Background: children with severe ptosis and poor levator function have a significant visual handicap. Frontalis suspension is usually used as the procedure of choice for those children. It is an efficient and simple method of treatment. However, many investigators believe that eventually all those cases will recur regardless of the sling material. Super-maximum levator resections (27 – 30 mm) can be integrated with superior tarsectomy to refine the ptosis corrective procedure in cases having poor levator function.
Aim and design: this study, a prospective randomized blind comparative clinical study, is to compare the results of augmented super-maximum levator resection versus frontalis suspension in management of severe ptosis with poor levator function.
Patients and methods: patients presented with severe ptosis (≥ 4 mm) of one lid (i.e. MRD-1 ≤ 0.5 mm), with poor levator function (i.e. LFT ≤ 4 mm), were randomly assigned to have either an augmented super-maximum levator resection (group 1) or frontalis sling procedure (group 2).
Results: A total of 22 eyelids were enrolled for the study. Group 1 included 10 lids, while group 2 had 12 lids. The mean preoperative amount of ptosis, the mean MRD-1, and the levator muscle function were similar in both groups. In group 1, the augmented super-maximum levator resection procedure reduced the amount of ptosis down to 2 mm, increased the MRD-1 up to 2.5 mm, and improved the levator function up to 5.4 mm. In group 2, the frontalis sling procedure reduced the amount of ptosis down to 0.88 mm, increased the MRD-1 up to 3.63 mm, while did not improve the levator function (2.83 mm). Comparing those parameters between the two groups revealed that the frontalis sling reduced the amount of ptosis and increased MRD-1 more than the augmented super-maximum levator resection did, while the later operation was superior in improving the levator function.
Conclusion: augmented super-maximum levator resection carries many potential advantages; the non use of an exogenous material so reducing the risk of infection and extrusion, no autogenous fascia lata so no leg scars or multiple incisions, superior cosmetic and aesthetic outcome. However, many disadvantages still exist including; insufficient corrective outcome, an akinetic appearance of the upper eyelid (lid lag) in everyday life, shortening of the tarsus that carry the risk of lid peaking and ectropion, altogether with conjunctival and lacrimal gland prolapse.