Ординатура / Офтальмология / Английские материалы / Atlas of Aesthetic Eyelid and Periocular Surgery_Spinelli, Lewis, Elahi_2004

CHOICE OF PROCEDURE

The surgeon may then choose an appropriate procedure based on these two key assessments: levator excursion or function and the degree of ptosis. Any upper lid retractor tightening procedure (i.e., levator advancement, levator resection, levator tuck, müllerectomy, or a tarsal conjunctival müllerectomy [Fasanella-Servat]) are all appropriate procedures when levator function is good. Levator advancement is by far the most powerful technique for correcting larger degrees of ptosis. All other procedures have limitations and, when applied to larger degrees of ptosis, result in untoward sequelae. Therefore, posterior lamella shortening (i.e., müllerectomy, Fasanella-Servat) and other procedures are indicated only in mild degrees of ptosis. In the case of the müllerectomy procedure alone, the best candidates are those with good to excellent levator function, those with mild degrees of ptosis, and those who respond to topical instillation of phenylephrine. The FasanellaServat operation is also indicated in mild degrees of ptosis, and this operation effectively shortens the entire posterior lamella of the upper lid by resecting Müller’s muscle, superior tarsal plate, and conjunctiva. It has similar indications to the müllerectomy alone and, in my opinion, is a more powerful technique for correcting ptosis. It does, however, have greater disadvantages, including an inability to provide graduated tension on

the lid retractors. It decreases wetting surface over the cornea and may produce corneal irritation secondary to exposed sutures. In addition, symmetric upper lid contour may be distorted by this procedure. Therefore, although I will describe the procedure for tarsal conjunctival müllerectomy (Fasanella-Servat), I recommend that all surgeons become familiar with levator aponeurosis plication or tuck, with or without resection, as well as levator advancement procedures. All of these techniques may be performed alone or in combination with various cosmetic procedures, especially upper lid blepharoplasty.

The just-mentioned procedures are all indicated in patients who have an intact endogenous lid elevator mechanism. In cases in which levator function is extremely poor or absent, use of exogenous muscles, such as the frontalis muscle sling procedures, is of most benefit. Patients with congenital ptosis usually present with significant degrees of ptosis, poor to absent levator function, and significant lid lag on down gaze. These patients have a fibrotic contraction of a relatively atonic levator muscle and have the characteristic combination of significant ptosis associated with significant lid lag or corneal exposure on down gaze. As always, one should be cognizant of the patient’s ability to adequately wet their corneal surface. Elevation of the lid with ptosis correction will produce increased evaporative tear loss, and this could therefore serve to trade one symptom (ptosis) for another (dry eye syndrome). Of course, in

cases in which profound symptomatic ptosis is present in combination with borderline or frank dry eyes, obliteration or limitation of tear drainage with punctal occlusion or plugs can be considered at the time of ptosis correction. The ptosis should be undercorrected in an attempt to diminish the loss of tears by way of evaporation.

PTOSIS PROCEDURES

Tarsal Conjunctival Müllerectomy

(Fasanella-Servat Operation)

The Fasanella-Servat procedure is a simple posterior approach to mild degrees of ptosis. It is important to achieve proper anesthesia without soft tissue distortion. Topical ophthalmic anesthetic (i.e., tetracaine) is instilled, local anesthetic is infiltrated, and adequate time for hemostasis is allowed to elapse. The upper eyelid is everted, and the tarsal plate along with the overlying conjunctiva and Müller’s muscle is engaged with a forceps. The everted tarsal plate and associated soft tissue are clamped at its most superior extent utilizing two identical curved clamps. A cuff of 3 to 4 mm of tarsal plate is left above the clamps. It is important to visualize the sweeping contour of the upper lid and

mimic this contour with clamp placement, adjusting the “heel and toe” of each clamp accordingly. Once this is accomplished, a monofilament nonabsorbable suture (i.e., 4-0 or 5-0 Prolene) is brought through the skin surface at the lateral external eyelid crease. The suture is brought into the conjunctival surface of the everted eyelid and woven from lateral to medial beneath the clamps in a horizontal mattress fashion. Once the suture is brought to the most medial extent of the clamped tarsal surface, it is brought back out through the skin surface. The soft tissue above the clamps (tarsus, conjunctiva, and Müller’s muscle) can be removed with a scissor or scalpel and the eyelid reverted. The lateral medial elements of the suture may be tied to each other loosely, and it is helpful to smooth the undersurface of the eyelid with a blunt instrument to diminish postoperative corneal irritation. No other closure is necessary, and the suture may remain in place for 1 to 2 weeks. In cases in which slight undercorrection has been achieved, it is useful to leave the suture in place for longer than 2 weeks, and the reverse is true in slight overcorrection. Early removal of the suture, frequent massage, and downward traction on the upper eyelid may also serve to improve slight overcorrection in this procedure. Because the wetting surface of the eyelid is decreased in this procedure, patients with dry eye syndrome or decreased tear production may be better served by direct levator procedures (Figs. 8-4 and 8-5).

