Outcomes for Müller aponeurosis composite flap advancement were considered excellent in 37.1% of cases, good in 32.6%, fair in 16.9%, and poor in 13.4% (Table 6).
Outcomes for frontal muscle transfer were excellent in 39.2%, good in 27.7%, fair in 25.7%, and poor in 7.4% (Table 6).
Undercorrection and eyelid asymmetry were the most common postoperative complications seen in both techniques.
Undercorrection was observed for the Müller aponeurosis composite flap advancement procedure in 13.4% and for frontal muscle transfer procedure in 7.4%, followed by asymmetry complications in 10.1% for the Müller aponeurosis composite flap advancement procedure and in 7.4% for frontal muscle transfer procedure.
Moreover, 10 patients (4.6%) had overcorrection after the frontal muscle transfer procedure compared with only 2 patients (2.2%) with overcorrection in the Müller aponeurosis composite flap advancement group (Table 10).
The selection method for correction of blepharoptosis depends on the severity of the ptosis and its etiology and the surgeon’s experience.
Mark et al15 performed Müller muscle conjunctival resection to treat mild ptosis cases, and their results showed an MRD1 improvement of up to 2 mm postoperatively with an increasing palpebrae fissure height of 2.4 mm. They concluded that Müller muscle–conjunctival resection using this method is not recommended for patients with poor levator function.15
In 2010, Shimizu et al16 discovered a new method for correction of mild and moderate ptosis using a nonincisional technique. They achieved improvements in 97.5% (406 eyelids) in mild cases and in 88.9% (185 eyelids) in moderate cases.
This technique has the advantages of nonvisible scar and fast procedures and creates the double eyelid fold that is defined as a desirable esthetic result in Asian countries such as Japan, Korea, and China where orientals constitute an ethnic majority.16
Nevertheless, the methods mentioned above yielded excellent outcomes for correction of mild or moderate ptosis.
Either frontal muscle suspension or frontal muscle transfer can be used for the correction of severe blepharoptosis. However, it is quite difficult to achieve good results in cases of severe blepharoptosis because the direction of traction in this method is anatomically different from that of levator resection. Frontal muscle suspension needs a lot of materials and is also associated with some problems, such as unnatural shape of eyelids after surgery, need for a donor site, and the possibility of recurring blepharoptosis due to stretched fascia or partial absorption of the tissue used for suspension. The L-shape of frontal muscle transfer by Song and Song5 resulted in a more natural and more dynamic shape of the eyelids and a more normal location of the eyebrow than frontal muscle suspension. Furthermore, it is associated with a lower rate of recurrence and does not need fascia. However, there is a risk of hematoma, paresthesia of the forehead due to supraorbital nerve injury, loss of wrinkles in the forehead, depression of the forehead, and requires 2 incision lines. Another disadvantage is that deformity may occur if the area of frontal flap fixation is pulled too tightly. To this end, different methods are being introduced to ensure that the tensile forces are evenly distributed by dividing the lower end of the frontal flap into 3 sections17 and resection of the frontal flap in an arch-shaped way with subsequent fixation to the tarsal plate.18 Holds et al19 are in favor of Whitnall’s sling with superior tarsectomy for the correction of severe unilateral blepharoptosis.
However, all the measurements used in ptosis surgery whether preoperatively or postoperatively (MRD1, marginal limbal distance, and vertical height of the palpebral fissure) are 1-dimensional figures that measure the distance between 2 points and have the limitation that they are measuring a 3-dimensional ocular surface.20,21 It is difficult to obtain precise results because the use of a graduated ruler to measure may make the patient nervous.
In this study, we also obtained the ACE, a 2-dimensional area that helps quantify the change between the sizes of the eyes.22,23
This study is a review of outcomes after Müller aponeurosis composite flap advancement versus frontal muscle transfer in severe ptosis.
The author performs Müller aponeurosis composite flap advancement when the levator muscle function is between 2 and 4 mm.
The postoperative MRD1 after conducting Müller aponeurosis composite flap advancement was 1.5 mm; frontal transfer showed an improvement of 1.8 mm.
The results of ACE showed improvement in 73.5% in the Müller aponeurosis composite flap advancement group and 71.2% in the frontal muscle transfer group.
In addition, eyebrow height results showed greater improvement in the Müller aponeurosis composite flap advancement group than in the frontal muscle transfer group, whereby the latter offers an esthetic advantage and produces a more natural appearance compared with the frontal muscle transfer technique.
The result showed no significant difference between the 2 surgical techniques; both techniques are effective for the correction of severe ptosis.
To end this discussion, in our study, the authors were able to significantly refine the indications for Müller aponeurosis composite flap advancement and frontal transfer for the correction of severe blepharoptosis (Table 4).
In severe ptosis, Müller aponeurosis composite flap advancement can be used for acquired and congenital disorders in children older than 8 years and in adults. Frontal transfer is usually used in congenital as well as oculomotor nerve palsy and blepharophimosis and is appropriate in adults older than 15 years only (Table 4).
Nevertheless, the surgical technique of frontal muscle transfer should be performed with great surgical care to avoid postoperative complications. In terms of the author’s own experience, it is appropriate to perform Müller aponeurosis composite flap advancement as a first line of severe ptosis treatment with the advantage of avoiding the postoperative complications that can occur when using frontal muscle transfer such as exposure keratitis and entropion, which are more commonly observed after frontal transfer.7,24 It is also valuable to preserve the frontal transfer technique as a second option in the future in cases of relapse.
Müller aponeurosis composite flap advancement and frontal muscle transfer techniques are both effective in severe blepharoptosis correction. Müller aponeurosis composite flap advancement can be the first choice as first line of treatment for correction of the upper eyelid in severe ptosis when the levator function is between 2 and 4 mm, thus helping the surgeon to avoid the postoperative complications associated with frontal muscle transfer as the first line of treatment and also preserve this latter technique as a second choice if the Müller aponeurosis composite flap should relapse in the future.
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