Journal of Pediatric Ophthalmology and Strabismus

Short Subjects 

Pre-aponeurotic Fat Prolapse Following Levator Resection for Congenital Ptosis

Andrea A. Tooley, MD; Elizabeth A. Bradley, MD, MHS; Brian G. Mohney, MD

Abstract

The authors describe three children who developed excess overhanging upper eyelid tissue following unilateral levator resection for congenital ptosis. This was thought to be pre-aponeurotic fat herniation. A second procedure, a variation of sulcoplasty, was performed at a mean 4.3 months later and all three children showed improved sulcus and crease symmetry. [J Pediatr Ophthalmol Strabismus. 2019;56:e1–e4.]

Abstract

The authors describe three children who developed excess overhanging upper eyelid tissue following unilateral levator resection for congenital ptosis. This was thought to be pre-aponeurotic fat herniation. A second procedure, a variation of sulcoplasty, was performed at a mean 4.3 months later and all three children showed improved sulcus and crease symmetry. [J Pediatr Ophthalmol Strabismus. 2019;56:e1–e4.]

Introduction

Congenital ptosis, characterized by a droopy upper eyelid and decreased levator function, occurs in approximately 1 in 850 children.1 Surgical intervention is often recommended to prevent amblyopia or improve cosmesis and generally includes levator resection, fasanella-servat, or brow suspension. Levator resection is the most commonly performed surgery, and complications of the procedure include overcorrection or undercorrection, eyelid asymmetry, wound infection, postoperative entropion or ectropion, suture material exposure with granuloma formation, and ptosis recurrence.2 Postoperative pre-aponeurotic fat prolapse is a complication of post-levator resection that has not been reported in children.

The purpose of this study was to describe three children who developed excess overhanging upper eyelid soft tissue following levator resection for congenital ptosis and had successful sulcus and eyelid crease reformation.

Patients and Methods

The medical records of all children who had undergone unilateral levator resection for congenital ptosis and developed pre-aponeurotic fat prolapse from November 1, 2015, to March 31, 2017, were retrospectively reviewed. Institutional review board approval and consent for use of clinical photographs were obtained for this Health Insurance Portability and Accountability Act–compliant study. Three patients, identified as developing postoperative prolapse of pre-aponeurotic fat, underwent surgical revision to reform the superior sulcus and eyelid crease. In each patient, unilateral levator resection was performed by one of two surgeons (BGM, EAB) using a standard surgical technique. If needed, the eyelid crease was reformed at the end of the procedure by incorporating orbicularis into the skin closure on every third suture pass. During the revision, pre-aponeurotic fat was observed to have prolapsed anteriorly in each case (Figure 1A). The eyelid crease and sulcus were reformed in all patients using the sulcoplasty technique, skin crease forming sutures, and/or by partially resecting and repositing the pre-aponeurotic fat superiorly in the eyelid. To perform the sulcoplasty, dissection was advanced in the suborbicularis plane to the superior orbital rim. If prolapsed pre-aponeurotic fat descended inferiorly or anteriorly, it was resected or reposited superiorly in the eyelid. The arcus marginalis (the confluence of orbital septum and supraorbital periosteum) was exposed as described previously in adult patients.3,4 Two to four absorbable sutures were passed through the arcus marginalis and used to engage the incisional edge of the orbicularis muscle (Figure 1B). The skin was closed with absorbable 6-0 sutures.

(A) Post-levator resection in patient 1 (right eye) showing excess tissue overhanging the upper eyelid. (B) Intraoperative photograph of sulcoplasty demonstrating suture attachment to the arcus marginalis.

Figure 1.

(A) Post-levator resection in patient 1 (right eye) showing excess tissue overhanging the upper eyelid. (B) Intraoperative photograph of sulcoplasty demonstrating suture attachment to the arcus marginalis.

