A New Treatment for Severe Unilateral Congenital Ptosis and for Ptosis with Jaw-Winking*

S.

252

D.

P A U L

A N D

O.

P.

A H U J A

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TREATMENT PTOSIS

AND

FOR FOR

SEVERE PTOSIS

UNILATERAL

WITH

CROWEM. REARD, San fose,

Symmetry in repose and in motion is as important as the monocular appearance ob­ tained in cosmetic surgery of the eye region. The surgical results obtained in ptosis often demonstrate this fact. An eyelid which looks excellent in the primar)- position may lookbizarre when compared to its fellow as the eyes look down or attempt to blink. Figure 1 depicts a patient with severe uni­ lateral ptosis which had been inadequately treated bv a levator resection done by a con­ junctival approach. Figure 2 shows the post­ operative result obtained by a second levator resection done by a skin approach. Figure 3 shows the asymmetrical effect on downward

of

and

53 : 2 7 9 - 2 8 5 . 1 9 6 2 .

Heterotransplantation:

NEW

* From

fresh

41 : 5 0 5 , 1 9 5 6

cilium Ophthalmologicum

A

of

49:1387-1395, 1960.

Murakami,

Matton-Yan I. O p h t h ,

Woods,

H ,

S.

14.

versity

material.

stored

B o n h o u r , C . : K e r a t o p l a s t i c l a m e l l a i r e p a r g r e f f o u l y o p h i l i z e . A n n . o c u l , 188

:

cisco.

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54:265-272, 1962.

13.

15.

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modified technique. Á m . J . O p h t h , 12.

corneal

42:71-75. 1956.

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Ophth, 8.

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the

Department

California

of

Ophthalmology,

Medical

Center,

San

Uni­ Fran­

CONGENITAL

JAW-WINKING*

M.D.

California

gaze. The effect in life is more startling than the photographs depict. Figures 4, 5 and 6 show a somewhat more marked defect caused by unilateral brow suspension used for cor­ rection of a monocular ptosis. The cosmetic defect which follows unilateral superior rectus suspension of the eyelid is caused by the inability of the eyelid to blink synchro­ nously with its fellow, even though the eye­ lids move up and down in unison. This, com­ bined with other well-known contraindica­ tions to superior rectus suspension, has made the indications for this type of surgery quite rare. I use it very infrequently now. There is no doubt that the best results in ptosis surgery are obtained by levator re­ section when this muscle has fair to good function (over five mm. of eyelid margin

PTOSIS

WITH

excursion when the eye goes from eyes-down to eyes-up position). Since most of the ptosis cases fall into this group, good results should be obtained by levator resection in these cases. When the levator function is poor, however, or has been proven inadequate by a previous unsuccessful levator resection, the surgeon often resorts to brow suspension. Brow suspension results can be considered good only if the ptosis is bilateral. Otherwise symmetry cannot exist. Since my results in bilateral fascia lata brow suspension were usually quite good, and those of my unilateral brow suspension always quite poor, it occurred to me that the deliberate creation of a ptosis on the normal side by levator excision, and repair of the consequent bilateral ptosis by bilateral fascia lata brow suspension might give good over­ all results. I have been satisfied by the results

253

JAW-WINKING

Fig. 4 (Beard). Severe unilateral ptosis.

Fig. 5 (Beard). Apparently good correction obtained by fascia lata brow suspension.

Fig. 6 (Beard). Severe deformity due to lack of symmetry on downward gaze. Fig. 1 (Beard). Severe unilateral ptosis undercorrected by one levator resection.

Fig. 2 (Beard). Adequate correction obtained by second levator resection.

obtained, as have the patients and, in the cases of children, their parents. To date I have restricted the use of this procedure to cases with severe unilateral ptosis which had been unsuccessfully treated by previous sur­ gery. I see no reason why it cannot be used as a primary procedure when the levator function is poor (less than five mm. of eye­ lid margin excursion when the eye goes from the eyes-down to the eyes-up position). In this type of case, an asymmetrical appearance will always be obtained even though the eyelid may be satisfactorily elevated with the eyes in the primary position. PROCEDURE

Fig. 3 (Beard). Bizarre appearance caused by resultant lid lag.

Levator excision is used to create a trau­ matic ptosis on the normal side. The opera­ tive technique has been used by others in the treatment of Marcus Gunn ptosis. The

CROWELL BEARD

Figs. 7-13 (Beard). The surgical procedure. (7) The palpebral conjunctiva is elevated from the undersurface of Mueller's muscle. (8) The levator aponeurosis and Mueller's muscle are undermined and fixed with a ptosis clamp. (9) The muscles are divided from their terminal attachments and rotated downward. ( 1 0 ) The orbital septum is separated from the levator aponeurosis and is allowed to retract. ( 1 1 ) The lateral and medial horns of the levator muscle are severed. ( 1 2 ) The levator muscle is crushed with a hemostat. It is divided along the crush mark and allowed to retract into the orbit. ( 1 3 ) The conjunctiva is resutured to the upper border of the tarsus.

PTOSIS WITH JAW-WINKING

255

Fig. 14 (Beard). Photomicrograph of a strip of autogenous fascia lata removed from eyelid one year after insertion. Typical collagenous fibers remain. The tissue has survived as a free graft.

