The role of frontalis orbicularis oculi muscle flap for correction of blepharoptosis with poor levator function.

CLINICAL PAPER

The Role of Frontalis Orbicularis Oculi Muscle Flap for Correction of Blepharoptosis With Poor Levator Function Chung-Sheng Lai, MD, EMBA, PhD,*Þ Kao-Ping Chang, MD, PhD,*Þ Su-Shin Lee, MD,*Þ Tung-Ying Hsieh, MD,* Hsin-Ti Lai, MD,* Yu-Hao Huang, MD,* and Ya-Wei Lai, MD* Abstract: On the basis of the close anatomical interdigitation between the longitudinal-oriented frontalis muscle and the horizontal-oriented orbicularis oculi muscle (OOM), frontalis OOM (FOOM) flap was developed to treat blepharoptosis. Retrospective study during an 11-year period, 66 patients with 81 poor levator function ptotic eyelids accepted FOOM flap shortening (65 lids; 80.2%) or double-breasted FOOM flap advancement (16 lids; 19.8%) to correct blepharoptosis. There were 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Severity of blepharoptosis included severe type in 72 (88.9%) lids, moderate type in 5 (6.2%) lids, and mild type in 4 (4.9%) lids. The underlying etiology included congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and neurologic origin in 4 (6.1%) patients. Marginal reflex distance 1 and lid slit distance improved from j1.6 (2.0) to 3.3 (1.2) and 3.2 (2.0) to 7.2 (1.4) mm, respectively, after operation. The postoperative outcome includes good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. The undercorrection or recurrence rate is 14.8%, and secondary revision rate is 11.1%. Positive Hering law is 17.6% among patients with unilateral ptosis. Overall patients’ satisfaction rate is 95.1%. Both FOOM flap shortening and double-breasted FOOM flap advancement are effective to treat poor levator function blepharoptosis. Double-breasted FOOM flap advancement is highly recommended because of the more natural contour and minimal lagophthalmos postoperatively, because of the maximal preservation of OOM. Key Words: blepharoptosis, poor levator function, frontalis orbicularis oculi muscle flap, frontalis sling (Ann Plast Surg 2013;71: S29YS36)

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umerous surgical procedures have been developed to treat blepharoptosis. The choice of an appropriate technique should be based on levator function (LF). For poor LF blepharoptosis, frontalis suspension is still the most commonly used method to correct challenging ptosis. Exogenous synthetic materials or autogenous tissue can serve as a connection between the frontalis muscle and the tarsus. This report is focused on the role of the autologous orbicularis oculi muscle (OOM) as a connector between the frontalis muscle and tarsus to treat poor LF blepharoptosis. The term ‘‘frontalis orbicularis oculi muscle (FOOM) f lap’’ was first named by Lai1 in 2005, and then the clinical results published2,3 after refinement of the original OOM f lap which was developed by Park et al,4,5 with the terminology more logical to define its anatomical linkage and function. Recently, Bhiromekraibhak6 also

Received October 3, 2013, and accepted for publication, after revision, October 6, 2013. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital; and †Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Chung-Sheng Lai, MD, EMBA, PhD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd, Kaohsiung 807, Taiwan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S029 DOI: 10.1097/SAP.0000000000000043

Annals of Plastic Surgery

used the term ‘‘FOOM’’ f lap in reference to the procedure used to repair blepharoptosis. This study aimed to demonstrate the clinical outcome of FOOM f lap shortening and double-breasted FOOM f lap advancement in treatment of blepharoptosis with poor LF.

MATERIALS AND METHODS A retrospective review of well-documented medical records of patients who accepted FOOM flap shortening or double-breasted FOOM flap advancement to treat upper blepharoptosis with poor LF (G5 mm) between January 2001 and December 2011 was studied. A senior surgeon (C.S.L.) performed all the surgeries. The investigated data include age, sex, unilateral or bilateral ptosis (only poor LF included), etiology, severity of ptosis, perioperative change of the marginal reflex distance 1 (MRD1) (represents the distance between the pupillary light reflex and the upper lid margin in primary gaze position) and lid slit distance (represents the maximal distance between the upper lid margin and lower lid margin in primary gaze position), the incidence of Hering law, and surgical complications. Testing of Hering law is done by patching the ptotic eye with gauze (covering test) for 5 minutes and then measuring the height of the contralateral upper eyelid margin. Positive Hering phenomenon indicates that the contralateral eyelid has drooped, usually around 1 to 2 mm.

