Ptosis Blepharoplasty

Congenital

Congenital ptosis is usually a result of fibrous and fatty tissue replacing the normal muscle fibers; these fibers are inelastic and lead to poor function and lagophthalmos on downgaze.

Deciding the best procedure for a patient is easiest when the patient has simple congenital ptosis, whether mild or severe. Patients with congenital ptosis are born with the problem; their ptosis remains relatively constant throughout the first few years of life or until surgery is performed, and their levator function is generally compatible with the degree of ptosis observed clinically.

In general, mild ptosis (1-2 mm) is accompanied by good levator function (>8 mm), moderate ptosis (3 mm) has fair levator function (5-7 mm), and severe ptosis (>4 mm) has poor levator function (< 4 mm).

Levator resection is the procedure of choice for patients with congenital ptosis when reasonable levator function is present. The amount of resection can be small (10-13 mm), medium (14-20 mm), or large (21-26 mm) and can be tailored to be smaller or larger depending on the levator function (ie, a patient with 7 mm of levator function and 3 mm of ptosis requires a smaller resection than a patient with 3 mm of ptosis and 5 mm of levator function).

At the time of surgery, the levator tendon is generally shortened until the lid is at the level the surgeon would like it to be postoperatively (much the way the lid level is set during the frontalis sling procedure). In patients with poorer levator function, setting the lid 1-2 mm higher may be appropriate, since these lids have a tendency to drop postoperatively. The amount of resection necessary in these patients is usually greater than 20 mm.

As a rule, the levators of patients with absent levator function, severe bilateral congenital ptosis, and blepharophimosis syndrome are so abnormal that a frontalis sling is necessary to obtain even passable results. In the past, 3 operative techniques for shortening the levator tendon were widely used. The choice depended on the degree of ptosis, the amount of existing levator action, and the personal preference of the surgeon.

In cases of severe ptosis with poor levator function, an anterior skin approach was used. If the ptosis was moderate and levator action fair or good, Iliff felt his modification of the Blaskovics conjunctival approach to advance the levator tendon was much simpler than the anterior skin approach and that it gave excellent results.

If the ptosis was slight and levator action good, the Fasanella Servat procedure, which excises the tarsus, conjunctiva, Müller muscle, and perhaps levator tendon, gained widespread popularity because of its relatively simple nature. Isolated Müller's muscle resection is a similar procedure that spares the conjunctiva in an effort to decrease the potential for dry eye symptomsis.[2] Some textbooks still discuss the use of the superior rectus muscle in ptosis surgery, but this procedure never should be performed. More recently, the aponeurotic technique for shortening the levator tendon has become the commonly accepted approach.

Congenital Marcus Gunn (jaw-winking) ptosis

Some forms of ptosis warrant individual consideration. Probably the most common and one of the most difficult to manage forms of ptosis is the jaw-winking syndrome (Marcus Gunn phenomenon). All patients with jaw-winking syndrome exhibit a variable degree of ptosis of the involved lid when the eyes are at rest in the primary position. The wink reflex consists of a rapid elevation and retraction of the lid to a higher level than that of the normal fellow lid and an almost equally rapid return to a less elevated level. The involved lid then may remain for a time at the height of the normal lid or may droop to the original ptotic position. The rapidity of the motion produces a bizarre appearance that is disturbing to the patient and observers.

The wink may be produced by sucking, swallowing, chewing, or lateral motion of the jaw to either side. The phenomenon is the result of an abnormal connection between the motor branches of the fifth cranial nerve (the pterygoid branch) and the superior division of the oculomotor nerve, which innervates the superior rectus-levator complex. Studies suggest that a central nervous system abnormality is underlying the anatomic defect in both the affected and clinically uninvolved sides.

The patient (if of appropriate age), parents, and ophthalmologist must decide whether the ptosis or the wink is responsible for the greater cosmetic blemish. If the ptosis is the more striking defect, elevate the lid by shortening the levator aponeurosis. However, this procedure is satisfactory only if the wink is a minimal part of the problem. Because the ptosis is usually mild to moderate, resection is a satisfactory procedure; however, the patient and parents must understand the mechanics of the problem and fully realize that shortening the levator, although improving the appearance of the ptosis in the primary position, also increases the height of excursion of the wink.

If the wink is the major cosmetic blemish, as it often is, it may be corrected in one of several ways. At this time, the most acceptable method of correcting the wink involves severing the levator tendon to destroy its action and then performing a fascia lata sling. Bilateral procedures, which cut the levator tendon of both the affected and the normal lids and suspend both lids from the frontalis muscle, yield a more attractive and symmetric result. Dryden and coworkers have advocated suturing the levator aponeurosis to the linea alba at the upper orbital rim to ensure its deactivation. This procedure does not destroy the levator tendon and muscle, which can be reactivated if, for some reason, reactivation is desired.

Surgery may be delayed for an observation period, since the Marcus Gunn phenomenon has been said to disappear in adulthood. This assumption apparently has been based on the impression that few adults are seen with the condition. In fact, such patients do exist; their apparent scarcity probably is because of prior surgery or a reluctance to continue visiting ophthalmologists for consultation about this problem. Although some decrease in the wink may occur, it does not universally disappear in adulthood.

Acquired

See the list below:

• Traumatic and iatrogenic ptosis

  • Adults with acquired ptosis secondary to levator tendon disinsertion or dehiscence may develop the problem either spontaneously or after minor trauma, allergic reactions, or surgery (this is the cause of postoperative, or postcataract, ptosis). The degree may be mild, with only 1-1.5 mm of ptosis, or severe, with a complete ptosis in which the patient is unable to open the eye. Generally, levator function is relatively good, and the ptosis remains essentially the same in both upgaze and downgaze, which readily differentiates it from the inelastic levator muscle typical of congenital ptosis. The lid crease is generally present and is often slightly higher than on the uninvolved side. Additionally, the upper sulcus is frequently deeper than on the uninvolved side, also indicating the diagnosis.

  • Acquired ptosis with levator dehiscence requires a simple repair to restore normal lid position and function. This is accomplished by reattaching the dehisced edge of the levator aponeurosis to the normal position on the anterior tarsus without resecting any portion of its tendon. Resection of the levator tendon in the presence of a normal muscle leads to overcorrection of the lid position. Overcorrections are observed with some frequency in acquired ptosis because of levator dehiscence, whereas they are difficult to obtain in simple congenital ptosis.

