scar may help maintain the longevity of the ptosis repair. Tarsectomy can be used in primary and secondary adult ptosis surgery, especially in cases with poor levator function.

Conclusion

External levator resection is a highly versatile procedure that can be used in patients with “levator function” (eyelid excursion) ranging from excellent to poor. Lid contour abnormalities can be addressed as well. A strong knowledge of the

anatomy of the upper lid as well as meticulous surgical technique is crucial. The procedure can be performed under straight local anesthetic or combined with intravenous sedation. The outline presented in this chapter should serve as a useful guide to the surgeon planning to use this approach for ptosis repair.

Suggested Reading

Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External levator advancement vs Müller’s muscle-conjunctival resection for correction

of upper eyelid involutional ptosis. J Ophthalmol. 2005;140(3):426–32.

Patel SM, Linberg JV, Sivak-Callcott JA, Gunel E. Modified tarsal resection operation for congenital ptosis with fair levator function. Ophthal Plast Reconstr Surg. 2008;24(1):1–6.

Bassin RE, Putterman AM. Full-thickness eyelid resection in the treatment of secondary ptosis. Ophthal Plast Reconstr Surg. 2009;25(2):85–9.

Older JJ. Ptosis repair and blepharoplasty in the adult. Ophthalmic Surg. 1995;26(4):304–8 (review).

Erb MH, Kersten RC, Yip CC, Hudak D, Kulwin DR, McCulley TJ. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg. 2004;20(6):418–22.

Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol. 1999;127(6):637–44.

Demartelaere SL, Blaydon SM, Shore JW. Tarsal switch levator resection for the treatment of blepharoptosis in patients with poor eye protective mechanisms. Ophthalmology. 2006;113(12):2357–63.

McCulley TJ, Kersten RC, Kulwin DR, Feuer WJ. Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis. Ophthal Plast Reconstr Surg. 2003;19(5):388–93.

Tucker SM, Verhulst SJ. Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology. 1999; 106(3):517–22.

Pak J, Shields M, Putterman AM. Superior tarsectomy augments super-maximum levator resection in correction of severe blepharoptosis with poor levator function. Ophthalmology. 2006;113(7):1201–8.

Baroody M, Holds JB, Sakamoto DK, Vick VL, Hartstein ME. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg. 2004;52(6):558–61.

Bartley GB, Lowry JC, Hodge DO. Results of levatoradvancement blepharoptosis repair using a standard protocol: effect of epinephrine-induced eyelid position change. Trans Am Ophthalmol Soc. 1996;94:165–73; discussion 174–7.

McCord CD, Seify H, Codner MA. Transblepharoplasty ptosis repair: three-step technique. Plast Reconstr Surg. 2007;120(4):1037–44.

Espinoza GM, Holds JB. Evolution of eyelid surgery. Facial Plast Surg Clin North Am. 2005;13(4):505–10, v (review).

Holds JB, McLeish WM, Anderson RL. Whitnall’s sling with superior tarsectomy for the correction of severe unilateral blepharoptosis. Arch Ophthalmol. 1993;111(9): 1285–91.

Abstract  Small-incision, minimal-dissection external levator advancement results in less disruption of the eyelid retractors. Preserving many of the levator aponeurosis attachments to the tarsus results in reduced operative time and less advancement of the levator needed to achieve satisfactory results.

tion performed­ is in the central 10 mm of the eyelid in the following locations: 1) between the pretarsal orbicularis muscle and the underlying levator aponeurosis, and 2) between the tarsal plate and the levator aponeurosis, from the lower edge of the aponeurosis insertion on tarsus to a point superior to tarsus.

Ptosis has been corrected in many different ways, all of which have some efficacy. What makes this procedure [1] not only unique but also highly successful is the minimal dissection, which leaves many features of the eyelid lifting apparatus intact, so that extra effort is not needed to make up for the lysing of helpful attachments. The procedure is not unique for using a small incision [2, 3], and the small incision is significant, but not critical.

Principle of the Procedure

By disrupting fewer of the attachments with minimal dissection, less tucking is required to obtain the same amount of lift. The only dissec-

B.R. Frueh (*)

Department of Ophthalmology, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA e-mail: daweinberg@hotmail.com

Incision planning:  A vertical mark is made over the center of the pupil, with the patient awake and looking in the primary position. This will be the center of the incision. The incision is marked on the lid crease, approximately 10–12 mm long, centered over the initial mark. The length of the incision is unimportant, as long as there is room to do the dissection.

