Aesth Plast Surg (2008) 32:604612 DOI 10.

1007/s00266-008-9125-y

ORIGINAL ARTICLE

Correction of Congenital Severe Ptosis by Suspension of a Frontal Muscle Flap Overlapped with an Inferiorly Based Orbital Septum Flap
Y. Pan H. Zhang L. Yang B. Song B. Xiao C. Yi Y. Han

Published online: 6 May 2008 Springer Science+Business Media, LLC 2008

Abstract Background This report introduces a new method for correction of congenital severe upper eyelid ptosis. Methods The poor levatorfunction upper eyelid ptosis of 22 patients was corrected using suspension of the frontal muscle ap overlapped with an inferiorly based orbital septum ap as a motor unit, which substituted for the function of the levator muscle. The frontal muscle ap and orbital septum ap were formed in the frontal part and upper eyelid, respectively. Two aps were overlapped and sutured to suspend the upper eyelid and to correct the congenital severe upper eyelid ptosis. This technique avoids the need for the linking structure necessary with the standard frontalis sling approach and improves the direction of pull to mimic that of a normal levator more closely than that of frontalis muscle advancement. Results The follow-up period ranged from 6 to 20 months (mean, 12 months). A total of 4 patients had bilateral surgery, whereas 18 patients underwent unilateral surgery (26 eyelids). In 22 cases (26 eyes), congenital severe upper eyelid ptosis was treated using suspension of the frontal muscle ap overlapped with an inferiorly based orbital septum ap. After the operation, 17 cases (19 eyes) were followed up and analyzed retrospectively. The average follow-up period was about 12 months (range, 620 months). The 17 corrected eyes had a symmetric redundant fold of preseptal skin according to the marginal reex distance-1 (MRD-1) measurement used to judge efcacy. Two eyes in this series required reoperation for undercorrection.

Complications such as ectropion and corneal exposure were avoided. Conclusion Use of a frontalis muscle lap overlapped with an inferior based orbital septum ap to manage severe congenital upper eyelid ptosis is a useful procedure that results in substantial cosmetic and functional improvement with few complications. Keywords Congenital severe ptosis Frontal muscle ap Orbital septum ap Upper eyelid ptosis is dened as an abnormally low-lying upper eyelid margin in primary gaze resulting in narrowing of the palpebral opening and ssure and covering for part of the eye [1]. Thus, upper eyelid ptosis can present both functional and aesthetic problems. Because this problem is difcult to solve, many surgical procedures have been developed. The most effective techniques must be performed in accordance with the amount of levator function and the degree of ptosis [2], which include simple skin excision, more complex resections with plication, or dynamic suspension techniques [3]. Severe upper eyelid ptosis is dened as a ptosis exceeding 4 mm and, most importantly, levator muscle function that provides less than 4 mm of measurable eyelid excursion [4]. Untreated severe eyelid ptosis may threaten functional loss, from reduced visual acuity to amblyopia on the more affected side. However, it is difcult to achieve satisfactory results for a patient with severe eyelid ptosis [46]. We show a new alternative for correction of congenital severe eyelid ptosis using suspension of a frontal muscle ap overlapped with an inferiorly based orbital septum ap. We believe this procedure also has application for Marcus Gunn jaw winking, a chronic progressive external ophthalmoplegia and traumatic ptosis with poor levator function.

Y. Pan H. Zhang L. Yang B. Song B. Xiao C. Yi Y. Han (&) Department of Plastic Surgery, Xijing Hospital, Xian, Peoples Republic of China e-mail: hanyan@fmmu.edu.cn

