RECONSTRUCTIVE Distinct Features in Koreans with Involutional Blepharoptosis Chang Yeom Kim, M.D., Ph.D. Sang Yeul Lee, M.D., Ph.D. Seoul, Republic of Korea
Background: The authors intended to present the distinct characteristics in Korean patients with involutional ptosis that deviate from typically defined features. Methods: This is a prospective observational study of 162 Korean patients with involutional ptosis. The patients underwent levator aponeurosis advancement surgery from January of 2006 to June of 2013. Patient characteristics including eyelid crease, palpebral fissure width, levator function, and the shape and condition of the levator muscle and aponeurosis were assessed. Results: Of 279 total eyes in 162 patients, high eyelid crease and levator aponeurosis disinsertion from the tarsal plate were observed in 19.7 percent and 13 percent of the eyes, respectively. Moderate to severe fat tissue infiltration on the levator muscle was noted in 90.6 percent of the eyes. Patients were older (p = 0.002) and the eyelid drooping was more severe (p < 0.001) in cases with more fat infiltration. Levator function was inversely proportional to the degree of fat tissue infiltration (p = 0.037). Conclusion: Slightly decreased levator function, infrequent high eyelid crease occurrence, thick and puffy eyelids, low incidence of levator aponeurosis disinsertion from the tarsal plate, and prominent fatty infiltration on the levator muscle are distinct and unique characteristics of involutional ptosis in Korean patients. (Plast. Reconstr. Surg. 135: 1693, 2015.)
I
nvolutional ptosis is a common form of ptosis that can also be classified as acquired aponeurotic ptosis. It is known to be caused by separation of the levator aponeurosis from the tarsal plate.1–3 Gravity and aging contribute to the development of involutional ptosis by stretching the levator muscle and aponeurosis. The muscle becomes thinned, and disinsertion or dehiscence of the aponeurosis occurs.4 De Figueiredo reported that levator aponeurosis defects with intact muscle or fat tissue infiltration of the aponeurosis could also result in involutional ptosis.2 Typical clinical features of involutional ptosis include good levator function, high eyelid crease, eyebrow elevation, eyelid thinning, upper sulcus deepening, and eyelid droop on downgaze.1–3 However, these features are primarily based on studies of Caucasian patients. Asians and Caucasians have different anatomical structures and distinct morphologic features From The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine. Received for publication September 15, 2014; accepted December 4, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001280
in their eyelids. Many Asians, especially East Asians (including Koreans), do not have a doubleeyelid crease and have puffy eyelids rather than thin ones.5,6 Furthermore, during ptosis surgery, we observed that levator aponeurosis disinsertion from the tarsal plate was not a common occurrence. Nevertheless, few studies have been conducted to investigate the structural changes and characteristics in Asian patients with involutional ptosis. In this study, we report the characteristics of Korean patients with involutional ptosis that deviate from the features typically seen in Caucasian patients.
PATIENTS AND METHODS Local institutional review board/ethics committee approval was obtained for this study. The study adhered to the tenets of the Declaration of Helsinki, and written informed consent was obtained from all participants (parents or legal guardians).
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
1693
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015 The adult patients with involutional ptosis enrolled in this study underwent standard levator aponeurosis advancement surgery between January of 2006 and June of 2013. Patients who underwent upper eyelid blepharoplasty for dermatochalasis or blepharochalasis correction were excluded. Patients with secondary ptosis, such as anophthalmic, neuromuscular, mechanical, or traumatic ptosis, and patients who had prior upper eyelid surgery were also excluded. Each patient had a detailed ptosis history collected and underwent a complete ophthalmic examination. This information was used to diagnose their ptosis type. Eyelid morphologic features were evaluated and the palpebral fissure width and levator function were measured preoperatively. The shape and condition of the levator muscle and aponeurosis were assessed intraoperatively. These characteristics were reassessed after surgery by comparing them with photographs taken during the surgical procedure. Several features were evaluated, including levator aponeurosis disinsertion from the tarsal plate, and levator muscle and aponeurosis morphology such as thinning, defects, and fat deposits. Fat tissue infiltration was defined as mild (less than one-third of the surface), moderate (one-third to two-thirds of the surface), or severe (more than two-thirds of the surface) (Fig. 1). The eyes were classified
into three groups according to the degree of fat infiltration. To determine sex differences, statistical analysis was performed using the independent t test or chi-square test. The three fat infiltration groups were analyzed with analysis of variance. The levator function distribution was determined by generating a frequency analysis histogram. A comparison between the degree of fat tissue infiltration on the levator muscle and observed medial defects was analyzed using the chi-square test. All statistical analyses were two-sided with the α level set at 0.05, and were performed using IBM SPSS Statistics Software Version 20 (IBM Corp., Armonk, N.Y.).
