Ординатура / Офтальмология / Английские материалы / Atlas of Aesthetic Eyelid and Periocular Surgery_Spinelli, Lewis, Elahi_2004
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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E R Y
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Figure 8-8 An 18-month-old child with left congenital ptosis had undergone previous surgery by another surgeon at 14 months of age. He presents with residual ptosis and lid lag (lagophthalmos) and asymmetric lid folds. The low fold on the congenitally ptotic side is caused by the low incision line initially used. Preoperative examination showed enough levator function to perform a ptosis repair using the levator muscle by way of an advancement procedure. Elevation of the lid fold would be necessary to achieve external lid symmetry independent of eyelid height (ptosis correction). I chose to perform a distal and proximal dissection over the tarsal plate with supratarsal fixation at the desired height along with a levator advancement procedure to address his lid fold asymmetry and eyelid ptosis, respectively. Because of his age, the procedure required general anesthesia. A, Photograph of the child before his initial surgery taken by another surgeon. Note the ptotic eyelid on the left side and absent lid fold. B, The patient at consultation with me. Note the ptosis in primary gaze. C, Despite ptosis in primary gaze there is lid lag on down gaze as well as asymmetric eyelid creases which the primary surgeon created. Continued
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Figure 8-8 Continued |
D, The incision line chosen is at the correct or matching height from the lash line as on the contralateral side. Wide |
distal and proximal undermining was performed in the suborbicularis plane. E, The levator was freed from the tarsal plate, the medial and lateral horns completely lysed, and the levator, along with loosely attached preaponeurotic fat, was advanced. Note the fibrotic and pale nature of the soft tissues. F, The levator was then reattached to the tarsal plate and excess levator aponeurosis amputated. G, Supratarsal fixation was used to create a lid fold at the appropriate height by apposing skin to levator aponeurosis on both sides of the incision. H, The skin closure was completed using the supratarsal fixation technique. I, The patient at approximately 3 months after the procedure.
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Ptosis Correction Using Exogenous Muscle
Action (Frontalis Sling)
Some of the more unsatisfying procedures for ptosis correction are the use of muscles outside the lid to serve as a lid elevator. These are, unfortunately, the only viable options when intrinsic levator function is not adequate. The more important of these procedures is the frontalis sling procedure, which uses a static linkage between the upper eyelid and the overlying brow. Lid elevation is achieved with contraction of the frontalis by way of eyebrow elevation. The procedure produces significant lid lag and corneal exposure, and it is important to preoperatively assess the presence or absence and degree of Bell’s phenomenon in addition to all of the other parameters that are routinely assessed in ptosis evaluation. There are a plethora of materials that have been described as appropriate in performing these sling procedures. These include Silastic tubing, Superamid and other alloplastic materials, as well as preserved fascia and autogenous fascia. Autologous tissue such as fascia lata or palmaris longus tendon tend to have the longest duration, most stable correction, and least complications associated with them.
A number of configurations of the frontalis sling have been proposed and include single rhomboids, double rhomboids, and various permutations of triangles. Each of these may be satisfactory, but none of them is ideal, given the underlying conceptual and practical limitations of this procedure.
The frontalis sling with a double rhomboid is performed by marking areas medially, centrally, and laterally at the superior border of the eyebrow hairs. The lower surgical incisions are delineated across the tarsal plate approximately 3 mm superior to the lash line. Local anesthetic with epinephrine is infiltrated, and
adequate time for hemostasis is allowed to elapse. Stab incisions are made at each of these marks extending down to the periosteum in the brow region and to the tarsal plate in the lid. A long curved or straight needle (i.e., Wright) is used to pass two separate pieces of fixation material (i.e., fascia) from the medial and lateral brow incisions, respectively. Each piece of fascia or other material is passed deep to the orbicularis muscle from the brow through the pretarsal area and back to the brow area. Locking sutures such as 4-0 Vicryl may be used to reinforce the sling ties, and it is generally useful to slide the knots through the subcutaneous tunnels away from the incision lines to obviate extrusion. The undersurface of the upper eyelid should be everted before tying any knots on these slings to ascertain whether there is any exposure or conjunctival penetration, because this will lead to corneal irritation and breakdown. Fascia or other material that is exposed should be removed and repassed. This procedure is generally performed with the patient under sedation or general anesthesia and with infiltration of local anesthetic with epinephrine. These agents limit frontalis muscle action and the ability of the surgeon to assess appropriate elevator action to the sling. It is helpful to tighten the sling so that the upper lid either pulls away from the globe or reaches the superior limbus or corneoscleral junction. The upper eyelid should be set at a lower level if the patient has a poor Bell reflex or poor seventh cranial nerve or orbicularis function. The greater the patient’s inability to forcibly close his or her eyes, the closer one should set the upper lid to the visual axis. Skin closure can then be performed in layers, and a temporary tarsorrhaphy to protect the cornea in the immediate postoperative period may be used, especially when compensatory mechanisms for corneal coverage are weak or compromised (Fig. 8-9).
