Lecture: Treatment Options for Congenital and Acquired Ptosis
This Live Lecture discusses the timing and operative/post-operative management of blepharoptosis.
Lecturer: Dr. Robert Kersten
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DR KERSTEN: Two weeks ago, we talked about the differential diagnosis of ptosis, and now I want to talk about the surgical correction of ptosis. And our choice of — as you guys recall, those who were with us two weeks ago — we sort of break ptosis up into those patients whose third cranial nerve and whose levator muscle themselves are normal, but the attachment of the levator to the eyelid, to the tarsal plate, which, of course, as you know, is the levator aponeurosis — that is either stretched, pulled loose, thinned, weakened — in one fashion or another, the lid is sitting at the wrong height. And yet there is still good levator function. So from downgaze to upgaze, we still have 13, 14, 16-plus millimeters of excursion. That tells us that the levator muscle and the third nerve are functioning well, and the problem is mechanical. So if we have good levator function, there are basically two operations we can talk about. We can talk about doing a Mullerectomy, and this is my first choice in anybody who has a good response to topical neosynephrine drops, where it lifts the lid to a good height, and if they have an inadequate response to neosynephrine — then is when I’ll start talking about doing a levator aponeurosis advancement, and we’re gonna demonstrate both those techniques today. If patients have intermediate to good function, that would be from, say, 6 millimeters up to 12 millimeters or so. At that range, I don’t generally find that a Mullerectomy is reliable, and therefore I would do a levator aponeurosis advancement on this group of patients with intermediate to good function. Patients who have poor levator function — in my mind, that’s less than 6 millimeters — I have two choices. If they show good brow elevation. So if they’re trying to see out of that eyelid by raising their eyebrow, then a frontalis sling is a very good operation to elevate the lid and yet still allow it to close reasonably well when they relax the eyebrow. If they do not recruit the frontalis, and the two situations we see that in are patients who have amblyopia, where they have no desire for single binocular vision. They generally don’t elevate their frontalis. In them, a frontalis sling is pretty ineffective. Or obviously if a patient has a 7th nerve palsy, for a selective palsy of the temporal branch of the 7th nerve, going to the frontalis muscle, then they’re not a good candidate for frontalis recruitment, and in those patients, we’re generally gonna do a supramaximal levator resection, where we go in and we not only cut out the levator aponeurosis — we also cut out a good amount of the levator muscle itself, and then reattach the levator muscle to the tarsal plate. So, again, this is the typical exam we’ll see in somebody who has good levator function. We’ll look at them and measure their excursion from downgaze to upgaze, and this patient has about 13 or 14 millimeters of levator function. Now, she’s a very good candidate for a Mullerectomy, if she responds to neosynephrine. If she does not, a very good candidate for an aponeurotic advancement. Here’s a patient who has a left sided ptosis, as we can see here. And after neosynephrine, we see that the lid lifts up to a very good height with a good contour. In that circumstance, a patient like this — I would do a Mullerectomy ptosis repair. So in those patients, we’d put a drop of 2.5 neosynephrine in. Again, I’d reserve this for patients who have good levator function. So that’s generally 12 millimeters or better of levator function. If we get an excellent lid height and contour after that, then we’ll plan to remove 8 millimeters of conjunctiva and Muller’s muscle. If they have an inadequate response, but still some elevation — say they started out with an MRD of 1 millimeter, and they went to 2.5 millimeters, but the opposite eye has 3.5 or 4 millimeters of MRD 1, then I’ll take more Muller’s. Then I’ll take 10 millimeters or even 12 millimeters or sometimes even 14 millimeters of conjunctiva and Muller’s. But the concept is the same. We measure out the amount of tissue that we wish to remove. We put a clamp across it. And then we suture across the conjunctiva and Muller’s muscle, just below our clamp. We then excise the clamp tissues and bring the sutures from the posterior fornix, full thickness through the eyelid, to exit through the eyelid crease. And we’re going to demonstrate that now. Here’s a patient. You can see she has bilateral ptosis. She’s really recruiting her frontalis on this side. Less so on this side. Which suggests to me this is very likely her dominant eye. She’s probably left eye dominant. That’s not important for us in determining a Mullerectomy. But as we’ll see later on, it is important in determining patients that we want to do a frontalis sling. But, of