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10.5 Operations 129
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10.5.1.1 Principle and Considerations
Draw the levator aponeurosis down by pulling on Müller’s muscle to create a fold.
The aponeurosis fold appears as a ‘white line’. Suture the white line to the upper
edge of the tarsal plate. This effectively shortens the aponeurosis.
10.5.1.2 Case Selection
Ptosis with good levator function (LF ≤ 12 mm). This includes age related, contact
lens induced and post-surgical ptosis.
10.5.1.3 Steps
1. Mark the new skin crease position on the surgical side while holding the skin
on gentle upward stretch (Fig. 10.8a). Match its height with the crease on the
contralateral lid. In bilateral ptosis set it at about 7–8 mm (for occidental lids).
2. Incise the skin along the marked line with a no. 15 scalpel while protecting the
eye with a guard held under the lid.
3. Deepen the incision centrally with Westcott scissors (Fig. 10.8b). Dissect per-
pendicularly through the orbicularis and posterior levator aponeurosis until the
upper 1/3 of the tarsal plate is reached.
Note: Angling the dissection can cause you to dissect too proximally, missing the
tarsal plate, or too low, where the aponeurosis inserts into the tarsal plate.
4. Bluntly dissect the pretarsal space medially and laterally with closed Westcott
scissors. Then extend the incision to the full extent of the skin incision. Do this
with one blade of the scissors inside the tunnel and the other on the orbicularis
surface (Fig. 10.8c).
5. Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any
remaining connective tissue, to ensure firm healing (Fig. 10.8d).
Note: Not cleaning thoroughly can lead to poor union and late surgical failure when
the sutures absorb.
6. Pull the lid downwards with toothed forceps and bluntly dissect upwards with
a cotton bud, beyond the upper edge of the tarsal plate to expose the anterior
surface of Müller’s muscle (Fig. 10.8e).
Note: This is usually an easy manoeuvre, but occasionally firmer connective tissue
is encountered and a little sharp dissection with Westcott scissors is required. In a
few patients some yellow fat may be encountered in this plane.
7. Now pull the upper extent of Müller’s muscle firmly downwards with toothed
forceps (e.g., Jayles) and continue the blunt dissection superiorly with a cotton
bud until a white fold of connective tissue appears—the so called ‘white line’
(folded levator aponeurosis) (Fig. 10.8f).
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8. Grasp the white line firmly and gently stretch it downwards. Instruct the
patient to look upwards. You should feel a strong tug. This confirms that the
structure is indeed the levator aponeurosis.
9. Insert a double armed suture 6/0 absorbable (Vicryl) suture through the white
line centrally with a double bite.
10. Insert both ends of this central suture into the upper 2–3 mm of the exposed
tarsal plate as partial thickness bites. Before completing each needle bite, evert
the lid to check that the needle pass has not penetrated the conjunctival surface.
If it has, withdraw the needle, and replace it more superficially to avoid corneal
irritation by the suture (Fig. 10.8g).
11. Tighten this suture and tie it as a bow. Check the lid height, curve, and movement by asking the patient to look first straight ahead and then up and down.
The lid margin height should be 1–2 mm higher than the contralateral side to
compensate for the local anaesthetic induced orbicularis paralysis.
12. Undo the bow and insert two further white line sutures similarly, one on either
side and each about 3 mm away from the central one. To do this ask an
assistant to pull downwards on the previously placed central suture to keep
the white line exposed.
13. Undo the temporary bows and pass one of each pair of suture ends out through
the upper and the other through the lower skin edge (Fig. 10.8h).
14. Tie the sutures on the skin. This advances the white line to the tarsal plate,
closes the incision, and reforms the skin crease. Do not cut the suture ends at
this stage but clip them out of the way.
15. Complete skin closure with a continuous 6/0 or 7/0 absorbable suture taking
a bite between each of the knots and tie it at each end (Fig. 10.8i).
Note: Although this suture is usually superfluous, it keeps the incision closed if you
need to remove an aponeurosis suture early because of an overcorrection.
16. Now pull the white line suture ends down and cut them at the level of the
lid margin. This ensures that the ends remain exposed and long enough to
identify and grasp easily should you need to remove them.
17. Instruct the patient to keep the eye closed and apply antibiotic ointment and a
pressure dressing overnight.
