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.

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.

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.

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.

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.

Conjoint Fascial Sheath Suspension for Correction of Severe Involutional Blepharoptosis.

Involutional ptosis is considered to be the result of the disinsertion of the levator aponeurosis from the tarsal plate. However, present histopathological studies indicate that the pathogenesis of involutional ptosis is multifactorial and complex. To create a more physiologic eyelid opening in patients with severe involutional blepharoptosis, the authors used conjoint fascial sheath (CFS) as suspension location. Sixty-seven involutional blepharoptosis patients (123 eyelids) with a degree of severe ptosis (marginal reflex distance 1, MRD-1 <1.0 mm) underwent the CFS suspension. The primary outcome was MRD-1 at 12 months after surgery. Secondary outcomes were cosmetic outcomes and postoperative complications. All the eyelids had fair MRD-1 (MRD-1≥2.0 mm) at 12 months. Complete correction of ptosis (MRD-1≥2.5 mm) at 12 months was obtained in 80 eyelids (65%). There were no overcorrections. The mean cosmetic outcome by patients was 3.56 ± 0.61 at 12 months. The most common complication was reoperation, which was done in 9 eyelids (7%) because of incomplete correction. CFS suspension was effective in the treatment of severe involutional blepharoptosis. The technique produced an elevating motion of the physiologic eyelid in a superior-posterior direction.

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.

[Effectiveness of groin flap with external oblique aponeurosis for tendon and skin defects of dorsal foot].

OBJECTIVE: To investigate the effectiveness of groin flap with external oblique aponeurosis in repair of tendon and skin defects of dorsal foot. METHODS: Between October 2016 and January 2020, 12 patients with compound tissue defects of the dorsal foot caused by trauma were treated. There were 9 males and 3 females, with a median age of 42 years (range, 32-65 years). The size of the skin defects ranged from 8 cm×5 cm to 12 cm×8 cm. All wounds were accompanied by extensor tendon injury, including 6 cases of extensor hallucis longus tendon defect, 5 cases of extensor digitalis longus tendon defect, and 3 cases of extensor digitalis longus tendon and extensor digitorum brevis defects. The interval between injury and admission was 1-6 hours (mean, 3 hours). After admission, the wounds were thoroughly debrided, and the groin flap with external oblique aponeurosis was used to repair the skin and tendon defects in the second stage. The size of skin flap ranged from 10 cm×6 cm to 13 cm×9 cm, and the size of the external oblique aponeurosis ranged from 5.5 cm×3.0 cm to 8.0 cm×5.0 cm. The wounds at donor sties were sutured directly. RESULTS: All flaps survived completely without significant complications. All incisions of the recipient and donor sites healed by first intention. All patients were followed up 16-24 months (mean, 18 months). The flaps were satisfactory in appearance and soft in texture. At last follow-up, 9 cases were excellent and 3 cases were good according to the American Orthopaedic Foot and Ankle Society (AOFAS) metatarsophalangeal-interphalangeal joint scale criteria. The toe function was satisfactory. The line scar was left without hernia or other morbidity on the donor site. CONCLUSION: The groin flap with the external oblique aponeurosis can repair the tendon and skin defects of the dorsal foot, with concealed donor site, easy dissection and adjustable thinness, as well as the enough tough aponeurosis.

Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review.

BACKGROUND: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease. METHODS: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool. RESULTS: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome. CONCLUSIONS: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis.

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

Double reinsertion including Whitnall's ligament in aponeurotic ptosis surgery : Comparison of results following simple aponeurosis reinsertion surgery and a combined reinsertion of the aponeurosis to Whitnall's ligament for aponeurotic palpebral ptosis: a cohort study of 722 cases.

PURPOSE: The results of a technique with a double reinsertion of the aponeurosis to the tarsus and aponeurosis to Whitnall's ligament (ATW) were compared with a simple reinsertion of the aponeurosis to the tarsus (AT) in acquired aponeurotic palpebral ptosis surgery. METHODS: Analytical, observational, retrospective, cohort study. Seven hundred and twenty-two consecutive cases with acquired aponeurotic palpebral ptosis have been treated surgically between 2000 and 2012 and have been followed up for 5 years. The cases were divided into two cohorts according to the applied surgical technique (AT vs ATW). RESULTS: The mean postoperative MRD after 1 month in cohort AT was 1 mm lower than in ATW (3 ± 0.9 mm vs 4 ± 1 mm). The mean MRD in the long-term follow-up (5 years) was 1 mm lower in cohort AT than in ATW (2.9 ± 1.5 mm vs 3.9 ± 0.9 mm). The rate of long-term recurrence (5 years) was 15% higher in A-T than in A-T-W (20% vs 5%). 70.5% of the eyes studied intra-surgically presented gaps between the Whitnall ligament and the aponeurosis, an anatomical area that we describe as the upper transition zone (UTZ). In an independent analysis, only those patients with open UTZ were evaluated and it was observed that those operated with A-T-W presented elevations greater than 1 mm compared to those operated with the AT technique (4 ± 0.9 mm A-T-W vs 2.8 ± 1 mm A-T) and a much lower recurrence rate (5.4% A-T vs 38.09% A-T-W). CONCLUSIONS: In our study, the A-T-W technique achieved better results in terms of palpebral elevation and fewer recurrences compared to the A-T technique in all cases studied with aponeurotic ptosis. However, it particularly demonstrates its superiority in patients with large gaps in the UTZ.

Anatomical basis of a safe mini-invasive technique for lengthening of the anterior gastrocnemius aponeurosis.

BACKGROUND: The surgical procedure itself of lengthening the gastrocnemius muscle aponeurosis is performed to treat multiple musculoskeletal, neurological and metabolical pathologies related to a gastro-soleus unit contracture such as plantar fasciitis, Achilles tendinopathy, metatarsalgia, cerebral palsy, or diabetic foot ulcerations. Therefore, the aim of our research was to prove the effectiveness and safety of a new ultrasound-guided surgery-technique for the lengthening of the anterior gastrocnemius muscle aponeurosis, the "GIAR"- technique: the gastrocnemius-intramuscular aponeurosis release. METHODS AND RESULTS: An ultrasound-guided surgical GIAR on ten fresh-frozen specimens (10 donors, 8 male, 2 females, 5 left and 5 right) was performed. Exclusion criteria of the donated bodies to science were BMI above 35 (impaired ultrasound echogenicity), signs of traumas in the ankle and crural region, a history of ankle or foot ischemic vascular disorder, surgery or space-occupying mass lesions. The surgical procedures were performed by two podiatric surgeons with more than 6 years of experience in ultrasound-guided procedures. The anterior gastrocnemius muscle aponeurosis was entirely transected in 10 over 10 specimens, with a mean portal length of 2 mm (± 1 mm). The mean gain at the ankle joint ROM after the GIAR was 7.9° (± 1.1°). No damages of important anatomical structures could be found. CONCLUSION: Results of this study indicate that our novel ultrasound-guided surgery for the lengthening of the anterior gastrocnemius muscle aponeurosis (GIAR) might be an effective and safe procedure.