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Methods Anatomic and Functional Considerations Anatomically, the anterior lamella of the upper eyelid is composed of skin and the orbicularis oculi muscle, whereas the posterior lamella consists of the tarsus and conjunctiva (Fig. 1). The supratarsal fold, formed by insertion of the levator aponeurosis and the orbital septum on the deep surface of the orbicularis oculi [7], further divides the upper eyelid into pretarsal and preseptal segments of the orbicularis muscle. The orbital septum, thickened along its origin from the superior orbital rim, covers the periconal fat deep to the orbicularis oculi. It inserts by blending with the levator aponeurosis into the anterior surface of the tarsal plate about 5 to 20 mm via the conjoined fascia, depending on ethnicity [810]. The orbital septum varies anatomically and can be thick or thin. It is vascularized by a randompattern vascular network. As the fusion or separation [11] of the orbital septum with the levator aponeurosis between the orbital septum and levator aponeurosis [12] (Fig. 1) is kept intact, maintaining the connection of the orbital septum and levator aponeurosis allows movement of the orbital septum to be transmitted directly to the levator aponeurosis and its areas of insertion. The levator muscle supplied by the third nerve and Mullers muscle innervated sympathetically are the lifting mechanisms of the lid. Although Muellers muscle provides

negligible lifting, this still is a useful and dynamic procedure for mild to moderate forms of ptosis. However, it is ignored for cases of severe ptosis operations because its function is too weak and adjuvant for treatment of the severe form. In the absence of adequate levator function, another powerful structure is needed to provide the desired lid elevation. The frontalis muscle is innervated by the frontal branch of the facial nerve entering the muscle from the lateral and deep aspect at the level of the foreheads temporal line of fusion. The supraorbital neurovascular bundle rises at about 2.7 cm from the midline [13] and is always located medial to the frontalis muscle ap. The frontalis muscle always contracts with excessive upper lid elevation such as in the extreme upward gaze. In cases of eyelid ptosis, even mild cases, if the lid obstructs the pupil to some extent, patients may attempt to clear their vision by arching their brows and corrugating their forehead. In severe ptosis, particularly if bilateral, brow elevation may not be enough, and the patient may have to tilt his or her head backward to gain sufcient pupillary clearance to see. Clinical Data Between 2002 and 2005, 22 consecutive outpatients (26 eyelids) underwent suspension procedures of a frontalis muscle ap overlapped with an inferiorly based orbital septum ap for eyelid ptosis with mostly poor eyelid excursion. These cases included 10 males and 12 females ranging in age from 15 to 48. Of these patients, 4 had

Fig. 1 Schematic diagram of the gross anatomy for the upper eyelid sagittal views. The anterior lamella of the upper eyelid is composed of skin and orbicularis oculi muscle, and the posterior lamella consists of the tarsus and conjunctiva. The orbital septum is deep to the orbicularis oculi. It inserts by blending with the levator aponeurosis into the anterior surface of the tarsal plate. As the fusion or separation of the orbital septum with the levator aponeurosis between the orbital septum and levator aponeurosis was kept intact, the orbital septum movement could be transmitted directly to the levator aponeurosis

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bilateral ptosis and 18 had unilateral ptosis. The etiology for all the patients was congenital. The eyelid excursion of the ptotic eyelid is measured by placing a ruler over the lid with one hand and noting the amount of lid elevation from a position of looking down to a position of looking up while immobilizing the brow with the thumb of the other hand [14]. This maneuver is repeated several times until the excursion of the lid is the same for two or more tests. The excursion of the levator muscle in the patients ranges from none to less than 4 mm. A complete ophthalmologic examination is undertaken [15].

Operation A step-by-step schematic is shown to demonstrate the procedure (Fig. 2). Concretely speaking, preoperative markings are made with the patient in the upright position. A lid crease is marked across the upper eyelid at a height symmetric with that of the opposite upper eyelid in unilateral ptosis. In bilateral ptosis, the proper lid crease incision is drawn 5 to 6 mm from the lash line according to the width of the tarsal plate and the specic needs of each patient [4] (Fig. 3, top left; Fig. 4, top left). Excess skin is estimated using a pinch