Surgical Technique The redundant lid skin is measured with a pinch test and marked along the upper lid crease, which is usually 6 to 8 mm from the lid margin in Asians, and extended over the lateral canthal commissure. In unilateral blepharoptosis, the upper lid crease is designed 1 to 2 mm less than the normal size because the long swelling and its stretching effect will increase the width of the involved upper lid crease. The supraorbital notch is palpated and marked to prevent nerve injury during f lap dissection. All patients accepted local anesthesia of 1% lidocaine and 1/200,000 epinephrine except children and pain-intolerable patients. There are 2 different types of f lap design consisting of the FOOM f lap shortening technique and the double-breasted FOOM f lap advancement technique. In cases of FOOM f lap shortening technique, the whole upper lid skin from the upper lid crease to the sub-eyebrow area is ballooned subcutaneously with anesthesia solution using a no. 26 fine needle. The redundant skin is resected, and subcutaneous dissection, proceeding upward to the sub-eyebrow area, is easily carried out because of hydrodissection by the anesthesia solution. The submuscular dissection begins from the superior border of the tarsus after injection of local anesthesia solution submuscularly, proceeding upward to extend over the superior orbital rim. The orbital septum is not included in the f lap, and the excessive fat bag is resected properly if puffy eyelid is presented. Dissection should be undergone laterally to the supraorbital nerve with meticulous hemostasis. Under gentle stretching by double hooks, superiorly based rectangular FOOM f lap is formed by 2 parallel cuts with a width less than the palpebral fissure, and the supraorbital nerve is kept intact. Upon completion of the biplane dissection including the subcutaneous layer and submuscular layer, the FOOM f lap is then pulled

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FIGURE 1. FOOM f lap shortening technique. A, Subcutaneous dissection up to the sub-eyebrow area is performed, with the FOOM f lap formed by bilateral parallel cuts over the OOM. B, Submuscular dissection proceeds up to the arcus marginalis. The orbital septum is not included in the f lap, and the pretarsal and orbital OOM are kept intact. C, The FOOM f lap is fixed to the tarsus to lift the ptotic lid to an ideal position, and the redundant f lap is resected.

downward and fixed to the tarsus to lift the ptotic eyelid to an ideal position, and finally the redundant f lap is resected (Fig. 1). In cases of double-breasted FOOM flap advancement, the preseptal OOM is maximally preserved. The required FOOM is designed and harvested in the upper third of the preseptal OOM after biplane dissection is completed. The lower border of the flap is usually located 10 to 20 mm superior to the tarsus in adults under gentle traction of the OOM with double hooks. The distance between the tarsus and the lower border of the double-breasted FOOM flap in children is determined case by case under the principle of preservation of maximal volume of OOM. Any tethered fibers hindering the FOOM flap advancement are totally freed, and the FOOM flap can then be easily pulled downward and passed beneath the OOM, with the excessive distal flap trimmed after evaluation of the lid height. The flap is then fixed to the superior third of the tarsus with 3 partial thickness horizontal mattress sutures of 6Y0 Nylon for children and 5Y0 Nylon for adults.

The center of the FOOM flap is first fixed to the tarsus at the center of the eyelid fissure and reinforced with medial and lateral sutures (Fig. 2). During operation, the height of the upper lid margin at primary gaze is adjusted approximately 1 mm below the limbus in sitting position and around the upper margin of the limbus in supine position. The pretarsal subdermal tissue is fixed to the tarsus with 6Y0 Nylon to form the upper lid crease. The wound is approximated subcutaneously with 6Y0 absorbable Vicryl after secure hemostasis, and the skin is closed with running 6Y0 nylon sutures. The stitches are removed 4 to 5 days after surgery.

