22 Posterior White Line Advancement
Abstract
The posterior white line advancement technique and the levatorpexy for congenital ptosis derived from it are two approaches of posterior ptosis repair. They are useful for mild to severe involutional ptosis and for congenital ptosis, respectively. The white line advancement can be performed on thinned tarsus and has consistently predictable results when modifying the technique according to preoperative measurements.
22.1 Introduction
The Müller’s muscle–conjunctival resection (MMCR) procedure is considered an evolution to the Fasanella–Servat procedure and has traditionally been used for patients with a positive phenylephrine test and mild to moderate ptosis as well as good levator function (LF). It does not involve a tarsectomy. It was described by Putterman and Urist in 1975. 1
The mechanism of posterior Müller’s muscle resection appears to work by the aponeurosis being splinted forward. This observation helps explain the concept of isolated posterior approach levator advancement developed by Collin, 2 and later modified as the white line advancement by Malhotra. 3 The difference between Collin’s levator advancement and Malhotra’s white line advancement is that the white line advancement technique advances the exposed posterior surface of the aponeurosis and does not breach the orbital septum or include a tarsectomy.
We prefer the posterior approach for severe involutional ptosis because the attenuated and retracted levator aponeurosis in the deeper orbit can be more difficult to find when approached anteriorly, and it requires more dissection, which can result in more trauma compared to the posterior approach. The thinned tarsus in severe involutional ptosis may be difficult to suture and the risk of full-thickness needle pass exists. In avoiding full-thickness needle passes, partial-thickness bites in thinned tarsus may be more vulnerable to early dehiscence.
The white line advancement technique for aponeurotic ptosis was subsequently modified into the levatorpexy procedure for congenital ptosis. The levatorpexy procedure plicates levator palpebrae superioris (LPS) to mimic levator resection, contributing to improved margin reflex distance 1 and decreased margin fold distance. This fold creates volume and contributes to improved cosmesis by adding fullness to the preseptal eyelid. Depending upon the LF, the position of suture placement varies, allowing the surgeon to make precise modifications in the surgical approach based on the individual patient needs. 4
22.2 Relevant Anatomy
Müller’s muscle is a smooth muscle that together with the LPS forms the upper lid retractors. Müller’s origin is situated on the underside of the levator aponeurosis and is sympathetically innervated.
Anatomically, Müller’s muscle inserts into the superior border of the tarsal plate. 5 It extends medially and laterally, as far as the medial rectus and lateral rectus pulleys, respectively. Along its lateral course, the extension of Müller’s muscle passes through the lacrimal gland fascia and can appear more attenuated. Müller’s muscle has, therefore, been described as a component of the peribulbar smooth muscle network rather than an isolated anatomical structure. 6
The LPS originates from the lesser wing of the sphenoid and transitions into its aponeurosis after approximately 36 mm. 7 At the musculotendinous transition, Whitnall’s ligament suspends the LPS and acts as its pulley. 8 Whitnall’s ligament extends from the lateral aspect of the trochlea and Whitnall’s tubercle (on the lateral orbital wall), passing between the orbital and the palpebral part of the lacrimal gland laterally.
The levator aponeurosis originates from the LPS and anatomically consists of two layers. Both of those layers—anterior and posterior—contain smooth muscle. 9 The anterior layer contains thick fibrous tissue, whereas the posterior layer consists of thin fibrous tissue and a much larger proportion of smooth muscle. 9
The postlevator aponeurosis fat pad has been known about for some time, initially reported in the late 1980s. 10 However, only a recent study confirmed these findings and conducted a detailed macroscopic and microscopic histological assessment. 11 This fat pad is a distinct entity in the postaponeurotic space, located between Müller’s muscle and the posterior layer of the levator aponeurosis with its associated smooth muscle. Macroscopically, the fat is located between the two layers of smooth muscle situated posterior to the aponeurosis, which has previously been described by Kakizaki and colleagues. 9 The postlevator aponeurosis fat tends to be central and medially located, where it overlies Müller’s muscle and commonly continues posterior to the aponeurosis up to the levator muscle. The fat pad tends to be diffuse with some more discreet, multilobulated areas 11 and it has been described in both adults and children. 4 , 11
The postaponeurotic fat pad is a significant landmark for ptosis surgery and will inform the oculoplastic surgeon to guide dissection of Müller’s muscle and the LPS aponeurosis. One has to avoid mistaking it for the preaponeurotic fat pad anterior to it.
22.3 Indications
All types of involutional ptosis, mild to severe.
Congenital ptosis, especially when a posterior approach with absence of a skin incision and creation of a skin crease is desired.
22.4 Risks
Corneal abrasion.
Undercorrection.
Overcorrection.
Eyelid contour abnormalities.
22.5 Benefits
Absence of skin incision, no external scar.
Predictable results and eyelid contour outcomes. 3 , 12 ID#b566a916_13 – ID#b566a916_14 15
Suture placement is independent of pupil position in primary gaze and is guided by the superior tarsal contour.
Avoids violation of the septum, particularly medially, avoiding disruption of the medial fibers of the medial horn of the LPS that continue anteriorly as the septum. 16 , 17
May be combined with skin-only or skin–muscle flap blepharoplasty.
May be performed under local, monitored, or general anesthesia in adults and children. 14 , 15 , 18
22.6 Informed Consent
Discussion of the aim of the procedure.
Benefits of the procedure, as above.
Risks of the procedure, as above.
Alternatives to white line advancement like MMCR or external levator advancement in aponeurotic ptosis.
Alternatives to levatorpexy like levator resection in congenital ptosis with diminished levator excursion (<4–10 mm).
