Clinical science
Functional centre of the upper eyelid: the optimal point for eyelid lifting in ptosis surgery Chang Yeom Kim,1 Byeong Jae Son,2 Sang Yeul Lee1 1
Department of Ophthalmology, The Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea 2 Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu, Korea Correspondence to Professor Sang Yeul Lee, Oculoplastic Division, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea; [email protected] Received 26 February 2014 Revised 5 August 2014 Accepted 1 September 2014 Published Online First 23 September 2014
ABSTRACT Aims To establish the novel concept of a functional eyelid centre to determine the optimal point for eyelid lifting in ptosis surgery. Methods This was a prospective study of 112 patients with congenital ptosis. The functional eyelid centre was defined as the point where the eyelid contour showed the best appearance when the upper eyelid was lifted manually. In patients who underwent frontalis suspension surgery using silicone rods, the postoperative outcome was assessed according to the fixation point of the rod. Results The average horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.9 and 10.1 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line. The outcomes of silicone rod surgeries were excellent when the rod was fixated 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre. These positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line. Conclusions The functional eyelid centre was located slightly temporal to the mid-pupillary line. A better eyelid contour in ptosis surgery is produced when eyelid lifting is centred around the functional eyelid centre. INTRODUCTION Ptosis is one of the most common oculoplastic problems and there is an ‘art’ to the final adjustment of eyelid height and contour in ptosis surgery.1 The highest point of the upper eyelid is just nasal to the vertical mid-pupillary line.1 2 Therefore, in ptosis surgery, postoperative eyelid height is commonly adjusted on this line by a central suture, at the peak of the eyelid, immediately nasal to the midpupillary point.1 3–5 However, in our experience, lifting the upper eyelid on the mid-pupillary line in ptosis surgery often produces an unnatural eyelid contour which includes partial peaking or drooping. In addition, recurrent ptosis commonly occurred in the form of temporal eyelid drooping. The upper eyelid had the most natural and best appearance occurred when the eyelid was lifted. However, that point may not be the same as the highest point of the eyelid. In this study, we defined this novel point as the ‘functional centre of the upper eyelid’ to establish the concept of the functional eyelid centre in congenital ptosis, and to evaluate its clinical significance when performing ptosis surgeries.
To cite: Kim CY, Son BJ, Lee SY. Br J Ophthalmol 2015;99:346–349. 346
MATERIALS AND METHODS Institutional Review Board (IRB)/Ethics Committee approval was obtained. The study adhered to the
tenets of the Declaration of Helsinki and written informed consent was obtained from all participants ( parents or legal guardians). A total of 112 Korean paediatric patients with congenital ptosis were enrolled in this study. The patients underwent ptosis surgery, including frontalis suspension using silicone rods (Frontalis Suspension Set #585192; Beaver-Visitec International, Waltham, Massachusetts, USA) with the pentagonal technique of Fox,1 using autogenous fascia lata by direct tarsal and frontalis fixation,6 and levator resection. The procedures were performed by the same surgeon (SYL), under general anaesthesia, from August 2011 to April 2013. The surgical methods were determined based on levator muscle function, degree of ptosis, and age of the patient. Patients with the following conditions were excluded from the study: neuromuscular diseases, blepharophimosis, strabismus, previous ptosis surgery, and those with less than 1 year of follow-up. After induction of general anaesthesia, the horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were measured using a ruler. The surgeon and two assisting ophthalmologists assessed the eyelid contour by lifting the eyelid manually at several points, with a lacrimal probe. The functional eyelid centre was determined by agreement between the three doctors as the point where the eyelid had the best contour. In patients with unilateral ptosis, the horizontal fissure width, the distance from the medial canthus to the mid-pupillary line, and the position of the functional eyelid centre were compared between ptotic eyes and contralateral non-ptotic eyes. Frontalis suspension surgery, using silicone rods, was performed based on the functional eyelid centre. After establishing the functional eyelid centre, two points on the eyelid for stab incision were determined, one being nasal and the other temporal from the functional eyelid centre. The three ophthalmologists also determined the locations which produced the best eyelid contour and optimal correction of ptosis by lifting the eyelid with two lacrimal probes. Two eyelid and three suprabrow stab incisions were made, and the silicone rod was passed from one eyelid incision site to the other. The silicone rod was fixed at the supratarsal tissue with 6-0 polypropylene sutures at the eyelid stab incision sites, and then passed under the orbital septum to the brow incision sites, in a pentagonal pattern. The distances from the midpupillary line and the functional eyelid centre to the two fixation points were measured. The postoperative outcomes were evaluated functionally
Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
Clinical science and cosmetically based on evaluation criteria which were presented elsewhere.7 The measured values were analysed to evaluate the significance of the functional eyelid centre. Both eyes in unilateral ptosis were compared using the paired t test. Two-sided statistical testing was performed using IBM SPSS Statistics V.20 software with the significance level set at 0.05.
