tarsus, or a combination of the two. A positive response (eyelid elevation) to the administration of preoperative phenylephrine drops is needed before performing a Muller’s muscle/conjunctival repair [6]. This approach is quick, easier than levator surgery, requires no skin incision, yields generally reproducible results, and requires no patient cooperation. This has made posterior approach ptosis repair popular amongst eyelid surgeons. Its main drawbacks are that it is nonanatomic, carries a risk of corneal abrasion, and does not allow intraoperative adjustment of lid height.

Anterior, or levator, ptosis surgery is a more complex procedure which requires a detailed knowledge of eyelid anatomy. In addition, the surgery involves an intricate dissection of the various layers of the eyelid, is time intensive, requires patient participation, is best performed with the patient awake, and carries a higher incidence of postoperative adjustment than its posterior counterpart [7]. It is advantageous in that it is powerful, anatomic, can be employed when posterior surgery is not indicated (poor response to phenylephrine drop testing), and can be titrated during surgery.

Which procedure is better is up for debate and the preference of the ptosis surgeon. As posterior ptosis repair is quick, simpler, and useful in most mild/moderate ptosis patients; the novice ptosis surgeon should be comfortable with the surgery. In this chapter I will review levator ptosis repair. Familiarization with this procedure is essential to the ptosis surgeon. However, this can be a difficult procedure to perform and attain acceptable outcomes, and has a steep learning curve. The noneyelid specialist should pursue appropriate training before undertaking this form of surgery.

12.3Patient Evaluation

Patients with ptosis may have a tired look, complain of reduced field of vision, and have headaches from chronic brow elevation. These symptoms can also be present with dermatochalasis, with or without ptosis. As stated previously, noting what lid pathology is present (ptosis, excess lid skin, fat) and to what degree it affects field of vision and appearance will help the surgeon and patient determine what procedures are necessary to attain the desire outcome.

Upper lid ptosis can be an early finding of a potentially serious neurological problem such as myasthenia gravis, third nerve pathology, or Horner syndrome [2–4]. These disorders must be ruled out prior to proceeding with any form of surgery. All patients should be questioned as to the duration and onset of the problem. In general, long-standing ptosis is more likely to have a benign etiology. On the other hand, a sudden onset of ptosis may be an early indicator of a more serious problem. Diplopia is a concern with the ptosis patient. It can be seen in myasthenia gravis and third nerve paresis. Patients with myasthenia gravis may also manifest variability of their ptosis. An enlarged (dilated) pupil can be present

Fig. 12.1 Levator excursion is measured by having the patient look down (a) and up (b) and measuring the excursion of the upper lid in millimeters

in third nerve paresis and a miotic (constricted) pupil in Horner syndrome. A severe headache and decreased facial sweating are a few of a variety of symptoms which may manifest in Horner syndrome. If any of these findings/complaints are identified on the history or examination, a prompt referral to a specialist is warranted. Once serious ptosis pathology has been ruled out, surgery can be considered.

In general, patients with involutional ptosis have a high lid crease and normal levator function [2, 4]. A normal lid crease is at approximately 10 mm above the lid margin. As the levator aponeurosis is attenuated/disinserted in involutional ptosis, the aponeurosis retracts and the crease elevates. However, while the aponeurotic attachments to the lid are higher, the levator muscle still typically functions normally. A normal levator function is 15 mm in adults. This is measured by assessing the excursion of the eyelid between downgaze and upgaze with the eyebrow fixed (Fig. 12.1). In addition to levator function and crease position, other standard lid parameters assessed should include the margin reflex distance 1 (MRD1), and the vertical palpebral fissure distance. The MRD1 is the distance between the corneal light reflex and the upper lid margin (Fig. 12.2). It is a true measure of eyelid ptosis as its reference point is the center of the pupil (light reflex). This measurement is not affected by lower lid position. The vertical palpebral fissure measures the

Fig. 12.3 The vertical palpebral fissure is determined by measuring, in millimeters, the distance between the upper and lower lid margin

Fig. 12.4 After instillation of topical anesthetic, Schirmer strips are placed in the inferior fornix and measured after 5 min

distance between the upper and lower lid margin (Fig. 12.3). It can be affected by both upper and lower lid position (i.e., lower lid retraction will increase this measurement) and thus is not the best measure of ptosis. A normal MRD1 is 3.5– 4.5 mm. A normal adult vertical palpebral fissure is 10 mm.