  • Traumatic ptosis may have 3 possible etiologies. Mild degrees of trauma associated with edema or hemorrhage may produce a levator disinsertion that can be readily repaired using an aponeurotic approach, as described above. Lacerations of the lid may sever the levator tendon, leading to scarring and secondary mechanical ptosis. This problem is best managed by careful repair of the levator aponeurosis at the time of primary repair of the lid injury. If this is not accomplished, often the orbit can be explored at a later time and the levator muscle identified and repaired.

  • The third major variety of traumatic ptosis involves damage to the nerve supply of the levator muscle. Since the levator and the superior rectus muscle are commonly innervated, such injuries may affect the elevation of the eye, including Bell phenomenon. In this situation, allow at least 6 months to 1 year to pass prior to performing any surgery, since some degree of regeneration often occurs. After this period, a levator resection or sling procedure can be performed, depending on the severity of ptosis and the degree of return of levator muscle function.

  • If aberrant regeneration is present (as often occurs after damage to the oculomotor nerve) and lid function is significantly abnormal, consider a procedure similar to that described for Marcus Gunn ptosis; however, exercise caution because the abnormal ocular motility may predispose the patient to corneal exposure related to the expected postoperative lagophthalmos.

• Neurogenic/myogenic ptosis

  • Acquired ptosis that is not associated with levator tendon dehiscence or trauma is a difficult problem. Myasthenia gravis, ocular-pharyngeal syndrome, idiopathic late-onset familial ptosis, progressive external ophthalmoplegia, and other neurogenic entities fall into this category. The ptosis of myasthenia gravis is usually managed medically and is not discussed in further detail.

  • The ptoses in the myogenic group are generally progressive and have a high frequency of recurrence despite repeated surgery, including levator resections. When additional surgery is contemplated for patients who have adequate tear secretion and orbicularis muscle function, consider a frontalis sling procedure. Surgery should be performed in these patients with the patient under local anesthesia whenever possible to allow intraoperative adjustment of the lid position with consideration of the degree of lagophthalmos that can be tolerated in that individual. Consider purposeful undercorrection in these patients.

• Mechanical ptosis: Many patients with tumors of the lid or orbit may present with ptosis, and the surgeon should be aware of such problems when evaluating any patient with acquired ptosis.

• Blepharophimosis ptosis syndrome

  • The last major subgroup that presents some difficulty in management is the autosomal dominant–inherited syndrome of blepharophimosis ptosis. Patients with this syndrome have blepharophimosis, severe ptosis (usually with no levator function), epicanthus inversus, and ectropion of the lateral portions of the lower lids. The ptosis is corrected by frontalis fixation at an early age. Canthoplasties may be performed to improve the blepharophimosis. The considerable epicanthus is usually best left until early adolescence, since the degree of this problem tends to diminish with time, and the skin becomes more supple and easy to move. The author has found Mustarde double Z-plasty the most effective method of correcting this problem.

  • The ectropion of the lateral portion of the lower lids is due to a paucity of skin in the vertical direction and may require skin grafting to repair. A lateral tarsal strip may be necessary in addition to skin grafting to effect proper tightening and elevation in the reconstruction of these lids. If available, although it rarely is in these patients, upper lid skin may be used. Otherwise, a retroauricular skin graft provides the best donor site.

Frequency

Aponeurotic senile ptosis is the most frequent cause of ptosis, increasing steadily with age. Congenital ptosis is the second most frequent cause. The other causes are relatively infrequent in comparison.

According to statistics from the American Society for Aesthetic Plastic Surgery, in 2016 blepharoplasty was the fourth most commonly performed cosmetic surgical procedure in the United States (173,883 procedures).[3]

See Problem.

Ptosis is an easily visible phenomenon, and patients often present because of cosmetic concerns. Patients may also present because of a decrease in superior visual field and an inability to read because of severe ptosis in downgaze.

In most instances, the primary reason for correcting congenital ptosis is cosmetic. Most surgeons agree that significant congenital ptosis should be repaired by age 5 years or before the child begins regular school. An exception to this timing is found in patients with severe bilateral ptosis that interferes with the child's ability to learn how to walk. The levator action in these children is always so poor that a frontalis sling procedure is necessary. Another exception is found in patients with unilateral congenital ptosis of such severity that normal visual development is compromised by total occlusion of the visual axis, in which instance surgical intervention may be indicated shortly after birth. Finally, patients who previously managed bilateral congenital ptosis using a chin-up head position may decompensate with discontinuation of the head-up position; this a sign of development of amblyopia, which must be treated urgently with surgical correction of the ptosis and amblyopia management.

In patients with acquired or secondary ptosis (eg, involutional or traumatic cases, ptosis associated with generalized disease or tumor), surgery often is recommended when the patient's daily activities are compromised by occlusion of the visual axis, superior visual field is lost, or extreme fatigability occurs while reading, among other difficulties.[4]

Vision may be affected in patients with secondary ptosis and sometimes in patients who have slight ptosis. During the preoperative evaluation, the physician must determine if visual or asthenopic components of the ptosis are present that indicate the need for surgery. Thorough documentation of symptoms, field defects, and submission of clinical photographs are now required routinely by third-party payers.[5]

For purposes of surgery and reconstruction, the lid structures may be divided into anterior and posterior lamellae.

The anterior lamella is the portion of the lid found anterior to the orbital septum and is composed primarily of the skin and the orbicularis oculi muscle. The orbital septum, which originates from the periosteum at the anterior-inferior edge of the orbital rim, hangs down as a curtain across the entire lid to fuse with the levator aponeurosis approximately 3 mm from the upper edge of the tarsus.

The posterior lamella is composed of tarsus, levator aponeurosis, Müller muscle, and conjunctiva. The levator muscle becomes tendinous at approximately the level of the superior rectus muscle insertion and extends anteriorly and then inferiorly to insert into the lower third of the anterior tarsal surface. The Whitnall ligament (superior suspensory ligament of the orbit) is a condensation of connective tissue fibers at the level of the junction of levator muscle and its aponeurosis, which in most instances is anterior to the levator, but it sometimes surrounds the muscle like an envelope. The Whitnall ligament is often missed by the ophthalmic surgeon at the time of surgery. It extends temporally to the lateral orbital rim through the orbital lobe of the lacrimal gland and nasally to the trochlear fascia.

