimed to investigate the value of the orbital septum attachment site on the levator aponeurosis (OSASLA) sling in correcting mild congenital blepharoptosis. METHODS: A total of 60 patients (92 eyes) with mild congenital blepharoptosis (levator function ≥ 8 mm) were treated in our hospital from January to October 2021, and relevant data of these patients were collected. All patients underwent OSASLA sling for ptosis correction. The distances from the superior tarsal border to the OSASLA were measured. The primary outcome was the number of postoperative changes in the marginal reflex distance 1 (MRD1). Pearson's correlation coefficient between the distance from the superior tarsal border to the OSASLA and the height of the upper eyelid elevated was analyzed. RESULTS: Fifty-eight patients (89 eyes) successfully underwent OSASLA sling surgery. The preoperative MRD1 was 1.4-3.6 mm (mean 2.1 ± 0.5 mm), and the postoperative MRD1 was 3.4-5.0 mm (mean 3.7 ± 0.6 mm). The distance from the superior tarsal border to the OSASLA sling was significantly and positively correlated with the height of the upper eyelid elevation (r = 0.7328, P < 0.0001). The eyelid margin positions of the patients did not regress substantially during 6-18 months of follow-up. CONCLUSIONS: Compared with the shortening of levator palpebrae superioris (LPS) and pleating of LPS, the OSASLA sling is a less invasive, more effective, and easy-operating surgery for mild congenital blepharoptosis.

Influence of muscle length on the three-dimensional architecture and aponeurosis dimensions of rabbit calf muscles.

The function of a muscle is highly dependent on its architecture, which is characterized by the length, pennation, and curvature of the fascicles, and the geometry of the aponeuroses. During in vivo function, muscles regularly undergo changes in length, thereby altering their architecture. During passive muscle lengthening, fascicle length (FL) generally increases and the angle of fascicle pennation (FP) and the fascicle curvature (FC) decrease, while the aponeuroses increase in length but decrease in width. Muscles are differently structured, making their change during muscle lengthening complex and multifaceted. To obtain comprehensive data on architectural changes in muscles during passive length, the present study determined the three-dimensional fascicle geometry of rabbit M. gastrocnemius medialis (GM), M. gastrocnemius lateralis (GL), and M. plantaris (PLA). For this purpose, the left and right legs of three rabbits were histologically fixed at targeted ankle joint angles of 95° (short muscle length [SML]) and 60° (long muscle length [LML]), respectively, and the fascicles were tracked by manual three-dimensional digitization. In a second set of experiments, the GM aponeurosis dimensions of ten legs from five rabbits were determined at varying muscle lengths via optical marker tracking. The GM consisted of a uni-pennated compartment, whereas the GL and PLA contained multiple compartments of differently pennated fascicles. In the LML compared to the SML, the GM, GL, and PLA had on average a 41%, 29%, and 41% increased fascicle length, and a 30%, 25%, and 33% decrease in fascicle pennation and a 32%, 11%, and 35% decrease in fascicle curvature, respectively. Architectural properties were also differentiated among the different compartments of the PLA and GL, allowing for a more detailed description of their fascicle structure and changes. It was shown that the compartments change differently with muscle length. It was also shown that for each degree of ankle joint angle reduction, the proximal GM aponeurosis length increased by 0.11%, the aponeurosis width decreased by 0.22%, and the area was decreased by 0.20%. The data provided improve our understanding of muscles and can be used to develop and validate muscle models.

Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Comparisons of the Fusion Point of Orbital Septum and Levator Aponeurosis in Patients with and Without Mild Ptosis.

OBJECTIVE: By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis. METHODS: In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed. RESULTS: The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001). CONCLUSION: The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis. LEVEL OF EVIDENCE III: 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 https://www.springer.com/00266 .

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision.

BACKGROUND: Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids. METHODS: We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months). RESULTS: The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations. CONCLUSIONS: Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids. 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 .