RESULTS A total of 224 eyes in 112 patients were included in the study; 152 (67.9%) eyes were from male patients. Patient ages ranged from 6 months to 11 years, with a mean age of 2.0 years. There were 67 patients with unilateral ptosis and 45 patients with bilateral ptosis. Levator resection surgery was performed on 32 eyes and frontalis suspension surgery on 125 eyes (98 eyes with silicone rods and 27 eyes with autogenous fascia lata). The average palpebral fissure of ptotic eyes was 4.3 mm before surgery. The horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.88±2.33 mm and 10.05±1.49 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line (figure 1). When the eyelid was lifted manually, nasal to the functional eyelid centre, the contour of the eyelid showed nasal peaking, and when lifted temporal to the functional eyelid centre, the eyelid drooped nasally. In patients with unilateral
ptosis, there was no significant difference in the horizontal fissure width, the distance from the medial canthus to the midpupillary line, or the location of the functional eyelid centre between both eyes ( p=0.484, p=0.708 and p=0.228, respectively). In cases of frontalis suspension using a silicone rod, most of the postoperative outcomes were excellent at 1 year after surgery. Ninety-three (94.9%) of these 98 eyes presented with a natural and symmetric eyelid contour without peaking or flattening, upper eyelid position above the papillary margin without complications, and eyelid height differences ≤1 mm, in unilateral cases. The fixation points at the supratarsal tissue, using the pentagonal method, were 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre, and these positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line, respectively (figure 2). The distance between nasal and temporal fixation points was about 40% of the horizontal fissure width (8.3 mm and 20.7 mm, respectively). There were five unsatisfactory cases. Two eyes had under-correction, and underwent a second operation within 2 weeks of surgery. In one eye of the two, a broken silicone rod was noted. Three eyes had recurrent ptosis at postoperative 1-year follow-up.
DISCUSSION In ptosis surgery, the location for central eyelid lifting influences postoperative eyelid appearance. The main point for lifting the
Figure 1 Photographs of eyelids showing the lifting points, using a lacrimal probe, to establish the functional eyelid centre. (A) When the upper eyelid was lifted at the mid-pupillary line, the eyelid shows nasal peaking and temporal drooping. (B) When the eyelid was lifted slightly temporal to the mid-pupillary line, the most natural and the best appearance was seen (functional eyelid centre). When the eyelid was lifted by two lacrimal probes to determine two fixation points of the silicone rod in frontalis suspension surgery, the points based on the functional eyelid centre show a better contour (D) than those based on the mid-pupillary line (C). Immediately postoperative (E) and 6-month postoperative photographs (F) of frontalis suspension surgery using silicone rods. The silicone was fixed nasal and temporal from the functional eyelid centre. Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
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Figure 2 The best fixation points for silicone rods were at nearly equidistant locations nasal and temporal from the functional eyelid centre, but extremely displaced to the temporal side from the mid-pupillary line. Black dotted lines indicate the position of the silicone rod; the thread grasped with the forceps shows fixation sutures of the silicone rod at the supratarsal tissue; the white dotted line indicates the mid-pupillary line; and the white solid line indicates the functional eyelid centre. eyelid in ptosis surgery was located at the centre of the tarsal plate or the mid-pupillary point, because this point is generally the highest part of the upper eyelid.1 2 In levator advancement surgery, the central tarsal suture should be placed immediately nasal to the mid-pupillary line and additional sutures then placed medially and laterally.3 4 Liu and Meltzer also proposed placing the suture slightly nasally or across the midline to obtain a very natural arc in single suture levator surgery.8 9 In frontalis suspension surgery, the location of tarsal fixation also determines postoperative eyelid height and contour. Nerad proposed placing a single central suture at the peak of the eyelid,1 while Salour et al5 suggested placement at the centre of the eyelid. However, in this study the point where the upper eyelid showed the most natural appearance was different from the highest point of the eyelid. For this reason, we introduced a new concept of ‘functional centre of the upper eyelid’ in ptosis surgery. In this study, the functional eyelid centre (i.e., the optimal point for