22.7 Contraindications
There are a few relative contraindications for the white line advancement technique. These include:
Individuals with conjunctival scarring disease (pemphigoid, Stevens–Johnson syndrome, and fornix contraction).
Glaucoma patients either with blebs or those in whom conjunctival scarring is to be avoided (i.e., those being considered for filtration surgery).
22.8 Instrumentation
Surgical skin marker.
Local anesthesia:
Approximately 0.5% bupivacaine with 1:200,000 adrenaline.
Syringe and needle, prefer 25 to 27 gauge.
Surgical skin preparation, for example, povidone-iodine.
Surgical drapes.
Routine suture tray with curved and straight needle holder, toothed forceps, and scissors.
Diathermy/cautery.
A #15 Bard-Parker blade.
Sutures:
The 4–0 silk traction sutures.
Double-armed x 5–0 Vicryl suture (the authors prefer an S-24, 8.0-mm, ¼ circle, spatulated needle).
Antibiotic ointment.
22.9 Preoperative Checklist
A routine preoperative checklist should be performed including:
Patient name.
Patient hospital record number/identifier.
Patient date of birth.
Procedure to be performed.
Left or right eye or bilateral procedure.
Any patient allergies.
Any surgical/anesthetic/nursing concerns.
Patient’s signature on the consent form for surgical and anesthetic consents.
22.10 Operative Technique
The authors have developed a transconjunctival levator advancement procedure for involutional ptosis (“white line advancement”), which then developed into a levator tuck procedure or levatorpexy for congenital ptosis, to advance and plicate the levator to the tarsal plate posteriorly. 4 This technique has all the advantages of posterior approach ptosis surgery, including the absence of skin incision and predictable and excellent lid contour, while avoiding tissue resection.
22.10.1 The White Line Advancement for Aponeurotic Ptosis
The white line advancement technique has been described in detail and is summarized below. 3 , 18 , 19 The white line advancement technique advances the exposed posterior surface of the aponeurosis to correct ptosis and also helps restore a more defined skin crease in the process.
Using 0.5% bupivacaine with 1:200,000 adrenaline, infiltrate 1 ml subcutaneously to eyelid skin crease and in the midpupil pretarsal region and 0.5 ml subconjunctivally (Fig. 22.1 a, b).
Place a 4–0 silk traction suture in the grey line and evert the eyelid over a Desmarres retractor (Fig. 22.1 c).
Apply gentle diathermy over the proposed conjunctival incision site (Fig. 22.1 d).
Incise the conjunctiva using a #15 Bard-Parker blade along but above the superior border of tarsus (Fig. 22.1 e).
Dissect Müller’s muscle and conjunctiva as composite flap to expose the white line, which represents the posterior border of the levator aponeurosis (Fig. 22.1 f).
Dissect further between the posterior surface of the levator aponeurosis and the conjunctiva to expose the postaponeurotic fat pad and the posterior surface of the LPS muscle (Fig. 22.1 g).
Pass a double-armed 5–0 Vicryl suture (5–0 Ethicon coated Vicryl ), polyglactin 910, undyed, S-24, 8.0-mm, ¼ circle, spatulated needle at a point in a vertical line with the central peak of the tarsal plate through the most proximal white line at its junction with the LPS (Fig. 22.1 h).
Then pass the suture through the conjunctival surface of the tarsal plate, 1 mm below its superior border, and then through the skin (Fig. 22.1 i, j).
Ensure the suture is passed through the skin at the level of the lid crease (Fig. 22.1 k).
Take care to pass both double-armed needles through the same exit skin site to facilitate burying of the eventually tied suture knot.
Assess the lid height and eyelid contour and tie the suture in a bow (Fig. 22.1 l).
If the lid height is too low after the first suture, relax it and pass a second suture higher through the white line and again the tarsal plate and the skin.
If the upper eyelid contour appears peaked after the first suture, then relax it (i.e., tie it loosely only) and place a second suture more centrally to the position of the peak. This way, the position of the second suture can alter and adjust the lid position without having to remove the initial suture.
In the majority of cases, the use of the second suture avoids the need to remove the initial suture. This can be tied gently as “support” rather than “cardinal suture.”
The sutures can be left to dissolve and the composite flap of Müller’s muscle and conjunctiva can be left to heal.
The above method can be combined with a skin-only or skin–muscle blepharoplasty, avoiding breach of the septum.
Apply antibiotic ointment and a pressure dressing as needed.
Excellent symmetric results may be achieved with this surgical technique (Fig. 22.2).
Fig. 22.1 White line advancement technique. (a, b) Approximately 1 ml of subcutaneous infiltration in the midpupil pretarsal region upon eversion and skin crease using 0.5% bupivacaine with 1:200,000 adrenaline. (c) A 4–0 silk traction suture placed in the grey line of the upper eyelid, everted over a Desmarres retractor. (d) Gentle diathermy applied to the conjunctiva immediately above and at the superior tarsal border. (e) Conjunctival incision made with a #15 Bard-Parker blade along but above the superior border of the tarsus. (f, g) Müller’s muscle and conjunctiva dissected off as a composite flap until the white line, representing the posterior border of the levator aponeurosis. (h–j) A double-armed 5–0 Vicryl suture was placed centrally through the posterior surface of the white line (h), in a forehand manner and was then passed through the conjunctival surface of the tarsal plate, 1 mm below its superior border (i), and then through to the skin (j). (k) The suture was captured through the skin in the region of the skin crease. (l) The final lid height and contour at the end of the procedure. 
Fig. 22.2 (a) Preoperative and (b) postoperative photographs at 3-month follow-up of three patients who underwent bilateral posterior approach white line advancement for aponeurotic ptosis.
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