158
Ptosis Repair by a Single-Stitch Levator Advancement
Don Liu
This versatile, simple technique for ptosis repair can be used to correct most cases of involutional, traumatic, and postsurgical ptosis of 1–5 mm. Patients must have at least 8 mm of levator function. It may be performed with local injection only or with additional intravenous sedation.
The steps for performing this procedure are as follows:
1.Identify, mark, and inject the lid crease with no more than 0.5 ml of 2% lidocaine with epinephrine. (An anesthetic injection of more than this amount would distort the anatomy and affect the function of various extraocular muscles.) Allow 10–15 minutes for hemostasis.
2.Use a No.15 blade to make the skin incision and a curved Stevens scissors and 0.5 forceps to perform dissection. Undermine the orbicularis superiorly for about 10 mm.
3.Identify the orbital septum by grasping and tugging the tissue in question with the forceps and placing a finger at the superior orbital rim. The orbital septum is identified when your finger feels the tug. This helps in the identification of all the relevant structures throughout the procedure.
4.Open the orbital septum with the scissors 5 mm above the skin incision to avoid injuring the aponeurosis (Figure 158.1). If this incision is too low, the aponeurosis and conjunctiva could be inadvertently incised. Prolapse of orbital fat into view serves as an indication that the incision is indeed of orbital septum. In patients with little fat, the aponeurosis comes directly into view.
5.Spread and tease aside the orbital fat with the curved Stevens scissors (Figure 158.2). Apply a Desmarres retractor superiorly to get the fat out of the way. Do not perform this dissection too vigorously as it may iatrogenically create aponeurosis dehiscence.
6.To better expose the deeper portion of the aponeurosis, roll a cotton-tipped applicator on the apeneurosis while the patient looks downward. The applicator is gently rolled, not pulled or pushed. This maneuver is a key to a successful repair.
497
498 D. Liu
7.Place a 6-0 nylon suture high up in the aponeurosis centrally
(Figure 158.3). This suture may be used as a traction suture if the initial placement is not high enough. Rarely a patient feels minor momentary discomfort.
8.Anchor the suture in the anterior surface of the superior tarsus and place a temporary slip-knot. This suture should be 1–2 mm medially displaced from the mid-pupillary line. Observe the lid curvature and height and make appropriate adjustment as necessary.
9.As the knot is being tied, watch the lid move up and aim for a 1 to 2 mm overcorrection with 2-mm lagophthalmos upon gentle lid closure.
10.When the position of the lid is satisfactory, tie the nylon suture permanently and cut its ends short. Double-check the lid curvature and height before skin closure. Close the skin with 6-0 nylon suture.
11.Instruct the patient to apply ice-cold compress over the operative eyelid for 3 days and to avoid any rubbing or squeezing of the lid.
12.If overcorrection is seen postoperatively, it can easily be eliminated by early institution of downward massage of the lid. Undercorrection and recurrence of ptosis may require a repeat operation. Since anatomy is least disturbed, a reoperation is usually very simple. Overand undercorrection rarely occur with this technique, however.
Figure 158.1. Open the septum 5 mm above the skin incision to avoid injury to the aponeurosis.
Chapter 158 Ptosis Repair by a Single-Stitch Levator Advancement 499
Figure 158.2.
Spread and tease aside the orbital fat with a curved Stevens scissors.
Figure 158.3. A 6-0 nylon suture is passed high up in the aponeurosis centrally.
Reference
Liu D. Simplified ptosis repair: single suture aponeurotic tuck. Ophthalmology 1993;100:251–259.
159
Postoperative Care in Ptosis Surgery
Edsel Ing
In patients with immediate postoperative lagophthalmos, an Opsite (Smith & Nephew) or Tegaderm (3M) plastic dressing can be used until local anesthetic effect on the orbicularis resolves or overnight in patients who have difficulty instilling eyedrops or if they have compromised corneas. The inferior portion of the plastic dressing can be crimped to make a channel for blood to seep through. Cold compresses can be still applied through this thin plastic dressing.
500
160
Pearls for Müller’s Muscle– Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty
Allen M. Putterman
The Müller’s muscle–conjunctival resection ptosis procedure is a relatively simple means of relieving upper eyelid ptosis in patients whose upper eyelids elevate close to a normal level when phenylephrine drops are placed in their upper fornix.1-3 Although the procedure is fast to perform, there are pearls to know and pitfalls to avoid in order to achieve optimal results.
•A frontal nerve block is performed to provide sensory anesthesia of the upper eyelid without infiltrating the lid, which can make the procedure more difficult to perform. The 1 1 /2-inch retrobulbar needle is placed centrally and hugs the roof of the orbit during insertion. The surgeon should aim toward the temporal roof of the orbit rather than the nasal roof to avoid penetration of the supraorbital artery, which could cause a retrobulbar hemorrhage. Also, the surgeon should withdraw the syringe before injecting the anesthetic to make sure that the needle has not been passed into a blood vessel.
•A scratch incision is made over the area of excessive upper eyelid skin outlined in ink. If this is not done, the marked areas could smear and disappear on eversion of the upper eyelid.
•Usually a medium-sized Desmarres retractor is employed, but occasionally it is necessary to use a large retractor.
•The 6-0 black silk marking suture is placed only through conjunctiva. If it penetrates Müller’s muscle, a subconjunctival hemorrhage can occur, which could interfere with the resection of both conjunctiva and
Müller’s muscle.
•The clamp made for this procedure (Bausch & Lomb Storz Instruments, Manchester, MO) that has three teeth on each side seems to work the best.
503