INTRODUCTION
The upper eyelids have a peculiar anatomical structure divided into three
lamellae as follows: the anterior lamella, consisting of skin and orbicularis
oculi muscle; the middle lamella consisting of the orbital septum, tarsus,
orbital fat pad, and lifting musculature (levator and Müller’s muscles); and
the
composite posterior lamella composed of the mucosa1. They protect the eyeball and aid in the lacrimal pump for
lubrication. The correct position and anatomy of the upper eyelid margin are
comprised of half the distance between the pupil and the corneoscleral junction
in the corneal limbus; when it is positioned outside this limit, ptosis or
palpebral retraction may occur2.
Eyelid ptosis occurs when the eyelid edge exceeds the upper limbus of the iris by
2 mm and may even cover the pupil in more severe cases. Palpebral ptosis is
classified as mild, moderate, and severe when the eyelid edge is 2-4, 4-6, and
>6 mm from the upper limbus of the iris, respectively (Table 1).
Table 1 - Classification of eyelid ptosis.
| Mild |
2-4 mm |
| Moderate |
4-6 mm |
| Severe |
> 6 mm |
Table 1 - Classification of eyelid ptosis.
The function of the eyelid levator muscle is evaluated as excellent at ≥13
mm, good between 8 and 12 mm, weak at 5-7 mm, and poor or severe at <4 mm
from the levator excursion (Table 2).
Table 2 - Classification of eyelid levator muscle function.
| Function |
Measurement of the excursion of the upper eyelid
margin (mm)
|
| Excellent |
≥13 mm |
| Good |
8-12 mm |
| Poor |
5-7 mm |
| Severe |
≤4 |
Table 2 - Classification of eyelid levator muscle function.
The 10% phenylephrine test is another fundamental test in the evaluation of
patients with eyelid ptosis. A drop is instilled at the bottom of the cul-de-sac
of each eye, and the resolution of ptosis is observed after 10 minutes. If the
eyelid returns to its anatomical position, surgical procedure on the Müller
muscle is indicated.
Eyelid ptosis can also be classified according to etiology, which may be acquired
or congenital. Acquired ptosis can be subdivided into neurogenic, myogenic, and
aponeurotic origins. Lesions of the III cranial pair and Horner’s syndrome are
of neurogenic origin. Myasthenia gravis, a motor plaque disorder, is classified
as of myogenic origin3. Direct trauma to
the eyes4, ophthalmologic surgeries in
which retractors are used to injure or disengage the aponeurosis5, craniofacial surgeries, and those of
involutional or senile origin6 are of
aponeurotic causes.
With regard to those with congenital etiology, which shows muscular atrophy due
to failure in the embryological development of the striated fibers of the eyelid
levator muscle, such as blepharophimosis syndrome2, which evolves with palpebral ptosis, epicanthus, and decrease of
the palpebral fissure, and the synkinesis phenomenon of the Marcus-Gunn
syndrome7.
However, another entity simulates ptosis, pseudoptosis. As the name indicates,
this is not a true ptosis and occurs in situations of enophthalmos, hypertrophy
of the ocular globe with fragility of the upper rectus muscle, severe
dermatochalasis, and tumors of the upper eyelid. In all cases, the upper eyelid
droops beyond the upper limbus of the cornea, mimicking a true ptosis.
Several techniques can be used to correct palpebral ptosis, and the choice of
technique depends on the etiology, degree of ptosis, and function of the levator
muscle. In mild ptosis with positive phenylephrine test, tarsoconjunctival
müllerectomy, described by Fasanella and Servat in 19618, can be performed. In cases of moderate ptosis, plication
or reinsertion with or without shortening of the levator muscle aponeurosis may
be indicated, and in cases of severe ptosis with poor levator function,
frontalis suspension is formally indicated. Therefore, the diagnostic definition
of the degree of ptosis and the function of the levator muscle will define the
choice of the best technique for surgical treatment.