course, there’s no need to do a frontalis sling here, because the patient has good levator function. So I put a drop of neosynephrine in, and it lifted the eyelid to a good height. So that tells me I’m gonna go ahead and do a Mullerectomy. My first step in doing that is to pass a traction suture through the tarsal plate here at the lid margin. I usually use a 4-0 silk suture, but any sort of suture will do. And I pass it through the lid margin. And that allows me to then evert the eyelid over a Desmarres retractor. So I put a Desmarres retractor on the back side, and bring the eyelid up and over it, exposing the superior border of tarsus here. We can see a little bit of the Desmarres retractor shining through the eyelid, and the palpebral conjunctiva and Muller’s muscle above that point. So step one is to evert the lid. Step two is: I’m then going to put my calipers on half the amount of Muller’s muscle and conjunctiva I wish to resect. So in this case, if I plan to do an 8 millimeter Mullerectomy, I will place my calipers on 4 millimeters, and I will mark this point just proximal to the superior border of tarsus. So I’m gonna mark 4 millimeters between the superior border of tarsus, which is here, and back into the fornix. I do one at a point sort of in the range of the medial limbus, and I mark a second point — again, 4 millimeters above the superior border of tarsus, at the temporal limbus. And then I grasp these two points, and I’m going to distract those, so I can put a clamp across the eyelid, incorporating that tissue. This happens to be my preferred clamp, which is a spring-loaded clamp. It’s not the standard Putterman clamp. It has a spring. So that when I release the clamp, it is automatically clamped. Its default position is to be closed on the tissues. In the Putterman clamp, one has to squeeze the clamp together, and then push a little slide to lock it into place. But if you don’t have either a Putterman clamp or a Uzcategui clamp, you can also just use two straight hemostats, and you can clamp across just at the superior border of tarsus, incorporating that measured tissue. And the reason we measure 4 millimeters here is we have two sides of this. We have from the superior border of tarsus to the point we’re grasping — is 4 millimeters. And then the back side of it is another 4 millimeters. So in order to excise 8 millimeters, I grasp at 4 millimeters, and then clamp the tissue. Once this tissue is incorporated within my clamp, I then am going to take a double-armed — and I happen to use a double-armed 6-0 plain gut suture. You can use any sort of double-armed suture that you wish, as long as it’s monofilament. You should not use a braided suture like vicryl, because that has the potential to abrade the cornea. But gut is fine. Prolene, nylon — any of those would work if they’re double-armed, or if you have free needles, so you can effectively make them into a double-armed suture. Once that tissue is clamped, here, I then start at one end, and here’s my 6-0 suture, and I just am going to do a back and forth, back and forth, right proximal to the clamp. So my suture is passing just on the inferior edge of that clamp. And I run across with the lid. So I put my first pass through here. Then I come back out through here. I’m gonna go back in here, come out on this side, go back in here, come out on this side. So I just do a running suture across the width of the lid. Staying just below the clamp. And you can see here’s my chromic, and here’s my suture line. The suture line is gonna be just proximal to the clamped tissues. Once I have run from one end to the other end, I just take a 15 blade, and I cut off the clamped tissue here. Now, when I do this, it’s important that I keep my 15 blade pointed largely toward the ceiling. You don’t want to just — you want to slowly saw across here. If you try and just make a single cut across, you have a high risk of cutting the suture, in which case you then have to go and start over and suture these two raw edges together. But as long as I keep my 15 blade against the superior border of the clamp, and here I have an assistant who’s using two Q-Tips to pull the lid tissue down — those steps are just intended to make sure that I don’t cut this suture that’s holding my tissues together. And once I’ve cut off that tissue, I check to be sure that my suture’s still intact. This is just a running suture. It started here. Came out here. And I have a needle at either end of it here. I then take that needle, and starting on the back side of the eyelid, I go through conjunctiva, above my suture line, and I exit through the eyelid skin in the area of the lid crease. I do this first on one side, and then I go back and do the same maneuver with the other end of the suture, through the temporal side here. So we’ve already brought it through on this side, and now I’m doing the same thing starting posteriorly and bringing it through full thickness eyelid to exit at about the area of the eyelid crease. Once I have the suture