The levator aponeurosis, as it passes inferiorly, fans out nasally and temporally to form the nasal and temporal horns. The temporal horn separates the palpebral from the orbital lobe of the lacrimal gland. These horns must often be cut at the time of surgery, especially when they act as check ligaments to the levator action.

At about the level of the upper border of the tarsus, aponeurotic fibers arise that extend through the orbicularis muscle to insert into the dermis. These fibers produce the lid crease. A few aponeurotic fibers also extend to the conjunctiva of the upper cul-de-sac to provide its support and to allow for conjunctival retraction with upward rotation of the eye. The levator tendon is separated from the orbital septum by the preaponeurotic fat, which is an important landmark in the exposure of the tendon during ptosis surgery. The tendon may be somewhat variable in length, usually measuring 14-20 mm.

The Müller muscle arises from the inferior surface of the levator originating at the level of the Whitnall ligament and lying between the aponeurosis and the conjunctiva. It passes anteroinferiorly to insert in the upper edge of the tarsus. The Müller muscle is thin and has a slightly darker color than the levator aponeurosis and levator muscle when seen during surgery.

In addition, the peripheral arcade of vessels at the upper edge of the tarsus courses through the Müller muscle and marks its anatomic location. The levator muscle is innervated by a branch of the superior division of the oculomotor nerve (cranial nerve III), which courses through the belly of the superior rectus muscle found beneath it. In congenital ptosis, histologic evidence of muscular dystrophy is present, and fatty tissue and fibrosis replace the levator muscle fibers. As the degree of fibrosis increases, the ptosis becomes more severe. Absence of muscle fibers in patients with congenital ptosis has been documented.

Some ophthalmologists feel that the presence or absence of Bell phenomenon is of significant importance in ptosis surgery. In most circumstances, its absence is not a contraindication to surgery in patients with congenital ptosis. However, exercise extreme caution in patients with processes (eg, thyroid myopathy, progressive external ophthalmoplegia) or dystrophies in which a poor Bell phenomenon, decreased random eye movements during sleep, and poor orbicularis muscle function may exist and produce lagophthalmos and corneal exposure. Loss of the blink reflex or corneal sensitivity, paralysis of the orbicularis, and significant keratitis sicca are definite contraindications to surgery.

CT scanning of orbits should be considered in patients with acute ptosis or if any suspicion of an orbital process, sulcus filling, or exophthalmos exists.

See the list below:

• Visual acuity: Careful vision testing is performed using an age-appropriate method. In the past, ptosis alone was not considered to produce amblyopia, and other associated factors (eg, anisometropia, strabismus) were always thought to be the cause. However, recent studies have documented that amblyopia is possible with an isolated ptosis. This problem should be searched for and treated as necessary.

• Orthoptic evaluation: Look for associated problems (eg, double elevator palsy) or other more common forms of strabismus. If indicated, muscle surgery can be performed at the same time as ptosis surgery.

• Visual field: Obtain visual field tests in patients who are able to cooperate in order to document peripheral and superior visual field restriction.

• Slit lamp examination: Include slit lamp examination, intraocular pressure measurement, and fundus examination in the preoperative evaluation.

• Refraction: A cycloplegic refraction is indicated in all children with ptosis, since a significant number of them have anisometropia primarily due to astigmatism on the ptotic side. Correct any significant refractive error.

• Tear function testing: In adults, obtain a measure of basal tear secretion by performing a Schirmer test of the anesthetized eye. In addition, evaluate the corneal tear film for evidence of abnormal debris or tear breakup.

• Ptosis measurements

  • Simple observation: Begin with simple inspection of the patient. Observe the lid level relative to the globe and to the other lid. The presence or absence of a lid fold or lid crease gives a significant clue to the degree of levator function. An absent lid crease is often accompanied by poor levator function. If a lid crease is present but is higher than normal (a normal lid crease is 8-10 mm from the lid margin measured above the pupil) and if a deeper upper lid sulcus is found on that side, note these as signs of a levator aponeurosis disinsertion. When the patient is asked to look up, both the sulcus and the lid crease may move superiorly slightly before the lid moves. This is caused by a delay in levator action due to the attenuation or stretching of the normal aponeurotic attachments to the tarsus. Measure and record the position of both upper lid creases.

  • Upper lid height

    • This is a measure of the amount of ptosis in the primary position with the patient's brows relaxed. The upper limbus can be used as a baseline from which to estimate the amount of ptosis. The upper lid normally crosses the cornea approximately 0.5-2 mm below the upper limbus, and under normal situations, it maintains this approximate relation in upward and downward gaze. The cornea is about 11 mm in height; therefore, in a patient with 3.5 mm of ptosis, the lid margin splits the visual axis, assuming the measurement from the visual axis to the upper limbus is 5.5 mm (2 mm below the upper limbus normal position + 3.5 mm ptosis = 5.5 mm).

    • Employing the corneal light reflex and its distance to the lid margin, keeping the above relationships in mind, also can provide a relatively precise estimation. For instance, if the lid margin appears to be approximately 1.5 mm above the corneal light reflex, 2-3 mm of ptosis is present. Ptosis is considered mild if 1-2 mm, moderate if 2-3 mm, and severe if 4 mm or more.

    • Levator function: Evaluation of the levator function is extremely important and begins with evaluation of the lid crease, as noted above. Presence of a crease suggests that some levator function exists even if the lid moves poorly. If the examiner everts the lid and it does not flip back to its normal position when the patient is asked to look up (known as Iliff sign), poor levator action is certain. With the exception of patients of Asian ancestry, in whom the lid crease may not be present, an absent lid crease usually indicates absent levator function.

    • In patients with abnormal levator function, the amplitude of action of the muscle is diminished and the lid fails to elevate and depress normally, producing a lid lag in downgaze. The involved lid may be higher than the uninvolved one in downgaze. This lid lag is exaggerated by ptosis surgery and hence must be discussed in advance with the patient or parents.

