Dr. Bernardini: After exposing the orbital septum,
the septum is incised until the fat prolapse.
Subsequently, the fat, the preaponeurotic fat
is exposed and dissected off the aponeurosis.
Levator aponeurosis is being shown here
all the way up to the Whitnall ligament.
The white band above is clearly visible.
Here we are dissecting the levator muscle
and the Müller en bloc off the anterior surface
of the tarsal plate and the conjunctiva.
The dissection initially is very tight,
the attachments are very tight.
Therefore, the dissection needs to be sharp.
Occasional button holes of the conjunctiva are left
healing for secondary intention and are left undisturbed.
Here we are peeling off strands of neuro muscle
from the conjunctiva underneath,
just to have a free flap of levator
and neuro muscle clean of the conjunctiva below.
This will help preventing a conjunctiva prolapse.
Key step, in my opinion, is to release
the lateral and medial horns of the levator muscle.
This is the lateral horn that's being released
all the way up to the Whitnall ligament.
Now is the time for the medial horn.
This will give our flap
of levator and Müller muscle en bloc free mobilization,
complete mobilization of every other orbital
and eyelid tissue.
And it can be displaced anteriorly.
As you see here, the flap is quite large
and involves all the levator muscle
in the palpebral component and also the orbital component.
The orbital rim is clearly visible and the entrance of that,
here is the entrance of the levator muscle in the orbit.
So, we are way above the Whitnall ligament
that is visible there.
So, not all the cases require this large of a dissection.
And this is dependent on the amount, the severity of ptosis
and the amount of functional, levator function.
The poorer the levator function, the larger the resection.
We place a 6-0 nylon stitch centrally
through the tarsal plate in our flap
somewhere up above,
above the Whitnall ligament.
And as a starting point, just to determine
how much elevation we get.
If we need to do some more or if we need to undo
and take less.
So, this is just to give us a starting point
and my goal is to see an elevation of the eyelid
at the final position is to be similar to where I leave
my eyelid margin with the frontalis suspensions link,
which is two millimeters below the superior limbus.
Again, variations occur based on the amount of the ptosis
and the amount of levator function.
We add a couple of stitches to the central stitch
medially and laterally.
This will give us a firmer hold to the levator muscle,
to the tarsal plate, all along,
and gives a rounder,
more regular contour to the eyelid margin.
Excess of the levator muscle and Müller are resected out,
just leaving enough for us to come back eventually
at second stage if we need to do less.
And this is the final position and contour of the eyelid.