Postoperative Care Postoperative eye care is of paramount importance. Vitamin A ointment is applied to the involved eyes and they are covered with a transparent wrap or eye patches during sleep to prevent keratopathy caused by lagophthalmos. TobraDex (tobramycin 0.3%, dexamethasone

FIGURE 2. Double-breasted FOOM f lap advancement. A, The rectangular FOOM f lap is designed and harvested in the upper third of the preseptal OOM after completion of the biplane dissection (subcutaneous and submuscular layers). B, The FOOM f lap is advanced to the tarsus beneath the preserved preseptal OOM. C and D, The FOOM f lap is fixed to the tarsus to lift the involved lid to an ideal position, and the excess distal end of the f lap is resected. S30


* 2013 Lippincott Williams & Wilkins




FOOM Flap for Correction of Blepharoptosis

TABLE 1. Evaluation Criteria for Postoperative Results Result

Ptosis Type Unilateral Bilateral

Good

Fair

Poor

Asymmetric upper lid margin e 1 mm Asymmetry MRD1 e 2 mm

Asymmetry upper lid margin between 1 and 2 mm Asymmetry MRD1 between 2 and 3 mm

Asymmetry upper lid margin Q 2 mm Asymmetry MRD1 Q 3 mm

0.1%; Alcon, Fort Worth, Tex) is administered to the operated eyes 3 times daily to treat conjunctive irritation and chemosis. Artificial tears or ophthalmologic gel is used for dry eye phenomenon in the daytime. Most patients accommodate well within 1 to 3 months and no further medication is needed.

Postoperative Evaluation The criteria of the postoperative outcome of blepharoptosis correction are revised from the report published by Souther and Vistnes in 1979.7 A good result is defined as follows: (1) less than 1 mm asymmetry of the upper lid margin in unilateral cases and (2) no more than 2 mm below the upper border of the limbus in bilateral cases. A poor result means that (1) more than 2 mm asymmetry of the upper lid margin in unilateral cases and (2) more than 3 mm below the upper border of the limbus in bilateral cases. A fair result indicates that (1) asymmetry of the upper lid margin between 1 and 2 mm in unilateral cases and (2) upper lid margin between 2 and 3 mm below the upper border of the limbus (Table 1). All patients are examined in primary gaze with a relaxed and comfortable position. The follow-up periods, revision rates, and patients’ satisfaction rates investigated through telephone are also studied.

RESULTS There were 66 patients (17 men and 49 women), totaling in a count of 81 ptotic eyelids reporting accepted FOOM flap shortening in 65 (80.2%) eyelids and double-breasted FOOM flap advancement in 16 (19.8%) eyelids between January 2001 and December 2011, with only cases of poor LF included in this study. Patients’ ages ranged from 5 to 82 years with an average of 33.6 years and their follow-up periods ranged from 6 to 60 months with an average of 9.1 months. There are 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Hering law investigated in 51 unilateral ptosis patients revealed positive results in 9 (17.6%) patients. Preoperative evaluation of the ptosis severity revealed mild ptosis in 4 (4.9%) lids, moderate ptosis in 5 (6.2%) lids, and severe ptosis in 72 (88.9%) lids. The underlying etiology includes congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and

neurogenic origin in 4 (6.1%) patients. The demographics of patients are shown in Table 2. The preoperative MRD1 ranged from j5 to 3 mm with a mean of j1.6 (2.0) mm, and the postoperative MRD1 ranged from 2 to 5 mm with a mean of 3.3 (1.2) mm. The preoperative lid slit distance ranged from 0 to 6 mm with a mean of 3.2 (2.0) mm, and the postoperative lid slit distance ranged from 6 to 9 mm with a mean of 7.2 (1.4) mm. On the basis of the revised criteria of postoperative outcome, there were good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. There were 12 (14.8%) lids with recurrence or undercorrection, with 9 (11.1%) lids among the total 81 ptotic lids that underwent secondary revision. The surgical results are shown in Table 3. There were no significant differences in postoperative MRD1 and lid slit distance between the FOOM f lap shortening group and the double-breasted FOOM f lap advancement group. However, the upper lid crease and contour looked relatively better in the double-breasted FOOM f lap advancement group (Fig. 3Y6). There was no overcorrection, but hematoma occurred in 1 case. Chemosis was common, but it usually subsided progressively within 2 to 3 weeks postoperatively. Every patient experienced lagophthalmos approximately 1 to 2 mm immediately after ptosis correction in the group of FOOM flap shortening patients, but it usually progressively improved within 3 months after surgery. The elasticity and pliability of the FOOM flap and the preservation of intact pretarsal and orbital OOM enable eye closing without problems. There was only minimal or no lagophthalmos immediately after the ptosis correction in the group of double-breasted FOOM flap advancement patients, primarily due to maximal preservation of the preseptal OOM. All patients accommodated and did well after postoperative eye care education, and no permanent keratopathy occurred in our series. The overall satisfaction rate investigated through telephone is 95.1%.