A Retrospective study of anatomical differences in levator aponeurosis angle and length in East-Asian blepharoplasty.

This study aimed to analyze the anatomical differences in levator aponeurosis angle and length between both sides in double eyelidplasty in East Asians. The retrospective study included patients with mild blepharoptosis who underwent upper blepharoplasty with levator aponeurosis. In the study, 140 patients were enrolled, 126 females and 14 males, with an age range of 16-73 years. The mean levator aponeurosis angle was 19.2 ± 2.9° on the right and 17.0 ± 3.8° on the left, which was significantly different (95% CI, p < 0.001). The mean length was 24.1 mm on the right and 23.2 mm on the left, a difference that was also statistically significant (95% CI, p < 0.001). The relationship between the dominant eye and levator aponeurosis prominence was also investigated, although there was no apparent correlation. Within the limitations of the study, it seems that this is the first study of the anatomical differences of the levator aponeurosis between both sides, leading to a greater predictability of surgery to maximize postoperative symmetry.

The Isolation, Culture, and Cryopreservation of Human Rectus Sheath Fibroblasts.

The vast majority of pelvic and intra-abdominal surgery is undertaken through at least one incision, through either the linea alba or the rectus sheath. These connective tissue layers are formed from the aponeuroses of the rectus muscles (anterior and posterior rectus sheath) and are vital for the structural integrity of the abdominal wall. Poor healing of these connective tissues after surgery can lead to significant morbidity for patients, who can develop unsightly and painful incisional hernias. Fibroblasts within the rectus sheath are responsible for laying down and remodeling collagen during the healing process after surgery. Despite their importance for this healing process, such cells have not been studied in vitro. In order to carry out such work, researchers must first be able to isolate these cells from human tissue and culture them successfully so they may be used for experimentation. This article provides an extensive and detailed protocol for the isolation, culture, cryopreservation, and thawing of human rectus sheath fibroblasts (RSFs). In our hands, this protocol develops confluent cultures of primary fibroblasts within 2 weeks, and sufficient cultures ready for freezing and storage after a further 2 to 4 weeks. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol: Collagenase digestion of human rectus sheath and isolation of RSFs Alternate Protocol: Collagenase digestion of human rectus sheath and isolation of RSFs, digestion in flask Support Protocol: Cryopreservation and thawing of human RSFs.

Evaluating Shared Decision-Making in Treatment Selection for Dupuytren Contracture: A Mixed Methods Approach.

BACKGROUND: Patients with Dupuytren contracture can receive a variety of surgical and nonsurgical treatments. The extent to which patients participate in the shared decision-making process is unclear. METHODS: An explanatory-sequential mixed-methods study was conducted. Participants completed the Nine-Item Shared Decision-Making Questionnaire and the brief Michigan Hand Outcomes Questionnaire before completing semi-structured interviews in which they described their experience with selecting treatment. RESULTS: Thirty participants [25 men (83%) and five women (17%); mean age, 69 years (range, 51 to 84 years)] received treatment for Dupuytren contracture (11 collagenase injection, six needle aponeurotomy, and 13 limited fasciectomy). Adjusted mean scores for the Shared Decision-Making Questionnaire and brief Michigan Hand Outcomes Questionnaire were 71 (SD 20) and 77 (SD 16), respectively, indicating a high degree of shared decision-making and satisfaction. Patients who received limited fasciectomy accepted invasiveness and prolonged recovery time because they believed it provided a long-term solution. Patients chose needle aponeurotomy and collagenase injection because the treatments were perceived as safer and more convenient and permitted rapid return to daily activities, which was particularly valued by patients who were employed or had bilateral contractures. CONCLUSIONS: Physicians should help patients choose a treatment that aligns with the patient's preferences for long-term versus short-term results, recovery period and postoperative rehabilitation, and risk of complications, because patients used this information to assist in their treatment selection. Areas of improvement for shared decision-making include equal presentation of all treatments and ensuring realistic patient expectations regarding the chronic and recurrent nature of Dupuytren contracture regardless of treatment received.

