Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Abstract

IMPORTANCE External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies. OBJECTIVE To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic. INTERVENTIONSThe technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations. MAIN OUTCOMES AND MEASURES Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1).RESULTS Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, −0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments. CONCLUSIONS AND RELEVANCEIn correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed.LEVEL OF EVIDENCE 3.

Considerations on the Role of Algorithm-Based Levator Aponeurectomy in Small Incision External Ptosis Surgery for Involutional Ptosis

“…We congratulate the authors on their work; however, some aspects should be underlined in their study. 1 First, the columellar suture proposed by the authors seems very similar to the one reported by Daley 2 in 1944 and later described by Aufricht 3 as "submerged" suture in 1969. In the Daley-Aufricht technique, the suture is introduced through the base of the columella to emerge in the middle of the columellar base where the philtrum begins.…”

“…5 Alessandro Innocenti, MD Serena Ghezzi, MD Marco Innocenti, MD In Reply We thank Innocenti et al for their comment on our article. 1 Although we do agree that long-term follow-up is necessary to establish the longevity of each procedure, there is no consensus in the literature regarding the necessary minimum follow-up time for upper-eyelid ptosis repair procedures. Several prior published reports of ptosis repair techniques have had similar or less follow-up time compared with our study.…”

“…To the Editor We read with great interest the article titled "Role of algorithm-based levator aponeurectomy in small-incision external ptosis surgery for involutional ptosis" by Repp et al 1 The authors clearly described a new surgical algorithm for treatment of involutional ptosis considering the biomechanical property of the superior levator complex. Aponeurotic ptosis is the most common type of acquired ptosis, resulting from involutional changes of the levator aponeurosis as a consequence of its gradual stretching or attenuation of its strength.…”

“…We use nondissolving sutures. 1 In the study by Innocenti et al, 5 it is unclear what type of sutures was used. In addition, it is unclear if their 7.5% recurrence rate represented late recurrences or if the failures occurred earlier and remained stable at 3 years.…”

“…To the Editor We read the article, "The Columella Retraction Suture: A Powerful Suture Technique," by Nolst Trenité and Nolst Trenité, 1 and watched the related video. We congratulate the authors on their work; however, some aspects should be underlined in their study.…”