Figure 8-4 The tarsal conjunctival müllerectomy or Fasanella-Servat procedure is one of the more simple procedures that reliably corrects mild to lesser degrees of moderate ptosis (i.e., 1 to 2 mm). The procedure shortens the entire posterior lamella of the upper lid, including the tarsal plate, Müller’s muscle, and conjunctiva. A, After topical anesthetic is applied and local anesthetic is infiltrated, the upper eyelid is everted. Small curved identical clamps are used to engage the tarsal complex. A monofilament suture is passed from the skin onto the conjunctival surface and woven below the clamps from lateral to medial. It is helpful to manipulate the clamps as a unit, without disengaging the tarsal complex (toward the surgeon when passing the needle from posterior to anterior and away from the surgeon when passing in the other direction [insert] ). B, The excess tissue above the suture line may then be resected with or without the clamps in place, after the suture is passed back onto the skin surface of the medial lid. C, Its suture ends are tied to each other after the eyelid is reverted. Slack should be left in the suture to prevent cheese wiring, and I like to apply a Steri-strip to prevent the suture from falling onto the eyeball when the patient ambulates. Although the procedure is straightforward from a technical standpoint, the selection of clamps (i.e., degree of curvature), clamp positioning (i.e., amount of tarsus engaged), and the clamp angulation (tip-to-heel angulation) all play an important role in determining the results achieved in the tarsal conjunctival müllerectomy.

TARSAL CONJUNCTIVAL MÜLLERECTOMY

Mild upper lid ptosis, 1-2 mm.

Cross section of suture placement

ARunning suture (full thickness) behind clamps, lateral to medial

B Trim excess clamped tissue

CClosure – suture tied on skin surface and covered with Steri-Strip

Levator Tuck with or without Resection

In mild to smaller degrees of moderate ptosis with good-to-excellent levator function, one may use a simple anterior approach to the levator aponeurosis that does not require extensive dissection. The redundant aponeurotic tissue is plicated or tucked. The redundant tissue above the suture line may be resected to avoid subcutaneous bulk. The procedure is carried out by performing an anterior cutaneous lid incision along the desired eyelid crease after local anesthetic with epinephrine is infiltrated and adequate time for hemostasis is allowed to elapse. Dissection is carried down to the levator aponeurosis after skin and orbicularis muscle is incised. The dissection should be carried cephalad along the levator aponeurosis, and the orbital septum should be incised, allowing visualization of the preaponeurotic fat pad. Distally, dissection is carried down to the superior border of the tarsal plate. The levator aponeurosis may be plicated at a level cephalad to the tarsal plate with an absorbable suture (i.e., 5-0 Vicryl). Generally, one chooses the medial aspect of the pupil as the apex of eyelid curvature and a plication suture is placed at this point. Two other plication sutures may be placed medially and laterally to this central suture, visualizing the anatomic sweep of the upper eyelid. Closure may be performed as in an upper lid blepharoplasty. Alternatively, the cuff of levator aponeurosis left after plication or tuck may be resected, being careful to leave the suture line intact. This is especially useful when larger cuffs are created in the treatment of larger degrees of ptosis. Larger cuffs may leave a cosmetically visible and palpable firmness to the upper lid behind, and these tend to obscure upper sulcus definition. Care should be taken to firmly and reliably plicate the underlying levator aponeurosis before resection of the overlying cuff to avoid dehiscence and postoperative ptosis. A one-to-one millimeter plication for the degree of ptosis is generally ideal. The patient may be seated upright for assessment of levator excursion and adequacy of ptosis correction before the levator aponeurosis is resected above the suture line. One must remember that the epinephrine that is infiltrated will cause some correction of ptosis by way of stimulation of Müller’s muscle (see Fig. 4-6).

