8.3 Surgical Technique of Levator Muscle Recession

Fig. 8.4 T he tape-down test of the left upper lid shows that the right brow is only elevated if the left lid is lowered. A left levator recession is indicated

suspension is only necessary on the side of the original ptosis. The difficulty is to adjust the amount of recession precisely just to stimulate the brow elevation. An excessive recession will create a ptosis that cannot be compensated by the brow elevation.

The difficulty of adjustment can be avoided if a total levator recession is performed to create a marked ptosis, which will be corrected with bilateral brow suspension.

Summary for the Clinician

■Patients must be checked for amblyopia, unilateral dominance, or ocular deviation.

■The tape-down test predicts whether compensatory brow elevation can be expected.

■The Hering pattern of bilateral frontalis innervation must be present.

8.3Surgical Technique of Levator Muscle Recession

8.3.1Principle

The levator muscle is transsected in the level of the fornix posterior to the fusion of the aponeurosis into the levator muscle and anterior to the Whitnall ligament. The advantage of this high approach is the reduced horizontal extension of the levator incision (10 mm) and more effective recession of the levator [9]. (Alternatively, the aponeurosis and the Müller muscle can be transsected at a lower level, but the transsection must be carried out over 30 mm from the medial to the lateral canthus to be

Fig. 8.5 T he ideal level of the levator recession is the high level because the incision is shorter and the effect on the subsequent rise of the skin crease is much less than the lower incision of the aponeurosis

effective and causes secondarily a much more pronounced rise of the lid crease; Fig. 8.5.)

8.3.2 Approach to the Levator

The transcutaneous approach is recommended because it offers better exposure of the high portions of the levator complex near the Whitnall ligament and leaves the conjunctiva and the fornix intact. A typical blepharoplasty skin incision can be used to divide the orbicularis muscle and expose the orbital septum. The orbital septum should be opened widely over more than 25 mm to be able to retract the preaponeurotic fat pad and expose the surface of the levator complex.

8.3.3 Partial Levator Recession

To localize the level of the incision, a malleable blunt spatula is introduced into the upper fornix. The upper margin of the spatula marks the incision line where the levator tissue is incised horizontally, leaving the underlying conjunctiva intact. The result is the formation of a gap with a width of about 12 mm in the levator sheath and significant lowering of the upper lid. To limit the amount of the recession, we can insert a patch of fascia lata into the gap (Figs. 8.5–8.11).

8.3.4 Total Levator Recession

After introducing the spatula into the fornix, the levator is transsected horizontally at two levels, first at the level of the Whitnall ligament and then at the junction of the

Fig. 8.6 Exposure of the levator after having opened the orbital septum. The spatula is introduced into the upper fornix up to the level of the Whitnall ligament

Fig. 8.9 T he spacer tissue is introduced into the gap of the recessed levator

Fig. 8.7 T he upper margin of the spatula marks the area of the levator transsection, which will be performed in the central third of the lid, leaving the conjunctiva intact

Fig. 8.10 Left congenital ptosis with amblyopia and without spontaneous brow elevation

Fig. 8.8 If no fascia lata had been extracted from the limb, the fascia of the subbrow fat pad (ROOF) could be harvested as spacer tissue

Fig. 8.11 After partial levator recession on the right side, the bilateral brow elevation is stimulated, and the left lid could be elevated via brow suspension