DISCUSSION Surgical correction of blepharoptosis with poor LF is still a major challenge for most oculoplastic surgeons due to its imperfect results and high recurrence rate. Frontalis sling is a relatively easier

TABLE 2. Demographics of Patients With Poor LF Accepted FOOM Flap Surgery No. lids Female/male Age (average), y Distribution of ptosis Etiology of ptosis

Positive Hering law in unilateral ptosis


Mild Ptosis

Moderate Ptosis

Severe Ptosis

Total No.

4 (4.9%) 3/1

5 (6.2%) 4/1

72 (88.9%) 42/15

81 49/17

5Y82 (33.6) Unilateral, 51 (77.3%) Bilateral, 15 (22.7%) Congenital, 43 (65.1%) Involutional, 19 (28.8%) Neurogenic, 4 (6.1%) 9 (17.6%)



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TABLE 3. Postoperative Results of Patients with Poor LF Accepted FOOM Flap Surgery MRD1, mm Lid slit distance, mm Evaluation of outcomes

Preoperative

Postoperative

j5 to 3 [mean, j1.6 (2.0)] 0Y6 [mean, 3.2 (2.0)]

2Y5 [mean, 3.3 (1.2)] 6Y9 [mean, 7.2 (1.4)]

No. lids with undercorrection or recurrence No. lids accepted secondary revision

procedure to perform to treat poor LF blepharoptosis, and the eyelid is surgically suspended to the frontalis muscle using autologous, heterologous, or alloplastic materials.8,9 Drawbacks of this technique include lagophthalmos during sleeping or eye closing, blepharoptosis in upward gaze, donor-site morbidity of the autologous tissue, and foreign body complications caused by exogenous materials. Direct transplantation of the frontalis muscle to the tarsus is another option

Good, 5 (81.8%) Fair, 10 (15.2%) Poor, 2 (3.0%) 12 (14.8%) 9 (11.1%)

for blepharoptosis with poor LF,10 but the procedure has several disadvantages, including forehead depression, loss of forehead wrinkles, need of 2 separate incisions, technical difficulty, and possible neurovascular injury. However, several authors have revised the original methods and declared good results.11Y14 Knize15 first reported in 1996 that the frontalis muscle and its fascia have been observed to enter the deep OOM surface at the eyebrow region, with

FIGURE 3. A, Left severe congenital blepharoptosis with poor LF in a 25-year-old woman. Asymmetric eyebrow and upper lid margin are shown. She accepted unknown procedures to correct the ptosis in her childhood. B, FOOM f lap shortening approximately 27 mm in ptotic eyelid and upper blepharoplasty in right upper lid is performed. Symmetric upper lid margin and eyebrow are shown, 9 months after operation. C and D, Lateral profile shows natural contour of the involved upper lid after correction. E, The height of the right ptotic upper lid margin is adjusted approximately 1 mm below the limbus in sitting position during operation. S32







FIGURE 4. A, Bilateral severe congenital blepharoptosis with poor LF in a 30-year-old woman. Abnormal high position of the eyebrows and increased distance between the eyebrows and eyelashes are shown. B, FOOM f lap shortening approximately 27 mm in right upper lid and 26 mm in left upper lid is performed. Symmetric upper lid margin and eyebrow are shown, 6 months after operation. C-F, Lateral profile shows natural upper lid contour.