eyelid lifting) was located about 4.3 mm temporal to the mid-pupillary line. This result suggests that for a better outcome, the centre of eyelid lifting in ptosis surgery should be placed laterally. When the eyelid was lifted at the mid-pupillary line, the eyelid showed nasal peaking. Although the eyelid contour can be adjusted with nasal and temporal additional eyelid lifting, central eyelid lifting has the greatest impact on postoperative eyelid height and contour. Therefore, the centre of eyelid lifting should be placed slightly temporal to the midpupillary line to produce a more natural eyelid contour. In a previous study using digital image analysis on patients with severe congenital ptosis, the eyelid contour was reported to be better when the eyelid was adjusted slightly laterally, not centrally at the midline.10 Hou et al11 suggested that the height of the lateral fixation point should be higher than that of the midpoint to 348
obtain a natural curvature in frontalis muscle flap suspension surgery for the correction of congenital ptosis. The concept of the functional eyelid centre could explain why the fixation point would be better placed slightly laterally in these studies. The position of the functional eyelid centre was not significantly different between the ptotic eye and contralateral nonptotic eye in patients with unilateral congenital ptosis. In patients with severe ptosis, temporal eyelid drooping was relatively more prominent than nasal drooping.10 12 In this situation, the functional eyelid centre could be moved more laterally. This disagreement could be because our study was carried out on patients under general anaesthesia while in the supine position. Further studies are warranted to analyse the position of the functional eyelid centre in standing patients. We evaluated the clinical significance of a functional eyelid centre in patients undergoing frontalis suspension surgery using silicone rods. The two fixation points of the silicone rods at the supratarsal tissue and showing the best eyelid contour and optimal correction of ptosis, were located medially and laterally equidistant from the functional eyelid centre. These points were displaced laterally from the mid-pupillary line. Therefore, if the surgeon sets the nasal and temporal points based on the midpupillary line, the fixation positions would be displaced nasally, and as a result, temporal under-correction could occur. Use of the functional eyelid centre could correct the temporal eyelid drooping better and prevent postoperative temporal re-drooping. In frontalis suspension surgery, two eyelid incisions for tarsal fixation were suggested at 10 mm to each side,5 13 located just lateral to the line of the punctum, and at an equal distance to the lateral side,14 or at the medial and lateral limbus.1 In this study of paediatric patients, the distance between the two supratarsal fixations was approximately 8 mm, and these distances corresponded to 40% of the horizontal fissure width, producing good patient outcomes. Eyelid peaking or flattening developed when the two fixation points were closer or farther away from each other than this, respectively. The standard of beauty differs from country to country and from culture to culture. Therefore, the cosmetic results of ptosis surgery judged excellent in this study may not be considered good in patients from other cultures. In addition, the assessment of eyelid height and contour using a single lacrimal probe might be inadequate. However, this method was adequate for illustrating the concept of the functional eyelid centre and determining its approximate location. The specific vectors for lifting the eyelid would be different depending on the surgical methods or individual fixation points on the tarsus. Additional studies are warranted to individually assess the clinical significance of the functional eyelid centre in levator resection surgery or frontalis suspension using various suspension materials. In conclusion, the functional eyelid centre lies slightly temporal to the mid-pupillary line, and surgeons should consider this when performing ptosis surgery. Eyelids should be lifted, centring at the functional eyelid centre not at the peak of the eyelid, to produce a more natural eyelid contour, and to avoid temporal under-correction in ptosis surgery. Contributors CYK, SYL: conception and design; CYK, BJS, SYL: conduct of the study, and collection, management, analysis and interpretation of the data; CYK, SYL: drafting the article or revising it critically for important intellectual content; SYL: review and final approval of the manuscript. Competing interests None. Ethics approval The Institutional Review Board (IRB)/Ethics Committee of Yonsei University Health System, Seoul, Korea approved this study. Provenance and peer review Not commissioned; externally peer reviewed.
Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
Clinical science REFERENCES 1
2 3 4
5
6
Nerad JA. Evaluation and treatment of the patient with ptosis. In: Nerad JA, ed. Oculoplastic surgery: the requisites in ophthalmology. St. Louis, MO: Mosby, 2001:157–92. Lieberman DM, Quatela VC. Upper lid blepharoplasty: a current perspective. Clin Plast Surg 2013;40:157–65. Shovlin JP. The aponeurotic approach for the correction of blepharoptosis. Int Ophthalmol Clin 1997;37:133–50. Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery—advancement of levator aponeurosis. Open Ophthalmol J 2010;14: 76–80. Salour H, Aletaha M, Bagheri A. Comparison of Mersilene mesh and autogenous fascia lata in correction of congenital blepharoptosis: a randomized clinical trial. Eur J Ophthalmol 2008;18:853–7. Spoor TC, Kwitko GM. Blepharoptosis repair by fascia lata suspension with direct tarsal and frontalis fixation. Am J Ophthalmol 1990;109: 314–17.
7
8 9 10 11 12
13 14
Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
Yoon JS, Lee SY. Long-term functional and cosmetic outcomes after frontalis suspension using autogenous fascia lata for pediatric congenital ptosis. Ophthalmology 2009;116:1405–14. Liu D. Ptosis repair by single suture aponeurotic tuck. Surgical technique and long term results. Ophthalmology 1993;100:251–9. Meltzer MA, Elahi E, Taupeka P, et al. A simplified technique of ptosis repair using a single adjustable suture. Ophthalmology 2001;108:1889–92. Cruz AA, Lucchezi MC. Quantification of palpebral fissure shape in severe congenital blepharoptosis. Ophthal Plast Reconstr Surg 1999;15:232–5. Hou D, Li G, Fang L, et al. Frontalis muscle flap suspension for the correction of congenital blepharoptosis in early age children. PLoS ONE 2013;8:e53185. Flynn TH, Rose GE, Shah-Desai SD. Digital image analysis to characterize the upper lid marginal peak after levator aponeurosis repair. Ophthal Plast Reconstr Surg 2011;27:12–14. Fox SA. Surgery of ptosis. Baltimore, MD: Williams & Wilkins, 1986:78. Tyers AG, Collin JR. Colour atlas of ophthalmic plastic surgery. Oxford: Butterworth-Heinemann, 2001:160.
349
Functional centre of the upper eyelid: the optimal point for eyelid lifting in ptosis surgery Chang Yeom Kim,1 Byeong Jae Son,2 Sang Yeul Lee1 1
Department of Ophthalmology, The Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea 2 Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu, Korea Correspondence to Professor Sang Yeul Lee, Oculoplastic Division, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea; [email protected] Received 26 February 2014 Revised 5 August 2014 Accepted 1 September 2014 Published Online First 23 September 2014
ABSTRACT Aims To establish the novel concept of a functional eyelid centre to determine the optimal point for eyelid lifting in ptosis surgery. Methods This was a prospective study of 112 patients with congenital ptosis. The functional eyelid centre was defined as the point where the eyelid contour showed the best appearance when the upper eyelid was lifted manually. In patients who underwent frontalis suspension surgery using silicone rods, the postoperative outcome was assessed according to the fixation point of the rod. Results The average horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.9 and 10.1 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line. The outcomes of silicone rod surgeries were excellent when the rod was fixated 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre. These positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line. Conclusions The functional eyelid centre was located slightly temporal to the mid-pupillary line. A better eyelid contour in ptosis surgery is produced when eyelid lifting is centred around the functional eyelid centre. INTRODUCTION Ptosis is one of the most common oculoplastic problems and there is an ‘art’ to the final adjustment of eyelid height and contour in ptosis surgery.1 The highest point of the upper eyelid is just nasal to the vertical mid-pupillary line.1 2 Therefore, in ptosis surgery, postoperative eyelid height is commonly adjusted on this line by a central suture, at the peak of the eyelid, immediately nasal to the midpupillary point.1 3–5 However, in our experience, lifting the upper eyelid on the mid-pupillary line in ptosis surgery often produces an unnatural eyelid contour which includes partial peaking or drooping. In addition, recurrent ptosis commonly occurred in the form of temporal eyelid drooping. The upper eyelid had the most natural and best appearance occurred when the eyelid was lifted. However, that point may not be the same as the highest point of the eyelid. In this study, we defined this novel point as the ‘functional centre of the upper eyelid’ to establish the concept of the functional eyelid centre in congenital ptosis, and to evaluate its clinical significance when performing ptosis surgeries.