passed through, I’m then going to just tie it on itself, on the surface of the skin here. And I leave these little knots. I just tie it to itself here and to itself there. And this is after I’ve done this on both sides. My little knot is sitting in the general area of the eyelid crease, one medially, one laterally. I have no knots on the underside of the cornea, and I have a monofilament suture. And it’s at the superior border of tarsus. So I really have not found keratopathy to be a problem doing it this way at all. I have — some of my colleagues talk about using a bandage contact lens afterwards. I’ve honestly never, ever had to do that. I have them put a little bit of lubricating ointment in the eye four times a day. They probably don’t even need to do that. And we just allow this suture to dissolve away after a week to ten days. And by that time, the conjunctiva and Muller’s has re-adhered, and in this case, it’s re-adhered 8 millimeters closer to the tarsal plate than it started. Because we’ve excised that 8 millimeters of conjunctiva and Muller’s muscle on both sides. And this is this patient now at the end of the procedure. Her knots on the surface. And you can see we get good lid height and good contour from the Mullerectomy. So for a good function that responds to neosynephrine, that’s my preferred approach. If the patient fails to respond to neosynephrine, or if I don’t have good function, then instead I will plan to do a levator aponeurosis advancement. I’m gonna take that tendon of the levator muscle, I’m gonna cut it off the anterior surface of tarsus, I’m going to shorten it, and I’m going to reattach it to tarsal plate. I do this under local anesthesia. I prefer an anterior approach, coming through the eyelid crease. And this allows me to sit the patient upright, to adjust lid height and contour. Now, when I was initially trained to do this procedure, I was trained to put three sutures in. One medially, one centrally, one laterally. I generally try and get by with just one suture now, centrally. If it’s well placed, I can get a good lid height and contour. Sometimes I’ll have to add a second suture, if I either have a little medial droop or temporal droop after my first suture, to correct the contour. Now, one thing to mention about local anesthesia. Local anesthesia can cause several artifacts in ptosis surgery. It can cause the eyelid on the table to be higher than it really will be. And this occurs if the local anesthetic paralyzes orbicularis muscle. And if the neosynephrine — or the epinephrine — and I use a 1 to 200,000 mixture of epinephrine — if it stimulates Muller’s muscle, the combination of a paralyzed orbicularis and a stimulated Muller’s may artificially elevate the eyelid. On the other hand, local anesthesia can also cause an artificially low eyelid on the table, compared to where it will be when the local anesthetic wears off. This occurs if the local anesthetic diffuses back into the levator muscle and paralyzes it. So if I get paralysis of the levator muscle, then the lid is gonna be artificially low during surgery. Also, if I use a high volume of local anesthetic, the extra weight of that in the tissues here can cause it to be too low. So consequently, I try to only use about 1 CC of local anesthetic, and I use a mixture of lidocaine with 1 to 100,000 epinephrine, and marcaine without epinephrine. So I effectively get a concentration of 1 to 200,000 epinephrine. I have done this without epinephrine at all, in an attempt to avoid that Muller’s muscle sympathetic stimulation. The problem with that is you get more bleeding, and more bleeding can lead to gravitational weight in the eyelid, and make things a little too low. So generally, unless I see somebody who has undergone a previous repair which ended up showing an overactive Muller’s muscle — and that would be a patient where I finish their surgery, when they’re sitting up they look perfect, and the next day, or say two hours later, when the epinephrine’s worn off, the lid drops back down again, then, if I have to reoperate them, I’ll do them without epinephrine. But generally I like to do epinephrine, to prevent bleeding. So here’s an example of an anterior levator aponeurosis approach. This is a patient who has a traumatic ptosis. He was involved in a motor vehicle accident. Had a lot of swelling. And now this is six months later. If we have a traumatic ptosis, we generally like to wait six months before attempting surgical repair, because I have seen traumatic ptoses improve for up to six months, or even rarely longer. So if it is improving, I wait until that improvement has plateaued, or a minimum of six months’ time. You can see that this patient also is recruiting the frontalis muscle on this side. There’s his eyebrow here, compared to this side. Now, again, this would be a very helpful observation if I planned to do a frontalis sling, where I’m attaching the eyebrow to the eyelid, because I know he can raise the eyelid up by raising his eyebrow. I don’t need