Surgery: External Levator Advancement

This video demonstrates an external levator advancement surgery in an adult patient with ptosis of the upper eye lid.

Surgery Location: on-board the Orbis Flying Eye Hospital, Hue, Vietnam
Surgeon: Timothy James McCulley, Wilmer Eye Institute, USA


So this gentleman has a droopy left upper eyelid, and it’s more than just 2 or 3 millimeters, so we’re not gonna use a Mullerectomy. What we’re gonna do is an external levator advancement. And so what I’m doing here is I’ve got a 4-0 silk suture. I’m gonna use this for traction. So what I’m gonna do is I’m gonna pass it through the tarsus, secure it to the drapes inferiorly, so when passing this suture, I lift the eyelid off of the eyeball, so I’m not gonna try to go full thickness. So eyelid off of the eyeball. So if it goes full thickness, I don’t poke him. So this always hurts patients. Now we’re gonna make the skin incision. Now, he has a nice lid crease. So we’re gonna hide the incision inside the lid crease. And as we’re just working on one side, I’m not gonna do a blepharoplasty. I’m not gonna excise any skin, because it would just make him look asymmetric. What we’re doing here is we’re going through the orbicularis oculi. There’s no subcutaneous fat in the eyelid, so it’s skin and then muscle immediately. Okay. So we’re through the orbic. And if you can see that shiny glisten right there, that’s gonna be the orbital septum. So what I’m doing is I’m gonna dissect a little between the orbic. So this is me cutting now. Between the orbic and the septum, just to expose a little more septum than was exposed. So I just cauterized it now. So one thing that’s useful: When you’re cauterizing, if you’re right on top of the eyelid, what you want to do is grab the tissue and lift up, so you don’t accidentally get the cornea. See that movement right there? That’s the preaponeurotic fat pushing through the septum. So I know that the septum is right here. So I’m cutting through the orbital septum now. Okay. There’s still more. So right there, I can still see the fat pushing through. I don’t see fat. I see fat underneath fibrous septum. The orbital septum actually has multiple layers. Not just one, like the textbooks would imply. So we’re still not there. We’re almost there. All right. So we’re getting there. So if you look here, when I push, you see that movement, and you can kind of see this yellow underneath the film. So I’ve still got another layer to go. Now I see fat. So we’ve reached the levator muscle. So the fact that I see fat tells me that what’s right deep to it, this structure right here, is levator muscle. I’m holding the aponeurosis in my forceps. So this is what we’re going to attach. I’m just trying to free a little bit more of the fat. Now, the next thing I have to do is expose the tarsus. So what I do, I grab the orbicularis oculi. I try not to grab the eyelid skin if possible, just so I don’t traumatize it more than necessary. I take this finger. I push on the lashes. That stabilizes the tarsus. I do this by feel. I can feel the tarsus underneath my Westcott scissors. And there you see the tarsus. So that’s the tarsus. Now, the next question is: Where do we want to put our suture? Usually I go at wherever the peak of the tarsus is. So wherever the widest portion is, which seems to be right about here. Now, what I’ll do: I’m gonna hold on to that orbic at that point, and I’ll pull the eyelid open, just to make sure that it gives a good contour, if I put my suture right there. So this — I’m gonna try to pass partial thickness. So I go about: Top of the tarsus is right here. This pink is Muller’s muscle. There’s the edge of the levator aponeurosis. So you guys can see it. So levator aponeurosis. Muller’s muscle. Tarsus. I’m gonna go right in the tarsus. So one thing I’ll do — see this pinky? I use this. I put this on the silk, so I pull the lid down for me. Retract for myself. There’s levator aponeurosis. So what I want to do is pass this, and I always point the needle up. So if my patient jumps, I don’t poke him. So there’s pretty good advancement. I go a little bit more. What I’m shooting for is right there. The aponeurosis looks healthy. And that’s my target. So I’m aiming for the healthy aponeurosis. Some people will use number of millimeters, or try to have a formula. Me, I just look for where the aponeurosis starts to look normal. And make sure that… I don’t want fat stuck in my suture. Or it’ll make my suture come undone. Any trapped fat will necrose, and then it makes your suture loose. Okay. So I like that lid height. If it wasn’t good, then I would adjust the suture. So what I’m gonna do is put two more 6-0 nylons. One medial and one lateral. Just so we’re not dependent on one suture alone. And then I’m gonna close the skin. Where I like to grab this needle is right in the middle. If you look at that — if you grab it at the end, it’s a little harder to control, and so for these, where I’m doing a really delicate suture that I don’t want to accidentally poke the eye, I grab it a little closer to the point, just to increase my control. So now if you look here, you see my one suture. There’s the one suture. Which I’m gonna trim a little. And then I’m gonna go just medial to it. And then here’s the aponeurosis again. And then I just place this at the same height. So let me show you something. If you look here at the aponeurosis, but this aponeurosis here is very thin. It’s so thin, it’s transparent. Up here, it becomes a little thicker and more white. I’m shooting for where it’s a little bit more thick. Otherwise, if you go through that really thin transparent part, your suture tends to pull through. And one thing I do: I keep the needle pointing up. It’s really important. So that if he jumps, I don’t poke him. So the needle is pointing at the ceiling. Then I just pull the aponeurosis over to go through it. Now, if the eyelid height was not good, you have two options. You can either move your suture on the tarsus, or you can move your suture on the aponeurosis. Or you could do both. The rule of thumb, the guideline, is: If you move 1 millimeter on the tarsus, you change the eyelid height by 1 millimeter. If you move 3 millimeters on the aponeurosis, you move the eyelid height 1 millimeter. So if you’re moving up and down the aponeurosis, you have to go further. If you’re moving up and down the tarsus, you don’t have to do as much to get an impact. Even though my goal with these last two sutures was just really for safety sutures, I want to make sure I didn’t accidentally change the eyelid height. Okay. And it still looks very, very good. Height, contour. Everything’s perfect. So the suture I like to use to close the skin is a 6-0 fast absorbing plain gut suture. Some people prefer to use a permanent suture. If you use a permanent suture, you want to use a monofilament. Something like a nylon or a prolene. And that’s fine. The only problem with them is you have to remove them. With this suture, I don’t have to remove them. So by using a plain gut or absorbable suture, I can just let them absorb. Now, what people forget is there’s no rule against removing absorbable sutures. So if you want to remove the suture, you can. But that way, if the patient doesn’t want the sutures removed, if they don’t return for their post-op visit, it’s not a problem. So if you do use a non-absorbable suture, usually you want to take them out on day 5 or 6. If you leave them in longer, you tend to get these little… What you call milia. Or these little round scars around your sutures, if you leave them in too long. Thank you very much!

September 14, 2019

Last Updated: October 31, 2022

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