    • In a patient with ptosis due to a dehiscence of the levator aponeurosis, the levator muscle is normal, its function generally is quite good, and the amount of ptosis remains the same in both upgaze and downgaze. This simple relationship allows the surgeon to readily differentiate true congenital ptosis from early-acquired ptosis, congenital ptosis associated with birth injury, and other forms of ptosis in which the levator muscle is normal. Although aponeurotic defects have been reported in congenital ptosis, these are not typical.

    • The levator function is determined by holding the brow immobile, placing a millimeter ruler over the lid in the plane of the pupil, and measuring the levator excursion from extreme downgaze to extreme upgaze. Levator function may be classified as poor levator function (≤ 4 mm), fair levator function (5-7 mm), and good levator function (>8 mm). Generally, in patients with congenital ptosis, mild ptosis usually is accompanied by good levator function, and moderate-to-marked ptosis is associated with fair-to-poor levator function. The measurements of the degree of ptosis and degree of levator function require the cooperation of the patient; usually a child must be aged 2-3 years before this cooperation can be obtained.

• Additional observations: The lid contour, lashes, and skin are also evaluated. The presence of jaw winking (Marcus Gunn phenomenon) can be assessed by asking the child to move the jaw from side to side or to chew or by allowing the infant to nurse under observation. In adults, redundant skin and ptosis of the brow may mask a true ptosis or produce ptosis due to mechanical factors. Test orbicularis oculi muscle function, corneal sensation, and Bell phenomenon. Palpation of the lids and orbits is important because it may reveal a mass not otherwise appreciable as the cause of acquired ptosis.

Blepharoptosis is one of the most challenging of the commonly encountered oculoplastic problems. The goal of ptosis surgery is to recreate as nearly perfect an anatomic result as possible by elevating the position of the lid or lids and by creating a lid fold, if necessary. In addition, special attention is given to the contour and symmetry of the lids.

A thorough understanding of the goals and limitations of ptosis surgery is important, and the patient should be fully aware of these before surgery is planned. Particularly in congenital ptosis, when factors inherent to the anatomic defect pose limitations to the surgical results, the expectations and goals of the surgery must be discussed carefully with the patient and/or the parents preoperatively. A defective levator muscle, whose function is abnormal or absent preoperatively, cannot be restored surgically. The lid level can be changed, but dynamic limitations of the affected muscle persist postoperatively, and these may result in significant lid lag and lagophthalmos. Often the best result that can be hoped for is a normal lid level and contour when the eyes are in the primary position. In adult-acquired ptosis, surgery may result in inappropriate eyelid closure, exacerbation of a preexisting tear deficiency, and secondary exposure keratopathy.

In a survey of its members, The Aesthetic Society found that 97.4% of the responding surgeons who performed ptosis repair most often employed levator advancement or plication.[6]

General anesthesia is necessary for all children. Local anesthesia is adequate for adults and is much preferred for some types of ptosis. Adequate anesthesia can be obtained with a simple subcutaneous injection of 1.5-2 mL of anesthetic across the breadth of the lid. Intraorbital injection is not necessary, and if patient cooperation is desirable for setting the lid height, avoid injection behind the orbital septum. This type of injection avoids levator akinesia, thus allowing the levator muscle to function normally intraoperatively. The maintenance of levator function is an essential part of some ptosis procedures. It allows demonstration of the redevelopment of normal lid function in patients who have aponeurotic defects and is a valuable guide in patients with other syndromes in which the amount of levator resection cannot be judged accurately from preoperative measurements. Plain lidocaine (2%), lidocaine with epinephrine, or a lidocaine-bupivacaine mixture are all satisfactory.

Under general anesthesia, the congenitally ptotic lid may appear less ptotic; therefore, marking the lid prior to anesthetizing the patient is wise, since the possibility exists of inadvertently operating on the wrong eye.

In a study by Guo et al in which upper lid ptosis was corrected via the Müller aponeurosis composite flap advancement approach, the investigators found comparable postsurgical results with either local, general, or sedative anesthesia. The investigators reported that postoperatively, the marginal reflex distance–1 and corneal exposure area for local, general, and sedative anesthetics were 3.28 mm and 75.4%, 3.01 mm and 73.4%, and 3.62 mm and 74.0%, respectively.[7]

Frontalis sling (modified Crawford technique)

Although many variations of technique and materials for the frontalis sling procedure exist, generally surgeons agree that autologous fascia lata or preserved fascia lata (as a second choice) placed as a double rhomboid, single rhomboid, or triangular sling from the frontalis to the lid produces the best result. Other materials, such as catgut, collagen, Prolene, silicone, stainless steel, silk, skin, Supramid, sclera, tantalum, tarsus, and recently Mersilene mesh, umbilical vein, tendon, and other new synthetics, have been tried. Most of these materials have resulted from a search for substitutes that are effective, easily available, inexpensive, easily placed and removed, and involve few complications. Perhaps most importantly, the hope was that these would be useful in infants or young children when autologous fascia was not available.

Many of these materials have clear disadvantages, and the author does not recommend their routine use. The primary problems include early and late failure due to absorption, stretching, fracture, or cheese wiring, as well as infection that may require removal of the foreign body, which may be difficult or impossible with Mersilene mesh. To date, none of these materials have matched fascia lata in effectiveness and safety.

Clearly, in some circumstances fascia lata may not be necessary, for example, in a young infant with congenital ptosis felt to be of traumatic origin or caused by a hemangioma and in whom a temporary lid elevation may be desired or in an adult with dry eyes and severe myogenic ptosis in whom a temporary and easily reversible procedure may be performed to assess the patient's tolerance to lid elevation.

The author recommends Supramid or Prolene suture in children and Prolene or perhaps a silicone band in adults; this may be placed in an adjustable fashion. Whatever material is used, the principle of the suspension is the same (ie, the frontalis muscle, which normally elevates the brow, is used to elevate the lid).

Crawford popularized the use of the patient's own fascia lata and developed a fascia lata stripper that bears his name. He has also devised a method for storing human fascia sterilized by radiation. Physicians have used this material since 1969, and it has produced results nearly comparable to those with autologous fascia. Crawford found a recurrence of ptosis in approximately 10% of more than 300 patients in whom this procedure was performed over a 20-year period when preserved fascia was used. For this reason, he uses autologous fascia in all but infants and elderly people. To avoid the necessity of harvesting fascia, the author generally uses the preserved material and reserves the autologous fascia for patients in whom it is unavailable or when a previous sling has failed.