An assessment of the Bell’s phenomenon and orbicularis strength is important. The orbicularis strength is assessed by asking the patient to squeeze his or her lids tightly shut while the examiner attempts to pry them open. In a normal setting, it should be difficult to open the lids. To assess the Bell’s phenomenon, ask the patient to relax the squeezing somewhat, manually open the lids, and check if the eye elevates under the upper lid. A normal response is elevation. When the Bell’s mechanism and orbicularis strength is normal, the patient has inherent corneal protection from potential postoperative exposure symptoms. If either is reduced, there is a higher risk or corneal compromise. The same is true if preoperative lagophthalmos or lower lid retraction is present.

Examining the cornea is important with regard to dry eye symptoms. Any evidence of dry eye, corneal epithelial disease, or exposure may be a contraindication to surgery. Even with a normal-appearing cornea, the patient should be questioned about dry eye symptoms and whether or not artificial

Fig. 12.5 The Zone-Quick can be performed in only 15 seconds without topical anesthesia

tear supplements are used. Schirmer testing, though not completely reliable, is still one objective way of measuring tear quantity and should be performed on every patient (Fig. 12.4) [8]. A strip of filter paper is placed in the lower conjunctival fornix of each eye for 5 min, and the amount of wetting of the filter paper is measured in millimeters. The Zone-Quick (Oasis, Glendora, CA) [9] technique can also be used. Fine cotton threads are placed in the inferior fornices of the eyelid for only 15 seconds (Fig. 12.5). When the threads become wet, they turn red. The amount of redness,

again in millimeters, is measured. This test is quick and less irritating to the eyes. Finally, the presence of redundant upper eyelid tissue (skin, fat) should be determined so as to plan appropriately for the addition of blepharoplasty.

A final note on preoperative evaluation is that while the phenylephrine test is a necessary component of posterior ptosis surgery via conjunctival/Muller’s muscle resection, it can also be helpful in levator resection patients [1]. If there is a positive response, it can demonstrate to the patient how the elevated eyelid may appear postoperatively [7]. Also, I have found that patients who respond well to phenylephrine drop testing also respond well to levator advancement surgery.

12.4Anatomy

Fig. 12.6 An artist’s rendition of the eyelid crease in Caucasians. The crease (dotted line) is formed by the superior aponeurotic attachments to the orbicularis muscle and eyelid skin

The eyelid is a dynamic structure which provides protection to the globe as well as conveys facial expression. Eyelid skin is the thinnest in the body with essentially no subcutaneous fat. The upper eyelid skin can be divided into two segments named for the underlying division of its associated orbicularis muscle counterpart. The pretarsal skin is below the eyelid crease and is firmly adhered to underlying tissue. The preseptal skin is above the eyelid crease, and is relatively mobile and lax allowing for eyelid movement.

The orbicularis oculi muscle, the sphincter (protractor) of the eyelid, consists of a palpebral (preseptal, pretarsal) and orbital component. The preseptal division overlies the orbital septum and the pretarasal segment the tarsus. The orbital division overlies the orbital rim and the corrugator muscle in the central lower forehead. As the orbicularis muscle is responsible for eyelid closure, it is recommended not to routinely debulk large amounts (especially with advancing age) of the muscle during surgery. Excessive muscle excision can leave the patient at risk for poor eyelid closure and exposure symptoms after surgery, even in the face of appropriate excision of skin. Also, maintaining the orbicularis muscle can enhance volume of the upper lid [10].