Auricular Cartilage Graft for Lengthening Levator Muscle Aponeurosis With Ectropion Correction for Paralytic Lagophthalmos.

BACKGROUND: Paralytic lagophthalmos can have devastating consequences for vision if left untreated. Several surgical techniques have been described, including the utilization of alloplastic and autologous materials. OBJECTIVES: The authors sought to evaluate the effectiveness of the surgical treatment of paralytic lagophthalmos with combined techniques employing autologous material and involving the upper and lower eyelids. METHODS: Patients with paralytic lagophthalmos underwent stretching of the levator aponeurosis with interposition of conchal cartilage in the upper eyelid associated with sectioning of the orbitomalar ligament and lateral canthoplasty in the lower eyelid. The effectiveness of the technique was evaluated employing subjective (symptomatology) and objective parameters (ophthalmologic evaluation and measurements of lagophthalmos and marginal reflex distances 1 and 2). RESULTS: Eight patients with paralytic lagophthalmos were subjected to the proposed technique. In the postoperative period, 85.7% reported complete improvement of symptoms and 62.5% presented a normal eye examination. The mean lagophthalmos measurement was reduced by 5.93 mm, the mean marginal reflex distance 2 was reduced by 2.61 mm, and the mean marginal reflex distance 1 was reduced by 0.69 mm. CONCLUSIONS: The technique presented herein, employing autologous material associated with sectioning of the orbitomalar ligament and lateral canthoplasty, was effective in the treatment of paralytic lagophthalmos and did not present significant complications, such as extrusion.

Small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique: A modified partial-incision double-eyelid blepharoplasty.

BACKGROUND: The partial-incision double-eyelid surgery remains a popular esthetic procedure in Asia, most of the previous partial-incision double-eyelid operations involved resection of the pretarsal orbicular muscle, resulting in a depressed and firm eyelid crease. In order to create a more natural, dynamic, and durable double-eyelid crease with less visible scar and shorter postoperative recovery time, we describe a modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique for Chinese patients. METHODS: A total of 132 patients who underwent bilateral modified partial-incision double-eyelid surgery were retrospectively reviewed. In this technique, three 2 mm incisions were designed, the orbicularis oculi muscle was preserved and conservatively dissected to expose the levator aponeurosis, and buried suture was used to fix the orbicularis oculi muscle to levator aponeurosis. The skin and orbicularis oculi muscle were then sutured together with the levator aponeurosis. RESULTS: With a follow-up period of more than 6 months, most of the double eyelids were natural and dynamic, and the crease was stable. The majority of the swelling faded in 2 weeks and completely faded in the first month for most patients. The scars of the small incision became invisible after 3 months of recovery. One patient (0.8%) complained of bilateral fold disappearance. Asymmetries occurred in 4.5% (6 of 132) patients. 97.7% (129 of 132) patients were satisfied with the postoperative appearance. No severe complications were reported during the follow-up period. CONCLUSION: The modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation double-eyelid blepharoplasty technique can create a more natural, dynamic, and durable double-eyelid crease with fast recovery and no visible scar or serious complications.

Re-positioning pretarsal tissue layers for double-eyelid surgery: 6-year experience.

