External Ptosis Repair

This video shows an external levator advancement ptosis repair in a patient with involutional eyelid ptosis.

Justin D. Pennington, BS
Suzanne K. Freitag, MD

This video shows an external levator advancement in a patient with involutional eyelid ptosis. The video documents each step of the procedure including skin incision, orbicularis oculi incision, dissection through the septum to identify the levator muscle, disinsertion of the levator from the tarsus, placement of mattress sutures to advance the levator and reattach to the tarsus. The narration includes surgical pearls including intraoperative adjustment.
This technique of ptosis repair via external levator advancement is effective in cases where there is moderate or better levator function. This includes aponeurotic dehiscence, and some cases of congenital, myogenic, and traumatic ptosis.
Possible contraindications include preoperative significant dry eye, significant corneal disease, advanced glaucoma, active ocular or peri-ocular infection, and previous ocular surgery or trauma. Systemic contraindications include bleeding disorders such as thrombotic thrombocytopenic purpura, hemophilia, or anticoagulant system
A standard eyelid surgical setup is recommended to include the following instruments: westcott scissors, small toothed forceps, castroviejo needle holder, protective shell, and cautery device. We use 5-0 polypropylene double-armed suture with small spatulated needles, silk traction suture, and 6-0 plain gut suture.
Preoperative work up must include a full ophthalmic examination. The more pertinent aspects include visual acuity, extraocular motility, pupillary examination, and slit lamp biomicroscopy with attention to the ocular surface and corneal pathology. The tear film should be evaluated carefully.
A thorough understanding of the complex upper eyelid anatomy is required before undertaking this procedure. The thin orbicularis oculi muscle underlies the skin. Deep to this lies the orbital septum which is opened to reveal the pre-aponeurotic fat. Beneath this fat lies the levator palpebri superioris. The complex relationship between these structures as well as the surrounding ones including the tarsus, lash follicles, and the lacrimal system must be understood in order to safely perform this procedure.
The advantages/disadvantages of external ptosis repair over internal ptosis repair have been debated for decades and are still a topic of much discussion. Many feel that external levator advancement is the anatomically correct surgery for levator dehiscence. However, proponents of internal ptosis repair argue that their procedure is quicker and more predictable.
Over-correction, under-correction, poor lid contour, and lagophthalmos (incomplete lid closure) leading to dry eye are somewhat common issues after blepharoptosis repair. As a result, the reoperation rate for this procedure is 10-15%. Rarer, but more serious complications have been reported including: infection, reaction to sutures or ophthalmic ointment, or hemorrhage which if post-septal (retrobulbar), can be sight threatening if not expedien
Jones LR, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol. 1975 Aug;93(8):629-34. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123-1128. Allen RC, Saylor MA, Nerad JA. The current state of ptosis repair: a comparison of internal and external approaches. Curr Opin Ophthalmol. 2011;22(5):394-9. Lowry JC, Bartley GB. Complications of blepharoplasty. Surv Ophthalmol. 1994;38(4):327-50. Beard C: Ptosis 3rd ed. St. Louis. CV Mosby, 1981: 191–2.

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