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 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.

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 .

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 .

Transconjunctival Orbital Septum Fat Release and Preservation for Orbitopalpebral Sulcus in Lower Eyelid Blepharoplasty.

BACKGROUND: Compared to the traditional transcutaneous approach, a safe and effective lower eyelid blepharoplasty has been recognized. In 2007, Sadove first reported a series of patients treated with transconjunctival septal suturing, but the inferior orbitopalpebral sulcus was not totally improved. PURPOSE: Orbital septal fat release and preservation through the transconjunctival approach was used to treat 20 young patients with bulging bags and inferior orbitopalpebral sulcus. METHOD: The orbital septal fat was released and transferred to infraorbital rim to be a base for the inferior orbitopalpebral sulcus. RESULT: Obvious bulging fat was released, and the orbitopalpebral sulcus was flattened by released and excessive orbital septal fat. Satisfactory results were achieved. CONCLUSION: The results achieved from this series of patients indicate that orbital septal fat release and preservation through the transconjunctival approach for reducing the orbitopalpebral sulcus is a safe and effective treatment for bulging fat and orbitopalpebral sulcus in young patients. 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 .