Ptosis repair is a challenging oculoplastic surgical procedure that requires correct diagnosis, thoughtful planning, thorough understanding of eyelid anatomy, experience, and good surgical technique. The patient’s ocular, medical, and surgical history help determine whether surgical repair of ptosis is appropriate for that individual. The surgeon should be aware of any history of dry-eye syndrome and should temper blepharoptosis repair in the presence of significant dry-eye problems. Patients should be questioned about their coagulation status. Other pertinent historical queries should include the presence of thyroid eye disease, previous eye or eyelid surgery, and prior periorbital trauma. See also the section Preoperative Considerations earlier in this chapter.
Ptosis that causes significant superior visual field loss or difficulty with reading is considered to be a functional problem, and correction of this defect often improves a patient’s ability to perform the activities of daily living. In many instances, ptosis is considered to be a cosmetic issue, causing a tired or sleepy appearance in the absence of a visual function deficit. Because ptosis repair is an elective surgical procedure, it is particularly important for the surgeon to have a preoperative discussion with the patient to communicate the alternatives, potential risks, and benefits.
Surgical procedures designed to correct ptosis should be directed toward correction of the underlying pathologic condition. The 3 categories of surgical procedures most commonly used in ptosis repair are
external (transcutaneous) levator advancement
internal (transconjunctival) levator/tarsus/Müller muscle resection approaches
frontalis muscle suspensions
The amount and type of ptosis and the degree of levator function are the most common determining factors in the choice of the surgical procedure for ptosis repair. The surgeon’s comfort level and experience with various procedures is also an important factor. In patients with good levator function, surgical correction is generally directed toward the levator aponeurosis: the levator muscle is the most potent and useful elevator of the eyelid in most patients. However, if levator function is poor or absent, frontalis muscle suspension techniques are the preferred repair procedures.
External (transcutaneous) levator advancement surgery is most commonly used when levator function is normal and the upper eyelid crease is high. In this setting, the levator muscle itself is normal, but the levator aponeurosis (its tendinous attachment to the tarsal plate) is stretched or disinserted, thus requiring advancement. The levator aponeurosis is approached from the outside of the eyelid through the upper eyelid crease. This approach for acquired aponeurotic ptosis repair is particularly useful because it allows the surgeon to simultaneously remove excess eyelid skin (dermatochalasis). Reinsertion of the aponeurosis usually produces an excellent result. In some cases, the distal end of the aponeurosis may be found to be higher than its normal position on the lower anterior surface of the tarsus.
The internal (transconjunctival) approach to ptosis repair may be directed toward the Müller muscle, the tarsus, or the levator aponeurosis or muscle. Müller muscle resections (Putterman müllerectomy) are used in patients who have an adequate upper eyelid position following instillation of a drop of 2.5% phenylephrine hydrochloride. Müller muscle resections are typically used for repair of minimal ptosis (2 mm) and are generally considered superior to the Fasanella-Servat procedure (tarsoconjunctival müllerectomy) in maintaining eyelid contour and preserving the tarsus. The Fasanella-Servat ptosis repair procedure, though also directed toward small amounts of ptosis, requires removal of the superior tarsus.
When levator function is poor, the surgeon should consider utilizing the accessory elevators of the eyelid in ptosis repair. This type of surgery is most commonly required in congenital ptosis with poor levator function or in various forms of neurogenic ptosis with poor levator function.
Most patients with significant ptosis automatically elevate the forehead and brow on the affected side in an attempt to raise the eyelid and clear the visual axis; however, this maneuver is normally very inefficient because of the elasticity of the eyelid skin. In frontalis suspension surgery (performed when levator function is poor or absent), the eyelid is suspended directly from the frontalis muscle so that movement of the brow is efficiently transmitted to the eyelid. Thus, the patient is able to elevate the eyelid by using the frontalis muscle to lift the brow. Frontalis suspension can be performed transcutaneously or transconjunctivally (Fig 11-16).
Autogenous tensor fascia lata, banked fascia lata, and synthetic materials have been used for this purpose. Autogenous fascia lata has shown the best long-term results but requires harvesting and additional surgery. Generally, patients need to be at least 3 years old or weigh 35 pounds or more. Banked fascia lata may be obtained from a variety of sources and obviates the need for additional operative sites and harvesting. However, this material may incite immune reactions or inflammation and have poorer long-term outcomes than autogenous tissue. Synthetic materials such as silicone rods are commonly used; they may improve eyelid elasticity and allow easier adjustment or removal if necessary.
There is some controversy about whether bilateral frontalis suspension should be performed in patients with unilateral ptosis. Unilateral frontalis suspension results in asymmetry in downgaze because of upper eyelid lag induced by the sling; in addition, there is less stimulus to elevate 1 brow. A bilateral procedure may improve the patient’s symmetry, especially in downgaze, but it subjects the normal eyelid to surgical risks. The decision to modify a normal eyelid in an attempt to gain symmetry must be discussed by the surgeon and patient (or the parents if the patient is a child).
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