Eyelash Ptosis in Unilateral Myogenic and Aponeurotic Blepharoptosis A Prospective, Controlled, Before- and After-Study Mohsen Bahmani Kashkouli, MD, Parya Abdolalizadeh, MD, Anahita Amirsardari, MD, Yasaman Hadi, MD, Maria Sharepour, MD, and Houri Esmaeilkhanian, MD Purposes: The purposes of this study were to compare lash ptosis (LP) with con- tralateral eyelid in patients with unilateral myogenic (MP) and aponeurotic (AP) ptosis before and after the ptosis repair and to assess the correlation between post- operative eyelid height and LP symmetry. Methods: Patients older than 5 years were included from June 2015 to April 2017. Eyelid examination, LP grading (0–3), and photography were performed before and at least 6 months after ptosis repair. Success of ptosis repair (levator resection) was defined as margin reflex distance 1 within 0.5 mm of the contra- lateral eyelid; LP improvement, as at least 1 grade improvement at the last follow-up; and LP symmetry, as 2 eyelids being within 1 grade. Results: There were 58 patients with MP and 20 with AP, with mean age of 19.2 and 49.5 years and median follow-up of 10 months. Lash ptosis was observed in 89.5% of ptotic and 33.3% of control eyelids. Mean LP grade was significantly higher in the MP (1.5) than in the AP (1.1), which significantly improved to 0.6 and 0.4, respectively. However, it persisted in 50.9% of MP and 31.2% of AP postoperatively. Lash ptosis symmetry was observed in 97.4% of patients, which was not correlated with margin reflex distance 1 symmetry. Lower levator function was the only significant factor correlated with LP. Conclusion: Lash ptosis was significantly worse in MP than in AP. Lower LF was correlated with more severe LP. Ptosis repair resulted in significant improve- ment of LP and its symmetry with the contralateral eyelid. Lash ptosis symmetry did not correlate with eyelid height symmetry postoperatively. Key Words: lash ptosis, myogenic ptosis, aponeurotic ptosis, levator resection (Ann Plast Surg 2018;00: 00–00) L ash ptosis (LP) is defined as declination of lash follicles of the upper eyelid. Hypotheses on the etiology of LP are largely based on ana- tomical changes within the upper eyelid. 1 It has been associated with floppy eyelid syndrome, congenital lamellar ichthyosis, long-standing ocular leprosy, bilateral acoustic neuroma, latanoprost eye drop usage, congenital and acquired ptosis, and dermatochalasis. 1–8 However, its significance in congenital and acquired blepharoptosis has just been re- ported twice in the literature. The first study was from Malik et al, 6 in which they found higher frequency of LP in both congenital and acquired ptosis than in normal control eyelids and proposed a grading scale for as- sessment of LP in the clinic. The second study reported a higher fre- quency of LP in Asian subjects with acquired ptosis as compared with normal eyelids. 7 However, it is not clear if repair of ptosis would improve the LP and how the success of ptosis repair correlates with possible LP improvement. Therefore, the aims of this study were to compare the LP grade between ptotic and normal eyelids in patients with unilateral myo- genic (MP) and aponeurotic (AP) ptosis before and after the ptosis repair (external approach levator resection) and to assess the correlation be- tween eyelid height symmetry and LP symmetry postoperatively. METHOD This study is a prospective comparative before- and after-study on patients with unilateral MP and AP who referred to a university- based hospital (Rassoul Akram Hospital, Tehran, Iran) and the senior author's (M.B.K.) private clinic from June 2015 to April 2017. Based on comparing the mean of LP between MP and AP 6 and considering α = 0.05, β = 0.2, σ = 1, and d = 0.8, the sample size was calculated to be 16 at each group. However, we planned to recruit all the patients during the study period. Informed consent and ethic committee approval (IUMS-9211257002) were obtained. This study adhered to the tenets of the Declaration of Helsinki. Included were patients older than 5 years and unilateral (margin reflex distance 1 [MRD1‘ of >1.5 mm lower than the normal side) MP or AP. Myogenic ptosis was defined as simple con- genital maldeveloped ptosis without any associated extraocular myopa- thy, and APwas defined as acquired AP. 9 Patients with previous eyelid surgery, extraocular myopathy, aberrant nerve regeneration, poor Bell's phenomenon, third nerve palsy, strabismus, congenital or acquired eyelid deformity, levator function of 3 or less (requiring sling procedure), and concurrent blepharoplasty and/or other procedures were excluded. To as- sess the sole effect of levator resection procedure on correction of eyelash ptosis, patients with other associated procedures were excluded, although blepharoplasty itself would also add some pull effect on eyelashes. To the senior author's experience, tucking of the levator almost always ends up with late undercorrection of the AP. To avoid undercorrection in time, to our view, all patients with AP require disinsertion and a few millimeters of dissection of remaining fibers of levator on the tarsal side before reattaching the retracted edge of the le- vator on the tarsus. This is, in fact, a kind of levator resection. Skin approach levator resection was performed for all patients under local or general anesthesia by or under direct supervision of the senior author (M.B.K.). Type of anesthesia was based on patient's age and cooperation. Intraoperative adjustment (sitting and supine) was per- formed for the patients under local anesthesia (1.5–2 mL of lidocaine 2% + adrenaline 1/200,000). A modification of Berke's guideline 10 was used to set the upper eyelid under general anesthesia based on up- per eyelid excursion (levator muscle function). The aim was to put the eyelid 1 mm higher than the contralateral eyelid (1-mm overcorrection) intraoperatively. Levator muscle was finally secured on anterior tarsus using 5-0 vicryl suture (3–6 stitches). Skin incision was closed (6-0 ny- lon), incorporating the attached end of levator muscle into all the su- tures, and dressing with topical steroid (hydrocortisone ointment) and antibiotic (tetracycline ointment) was put on the incision for 1 day. Two ointments were continued for 1 week when skin sutures were re- moved. They were also instructed to put artificial eye drop (4 times a day) and ointment (on sleeping). Follow-up was set on day 1, week 1, and at least 6 months after the procedure. Received March 25, 2018, and accepted for publication, after revision July 3, 2018. From the Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. Conflicts of interest and sources of funding: The authors have no conflict of interest. This study was funded by Iran University Eye Research Center, which did not have any role in the design, execution, and presentation of results. This study was presented at the 48th American Society of Ophthalmic Plastic and Reconstructive Surgery meeting, New Orleans, 2017. Reprints: Mohsen Bahmani Kashkouli, MD, Rassoul Akram Hospital, Sattarkhan Niayesh St, Tehran 1455364, Iran. E-mail: mkashkouli2@gmanil.com. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/18/0000–0000 DOI: 10.1097/SAP.0000000000001599 AESTHETIC SURGERY Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 www.annalsplasticsurgery.com 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.