technique, and appropriate markings are made identifying the redundant skin to be removed. Local inltration anesthesia (0.5% lidocaine with 1:200,000 epinephrine) is used for the incision line and nerve block anesthesia to the supraorbital foramen (During the operation, anesthesia for the frontal part using nerve block anesthesia of supraorbital foramen is to keep the movement of the frontal muscle for observation and operation). Local anesthetic is injected to facilitate the tissue dissection below the orbicularis oculi muscle. The marked skin and muscle are removed using standard techniques. It is important that care be taken not to damage the orbital septum. In a plane between the orbicularis oculi muscle and the orbital septum, the careful submuscular dissection is performed superiorly, and ceases occur near the supraorbital rim and below Whitnalls ligament (Fig. 3, top middle). On the surface of the orbital septum, a trapezoidal ap on the superior border of tarsal plate is designed. According to the design line, two cuts are made at the lateral and medial sides of the orbital septum, fully opening the orbital septum and forming the inferiorly based orbital septum ap (Fig. 3, top right; Fig. 4, top middle and top right). Dissection through the suprabrow incision is performed 1.5 to 2 cm superiorly to separate the skin and subcutaneous

Fig. 2 A step-by-step schematic demonstrating the procedure

Fig. 3 Top (left): A 15-year-old girl with left side severe congenital ptosis. Top (middle): Exposure of the orbital septum using a standard blepharoplasty incision. Top (right): Formation of the orbital septum ap. Bottom (left): Frontal muscle formed by superior border incision of the brow. Bottom (right): View 7 days after ptosis correction

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Aesth Plast Surg (2008) 32:604612 Fig. 4 Top (left): A 42-year-old man with right severe congenital ptosis. Top (middle): Intraoperative view of the orbital septum ap formed using a standard blepharoplasty incision. Top (right): Testing of ability to correct the ptosis by pulling the orbital septum ap. Bottom (left): Elevation of the U-shaped frontal muscle ap and the orbital septum ap. Bottom (right): View 3 days after the operation

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structures from the underlying frontalis muscle, which facilitates identication and exposure of the vertically oriented muscle bers of the frontalis muscle. Through this incision, the separation of the skin from the underlying muscle continues and reaches as far as 1.5 cm above the superior margin of the eyebrow. The submuscular dissection continues superiorly and reaches to 1.5 cm above the supraorbital margin of the frontal bone. The supraorbital nerve and vessels medial to the portion of the frontalis muscle to be used are dissected and preserved. Two parallel cuts are made at the medial and lateral sides of the ap between the two dissected planes, forming a U-shaped superiorly based rectangular frontalis muscle ap, which can advance toward the eyelid (Fig. 3, bottom left; Fig. 4, bottom left). Injury to the supraorbital neurovascular bundle is avoided by making the most medial incision at least 5 mm lateral to the supraorbital notch. A tunnel is made above the orbital septum by passing bluntpointed scissors into the lid crease incision to emerge through the incision at the superior margin of the eyebrow. The orbital septum ap is passed superiorly through tunnels and sutured to the anterior surface of the frontal muscle ap with three permanent 5-0 silk sutures through the central, medial, and lateral portions of the two aps (Figs. 3 bottom left; Fig. 4 bottom left). The mattress suture must be tied with appropriate tension. The best guideline for setting the central portion of the upper eyelid at the proper level is to place it 1 mm below the upper border of the globe limbus at the primary position in bilateral cases and 1 mm higher than that of the normal side in unilateral cases. Several eyelid crease sutures are placed to form a beautiful double eyelid going from a point on the skin surface below the inferior skin incision to the superior edge of the tarsus and back to the point on the skin surface below

the inferior skin incision. The skin is closed with running and interrupted nonabsorbable 6-0 sutures. At completion of the operation, a temporary lid occlusive suture using a modied Frost method is placed to protect the cornea and relieve tension on the sutures. This modied Frost suture is removed after 48 h. Articial tears and ointment are applied to the eyes during the early postoperative period for corneal protection. Before closure of the eyebrow skin incisions, a small rubber drainage strip is placed through a minimal stab wound incision. A pressure bandage is placed over the frontalis area because this is necessary to reduce the chance of hematoma. The drainage strip is removed 3 days after the operation and the stitches 7 days after the operation (Fig. 3, bottom right; Fig. 4, bottom right).

