Unilateral Levator Aponeurosis Excision for Marcus Gunn Syndrome and Risk Factors of Residual Jaw Winking

Abstract

Purpose To investigate the association of ptosis, levator, and jaw winking in Marcus Gunn jaw-winking synkinesis (MGJWS), and the risk factor of preservation and outcomes of the unilateral levator excision and frontalis suspension. Methods Clinical features of MGJWS case series from 2011 to 2018 were retrospectively reviewed. Association between jaw winking and ptosis/levator function was statistically analyzed. The patients underwent unilateral levator excision and frontalis suspension using silicone rod or autogenous fascia lata. Clinical outcomes were evaluated in operated patients and the independent risk factors of residual jaw winking were investigated after a long follow-up. Results There were 42 MGJWS patients in 2011 to 2018, accounting for 2.87% of all congenital blepharoptosis. 80% of mild jaw winking was accompanied with mild ptosis and fair levator function, and moderate-to-severe jaw winking was often accompanied with moderate-to-severe ptosis and poor levator function (P < 0.05). Ptosis showed a strong association with excursion of jaw winking (R = 0.785, P < 0.01). Jaw winking was resolved in all 34 operated patients with good correction of ptosis. Severity of jaw winking is an independent risk factor for the residual synkinesis after surgery. Severe preoperative jaw winking had an 18.05 times increased risk of postoperative residual synkinesis compared with moderate jaw winking (P < 0.05). Conclusions In MGJWS eyelid excursion of jaw winking has a direct correlation with ptosis and dysfunction of levator muscle. Unilateral levator aponeurosis excision and frontalis suspension is an efficient approach for MGJWS. Severe jaw winking is a risk factor of residual eyelid synkinesis after surgery.

Surgical management of jaw-winking synkinesis and ptosis in Marcus Gunn syndrome: a systematic outcomes analysis

“…Only initial excursion was recorded: poor (≤ 4 mm) in 22.2% of eyelids, fair (5-7 mm) in 19%, and good (8 mm or more) in 59% N/A Bowyer and Sullivan [13] Unilateral levator advancement: persistent. Bilateral levator weakening with bilateral frontalis suspension: resolution N/A Only initial excursion was recorded: poor (≤ 4 mm) in 7% of eyelids, fair (5-7 mm) in 25%, and good (8 mm or more) in 68% Improved Ning et al [32] Resolution in all patients From -0.57 mm to 2.96 ± 0.48 mm.…”

“…The surgical approach will differ according to the condition. Patients with bilateral surgery had wink elimination while unilateral surgery had detectable wink Ning et al [32] 2019 Mild (n = 7); moderate (n = 24); severe (n = 11)…”

“…Reported surgical interventions included bilateral levator excision with bilateral frontal sling [13,19,21] (3 articles), unilateral levator excision with bilateral frontal sling [16,19,23,33] (4 articles), unilateral levator excision with unilateral frontal sling [16,28,29,32,33] (5 articles), the Neuhaus/Lemagne method [11,13,17,29,35,37] (6 articles), levator plication/resection without eyelid suspension [13,15,30,33] (4 articles), the Motais-Parinaud procedure [26,33] (2 articles), and the use of an orbicularis oculi muscle flap [27,30] (2 articles). Although the Neuhaus and Lemagne methods differ slightly, the procedures are not significantly differentiated with regard to practice and analyses of outcomes in the majority of studies we found.…”

“…Two out of 4 studies that reported on unilateral levator excision followed by bilateral frontalis suspension resulted in improvement of both ptosis and jaw-winking [16,33] ; the other two studies [19,23] revealed unsatisfactory outcomes for ptosis but improvement in jaw-winking. Four out of 5 studies that described unilateral levator excision with unilateral frontalis suspension resulted in satisfactory improvement of both ptosis and jaw-winking [16,28,29,32] ; however, one study [33] did not report any improvement in either ptosis or jaw-winking. Six out of 6 studies that assessed the Neuhaus/Lemagne method resulted in satisfactory improvement of both ptosis and jaw-winking (with significantly more improvement in jaw-winking).…”

“…Ho et al [24] reported recurrence of ptosis in 2/8 patients (25%), although the procedures involved were not specified. Ning et al [32] reported recurrence of jaw-winking in 1/34 patients (2.9%) who received unilateral levator excision and unilateral frontalis suspension. Demirici et al [16] reported recurrences of ptosis in 3/30 of patients (10%) who received unilateral excision and bilateral frontalis suspension.…”