Levator Advancement

The levator advancement procedure is by far the most powerful technique for the correction of ptosis in

patients who have good-to-excellent levator function no matter how severe their ptosis. This technique may be applied in congenital ptosis when there is fair-to-good levator function. In distinction to levator plication with or without resection, this procedure involves more extensive dissection with complete mobilization of the levator aponeurosis from the tarsal plate, lysis of both the medial and lateral levator excursions (horns), and dissection carried cephalad into the orbit behind the septum. In this procedure the distal aponeurosis is resected after appropriate advancement and fixation to the superior tarsal plate. In cases of disinsertion of the levator aponeurosis or involutional ptosis (senescent ptosis) the levator aponeurosis may be freed from its other tethering points (as described earlier) and simply advanced without resection of the distal aponeurosis. In cases in which the lid crease is not well defined or deficient (i.e., involutional ptosis or congenital ptosis with adequate levator function), the lid crease may be defined at an appropriately chosen level with supratarsal fixation, which will be further delineated and has already been mentioned. I prefer the patient to be lightly sedated whenever possible to maintain his or her cooperation. Local anesthetic infiltration should be minimized to avoid soft tissue distortion and compromise of levator function. It is best that the patient become maximally cooperative once the adjustment stage of the procedure is performed. Skin resection may be performed as in an upper lid blepharoplasty, and the degree of skin excision is chosen as described in Chapter 4. Residual excess skin after the correction of ptosis can result in a prominent lid fold, distortion of eyelashes, and, in extreme cases, the creation of entropion. In cases of mild skin excess after a lid elevation procedure, a secondary skin resection can be performed later after swelling dissipates. I always try to defer significant skin resections after a ptosis correction, especially in secondary or tertiary cases, until a later date. This affords a maximal cosmetic and functional result.

Levator Advancement Technique

Local anesthetic is infiltrated once the upper eyelid crease is delineated with a marking pen. Adequate time is allowed to elapse for vasoconstriction to occur. The incision is carried down through the skin and orbicularis muscle, exposing the levator aponeurosis. I prefer to perform all dissection after the initial incision with an insulated needlepoint cautery. Skin is retracted cephalad, and the dissection is carried cephalad through the orbital septum and along the levator aponeurosis. Preaponeurotic fat is exposed and left in

place unless concomitant cosmetic improvement of herniated fat and so on is desired. In levator dehiscence, preaponeurotic fat will be retracted into the orbit along with the levator to which it is loosely attached. Levator advancement will reposition this fat, and resection is not necessary in routine cases. Attention is then brought to the superior tarsal plate and with the pretarsal orbicularis and skin retracted the levator aponeurosis is dissected off the tarsal plate in a caudal to cephalic fashion. Müller’s muscle may be carried with the overlying levator aponeurosis, leaving conjunctiva behind as dissection is carried superiorly. It is preferable, but not always possible, to leave Müller’s muscle behind. A corneal protector may be placed before this surgery because conjunctiva alone may not serve as an adequate corneal protector for some surgeons. It is important to carry out the dissection as cephalad as possible so that the entire levator aponeurosis is freed and adequate advancement may be performed. The medial and lateral horns of the levator muscle are similarly severed with cautery or other dissection. Needle-point cautery is preferable because difficult bleeding can be encountered, especially laterally near the lacrimal gland during lateral horn interruption. Medial and lateral horn division is an important step, because untethered levator advancement is impossible without it. The levator aponeurosis is then advanced and reinserted into the upper one third of the tarsal plate. I prefer to use a double-armed absorbable suture such as 5-0 Vicryl. This may be temporarily tied so that the degree of advancement and correction may be assessed in the operating room, demonstrating lid position and excursion after repositioning the patient. This is achieved by removing the protective contact lens, decreasing the ambient light, and sitting the patient as upright as possible. Highintensity light will cause the patient to squint and alter the accuracy of the intraoperative assessment. Should the advancement be too little or too much, the patient may be placed in a recumbent position and the suture may be adjusted until the desired lid height is achieved. Once the appropriate degree of lid height and ptosis correction is obtained, the suture may be permanently tied down and the excess levator aponeurosis resected. A second or even third simple interrupted suture may be placed medially and laterally to fixate the distal levator aponeurosis to the tarsal plate and ensure stabilization without distortion. The key central suture should lie