Beneath the skin and preseptal orbicularis muscle is the orbital septum. The septum is a dense connective tissue band which originates from the arcus marginalis of the superior orbital rim. The arcus marginalis is the fusion point of perisoteum overlying the orbit and frontal bone. In Caucasians, the septum inserts onto the levator aponeurosis several millimeters above the superior tarsal border. The eyelid crease is formed by the attachment of fibers of the distal levator aponeurosis to the orbicularis muscle and skin (Fig. 12.6). When the fusion of the septum to the aponeurosis occurs below the superior tarsal border, as in Asian individuals, it allows eyelid fat to lie more inferiorly, resulting in more fullness of the upper lid with blunting of the crease (Fig. 12.7).

The orbital septum is the anatomic landmark which separates the eyelid proper from the orbit [11]. Posterior to the septum are the eyelid fat pads, and below the fat is the levator

Fig. 12.7 In Asian patients, the crease is absent or indistinct. Note the lower attachment of the septum to the aponeurosis/tarsus, allowing fat to descend in the eyelid and blunt aponeurotic attachments to the skin

aponeurosis. Identifying the aponeurosis, the critical structure for surgical repair, is the single most important step in surgery. The nasal fat pad is whiter in appearance and denser. The central fat pad, which lies on the levator, is yellow and more flaccid. There are only two fat pads in the upper lid (as opposed to the lower lid). Laterally, the upper lid may have a visible lacrimal gland (if it is prolapsed). Exercise caution when dissecting in this area so as not to inadvertently excise or damage the lacrimal gland. Care should also be taken not to overresect the central fat pad, as its natural tendency is to involute with age. This may lead to a hollowed upper sulcus postoperatively.

The levator aponeurosis, the tendon of the levator muscle (predominant retractor of the upper lid), lies just beneath the eyelid fat pad. The levator muscle originates from the posterior orbit at the lesser wing of sphenoid, extending anteriorly until approximately 15 mm from the superior tarsal border, where it becomes the fibrous aponeurosis. The muscle/ aponeurosis transition occurs at Whitnall’s ligament. The levator aponeurosis continues inferiorly until it attaches to

Fig. 12.8 A schematic of upper lid anatomy depicts all relevant anatomic structures

the anterior tarsal plate. Muller’s muscle and conjunctiva are loosely adherent to the underside of the levator. During surgery, the levator can be gently dissected free from Muller’s muscle for several millimeters superior to the tarsus. This allows isolation of the aponeurosis for resection/advancement. This should be done with care so as not to disturb the vascular arcades of the eyelid with resultant hematoma. Immediately posterior to the conjunctiva is the globe. It is recommended to place a corneal protector when dissecting in this area.

The tarsal plate lies posterior to the pretarsal orbicularis muscle. It is made up of dense connective tissue and provides the structural support to the lids. In the upper lid, the central tarsus is about 10 mm in vertical height [10, 11]. The tarsus is also an important landmark in levator ptosis surgery as it is the anchor point for levator reattachment during surgery.

Figure 12.8 depicts the relevant anatomic structures of the upper eyelid.

12.5Procedure

A basic blepharoplasty tray is used for the procedure. The lid crease is marked with a fine-toothed marking pen. I prefer to use the patient’s natural crease if it is present and favorably positioned. If the lid crease is significantly elevated, as in many patients with involutional ptosis, or if there is no visible crease, the incision is marked at approximately 10 mm from the central lid margin in women and at 8 mm in men. The crease is then tapered nasally and temporally to 5–6 mm from the margin to an endpoint of the puncta nasally and the canthus temporally. In Asians, the crease is drawn at a lower position as described in Chap. 14. When blepharoplasty is added, I demarcate an ellipse for skin excision. Even in isolated ptosis repair, I often excise mild amounts of skin, as the preoperative lid depression masks a degree of excess skin (latent dermatochalasis). That stated, it is important to note that caution must be taken when simultaneously lifting the lid and excising skin, to maintain

Fig. 12.9 After marking the lid, the local anesthetic mixture is infiltrated just beneath the skin, using minimal volume

postoperative lid dynamics (function, closure), and prevent exposure symptoms. An awareness of appropriate skin excision comes with surgical experience. In those cases when no skin excision is warranted, only the lid crease is demarcated [12, 13].

