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Management of
jaw-winking Syndrome
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Consider eyelid surgery only
when the parents (or the patient) and the
surgeon agree about whether the most
cosmetically objectionable condition is the
ptosis or the
jaw-winking
or whether it is a combination
of both.
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Many techniques are
described for the correction of jaw-winking
ptosis, reflecting the ongoing controversy
regarding the surgical management of this
condition.
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If the jaw-winking is
cosmetically insignificant, it can be
ignored in the treatment of the ptosis.
If the ptosis is
mild, the patient may elect not to
proceed with surgery. If correction is
desired, perform a Müller muscle and
conjunctival resection (MMCR), a
Fasanella-Servat procedure,
or a standard external levator resection
If the ptosis is
moderate to severe, a levator resection
may be indicated. Beard advocated
performing more resection than normal to
avoid undercorrection.
In severe ptosis,
a supermaximum (>30 mm) levator
resection or
frontalis suspension is necessary.
Although the amount of ptosis and synkinetic
eyelid movement is variable, those patients
with more severe ptosis tend to have the
worse aberrant upper eyelid movement.
The jaw-wink is considered
cosmetically significant if it is 2 mm or
more.
Any
attempt to repair the ptosis without
addressing the jaw-winking would result in
an exaggeration of the aberrant eyelid
movement to a level well above the superior
corneal limbus, which would be unacceptable
to the patient.
If the
jaw-wink is significant, ablation of the
levator and resuspension of the eyelid to
the brow are necessary. Several techniques
have been suggested to obliterate levator
function, which effectively dampens the
aberrant eyelid movement.
Beard and others have
advocated bilateral excision of the levator
muscle and bilateral frontalis suspension.
While this approach almost completely
eliminates the wink and arguably results in
better symmetry, it is often difficult to
persuade the parents and the patient to
perform surgery on and effectively damage
the normal contralateral levator muscle.
Satisfactory and predictable results also
can be obtained after only unilateral
levator excision on the affected side,
combined with bilateral frontalis
suspension. This leaves the normal
functioning levator muscle to elevate the
nonptotic eyelid in primary position but
produces a lag in downgaze for improved
symmetry.
Kersten et al
advocate unilateral levator muscle excision
and frontalis sling only on the affected
side.
If
the postoperative result is judged to be
unsatisfactory, the parents or the patient
can opt for further surgery to the
contralateral side. Any amblyopia and
strabismus should first be addressed, as
there may be insufficient drive to lift the
disinserted eyelid.
Islam et al described
a technique of dissecting a frontalis flap
hinged superiorly through a suprabrow
incision that is then brought down into an
eyelid crease incision.
The
frontalis flap is used to suspend the ptotic
eyelid after extirpation of the levator
muscle.
Lemagne and Neuhaus described techniques
that involve transection of the involved
levator followed by transposition of the
distal segment to the brow, which
effectively suspends the eyelid to the
frontalis muscle.
Their techniques maintain normal eyelid
contour, as the levator aponeurotic
attachments are left undisturbed.
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