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FRONTALIS FIXATION (no levator function)
Subcutaneous placement of suspension material
to create a static sling
Protective
contact lens
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Figure 8-9 The frontalis sling, like all other static eyelid procedures, depends on exogenous forces to elevate the upper lid. In this case, the eyebrow is the primary provider and this, like all other static procedures, is nonanatomic with obvious pitfalls. Illustrated here is a double suspension technique in which fascia is used to connect the eyelid to the eyebrow. Three incisions are located approximately 3 mm above the lash line and three above the eyebrow (top). The upper incisions extend to the periosteum and the lower to the tarsal surface. A long curved needle (i.e., Wright) is used to pass two separate pieces of fascia from the preperiosteal to the pretarsal planes and back. Care must be taken to avoid passing the fascia through the conjunctival surface (bottom). Although a number of permutations for fascial linkage and placement exist, the technique used in this drawing requires linking the fascial strands together both with knots and a reinforcing absorbable suture (insert). The upper lid height should be set at the limbus for patients with good Bell’s and lid protractor function. For those with poorer protective mechanisms, the lid should be set at a lower level. Skin incisions can then be closed in layers, and a temporary tarsorrhaphy is sometimes necessary in those patients who are not capable of protecting their eyes initially.
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Upper Eyelid Retraction
Upper eyelid retraction usually occurs as a sequela of previous trauma or surgery. Upper lid retraction results from compromise, shortening, or fibrosis of the underlying eyelid elevator system and should be distinguished from seventh cranial nerve paralysis or orbicularis muscle dysfunction in which there is adequate uncompromised “slack” in the lid elevator system but the inability to close the eye is caused by failure neurologically or mechanically to initiate or complete the closure reflex. This is a distinctly different entity from true eyelid retraction, in which there is infiltrative, post-
traumatic, or surgical tethering of the upper eyelid at the middle lamella level. This may occur in Graves’ disease or in other infiltrative phenomena. It may also occur in the case of overcorrection of ptosis, especially with levator advancement or Fasanella-Servat procedures. In the case of a deficiency of both the middle and internal lamella (conjunctiva), a composite graft such as a mucoperiosteal palatal graft may be used as an interposition between the levator/conjunctival surface and the superior border of the tarsal plate. This is similar to the procedure described for lower lid retraction, with the exposure and dissection similar to that used in ptosis correction (Fig. 8-10).
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Figure 8-10 A patient with eyelid retraction after overcorrection of acquired ptosis by another surgeon. Note the involuntary eyebrow asymmetry as the patient attempts to compensate for the condition. Another interesting and even more important compensatory mechanism is contralateral upper lid ptosis. This is caused by the concept of equal and opposite innervation to both eyelids. In the case of eyelid retraction, the brain will send less elevational drive to the retracted eyelid and, because of an inability to innervate each lid differently, the relaxation will be mirrored in the contralateral normal eyelid, resulting in relative ptosis on that side. The converse is true in primary ptosis cases, and this produces eyelid retraction on the contralateral normal side.
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A deficiency in the middle lamella either from Graves’ disease or iatrogenically after a previous ptosis procedure is more common. In these instances, I prefer autogenous deep temporal fascia as an interposition graft, although the ophthalmic literature is filled with other suggestions (e.g., banked scleral, banked fascia). In general, allografts are plagued by unpredictable longterm results. In cases of orbicularis or facial nerve compromise, simply weighing down the upper lid may serve as either a temporary or permanent solution, and this can be achieved with a pretarsal gold weight insertion. In these cases, providing additional upper lid weight is all that is needed to lower the upper lid and provide adequate corneal coverage on attempted closure. Preoperatively, with the patient awake, an appropriate weight may be taped to the outside of the eyelid to achieve the desired lid height. Basically, a minimal weight may be chosen from a trial kit that allows the upper eyelid to drape and move most appropriately. At surgery, an upper lid crease incision is made and dissection is carried down distally, raising an orbicularis myocutaneous flap. The underlying tarsal plate should be exposed and care should be taken not to carry the dissection distally to the hair follicle margin. This will result in loss of lid cilia and/or distichiasis. The appropriate gold weight is then fixed to the anterior tarsal plate, being careful not to place the weight above the superior margin of the tarsus. This is a common etiology for postoperative sulcus obliteration, lid malposition, or underutilization of the mass engendered by the gold weight. Temporary suture fixation above and below, utilizing an absorbable suture (i.e., 5.0 Vicryl), is all that is necessary, and skin closure is performed as described in Chapter 4. I have never had a malpositioned gold weight or one dislodge after an appropriate pretarsal pocket is made, and temporary immobilization is performed as described earlier.