Results Of the 22 cases (12 women and 10 men) reviewed, 17 (19 eyes) were followed up and analyzed retrospectively after the operation. An additional ve patients could not be contacted after the operation because they had changed their place of the residence. The average follow-up period was about 12 months (range, 6 20 months). In this study, 17 eyes with ptosis were corrected and had a symmetric redundant fold of preseptal skin, and two eyes with ptosis required reoperations. No corneal exposure or ectropion was encountered (Table 1). Figures 5 to 7 show the results of the procedure, evaluated according to criteria for an ideal correction by Souther et al. [16] and Jordan and Anderson [17] for perfect eyelid ptosis postoperative results. During a 6- to 20month postoperative period, 17 patients (19 eyes) were interviewed at random. The ndings showed that 17 eyes got better effects. The eyes with ptosis were corrected and

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608 Table 1 Patients characteristics and results by suspension of the frontal muscle ap overlapped with the inferiorly based orbital septum ap for congenital ptosis, 2002 2005

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Patient no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Sex

Age (years) 15 37 17 23 25 31 17 19 28 21 15 19 42 26 40 22 17 21 16 48 17 19

Upper Eyelid Left Left Left Right Right Left Right Left Right Left Right Right Left Left Right Right Right Right Left Left Left Right Right Right Right Left Right

Preoperative Ptosis (mm) 4 5 4 4 4 4 5 4 4 4 4 4 4 4 5 4 4 4 5 4 5 4 4 4 4 4 5

Levator function Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor

Follow-up Period (mo) 6 12 18 0 0 18 6 0 18 20 12 10 6 12 12 12 0 18 0 6 6 12

Lid results (after 6 mo) Good Good Good Good

F F F F F F F F F F F F M M M M M M M M M M

Good Unsatisfactory

Good Good Good Good

Good Good Good Good Unsatisfactory Good Good

had a symmetric redundant fold of preseptal skin, but two eyelids had unsatisfactory results after surgery and required reoperation. The revision surgeries resolved these undercorrections. Almost all the patients had incomplete closure of the eyelid for several months after the operation but experienced normal opening and closing of the palpebral ssure within 3 months. The suprabrow scar was nearly negligible within 6 months after the operation. The supratasal double fold line became indenite in some cases. The most frequent complication was reduced eyelid excursion in extreme upward and downward gaze, mainly observed in the immediate postoperative period. Severe complications such as orbital hemorrhage and corneal exposure were not seen in our series. The asymmetry and contour irregularity improved with time and local care. The patients who had difculty closing their eyes and experienced eye irritation were treated with ophthalmic ointment, steroid drops, massage, and eye patching.

Discussion Normally, the eyelid covers 1 to 1.5 mm of the upper limbus. When the ptotic lid covers enough of the upper limbus or pupil, it can result in both functional and aesthetic deformities [18]. The severity of ptosis is classied by determining how much of the upper limbus is covered by the lid margin according to the following scale: 2 mm (mild), 3 mm (moderate), 4 mm or more (severe). Levator function is classied based on the distance of lid margin excursion as follows: 12 to 15 mm (excellent), 8 to 12 mm (good), 5 to 7 mm (fair), and 2 to 4 mm (poor). The surgical options for eyelid ptosis depend on the degree of ptosis and levator function [19]. Numerous procedures are described for the correction of eyelid ptosis. Treatment of severe eyelid ptosis with poor eyelid excursion presents an especially difcult therapeutic problem. Procedures such as levator plication [20] and levator resection [4] are the most useful for mild to moderate cases

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Aesth Plast Surg (2008) 32:604612 Fig. 5 Left: Preoperative view of a 26-year-old man with bilateral severe ptosis. The degree of upper lid ptosis is 5 mm on the left and 4 mm on the right. Right: View 1 year after ptosis correction using suspension of frontal muscle ap overlapped with the orbital septum ap. A satisfactory result was obtained