OBJECTIVE
The aim of the present study was to prospectively analyze the results of ptosis
correction, including aesthetic and functional results, in patients with
moderate and severe eyelid ptosis of various etiologies operated by the author
using various repair techniques.
METHODS
This was a prospective study conducted from March 2013 to May 2015, in accordance
with the ethical principles of the Declaration of Helsinki. The study sample
was
composed of 14 patients who underwent surgical treatment for moderate and severe
unilateral or bilateral ptoses. The total number of eyelids surgically treated
was 21. Cases of mild ptosis were excluded and, therefore, not included in the
10% phenylephrine test.
The factors studied were etiological demographics, degree of ptosis and function
of the eyelid levator muscle, type of repair technique used, immediate and late
complications, reoperation rate, analysis of results, and index of patient
satisfaction. All the patients underwent a photographic study before and after
the surgery. The work was conducted at Barata Ribeiro Municipal Hospital and
in
a private clinic in Rio de Janeiro, RJ.
RESULTS
Of the 14 patients, 42.8% (n = 6) were male and 57.2% (n = 8) were female. The
age ranged from 12 to 74 years, with a mean of 51 years. Regarding
comorbidities, systemic arterial hypertension and diabetes mellitus were
predominant, with 5 and 4 cases, respectively. Alcoholism and smoking were found
in 4 cases, and only 1 case of myasthenia gravis was observed.
Of the 21 eyelids surgically treated, 85% had acquired ptosis and 15% had
congenital ptosis (Figures 1 and 2). Among the acquired cases, involutional
ptoses after ophthalmic surgeries were the most common, with 4 cases in 8
patients. Other etiologies were direct blunt trauma on the orbit (3 cases) and
myasthenia gravis (only 1 case).
Figure 1 - Preoperative aspect of a case of frontalis suspension with a
fascia lata graft.
Figure 1 - Preoperative aspect of a case of frontalis suspension with a
fascia lata graft.
Figure 2 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft.
Figure 2 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft.
With respect to the degree of ptosis, 64.3% of the cases were classified as
moderate; and 35.7%, as severe (Figures 3
to 5). Regarding the function of the
eyelid levator muscle, 28.5% (n = 4) of the cases presented good function; 28.5%
(n = 4) moderate function; and 43% (n = 6), poor function. Only one case of
severe ptosis was associated with moderate levator muscle function.
Figure 3 - Preoperative aspect of a case of severe acquired ptosis with poor
eyelid levator muscle function.
Figure 3 - Preoperative aspect of a case of severe acquired ptosis with poor
eyelid levator muscle function.
Figure 4 - Preoperative aspect of a case of bilateral frontalis suspension
with a fascia lata graft in a patient with severe ptosis and poor
eyelid levator muscle function.
Figure 4 - Preoperative aspect of a case of bilateral frontalis suspension
with a fascia lata graft in a patient with severe ptosis and poor
eyelid levator muscle function.
Figure 5 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft.
Figure 5 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft.
The surgical technique most commonly used was the frontalis suspension surgery (9
eyelids), followed by reintegration of the aponeurosis in the tarsal plate (6
eyelids), shortening followed by reinsertion of the aponeurosis in 5 (Figures 6 and 7), and plication of the aponeurosis (1 case). In all the cases of
shortening and plication, a proportion of 4:1 was used. Local anesthesia was
used in all the cases, which enabled the positioning of the patient’s upper
eyelid in the most anatomical position possible.
Figure 6 - A patient with ptosis acquired by disinsertion of the aponeurosis
of the eyelid levator muscle.
Figure 6 - A patient with ptosis acquired by disinsertion of the aponeurosis
of the eyelid levator muscle.
Figure 7 - Appearance at 12 months after the shortening with reinsertion of
the aponeurosis of the eyelid levator muscle.
Figure 7 - Appearance at 12 months after the shortening with reinsertion of
the aponeurosis of the eyelid levator muscle.
