Techniques

The preoperative preparation is identical whether using the lamellar or en bloc full-thickness eyelid resection technique. Pay detailed attention to MRD1, eyelid margin contour, and palpebral fissure height at various points along the horizontal axis of both upper eyelids. Additionally, record the margin-to-crease distance (MCD) as well as the margin-to-fold distance (MFD); the latter is the vertical distance between the eyelid margin and the skin draping over the eyelid crease in some patients. Compare these measurements between the two upper eyelids. Asymmetric MCD or MFD, which result in asymmetric tarsal platform show, is often more cosmetically bothersome to patients than true eyelid margin blepharoptosis. We believe that a crucial component of blepharoptosis correction is the attainment of symmetric tarsal platform show. It is our experience that the majority of patients who are candidates for full-thickness blepharoptosis correction surgery have a higher eyelid crease on the ptotic eyelid and that the vertical distance between the existing and desired crease positions equals the amount of needed blepharoptosis correction (Fig. 22.3a). Thus, the ensuing description of surgical techniques applies to this patient presentation. Management of asymmetric MCD is discussed in the challenges and solutions section of this chapter.

The amount of tarsus to be resected is the predetermined millimeter-for-millimeter difference between the preoperative eyelid margin level and the target eyelid margin level. Photographic documentation of both eyes is especially useful for preoperative planning and intraoperative comparison.

sutures, however, because this will shorten the eyelid crease to 7 mm. The superficial closure should be performed at the level of the preexisting eyelid crease, incorporating levator aponeurosis if a harsh crease is desired, and preserving the inferior 10 mm of MCD

a

x y

d Skin and

Fig. 22.3  Lamellar dissection technique. (a) The majority of patients have a higher crease on the ptotic eyelid, as shown here. On the ptotic right upper eyelid, long dashed line represents the desired crease position and short dashed line represents the desired eyelid margin position, both matching the fellow nonptotic eyelid. The vertical amount of eyelid crease asymmetry (x) is equal to the amount of blepharoptosis correction needed (y), thus x = y. The initial incision should be made at the existing eyelid crease and tissue excision should be performed inferior to the crease. (b) Cross-sectional view of this eyelid. (c) 3 mm of superior tarsoconjunctiva is to be excised, and 3 mm of skin orbicularis flap is to be excised. (d) Deep closure is achieved by suturing the cut edge of tarsus to the cut edge of levator aponeurosis. The anterior lamella cannot be closed at the same level as the deep

Lamellar Technique

Use a marking pen to trace along the existing eyelid crease. Local anesthesia, usually consisting of 2% lidocaine with 1:100,000 epinephrine and hyaluronidase, is sparingly infiltrated into the upper eyelid along this marking. A protective corneal shield may be inserted at this point. Use a #15 blade to incise skin and orbicularis muscle along the marking. With Stevens scissors, carry the dissection inferiorly in a plane anterior to the levator aponeurosis, until the superior tarsal border is encountered.

Reflect the skin–orbicularis muscle flap such that the next step of surgery is performed beneath the flap. The #15 blade is now used to make a near full-thickness horizontal incision just superior to the superior tarsal border, cutting through all tissues anterior to the conjunctiva. Use scissors to expose the superior anterior surface of tarsus along the full horizontal length of the area to be operated, excising all pretarsal tissue including levator aponeurosis and intercalated scar tissues. On the bare anterior tarsal surface, use calipers and marking pen to delineate the segment of tarsus and underlying conjunctiva to be excised, from the superior tarsal border extending inferiorly toward the eyelid margin. The amount of tarsoconjunctival excision corresponds to the predetermined millimeter-for-mil- limeter difference between the preoperative and proposed eyelid margin positions. In the case of segmental upper eyelid contour deformity, divide the horizontal length of the tarsus into segments to facilitate accurate marking. For example, if the medial one-third of the eyelid is 2 mm low, the central one-third of the eyelid is 1 mm low, and the lateral one-third of the eyelid is 2 mm low, mark this amount of tarsus for excision from each segment respectively. Once satisfied with the markings, use either the #15 blade or a Stevens or Wescott scissor to excise the desired amount of tarsus and underlying conjunctiva.

Place three interrupted simple vertical sutures centrally, centromedially, and centrolaterally, using 6-0 resorbable material on a half-circle spatula needle. First, pass the suture through the

cut edge of the tarsal plate in a very deep lamellar fashion, then through the cut edge of the levator aponeurosis. Care is taken to avoid penetration of the conjunctiva. In cases with scarring and cicatricial loss of defined tissue planes, the tarsus may be sutured to scarred tissues superiorly. Some surgeons may choose to tie these sutures in a slip knot, sit the patient upright, and inspect the eyelid contour and eyelid margin level. If a corneal protector was inserted during the case, it should be removed so that the pupil and corneal light reflex are visible while gauging eyelid position. After inspection, residual irregularities may be repaired by adjusting suture tension or excising additional tissue. The eyelid margin position should be reinspected after each manipulation.

At this point, the posterior lamella reconstruction has been completed, and satisfactory eyelid margin position and contour have been achieved. Attention is now turned to trimming the excess skin–orbicularis flap. In the typical patient described, this excision starts from the superior edge of the reflected pretarsal skin– orbicularis flap. Care must be taken to preserve the vertical anterior lamella distance from the eyelid margin superiorly that is equal to the desired MCD (Fig. 22.3b–d). If the fellow nonptotic eyelid has excess skin draping over the eyelid crease, then the surgeon may consider purposely leaving excess skin to match the MFD of the fellow nonptotic eyelid, or perform blepharoplasty on the fellow nonptotic eyelid. Again, the goal is to achieve symmetric tarsal platform show.

Prior to skin closure, the surgeon should decide whether a soft or harsh eyelid crease is desired. Recall that the anatomic definition of an eyelid crease is the superior-most insertions of levator muscle fibers to the skin [8]. To achieve a soft crease, use several interrupted or a continuous running suture to close the skin edges only. A harsh crease is formed by incorporating 1–2 mm of levator aponeurosis into the skin closure with every other stitch such that the skin is adherent to the levator aponeurosis and the eyelid crease is clearly visible with the eyelids closed.