our fresh cadaver dissection also clearly showing the close interdigitation between the longitudinal-oriented frontalis muscle and horizontal-oriented OOM (orbital portion).2,3 On the basis of the anatomic finding, Park et al,4,5 Baik et al,16 and Tsai et al17,18 used the OOM f lap as a connector of the frontalis muscle to treat blepharoptosis, and Borman and Maral19 further developed the double-breasted OOM f lap to minimize postoperative lagophthalmos in blepharoptosis correction. Resection of levator muscle by either the cutaneous or conjunctival approach is usually recommended in patients experiencing mild or moderate ptosis with fair or good LF. Traditionally, the levator resection is not indicated for the correction of blepharoptosis with poor LF. However, satisfactory results were achieved by maximal levator resection in several reports, but it still has the shortcomings of lagophthalmos, undercorrection, and ptosis in upward gaze.20Y22 All autologous or synthetic suspension materials, including silicone rod, Gore-Tex, fascia lata, palmaris longus tendon, and others, are nonviable without contractility and only limited elasticity. Therefore, tenting deformity and lagophthalmos are the most common postoperative sequelae. Recurrence rates may range from 0% to 100%, depending on different suspension materials.13,14,23,24 However, the frontalis sling is a simpler and less-invasive procedure, and * 2013 Lippincott Williams & Wilkins

it allows readjustment to be performed at any time, remaining as an attractive and ideal option for correction of blepharoptosis with poor LF. The FOOM f lap is a viable tissue with good elasticity and contractility. Hence, early postoperative lagophthalmos can be progressively improved without tenting deformity, foreign body reactions, and donor-site morbidity. Most of the ptotic and elongated septal OOM (usually 22Y27 mm in length under gentle traction) was resected in the FOOM f lap shortening group, whereas the preseptal OOM was preserved in the double-breasted FOOM advancement group. The FOOM f lap plays an effective connector to lift the ptotic eyelid dynamically, and more natural appearance of the eyelid can be achieved, but it requires skillful technique and a longer operation time. The comparison of the characteristics between FOOM f lap and frontalis sling for correction of blepharoptosis is shown in Table 4. On the basis of the anatomic tight linkage between the frontalis muscle and OOM, FOOM flap was developed, and it effectively elevates the ptotic eyelid to an ideal position. Most of our patients with blepharoptosis belong to the severe type (88.9%), and the congenital origin (65.1%) is the most common etiology. MRD1 improved from j1.6 (2.0) mm preoperatively to 3.3 (1.2) mm postoperatively, and the lid slit distance improved from 3.2 (2.0) mm preoperatively to 7.2 (1.4) mm postoperatively. Overall satisfaction rate of the patients is 95.1%, and the www.annalsplasticsurgery.com


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FIGURE 5. A, Severe congenital blepharoptosis with poor LF of the left upper lid in a 28-year-old woman. She accepted frontalis sling operation in her childhood. B, Double-breasted FOOM flap advancement with symmetric upper lid margin and eyebrow are shown, 7 months after operation. Excision of the lower lid mole is also performed. C, Lateral profile shows drooping of the left upper lid. D, Natural upper lid contour is shown. E, The height of the involved upper lid margin is adjusted to rest on the upper margin of the limbus in supine position during operation.

postoperative good result is 81.8%. The undercorrection and recurrence rate in poor LF blepharoptosis correction is usually high,13,14 it is 14.8% in our series, and the overall secondary revision rate is 11.1%. Although the long-term result of the MRD1 and lid slit distance portrays no significant differences between the FOOM flap shortening group and the double-breasted FOOM flap advancement group, the latter group results in a more natural eyelid contour. Because the doublebreasted FOOM flap advancement group preserves the preseptal OOM, immediate postoperative lagophthalmos is only minimal. Therefore, we have already totally changed to routinely use this particular technique to treat blepharoptosis with poor LF in the recent 2 years. FOOM flap is a dynamic connector, transmitting the powerful lifting force of the frontalis muscle to the tarsus during eye opening and relaxing to facilitate the contraction of the intact OOM during eye closing. Singh25 used orbicularis plication and Bagheri et al26 applied tarsus directly to frontalis to correct blepharoptosis without flap creation. Upper lid crease formation is an important procedure in Asian blepharoptosis correction, and the pretarsal subdermal tissue is fixed to the tarsus directly to form natural and deep double eyelids. Shallow upper lid crease is always presented if the pretarsal subdermal tissue is fixed to the distal end of the FOOM flap. S34