In relation to complications, 2 cases of conjunctival hyperemia of unknown
etiology were treated conservatively with corticosteroids (Maxtrol®) and
one case of large edema that lasted for more than a week was treated
conservatively. Although common after palpebral ptosis correction surgery,
eyelid asymmetries of >2 mm were considered late complications. For the cases
with complications, surgical revision was indicated only in one case because
the
patient was a 17-year-old girl in whom asymmetry caused aesthetic impairment.
We
also observed a patient with mild eyelid retraction who was treated
conservatively with massage.
The study results were analyzed in two ways. First, a critical analysis was
performed by the author, in which the correct positioning and anatomy of the
eyelids, presence or absence of significant asymmetries (those >2 mm), eyelid
retraction, eyelid function, and improved aesthetics were observed. Thus, 50%
(n
= 7) of the cases were classified as optimal, 42.8% (n = 6) showed good results,
and only one case was considered poor.
Second, the patients were asked about their opinion of the outcome. A high index
of satisfaction (85.7%, n = 12) was indicated by all the patients, except two
who reported that they were poorly satisfied with the outcome of the
surgery.
DISCUSSION
Currently, a myriad of techniques are available for repair of palpebral ptosis.
The choice of technique depends on the type, degree of ptosis, and levator
muscle function. For mild ptoses, that is, those with the eyelid edge 2-4 mm
from the corneal limbus, the Fasanella-Servat8 technique can be used, as cited previously but not assessed in
this study.
For moderate ptosis with the eyelid edge 4-6 mm from the corneal limbus and good
levator muscle function, according to etiology, we indicate reinsertion,
plication, or shortening of the aponeurosis of the muscle. In 2010, Saito et
al.9 published a study that analyzed
two different types of approaches to the aponeurosis of the levator muscle,
performing plication with a mean shortening of 9.78 mm and resection with
reinsertion with a mean shortening of 14 mm, with good results in both
techniques.
Alves10, in 2014, described a technique of
continuous suture on the aponeurosis, with an average shortening of 12 mm with
plication at a proportion of 4:1 mm, which attained good results in 92.3% of
the
cases.
With regard to severe ptosis with the eyelid edge >6 mm from the corneal
limbus and with poor levator muscle function (Figures 8 and 9), the
frontalis suspension is formally indicated. The use of the fascia lata in the
form of small bundles of 2 mm in width is the most commonly used technique, as
described by Crawford in 195611. As this
is a fascial graft, an autologous inert tissue, the immediate complication and
recurrence rates are. Several studies12-16 showed the
safety of the procedure, with a low complication rate and good results in the
short and long terms, even in children aged <3 years15,16.
Figure 8 - Preoperative aspect of a case of bilateral frontalis suspension
in a patient with severe ptosis and poor eyelid levator muscle
function.
Figure 8 - Preoperative aspect of a case of bilateral frontalis suspension
in a patient with severe ptosis and poor eyelid levator muscle
function.
Figure 9 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft. Note the small residual asymmetry of >2
mm. Despite the asymmetry, the patient did not express any desire
for surgical correction.
Figure 9 - Appearance at 12 months after the bilateral frontalis suspension
with a fascia lata graft. Note the small residual asymmetry of >2
mm. Despite the asymmetry, the patient did not express any desire
for surgical correction.
In our sample, the fascia lata was used in 100% of the cases with severe ptosis
and poor levator muscle function (Figures 10 and 11). We used small bands
of 2 × 60 mm in W formation in a plane below the orbicularis muscle,
harvested from the lateral aspect of the non-dominant thigh through 2-minute
incisions of 2 cm, equidistant by 7 cm. The bands were sutured with 5-0
mononylon sutures in the tarsal plate and frontalis muscle, with the patient
awake; the most adequate and anatomical position was evaluated.
