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      Mild Ptosis Correction with the Stitch Method During Incisional Double Fold Formation

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          Abstract

          Background

          Numerous methods exist for simultaneous correction of mild blepharoptosis during double eyelid surgery. These methods are generally categorized into either incisional (open) or non-incisional (suture) methods. The incisional method is commonly used for the creation of the double eyelid crease in patients with excessive or thick skin. However, concurrent open ptosis correction is often marred by the lengthy period of intraoperative adjustment, causing more swelling, a longer recovery time, and an increased risk of postoperative complications.

          Methods

          The authors have devised a new, minimally invasive technique to alleviate mild ptosis during incisional double eyelid surgery. The anterior lamella is approached through the incisional technique for the creation of a double eyelid while the posterior lamella, including Muller's and levator muscles, is approached with the suture method for Muller's plication and ptosis correction.

          Results

          The procedure described was utilized in 28 patients from June 2012 to August 2012. Postoperative asymmetry was noted in one patient who had severe preoperative conjunctival scarring. Otherwise, ptosis was corrected as planned in the rest of the cases and all of the patients were satisfied with their postoperative appearance and experienced no complications.

          Conclusions

          Our hybrid technique combines the benefits of both the incisional and suture methods, allowing for a predictable and easily reproducible correction of blepharoptosis with an aesthetically pleasing double eyelid.

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          Most cited references9

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          Conjoint fascial sheath of the levator and superior rectus attached to the conjunctival fornix.

          The aim of this study is to elucidate the microscopic structures above the superior fornix relation to blepharoptosis operation. Eight fixed cadavers of Korean adults were used. In six cadavers, 12 orbits were explored after removal of brain. In two cadavers, histologic sections were made. Below the levator, thick fibrous sheath was covering superior rectus. According to Whitnall's description, we called the thickened portion the "conjoint fascial sheath" (CFS) of the levator and superior rectus attached to the conjunctival fornix. CFS was located 2.5 +/- 0.2 mm (range, 2-8 mm) posterior to the fornix. It was 12.2 +/- 2.0 mm (range, 8-14 mm) anteroposterior length and 1.1 +/- 0.1 mm (range, 0.5-1.5 mm) thick. The shape was equilateral trapezoid with a longer base anteriorly. Posteriorly, it was extended from the fascia of the levator and superior rectus. Anteriorly superficial and deep extensions of CFS were continued approximately 2 mm to the superior conjunctival fornix and then 2 to 3 mm distally along and beneath the palpebral and bulbar conjunctiva. Surgeons should be aware of the presence of CFS between levator and superior rectus in performing ptosis surgery.
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            A new non-incisional correction method for blepharoptosis.

            The present report introduces our correction method for blepharoptosis, in which major incisions are made on neither the skin nor the conjunctiva of the upper eyelid, and no dissection of the eyelid tissues is required. After turning the upper eyelid inside out, threads are introduced into it through the conjunctiva close to the superior fornix. Then the superior palpebral levator muscle and the tarsus are connected using threads. This thread application is performed at two-to-four locations of the upper eyelid. By tightening the threads, the tarsus is elevated and the ptotic eyelid is corrected. A total of 624 eyelids in 390 patients with mild or moderate ptosis were operated on with this surgical method. Effectiveness of the treatment was evaluated referring to the degree of improvement. Furthermore, frequencies of complications were evaluated. Among 416 eyelids with mild ptosis, complete correction of ptosis was achieved with 406 eyelids (97.5%). Among 208 eyelids with moderate ptosis, improvement was achieved with 185 eyelids (88.9%), with complete correction for 156 eyelids (75%). Since the present method enables effective correction of the blepharoptosis with a simple technique, minimised recovery time and no scarring, it provides a useful surgical option for the treatment of mild and moderate blepharoptosis. Copyright © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
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              Upgaze eyelid position allows differentiation between congenital and aponeurotic blepharoptosis according to the neurophysiology of eyelid retraction.

              To differentiate between congenital and aponeurotic blepharoptosis, we investigated whether upgaze with stretching of the mechanoreceptor of Mueller muscle increases involuntary reflex contraction of the levator slow-twitch muscle fibers. In 50 cases each of unilateral congenital blepharoptosis and of asymmetric aponeurotic blepharoptosis, the mean increases by upgaze in the upper eyelid margin to the line between the medial and lateral canthi as upper eyelid retraction distance (UERD) of the ptotic eyelid 0.4 mm and 2.9 mm, respectively. These were significantly smaller and significantly larger than those of the corresponding nonptotic eyelid, 2.0 mm and 2.3 mm, respectively.Worsening of ptosis on upgaze is common in congenital ptosis and is an abnormal differentiating sign, lacking the involuntary reflex contraction. Improvement of ptosis on upgaze is common in aponeurotic blepharoptosis and likely represents a normal physiological process, restoring the involuntary reflex contraction.
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                Author and article information

                Journal
                Arch Plast Surg
                Arch Plast Surg
                APS
                Archives of Plastic Surgery
                The Korean Society of Plastic and Reconstructive Surgeons
                2234-6163
                2234-6171
                January 2014
                13 January 2014
                : 41
                : 1
                : 71-76
                Affiliations
                [1 ]Department of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA.
                [2 ]Gyalumhan Plastic Surgery, Seoul, Korea.
                Author notes
                Correspondence: Tae-Joo Ahn. Gyalumhan Plastic Surgery, 21th, Mijinplaza, 390 Gangnam-daero, Gangnam-gu, Seoul 135-934, Korea. Tel: +82-2-535-6688, Fax: +82-2-535-8580, cmcanti@ 123456hanmail.net
                Article
                10.5999/aps.2014.41.1.71
                3915160
                ec413f2c-5ff5-46b1-8993-4bdd644e69fb
                Copyright © 2014 The Korean Society of Plastic and Reconstructive Surgeons

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 02 April 2013
                : 29 May 2013
                : 07 June 2013
                Categories
                Original Article

                Surgery
                conjunctiva,blepharoptosis,muscles
                Surgery
                conjunctiva, blepharoptosis, muscles

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