18. Review the lid height the next day. If there is an overcorrection remove one
or more of the levator aponeurosis sutures by lifting the knot and cutting one
side of the suture below it. Pull the whole suture out.
10.5.1.4 Notes
Some surgeons advocate using only a single aponeurosis suture to save time. While
this can work it does risk creating an unattractive ‘cathedral arch’ upper lid contour if you insert the suture too low on the tarsal plate. Furthermore, there is no
redundancy for the eventuality of suture failure. Using three sutures gives more
control over the lid contour and the extra time they take to place is a worthwhile
investment for the novice.
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10.5.2 Conversion to an Anterior Levator Aponeurosis
Reinsertion/Resection Fig. 10.9
Steps 1–5 are as above. If step 7 is problematic (the white line cannot be found)
or the lid height is too low at the end of surgery proceed as follows:
a b
c d
Fig.10.9 Conversion to an anterior levator aponeurosis reinsertion. a While retracting the upper
skin and orbicularis edge upwards, grasp the anterior layer of the levator aponeurosis (immediately posterior to the orbicularis) and incise it. b Pull the aponeurosis and bluntly dissect upwards
to expose the orbital septum and pre-aponeurotic fat pad. c Insert a double armed 6/0 absorbable
suture into healthy aponeurosis. d Place 2 more sutures similarly and insert them into the upper
tarsal plate, bringing all three pairs out through the skin edges. e Tie the sutures while observing the lid margin position and curve. Insert a continuous skin suture taking a bite between each
aponeurosis suture
e
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7. While pulling the upper lid skin incision edge upwards, grasp the layer imme-
diately posterior to the orbicularis muscle layer. This is the anterior layer of
the levator aponeurosis (and not the orbital septum as many mistakenly think).
Incise this layer along the whole length of the wound (Fig. 10.9a)
8. Pull down the proximal cut edge of the aponeurosis and bluntly dissect upwards
on its anterior surface to expose the actual orbital septum. Pressing on the
lower lid causes the pre-aponeurotic fat pad to flow forwards under the septum,
positively identifying it.
9. The orbital septum is not a single layer but made up of seven thin layers.
Divide the several thin layers of orbital septum to expose the pre-aponeurotic
fat (Fig. 10.9b)
Note: This fat is very fine and has a characteristic deep yellow colour. It is a constant
landmark in the lid and helpful for orientation.
10. Retract the pre-aponeurotic fat to expose the full extent of the levator aponeurosis, up to the transversely running Whitnall’s ligament and the aponeurosis
levator muscle junction.
11. Insert a double armed 6/0 absorbable suture into healthy aponeurosis, close to
its lower edge (Fig. 10.9c)
12. Insert this same suture into the upper tarsal plate centrally and tie it with a
bow.
13. Assess the lid height by asking the patient to follow your finger. The operated
lid should be set 1–2 mm higher than the other side to compensate for the
anaesthetised orbicularis. If the lid is not at the correct height replace the
suture higher or lower in the aponeurosis and recheck the lid height.
14. Place two further sutures similarly, one on either side of the first.
15. Now bring all three pairs of aponeurosis/tarsal plate sutures out through the
skin edges, one of each pair on either side of the skin incision (Fig. 10.9d)
16. Tie the sutures while observing the lid margin position and curve. If a suture
is lifting the lid too much you can loosen it before placing the locking throw.
17. Before cutting the suture ends run a continuous suture along the length
of the wound taking a bite between each aponeurosis suture. This suture
keeps the wound closed should the aponeurosis sutures require early removal
(Fig. 10.9e)
18. Cut the aponeurosis sutures about 4 mm long so that they are easy to find and
grasp, should early removal be required.
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10.5.3 Levator Resection Fig. 10.10
10.5.3.1 Principle and Considerations
The approach to levator resection is identical to the anterior levator aponeurosis
reinsertion/resection described above. It differs in that the ‘horns’ (the medial and
lateral extent) of the levator aponeurosis are cut and the aponeurosis dissected free
from the overlying Whitnall’s ligament. Müller’s muscle is also separated from
its insertion into the upper border of the tarsal plate and dissected free from the
underlying conjunctiva. This enables the levator/Müller’s complex to be pulled
down as one to enable sutures to be placed higher up within the levator muscle
belly. Check the lid height as previously. The desired ‘on table’ lid height depends
on the pre-operative levator function.
