Levator extirpation with silicone frontalis sling
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This is Richard Allen at the University of Iowa.
This video demonstrates repair of a unilateral congenital ptosis associated with a Marcus Gunn jaw wink.
A levator extirpation and silicone frontalis sling will be performed. Stab incisions are made above the brow with a 15 blade. These incisions are bluntly dissected open with a hemostat. A 15 blade is then used to make an incision along a small blepharoplasty marking. The skin is removed with the needle tip cautery. Dissection is then performed through the orbicularis muscle to the underlying orbital septum. Dissection then is carried out through the orbital septum to identify the underlying preaponeurotic fat. The preaponeurotic fat is demonstrated and dissected from the underlying levator aponeurosis and muscle. Dissection is carried out superiorly as far as possible at least to the level of Whitnall’s ligament.
The thermal cautery is then used to disinsert the levator aponeurosis from the anterior surface of the tarsus. Dissection is then carried out in a plane beneath the Muller muscle to elevate the Muller muscle and levator aponeurosis from the underlying conjunctiva. This then proceeds superiorly as far as possible. This dissection will proceed to the plane between the levator muscle and the underlying superior rectus. The levator muscle is then pulled down and additional dissection is carried out with the thermal cautery as superiorly/posteriorly as possible. The levator muscle is then transected as posterior as possible to ablate its action on the upper eyelid.
The thermal cautery is used to expose more of the anterior surface of the tarsus. A 5-0 Mersilene suture is placed partial thickness through the anterior surface of the tarsus. This suture then is tied to fixate the silicone sling to the anterior surface of the tarsus, 1-2 mm inferior to the superior border of the tarsus. Two additional sutures are placed and the contour is evaluated.
The sling is then placed in a retroseptal fashion to exit out the medial stab incision. The same is performed for the other end of the sling to exit out the lateral stab incision. The contour is again checked and the sling is placed to exit out the superior stab incision.
Lid crease formation sutures are then placed with 5-0 fast absorbing suture. This suture engages the inferior skin edge, followed by the superior border of the tarsus, followed by the superior skin edge. The suture is left untied so that the adjacent suture can be placed. One can use 7-0 Vicryl suture or 5-0 fast absorbing suture. Multiple sutures are placed and tied. The sling is tightened and the contour and eyelid crease appears appropriate. The tension of the sling is checked and tightened more. The sleeve around the sling is fixated and the stab incisions are closed as demonstrated in other frontalis sling videos.