30.1 Introduction

Levator resection is employed in patients with static congenital ptosis with levator excursion between 4 and 10 mm. The immediate goal of surgery in the pediatric patient is to provide an unobstructed visual axis for optimization of the child’s developing vision. Surgery should be performed as soon as it is convenient and more rapidly in the child at risk for amblyopia. When there is no evidence of amblyopia, obstructed pupillary axis in primary gaze, asymmetric astigmatism, or significant chin-up posture, the surgery is less urgent and may be performed according to family and physician preferences. Advantages of early, nonurgent surgery include less disruption of the child’s schedule, fast wound healing, and less patient/parent anxiety. Advantages of later surgery include more accurate lid measurements and better ability to assess and modify eyelid crease and eyelid fold for improved cosmesis. The algorithms reviewed in Chapter 28 allow the surgeon to determine the appropriate amount of levator resection. Individually customized modifications to the suggested algorithms will develop with surgeon experience.

30.2 The Anatomy of the Eyelid Crease

In normal eyelids, the levator aponeurosis divides into anterior and posterior portions prior to its insertion. The anterior portion is composed of fine leaflets of aponeurosis that insert into the septa between the pretarsal orbicularis muscle and the skin, forming the normal upper eyelid crease. ^{1 ,​ 2} In congenital ptosis, there is a spectrum of lid crease formation from relatively normal to absent. ³ The surgeon may surgically create aponeurotic attachments to the pretarsal tissues to create a more prominent crease during ptosis surgery or in a staged approach. The goal is to create symmetry in the margin crease distance (MCD) and margin fold distance (MFD) in primary gaze.

30.3 Preoperative Assessment

The accuracy of the eyelid evaluation in pediatric patients requires patient cooperation and is challenging; repetition, patience, and skill to encourage patient cooperation are necessary. Important preoperative measurements include palpebral fissure, palpebral fissure on downgaze, margin reflex distance 1, MCD, MFD, lagophthalmos amount, Bell’s phenomenon, and levator excursion. The preoperative encounter is the final opportunity to refine the surgical plan.

30.4 Informed Consent

Adult patients or parents of affected children must be informed of the benefits, risks, and alternatives of the surgical procedure, including the intraoperative risks, postoperative consequences of levator resection, and postoperative complications.

30.5 Instrumentation

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  Local anesthetic on 3-mL syringe with 30-gauge needle:

  
  
  
  
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    Marcaine 0.025% with 1:200,000 epinephrine for infants.

    
    
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    Lidocaine 1% or 2% and 0.75% bupivacaine (50/50 mix) with 1:200,000 epinephrine for older children and adults.

  
  
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  Marking pen.

  
  
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  Protective scleral shell.

  
  
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  A 0.3 toothed forceps.

  
  
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  A #15 blade.

  
  
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  Westcott scissors.

  
  
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  Straight iris scissors.

  
  
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  Ptosis clamp.

  
  
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  Monopolar needle-tip cautery.

  
  
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  Castroviejo needle drivers.

  
  
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  Desmarres retractor.

  
  
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  Serafin clamps.

  
  
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  Suture:

  
  
  
  
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    Three double-armed 5–0 or 6–0 Vicryl on spatulated needles per side.

    
    
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    The 6–0 plain absorbing gut.

    
    
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    The 6–0 polypropylene on a P-1 needle for older children or adults.

30.6 The Levator Resection Procedure

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  The eyelid crease is marked prior to local infiltration (before sedation in the adult and after in the child).

  
  
  
  
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    In unilateral cases, the contralateral eyelid crease is used for comparison.

    
    
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    In bilateral surgery, the more natural eyelid crease height is used.

    
    
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    If neither eyelid presents a distinct crease, gentle digital upward lift of the margin will often delineate the most natural fold and crease.

  
  
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  Inject local anesthetic with epinephrine to improve postoperative comfort, provide hemostasis, and delineate tissue planes.

  
  
  
  
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    Pediatric patients may reach toxic level of local anesthetic.

    
    
    
    
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      Lidocaine maximum dosage of 4.5 mg/kg (7 mg/kg is allowable with use of lidocaine with epinephrine).

      
      
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      Bupivacaine maximum dosage of 3 mg/kg.

  
  
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  A protective scleral contact lens may be used for ocular surface protection.

  
  
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  Incise the eyelid crease at the previously made skin marking with a #15 blade.

  
  
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  Sharply dissect through orbicularis and septum with Westcott scissors.

  
  
  
  
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    Septum and fat are teased away from the levator aponeurosis and muscle and pushed superiorly to reveal Whitnall’s ligament.

  
  
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  Decide if degree of levator resection requires some removal of conjunctiva to prevent conjunctival prolapse.