Results

The initial clinical characteristics and outcomes for the 3 patients are shown in Table 1. Three children (1 boy and 2 girls) were identified as having developed pre-aponeurotic fat prolapse following levator resection for unilateral congenital ptosis. The patients' ages ranged from 2 to 7 years. Two patients had mild Marcus Gunn jaw-winking but were not noted to have fluctuating margin reflex distance-1 measurements. All measurements were taken with patients in a resting position, without activation of the pterygoid. The average palpebral fissure height, margin reflex distance-1, and eyelid excursion was 5.6 mm (range: 3 to 7 mm), 1.2 mm (range: 0 to 2 mm), and 10.2 mm (range: 8.5 to 12 mm) for the ptotic eyelid compared to 8.3 mm (range: 7 to 9 mm), 3.2 mm (range: 2 to 4 mm), and 13.5 mm (range: 12 to 15 mm) for the normal fellow eyelid.

Clinical Features and Post-sulcoplasty Results After Sulcoplasty in 3 Children Who Developed Pre-aponurotic Fat Prolapse Following Unilateral Levator Resection

Table 1:

Clinical Features and Post-sulcoplasty Results After Sulcoplasty in 3 Children Who Developed Pre-aponurotic Fat Prolapse Following Unilateral Levator Resection

The average amount of levator aponeurosis initially resected was 11.2 mm (range: 5.5 to 15 mm). The eyelid crease was reformed at the end of the case in 2 of 3 patients. Ptosis repair was considered successful for all three children, each with an improvement in palpebral fissure height and margin reflex distance-1. Excess tissue overhanging the eyelid margin developed in all patients (Figure 2B and Figure 2E). A revision was performed at a mean 4.3 months (range: 1 to 8 months) following the initial procedure and consisted of sulcoplasty, skin crease forming sutures, and/or partially resecting and repositing pre-aponeurotic fat superiorly in the eyelid. All patients had improved sulcus and crease symmetry without overhanging tissue or eyelid fullness after the revision (Figure 2C and Figure 2F). The three patients were followed up postoperatively for 3 to 18 months, during which no complications were noted.

Preoperative photograph of patient 2 (left eye) showing (A) congenital ptosis, (B) post-levator resection in the left eye (showing excess tissue overhanging the upper eyelid), and (C) post-sulcoplasty with improved sulcus and eyelid crease. Preoperative photograph of patient 3 (right eye) showing (D) right congenital ptosis, (E) post-levator resection in the right eye with excess tissue overhanging the upper eyelid, and (F) post-sulcoplasty with improved sulcus and eyelid crease.

Figure 2.

Preoperative photograph of patient 2 (left eye) showing (A) congenital ptosis, (B) post-levator resection in the left eye (showing excess tissue overhanging the upper eyelid), and (C) post-sulcoplasty with improved sulcus and eyelid crease. Preoperative photograph of patient 3 (right eye) showing (D) right congenital ptosis, (E) post-levator resection in the right eye with excess tissue overhanging the upper eyelid, and (F) post-sulcoplasty with improved sulcus and eyelid crease.

Discussion

Complications following levator resection for congenital ptosis are uncommon and include poor eyelid symmetry, undercorrection, overcorrection, and exposure.2 To our knowledge, pre-aponeurotic fat prolapse has not been previously reported in children but occurred in three patients over a relatively short time period at one institution. Resolving this complication with the brassiere suture or sulcoplasty technique, crease reforming sutures, or resection and repositioning of fat was successful in the three children.

