Pediatric levator advancement
This is Richard Allen at the University of Iowa. This video demonstrates an external levator advancement in a pediatric patient. A 15 blade is used to make an incision through the skin and orbicularis muscle. The monopolar cautery is then used to dissect further though the orbicularis muscle until the orbital septum is identified. The orbital septum in children is very thick. It can at time be difficult to find the preaponeurotic fat due to the thick orbital septum and one should take his or her time. Gentle pressure on the globe will often be helpful in identifying the area of the preaponeurotic fat. After the preaponeurotic fat is identified, it is dissected from the underlying levator aponeurosis. In this case, the amount of levator to be advanced was predetermined. The upper boarder of the tarsus is marked and the prescribed amount of levator to be advanced is marked. This is very close to whitnals ligament, therefore the levator is dissected free from whitnalls so whitnalls is not included in the advancement. A thermal cautery is then used to disinsert the levator aponeurosis from the anterior surface of the tarsus. Dissection then continues between the levator aponeurosis and the underlying mullers muscle. The assistant then holds the mullers muscle, this would be uncomfortable for the patient if he or she were awake. Further dissection is then performed until the area of the marking. A double armed 5-0 nylon suture on a spatula needle is then placed partial thickness through the tarsus about 2 mm inferior to the superior border of the tarsus at the region where you would like the peak of the eyelid. This is usually 1 mm medial to the center of the cornea. Each arm is then placed through the levator aponeurosis at the marking. Sometimes the muscle needs to pull down from under the Whitnalls ligament. The assistant then holds the levator aponeurosis and a temporary tie is placed. The contour and height of the eyelid is then inspected. In this case, the height was thought to be appropriate and the temporary tie was then converted into a permanent tie. The redundant portion of the levator aponeurosis is the excised. It was determined that addition temporal support was needed, which is often useful especially in children as the will often have temporal ptosis after a repair. The same nylon suture is used to engage the tarsus and advance the levator laterally. The preaponeurotic fat is then reposited. There are very few nevers in life, but I believe the preaponeurotic fat in pediatric ptosis cases should never be resected. The skin is then closed with a 5-0 fast absorbing suture. 3-5 lid crease formation sutures are placed by incorporating the levator aponeurosis into the skin closure. Additional interrupted sutures are placed. IN this child a Frost suture will be placed followed by a patch to prevent exposure immediately post op. The patient will return the following morning for patch and frost suture removal.