Using a sling for unilateral ptosis produces a cosmetic blemish on downward gaze because the motion of the lid is restricted when following the downward movement of the globe; however, excellent cosmetic results can often be obtained with the unilateral sling. The patient can learn to move one side of the brow to set the lid level close to that of the unaffected side and can ease the brow on downgaze to minimize asymmetry. Use of a bilateral sling is now accepted in patients with unilateral ptosis or with unilateral jaw-winking phenomenon to give symmetry to the 2 lids. This is felt by some to be cosmetically pleasing and to give coordination to the movements of the lids as they follow the globe in the up and down positions.

Frontalis suspension for the surgical correction of poor levator function congenital ptosis has been a matter of debate in the last decade, but recently progress has been made. A study by Bernardini et al highlights the relevant keystones regarding sling material, surgical steps, and approach that can improve functional and esthetic results, while minimizing risk to the eye.[8]

A Chinese study indicated that in severe congenital ptosis, the success of treatment using the frontalis muscle transfer technique depends on the preoperative quality of frontalis muscle function, with the investigators finding that patients whose frontalis muscle had a preoperative excursion of greater than 7 mm tended to have better correction outcomes than did those whose frontalis muscle had an excursion of 7 mm or less (91.2% sufficient correction vs 63.2%, respectively).[9]

Harvesting fascia

Children older than 3-4 years are usually large enough to allow harvesting of fascia. If in doubt, use preserved fascia or an alternate material. To obtain fascia for use in the modified Crawford technique, place the fascia lata of the leg on stretch by slightly bending the knee and turning the knee inward and the heel outward. Place a pillow beneath the hip and between the legs with a piece of adhesive tape across the lower leg to hold the knee in position.

Provide routine surgical preparation to the skin of the lateral surface of the thigh from the knee to the upper portion of the thigh, and apply the adhesive portion of a sterile plastic sheet (eg, 3-M #1060) with the hole 2.5 inches above the knee. Make a 1.5- to 2-inch horizontal incision 2.5 inches above the joint and carry it down through skin, subcutaneous tissue, and fat to the fascia, which can be seen as a white, glistening, heavy tissue with fibers running parallel to the axis of the leg. Control superficial bleeding with cautery. Use 2 skin rakes to give exposure.

Pick up the fascia with Adson skin forceps and make a 1-cm full-thickness incision through and perpendicular to the fascial fibers (horizontal). Then, make 2 vertical cuts (parallel to the fascial fibers) at the ends of the horizontal incision and extend them toward the hip for approximately 2 cm. This mobilizes the ends of the fascia so it can be threaded into the Crawford stripper (Storz #N-4298). Tie a 4-0 black silk suture in this end of the fascia to aid in threading and holding the fascia as the stripper is passed up the tendon, directed on a line from the head of the fibula or lateral tibial condyle to the iliac crest. The stripper has sharp lateral cutting edges.

After the cut is well started, the fascia splits along the parallel fibers with relative ease. Pass the stripper along the tendon for 20-25 cm; the lever is closed to cut the fascia at this point, and the stripper and fascia are withdrawn. Close the subcutaneous tissue of this incision with 4-0 chromic catgut and close the skin with an end-on mattress suture of 4-0 silk, nylon, or Prolene. Apply an elastic bandage to the thigh for 2 days for hemostasis.

The patient's activities are restricted for several days because, occasionally, a late hemorrhage occurs; however, very little postoperative reaction or pain is experienced from the thigh. Remove the skin sutures after 8 days. Place the excised fascia strip on a board and pin it to hold it on stretch. Remove any clinging fat or subcutaneous tissue. Split the strip of fascia, approximately 8 mm wide, for its full length, taking great care to separate the fibers with straight scissors and cutting across as few as possible. This gives 2 excellent strips 3-4 mm wide and 20-25 cm long, which is enough to perform the procedure on both lids.

Procedure

Make 3 stab incisions in the brow down to the periosteum with a No 15 Bard-Parker knife. Make the lateral incision 0.5 cm above the orbital rim (at the upper border of the eyebrow) and 0.5 cm temporal to a line drawn perpendicularly above the lateral canthus. The second incision is made 0.5 cm above the orbital rim, perpendicular to the center of the lid, and the third incision is made 0.5 cm above the orbital rim and 0.5 cm nasal to a line drawn perpendicular to the inner canthus. Always make the lateral incision first because the brow is fairly vascular, and if the nasal and middle incisions are made first, the blood flows over the operative site, making the lateral incision difficult. Place a Halsted hemostat in the base of each incision and spread to create a wide base for the location of the knot of fascia. Pressure over the 3 incisions provides hemostasis.

Place a 4-0 black silk traction suture in the tarsus and pass the needle in and out of the gray line in the center of the lid. Place a Storz lid plate (#E2504), which has a knurled knob at the end, under the lid, and fasten the traction suture to the knob to put the lid on constant stretch. A protective contact lens may also be used to protect the eye, but the author finds the lid plate more flexible. Make 3 horizontal stab incisions, 2 mm long, in the upper lid 1 mm above the cilia line through the skin and pretarsal muscle to the tarsus. Place the temporal incision 3 mm from the medial canthus, the middle incision in the center of the lid, and the nasal incision 3 mm from the medial canthus.

With the lid plate in place, insert an empty Wright needle (Storz #E954) into the middle brow incision to the depth of the periosteum. Pass it across the orbital rim without incorporating periosteal fibers of the linea alba. Direct the needle inferiorly and posteriorly to pass behind the orbital septum and then superficially into the lid anterior to the tarsal plate to emerge through the middle lid incision. Thread the fascia through the needle until the center of the strip is reached. Then withdraw the needle, pulling the doubled fascia through the middle incision and out the middle brow incision. Cilia must not be pulled into the tract with the fascia, since this increases the possibility of infection. Cut the double fascia at the needle, making 2 strips of equal length that are used to produce the double rhomboids.

Insert the empty Wright needle into the temporal lid incision and pass it beneath the skin to the middle lid incision. Thread the end of one fascial strand through the needle and withdraw it toward the temporal lid incision. Direct the empty needle from the temporal brow incision downward and out through the temporal lid incision in the same fashion as it was placed through the central brow and lid incisions. The fascia is then drawn through the temporal brow incision. Pass the empty needle from the temporal brow incision to the middle brow incision, and thread the opposite end of the same fascial strand through the needle and pull it out through the temporal brow incision.