Figure 10 - Preoperative aspect of a case of bilateral frontalis suspension
in a patient with severe ptosis on the right eye and moderate ptosis
on the left eye, both with poor eyelid levator muscle
function.
Figure 10 - Preoperative aspect of a case of bilateral frontalis suspension
in a patient with severe ptosis on the right eye and moderate ptosis
on the left eye, both with poor eyelid levator muscle
function.
Figure 11 - Appearance at 12 months after the bilateral frontalis
suspension.
Figure 11 - Appearance at 12 months after the bilateral frontalis
suspension.
Other techniques using suture wires with mononylon, polypropylene yarns17,18, deep temporal fascia19, and orbicularis muscle in the form of a wing, as described by
Freitas and Sperli in 200920, were also
described. Friedhofer et al.21 published
in 2012 a large-scale study with 112 patients with severe ptosis who were
treated with a silicone device, known as an eyelid implant suspensor. This
apparatus consists of two rods connected to a plate with equally spaced holes
to
pass the attachment sutures.
They obtained an excellent result in 68.75% of the cases and good result in
26.79%. However, despite the high success rates, some complications related to
the implant, such as cutaneous ulcerations, partial extrusion, and infection,
occurred. Another study published by the same group22 showed the effectiveness of the implant suspensor in
patients with blepharophimosis syndrome, both in adults and children, with
minimal morbidity and optimal results.
Ramirez and Peña, in 200423, described a
series of cases of severe congenital ptosis treated with transposition of a flap
of the innervated frontalis muscle with good functional and cosmetic results
and
low complication rate. This technique was initially described by Fergus in
190124, followed by Song and Song in
198225, and Zhou and Chang in
198826.
Other authors described the effectiveness of this technique27,28
with minimal morbidity and good results. Zou et al.29 published in 2013 a histological analysis of the
frontalis muscle flap in experimental models of pigs. They observed under
scanning electron microscopy the viability of the muscle flap 6 and 12 months
after its preparation and showed that this technique was applicable in severe
cases.
CONCLUSION
Palpebral ptosis is a disease commonly found in clinical practice and requires
the surgeon to have a comprehensive anatomic and functional knowledge of the
delicate structure of the eyelid. In this study, 14 patients (21 eyelids)
underwent surgery. The acquired form is the most common in Brazil, with the
involutional form being the most common, as the study showed. This type of
ptosis, typical of elderly patients, is caused by disinsertion of the
aponeurosis of the tarsal plaque or its weakening.
With respect to the repair technique applied, frontalis suspension was performed
in 9 eyelids; reinsertion of the aponeurosis in the tarsal plate, in 6 eyelids;
shortening with reintegration in the tarsal plate, in 5 eyelids; and plication
of the aponeurosis at a ratio of 4:1, in only 1 case. The complication rate was
low, with asymmetries being the most difficult to treat.
Therefore, a good evaluation of patients with eyelid ptosis becomes mandatory, as
well as the choice of the surgical repair technique to be used to obtain the
best aesthetic-functional outcome.
COLLABORATIONS
|
RC
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
completion of surgeries and/or experiments; writing the manuscript
or critical review of its contents.
|
|
CJB
|
Writing the manuscript or critical review of its contents.
|
|
FSG
|
Statistical analyses.
|
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1. Sociedade Brasileira de Cirurgia Plástica, São
Paulo, SP, Brazil.
2. Hospital Municipal Barata Ribeiro, Rio de
Janeiro, RJ, Brazil.
3. Universidade do Estado do Rio de Janeiro, Rio
de Janeiro, RJ, Brazil.
Corresponding author: Rodolfo Chedid
Avenida Armando Lombardi, 1000, sala 136, bloco 02 - Barra da Tijuca
Rio de
Janeiro, RJ, Brazil Zip Code 22640-000
E-mail: rodolfochedid@gmail.com
Article received: December 04, 2017.
Article accepted: May 17, 2018.
Conflicts of interest: none.