Fig. 16 (Beard). Result obtained in patient shown in Figure 15 by excision of right levator and bilateral autogenous fascia lata brow suspen­ sion.

normal upper eyelid is everted on a Des­ marres retractor. The conjunctiva is incised along the upper border of the tarsus. The palpebral conjunctiva is then elevated from

Fig. 15 (Beard). Severe unilateral ptosis undercorrected by one levator resection. See Figure 16.

Fig. 17 (Beard). Severe unilateral ptosis. A nonabsorbable suture brow suspension had been done several years previously. See Figure 18.

256

C R O W E L L

B E A R D

the under surface of Mueller's muscle (fig. 7 ) . The levator aponeurosis and Mueller's muscle are undermined and are fixed with a ptosis clamp (fig. 8 ) . They are severed from their terminal attachments and rotated down­ ward (fig. 9 ) . The orbital septum is elevated from the levator aponeurosis and is allowed to retract (fig. 10). The lateral and medial horns of the levator aponeurosis are cut (fig. 11), care being taken not to damage the re­ flected tendon of the superior oblique muscle. The levator muscle is crushed with a hemostat and is severed along the crush marks (fig. 12). It is allowed to retract into the orbit. The conjunctiva is resutured to the upper tarsal border with a running suture of 6-0 plain catgut (fig. 1 3 ) .

Fig. shown and

18 in

(Beard). Figure

bilateral

17

Result by

autogenous

obtained

excision fascia

on

patient

of

right

levator

lata

brow

suspen­

sion.

Fig. shown

20 in

bilateral

Fig.

19

resection

had

mild been

obtained

e x c i s i o n of

Severe ptosis

done

on

ptosis

of

left

the

on

left

fascia lata b r o w

(Beard). with

Result

19 by

autogenous

combined

20.

(Beard). Figure

patient

levator

and

suspension.

of eye.

right.

right

eye

A

levator

See

Figure

PTOSIS WITH JAW-WINKING

257

It has not been found necessary to delay the bilateral brow suspension. It can be done in one operation, immediately following the levator excision on the previously normal eyelid. Some slight levator function will re­ main because of unsevered attachments. This will match (to a degree) the function of the levator muscle of the ptotic eyelid. Strips of fascia lata are removed from the thigh and are used to suspend both upper eyelids by one of the accepted techniques. I have had excellent results with the Crawford opera­ tion and have seen no reason for trying others. The Lexer or Johnson operations would no doubt do as well in some hands. 1

2

3

I do not recommend nonabsorbable suture brow suspension. The use of preserved beef fascia must be undertaken with some cau-

Fig. shown and

22 in

(Beard). Figure

bilateral

21

Result by

autogenous

obtained

bilateral fascia

in

levator

lata

brow

patient excision suspen­

sion.

tion. Reconstituted collagen strips have been recommended recently for brow suspension. Until use of this material has withstood the test of time, I would consider it experi­ mental. Autogenous fascia lata is easily ob­ tained. Its removal causes no loss of leg function and only a minimal scar. Adverse reactions to it do not occur. It survives as a living free graft (fig. 1 4 ) . I believe it to be 4

Fig. winking

21

(Beard). factor

photograph parents

was

requested

in

Mild an

taken that

at the time o f surgery.

ptosis

oriental with

the

occidental

with

severe

jaw-

child.

The

lower

mouth folds

See Figure

22.

opened. be

T h e

produced

CROWELL BEARD

258

the best material for use in suspending the eyelid from the brow.

autogenous fascia lata brow suspension for this type of ptosis. The results have been satisfactory. Figures 21 and 22 depict such a case.

COMMENT

The procedure just described results in two abnormal eyelids which are presentable in appearance. They move synchronously. The lid lag on downward gaze is not too noticeable because it is bilateral. While the results cannot be considered perfect, I be­ lieve that the postoperative state is more pleasing cosmetically than is the result ob­ tained by unilateral maximum levator resec­ tion or unilateral brow suspension used for the treatment of severe unilateral ptosis with poor levator function. Figures 15, 16, 17, 18, 19 and 20 show preoperative and postoperative photographs of some representative cases treated by this procedure. MARCUS GUNN P T O S I S

In Marcus Gunn ptosis, levator resection can be done if the jaw-winking factor is minimal. Otherwise it has been customary to do nothing ( a poor form of treatment), or to do a levator excision followed by suspen­ sion of the eyelid from the brow or from the superior rectus muscle. I have done bi­ lateral levator muscle excision and bilateral

SUMMARY

Maximum levator muscle resection or brow suspenesion do not give good results in the treatment of severe unilateral con­ genital ptosis with poor levator function. Autogenous fascia lata brow suspension gives good results in severe bilateral ptosis with poor levator function. Conversion of a unilateral ptosis to a bilateral ptosis by means of a levator muscle excision on the normal side, followed by bilateral fascia lata brow suspension seems to be a logical treat­ ment for severe unilateral ptosis. Bilateral levator muscle excision, followed by bilateral fascia lata brow suspension is offered as a new treatment for congenital ptosis with the jaw-winking phenomenon of Marcus Gunn. 240 Meridian Avenue. ADDENDUM Fifteen me

o f

to date

done

these

operations

(November,

f o r severe unilateral

adequately

repaired

done a s primary Marcus

Gunn

leagues

have

have

1964).

done

by

were

ptosis which h a d been i n ­

by previous

procedures

surgery,

two were

and three were done f o r

ptosis. I n addition, used

been

T e n o f these

several o f m y col­

the procedures

with

satisfactory

results.

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(Jan.)

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