Maximal Levator Resection Beyond Whitnall’s Ligament in Severe Simple Congenital Ptosis with Poor Levator Function

Figures & data

Figure 1 Preoperative and postoperative photographs of patients with successful surgical outcomes. These patients demonstrated both excellent functional and symmetrical cosmetic outcomes with a favorable eyelid margin contour.

Abbreviation: Post op, postoperative.

Figure 2 Surgical procedure; full-thickness maximal levator resection beyond Whitnall’s ligament, modified from Berke technique.¹³ (A) eyelid crease skin incision. (B) orbital septum was opened to exposed preaponeurotic fat. (C) preaponeurotic fat was separated from the underlying levator aponeurosis. (D) superior 1/3 of tarsal plate was clearly exposed. (E) The Berke ptosis clamp was placed. (F) levator aponeurosis, Muller’s muscle, and conjunctiva were entirely detached from tarsus. (G) straight upward cuts to release the horns of the levator aponeurosis together with Whitnall’s ligament, and 1% lidocaine with 1:100,000 epinephrine was subconjunctivally injected. (H and I), palpebral conjunctiva was freed from the levator-Muller’s muscle flap, and reattached to superior boarder of tarsus. (J) the levator-Muller’s muscle flap was reinserted to the anterior surface (not below superior 1/3) of the tarsus (K) two additional fixation sutures were placed nasally and temporally for good eyelid contour. (L) the length of the redundant levator-Muller’s muscle flap was measured before resection. (M) the eyelid crease was created, and skin was closed.

Table 1 Comparison of Demographic and Clinical Data Between Outcome Groups (31 Patients, 38 Eyelids)

	Successful*	Unsuccessful*	p-value
Sex, n (%)
Male	15 (83.33)	3 (16.67)
Female	11 (84.62)	2 (15.38)
Laterality, n (%)
Unilateral	21 (87.50)	3 (12.50)
Bilateral	5 (71.43)	2 (28.57)
Age at surgery
Years (mean ± SD)	5.66 ± 0.82	4.04 ± 0.63	0.363
Preoperative amount of ptosis
mm (mean ± SD)	4.19 ± 0.20	4.72 ± 0.36	0.242
Preoperative levator function
mm (mean ± SD)	3.16 ± 0.15	2.29 ± 0.61	0.561
Amount of levator resection
mm (mean ± SD)	18.15 ± 0.44	14.29 ± 0.94	0.011

Notes: *Successful (successful surgical outcomes) was defined as at least good functional outcome (MRD1 ≥ +2 mm) and at least good symmetrical cosmetic outcome (difference in MRD1 ≤ 2 mm) with a favorable eyelid contour at 12 months postoperatively. *Unsuccessful (unsuccessful surgical outcomes) was defined as the failure to meet successful surgical outcomes criteria.

Figure 3 Comparison of postoperative results (MRD1) between patients with successful and unsuccessful surgical outcomes, assessed over time.

Abbreviations: MRD1, marginal reflex distance-1; SD, standard deviation; Post OP, postoperative; wk, week; M, month/months; Successful, successful surgical outcomes; Unsuccessful, unsuccessful surgical outcomes.

Table 2 Comparison of Postoperative Results (MRD1) Between Outcome Groups, Assessed Over Time

	Successful*	Unsuccessful*	p-value
MRD1 at 1 week postoperatively
mm (mean ± SD)	3.61 ± 0.27	2.00 ± 0.49	0.0115
MRD1 at 1 month postoperatively
mm (mean ± SD)	3.68 ± 0.22	1.57 ± 0.30	0.0001
MRD1 at 3 months postoperatively
mm (mean ± SD)	3.65 ± 0.16	1.00 ± 0.22	< 0.0001
MRD1 at 6 months postoperatively
mm (mean ± SD)	3.52 ± 0.17	0.86 ± 0.14	< 0.0001
MRD1 at 12 months postoperatively
mm (mean ± SD)	3.51 ± 0.17	0.57 ± 0.20	< 0.0001

Notes: *Successful (successful surgical outcomes) was defined as at least good functional outcome (MRD1 ≥ +2 mm) and at least good symmetrical cosmetic outcome (difference in MRD1 ≤ 2 mm) with a favorable eyelid contour, at 12 months postoperatively. *Unsuccessful (unsuccessful surgical outcomes) was defined as the failure to meet successful surgical outcomes criteria.

Abbreviation: MRD1, marginal reflex distance-1.

Table 3 Postoperative Functional Outcomes Assessed Over Time in 38 Eyelids

	1 Wk Post Op	1 Mo Post Op	6 Mo Post Op	12 Mo Post Op
	n (%)	n (%)	n (%)	n (%)
Excellent outcome	29 (76.32)	25 (65.79)	26 (68.42)	27 (71.05)
Good outcome	3 (7.89)	9 (23.68)	5 (13.16)	4 (10.53)
Fair outcome	4 (10.53)	3 (7.89)	5(13.16)	3 (7.89)
Poor outcome	2 (5.26)	1 (2.63)	2 (5.26)	4 (10.53)

Notes: Excellent outcome, MRD1 ≥ +3; Good outcome, MRD1+ 2; Fair outcome, MRD1 +1; Poor outcome, MRD1 ≤ 0.

Abbreviations: wk, week; mo, month/months; post op, postoperative; MRD1, marginal reflex distance-1.

Table 4 Postoperative Symmetrical Cosmetic Outcomes in Patients with Unilateral Disease, Assessed Over Time in 24 Patients (MRD1 Compared Between Eyes)

	1 Wk Post Op	1 Mo Post Op	6 Mo Post Op	12 Mo Post Op
	n (%)	n (%)	n (%)	n (%)
Excellent outcome	23 (95.83)	20 (83.33)	20 (83.33)	20 (83.33)
Good outcome	0 (0)	3 (12.50)	2 (8.33)	1 (4.17)
Poor outcome	1 (4.17)	1 (4.17)	2 (8.33)	3 (12.50)

Notes: Excellent outcome, difference of ≤ 1 mm; Good outcome, difference of 1–2 mm; Poor outcome, difference of > 2 mm.

Abbreviations: MRD1, marginal reflex distance-1; wk, week; mo, month/months; post op, postoperative.

Table 5 Complications of Maximal Levator Resection Beyond Whitnall’s Ligament in Patients Who Had Severe Simple Congenital Ptosis with Poor Levator Function

Complications	% (n/Total Eyes)
Lagophthalmos	81.58 (31/38)
Exposure keratopathy	26.31 (10/38)
Corneal astigmatism	31.58 (12/38)
Undercorrection/Recurrence of ptosis*	18.42 (7/38)
Redundant and prolapsed conjunctiva	2.6 (1/38)
Disparity of eyelid in downgaze (n/total patients)	77.41 (24/31)
Amblyopia (n/total patients)	45.16 (14/31)
● Mild (VA 20/32–20/40)	32.26 (10/31)
● Moderate (VA 20/50–20/100)	6.45 (2/31)
● Severe (VA < 20/100)	6.45 (2/31)
Entropion and ectropion	0
Eyelid retraction*	0

Notes: *Undercorrection/Recurrence of ptosis; MRD1 ≤ +1 mm at 12 months postoperatively. *Eyelid retraction; MRD1 > +5 at 12 months postoperatively.

Figure 4 Photographs demonstrated improvement in postoperative lagophthalmos over time.

Abbreviation: Post op, postoperative.

Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. Trans Am Ophthalmol Soc. 1958;56:288–322; discussion 323–6.

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