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Fig. 6 Left: Preoperative view of a 40-year-old man with severe ptosis of the left upper eyelid. The left eyelid excursion is 3 mm. Right: View 1 year after ptosis correction. The patient has symmetric palpebral ssures and eyebrow heights. He is very satised with the postoperative result

Fig. 7 Left: Preoperative view of a 37-year-old woman with severe ptosis of left side upper eyelid. The eyelid excursion of both eyes is 1 mm, and the degree of ptosis of both upper lids is 5 mm. Right: Both eyelids 1 year after the operation are well matched and symmetric in height

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of ptosis. The levator resection for patients with minimal eyelid excursion frequently results in undercorrection [20]. Early results from a technique for small-incision external levator repair of severe eyelid ptosis demonstrate that it is safe and effective. However, strict preoperative patient selection has limited the number of patients undergoing this technique [21]. Park et al. [22] mention selective use of superiorly based muscle aps to repair eyelid ptosis. The action of the frontalis muscle, vertically oriented and for eye opening, and that of the orbicularis oculi muscle, transversely oriented and for eye closing, are antagonistic. The dilemma must be solved by using the orbicularis oculi muscle ap in less severe cases and the frontalis muscle ap in severe cases. However, the ap technique needs too much sacrice of the orbicularis oculi muscle. The frontal sling procedure, a static correction method, usually is performed. The eyelid is surgically attached to the frontal muscle at the desired height using autologous, heterologous or alloplastic material [3, 2327]. However, this technique has several disadvantages: added morbidity of the donor site for autogenous fascia lata collection, lagophthalmos during sleeping or with closure of the eyelids, eyelid ptosis of the corrected eyelid exhibited with upward gaze, a tendency for the eyelid to lift away from the globe with upward gaze due to the abnormal direction of pulling force exerted by the material used, risks of extrusion with nonautogenous sling materials, granuloma and infection, looseness at the site of the frontalis muscle, and a high incidence of ptosis recurrence [19, 28, 29]. Another option for patients with severe eyelid ptosis and poor levator function and for those with previously failed levator resection surgery is direct transplantation of the frontalis muscle to the tarsal plate [30, 31]. This fundamental procedure using the frontalis muscle as a motor unit is considered the most popular and effective approach for correction of apparent eyelid ptosis. Besides the fact that the frontalis muscle advancement may not reach the tarsal plate easily, this procedure has the following shortcomings: unnatural appearance, lagophthalmos, long distance from the frontalis muscle to the tarsal plate, and injury to the supraorbital neurovascular bundle [30, 32, 33]. A superiorly based orbicularis oculi muscle ap or an interdigitated orbicularis oculi frontalis muscle ap is a modication of Song and Songs L-shaped frontalis muscle ap technique that uses no medial vertical frontalis muscle incision to avoid the complications [22]. The frontalis or orbicularis oculi muscle has no loss of the function. However, ptosis with upward gaze and lagophthalmos with downward gaze still may occur. The pull exerted by the frontalis muscle for elevating the lid tends to pull the lid away from the globe. To overcome these shortcomings, the tripartite frontalis muscle ap technique [34] and a frontalis myofascial ap [35, 36] have been reported but have failed to overcome