to do that here, because he has good levator function. So instead, I’m just going to be shortening the levator aponeurosis and reattaching it. Our approach is to do an eyelid crease incision. We incise through skin and orbicularis, and then we dissect through the layer beneath skin and orbicularis — the next layer will be the orbital septum, up above the eyelid crease. Below the eyelid crease, the next layer would be the levator aponeurosis. But in this case, the levator aponeurosis is disinserted. You see this straight white edge of tissue here. This is the levator aponeurosis. Normally it should be down here on the surface of tarsus. But it has pulled and retracted up, causing the lid to droop. So once I identify this free edge — and I do this by incising through skin and orbicularis, and then I open the orbital septum, so that orbital fat, preaponeurotic fat, can prolapse. I can then retract that, and see right beneath the preaponeurotic fat is the levator aponeurosis. I’m then gonna go down and free up the edge of tarsal plate here. So once I’ve exposed tarsus, it’s quite simple for me to suture the free edge of levator aponeurosis to this free surface of tarsus in the eyelid. And the suture I personally prefer through this is a 6-0 nylon. I don’t think it has to be a nylon. A nylon, a prolene, a gut. Again, I prefer not to use vicryl or any braided suture, because if I happen to inadvertently go full thickness through the tarsal plate, that braided suture, if it’s exposed on the back side of the palpebral conjunctiva, will definitely cause a keratopathy. Even with a full thickness bite with a nylon — even if I go full thickness, I have not found that to cause keratopathy. Because the monofilament is pretty well tolerated by the cornea. So I pass this suture in a horizontal mattress fashion through the tarsal plate, and then I go up and take a horizontal mattress bite through the levator aponeurosis, and I advance it down and tie it, by bringing the aponeurosis back down to the surface of tarsus again. I then want to sit the patient upright, and inspect the lid height and contour. This is a patient I just used one suture for, and I’m actually quite pleased with the contour I have, and I’m pleased with the height that I have. Here there is a slight overcorrection. I actually don’t generally aim for overcorrection. I like it to be exactly where I want it to be. You will certainly read in textbooks and some other surgeons who purposefully want to overcorrect by 1 millimeter. I have found if I do that, I tend to get a persistent overcorrection of 1 millimeter. So I generally try to make it exactly match the other side. Once I’m happy with the height and contour, it’s quite simple. I just do a running closure of that lid crease incision. Again, in this case, we used fast-absorbing 6-0 gut suture. You can use a prolene or nylon. You can use silk. You can use whatever you want in the skin here. And you can see here preoperatively and postoperatively, we have lifted the eyelid up to a symmetrical height and contour to the contralateral side. And the reason we can do this is by doing the patient under local anesthesia, sitting him up, and making sure in the operating room that he matched up well. The other thing I want you to just take a minute to look at is: This is his eyebrow, preoperatively. And this is his eyebrow, postoperatively. So you can see he was automatically recruiting the frontalis muscle here. This is not something he consciously does. This is a brain stem reflex. When your superior field is occluded by the eyelid, your brain automatically cranks in some extra innervation to the frontalis on that side. And interestingly, it’s almost always a unilateral phenomenon. Less than 1% of the time do I see bilateral recruitment in the case of a unilateral ptosis. So it’s pretty hard for us to individually raise the eyebrow volitionally, but if it’s in response to a droopy eyelid, your brain does that for you. And here after surgery, he’s relaxed that, because his brain says — oh, I now have a normal superior visual field on both sides, so I don’t have to do that anymore. Again, this is important, as we’ll discuss when we talk about frontalis slings here in just a minute. Here’s another patient. We did a combination of an upper blepharoplasty, and certainly part of this is a pseudoptosis, caused by dermatochalasis. But in addition, when we held the dermatochalasis out of the way, he still had an underlying ptosis as well, and this allows us to correct both the dermatochalasis and the ptosis with one operation. Another patient here — preoperatively and postoperatively — fairly subtle ptosis. But we’re able to fine-tune this in the fashion that we want, by doing this under local anesthesia. Again, here’s a patient with a fairly mild left upper lid ptosis. But she’s maybe got a little higher brow on this side than this side. And in this case, we did bilateral blepharoplasties, and a left upper lid levator advancement. Now, the question always comes up: What happens in a patient who has a Hering’s response? And here’s a patient who had a ptosis on both sides, but it was partially disguised by the fact that she was recruiting her brow on this side, and this is after bilateral levator advancement. Now, here’s a circumstance — this patient has a ptosis, but he also has proptosis. You can see here the globe is more prominent on this side than the opposite side. And this circumstance we want to be careful not to overcorrect that eyelid, because that’s gonna cause lid retraction, and could cause incomplete closure. So again, it’s very helpful to adjust this intraoperatively, and put it exactly where we want it to be. Now, this is a patient who had a modest left upper lid ptosis. And at the time of surgery, we corrected that. And I made an eyelid crease to match her other side. But postoperatively, she looked great one week postop, but when she came back three months later, she had too much skin here, and that lid crease had migrated back down and caused asymmetry. So in that circumstance, we can go back and just do a little upper blepharoplasty on this side, to match up the other side, and get a good symmetrical cosmetic result. Now, an operation that I really like to use is a, quote, “small incision” ptosis repair. I showed you an example where we make an incision the entire width of the eyelid. I’m sorry. Let me go back here for a minute. But if I’m going to do a blepharoplasty, I have to do that. If it’s a congenital ptosis, I want to do that. But if it’s an acquired ptosis, and the patient has a deep superior sulcus and a high lid crease, those patients are particularly good candidates to do a small incision, only about 1 centimeter, right here in the center of the eyelid. And then, again, identifying and advancing the levator aponeurosis. So here we’ve just made this small, 1-centimeter-wide incision. We peel that open, and we remove a little bit of orbicularis here, to expose the distal tarsal plate. I pass a suture through the tarsus. And then I pass a suture through the levator aponeurosis, above, and bring that in apposition to the tarsus. And sitting this patient upright, he was a little bit overcorrected here, so we went back and backed that suture off a little bit. But you can see through just a 1-centimeter incision, in one stitch, we can get pretty good matching contour and height, and this is a little bit simpler than making a full width eyelid incision. Now, the other thing we talked about in the diagnosis of ptosis is the concept of Hering’s dependency. And as we all know, Hering’s law refers to the fact that yoke muscles receive equal innervation. And the bilateral levator muscles are yoke muscles. You can’t really open one eye without opening the other eye. You can close one eye by activating orbicularis. But you can’t unilaterally fire off your levator on one side and not on the other. So here’s an example of the patient. He had marked left upper eyelid ptosis. When I lifted his left eyelid, however, you can see the opposite eyelid dropped. And the reason is: When this eyelid is occluding the visual axis, his brain is trying to get it open. It does two things. One is it recruits the frontalis. You can see how the eyebrow is higher on this side than it is on this side. So he’s recruiting the frontalis. But in addition, the body turns up the innervation to the levator muscle. But it can’t do that unilaterally. So it sends extra energy to both levator muscles. We then elevate the ptotic eyelid, and all of a sudden the brain says — oh! I don’t have to try to get it open so hard. And when it stops trying so hard, the opposite eyelid then drops. This is an example of Hering’s dependency. And that generally means that we need to do bilateral repair. That patient refused repair on the right side. We showed him the picture, and he said — well, just fix the left eye. Because it doesn’t bother me that much. But afterwards, he said… Oh yeah. Now I need to get this eyelid fixed. The problem is: When we fix this eyelid, now he gets further droop on the contralateral side. So Hering’s dependency can make it really difficult to fine-tune the ptosis. And generally, I like to do both eyelids simultaneously, if I can. However, we have seen the occasional patient, where they show us evidence of Hering’s dependency in the office, but after we do repair on just one side, the opposite eyelid did not drop, and we would not have had to do surgery on the other side. And again, here’s an example of a patient. Droopy eyelid. This is intraoperative adjustment of that lid height and contour to get it to match the other side. But here’s another example. This patient had ptosis on this side. We repair the ptosis. And the opposite lid drops down. You can see that the MRD here is probably 3 millimeters or so. And here it’s about 1.5 millimeters. On the other hand, here’s a patient who also shows Hering’s dependency. More ptotic eyelid here, but we lift that up with a Q-Tip, and this side drops. Our margin reflex distance