This procedure produces a temporal rhomboid, and the tension on the 2 ends elevates the lateral half of the lid. The same steps are carried out in the same order to complete the medial rhomboid, using the second strip of fascia in the middle and nasal incisions of the brow and lid. By using the 2 strands of fascia in this fashion, the middle, temporal, and nasal portions of the lid can be controlled to produce a good lid contour that is slightly higher in the nasal third than in the temporal third. Both strands of fascia are pulled tightly enough to produce a good lid fold and to elevate the lid so it crosses the upper limbus with the eye in the primary position.

If bilateral ptosis is present, perform the procedure on both lids during the same operation to produce symmetry. Grasp the ends of the fascia projecting from the nasal brow incision with small Halsted clamps, and place a single tie with the fascia pulled as tightly as necessary. As mentioned, tie the sling so that the upper lid crosses the globe at the upper limbus in the primary position at the time of operation.

Some postoperative relaxation always occurs, usually 1-2 mm, which puts the lid at approximately the correct position. The author has found that overcorrection is difficult in these situations, and generally the fascia is pulled as tightly as possible. Suture the knot firmly with 4-0 chromic catgut suture or 5-0 Vicryl, using multiple passes to prevent slippage. The author has found placement of a second tie in the fascia unnecessary, since slippage does not occur if the single fascial throw is adequately sutured in place. In addition, deleting the second loop considerably reduces the bulk of the knot in the brow incisions.

However, the fascia is extremely slippery, and the ends must be fastened securely with suture material. The ends of the fascia are left long, projecting from the wound. Grasp the knot with the Halsted clamp and push it into the base of the incision so that it is well buried. Tie the fascia projecting from the temporal brow incision similarly. The temporal rhomboid usually is not tied quite as tightly as the nasal one in order to obtain proper lid contour. Examine the lids for symmetry.

Grasp the tarsal plate with two Adson skin forceps and pull the lid down into the proper position to produce a good curve without any peaking. This pulling on the lid actually sets the fascia in the desired position. If any notching or irregularity of the lid is present, pull it out by grasping the tarsus firmly with Adson forceps and pulling the lid margin to its proper place to equalize the pull of the vertical components of the sling.

When satisfied with the height of the lid, bury the projecting ends of the fascia by pulling them horizontally within the brow tract with the Wright needle from the nasal and temporal incisions toward the middle incision. In this procedure, the fascia should be inserted only slightly into the eye of the needle so it pulls free as the needle is drawn across the brow. If enough of the end of the fascia is left so that it projects from the middle wound, cut it off so that the buried portion lies deep and retracts into the incision. Close the brow skin incisions with 2-3 7-0 chromic catgut sutures placed very superficially. The lid incisions need not be closed. If the lid is picked up off the globe by elevating the brow, the fascia likely has not been placed behind the orbital septum superiorly. Patrinely and Anderson emphasized this well-recognized consideration in 1986. If this situation is detected, the fascia should be replaced prior to final suturing.

At the end of the procedure, a Frost suture of 6-0 black silk is usually placed, allowing closure of the eye(s) by fastening the lower lid to the forehead with adhesive strips. Some patients have fared well using ointment liberally once discharged. In this situation, emphasize to the patient or parents that large amounts of ointment are necessary, since the eye is most at risk of exposure during the first 24-48 hours when the lids are sore and closure is poor. If a Frost suture is placed, dress the eye with antibiotic ointment and a pressure patch for 24 hours.

Anterior approach for levator resection

At the level of the lid crease, make a 2-cm skin incision with a scalpel. If no lid crease is present, carefully place the skin incision to match the lid crease on the contralateral side. Use skin hooks to gently spread and elevate the skin edges, and divide the orbicularis muscle using fine, sharp scissors. Meticulous control of bleeding is essential at this point and throughout the procedure. Wet-field cautery gives excellent control and minimal reaction, but a fine hot-tip cautery also works well.

Perform dissection superiorly, posterior to the orbicularis in the preseptal space, until orbital fat can be identified through the intact orbital septum. Put slight pressure on the globe; this causes the orbital fat to prolapse, making the identification easier. The orbital septum is then divided with a horizontal incision for the length of the skin incision. The orbital fat, orbital septum, and skin are retracted superiorly with a Desmarres retractor. The levator tendon is thus exposed and is identified generally as a glistening white membrane.

In patients with severe congenital ptosis and very poor levator function, the levator tendon is very thin and is easily damaged with rough manipulation. Great care should be taken in its handling since a shredded tendon becomes difficult to repair. Make a small buttonhole in the levator tendon at the level of the inferior wound margin over the upper third of the tarsal plate and divide the tendon with scissors across the tarsus for the width of the incision.

The Müller muscle is then identified as a slightly reddish-brown and friable structure immediately beneath the levator tendon. A relatively large marginal vessel generally overlies the retrotarsal margin and serves as a good landmark of the Müller muscle, especially in cases of levator dehiscence, in which identification of the dehisced edge of tendon at the retrotarsal margin can be difficult. Gently elevate the levator aponeurosis with fine forceps while dissecting it with blunt-tip scissors from the underlying Müller muscle.

In cases of mild-to-moderate ptosis, dissection up to the origin of the Müller muscle from the undersurface of the levator muscle is generally sufficient to allow adequate levator resection. In cases of severe ptosis, the origin of the Müller muscle may be divided from the undersurface of the levator using a hot-tip cautery as a cutting instrument. The levator muscle may be held with a ptosis clamp if desired. With the muscle on stretch, the levator horns can be identified and divided.

In some cases, the Whitnall ligament may serve as a check ligament to the levator and also can be divided. If Müller muscle has been divided from the levator muscle, it then can be resutured to the belly of the levator muscle with an absorbable suture as far proximally as possible with the levator tendon on stretch. This effectively advances the levator tendon and muscle without resection or folding of the Müller muscle.

Place mattress sutures of a nonabsorbable material (eg, 5-0 Mersilene, Prolene) in the anterior-superior portion of the tarsal plate, or, if some advancement is desired, perform dissection anterior to the tarsus down to the lash follicles. The mattress sutures may be placed in the anterior-inferior third of the tarsus, giving advancement of an additional 4-6 mm. The sutures are placed equally across the lid, brought out through the aponeurosis, and tied temporarily until the appropriate degree of shortening is determined.