shortcomings. Another correction method using the frontalis muscle ap overlapped with a levator muscle ap of the upper eyelid has been used for patients with severe ptosis, showing improved results [37]. This method is technically more challenging and more traumatic, especially if levator muscle aponeurosis of upper eyelid has bad development and is very weak. In this case, dependability and rmness of suspension will be affected. Recently, we adopted the method of suspending the frontal muscle ap overlapped with an inferiorly based orbital septum ap to correct severe ptosis. This improved the methods mentioned earlier, avoiding injury to the levator muscle of the upper eyelid with an easy operation, relatively less trauma, and a better effect. We have aimed to nd a method not only to correct the ptosis but also to keep the completeness of the eyelid, making it more suitable physiologically, more characteristic biomechanically, and better in its static and dynamic states. The study demonstrated that the orbital septum has an adhesion to the levator aponeurosis above the tarsus. The septal extension, which lies between the orbicularis and the levator-tarsus junction, begins at the adhesion of the orbital septum to the levator and extends to the ciliary margin [38]. By suspension of a frontal muscle ap overlapped with an inferiorly based orbital septum ap, the dynamic frontal and levator muscles were connected by the orbital septum, which avoids damage to the levator muscle. During the operation, we found that the texture of the orbital septum can meet the requirements of suspension and is not easily torn. Suspension of the upper eyelid by overlapped suturing of a frontal muscle ap and an orbital septum ap can give a very rm effect. Two eyelids had unsatisfactory results due to lifting of the eyebrow or closing of the eye with substantial force earlier than 7 days postoperatively. Revision surgeries resolved these undercorrections. During the operation, anesthesia for the frontal part should be nerve block anesthesia of the supraorbital foramen to keep the movement of the frontal muscle for observation and operation. At the same time, rmness also is added through suture of these two aps overlapped, reducing the possibility of affecting the operation effect of tissue avulsion from severe tension during suturing suspension. Sufcient orbital septum fat is left to facilitate gliding of the frontalis muscle. No upward arching of the corrected eyelid margin occurs because the pulling force for elevating the lid is the normal direction of the levator muscles forces. The orbital septum ap has an adhesion to the levator aponeurosis above the tarsus and passes the frontal muscle ap along the orbital septal pulley, improving the direction of pull to mimic more closely the natural direction of normal levator pull as opposed to pulling of the lid directly toward the eyebrow.

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611 2. Collin JRO (1990) The surgical management of ptosis. In: McCarthy JG (ed) Plastic Surgery. vol 2. 1st edn. Saunders, Philadelphia, 1759 pp 3. Beard CP (1981) Ptosis. 3rd edn. CV Mosby, St Louis 4. Callahan MA, Beard C (1990) Beards Ptosis. 4th edn. Aesculapius Publishing, Birmingham, AL 5. Berke RN (1952) A simplied Blaskovics operation for blepharoptosis: results in ninety-one operations. AMA Arch Ophthalmol 48:460495 6. Mustarde JC (1980) Repair and Reconstruction in the Orbital Region. 2nd edn. Churchill Livingstone, Edinburg, 304 pp 7. Siegel RJ (1992) Advanced upper lid blepharoplasty. Clin Plast Surg 19:319328 8. Iliff JW, Pacheco EM (2001) Ptosis surgery. In: Tasman W, Jaeger EA (eds) Duanes Clinical Ophthalmology. Lippincott Williams and Wilkins, Philadelphia, pp 118 9. Siegel RJ (1993) Essential anatomy for contemporary upper lid blepharoplasty. Clin Plast Surg 20:209212 10. Lemke BN, Lurcarelli MJ (1998) Smiths Ophthalmic Plastic and Reconstructive Surgery. 2nd edn. Mosby, St. Louis, pp 374 11. Anderson RL, Beard C (1977) The levator aponeurosis: attachments and their clinical signicance. Arch Ophthalmol 95:14371441 12. Yuzuriha S, Matsuo K, Kushima H (2000) An anatomical structure which results in pufness of the upper eyelid and a narrow palpebral ssure in the Mongoloid eye. Br J Plast Surg 53:466472 13. Lorenc ZP, Aston SJ (1996) How to introduce endoscopic techniques into routine face-lifting. In: Ramirez OM, Daniel RK (eds) Endoscopic Plastic Surgery. Springer-Verlag, New York 14. Knize DM (1996) An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 97:13211333 15. Jelks GW, Smith BC (1990) Reconstruction of the eyelids and associated structures. In: McCarthy JG (ed) Plastic Surgery. Saunders, Philadelphia, 1757 pp 16. Souther SG, Corboy JM, Thompson JB (1974) The FasanellaServat operation for ptosis of the upper eyelid. Plast Reconstr Surg 53:123128 17. Jordan DR, Anderson RL (1990) The aponeurotic approach to congenital ptosis. Ophthal Surg 21:237244 18. Carraway JH (1997) Reconstruction of the eyelids and correction of ptosis of the eyelid. In: Aston SJ, Beasley RW, Thorne CHM (eds) Grabb and Smiths Plastic Surgery. 5th edn. LippincottRaven, Philadelphia, pp 529544 19. Signorini M, Baruffaldi-Preis FW, Campiglio GL et al (2000) Treatment of congenital and acquired upper eyelid ptosis: report of 131 consecutive cases. Eur J Plast Surg 23:349355 20. de la Torre JI, Martin SA, De Cordier BC et al (2003) Aesthetic eyelid ptosis correction: a review of technique and cases. Plast Reconstr Surg 112:655660 21. Lucarelli MJ, Lemke BN (1999) Small-incision external levator repair: technique and early results. Am J Ophthalmol 127:637644 22. Park DH, Ahn KY, Han DG et al (1998) Blepharoptosis repair by selective use of superiorly based muscle aps. Plast Reconstr Surg 101:592603 23. Waller RR, McCord CD Jr, Tanenbaum M (1987) In: McCord CD Jr, Tanenbaum M (eds) Oculoplastic Surgery. 2nd edn. Raven Press, New York, pp 365374 Chap. 13 24. Broughton WL, Matthews JG, Harris DJ (1982) Congenital ptosis: results of treatment using lyophilized fascia lata for frontalis suspension. Ophthalmology 89:12611266 25. Manners RM, Tyers AG, Morris RJ (1994) The use of prolene as a temporary suspensory material for brow suspension in young children. Eye 8(pt 3):346348 26. Leibovitch I, Leibovitch L, Dray JP (2003) Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age. Am J Ophthalmol 136:866871