  
  
  
  
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    The larger the resection, the more likely one will wish to prophylactically remove 2 to 5 mm of conjunctiva to prevent conjunctival prolapse postoperatively.

    
    
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    Large resection:

    
    
    
    
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      Perform a full-thickness punch incision nasally and temporally (performed with sharp iris scissors above the tarsus starting at the anterior surface and exiting through the conjunctiva) (Fig. 30.1 a). The lid is everted so that the exit sites above the tarsus are directly visualized as the scissor tip is advanced (Fig. 30.1 b).

      
      
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      Cut full thickness above the tarsal plate to unite the punch incisions (Fig. 30.1 c).

      
      
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      Place the ptosis clamp on the tissue above the incision, incorporating conjunctiva, Müller’s muscle, and levator aponeurosis. If further separation of the septum and fat from the eyelid elevators is desired, it is easier to do with the ptosis clamp in position to act as a retractor (Fig. 30.1 d).

      
      
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      Use the straight iris scissors to bluntly separate the conjunctiva from Müller’s muscle. Müller’s muscle is firmly adherent to conjunctiva. The tip of the scissors is inserted about 3 mm above the clamp between the conjunctiva and Müller’s muscle, spread, and then pulled out without closing the scissor, bluntly dissecting with slow horizontal movement across the backside of the eyelid (Fig. 30.1 e). Once the entire horizontal breadth of the conjunctiva is lifted away from the Müller’s muscle, the conjunctiva is horizontally transected at a level above the clamp that leaves the excess conjunctiva in the clamp (Fig. 30.1 f).

      
      
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      After the conjunctival transection, additional superior separation of the conjunctiva from the Müller’s muscle and aponeurosis is accomplished with the Westcott scissors. The height of the separation extends to just above the desired placement of the fixation sutures. The incised conjunctival edge is sutured to the superior border of the tarsus with 6–0 gut suture (Fig. 30.1 g).

    
    
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    Smaller resections do not require conjunctival disinsertion.

    
    
    
    
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      While applying downward traction on the eyelid margin, make a central snip incision to open the levator aponeurosis and Müller’s muscle just above the tarsal plate. Undermine medially and laterally with Westcott scissors to raise up the edge of the lid retractors from the conjunctiva across the horizontal breadth of the eyelid.

      
      
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      Dissect in a preconjunctival plane just enough to elevate the upper lid retractor complex.

      
      
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      Place the ptosis clamp on the edge of Müller’s muscle and levator aponeurosis.

  
  
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  Dissect conjunctiva from Müller’s muscle. With the clamp rotated towards the surgeon sitting at the head of the bed, sharply dissect Müller’s muscle off the conjunctiva with a blunt Westcott scissors and continue dissection up past the origin of Müller’s muscle (Fig. 30.1 h).

  
  
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  Dissect the orbital septum from the levator. With the clamp then rotated downward towards the eyelid margin, elevate the septum and fat off the levator complex anteriorly. Attempt to leave the fat with the septum. Elevate the septum and fat to above the desired level for placement of the sutures (Fig. 30.1 i).

  
  
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  Perform the resection.

  
  
  
  
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    Place three double-armed 5–0 or 6–0 polyglactin suture partial thickness through the tarsus nasally, centrally, and temporally (Fig. 30.1 j).

    
    
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    Measure the amount of levator retractor complex to be resected and place the double-armed sutures through the clamped material (Fig. 30.1 k).

    
    
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    Tie sutures in slipknots.

    
    
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    Remove scleral shell for assessment of intraoperative eyelid height and contour (Fig. 30.1 l).

    
    
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    Adjust sutures as necessary to provide the desired eyelid gap and contour.

    
    
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    When satisfied, convert to square knots.

    
    
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    Remove excess retractors distal to suture placement (Fig. 30.1 m).

  
  
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  Consider conservative skin/orbicularis excision.

  
  
  
  
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    Once the eyelid has been elevated, there may be skin and/or orbicularis redundancy along the incision. Drape the upper tissue above the incision over the line of the resection to assess how much skin overlap is present. One to two millimeters of overlap is appropriate. A small skin–muscle ellipse may be removed while assessing to ensure that the anterior lamellar length will not limit eyelid closure.

  
  
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  Close incision with eyelid crease formation sutures.

  
  
  
  
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    Orbicularis to advanced levator stump to orbicularis in an interrupted buried fashion (Fig. 30.1 n).

    
    
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    Skin to advanced levator stump to skin ( Fig. 30.1 o).

    
    
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    A simple interrupted dissolvable suture is used to close the remaining wound (Fig. 30.1 p).

  
  
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  A typical pre- and postoperative result is noted in Fig. 30.2.