Actual resection of the tendon is reserved until the sutures have been permanently tied and the position and contour of the lid accomplished. The lid curvature and lid level can be readily adjusted by tightening one or the other of the mattress sutures to give the ideal contour. Divide the levator tendon or muscle with scissors and ensure hemostasis. Additional sutures may be placed for reinforcement as desired. Suture the orbicularis at the inferior skin edge to the resected edge of levator tendon with several interrupted sutures. This ensures formation of a lid crease and appropriate movement of the upper lid skin fold with motion of the lid.

The skin is closed with running 8-0 black silk suture, which remains in place for 5-7 days. Absorbable sutures may be used in children, placing subcuticular or interrupted sutures of a fine material. The lower lid may be elevated with a Frost suture in the immediate postoperative period. A 4-0 or 6-0 black silk suture placed through the skin of the lower lid and taped to the brow works well.

Anterior approach for levator aponeurosis repair

Local anesthesia is preferred for anterior-approach levator aponeurosis repair because it allows documentation of levator function at the time of surgery and allows the patient to cooperate with the surgeon in setting the proper height and contour of the lid(s). Resection or advancement of a tendon with a normal muscle is likely to produce an overcorrection, and local anesthesia allows for accurate determination of lid level. Lidocaine (2%) provides adequate anesthesia for this procedure, which generally takes only about 30-40 minutes to perform. Approximately 0.5-1.5 mL of lidocaine is injected subcutaneously across the lid at the level of the lid crease. Injecting posterior to the septum is not desirable, since this paralyzes the levator muscle. The skin incision and dissection through the orbicularis are the same as for a levator resection.

If a full dehiscence has occurred, often the septum is rolled superiorly and attached to the free edge of the levator aponeurosis, making its identification difficult. In this setting, after the orbicularis is divided, the Müller muscle is the next structure the surgeon encounters. The slight reddish-brown color and the transverse peripheral vascular arcade at the retrotarsal margin readily identify this muscle. If dissection is carried superiorly for several millimeters, the septum and tendon can be identified and separated. Remember that orbital fat is a crucial landmark separating these 2 structures. Dissecting superiorly under the orbicularis and over intact septum until preaponeurotic fat can be identified may be wise. At this point, the septum can be incised and the fat retracted to identify the levator aponeurosis proximal to the dehiscence.

When a complete dehiscence occurs, the edge of the levator tendon is identifiable as a relatively thick, rolled, white structure. If the patient is asked to open his or her eye or look up at this point in the procedure, the tendon is seen to retract into the orbit forcefully. After isolation, resuture the tendon to the upper mid portion of the tarsus, but slightly nasal to the pupil in the primary position, using a nonabsorbable suture. Use 2 additional sutures to set the lid contour nasally and temporally. Temporary suture placement initially allows for demonstration of good lid level and function prior to final closure. Care in closure prevents lid contour problems.

Occasionally, the levator tendon does not have a complete dehiscence but is attenuated and elastic in nature, termed a stretchy tendon. At surgery, this can often be identified by having the patient open his or her eyes and look up, demonstrating good levator function superiorly in the orbit but with poor lid motions. In this situation, simply resuture the tendon to the upper tarsal border to produce a firm attachment of the tendon to the lid at the desired height. This sometimes requires the use of hang-back sutures.

Close the skin with 8-0 black silk sutures in the same fashion as described for levator resection. The lid fold usually reforms spontaneously, but 2-3 fine sutures attaching the orbicularis to the levator tendon ensure its reformation. The author prefers not to suture skin to the tendon because this gives an unnaturally deep crease, which is noticeable when the lids are closed. No Frost suture is required.

A light patch may be used at the surgeon's discretion, although an antibiotic ointment may suffice. The author has found that the best results are obtained with minimal anesthesia and a rapid, atraumatic procedure. Postoperatively, the lids usually remain within 1 mm or so of the level set at surgery.

Orbicularis plication for ptosis

Recently, Singh[10] suggested a novel surgery that he believes is a viable addition or alternative to the existing methods of ptosis surgery. This procedure involves exposure of the orbicularis oculi muscle via a skin flap that starts near the upper orbital margin and progresses downward. The orbicularis oculi fibers near the lid margin are then joined to the proximal orbicularis fibers and the skin flap is sutured back to normal position. Singh claims that, in over 9 years, 265 operations have been performed on a wide variety and severity of ptosis.

With levator resection or a fascia sling procedure, in which some lagophthalmos is expected, the lower lid is pulled up with a modified Frost suture to cover the cornea.

Place antibiotic ointment in the eye and apply a light patch, which should be left in place for 24 hours. Use an antibiotic-steroid ointment on the suture line during the postoperative period and in the eye to guard against possible drying. Generally, only 1-2 weeks of ointment use is necessary for complete adjustment to the new situation. The patient is seen on the first postoperative day mainly to look for exposure problems and infection. If evidence of surface drying or a persistent epithelial defect is observed, the Frost suture may be left in place until healing occurs.

Remove the sutures 5-7 days postoperatively and recheck the patient. If lagophthalmos seems severe and the patient is unable to close the eye, the lid may be taped closed at nighttime, or a bubble-shield moisture chamber may be placed for protection in addition to generous ointment application. Once the repair is stable, a final visit in 1-2 months allows evaluation of the result.

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Black Eye.

Undercorrection

Undercorrection of a ptotic lid is the most common complication. Most often, undercorrection is caused by inadequate resection of the levator tendon owing to inadequate preoperative evaluation. Occasionally, excessive hemorrhage at the time of surgery may cause the surgeon to fail to identify and resect the proper structures. Excessive hemorrhage and the resultant scarring may lead to a less mobile lid and, even in the presence of an adequate levator resection, may lead to an undercorrection. Misplaced sutures or slippage of sutures in the postoperative period may also cause this complication. These situations can usually be avoided by careful preoperative evaluation and careful surgery. Unfortunately, occasional undercorrections occur even when proper preoperative evaluation and excellent surgical technique are used.

