Biomechanics of the Levator Aponeurosis

Repp, Daniel J.; Rubinstein, Tal J.; Herreid, Peter A.; Sires, Bryan S.

doi:10.1097/iop.0000000000000731

Cited by 7 publications

(7 citation statements)

References 11 publications

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“…We began using the medical scale as part of our technique after finding that the levator aponeurosis extends under stress, because the length of ex vivo specimens of aponeurosis aligned in their anatomical position depends on the stress applied to the tissue. 15 In vivo, stress is applied to eyelid tissue via instruments used for exposure, such as Desmarres retractors (Skylar Surgical Instruments), traction sutures, or an assistant's forceps. If the length of the aponeurosis is dynamic in vivo, it is insufficient to describe a resection based solely on the length of tissue removed; we would also need to communicate the stress the surgeon applied to the tissue during the resection.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…A recent study 15 demonstrated that the levator aponeurosis is extensile and that small stresses applied to the aponeurosis cause it to lengthen. We believe that a proposed aponeurectomy algorithm needs to consider this biomechanical property.…”

mentioning

confidence: 99%

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Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Repp¹,

Rubinstein²,

Sires³

2017

JAMA Facial Plast Surg

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IMPORTANCE External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies. OBJECTIVE To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic. INTERVENTIONSThe technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations. MAIN OUTCOMES AND MEASURES Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1).RESULTS Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, −0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments. CONCLUSIONS AND RELEVANCEIn correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed.LEVEL OF EVIDENCE 3.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Repp¹,

Rubinstein²,

Sires³

2017

JAMA Facial Plast Surg

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“…Decreasing numbers of elastic fibers were found in aging skin and a negative correlation between eyelid laxity and content of collagen and elastic fibers was widely reported 20. In a study comparing the primary and revision ptosis patients’ levator aponeurosis, more collagen and elastin fibers were found in the revision specimens which would elongate less than the primary specimens given the same amount of stress 21. As we all knew, the eyelid excursion was much larger than the brow.…”

Section: Discussionmentioning

confidence: 87%

“…20 In a study comparing the primary and revision ptosis patients' levator aponeurosis, more collagen and elastin fibers were found in the revision specimens which would elongate less than the primary specimens given the same amount of stress. 21 As we all knew, the eyelid excursion was much larger than the brow. We may speculate that: the differences in the contents of collagen and elastin fibers in the levator aponeurosis and frontalis muscle fascia may lead to the differences in the tissues' elasticity and stiffness, which may be one of the basic factors underlining the levator and frontalis muscle's different mechanic features.…”

Section: Hints Given By the Difference In Collagen And Elastin Conten...mentioning

confidence: 98%

Factors Influencing the Lagophthalmos and Lid Lag After Simple Congenital Blepharoptosis Correction

Miao

Wang

2022

Journal of Craniofacial Surgery

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Background: Lagophthalmos and lid lag is the most common complication after ptosis correction. Great efforts had been made to control it, but little was known about the factors influencing it. So we ran this research to explore the possible mechanisms underlying it. This would be beneficial to solving this problem. Materials and Methods: In this cohort study, patients treated with the forked frontalis muscle aponeurosis suspension and levator aponeurosis-Muller’s muscle complex resection were identified. Lagophthalmos height and lid lag was measured at the postoperative week 1 visits. The Spearman correlation test was run to test whether lagophthalmos was related to patients’ age, levator function, and severity of ptosis. Then we measured the contents of collagen and elastin fibers of frontalis muscle fascia and levator aponeurosis from the patients and levator aponeurosis from cadaver heads histologically and compared the contents in these 3 groups. Results: No correlation was found between patients’ age, levator function, the severity of ptosis, and with lagophthalmos height. However, the contents of collagen and elastic fibers were both higher in the frontalis fascia than in the normal aponeurosis tissues. The difference in collagen fibers content between frontalis muscle fascia and patients’ aponeurosis was statistically insignificant. Conclusions: The severe lagophthalmos and lid lag may be caused by the poor mechanical features of the frontalis muscle. A better source of motive force to elevate the eyelids and a novel sling material with proper elasticity and stiffness would be the solution to improve the lagophthalmos and lid lag after ptosis correction.

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Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives

Alahmadawy,

Ahmed

2024

Int Ophthalmol

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Purpose Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair. Methods This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients’ records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs. Results Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat. Conclusion Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

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Biomechanics of the Levator Aponeurosis

Cited by 7 publications

References 11 publications

Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Factors Influencing the Lagophthalmos and Lid Lag After Simple Congenital Blepharoptosis Correction

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives

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