These cases are preferably performed under local anesthesia with sedation. In children, levator resection can be done by formula (Beard or Berke) under general anesthesia (Table 1 and Table 2).
- Preoperative factors influencing choice of technique and amount of advancement
- Amount of ptosis
- Levator function (poor, fair, good, excellent)
- Contour deformities
- Presence or absence of normal globe supraduction
- Presence and amount of jaw-winking
- Intraoperative factors influencing decision-making
- State of levator elasticity
- Intraoperative position of lid margin achieved by advancement
Table 1. Estimation of levator resection (Beard, 1976).
|
Amount of Ptosis
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Upper lid excursion
|
Amount of Resection
|
|
2 mm (mild)
|
0-5 mm (poor)
|
22-27 mm
|
|
6-11 mm (fair)
|
16-21 mm
|
|
12 or more (good)
|
10-15 mm
|
|
3 mm (moderate)
|
0-5 mm (poor)
|
Maximum (30 mm)
|
|
6-11 mm (fair)
|
22-27 mm
|
|
12 or more (good)
|
16-21 mm
|
|
4 mm or more (severe)
|
0-5 mm (poor)
|
Maximum (30 mm)
|
|
6-11 mm (fair)
|
25-30 mm
|
|
12 or more (good)
|
25-30 mm
|
Table 2. Intraoperative eyelid height (Berke 1959, Berke 1961).
|
Upper lid levator function
|
Superior corneal coverage by upper lid
|
|
0–5 mm (poor)
|
0 mm (lid margin at superior limbus)
|
|
6-11 mm (fair)
|
2 mm
|
|
12 or more (good)
|
4 mm
|
Dissection
- Lid crease incision (or following blepharoplasty flap excision)
- Small-incision technique can be performed through a small 8‑mm incision at the central lid (Figure 1).
- Useful for reoperations or in cases of minimal skin redundancy
- Expose the central superior tarsal plate.
- Open orbital septum, taking care to avoid injury to the levator muscle.
- Elevate fat off the anterior aspect of the levator aponeurosis (Figure 2).
Levator surgery
If dehiscence of the levator aponeurosis is present, advancement of the upper edge of aponeurosis is appropriate as first step.
The superior aponeurosis should be sutured to the tarsus, and lid height checked.
- Suture to superior third of tarsus with partial thickness bite.
- Evert the lid to confirm no suture exposure on posterior lid.
- Patient can be moved to a seated position and asked to open and close lids.
- Adjust margin contour by placement of second suture if needed.
- If significant lagophthalmos is noted intraoperatively, consider lowering lid slightly.
If inadequate height has been achieved, the levator aponeurosis can be further advanced by placing the suture higher up on the aponeurosis, sutured lower on the tarsus, and the excess excised.
- Suturing too inferior on the tarsus can result in lid margin eversion or peaking of contour.
If no dehiscence is present (i.e., congenital), the levator is resected and advanced appropriately based on preoperative measurements and algorithms (Beard 1976; Berke 1959 and 1961), often leaving a 1–2 mm overcorrection.
- Levator resections typically vary between 8 and 30 mm.
- A Berke ptosis clamp is useful to isolate and measure the tissue (Figure 3).
- To achieve larger resections, carefully dissect levator muscle off the underlying Muller muscle.
- Resection often approaches or includes Whitnall's ligament, as opposed to levator advancement surgery in adults.
- Approximately 3 nonabsorbable sutures are placed at the edge of the resected levator complex to secure it to the tarsus.
- Intraoperative adjustment is not needed, making this approach ideal for children or patients with limited cooperation.
- Final lid height is set intraoperatively based on levator function, with the principle that a lid with poor excursion should be set higher because it might fall postoperatively, whereas a lid with better function tends to rise after surgery.
Closure
Reformation of the eyelid crease is sometimes performed with skin closure.
The orbicularis muscle is sometimes closed as a separate layer than the skin.
If a more defined lid crease is desired, suture the pretarsal orbicularis edge to the superior tarsus or underlying levator aponeurosis at the desired crease height.
Closure should blend smoothly into any existing epicanthal fold.
Figure 1. Small-incision ptosis technique performed through a small 8‑mm lid crease incision.
Figure 2. Levator muscle and aponeurosis complex of the upper lid.
Figure 3. Levator muscle clamped with a Berke ptosis clamp in levator resection procedure.