The eyelid skin is infiltrated with a 50:50 mixture of 2% lidocaine with 1:100:000 epinephrine and 0.5 or 0.75% bupivacaine. The solution may be buffered with sodium bicarbonate for pain control [14]. I do not add hyaluronidase to the mixture, as it may cause inadvertent spread of the anesthetic into the levator muscle, reducing native levator excursion and the surgeon’s ability to accurately assess intraoperative lid position. The local anesthetic is infiltrated just beneath the skin (Fig. 12.9). It is important to use a minimal volume of anesthetic solution (1 cc or less, if possible), as the mechanical effect of volume can also cause spread of the solution to the levator muscle and reduce surgical accuracy. A small amount of local anesthetic is also injected subcutaneously over the central tarsus where the tarsal sutures will be passed. I avoid intramuscular infiltration to prevent hematoma formation and swelling. Intravenous sedation may be added, but with caution, as the patient must be fully cooperative during the lid adjustment phase of the surgery. I do not perform this procedure under general anesthesia as it is difficult to know how much to advance/resect the levator without patient cooperation. In the unusual circumstance where conditions dictate general anesthesia, a mild plication of the aponeurosis may be safest so as not to result in an overcorrection.

Following injection of anesthetic, topical anesthetic is instilled in the eyes, and the patient undergoes full face prep with a head drape and split sheet to leave the entire face exposed. Patients are more comfortable with the entire face left open,

and it allows both eyes to be compared during the procedure. A rigid corneal (or eye) shield is placed over the eye to protect the globe during the procedure.

The eyelid skin incision is made with a No. 15c blade along the demarcated line(s) (Fig. 12.10a). The skin is excised (if performed) with a Wescott scissors, Colorado needle, Ellman radiofrequency unit (Ellman International, Inc., Oceanside, NY), or CO2 laser. Hemostasis is obtained with bipolar or monopolar cautery. With an assistant retracting the superior skin edge, the surgeon grasps the pretarsal orbicularis muscle inferiorly, and dissection is carried in a superior direction in the suborbicularis plane to identify the orbital septum (Fig. 12.10b). In older patients with a high lid crease (recessed levator) and in those with a deeper superior sulcus (recessed levator/septum with little or no preaponeurotic fat), it is especially important to dissect in a more superior direction to assure division of the septum. In these thin lids of older patients it is easy to mistaken tissue planes and inadvertently injure the levator aponeurosis when attempting

to divide the orbital septum. Once the septum is identified and opened, the preaponeurotic fat prolapses into the field. As stated, identifying the fat is important as the levator aponeuriosis is just below it.

The preaponeurotic fat may be excised or contracted with cautery if desired (Fig. 12.11). Reduction of upper eyelid fat should proceed with caution so as not to create a hollow superior sulcus postoperatively. As discussed, there is no lateral fat pad in the upper lid. It is important not to confuse the lacrimal gland with eyelid fat pad. The lacrimal gland tends to be whiter in color and firmer in texture than fat. A dislocated lacrimal gland (Fig. 12.12a) can be repositioned but should not be excised.

Once the eyelid fat is reduced or brushed away, the levator aponeurosis is identified. In patients with involutional ptosis, there may be fatty infiltration of the levator muscle and/or attenuation of the aponeurosis. A frank disinsertion of the aponeurosis is less common. The assistant retracts the inferior skin edge of the wound and dissection is carried in a suborbicularis plane inferiorly to expose the tarsal plate (Fig. 12.12b).

The aponeurosis is separated from the tarsal plate and from underlying Müller’s muscle by dissecting superiorly in a graded fashion (Fig. 12.13). In appropriate patients, a strip of pretarsal orbicularis muscle can be excised to debulk the incisional portion of the eyelid and create a fresh edge of tissue which will adhere to the tarsus and help reform an eyelid crease (Fig. 12.14a).