Intraoperative adjustment is the most important step to lift the ptotic upper lid margin to the desired position. There are many factors that affect the final position of the upper lid margin during operation, resulting in necessary careful judgment based on the preoperative and intraoperative conditions of the involved eyelids. Eyelid drooping intraoperatively may result from eyelid swelling, ecchymosis, hematoma, anesthetized levator muscle and Mu¨ller muscle, heavy sedation, light brightness, pain, or patients’ discomfort and anxiety. Epinephrine contained in the anesthesia solution will stimulate muscle contraction and increase the height of the upper lid margin up to 1.1 (1.5) mm, as reported by Bartley et al.27 Tucker and Verhulst28 revealed that, when compared with the intraoperative measurement of the involved eyelid immediately after correction, 40% of ptotic eyelids reach final height 1 week after surgery, 52% ptotic eyelids reach the permanent height 6 weeks after correction, and the upper lid margin usually increases approximately 1.1 mm in height. Positive and negative factors affecting the final height of upper lid margin should be carefully evaluated. However, after longterm follow-up in the respective literatures, undercorrection seems to still be the most common complication of ptosis correction surgery. * 2013 Lippincott Williams & Wilkins





FIGURE 6. A, Severe bilateral involution blepharoptosis with poor LF in an 82-year-old-man. Depressed upper lids, heavy forehead wrinkles, and high position of eyebrows are also noted. B, Correction with double-breasted FOOM f lap advancement results in symmetric upper lid margin and eyebrow position, along with f lattened forehead wrinkles, 12 months after operation. C, Lateral profile shows marked insufficiency of upper lid volume besides ptosis. D, Not only the ptosis is corrected, the upper lid volume insufficiency is also augmented by the double-breasted OOM. E, Normal eye closing without lagophthalmos.

Therefore, we overcorrected the ptotic upper lid height 1 mm in sitting position and 2 mm in supine position intraoperatively. Consideration of the bilateral symmetry of the upper eyelid height, preoperative covering test or lifting test should be performed to evaluate Hering law. Positive Hering phenomenon ranges from 10% to 30% in the literatures,29,30 and our series reveals 17.6% positive rate in

patients experiencing unilateral blepharoptosis with poor LF. Informed consent of the possibility of simultaneous correction of the contralateral upper lid should be noted before operation. In conclusion, FOOM f lap has been used successfully to correct poor LF blepharoptosis, and it can be applied in a manner of f lap shortening or double-breasted advancement. Compared with the

TABLE 4. Comparison Between Frontalis Sling and FOOM Flap for Correction of Blepharoptosis With Poor LF Method Characteristics Suspending material Contractility Elasticity Tenting deformity Foreign body reaction Surgical procedure Operation time Lagophthalmos Donor-site morbidity Undercorrection and recurrence rate


Frontalis Sling

FOOM Flap Shortening

Fascia or synthetic material No +/j Yes +/j Simple Shorter Mild to severe, depending on the suspension material +/j 0%Y100% (average, 30%Y40%), depending on the suspension material

Muscle flap Yes Good No No Skillful Longer Minimal, progressively improved Minimal 14.8%



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traditional frontalis sling, the FOOM f lap is a viable, contractile, and pliable tissue, effectively lifting the ptotic lid to an ideal height with a relatively lower undercorrection and recurrence rate. Doublebreasted FOOM f lap advancement is highly recommended because of maximal preservation of the OOM, minimal immediate postoperative lagophthalmos, and relatively more natural eyelid contour.

ACKNOWLEDGMENTS The authors thank Mr Austin Deng Chen for his eager assistance in English correction without payment.

