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A Pediatric Case of Levator Palpebrae Resection

In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis.

In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved.

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An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures.
Though not always necessary, Levator Palpebrae resection is often indicated in congenital ptosis as well as acquired ptosis, such as myogenic, neurogenic, aponeurotic, mechanical & traumatic. The goal is to tighten the muscles so that the eyelid can match the lid on the other side.
Contraindications mainly include loss of blink reflex, corneal sensitivity, weakness of the orbicularis oculi, or keratitis sicca. Patients with thyroid myopathy should be carefully evaluated, as well as chronic progressive external ophthalmoplegia and poor decreased random eye movements during sleep, lagophthalmos, or poor orbicularis function.
For procedure setup, the patient was positioned supine and placed under general anesthesia. Povidone-iodine was used to disinfect the peri-orbital skin. An eye shield was placed under the eyelid to protect the cornea.
Preoperative examinations should include those recommended for neurologic and ophthalmologic examinations. In addition, a photo should be taken preoperatively to compare to the post-op.
The upper lid has a small operating field but tremendously complex anatomy. It is crucial to understand the tissue relationships between the skin, orbicularis oculi, septum, aponeurotic fat, tarsus plate, levator palpebrae, and Muller's muscle.
The two main ways to achieve elevation of the upper lid are 1). levator muscles procedures or Muller's muscle procedures, and 2) brow/frontalis suspension procedure Muller's muscle procedures and levator muscle procedures (advancement & resection): Patients with unilateral congenital ptosis and levator excursions of 5-6 mm often profit from this technique. The amount of resection can be tailored. Muller's muscle excision should be avoided in patients with significant corneal disease or filtering blebs. In some cases, eyelid crease promotion can be poor. Brow/frontalis procedures: It usually gives good results. In some cases, to achieve symmetry, it may be necessary to carry out a bilateral brow suspension even if there is only unilateral ptosis, which increases the recovery burden for the patient.
Immediately after the surgery up to several days, the eyelids are often bruised and swollen. Bleeding could occur. The later periods can reveal undercorrection, overcorrection, transient diplopia, eyelid crease abnormalities, distortion of the eyelid margin contour, keratitis, and lid asymmetry. Infection can occur at any point.
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1. Lee, Ju-Hyang et al. “Maximal levator resection in unilateral congenital ptosis with poor levator function.” The British journal of ophthalmology vol. 101,6 (2017): 740-746. doi:10.1136/bjophthalmol-2016-309163 2. Finsterer, Josef. “Ptosis: causes, presentation, and management.” Aesthetic plastic surgery vol. 27,3 (2003): 193-204. doi:10.1007/s00266-003-0127-5 3. Jones, L T et al. “The cure of ptosis by aponeurotic repair.” Archives of ophthalmology (Chicago, Ill. : 1960) vol. 93,8 (1975): 629-34. doi:10.1001/archopht.1975.01010020601008 4. Allen, Richard C et al. “The current state of ptosis repair: a comparison of internal and external approaches.” Current opinion in ophthalmology vol. 22,5 (2011): 394-9. doi:10.1097/ICU.0b013e32834994a0 5. Iliff JW, Pacheco EM: Ptosis surgery. In: Tasman W, Jaeger EA Eds. Duane’s clinical ophthalmology. Lip- pincott Williams and Wilkins, Philadelphia, pp 1–18, 2001 6. https://eyewiki.aao.org/Blepharoptosis#Levator_advancement_or_resection
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Nitin Balakrishnan
Tianyuan Yao

Excellent video. Very well done meticulous surgery

5 months ago

Review A Pediatric Case of Levator Palpebrae Resection.

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