Re: “Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair

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We read with great interest the article entitled “Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?” by Rubinstein et al.1
The authors, referring to as previously described algorithm technique “small-incision external levator resection” for treatment of involutional ptosis, highlighted that the addition of upper blepharoplasty to the ptosis procedure repair alone provides good but less predictable results comparing to the ptosis repair technique alone. Aponeurotic ptosis is the most common type of acquired ptosis resulting from an involutional dehiscence, stretching, or thinning of the aponeurotic fibers of the levator aponeurosis. We congratulate for the authors’ algorithmic surgical technique and for the device proposed to hold the aponeurosis; it seems to be useful to standardize the amount of stress placed on aponeurosis between different patients, minimizing the variable depending on the operator, standardizing the method to calculate the amount of tissue resection and surgical correction.
We retain that the function of superior levator system must be evaluated preoperatively, but also the asymmetry between the 2 eyes must be carefully assessed. As stated by Hering law, both levator muscles are innervated from a single nucleus producing equal neural output from both sides, and so the less affected eyelid may be capable of maintaining a normal level of elevation due to an excessive nerve stimulation determined by the more ptotic eyelid.2 The compensatory retraction of the less affected eye make it difficult to adjust the balance between the 2 eyes. Furthermore, an assessment of compensation for the superior visual field loss by the recruitment of the frontalis muscle and a long-term functional evaluation of results is important.
We recently published an article to evaluate long-term follow-up results after ptosis correction by external levator advancement with or without blepharoplasty, considering both functional and aesthetic results.3,4 The former was evaluated basing on postoperative upper eyelid margin reflex distance and the second one on symmetry. According to the British Oculoplastic Surgery Society National Ptosis Survey, a successful outcome can be considered when upper eyelid margin reflex distance was between 3 mm and 5 mm. Symmetry was achieved when all the following 3 different criteria were met:5
We agree with the authors that concomitant blepharoplasty requires addition of local anesthesia and causes more pronounced postoperative swelling that can interfere with the intercourse of the main surgical procedure. However, our study showed that patients, especially older subjects, underwent concomitant blepharoplasty and ptosis correction and reported satisfactory, more symmetrical, and more stable results in long-lasting period, reducing residual asymmetry. In conclusion, concomitant procedures could be considered in very selected patients, thus, to obtain more satisfactory outcomes, reducing the recurrence of secondary procedures.

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