10.5.3.2 Case Selection
Ptosis with levator function of 5–11 mm.
Because levator resection is reserved for patients with poorer LF, the surgical
outcome is less predictable. Therefore, it should be performed by more experienced surgeons. A detailed description of the technique is beyond this book’s
remit.
a b
Fig.10.10 Levator resection ptosis correction. a After exposing the levator aponeurosis cut its
medial and lateral horns. b Pull the levator down and insert a suture into the muscle belly and tarsal
plate. Check the lid height and replace if necessary. c Insert 2 more sutures similarly
c
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10.5.4 Addition of a Skin and Muscle Blepharoplasty Fig. 10.11
10.5.4.1 Principle and Considerations
As already mentioned, the anterior approach ptosis corrections described above
may easily be combined with skin and muscle blepharoplasty. Perform this conversion after performing the ptosis correction but before bringing the levator sutures
out through the skin and tying them. Drape the excess upper edge skin and orbicularis over the lower wound edge with the eye closed to ascertain how much may
safely be removed.
10.5.4.2 Case Selection
Any ptosis correction in which there appears to be excess upper lid skin at the end
of the procedure.
10.5.4.3 Steps
1. With the upper eyelid closed drape the upper wound edge skin and orbicularis
over the lower edge to achieve the desired skin appearance (Fig. 10.11b).
2. Make an upward cut centrally through the draped skin and orbicularis as far as
the lower wound edge (Fig. 10.11c).
3. Pull down and laterally on the flap you have created and excise the redundant
anterior lamellar triangle with Westcott spring scissors to meet the medial end
of the wound (Fig. 10.11d).
4. Pull the lateral flap down and medially and repeat the same manoeuvre to the
lateral wound end (Fig. 10.11e).
5. The blepharoplasty is now complete. Proceed with wound closure by insert-
ing your preplaced levator sutures across the wound as previously described
(Fig. 10.11f, g).
Notes: You may extend the ptosis correction wound laterally to remove more lateral
skin if required.
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a b
c d
e f
Fig.10.11 Conversion to blepharoplasty. a Insert the aponeurosis sutures into the tarsal plate
only. b With the upper eyelid closed drape the upper wound edge skin and orbicularis over the
lower edge to achieve the desired skin appearance. c Make an upward cut through the draped skin
and the orbicularis as far as the lower wound edge. d Excise the medial redundant anterior lamel-
lar triangle with Westcott spring scissors to meet the medial end of the wound. e Excise the lateral
triangle similarly. f With the blepharoplasty complete, proceed with wound closure as previously.
g Place a skin suture
g
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a
4mm
b
8mm
c d
e f
Fig.10.12 Müllers muscle resection. a Double evert the upper lid and mark the upper border of
the tarsal plate. Using a calliper, place a row of marks 4 mm from the border. b Then place a third
row of marks again 4 mm more proximally to the previous ones. c Insert a 5/0 monofilament traction suture through the conjunctiva and Müller’s muscle along the middle row of marks. Pull down
a fold of conjunctiva and Müller’s muscle and apply two fine artery forceps across this fold spanning the first and third row of marks. Insert a 5/0 monofilament suture transcutaneously so that
it exits the conjunctival surface at the lateral edge of the crushed fold, just above the artery clip.
d Pass this suture in and out through the fold above the artery clip. Bring the suture out through
the skin crease medially. e Remove the artery clips, one at a time and cut along the centre of the
crush line to excise the fold of conjunctiva and Müllers. f Pull the suture ends tight to take up any
slack. g Tape them to the brow skin in a relaxed position so that they do not impair eyelid closure
g
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10.5.5 Müller’s Muscle Resection Fig. 10.12
The simplest and least invasive ptosis operation is a Müller’s resection. It is seductively simple but only effective when restricted to the specific selection criteria
already mentioned. The indications for it are therefore limited. Müller’s resection
is very unlikely to over-correct a ptosis and requires no dissection. It replaces
the formerly popular, but now outdated, Fasanella Servat operation. Both sacrifice
conjunctiva and work on the principle of shortening Müller’s muscle. The latter
also sacrifices the upper tarsal plate (rarely a good idea).