RESULTS During the study period, 309 Korean patients with acquired ptosis underwent ptosis surgery. Of those, 136 patients had secondary ptosis (52 anophthalmic, 54 neuromuscular, and 30 mechanical or traumatic) and 11 patients had essential blepharospasm. These patients were excluded. In total, 279 individual eye operations in 162 patients with primary involutional ptosis were included in this study. There were 45 patients with unilateral ptosis and 117 patients with bilateral ptosis. In addition to the ptosis surgery, 31 individual eyes simultaneously underwent transeyelid browpexy
Fig. 1. Intraoperative photographs of mild (above, left), moderate (above, center), and severe (above, right) fat tissue infiltration on the levator muscle. A prominent fat deposit (below, left), severe thinning revealing the underlying cornea (below, center), and a medial side defect (below, right) are also shown.
1694 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Involutional Blepharoptosis in Koreans Table 1. Characteristics of 162 Korean Patients with Involutional Ptosis No. of eyes Age, yr* Onset age, yr*† Laterality, % of bilateral Double eyelid before surgery, % High eyelid crease, % Preoperative PF, mm* Preoperative LF, mm* Detached levator aponeurosis, % Fat tissue infiltration, % of eyes‡ Mild Moderate Severe
Total
Male
Female
279 63.1 ± 10.0 55.7 ± 10.7 85.0 49.2 19.7 5.3 ± 1.6 10.7 ± 2.2 13.0
106 64.0 ± 9.7 57.7 ± 10.3 89.5 39.1 15.3 4.8 ± 1.7 10.5 ± 2.4 16.0
173 62.6 ± 10.2 54.4 ± 10.9 82.3 55.3 22.4 5.6 ± 1.5 10.8 ± 2.2 11.4
9.3 59.1 31.5
14.9 52.7 32.4
6.3 62.7 31.0
p 0.280§ 0.205§ 0.121‖ 0.015‖ 0.173‖
Background: The authors intended to present the distinct characteristics in Korean patients with involutional ptosis that deviate from typically defined features. Methods: This is a prospective observational study of 162 Korean patients with involutional ptosis. The patients underwent levator aponeurosis advancement surgery from January of 2006 to June of 2013. Patient characteristics including eyelid crease, palpebral fissure width, levator function, and the shape and condition of the levator muscle and aponeurosis were assessed. Results: Of 279 total eyes in 162 patients, high eyelid crease and levator aponeurosis disinsertion from the tarsal plate were observed in 19.7 percent and 13 percent of the eyes, respectively. Moderate to severe fat tissue infiltration on the levator muscle was noted in 90.6 percent of the eyes. Patients were older (p = 0.002) and the eyelid drooping was more severe (p < 0.001) in cases with more fat infiltration. Levator function was inversely proportional to the degree of fat tissue infiltration (p = 0.037). Conclusion: Slightly decreased levator function, infrequent high eyelid crease occurrence, thick and puffy eyelids, low incidence of levator aponeurosis disinsertion from the tarsal plate, and prominent fatty infiltration on the levator muscle are distinct and unique characteristics of involutional ptosis in Korean patients. (Plast. Reconstr. Surg. 135: 1693, 2015.)
I
nvolutional ptosis is a common form of ptosis that can also be classified as acquired aponeurotic ptosis. It is known to be caused by separation of the levator aponeurosis from the tarsal plate.1–3 Gravity and aging contribute to the development of involutional ptosis by stretching the levator muscle and aponeurosis. The muscle becomes thinned, and disinsertion or dehiscence of the aponeurosis occurs.4 De Figueiredo reported that levator aponeurosis defects with intact muscle or fat tissue infiltration of the aponeurosis could also result in involutional ptosis.2 Typical clinical features of involutional ptosis include good levator function, high eyelid crease, eyebrow elevation, eyelid thinning, upper sulcus deepening, and eyelid droop on downgaze.1–3 However, these features are primarily based on studies of Caucasian patients. Asians and Caucasians have different anatomical structures and distinct morphologic features From The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine. Received for publication September 15, 2014; accepted December 4, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001280
in their eyelids. Many Asians, especially East Asians (including Koreans), do not have a doubleeyelid crease and have puffy eyelids rather than thin ones.5,6 Furthermore, during ptosis surgery, we observed that levator aponeurosis disinsertion from the tarsal plate was not a common occurrence. Nevertheless, few studies have been conducted to investigate the structural changes and characteristics in Asian patients with involutional ptosis. In this study, we report the characteristics of Korean patients with involutional ptosis that deviate from the features typically seen in Caucasian patients.