The sulcoplasty or brassiere suture technique has not been previously described for use in children for the treatment of postoperative pre-aponeurotic fat herniation. The brow fat suspension suture, also termed sulcoplasty, is a commonly used adjunct for adults undergoing upper eyelid blepharoplasty. The procedure, initially described by Zarem et al.3 in 1997, involves securing the incision edge of the orbicularis muscle to the arcus marginalis periosteum at the superior orbital rim before skin closure. Sulcoplasty supports the outer brow from dropping below the superior orbital rim, and creates a more defined sulcus.4 In a large retrospective analysis, the brow fat pad suspension suture was shown to be a safe and effective adjunct to upper eyelid blepharoplasty.5

Pre-aponeurotic fat prolapse is not a common complication in adults following levator resection. Instead, sulcoplasty is most often used to support lateral brow tissue. We hypothesize that this complication may be seen in children with congenital ptosis because of an intrinsically tight levator muscle. It is possible that, in the setting of a tight aponeurotic tendon, pre-aponeurotic fat seeks the path of least resistance, anteriorly, leading to anterior fat prolapse. The eyelid skin crease was reformed at the time of initial surgery in 2 of 3 patients, but preaponeurotic fat was not debulked or removed. It is possible that removal of fat and consistent skin crease reformation would minimize the possibility of this complication occurring. It is also possible that skin crease reforming sutures placed by incorporating levator fibers into the skin closure would have better avoided this complication. In this series, three children had improved symmetry of the sulcus and eyelid crease after revision.

Two patients had Marcus Gunn jaw-winking, which is an uncommon form of congenital ptosis.1 Ho et al.2 reported these patients have less optimal eyelid height following levator resection for congenital ptosis. It is unclear if children with Marcus Gunn jaw-winking are more prone to fat prolapse from an innervational or structural defect, or if the findings are due solely to the small sample size. Ho et al.2 did not describe this complication in children.

There are several limitations to this study. Its retrospective design is limited by incomplete data and an evolving, variable surgical technique for managing pre-aponeurotic fat prolapse. The absence of this condition among children in published reports contrasts with the 3 children described here, observed over a 16-month period. Although not previously reported in children, pre-aponeurotic fat prolapse can occur following levator resection for congenital ptosis. In these cases, eyelid symmetry can be restored by resecting and repositing preaponeurotic fat, using skin crease reforming sutures, and/or sulcoplasty. The sulcoplasty technique is a simple and effective technique to reform the sulcus and optimize eyelid symmetry.

References

  1. Griepentrog GJ, Diehl NN, Mohney BG. Incidence and demographics of childhood ptosis. Ophthalmology. 2011;118:1180–1183. doi:10.1016/j.ophtha.2010.10.026 [CrossRef]
  2. Ho YF, Wu SY, Tsai YJ. Factors associated with surgical outcomes in congenital ptosis: a 10-year study of 319 cases. Am J Ophthalmol. 2017;175:173–182. doi:10.1016/j.ajo.2016.12.013 [CrossRef]
  3. Zarem HA, Resnick JI, Carr RM, Wootton DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg1997;100:1258–1261. doi:10.1097/00006534-199710000-00029 [CrossRef]
  4. Zarem HA. Browpexy. Aesthet Surg J. 2004;24:368–372. doi:10.1016/j.asj.2004.05.004 [CrossRef]
  5. Eftekhari K, Peng GL, Landsberger H, Douglas R, Massry GG. The brow fat pad suspension suture: safety profile and clinical observations. Ophthalmic Plast Reconstr Surg. 2018;34:7–12.

Clinical Features and Post-sulcoplasty Results After Sulcoplasty in 3 Children Who Developed Pre-aponurotic Fat Prolapse Following Unilateral Levator Resection

CharacteristicsPatient 1Patient 2Patient 3
Age (years)762
GenderMFF
LateralityRLR
Marcus Gunn presentYNY
Palpebral fissure (mm)7/97/37/9
MRD1 (mm)+1.5/+3.5+2/0+2/+4
Eyelid excursion (mm)12/1512/8.510/NA
Amount of levator resected (mm)13155.5
Time between surgeries (months)481
Follow-up after revision (months)9183
Authors

From the Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

Supported in part by Research to Prevent Blindness, New York, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Brian G. Mohney, MD, Department of Ophthalmology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901. E-mail: mohney@mayo.edu

Received: July 02, 2018
Accepted: September 06, 2018
Posted Online: February 08, 2019

10.3928/01913913-20181017-02

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