18 External Levator Advancement with Orbicularis-Sparing Technique
Abstract
External levator advancement is an optimal procedure for moderate to severe aponeurotic ptosis. This technique has the advantage of addressing both dermatochalasis and ptosis simultaneously through a single incision. With practice and a precise awareness of anatomy, this procedure allows the surgeon a high degree of control over eyelid contour, height, and symmetry. This chapter describes external levator advancement using an orbicularis muscle–sparing technique to maintain blink and minimize exposure keratopathy and lagophthalmos.
18.1 Introduction/Goals of Intervention
External levator advancement (ELA) is a workhorse procedure for aponeurotic/involutional ptosis, which arises from attenuation of the levator aponeurosis resulting in its elongation or dehiscence from the tarsus. 1 ID#b214a130_2 – 3 Aponeurotic ptosis is characterized by decreased palpebral fissure (PF) in primary and downgaze, decreased margin reflex distance 1 (MRD1), increased margin crease and margin fold distances (MFD), normal Bell’s phenomenon, and normal levator excursion (>10 mm; Fig. 18.1). 2 , 3 Evaluation for concurrent dermatochalasis, brow ptosis, lagophthalmos, and dry eye should be performed prior to surgery.
The main goals of ELA include elevating the eyelid height (MRD1) to improve the superior visual field in primary gaze, improve PF on downgaze for reading, improve aesthetic eyelid contour and symmetry, and avoid lagophthalmos. To achieve the best results, reversible sedation should be used with local anesthetic so that the patient may cooperate with instructions from the surgeon to allow for intraoperative adjustment of eyelid height, contour, and symmetry. In experienced hands, this approach is very effective in establishing good eyelid position, with reported success rates ranging from 77 to 95%. 4 , 5 Primary external levator surgery is less complex than reoperation. 6 With practice, ELA can be a very predictable and successful technique alone or combined with blepharoplasty for patients who need simultaneous dermatochalasis and ptosis management.
18.2 Risks
Ptosis repair is an elective surgery and it is vital for the surgeon to have a thorough preoperative discussion with the patient. Main surgical risks include:
Prolonged bruising and swelling of the eyelids (including lower eyelids).
Exacerbation or new development of dry eye symptoms from exposure keratopathy.
Contour abnormalities.
Undercorrection.
Overcorrection.
Scarring.
Lagophthalmos (incomplete eyelid closure).
Orbital hemorrhage.
The risk may be slightly higher with an external levator surgery than blepharoplasty or posterior approach surgery that does not violate the orbital septum.
A disastrous orbital hemorrhage could lead to vision loss.
Less severe hematomas may cause delayed wound healing and/or recurrent ptosis.
Damage to adjacent structures, including:
Trochlea medially, causing double vision. 7
Lacrimal gland injury laterally.
Wound infection or dehiscence.
18.3 Benefits
Improvement in MRD1, PF, and superior visual field.
Improved aesthetic appearance of face.
May be performed with blepharoplasty without an additional incision.
Allows for creation or adjustment of eyelid crease.
Allows for intraoperative adjustment of eyelid contour and treatment of concurrent lacrimal gland prolapse (see Chapter 26).
18.4 Informed Consent
What is ptosis?
Surgical steps for ptosis repair.
How will ptosis surgery benefit vision and appearance?
Major risks and complications of the procedure.
Alternatives to surgical repair:
No surgery.
Blepharoplasty only.
Posterior approach ptosis surgery.
Anesthesia risks.
18.5 Indications
Ability for patient to cooperate intraoperatively.
Desire for improved facial aesthetics with an improved MRD1 and PF.
Normal levator excursion (>10 mm).
Compromise of superior visual field leading to decreased quality of life and function, such as difficulty reading, peripheral vision obstruction affecting driving or ambulating, or difficulty with work requirements.
18.6 Relative Contraindications
Severely decreased blink reflex (such as in Parkinson’s disease patients).
Loss of corneal sensitivity.
Significant keratoconjunctivitis sicca and resultant exposure keratopathy.
Paralysis or weakness of orbicularis oculi muscle.
Absent Bell’s phenomenon (involuntary upward excursion of eye with attempted lid closure).
Abnormal levator excursion (<10 mm).
External levator resection is an option for some patients with 5- to 10-mm levator function (See Chapter 30).