To cite: Kim CY, Son BJ, Lee SY. Br J Ophthalmol 2015;99:346–349. 346
MATERIALS AND METHODS Institutional Review Board (IRB)/Ethics Committee approval was obtained. The study adhered to the
tenets of the Declaration of Helsinki and written informed consent was obtained from all participants ( parents or legal guardians). A total of 112 Korean paediatric patients with congenital ptosis were enrolled in this study. The patients underwent ptosis surgery, including frontalis suspension using silicone rods (Frontalis Suspension Set #585192; Beaver-Visitec International, Waltham, Massachusetts, USA) with the pentagonal technique of Fox,1 using autogenous fascia lata by direct tarsal and frontalis fixation,6 and levator resection. The procedures were performed by the same surgeon (SYL), under general anaesthesia, from August 2011 to April 2013. The surgical methods were determined based on levator muscle function, degree of ptosis, and age of the patient. Patients with the following conditions were excluded from the study: neuromuscular diseases, blepharophimosis, strabismus, previous ptosis surgery, and those with less than 1 year of follow-up. After induction of general anaesthesia, the horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were measured using a ruler. The surgeon and two assisting ophthalmologists assessed the eyelid contour by lifting the eyelid manually at several points, with a lacrimal probe. The functional eyelid centre was determined by agreement between the three doctors as the point where the eyelid had the best contour. In patients with unilateral ptosis, the horizontal fissure width, the distance from the medial canthus to the mid-pupillary line, and the position of the functional eyelid centre were compared between ptotic eyes and contralateral non-ptotic eyes. Frontalis suspension surgery, using silicone rods, was performed based on the functional eyelid centre. After establishing the functional eyelid centre, two points on the eyelid for stab incision were determined, one being nasal and the other temporal from the functional eyelid centre. The three ophthalmologists also determined the locations which produced the best eyelid contour and optimal correction of ptosis by lifting the eyelid with two lacrimal probes. Two eyelid and three suprabrow stab incisions were made, and the silicone rod was passed from one eyelid incision site to the other. The silicone rod was fixed at the supratarsal tissue with 6-0 polypropylene sutures at the eyelid stab incision sites, and then passed under the orbital septum to the brow incision sites, in a pentagonal pattern. The distances from the midpupillary line and the functional eyelid centre to the two fixation points were measured. The postoperative outcomes were evaluated functionally
Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
Clinical science and cosmetically based on evaluation criteria which were presented elsewhere.7 The measured values were analysed to evaluate the significance of the functional eyelid centre. Both eyes in unilateral ptosis were compared using the paired t test. Two-sided statistical testing was performed using IBM SPSS Statistics V.20 software with the significance level set at 0.05.
