19 Small Incision Anterior Levator Advancement
Abstract
Aponeurotic blepharoptosis is a commonly encountered problem in patients with functional and/or cosmetic concerns. Both external levator repair and conjunctival mullerectomy are time-honored surgical approaches. A subset of patients with upper eyelid ptosis are good candidates for external levator repair through a modified incision. Initially, small incision external levator repair was described through an 8-mm incision. This chapter describes a useful modification of small incision external levator repair through a slightly larger incision.
19.1 Introduction
A frequent argument at oculofacial surgical conferences debates whether conjunctival mullerectomy (CML) or external levator repair is superior. In fact, both are excellent surgical options and should be part of the surgical armamentarium of any experienced oculofacial surgeon. Each of these operations has its advantages and disadvantages.
This chapter will focus on external levator repair through a limited eyelid crease incision. 1 – 7 When upper blepharoplasty is not desired, a small incision may be advantageous in terms of time, efficiency, reduced postoperative edema and ecchymosis, and possibly increased accuracy. The main disadvantage to this small incision variation is the reduced exposure. The modified external levator repair described in this chapter strikes a balance between full-incision ptosis repair (i.e., in the setting of upper eyelid blepharoplasty) and the previously described small incision external levator advancement performed through an 8-mm eyelid crease incision. For surgeons experienced in full-incision external levator repair, this modified approach is easily learned.
19.2 Goals/Indications
Elevation of the upper eyelid (i.e., increase the margin reflex distance 1).
Improved visual function and visual field for patients with visually significant blepharoptosis.
Improved cosmesis.
Avoidance of complications such as overcorrection or undercorrection.
19.3 Risks of the Procedure
Hemorrhage.
Infection.
Upper eyelid asymmetry.
Eyelid crease abnormalities.
Overcorrection/undercorrection.
Exposure keratopathy/worsening of dry eye symptoms.
Lagophthalmos.
19.4 Benefits of the Procedure
Improvement of visual field and visual function.
Improvement of periocular aesthetics.
19.5 Contraindications
19.5.1 Absolute Contraindications
Poor levator excursion:
For levator excursion 5 mm or less, frontalis suspension is usually recommended.
For levator excursion between 5 and 10 mm, a full-incision open approach is often preferable.
The eyelid that has had many surgeries.
19.5.2 Relative Contraindications
Patients at risk for ocular surface decompensation (i.e., corneal anesthesia, poor blink, poor Bell’s phenomenon, or very severe dry eyes).
19.6 Informed Consent
Careful discussion of the risks and benefits as described above.
It is important that the patient understands that he or she will need to awaken, sit up, and look up and down during the surgery to allow eyelid height adjustment. This intraoperative assessment helps improve the accuracy of the procedure.
19.7 The Procedure
19.7.1 Instruments Needed
Marking pen.
Ruler.
Corneal protective shield.
Incisional devices such as scalpel, Westcott scissors, and monopolar unit with microdissection needle.
Tissue forceps (0.5-mm forceps).
Sutures:
The 6–0 Prolene, blue, for advancement of the levator aponeurosis onto the anterior tarsus.
The 7–0 Vicryl for orbicularis closure.
A 6–0 fast-absorbing or 6–0 Prolene suture for skin closure.
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