Lid retraction due to fibrosis, trauma, previous ptosis surgery, or infiltrative disease such as Graves’ disease is
best corrected with recession of the levator and Müller’s muscle complex with placement of an interposition autogenous graft. The patient is appropriately sedated, and an upper lid crease incision is designed. Local anesthetic containing epinephrine is infiltrated, and adequate time for hemostasis is allowed to elapse. Dissection is carried down through skin and orbicularis, and with the use of an insulated needle cautery the levator aponeurosis and tarsal plate are exposed as in the description for correction of ptosis. It is necessary to free the levator and Müller muscle complex from the underlying conjunctival surface by a similar dissection as described previously. The entire complex is disinserted from the tarsus, and the medial and lateral horns of the levator aponeurosis are severed, with a dissection carried out posterior to the orbital septum. Deep temporal fascia is harvested with a small incision in the coronal plane below the palpable temporal line of the skull. An appropriate amount of deep temporal fascia can easily be harvested in minutes, and the scalp may be closed with staples or sutures as the surgeon desires. I prefer to use a few deep absorbable sutures followed by staples or a running 3-0 absorbable suture. The fascia is then interposed between the free edge of the levator aponeurosis and the superior edge of the tarsal plate and sutured into place. Approximately a 2:1 ratio of fascia to degree of retraction is necessary to appropriately lengthen the lid. Several interrupted absorbable sutures (5-0 Vicryl) on both the distal and proximal ends of the interposition graft are all that is necessary for stabilization and fixation. Skin closure is performed as described in Chapter 4, and the lid crease may be created with supratarsal fixation when appropriate (see Fig. 4-6). Temporary tarsorrhaphy or Frost sutures are especially useful in these procedures in the immediate postoperative period. These provide immobilization of the graft, adequate maintenance of length, and general patient comfort (Figs. 8-11 and 8-12).
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LEVATOR SPACER FOR LID RETRACTION
A Lid is incised through orbicularis muscle
B Skin and orbicularis muscle are retracted exposing levator aponeurosis, cut edge of orbital septum, and preaponeurotic fat
Figure 8-11 The levator muscle may be recessed instead of advanced; however, a spacer is needed when recession is above the level of the superior tarsal border. The procedure entails the same technique and maneuvers as used in levator advancement until the recession step. A, An upper lid incision is made.
B, The levator aponeurosis and levator muscle are exposed transseptally. C, The tarsal plate is exposed distally in the suborbicularis plane. D, The levator is freed in a distal-to-proximal dissection. E, The medial and lateral horns of the levator are divided.
C Upper margin of tarsal plate is dissected free
D Levator aponeurosis dissected cephalad
EMedial and lateral horns are divided freeing superior aspect of levator aponeurosis
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Figure 8-11 Continued F, An incision is made in the coronal plane overlying the temporalis muscle. The donor site can be made inconspicuous by beveling the incision according to the direction of hair growth, approximating the temporal line superiorly and curving it well behind the anterior hair line. It is helpful to delineate the incision preoperatively by having the patient masticate and palpating the underlying anatomy of the temporalis muscle. I harvest a large section of fascia and then split or contour it according to the requirements of the recipient site or sites. Despite the sequence depicted here, I usually harvest the graft first and close the donor site before beginning the eyelid aspect of the procedure. I find this speeds the entire procedure and obviates head movement after the eyelid has been incised. G and H, The deep temporal fascial graft is then used as a spacer between the levator aponeurosis and the tarsal plate. I find it easier to first suture the graft to the tarsal plate and then contour or trim the graft and appose the levator aponeurosis to the superior edge of the graft; however, either way is acceptable. I, Finally skin is approximated and whenever possible I use a temporary tarsorrhaphy postoperatively.
F Deep temporal fascia (DTF) harvest
G Graft sutured to tarsal plate
HDTF graft sutured to free end of levator aponeurosis
IClosure - intracuticular running suture medial to lateral
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Figure 8-12 The clinical sequence for autogenous facial upper lid interposition lengthening requires only a few additional techniques beyond what has already been described for levator surgery in the case of ptosis. A, The deep temporal fascia is harvested with a small incision in the hairline below the temporal line. Closure without drains may be performed as described in the text. B, The levator is completely freed distal to the tarsal plate as well as medially and laterally. Remember the lateral horn of the levator divides the lacrimal gland. In this case, with significant previous surgery by others, there is a great deal of fibrosis and the right forceps overlies a small segment of exposed lacrimal gland. Note the thickened and whitened fibrotic tissue of the levator distracted by the left forceps. C, Fascial graft is interposed between the levator and tarsal plate. Here a lateral view shows the width of the temporal fascial graft, which is tented by the two forceps as it is being inset. D, Another patient with the facial graft already sutured to the tarsal plate and inset on the left side (nasal) to the levator after the desired length and width is created. The forceps is engaging the temporal side in preparation for the placement of a stabilizing suture. E, Same patient as seen in D preoperatively. F, Same patient postoperatively as in the previous two photographs (D, E). This is approximately 1.5 years after the lengthening procedure. Note the relative symmetry of eyelid position; however, there remains a modest superior sulcus deformity on the treated left side.
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