along a vertical line that intersects with the nasal pupillary margin. This usually corresponds to the highest point of the lid. Should the high point on the contralateral side differ, then one may adjust the location of the key central suture during the repair of the ptotic eyelid (Fig. 8-6). An appropriate lid fold may then be accentuated with supratarsal fixation by attaching the upper and lower skin margins to the levator aponeurosis at an appropriately chosen height with several spaced absorbable sutures (i.e., 5-0 Vicryl). Skin may be closed as in the upper lid blepharoplasty procedure with intracuticular or other preferred technique as previously described in Chapter 4 (Figs. 4.4 and 8-6). Although supratarsal fixation or lid crease sutures may be applied to any upper lid procedure, I usually find it necessary only in congenital ptosis and in rare instances of involutional ptosis (see Figs. 4-6 and 8-1).

In cases of congenital ptosis with fair-to-good levator function in which levator aponeurotic advancement is used, much larger degrees of levator advancement are necessary to effect a change in the degree of ptosis (Fig. 8-7). This is because of the relatively atonic levator and part of the congenital abnormality. Significant levator advancement and resection in congenital ptosis cases leads to significant degrees of lid lag, but this is invariably well tolerated in the pediatric population. The surgeon also has the significant disadvantage in the pediatric population of not having a cooperative patient in whom to adjust levator advancement and resection in a dynamic fashion at surgery. In cases of congenital ptosis, 2 to 3 mm of advancement and resection for each millimeter of ptosis is usually necessary. In distinction, much lesser degrees of advancement and resection are necessary in cases of noncongenital ptosis. I prefer to avoid relying on any formulas to determine the amount of levator advancement necessary at surgery. These formulas may serve as rough guidelines for preoperative planning but are usually not accurate enough by themselves to be relied on to determine a specific advancement. This is because of the large number of variables involved with ptosis correction, including preoperative and postoperative nuances in levator function and lid position, as well as the induced intraoperative variables, such as swelling and changes in neuromuscular activity introduced by local anesthetic and other agents (Fig. 8-8).

Figure 8-6 The levator may be advanced onto the tarsal plate in a controlled fashion for correction of significant degrees of ptosis provided the muscle has adequate function. The initial steps are those required for an upper lid blepharoplasty. A, After local anesthetic is conservatively infiltrated, a curvilinear incision is made in the upper eyelid crease or in a line where a new lid crease will be created. A suborbicularis dissection is carried out superiorly, exposing the orbital septum, which is then opened. B, The preaponeurotic space is exposed, and both fat and levator aponeurosis are visualized. C, The superior tarsal plate is exposed with inferior suborbicularis dissection. Care should be taken to avoid distal tarsal exposure, because hair follicles may be damaged. D, The levator aponeurosis is then freed from the tarsal plate and dissected superiorly.

LEVATOR ADVANCEMENT

A Lid is incised through orbicularis muscle

B Skin retracted exposing levator aponeurosis, cut edge of orbital septum, and preaponeurotic fat

Tarsal plate

CLevator aponeurosis is freed from upper margin of tarsal plate

D Levator aponeurosis dissected cephalad

Continued

Figure 8-6 Continued E, The medial and lateral extensions (horns) of the levator are lysed, and the levator muscle may then be freely advanced. At this point the patient may be asked to look down and then up and the free distal levator should move superiorly under the orbital rim and roof (anterior skull base). F, The levator may then be advanced onto the tarsal plate and temporarily suture-secured. The patient can sit upright with or without the help of an operating table, and the eyelid height and excursions from down gaze to up gaze can be assessed. The process can be repeated with repositioning of the temporary suture until the surgeon is satisfied. G, Permanent sutures may then be substituted and excess levator may be removed distal to the suture fixation. H, Skin closure may be performed as in a blepharoplasty, or supratarsal fixation may be used where the lid fold needs to be accentuated or its height changed (i.e., congenital ptosis). The surgeon should minimize the amount and depth of local anesthetic used because this may affect levator function and compromise intraoperative assessment. One should also remember that epinephrine can stimulate Müller’s muscle and this may “artificially” elevate the eyelid,

resulting in undercorrection. However, slight undercorrection is always a better problem than overcorrection of ptosis.

EMedial and lateral horns divided freeing superior aspect of levator aponeurosis

F Advance levator aponeurosis and suture to tarsal plate

G Trim excess levator aponeurosis

H Intracuticular running suture medial to lateral