here goes from about 2.5 millimeters down to about 0.5 millimeters. And yet when we repaired the one side, the opposite side really did not drop. So Hering’s dependency is something to be aware of. But it is not universally predictive that the opposite eye will become ptotic. Here is this patient after just undergoing unilateral repair, and she does not have very significant ptosis on the contralateral side. And just a few more pre-op and postop examples. Another patient here, with acquired ptosis. Good function. He has no lag in downgaze. In that case, we want to flip the eyelid. If they’re a soft contact lens wearer — to make sure that they don’t have any papillary conjunctivitis. Because some people will get a papillary conjunctivitis in response to their soft contact lens. If I see that, I make them stay out of their contact lenses for 90 days, which he did. Comes back in three months later, wearing his glasses. He’s still ptotic. Then that tells me he’s a candidate for repair. Now, the other option we have is: When we do this under local anesthesia, we can over — or we can purposely undercorrect ptosis height. This is a patient who has bilateral ptosis, but he did not perceive any problem in the right eye. I talked to him about the fact that when we lifted this side, this side might become more apparent. He said no. Just operate on this eyelid. So in this case, we purposefully undercorrected it. I just wanted to get an MRD of about 1.5 millimeters on this side, in order to match the MRD that he had on the contralateral side. And by sitting him up, and making him lower than I normally would have liked to, making him just match the other eye, it allowed me to just do unilateral surgery. And just one more example, again, of this small incision ptosis. Again, the traction suture. That small, 1-centimeter incision. Exposing the tarsus plate — in this case, I’m sorry, we spread to expose the levator aponeurosis here. And then we exposed the tarsal plate here. By excising the pretarsal levator muscle. So once we have tarsus exposed here, levator exposed up above, we’re just going to pass a suture through the tarsus, and then through the levator aponeurosis. Bringing that back down onto the surface of tarsal plate, and then sitting the patient upright, to adjust lid height and contour. And again, this is a little too high, and we’re gonna wanna back that suture off, so that we get a better match to the contralateral side. Again, a reminder of the importance of Hering’s. In this case, we sat this patient upright, and she looks like she’s overcorrected. But then I took a Q-Tip and I lifted the more ptotic side here. Because now I can see she’s raising her eyebrow. Tells me she’s trying to get this eyelid open. And when I lift this ptotic eyelid on the left side, the right eyelid relaxes and comes back down to the limbus. Again, because of Hering’s dependency. Now, the other advantage to intraoperative adjustment is that we can take — and we can use this procedure to correct contour abnormalities. This patient had just an isolated medial ptosis. Her eyelid laterally, say from the lateral limbus over, is fine. So in this case, I’m just gonna advance levator aponeurosis here, medially. And when I do that, and sit her up, I can see that I’ve got a nice correction of lid height, with one suture placed here. There was no need to do correction across the board there. It also allows me to adjust the contour of the eyelid. This is a patient with a right upper lid ptosis, and you can see she’s got a bit of a temporal flare to her normal eyelid. Normally, we expect the high point of the lid to be just nasal to the pupil, but in this case, we can see she’s actually got a little bit of temporal flare there. But I can match that in this eyelid, by moving my sutures laterally, and trying to get greater elevation here than I had medially. When I sat her up, this allowed me to get a pretty good match of the temporal peak in both eyes. So again, one final look here at the Mullerectomy. This is a good candidate for that. She’s got a preoperative ptosis. We put a drop of 2.5% neosynephrine in her left eye, and 5 minutes later, the lid comes to a good height. So we’re gonna go ahead and measure 4 millimeters from the superior border of tarsus up into the superior fornix, and we’re gonna place in this case — I’m showing you how we can do this with two hemostats. So if you don’t have a fancy clamp, you can still do this procedure. We take two straight hemostats, and clamp this 8 millimeters of tissue, 4 millimeters up and 4 millimeters back down. Do our running suture just below it. And then cut it off. And this gives us a good lid height and contour as well. Now, if we do a levator aponeurosis advancement, one advantage is we can do a little fine-tuning of this, even if one week postoperatively. Here’s a patient preoperatively, and one week postop. Obviously when I sat her up in surgery, I did not want to overcorrect this side. I thought it matched the other side quite nicely. But