Frontalis suspension is the option for patients with levator excursion less than 4 mm (See Chapter 29).
18.7 The Procedure
The procedure can be performed under local or monitored anesthesia in an office-based setting, outpatient surgical center, or hospital.
18.7.1 Preoperative Checklist
Review chart to confirm patient, informed consent signed, and past surgical, medical, and ocular histories.
Confirmation of aponeurotic ptosis with decreased PF in primary and downgaze, decreased MRD1, increased margin crease distance, and MFD with normal levator excursion.
Confirm ptosis is not variable to rule out myogenic (or neurogenic) ptosis.
Confirm no severe dry eye or lagophthalmos and normal Bell’s phenomenon.
Discuss upper eyelid crease and fold distances with patient to determine whether simultaneous blepharoplasty is warranted (See Chapter 6).
Set the crease at 8 to 10 mm in Europeans.
Set the crease at 6 to 8 mm in East Asians who desire a double eyelid.
Preoperative photographs, documenting the ptosis (primary and oblique views).
Anticoagulation status.
18.7.2 Instruments Needed
Castroviejo calipers.
#15 Bard-Parker blade.
Westcott scissors (both sharp and blunt-tipped).
0.3-mm Castroviejo forceps.
Curved Castroviejo needle driver.
Small two-prong skin retractor.
22-gauge needle.
18.7.3 Sutures Used
The 5–0 Vicryl on a spatulated needle (or 6–0 nylon or Prolene for nondissolving suture, frequently used in reoperations).
The 6–0 Prolene or 6–0 fast-absorbing or plain gut for skin closure.
18.7.4 The Operative Technique: Step by Step
The patient is marked along the desired upper eyelid crease (8–10 mm from margin) in the upright position.
If any skin needs to be excised, a modified ellipse is marked for a simultaneous blepharoplasty.
The patient is positioned supine in the operating room.
The eyelids and face are prepared with 5% Betadine and draped in the usual sterile fashion for ophthalmic plastic surgery—the entire face is exposed, with nasal cannula for supplemental oxygen as needed.
After Betadine cleansing, both upper eyelids are infiltrated with an equal amount of 1:1 mixture of lidocaine 2% with 1:100,000 epinephrine mixed with 0.5% bupivacaine (+/− about 0.2 mL of hyaluronidase per 10 mL).
No more than 1.5 mL per eyelid is injected to minimize the effect of the epinephrine on Müller’s muscle.
The preoperative skin markings are checked in the supine position by remeasurement and confirmation with the pinch test.
An incision is made with a #15 Bard-Parker blade along the markings. Any marked excess skin is removed using Westcott scissors and 0.3-mm forceps, preserving underlying orbicularis to maximize postoperative eyelid closure. Hemostasis can be achieved with minimal bipolar or monopolar cautery.
The patient’s baseline eyelid position is assessed. The epinephrine in the block and the supine patient position usually partially corrects the patient’s ptosis. Knowing the baseline position in this state helps assess how much intraoperative overcorrection should be targeted.
Holding the inferior skin edge with forceps, Westcott scissors are used to cut straight down to the tarsus at the lower edge of the incision. The incision is extended medially to just before the punctum and laterally to approximately 3 mm nasal from the lateral canthus.
A Colorado needle tip cautery and a “Q-tip roll technique” can be used for focal cautery to achieve hemostasis.
A two-prong skin retractor is placed at the level of the pupil on the lower edge of the incision for inferior retraction by an assistant.
The orbicularis is tented superiorly with forceps, and the dissection is made down to the orbital septum, angling the Westcott scissors superiorly to peel the orbicularis muscle away from orbital septum. Care must be taken to avoid injury to the levator aponeurosis during dissection. Because the dissection is started inferiorly at the level of the tarsus, it is important to recognize that the levator has been disinserted and to carefully search for the inferior edge of the aponeurosis.
The septum is opened, and orbital (preaponeurotic) fat is exposed superiorly.
Anatomically, the levator is just posterior to this fat pad and is further exposed with blunt dissection (Fig. 18.2).
To aid in exposing the levator aponeurosis, the patient can be asked to look up and down to visualize the levator muscle action.
Forced generation of the levator muscle can be tested by grasping the levator with toothed forceps and asking the patient to look up while pulling the levator aponeurosis down.
If no force is felt, the surgeon is most likely grasping the orbital septum.
