From 1994 to 1999, 1121 operations for blepharoptosis were performed in our department on 987 patients. In 44 cases we found a moderate to severe congenital ptosis with a levator function of less than 2 mm. Until today, in such cases, it is recommended to use a frontalis suspension in order to elevate the upper eyelid. Unsatisfactory cosmetic results in facial expression and lack of skin-fold are only a few of the disadvantages of this technique. In 1994, therefore, we decided to perform a maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function. All children included in our study were younger than six years of age. The ptosis was moderate (2-4 mm) in 36/44 and severe (>4 mm) in 8/44 cases. The levator function was less than 2 mm. Complete transsection of the medial and lateral horn of the levator aponeurosis under preservation of the Whitnall ligament is the most important surgical step in mobilizing the levator muscle. A satisfactory eyelid elevation (generally considered to be a difference of less than 1 mm between both eyelid fissures) was achieved in 36/44 cases. Our results indicate that, in contrast to established practice, maximal levator resection is the treatment of choice for congenital ptosis with poor levator function.
There are numerous different procedures for eyelid reconstruction, one of them being the transfer of pedicled full eyelid flaps. With regard to the increasing demands of the patients the so-called sandwich techniques in most cases offer the chance to get the best functional and aesthetic result in a individual situation. Some of these techniques are presented here.
The author first used modified full-thickness lid grafts (tarsomarginal grafts) in lid reconstruction in 1972. They consist of only conjunctiva, tarsus, and lid margin. The anterior lid lamella is rebuilt by a myocutaneous flap from the adjacent tissue. As compared to conventional full-thickness lid grafts, this reduces the risk of necrosis. No cosmetic or functional disturbance of donor eyelids was observed. In cases of total lid loss up to three tarsomarginal grafts can be inserted simultaneously. The use of modified full-thickness grafts is superior to other well-known techniques, especially in cases with defects of the medial half of the lower lid and upper lid defects, up to and including total upper lid loss, even if the tarsus in the grafts is subject to regressive changes and the lashes are usually lost.
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