at one week, she’s overcorrected. Well, I can do something about that. In this case, we take her into the minor surgery room, put a little local anesthetic in, and we can just grasp the wound and peel it apart here. And I can reexpose the tarsal plate here, and I find the suture where I’ve advanced levator aponeurosis, and I can cut the suture. And let the levator recess there. And here she is, at the end of that little minor room procedure, where I’ve released that suture here, and then I suture the skin back together, and here she is, one week postoperatively, with good symmetry of lid height and contour. So it is possible for me to fine tune a levator advancement. Another example. This patient has poor contour with a definite peak here on this side, on the left upper lid. And this is after releasing that left upper lid in the minor room, and this gives us pretty good symmetry, but she still does have a little bit of right upper lid overcorrection. Okay. So those are approaches for patients who have good levator function, or have intermediate levator function. If they have good levator function, and they respond well to neosynephrine, we do the Mullerectomy. And we can do that with the clamp or with the two hemostats. If, on the other hand, the neosynephrine test is not good, or if they have decreased levator function, less than 12 millimeters, we do the levator advancement. Now we’re gonna talk about patients with poor levator function. Patients with poor levator function generally have this, either because there’s a problem with the muscle itself — and we talked about this two weeks ago. They could have chronic progressive external ophthalmoplegia, they could have congenital ptosis with a localized muscular dystrophy, or patients who have a nerve problem, like a third nerve problem, where they’re getting inadequate innervation to that muscle. In those cases, it’s not gonna work to try and tighten or shorten the levator muscle. Instead, we have to bypass that levator muscle. And this is where we like to do a frontalis sling. And the approach I use — I do this through an open lid crease. There are some people who will just do stab incisions, but I’ll show you why I think that an open lid crease is preferable in my mind. And I suture the sling directly onto the tarsal plate. This allows me to adjust the lid contour with these tarsal sutures, and then I adjust the height of the eyelid by how much tension I tighten my sling at my brow incision. And again, the way this operation works is to make this reflexive frontalis recruitment more efficient. Here’s an example of a patient who’s trying to open this right eyelid, and she’s doing a pretty good job of it. She’s only got about a millimeter of ptosis here, but you can see her eyebrow is way up on this side, compared to the other side. And when we block her eyebrow, you can see she’s got a pretty profound ptosis. The whole concept of this sling is to attach the tarsal plate to the frontalis, so we get a one to one transmission of force. Right now, I don’t have a one to one transmission of force. I have to raise my eyebrow about a centimeter to get a 1 millimeter elevation of the lid height. So a frontalis sling will make that a much more direct transfer. Now, interestingly, this is a patient I saw recently who had figured this out, and he did his own frontalis sling. He actually came in, and he had acute onset of myasthenia, with a poor function ptosis. But he had already figured out if he put a piece of Band-Aid to the eyelid, and to his forehead, he could lift the lid better than if he didn’t have that there. So he’s kind of got the concept of a frontalis sling down. And again, this just allows this to be more efficient. Here’s a patient who has a ptosis, and he’s got marked frontalis recruitment here. But even with that marked recruitment, he only gets that lid open about a millimeter or so. This is after we do a frontalis sling. This has just allowed him to have pretty good symmetry between the two sides. He can relax his eyebrow. His eyebrow here is about the same height as the other eye, and he can use this to more efficiently lift the eyelid. Now, we have a number of different options for surgical materials to do a frontalis sling. Probably the gold standard is to use autogenous fascia, to harvest that from the iliotibial tract. However, we have to have a patient who’s probably four to five years of age. And if they get much older than that, they don’t want to have this done. If they’re much younger than that, we can’t really get a good fascial strip. We can use donor fascia. We can use Gore-Tex — either Gore-Tex suture or a Gore-Tex patch, which we can cut into strips. Supramid, Mersilene mesh, prolene sutures. Some people talk about using the frontalis muscle itself as sling material. I’m not wild about that. But here’s an example of this operation in a very young patient. This patient is only a month old. But she’s got a pretty profound left ptosis. But the good news is she’s still trying to