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Minimally Invasive Ptosis Repair

Francesco P. Bernardini

Minimally invasive ptosis surgery offers many advantages—a less visible scar, a reduced surgical time, and an improved postoperative period— and it is as effective and reliable as the traditional surgical approach. I have been delighted with the minimally invasive approach in aponeurogenic ptosis.

Mini-invasive Ptosis Surgery

When dealing with a patient affected by aponeurogenic ptosis, where an upper eyelid blepharoplasty is not required and the levator function is normal (i.e., 12 mm), I make a 1-cm incision in the eyelid crease and perform a routine levator advancement through that minimal skin incision. What makes this procedure very fast is the simple exposure of the orbital septum after opening the orbicularis muscle (Figure 156.1). With the surgeon holding the superior skin\orbicularis edge apart with one rake retractor in one hand, the orbital septum can be identified by gently moving the rake up toward the brow with minimal dissection in the suborbicularis plane. After opening the orbital septum, the dissection is carried between the levator aponeurosis and the fat so that the aponeurosis and levator muscle will be clearly visualized (Figure 156.2). A single suture between the tarsal plate and the aponeurosis will give an excellent contour in the vast majority of cases. A slight overcorrection of 1–2 mm is required to achieve an optimal final result and two or three individual sutures are used to close the skin (Figure 156.3). The technique requires an injection of a very small amount of local anesthesia in the eyelid ( 1 ml), limiting its impact on the eyelid position; in my hands the procedure takes usually 8–10 minutes at most and postoperative swelling and bruising are also greatly reduced.

Suggested Reading

Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol 1999;127:637–644.

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Figure 156.1. Exposure of the septum.

Figure 156.2. Exposure of the pre-aponeurolic fat and levator aponeurosis.

157

Small Incision External

Levator Repair

Mark J. Lucarelli

External levator repair is a time-honored method of correcting ptosis. Such surgery is performed frequently by specialists who specialize in significant amounts of eyelid surgery. Achieving predictable, aesthetically appealing results can sometimes, however, be challenging. Hence, alternatives such as the conjunctival muellerectomy have found an important place in the surgical eyelid armamentarium. This section provides a number of guidelines that have been helpful to me in achieving more consistent results with an external levator repair utilizing a smaller incision and limited dissection.

1.As with other procedures, proper patient selection is key. In order to achieve excellent results, this operation must be restricted to patients with minimal dermatochalasis. The best candidates are patients with dermatochalasis ratings of 0–1 + on a scale of 0–4+

2.If the patient’s ptosis is unilateral, a phenylephrine test is helpful. This is done by placing on drop of 2.5% phenylephrine on the ocular

surface of the ptotic side Q 5 minutes 2. The phenylephrine test will help determine if the patient is a good candidate for internal ptosis repair (conjunctival muellerectomy). It will also help reveal asymmetric, subclinical ptosis on the supposedly normal side (Hering’s effect).

3.The upper eyelid position (margin reflex distances) should always be evaluated with the brow relaxed. Significant brow recruitment can dramatically alter the true position of the upper eyelid margin.

4.This procedure can be readily performed in the office under local anesthetic or using monitored anesthesia care. If intravenous sedation is used, propofol is an excellent agent, as its effects wear off nearly completely in 10 minutes.

5.Although our previously published description of this procedure recommended an 8-mm incision, I have found that a slightly larger incision of approximately 12 mm that extends from the medial limbus to the lateral limbus allows the procedure to remain minimally invasive yet affords considerably better surgical exposure. These markings are always placed before the patient is sedated so that the ideal horizontal position of the incision can be marked without concern for any deviation of the ocular position owing to sedation. In women, the relevant segment of

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