8 Upper Eyelid: Clinical Overview

The chapters in this section on the upper eyelid address many critical issues. In one way or another, most will have to take the levator muscle into consideration. As the main functional structure in the upper eyelid, the levator muscle must always be considered when doing surgery here. It must be carefully avoided or appropriately treated as the case may be. It is critically important in ptosis repair and in the formation of the upper eyelid crease and fold.

The levator muscle arises from the lesser wing of the sphenoid bone just above the annulus of Zinn. It inserts into the upper tarsal border, the anterior surface of tarsus, the medial canthal tendon, the lateral canthal tendon (after splitting the orbital and palpebral lobe of the lacrimal gland), the pretarsal skin, and orbicularis. It contains Whitnall’s ligament (superior transverse ligament) at the level of the equator of the globe at which point it changes direction from posterior-anterior to superior-inferior. The striated portion is 40-mm long and the aponeurosis is 15-mm long, though these measurements vary depending on individual anatomy and ethnicity. The adrenergic Müller’s muscle is approximately 10-mm long, arising from the underside of the levator and inserting along the superior tarsal border (Fig. 8-1).

When repairing the ptotic lid, one must differentiate between congenital and acquired ptosis since the surgical parameters are significantly different. Congenital ptosis is most often unilateral and can be considered to be a dystrophic muscle. In general, the more severe the ptosis, the more dystrophic the levator muscle and the more likely to be associated with anisometropia, amblyopia, or strabismus. Congenital ptosis can be accompanied by blepharophimosis syndrome, Marcus-Gunn “jaw-winking,” or superior rectus weakness. Surgical repair involves relatively large shortenings of the levator muscle in the range from 12 mm to more than 20 mm and is typically referred to as “levator resection surgery.” This resection sometimes includes the Müller muscle at the same time. In severe congenital ptosis, there is not enough functional levator muscle to shorten and will necessitate performance of a frontalis sling procedure utilizing alloplastic materials or autogenous fascia lata. Congenital ptosis repair can be expected to result in lagophthalmos, which, if done before age 10, is well tolerated for the life of the patient.

Sometimes, if the history is unclear, the physician may have to determine if the ptosis is congenital or acquired. Congenital ptosis typically has reduced levator function (2–10 mm) as compared to acquired ptosis (>12 mm). To measure levator function, hold a ruler over the center of the eye with the patient looking down and the brow stabilized so as to negate any contribution from the frontalis muscle (Fig. 8-2a). Then, have the patient look up and measure the excursion of the upper eyelid from downgaze to upgaze to obtain the levator function (Fig. 8-2b).

A helpful clue in unilateral cases is the position of the ptotic lid on downgaze. In unilateral congenital ptosis, the upper eyelid will not descend as far in downgaze as compared to the normal eyelid (Fig. 8-3). This is due to the fact that the muscle in congenital ptosis is partially replaced by fibrous tissue and is, in effect, less elastic and thus tends to hang up a bit in downgaze. In contrast, the eyelid with acquired ptosis behaves as if the muscle/aponeurosis is stretched out and thus descends to a lower level than the normal eyelid on downgaze (Fig. 8-4). This finding will, of course, not be helpful in bilateral ptosis.

The majority of ptosis cases encountered in routine practice will be acquired and age-related. This is typically conceptualized as a thinning and/or stretching of the levator aponeurosis and the repair is often referred to as “aponeurotic surgery.” True aponeurotic disinsertion, although frequently discussed, is probably very uncommon since the surgeon can almost always appreciate a continuous, albeit a very diaphanous, aponeurosis. Surgical tightening of the levator is relatively smaller than that done in congenital ptosis and is usually in the range of 2 to 10 mm. Postoperative lagophthalmos is uncommon and should generally be avoided given the age of the patients having surgery.

Acquired ptosis can also be treated by shortening of the Müller muscle with or without partial tarsal resection, and this approach has a number of variations. It is often quicker and can be less invasive than levator aponeurosis surgery and is the preferred method for many surgeons.

The eyelid crease is the neglected stepchild in upper eyelid surgery. I believe that it is often overlooked resulting in less-than-optimal results. The upper eyelid margins may be in identical position after ptosis repair, but if the crease and folds are not even, the patient will look asymmetric. From a historical perspective, consideration of the upper eyelid crease and fold traces its origins back over 100 years to Asian “double eyelid” surgery. More contemporary observations were made by Flowers who used the term “anchor blepharoplasty,” Sheen who spoke of “supratarsal fixation,” and Tenzel who referred to the “high upper eyelid crease.” They noted that crease formation in the upper eyelid resulted in a “crisp” invaginated lid fold that tightened and smoothed the pretarsal skin. Although a crease will often spontaneously form at the upper lid incision line, this is not always reliable. The addition of crease formation techniques assures the location and symmetry of a crease and can give pleasing results while minimizing the amount of skin resection needed. The lid crease can be formed in both upper eyelid blepharoplasty and ptosis repair. For a detailed discussion of eyelid crease formation, the reader is referred to the excellent article by doctors Putterman and Urist.

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