PATIENTS AND METHODS Local institutional review board/ethics committee approval was obtained for this study. The study adhered to the tenets of the Declaration of Helsinki, and written informed consent was obtained from all participants (parents or legal guardians).
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
1693
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015 The adult patients with involutional ptosis enrolled in this study underwent standard levator aponeurosis advancement surgery between January of 2006 and June of 2013. Patients who underwent upper eyelid blepharoplasty for dermatochalasis or blepharochalasis correction were excluded. Patients with secondary ptosis, such as anophthalmic, neuromuscular, mechanical, or traumatic ptosis, and patients who had prior upper eyelid surgery were also excluded. Each patient had a detailed ptosis history collected and underwent a complete ophthalmic examination. This information was used to diagnose their ptosis type. Eyelid morphologic features were evaluated and the palpebral fissure width and levator function were measured preoperatively. The shape and condition of the levator muscle and aponeurosis were assessed intraoperatively. These characteristics were reassessed after surgery by comparing them with photographs taken during the surgical procedure. Several features were evaluated, including levator aponeurosis disinsertion from the tarsal plate, and levator muscle and aponeurosis morphology such as thinning, defects, and fat deposits. Fat tissue infiltration was defined as mild (less than one-third of the surface), moderate (one-third to two-thirds of the surface), or severe (more than two-thirds of the surface) (Fig. 1). The eyes were classified
into three groups according to the degree of fat infiltration. To determine sex differences, statistical analysis was performed using the independent t test or chi-square test. The three fat infiltration groups were analyzed with analysis of variance. The levator function distribution was determined by generating a frequency analysis histogram. A comparison between the degree of fat tissue infiltration on the levator muscle and observed medial defects was analyzed using the chi-square test. All statistical analyses were two-sided with the α level set at 0.05, and were performed using IBM SPSS Statistics Software Version 20 (IBM Corp., Armonk, N.Y.).
RESULTS During the study period, 309 Korean patients with acquired ptosis underwent ptosis surgery. Of those, 136 patients had secondary ptosis (52 anophthalmic, 54 neuromuscular, and 30 mechanical or traumatic) and 11 patients had essential blepharospasm. These patients were excluded. In total, 279 individual eye operations in 162 patients with primary involutional ptosis were included in this study. There were 45 patients with unilateral ptosis and 117 patients with bilateral ptosis. In addition to the ptosis surgery, 31 individual eyes simultaneously underwent transeyelid browpexy
Fig. 1. Intraoperative photographs of mild (above, left), moderate (above, center), and severe (above, right) fat tissue infiltration on the levator muscle. A prominent fat deposit (below, left), severe thinning revealing the underlying cornea (below, center), and a medial side defect (below, right) are also shown.
1694 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Involutional Blepharoptosis in Koreans Table 1. Characteristics of 162 Korean Patients with Involutional Ptosis No. of eyes Age, yr* Onset age, yr*† Laterality, % of bilateral Double eyelid before surgery, % High eyelid crease, % Preoperative PF, mm* Preoperative LF, mm* Detached levator aponeurosis, % Fat tissue infiltration, % of eyes‡ Mild Moderate Severe
Total
Male
Female
279 63.1 ± 10.0 55.7 ± 10.7 85.0 49.2 19.7 5.3 ± 1.6 10.7 ± 2.2 13.0
106 64.0 ± 9.7 57.7 ± 10.3 89.5 39.1 15.3 4.8 ± 1.7 10.5 ± 2.4 16.0
173 62.6 ± 10.2 54.4 ± 10.9 82.3 55.3 22.4 5.6 ± 1.5 10.8 ± 2.2 11.4
9.3 59.1 31.5
14.9 52.7 32.4
6.3 62.7 31.0
p 0.280§ 0.205§ 0.121‖ 0.015‖ 0.173‖