Some investigators report an 80-90% success rate with aponeurotic surgery, but in some of the remaining 10-20%, reoperation is necessary. Significant undercorrection or overcorrection can be adjusted in the early postoperative period by opening the wound and replacing the necessary suture(s) within 48-72 hours, before significant healing has occurred.

Occasionally, the surgeon attempts to correct severe ptosis with a levator resection when a frontalis sling procedure is more appropriate. Good results may be obtained, but often a frontalis sling procedure is required later, since even very large (>25 mm) levator resections may not elevate the lids. Sometimes, the manipulations of surgery produce mild paresis of the levator muscle and the lid appears undercorrected in the immediate postoperative period but improves with time. For this reason, repeat surgery should be delayed several months.

At that time, careful evaluation of the situation and discussion with the patient or parents should be undertaken to determine if the amount of undercorrection is considered a problem to those involved and if repeat surgery is desired. If levator function is present, repeat levator resection is performed using the guidelines presented for primary resections. If levator function is poor, a frontalis sling procedure is necessary.

Undercorrection following a frontalis sling procedure is treated with repeat operation; make sure to leave the lids near the upper limbus at surgery. If available, autologous fascia is preferable in these cases.

Overcorrection

Overcorrection in moderate or severe congenital ptosis is rare. It can occur if the lid is unintentionally sutured to the Whitnall ligament or to an excessively shortened orbital septum, but it is very difficult to produce by any reasonable amount of levator resection. Overcorrection in a patient with acquired ptosis, particularly levator dehiscence, is rather easy to produce if a levator resection is performed rather than simply a repair of the dehiscence. This problem was more frequent before the pathophysiology of this type of ptosis was recognized and when the defect was treated with either anterior or conjunctival approach levator resection.

If significant overcorrection occurs, it can be adjusted in the early postoperative period (1-3 d) as described for undercorrection. Alternately, massage of the lid can be instituted in 4-5 days and can be continued for several months to ensure the maximum effect is achieved.

Stretching the lid in a downward fashion in the immediate postoperative period can also provide some effect. The lid may be doubled over a Desmarres retractor and pulled on daily for several days, again beginning after an observation period of 3-4 days. Levator recession is required if a significant overcorrection persists several months after ptosis surgery. Preserved sclera and fascia lata have been used to lengthen the levator muscle in the same fashion as for correction of lid retraction in thyroid disease; however, levator recessions are frequently performed with no spacers, since usually only hang-back sutures suffice. Generally, the amount of recession is equal to the amount of lid retraction. Again, this procedure can be performed with the patient under local anesthesia to allow the patient's assistance in accurately setting the lid level.

Poor or improperly positioned lid crease

A poor or improperly positioned lid crease may occur if the skin incision is placed incorrectly or if the skin and orbicularis muscle are not fixated to the levator aponeurosis during the skin closure. A lid crease can be lowered by making an incision at the desired level for the new crease and then excising the intervening scar and closing the new incision. Conversely, elevating the crease is difficult, since making a new adhesion higher exposes the original scar. In that situation, lowering the crease on the contralateral side may be easier.

Peaking of the lid

Peaking of the lid rarely occurs with levator resection if the tarsus is left intact, since its width serves to stabilize the lid contour. However, if sutures are placed unevenly or if suturing is directly to the tarsus in one area and to pretarsal tissues in another, contour problems are more likely to occur. Reoperation may be necessary to obtain the best result. Operations in which the tarsus is resected partially produce a much higher frequency of lid contour problems and are therefore no longer advocated.

Exposure keratitis

Mild exposure keratitis is frequently noted for the first few weeks after surgery. This seems to cause little or no problem in children, since the epithelium soon heals and the patient readjusts to the new situation. In adults, corneal staining may persist and be significant. Tear function must be reevaluated. In general, temporary tear replacement, ointments, and lid closure at night produce adequate protection, and the problem disappears. If the problem persists, consider placement of temporary punctal plugs. Significant lagophthalmos is unusual in patients with levator dehiscence, since lid function is simply restored. Some lagophthalmos is common after frontalis sling procedures and with maximal levator resections. The parents should always be informed preoperatively that the eyes will remain open to some extent while a child is asleep and that temporary protection is necessary.

Corneal abrasion

Corneal abrasion can result from sutures inadvertently placed through the tarsus or conjunctival surface. After suture placement, evert the lid to check that a suture is not exposed. Protect the globe and cornea during dissection and suture placement and, as noted above, especially during Wright needle insertion. Consider using a contact lens corneal protector or lid plate.

Lid lag

Lid lag, like lagophthalmos, is an expected compromise of congenital ptosis surgery that must be accepted.

Infection and inflammatory reactions

Infection is extremely rare following levator surgery. It may occasionally occur with frontalis sling procedures, since an avascular, possibly foreign material is introduced. In addition, a noninfectious inflammatory reaction to implanted materials may occur. Chances of infection may be reduced by irrigating the operative site with an antibiotic solution at the end of the procedure. Take great care to avoid introducing cilia or other foreign material into the operative site during placement of the fascia. Treat infections by heat and appropriate systemic antibiotics. If some material other than fascia is placed, its removal may be necessary.

Late granulomatous inflammatory reactions can be observed around suture materials. Once a suture abscess has been excluded, treat these conservatively with warm compresses and antibiotic-steroid combination ointments if superficial, followed by steroid injection at the site, with or without removal of the inciting material and fistulous tract.

Double vision

Usually, postoperative diplopia is due to direct damage to the superior rectus muscle and sometimes the superior oblique muscle; rarely, it is due to direct nerve damage.

Usually, good-to-excellent results are obtained when these procedures are performed by experienced surgeons.[11]

A study by Bahceci Simsek indicated that ptosis blepharoplasty can lead to significant relief from tension-type headaches. In the study, patients with tension-type headache symptoms were treated with either standard upper eyelid blepharoplasty or ptosis repair, with the latter consisting of levator resection, Müller muscle resection, or frontalis suspension. The investigators found that for both groups of patients, mean postoperative scores on the Headache Impact Test (HIT-6) showed significant improvement over the mean preoperative scores.[12]

No true controversies exist regarding this surgery bar the decision of whether to operate on both eyes in severe unilateral congenital ptosis, particularly in patients affected by Marcus Gunn winking. The consensus and recent studies have demonstrated that bilateral frontalis slinging is the best option, but some surgeons remain hesitant to take this severe approach.