RESULTS A total of 224 eyes in 112 patients were included in the study; 152 (67.9%) eyes were from male patients. Patient ages ranged from 6 months to 11 years, with a mean age of 2.0 years. There were 67 patients with unilateral ptosis and 45 patients with bilateral ptosis. Levator resection surgery was performed on 32 eyes and frontalis suspension surgery on 125 eyes (98 eyes with silicone rods and 27 eyes with autogenous fascia lata). The average palpebral fissure of ptotic eyes was 4.3 mm before surgery. The horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.88±2.33 mm and 10.05±1.49 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line (figure 1). When the eyelid was lifted manually, nasal to the functional eyelid centre, the contour of the eyelid showed nasal peaking, and when lifted temporal to the functional eyelid centre, the eyelid drooped nasally. In patients with unilateral
ptosis, there was no significant difference in the horizontal fissure width, the distance from the medial canthus to the midpupillary line, or the location of the functional eyelid centre between both eyes ( p=0.484, p=0.708 and p=0.228, respectively). In cases of frontalis suspension using a silicone rod, most of the postoperative outcomes were excellent at 1 year after surgery. Ninety-three (94.9%) of these 98 eyes presented with a natural and symmetric eyelid contour without peaking or flattening, upper eyelid position above the papillary margin without complications, and eyelid height differences ≤1 mm, in unilateral cases. The fixation points at the supratarsal tissue, using the pentagonal method, were 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre, and these positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line, respectively (figure 2). The distance between nasal and temporal fixation points was about 40% of the horizontal fissure width (8.3 mm and 20.7 mm, respectively). There were five unsatisfactory cases. Two eyes had under-correction, and underwent a second operation within 2 weeks of surgery. In one eye of the two, a broken silicone rod was noted. Three eyes had recurrent ptosis at postoperative 1-year follow-up.
DISCUSSION In ptosis surgery, the location for central eyelid lifting influences postoperative eyelid appearance. The main point for lifting the
Figure 1 Photographs of eyelids showing the lifting points, using a lacrimal probe, to establish the functional eyelid centre. (A) When the upper eyelid was lifted at the mid-pupillary line, the eyelid shows nasal peaking and temporal drooping. (B) When the eyelid was lifted slightly temporal to the mid-pupillary line, the most natural and the best appearance was seen (functional eyelid centre). When the eyelid was lifted by two lacrimal probes to determine two fixation points of the silicone rod in frontalis suspension surgery, the points based on the functional eyelid centre show a better contour (D) than those based on the mid-pupillary line (C). Immediately postoperative (E) and 6-month postoperative photographs (F) of frontalis suspension surgery using silicone rods. The silicone was fixed nasal and temporal from the functional eyelid centre. Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
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Clinical science
Figure 2 The best fixation points for silicone rods were at nearly equidistant locations nasal and temporal from the functional eyelid centre, but extremely displaced to the temporal side from the mid-pupillary line. Black dotted lines indicate the position of the silicone rod; the thread grasped with the forceps shows fixation sutures of the silicone rod at the supratarsal tissue; the white dotted line indicates the mid-pupillary line; and the white solid line indicates the functional eyelid centre. eyelid in ptosis surgery was located at the centre of the tarsal plate or the mid-pupillary point, because this point is generally the highest part of the upper eyelid.1 2 In levator advancement surgery, the central tarsal suture should be placed immediately nasal to the mid-pupillary line and additional sutures then placed medially and laterally.3 4 Liu and Meltzer also proposed placing the suture slightly nasally or across the midline to obtain a very natural arc in single suture levator surgery.8 9 In frontalis suspension surgery, the location of tarsal fixation also determines postoperative eyelid height and contour. Nerad proposed placing a single central suture at the peak of the eyelid,1 while Salour et al5 suggested placement at the centre of the eyelid. However, in this study the point where the upper eyelid showed the most natural appearance was different from the highest point of the eyelid. For this reason, we introduced a new concept of ‘functional centre of the upper eyelid’ in ptosis surgery. In this study, the functional eyelid centre (i.e., the optimal point for eyelid lifting) was located about 4.3 mm temporal to the mid-pupillary line. This result suggests that for a better outcome, the centre of eyelid lifting in ptosis surgery should be placed laterally. When the eyelid was lifted at the mid-pupillary line, the eyelid showed nasal peaking. Although the eyelid contour can be adjusted with nasal and temporal additional eyelid lifting, central eyelid lifting has the greatest impact on postoperative eyelid height and contour. Therefore, the centre of eyelid lifting should be placed slightly temporal to the midpupillary line to produce a more natural eyelid contour. In a previous study using digital image analysis on patients with severe congenital ptosis, the eyelid contour was reported to be better when the eyelid was adjusted slightly laterally, not centrally at the midline.10 Hou et al11 suggested that the height of the lateral fixation point should be higher than that of the midpoint to 348
