Minimally Invasive Conjoint Fascial Sheath Suspension for Blepharoptosis Correction

Dear editors, We read with great interest the article titled ‘‘Minimally invasive Conjoint Fascial Sheath Suspension for Blepharoptosis correction’’ by Jing Zhou et al. [1]. Wecongratulate the authors for the innovative method, its minimal surgical invasiveness, satisfactory results reported in the paper and for the large series of cases based on 44 patients. The authors enrolled only subjects affected by mild or moderate blepharoptosis, who underwent correction using suspension of the conjoint fascial sheath of the levator and superior rectus, but we have some elements to discuss. The proposed cohort of patients is represented only by young Asian people, mostly (25 patients) affected by unilateral congenital ptosis. Do the authors have any experience with older patients? Did the authors select differently congenital and or acquired deformity? In the presence of acquired ptosis, do the authors apply indifferently the method for involutional or traumatic ptosis? Furthermore, the paper reported only Asian patients. Do the authors have any experience with Caucasian patients? The mean follow-up reported in the authors’ paper was 13.40 ± 4.60 months. Is this long enough to evaluate long lasting results in such young patients? Correction of ptosis by only suspension, without advancement of the levator complex, may lead to recurrence of the ptosis in the longterm follow-up and therefore we retain that this approach, even if minimally invasive, should be carefully considered in younger patients who may benefit from different procedures,such as the levator complex muscle advancement procedure [2–4]. Recently, we published a paper reporting 20 patients (40 eyes), with a mean age of 56 years and 36-month follow-up who underwent blepharoptosis correction with levator complex muscle advancement [5]. We cannot completely agree with the authors regarding major discomfort using the traditional anterior levator aponeurotic approach. In our case series, we have not observed any major complications, with a rapid return to daily activities. In particular, any sensitive discomfort with scarring was reported. The main advantage of the proposed technique is the reliability and the minimally invasive approach, but complications were not discussed. Did any patient experience discomfort or foreign body sensation, especially in patients requiring multiple anchorages (from 3 to 5)? Moreover, can the authors clarify how they estimate the number of required sutures? Therefore, further studies with longer follow-up are encouraged to better analyze complication data, especially recurrences, on this new and interesting technique.