External levator advancement for repair of ptosis
This is Richard Allen at the University of Iowa. This video demonstrates an external levator advancement. This is an adult patient.
A 15 blade is used to make an incision through the skin and orbicularis muscle along the eyelid crease. In this case, a small blepharoplasty is also performed. Westcott scissors are then used to excise the skin and orbicularis muscle. The monopolar cautery is then used to dissect through the orbital septum. The goal of this dissection is to identify the preaponeurotic fat which is posterior to the orbital septum.
The thermal cautery is used to perform additional dissection until the preaponeurotic fat is identified.
The preaponeurotic fat is then dissected from the underlying levator aponeurosis. As you can see in this case, there is a fair amount of fat in the levator muscle.
A thermal cautery is then used to disinsert the levator aponeurosis from the anterior surface of the tarsus.
Dissection is then carried out between the levator aponeurosis and the underlying mullers muscle with the thermal cautery. This can at times be uncomfortable for the patient and topical tetracaine can be used to relieve any discomfort.
The assistant then holds Mullers muscle which can also be somewhat uncomfortable for the patient. As you can see in this case, the patient also has fat in the mullers muscle.
Dissection is carried out until the end of the aponeurosis and can be carried out further in more severe cases of ptosis.
A double armed 5-0 nylon suture on a spatula needle is then placed partial thickness through the anterior surface of the tarsus, 2 mm inferior to the superior boarder of the tarsus. This is placed at the area where the peak of the eyelid should be. Each of the needles is then placed through the levator aponeurosis.
In this case the sutures are placed right at the junction of the aponeurosis and the muscular portion of the levator, which I think is a good place to start. A temporary tie is then placed.
The patient then opens his or her eyes. In almost all of my adult patients, I place the patient in a sitting position at this point in the surgery to inspect the height and contour. In this case, it was determined that the height was a bit too high, therefore the sutures are positioned more inferior on the aponeurosis and a temporary tie is again placed.
The height and contour are reinspected and found to be acceptable. The temporary tie is now converted to a permanent tie.
A portion of the redundant levator aponeurosis is excised and the skin is closed by placing approximately three lid crease formation sutures. This suture incorporates the cut end of the levator aponeurosis into the skin closure. This is performed with a 6-0 prolene suture.
Additonal interrupted sutures are placed. Antibiotic ointment is placed over the incision and the patient will return in one week for suture removal.