Double reinsertion including Whitnall's ligament in aponeurotic ptosis surgery : Comparison of results following simple aponeurosis reinsertion surgery and a combined reinsertion of the aponeurosis to Whitnall's ligament for aponeurotic palpebral ptosis: a cohort study of 722 cases.

Purpose: The results of a technique with a double reinsertion of the aponeurosis to the tarsus and aponeurosis to Whitnall's ligament (ATW) were compared with a simple reinsertion of the aponeurosis to the tarsus (AT) in acquired aponeurotic palpebral ptosis surgery.

Methods: Analytical, observational, retrospective, cohort study. Seven hundred and twenty-two consecutive cases with acquired aponeurotic palpebral ptosis have been treated surgically between 2000 and 2012 and have been followed up for 5 years. The cases were divided into two cohorts according to the applied surgical technique (AT vs ATW).

Results: The mean postoperative MRD after 1 month in cohort AT was 1 mm lower than in ATW (3 ± 0.9 mm vs 4 ± 1 mm). The mean MRD in the long-term follow-up (5 years) was 1 mm lower in cohort AT than in ATW (2.9 ± 1.5 mm vs 3.9 ± 0.9 mm). The rate of long-term recurrence (5 years) was 15% higher in A-T than in A-T-W (20% vs 5%). 70.5% of the eyes studied intra-surgically presented gaps between the Whitnall ligament and the aponeurosis, an anatomical area that we describe as the upper transition zone (UTZ). In an independent analysis, only those patients with open UTZ were evaluated and it was observed that those operated with A-T-W presented elevations greater than 1 mm compared to those operated with the AT technique (4 ± 0.9 mm A-T-W vs 2.8 ± 1 mm A-T) and a much lower recurrence rate (5.4% A-T vs 38.09% A-T-W).

Conclusions: In our study, the A-T-W technique achieved better results in terms of palpebral elevation and fewer recurrences compared to the A-T technique in all cases studied with aponeurotic ptosis. However, it particularly demonstrates its superiority in patients with large gaps in the UTZ.