The best guideline calls for placing the central portion of the upper eyelid margin immediately below the upper border of the limbus at the primary position in bilateral cases. In unilateral cases, the position of the corrected lid margin is 1 mm higher than that of the normal side [16,17]. There was no upper eyelid ectropion, distraction of the eyelid from the eyeball, abnormal shape of the eyelid or double eyelid folds. The frontalis muscle connected to the orbital septum is a powerful motor unit, and patients eventually learn to set the eyelid position at the appropriate functional and aesthetic level. All the cases were congenital in nature. The patients ranged in age from 15 to 48 years. The reason for such a late presentation of these patients was the family economic situation, not inappropriateness of the procedure for younger patients. All the patients underwent surgery in the outpatient department under local anesthesia. Bleeding can be controlled by subcutaneous inltration of a solution comprising lidocaine with 1:200,000 epinephrine. Complete hemostasis during the operation and bandaging of the frontal part with pressure after the operation can avoid hematoma. Patients should be told not to lift the eyebrow or close the eye with substantial force earlier than 7 days postoperatively to avoid avulsion of the suspending tissues, which could inuence the outcome of the operation. An eye with lagophthalmos should be protected to avoid corneal exposure. In fact, after a 1-month postoperative course of articial tears during the day and lubricating ointment at night, no further ocular lubrication was needed for any patient studied. The incision scar was nearly negligible within 6 months after the operation. Conclusion A new procedure for correction of eyelid ptosis introduced on the basis of anatomic study and literature review has proved to be a simple and reliable technique, producing pleasing results in a relatively large series of patients. The procedure offers several advantages over conventional techniques such as no ectropion, no separation of eyelid and eyeball, a natural shape of the eyelid and a double eyelid line, no risk of neurovascular injury, and a relatively easy surgery with fewer complications.
Acknowledgments The authors thank Miss Xiaoqi Fan and Xianhui Zeng for their help with the illustrations.

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