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13. Medel R, Alonso T, Giralt J, et al. Frontalis muscle flap advancement with a pulley in the levator aponeurosis in patients with complete ptosis and deep-set eyes. Ophthal Plast Reconstr Surg. 2006;22:441Y444. 14. Pan Y, Zhang H, Yang L, et al. Correction of congenital severe ptosis by suspension of a frontal muscle flap overlapped with an inferiorly based orbital septum flap. Aesthetic Plast Surg. 2008;32:604Y612. 15. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321Y1333. 16. Baik BS, Lee JH, Cho BC. Severe blepharoptosis: correction by orbicularis oculi muscle and orbital septum resection and advancement. Ann Plast Surg. 1998;40:114Y122. 17. Tsai CC, Lin TM, Lai CS, et al. Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg. 2000;53:473Y476. 18. Tsai CC, Lin TM, Chou CS, et al. Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous levator muscle resection. Ann Plast Surg. 2003;50:292Y295. 19. Borman H, Maral T. Technique for blepharoptosis correction using doublebreasted orbicularis oculi muscle flaps. Ann Plast Surg. 2006;57:381Y384. 20. Epstein GA, Putterman AM. Super-maximum levator resection for severe unilateral congenital blepharoptosis. Ophthalmic Surg. 1984;15:971Y979 21. Mauriello JA, Wagner RS, Caputo AR, et al. Treatment of congenital ptosis by maximal levator resection. Ophthalmology. 1986;93:466Y469. 22. Press UP, Hu¨bner H. Maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function. Orbit. 2001;20:125Y159. 23. Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140:877Y885. 24. Hayashi K, Katori N, Kasai K, et al. Comparison of nylon monofilament suture and polytetrafluoroethylene sheet for frontalis suspension surgery in eyes with congenital ptosis. Am J Ophthalmol. 2013;155:654Y663. 25. Singh D. Orbicularis plication for ptosis: a third alternative. Ann Ophthalmol (Skokie). 2006;38:185Y193. 26. Bagheri A, Ahadi H, Babsharif B, et al. Direct tarsus to frontalis muscle sling without flap creation for correction of blepharoptosis with poor levator function. Orbit. 2012;31:48Y52. 27. Bartley GB, Lowry JC, Hodge DO. Results of levator-advancement blepharoptosis repair using a standard protocol: effect of epinephrine-induced eyelid position change. Trans Am Ophthalmol Soc. 1996;94:165Y173. 28. Tucker SM, Verhulst SJ. Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology. 1999;106:517Y522. 29. Erb MH, Kersten RC, Yip CC, et al. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg. 2004;20:418Y422. 30. Wladis EJ, Gausas RE. Transient descent of the contralateral eyelid in unilateral ptosis surgery. Ophthal Plast Reconstr Surg. 2008;24:348Y351.



Restoration of orbicularis oculi function by contralateral orbicularis oculi innervated muscle flap vs neuromuscular pedicle technique.

Early frontalis flap surgery as first option to correct congenital ptosis with poor levator function.

Comparison of Blepharoptosis Correction Using Müller-aponeurosis Composite Flap Advancement and Frontalis Muscle Transfer.

Ten Years of Results of Modified Frontalis Muscle Transfer for the Correction of Blepharoptosis.

Beneficial effects of turnover orbicularis oculi muscle suspension flap for treating facial fractures via subciliary incision.

Blepharoptosis Reoperation With Combining Excision of Tarsus and Levator Muscle.

Reconstruction of the entire upper eyelid area with a subcutaneous pedicle flap based on the orbicularis oculi muscle.

Levator resection with suspensory ligament of the superior fornix suspension for correction of pediatric congenital ptosis with poor levator function.

Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion.

Borderline to Moderate Blepharoptosis Correction Using Retrotarsal Tucking of Müller Muscle: Levator Aponeurosis in Asian Eyelids.

Surgical correction of blepharoptosis using a modified levator aponeurosis-Müller muscle complex reinsertion technique.

Blepharoptosis correction: levator aponeurosis-Müller muscle complex advancement with three partial incisions.

Repositioning the orbicularis oculi muscle in the composite rhytidectomy.

Regional differences in the orbicularis oculi muscle: conservation between species.

Medial and lateral canthal reconstruction with an orbicularis oculi myocutaneous island flap.

Long-term histopathologic study of the frontalis muscle flap after frontalis suspension for severe ptosis repair.

Surface electromyographic mapping of the orbicularis oculi muscle for real-time blink detection.

Comparison of Orbicularis Oculi Muscle Activity during Computer Work with Single and Dual Monitors.

Frontalis muscle flap advancement for correction of severe ptosis under general anesthesia: modified surgical design with 162 cases in China.

Dimensions and anatomic variations of the orbicularis oculi muscle in nonpreserved, fresh-frozen human cadavers.

Origin of the Lower Orbicularis Oculi Muscle in Relation to the Nasojugal Groove.

Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion.

Regional Variations in Orbicularis Oculi Histology.

Orbicularis oculi reflex in brain death.