Anesthesia:  The patient may be sedated with a short-acting drug prior to the injection, or the injection can be made with the patient wide awake. It is important that the patient be wide awake several minutes after the injection, when the patient needs to sit up, to determine the adequacy of the elevation of the lid position accurately. The local anesthetic customarily used by the author is a 50:50 mixture of 1.0% lidocaine with epinephrine 1:100,000 and 0.75% bupivacaine. Local anesthetic is first injected under the skin of the marked incision. The needle is then placed perpendicular to the eyelid, halfway between the center of the marked incision and the lashes. It is inserted until the tarsal plate is felt with the tip of the needle, and enough anesthetic is then injected

to raise a small wheal. Usually, a total of 0.6 cc of local anesthetic or less is adequate for good anesthesia.

Operative details: The skin is incised (the author prefers a sharp stitch-ribbon scissor) along the marking, staying superficial to the orbicularis, if possible, so as to minimize bleeding. Any bleeding is cauterized to make it a bloodless field. Sharp scissors are used to bluntly spread the orbicularis fibers at the incision and then aimed toward the center of the tarsal plate until the tarsal plate comes into view through the semi-transparent levator aponeurosis (Fig. 18.1). The pathway created will be about 10 mm at the skin and 8 mm at the tarsal plate (not necessary to measure – this is just an approximation to guide you). This dissection is preferably bloodless, but should there be bleeding, it is cauterized. The aponeurosis is incised with sharp scissors horizontally over the tarsal plate, just below its vertical center, under direct observation, using multiple small snips to obtain a defect that

is approximately 8 mm wide (Fig. 18.2). The tarsal plate will present a clearer view than it does when viewed through the thin aponeurosis. The lower edge of the skin incision is pulled down and sharp scissors are used to bluntly dissect superiorly under the cut aponeurosis, anterior to the tarsal plate, until it is free from the underlying tarsal plate and Müller’s muscle, a distance of about 12–15 mm (Fig. 18.3). An 8-mm spatula needle on a permanent single-armed 6-0 suture is then passed through this space, in line with the central vertical lid marking, as high as it will reach, and then curved forward and brought out through the upper edge of the incision, just posterior to the orbicularis oculi muscle (Fig. 18.4). The two ends of the suture are then tightly grasped and brought inferiorly, leaving a little slack in the suture. The operative lights are dimmed and the patient is requested to open his/ her eyes and look up. A firm tug should be felt on the tightly held suture if the upper extent of its passage is through the aponeurosis. For the

Fig. 18.1 Cross-sectional view of the lid anatomy, showing that after incising the skin, the orbicularis is bluntly spread to expose the aponeurosis over the mid-tarsal plate

Fig. 18.2 Cross-sectional view of the eyelid with arrow at the aponeurosis incision

Fig. 18.3 Cross-sectional view of the eyelid with the arrow following the blunt dissection under the aponeurosis over the tarsal plate and then Müller’s muscle

Fig. 18.4 Cross-sectional view of the eyelid showing the needle passage through the dissected space and then through the posterior surface of the aponeurosis and out of the anterior surface, posterior to the orbicularis oculi muscle

infrequent times that a firm tug is not felt (less than 5% of the time in the author’s experience), the suture is re-passed and the pull on upgaze rechecked. Having demonstrated that the aponeurosis has been engaged by the suture, the tarsus is lifted from the cornea and held there, while the needle is passed horizontally through the tarsal plate in mid-tarsus, centered on the vertical central lid mark. Once the needle is placed in tarsus, the eyelid is everted to check the posterior tarsal surface, making certain that the suture is not exposed. The suture is tied with a slip knot over a surgeon’s knot, leaving the suture at the correct tension that will hopefully place the eyelid at the desired position.

The patient is then asked to sit up and open his/her eyes. The eyelid height and contour are inspected. The suture tension is adjusted until the height seems optimal. If the eyelid cannot be elevated sufficiently, the suture is removed and replaced higher in the aponeurosis or lower in the tarsal plate. If the lid appears low medially or laterally, the dissection is extended in that direction by incising the skin, extending the