The levator aponeurosis is isolated. Grasping the aponeurosis and asking the patient to look up will cause the muscle to retract into the orbit, and the surgeon will feel the pull as the muscle moves. This ensures that the tissue dissected free is the aponeurosis. The aponeurosis is now advanced to the tarsus. This can be done directly if there is a frank disinsertion. As stated previously, more often an aponeurotic attenuation is present. In this instance, the free edge of the aponeurosis is resected appropriately (to shorten and create a fresh edge) before advancement. A variety of sutures are used to secure the aponeurosis to the tarsus. These include both permanent and long-term absorbable sutures. I prefer a 5–0 absorbable polyglactin 910 or nonabsorbable 5–0 polypropylene suture. It is important to use a spatulated needle in order to pass the suture partial thickness through tarsus with-

out cheese wiring the tissue. A double-armed suture is preferred, so that after the tarsal bite is placed, both ends can be passed through the aponeurosis for tying.

The suture is passed through partial-thickness tarsus, a few millimeters below its superior edge (Fig. 12.14b), in the central/medial region of the lid. I use a toothed forceps to engage the tarsus, elevate the lid, and evaluate contour, until I identify the best placement location. After passing the suture I evert the eyelid to ensure that the suture is not passed full-thickness, which may lead to corneal abrasion after surgery (Fig. 12.15a). Both needle ends are carried through the levator aponeurosis (Fig. 12.15b) and tied in a temporary slip knot (Fig. 12.16). If there is uncertainty as to what level of the levator to pass the suture, slightly below the muscle/ aponeurotic border is a good place to start, however, the amount of ptosis and levator function should be taken into account. I have found that the greater the degree of ptosis, and the less the levator function, the higher the suture should be placed. However, I have been fooled.

Care should be taken when passing the levator suture to avoid inadvertent injury to the underlying Müller’s

Fig. 12.15 (a) The lid is everted to ensure that the suture did not penetrate full-thickness through the tarsus where it could abrade the cornea. (b) One end of the 5–0 vicryl suture is passed through the levator

aponeurosis (tissue adjacent to tip of forceps). The first arm of the suture has already been passed

muscle. An injury to Muller’s muscle often results in a hemorrhage, making it more difficult to gauge eyelid position intraoperatively. After placement of the first levator suture, the eyelid is examined for height and contour. It is critical for the patient to be alert when examining lid position. If used, intravenous sedation (IV) is discontinued prior to evaluating eyelid position. The overhead lights are turned away from the patient’s face and additional topical anesthetic can be given. I prefer to have the patient sit up intraoperatively as this provides a more physiologic assessment of the eyelid position and contour. This maneuver also helps to wake the patient in cases when IV sedation is used. The lid height should be set slightly above the desired level, allowing for normal postoperative drop. Tightening or loosening the suture can be accom-

plished in the sitting position until the desired lid height is achieved. When lid position is too high, or a central peak in contour is created, the suture can be loosened and allowed to hang back. This reduces the need to re-pass the suture. If the lid position is too low, the suture needs to be re-passed to a higher position on the aponeurosis. In this instance, the patient is returned to the supine position for suture adjustment.

Additional sutures are then placed just nasal and temporal to the central suture. The lid contour may appear appropriate intraoperatively with a single central suture. However, I have found that placement of additional nasal and temporal sutures helps to stabilize the eyelid contour postoperatively. This also helps take tension off of the central suture, reducing the chance of suture cheese wiring postoperatively. Once

Fig. 12.17 (a) Once the aponeurosis has been resecured to tarsus, the lid crease may be reformed by passing an absorbable suture through one or both edges of the skin, or orbicularis muscle, while incorporating a bite of

the edge of the levator aponeurosis (tip of needle in surgical photo). (b) Associated artist’s rendition shows passage of suture. (c) The incision is closed with a running suture of 6–0 absorbable or nonabsorbable suture

the desired eyelid position and contour has been obtained, the sutures are tied and trimmed. The lid crease may be reformed, if desired, to more precisely define its location. This is accomplished by passing a few interrupted 6–0 absorbable sutures through one or both edges of the skin, or orbicularis muscle, while incorporating a bite of the edge of

the levator aponeurosis (Fig. 12.17a,b). This supratarsal fixation creates a deep and well-defined crease. Alternatively, this step can be omitted, and a softer, less distinct, crease will form. The skin incision is closed with a running 6–0 plain gut or 6–0 Nylon or Polypropylene suture (Fig. 12.17c). Antibiotic ointment is applied to the wound.