Downloaded from http://journals.lww.com/jcraniofacialsurgery by BhDMf5ePHKbH4TTImqenVNt18fBITteXqK39VTSdmmtH2Mya1kO23vbJqY+jOOSdqa3Uy+VJ8pY= on 07/07/2020 Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Anterior-Approach Versus Posterior-Approach Levator Advancement Surgery in Aponeurotic Ptosis Korhan Fazil, MD, Can Ozturker, MD, Gamze Ozturk Karabulut, MD, Ebru Demet Aygit, MD, Burcin Kepez Yildiz, MD, Muhittin Taskapili, MD, and Pelin Kaynak, MD Purpose: To compare the effectiveness and complications of levator reinsertion in aponeurotic ptosis surgery using anterior and posterior approaches. Methods: Seventy-eight (36 females, 42 males) patients with acquired aponeurotic ptosis were evaluated. Pre- and postoperative margin reflex distance, symmetry of height, contour and skin crease, corneal problems, and lagophthalmus were evaluated and compared between the 2 groups. Independent and paired samples t-test, Pearson Chi-square, and Fisher exact test were used to evaluate the results. Results: The anterior approach was performed on 43 eyelids and the posterior approach was performed on 35 eyelids. The mean age of the anterior-approach group was 62.1  11 years, and posterior- approach group was 50.1  15.1 years, respectively (P < 0.001). The male-female ratio was 28/15 in the anterior-approach group, and 14/21 in the posterior approach group (P ¼ 0.027). The success rate of the anterior approach was 69.8% and the posterior approach was 57.1% (P ¼ 0.248). The mean margin reflex distance change was statistically significant in both anterior- and posterior-approach techniques (P < 0.001, P < 0.001, respectively). Three (6.9%) patients in the anterior-approach group and 11 (31.4%) in the posterior-approach group required reoperation (P ¼ 0.005). Lagophthalmus rates were similar (3 eyes in the anterior versus 7 eyes in the posterior group, P ¼ 0.103). Conclusions: Both anterior- and posterior-approaches are effective and safe techniques for aponeurotic ptosis treatment. The posterior approach seems to be preferred by female and younger patients because there is no undesirable scar formation although it has the disadvantage of higher rates of reoperation. Key Words: Anterior approach, aponeurotic ptosis, levator surgery, posterior approach, ptosis surgery (J Craniofac Surg 2020;31: 1318–1321) P tosis is an abnormally low position of the upper lid that may be congenital or acquired. It can be classified etiologically as neurogenic, myogenic, aponeurotic, or mechanical. 1 Involutional ptosis is an age-related condition caused by dehiscence, disinser- tion, or stretching of the levator aponeurosis, which restricts transmission of force from a normal levator muscle to the upper eyelid. Almost any case of ptosis with adequate levator function (LF) could be corrected by surgery directed at the levator aponeurosis. 2,3 Ptosis surgery can be performed via 2 different approaches, trans- cutaneous (anterior) or transconjunctival (posterior). 4–13 In the majority of cases, aponeurotic ptosis surgery is performed through an anterior approach because of the simplicity of the procedure and advantage of sparing conjunctiva, Mu ¨ller muscle and accessory lacrimal glands as well as goblet cells avoiding possible dry eye symptoms. 3,6 However, the necessity to incise the eyelid skin is the main disadvantage of the anterior approach. 11 Some the patients refuse to undergo the operation because of the skin incision. Another disadvantage is the loss of eyelid sensation. 14 Skin incision is avoided in the posterior approach, which also has the advantage of rapid healing. However, the posterior approach is a more complex procedure with the disadvantage of temporary eye irrita- tion. 11 To the best of our knowledge, there is no head to head compari- son of the anterior and posterior approaches for ptosis surgery in a study to date (from a PubMED search in December 2017). There- fore, we aimed to compare the anterior and posterior approach techniques of aponeurotic ptosis surgery in regards to efficacy and complications. METHODS The surgical records of patients with aponeurotic ptosis who underwent levator surgery for ptosis repair either by anterior or posterior approach between March 2010 and May 2013 in the Istanbul Beyoglu Eye Training and Research Hospital Oculoplastic Surgery Division were reviewed retrospectively. The study protocol was approved by the Institutional Review Board of the hospital. Written informed consent was given by all patients and the study followed the tenets of the Declaration of Helsinki. Inclusion criteria were patients aged 18 years, acquired uni- lateral aponeurotic ptosis, LF 10 mm, and surgery performed under local anesthesia. Patients with LF <10 mm, inadequate follow-up (<3 months after surgery), bilateral ptosis, previous history of trauma or ptosis surgery, ptosis of congenital, myogenic and neurogenic etiologies, and patients who had brow ptosis and excessive upper eyelid laxity were excluded from the study. We also excluded patients with positive 2.5% phenylephrine test results. Data collection included age, sex, preoperative LF, pre- and postoperative upper eyelid margin reflex distance (MRD), postop- erative presence of skin crease, postoperative eyelid symmetry, and normal eyelid contour. Photographs were taken pre- and postoper- atively at every visit and used to determine presence of skin crease, eyelid height symmetry, and judge to eyelid contour. Measurements at the last follow-up visit were used for comparison. From the Beyoglu Eye Training and Research Hospital, Istanbul, Turkey. Received August 13, 2018. Accepted for publication October 1, 2019. Address correspondence and reprint requests to Korhan Fazil, MD, Beyoglu Eye Training and Research Hospital, Bereketzade Camii Sok., 34421 Kuledibi, Beyoglu, Istanbul, Turkey; E-mail: korhanfazil@hotmail.com This study had been presented in part in the 48th National Congress of Turkish Ophthalmology Society (5-9 November 2014) Antalya, Turkey. The authors declare no conflict of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofa- cialsurgery.com). Copyright # 2020 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000006189 CLINICAL STUDY 1318 The Journal of Craniofacial Surgery  Volume 31, Number 5, July/August 2020