obtain a natural curvature in frontalis muscle flap suspension surgery for the correction of congenital ptosis. The concept of the functional eyelid centre could explain why the fixation point would be better placed slightly laterally in these studies. The position of the functional eyelid centre was not significantly different between the ptotic eye and contralateral nonptotic eye in patients with unilateral congenital ptosis. In patients with severe ptosis, temporal eyelid drooping was relatively more prominent than nasal drooping.10 12 In this situation, the functional eyelid centre could be moved more laterally. This disagreement could be because our study was carried out on patients under general anaesthesia while in the supine position. Further studies are warranted to analyse the position of the functional eyelid centre in standing patients. We evaluated the clinical significance of a functional eyelid centre in patients undergoing frontalis suspension surgery using silicone rods. The two fixation points of the silicone rods at the supratarsal tissue and showing the best eyelid contour and optimal correction of ptosis, were located medially and laterally equidistant from the functional eyelid centre. These points were displaced laterally from the mid-pupillary line. Therefore, if the surgeon sets the nasal and temporal points based on the midpupillary line, the fixation positions would be displaced nasally, and as a result, temporal under-correction could occur. Use of the functional eyelid centre could correct the temporal eyelid drooping better and prevent postoperative temporal re-drooping. In frontalis suspension surgery, two eyelid incisions for tarsal fixation were suggested at 10 mm to each side,5 13 located just lateral to the line of the punctum, and at an equal distance to the lateral side,14 or at the medial and lateral limbus.1 In this study of paediatric patients, the distance between the two supratarsal fixations was approximately 8 mm, and these distances corresponded to 40% of the horizontal fissure width, producing good patient outcomes. Eyelid peaking or flattening developed when the two fixation points were closer or farther away from each other than this, respectively. The standard of beauty differs from country to country and from culture to culture. Therefore, the cosmetic results of ptosis surgery judged excellent in this study may not be considered good in patients from other cultures. In addition, the assessment of eyelid height and contour using a single lacrimal probe might be inadequate. However, this method was adequate for illustrating the concept of the functional eyelid centre and determining its approximate location. The specific vectors for lifting the eyelid would be different depending on the surgical methods or individual fixation points on the tarsus. Additional studies are warranted to individually assess the clinical significance of the functional eyelid centre in levator resection surgery or frontalis suspension using various suspension materials. In conclusion, the functional eyelid centre lies slightly temporal to the mid-pupillary line, and surgeons should consider this when performing ptosis surgery. Eyelids should be lifted, centring at the functional eyelid centre not at the peak of the eyelid, to produce a more natural eyelid contour, and to avoid temporal under-correction in ptosis surgery. Contributors CYK, SYL: conception and design; CYK, BJS, SYL: conduct of the study, and collection, management, analysis and interpretation of the data; CYK, SYL: drafting the article or revising it critically for important intellectual content; SYL: review and final approval of the manuscript. Competing interests None. Ethics approval The Institutional Review Board (IRB)/Ethics Committee of Yonsei University Health System, Seoul, Korea approved this study. Provenance and peer review Not commissioned; externally peer reviewed.
Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
Clinical science REFERENCES 1
2 3 4
5
6
Nerad JA. Evaluation and treatment of the patient with ptosis. In: Nerad JA, ed. Oculoplastic surgery: the requisites in ophthalmology. St. Louis, MO: Mosby, 2001:157–92. Lieberman DM, Quatela VC. Upper lid blepharoplasty: a current perspective. Clin Plast Surg 2013;40:157–65. Shovlin JP. The aponeurotic approach for the correction of blepharoptosis. Int Ophthalmol Clin 1997;37:133–50. Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery—advancement of levator aponeurosis. Open Ophthalmol J 2010;14: 76–80. Salour H, Aletaha M, Bagheri A. Comparison of Mersilene mesh and autogenous fascia lata in correction of congenital blepharoptosis: a randomized clinical trial. Eur J Ophthalmol 2008;18:853–7. Spoor TC, Kwitko GM. Blepharoptosis repair by fascia lata suspension with direct tarsal and frontalis fixation. Am J Ophthalmol 1990;109: 314–17.
7
8 9 10 11 12
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Kim CY, et al. Br J Ophthalmol 2015;99:346–349. doi:10.1136/bjophthalmol-2014-305101
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