This is a report of 35 children with unilateral congenital ptosis who underwent a supramaximal levator resection, involving extensive dissection of levator including cutting Whitnall’s ligament. The average preoperative margin reflex distance to the upper lid (MRD1) was 0.5mm, and the average levator function was 6.6mm. Photographic analysis at least six months post-surgery showed the average MRD1 had improved to 3.4mm, and the difference in MRD1 with the fellow eye had reduced from 3.1mm to 0.1mm, with 80% of patients having 1mm or less of asymmetry. There were minor contour abnormalities in 29% and 31% had lash ptosis. Fourteen patients also underwent assessment of their blink amplitudes, both spontaneous and when looking from primary to 30 degrees of downgaze, using a magnetic search coil. Blink amplitudes were very poor on the first postoperative day, requiring intense lubrication and Frost sutures for the first week. They remained reduced at a mean of 37 months post-surgery, when the average spontaneous blink amplitude was 37%, and the downward saccadic movement 55%, of the fellow eye amplitudes. The discussion describes how our understanding of Whitnall’s ligament has evolved, with reasons to question the traditional view of it as either a significant supporting structure or a fulcrum to change the direction of pull of the levator muscle. These previously held concepts have been reasons to avoid supramaximal surgery which requires cutting Whitnall’s. The authors admit the procedure remains contentious, but also explain that the alternatives are limited. Unilateral brow suspension in the absence of compensatory ipsilateral frontalis overaction is often unsatisfactory, and parents usually refuse bilateral surgery. The technique lifts the lid well, but has the drawback of exposure from reduced blink amplitudes and should not be used if there is a poor Bell’s reflex. Contour defects and lash ptosis also occur, but the latter can be reduced by careful re-fixation of the tarsal skin muscle flap to levator. Due to its retrospective nature some data which would have been interesting is not provided, such as the preoperative blink amplitude to see how much this had been affected by the supramaximal resection.

Supramaximal levator resection for unilateral congenital ptosis: cosmetic and functional results.
Cruz AAV, Akaishi PMS, Mendonca AKTS, et al.
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James Hsuan

Aintree University Hospital, Liverpool, UK.

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