Double-eyelid surgery is a very common practice in East Asian patients. The differential distribution of pretarsal tissue layers is considered to be the anatomical mechanism of natural Asiatic single eyelid, it is possible to form double-eyelid crease by re-positioning the pretarsal structure layers. The author presents a new double-eyelid surgery based on re-positioning of the pretarsal structure layers without tissue removal. Over a 6-year period, 1440 patients underwent new double-eyelid surgeries. With the pretarsal orbicularis oculi muscle incised, the pre-pretarsal levator aponeurosis fascia fibroadipose was first dissected to form a fibroadipose flap, and then repositioned with the eyelid lower lip orbicularis oculi muscle flap. The new composite structure was anchored at 3 points on the pretarsal levator aponeurosis fascia; the skin was sutured to form a smooth crease. Post-operative outcome and follow-up data were analyzed. Patients were followed up for an average of 2 years. esthetic outcomes were satisfactory for 97.91% of patients, who enjoyed new double upper eyelids with smooth creases and invisible incision lines. Outcomes were unsatisfactory for 2.08% of patients (double-eyelid regression, 0.76%; asymmetric creases, 1.32%). All patients who were not satisfied with their esthetic outcomes underwent second correction surgery. This new Pan-flap technique focuses on the correct dissection and repositioning of differentially thickened pre-pretarsal levator aponeurosis fascia fibroadipose tissue in East Asian patients. This new technique can generate broader and tighter attachment between pretarsal orbicularis oculi muscle and levator aponeurosis fascia, and form smooth double-eyelid crease without pretarsal soft tissue removal.

Orbicularis-Tarsus-Orbital Septum Fixation Technique in Asian Double-Eyelid Blepharoplasty: a Retrospective Study.

BACKGROUND: The skin-tarsus-skin and orbicularis-levator fixation approaches are the 2 most applied techniques for double-eyelid blepharoplasty in China. However, both approaches have their own disadvantages. To achieve stable and dynamic upper eyelid creases, we take the merits of the 2 techniques. In this study, our orbicularis-tarsus-orbital septum fixation technique is introduced and evaluated. METHODS: By transversely opening and turning down the anterior orbital septum, we created the septum roll anchored to the tarsus and the pretarsal muscular flap. As the motion transmitter, the roll could receive the pulling power of the levator aponeurosis transmitted to the tarsus and the septum respectively. With the help of the skin-septum roll-skin sutures, the roll passed on the pulling power directly to the pretarsal skin and thus the upper eyelid crease was formed. RESULTS: This study identified 105 Chinese patients (210 eyes) who underwent this technique in our department between September 2020 and May 2021. The follow-up ranged from 7 to 15 months. 90, 6, and 7 patients were satisfied, somewhat satisfied, and somewhat unsatisfied with the postoperative outcome, respectively. The satisfaction rate was 91.43% (96/105). Two patients were unsatisfied with the outcome, including 1 case of bilateral crease disappearance and 1 case of sunken upper eyelid. CONCLUSIONS: The orbicularis-tarsus-orbital septum fixation technique is safe and effective for double-eyelid blepharoplasty. This technique helps to form stable upper eyelid creases. Meanwhile, it is easy to achieve ideal curve and symmetry. By preserving the pretarsal tissue and using the orbital septum, sunken scar formation can be avoided.

One Patient of Blepharoptosis Caused by Levator Palpebrae Superioris Aponeurosis Degeneration.

Ptosis is one of the common diseases of plastic surgery, which is caused by various causes of levator palpebrae superioris dysfunction or Müller muscle insufficiency, which is manifested by the upper eyelid margin being lower than normal when level viewed. Ptosis can be divided into congenital and acquired, and the main cause of congenital ptosis is due to congenital levator palpebrae superioris dysplasia or the motor nerve innervation that innervates it is caused by abnormal oculomotor neurodevelopment and dysfunction. Acquired ptosis can be divided into traumatic, neurogenic, myogenic, senile, mechanical, and false ptosis. At present, there are few reports of ptosis due to the degeneration of the aponeurosis of the upper eyelid muscle. We received a case of ptosis caused by degeneration of the levator palpebrae superioris aponeurotic membrane, we use the method of the levator palpebrae superioris high advancement. The levator palpebrae superioris-Miller muscle was folded to form a stable composite structure by the levator palpebrae superioris high advancement. During the operation, the levator palpebrae superioris was separated along the gap, and the surrounding tissues were less damaged. Therefore, postoperative adhesion was less, and the main complications of severe blepharoptosis after the operation, such as upper eyelid hysteresis and incomplete closure, almost did not occur, and after surgery, the results were good.

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.