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

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We thank Innocenti et al. for their readership of our manuscript entitled, “Blepharoplasty effect on a described algorithmic approach to external ptosis repair: Is it Time for Unbundling?”1 We agree that Hering’s law and brow compensation complicate ptosis surgery. Consideration of both, especially in unilateral cases, may lead to more predictable results. In our patient sample, no patients with unilateral ptosis exhibited Hering’s phenomenon as tested by the lift test.2 Worley et al.3 found no postoperative asymmetry of >1 mm in bilateral cases, including in patients with Hering’s dependence. In regards to brow compensation, we measure preoperative, intraoperative, and postoperative margin to reflex distance (MRD1) with the brow at rest. Indeed, while Kokubo et al.4 noted eyebrow descent after levator resection, it is unknown whether preoperative brow compensation affects surgical correction of MRD1 in cases when the surgeon does not account for this. Due to the poor understanding of the interconnected neurological feedback systems regarding the brows, eyelid height, Hering’s law, and eye dominance, further studies are necessary.
Concomitant external ptosis repair and blepharoplasty with our technique have good results: 80% met our primary criteria of success and 84% met the secondary criteria of symmetry. In some patients, we aim below an MRD1 of 3 mm, and we believe that 5 mm may be too risky for causing lagophthalmos and dry eye syndrome.5 By evaluating success based on a preoperative MRD1 goal, eyelid height can be customized, and measurements of technique predictability can be better assessed. Importantly, by aiming for a goal MRD1 with an average of 3.3, we aim for the lower range of MRD1 as described by the British Oculoplastic Surgery Society.6 This can lead to more undercorrections overall, especially when intraoperative swelling and local anesthetic effect distort intraoperative evaluation of suture adjustments. We prefer to undercorrect rather than the potential for ocular consequences of exposure. We believe that ptosis surgery should be based on customized goal MRD1, but due to such variability in success criteria in the literature, comparing one study to another is like comparing apples to oranges.
We reviewed the study by Innocenti et al.7 In that manuscript, patients undergoing concomitant external levator resection and blepharoplasty fared well compared with those undergoing what we surmise to be large incision external ptosis repair. Only 12 eyelids underwent combined surgeries, which is a relatively small sample. The large skin incision for external ptosis repair, more dissection, more local anesthesia, and more swelling compared with small-incision approaches may equalize the results when compared with concomitant surgery. Finally, if we aimed at MRD1 goals as high as 5 mm, we believe concomitant surgery would fare better with less risk of undercorrection. We emphasize that our technique with concomitant surgery works well compared with similar techniques, is predictable, and we encourage the use of it. However, it may be less predictable in achieving the height goal we set compared with the technique through a small incision without blepharoplasty.
In the United States, current Medicare and Medicaid rules have bundled ptosis and blepharoplasty together, despite distinct International Classification of Diseases, tenth revision, diagnosis codes for dermatochalasis and acquired ptosis. This has changed practice patterns toward combined external ptosis with blepharoplasty.8 Importantly, even sequential surgeries, functional and cosmetic, are bundled. The effect of blepharoplasty on ptosis repair is not yet fully understood in the literature.
A majority of our clinic ptosis patients undergo combined blepharoplasty with ptosis repair. Patients with minimal dermatochalasis, superior sulcus hollowing, and orbital fat atrophy pose a conundrum. Small-incision approach may be more predictable but risks a difficult patient–doctor relationship due to subsequent cosmetic or functional increases in dermatochalasis.

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