Müller’s muscle is carefully peeled off the underside of the levator aponeurosis with sharp Westcott scissors to allow for easy advancement. If Müller’s muscle is violated, a significant amount of bleeding can occur.
The patient is asked to open the eyes, and the eyelid position is reexamined to check the new baseline eyelid position before advancement because exposure of the levator aponeurosis may make the ptosis appear to be improved.
A horizontal mattress suture between the levator and tarsus is begun with a 5–0 polyglactin suture with spatulated needle (or 6–0 Prolene or nylon) placed in a backhanded fashion through the levator at the desired height.
Before passing the suture through the tarsus, the eyelid is lifted off of the globe to avoid ocular penetration. A protective corneal shield may also be used to prevent ocular injury. The needle is passed partial thickness through the tarsal plate approximately 8 mm above the lid margin (Fig. 18.3 a). One should be able to feel the firmness of the tarsus when making the tarsal bite. The lid is everted to ensure the needle does not travel full thickness through the eyelid tarsus (Fig. 18.3 b).
The suture is passed through the levator again in the opposite direction to complete the horizontal mattress suture (Fig. 18.3 c). The suture is tied temporarily to allow for intraoperative assessment of the eyelid position (Fig. 18.4).
Eyelid position is reassessed by asking the patient to look up, down, and straight. The surgeon has to be mindful of the local anesthetic epinephrine effect on both the orbicularis oculi and levator muscles.
Additional horizontal mattress sutures may be placed medially and laterally to support the central suture or adjust contour. Both the central and medial sutures are tied down temporarily, and the patient’s eyelid position is re-evaluated (Fig. 18.5).
If the contour or height of the eyelid requires adjustment, the temporarily tied sutures can be released by pulling on the shorter end.
If the suture needs to be relaxed, it is temporarily retied in a hang-back fashion.
If it needs to be advanced, the placement on the levator can be adjusted (Fig. 18.6) or the suture can be removed entirely and replaced.
Once the ideal contour and height are achieved (Fig. 18.7), the sutures are permanently tied down, being careful to not adjust the levator aponeurosis position from the desired temporarily tied location (Fig. 18.8).
Overtightening may cause the suture to cheese-wire through the tarsus, advance the levator aponeurosis, or crimp the levator aponeurosis.
The orbicularis muscle is redraped over the advanced levator aponeurosis. The lid can now be reinjected with more local anesthetic for comfort during closure or excess skin removal. The skin is closed using a suture of choice, such as a running 6–0 Prolene or plain gut. The goal is to achieve excellent eyelid height, contour, and eyelid crease and fold symmetry ( Fig. 18.9).
Fig. 18.2 The levator muscle is pulled forward for visualization after dissection from the orbital septum and preaponeurotic fat. 
Fig. 18.3 After passing the 5–0 Vicryl suture through the levator aponeurosis at the desired height for advancement, the needle is passed through the tarsal plate at the level of the lower edge of the incision, approximately 8 mm above the lid margin (a). The lid is everted to ensure the needle does not travel full thickness through the eyelid (b). The needle will then be passed back through the levator to complete the horizontal mattress suture (c). 
Fig. 18.4 The suture is tied temporarily to allow for intraoperative assessment of the eyelid position (a) with a slip knot (b). 
Fig. 18.5 After the right upper eyelid sutures have been temporarily tied down, then the patient’s eyelid position is re-evaluated. The right upper eyelid has been advanced, the left side has not. 
Fig. 18.6 To avoid having to remove the whole suture or use multiple double-armed sutures, a 22-gauge needle can be used to pass through the new desired position on the levator. 
Fig. 18.7 After both levator aponeuroses have been temporarily advanced, the lids are assessed for symmetry, height, and contour. 
Fig. 18.8 Once the ideal contour and height are achieved, the sutures are permanently tied down one by one, being careful to not adjust the levator aponeurosis position from the desired temporarily tied location. One should not overtighten the suture. 
Fig. 18.9 (a–c) Representative pre- and postexternal levator aponeurosis repair. (a) Before bilateral upper external levator advancement (upper panel) and after bilateral upper eyelid ptosis repair (1 year) (lower panel). (b) Before bilateral external levator advancement (upper panel) and after 1 week (lower panel). (c) Before (upper panel) and 9 months after (lower panel) bilateral upper eyelid external levator advancement with lid crease external modification.
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