10.5.5.1 Principle and Considerations
Müller’s muscle modulates the effect of the levator on the lid margin. Shortening
Müller’s muscle lifts the lid by about 2 mm.
10.5.5.2 Case Selection
Patients with no more than 2 mm of ptosis and normal levator function. Some
surgeons advocate only operating on patients whose ptosis disappears after instilling a drop of phenylephrine. While these patients invariably do well so do many
that fail to respond to the phenylephrine test. This is unsurprising as the procedure
excises Müller’s muscle rather than relying on it to lift the lid.
10.5.5.3 Steps
1. Double evert the upper lid over a large Desmarres retractor, using it as a lever
to visualize the conjunctiva above the tarsal plate.
2. Dry the conjunctiva and mark the upper border of the tarsal plate using a mark-
ing pen. Make three marks, one in the centre of the lid and one 6 mm to either
side.
3. Using a calliper, place a further row of three marks 4 mm proximal to the first
row (Fig. 10.12a).
4. Then place a third row of marks again 4 mm more proximally to the previous
ones (Fig. 10.12b).
5. Insert a 5/0 monofilament traction suture through the conjunctiva and under-
lying Müller’s muscle along the middle row of marks. Remove the Desmarres
retractor.
6. Pull downwards on the traction suture to pull down a fold of conjunctiva and
Müller’s muscle. Apply two fine artery clips (or use a Putterman clamp if avail-
able) across this fold to span the first and third row of marks (Fig. 10.12c). The
clips contain an 8 mm wide (4 mm + 4 mm) ellipse of conjunctiva and Müller’s
muscle.
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Note: Ensure that the tips of the artery clips are pointed slightly down (as in the
diagram) to avoid creating a central lid peak.
7. Insert a 5/0 monofilament suture transcutaneously at the skin crease (approximately 7 mm from the lid margin) so that it exits the conjunctival surface at
the lateral edge of the crushed fold, just above the artery clip (Fig. 10.12c).
8. Pass this same suture through the conjunctiva and Müller’s fold above the
artery clip exiting on the other side. Then pass it back. Repeat this approximately four or five times to reach the medial end of the fold (Fig. 10.12d). The
more suture passes that are made, the harder it will be ultimately to remove
the suture.
9. Bring the suture out through the skin crease medially.
10. Remove the artery clips, one at a time and cut along the centre of the crush
line to excise the fold of conjunctiva and Müllers along with the traction suture
(Fig. 10.12e, f). Allow the everted lid to flip back to its normal orientation.
11. Pull the suture ends tight to take up any slack and tape them to the brow skin
in a relaxed position so that they do not impair eyelid closure (Fig. 10.12g)
12. Apply antibiotic ointment to the eye and secure a protective shield. No pad is
required.
13. Review the patient a week later and remove the suture by cutting one end
flush with the skin and pulling on the other end. The smooth monofilament
suture slips out with minimal discomfort.
Note: In a child an absorbable suture with buried knots can be used to avoid the
need for suture removal. However, when it loosens it may cause corneal irritation,
which is why a smooth removable suture is preferred for adults.
10.5.6 Frontalis Suspension (Fox’s Pentagon) Fig. 10.13
10.5.6.1 Principle and considerations
A patient with poor levator function does not benefit from having their levator
muscle shortened. The only alternative power source available for opening the lid
is the frontalis muscle. Frontalis suspension is not technically difficult to perform
but as it is rarely needed it is harder to gain experience with this technique. Furthermore, patients with poor levator function have a less satisfactory outcome from
ptosis surgery. The likelihood of under or over correction is much higher as is the
risk of symptomatic corneal exposure.
The operation works by connecting the eyelid to the brow using a sling. The
best and longest lasting sling material is undoubtedly living autogenous fascia
Lata, harvested from the patient’s own thigh. Such harvesting falls outside the
remit of this book (but is available to view on YouTube [2]). However, for the sake
of completeness I describe here the Fox pentagon frontalis suspension using a silicone sling. Non-autogenous materials are more prone to infection, extrusion, and
late failure. The silicone sling may be supplied swaged onto two long, extremely
sharp, malleable needles. I strongly urge the novice not to use these as they are
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