use that eyelid. She’s kind of raising her eyebrow here. So we’re gonna make an eyelid crease incision here. And we’re gonna mark three points in the brow. Some people will take this point and mark it up here, over the — higher up above the brow. There’s no need to do that. You can keep these little incisions at the brow. And we’re gonna open this lid crease incision and expose the tarsal plate. We’re gonna make stab incisions medially, centrally, and temporally. And in this case, I’m using a Supramid — I misspoke. A Gore-Tex patch material, which I cut into a strip, and then I can suture it to the surface of tarsus. I suture this with Mersilene suture, 5-0 Mersilene. But you have to be very, very careful not to get a full thickness pass through the cornea, because if you do, you will definitely cause keratopathy. So in this case, I flip the eyelid over, after I pass these sutures, to make sure there’s nothing exposed in the conjunctival surface. And then after we’ve sutured this to tarsus, we can use a right needle or a free abdominal needle, or even — you can make a tract with a scissors and pass a hemostat down here, to pull the sling material up through your temporal brow incision and your nasal brow incision. And this allows me to then look at the contour that I have, and if I’m pleased with the contour, I then bring these two pieces of the sling together to that central stab incision, and I tie the sling, trying to lift the eyelid up as high as I can. And I want to get it up as close to the superior limbus as possible. And then I bury this — I leave these ends long enough so that if I have to go back and untie and lower it, I’m still able to find it, you know, for a month to six weeks after surgery. So I can go back and adjust this, or even years later, it’s possible to find this and untie it and relax it. Or if my sling is too low, I can untie it and make more tension. Make a tighter junction there. And here is this patient, one week postoperatively. You can see that she’s using her brow. She can get the lid open. We have good height and contour. And because I opened the lid crease and reformed the lid crease, I get good symmetry of my eyelid creases. And this is this patient now, six months postoperatively. You can see these brow incisions healed almost to the point of imperception. And we maintained good lid height and contour. Another example of a patient — she has very little levator function here. But she has good brow recruitment. She’s trying to elevate this lid by stimulating her frontalis on that side. And this is her after a Gore-Tex sling. You can see that she now, with very subtle brow movement, she can get the eyelid to open, and by relaxing that brow, she gets it to close. So I do like slings if patients will recruit their frontalis. Another example where a sling is important. This is a patient who has a congenital right third nerve palsy. And you can see he has a ptosis here, but he has aberrant functioning. He gets crosstalk between the medial rectus and the levator, so when he adducts his eye, the lid comes up to a normal height. Well, I can’t do a levator advancement, because this would be all over the place, as he looks from right to left. So instead, we go in and we disinsert the levator muscle. I sutured the levator to the periosteum, up at the orbital rim, to keep it from reattaching to the eyelid, and then we do a frontalis sling. And again, he can open it by raising the eyebrow gently. He can close it by relaxing the eyebrow gently. And this gives us good height and contour. And this is an example of a patient who was undercorrected after his initial surgery. I’m able to go ahead and open this incision here, find my knot, untie it, and tighten it up, and again, sit him up until I have good height and contour. So I can adjust this postoperatively. Here’s a little patient with — after her initial sling, she has bad contour. We can then go through the eyelid crease, and we can tighten the sling to the temporal tarsus here, to give us a better contour on each side. Another patient with bilateral third nerve palsy, and this was kind of wild. When she would look to the right, her right eye would close and her left eyelid would open. When she’d look to the left, her left eye would close and her right lid would open. But we can see she’s trying still to get that eye open. You can see she’s recruiting her frontalis on this side when she looks this direction. She’s recruiting her frontalis on this side when she looks in this direction. So she’s gonna be a very good candidate to do a bilateral sling. We again disinsert the levator first, and then we go in and do bilateral slings. She can open well. She can close well. Now, the question always comes up: Should you do a unilateral sling in unilateral congenital ptosis, or bilateral slings? My bias is to just do a unilateral sling. And I’ll show you why. This is a patient with unilateral ptosis. She’s trying to get the eye open, so I know the sling should work well for her. But she doesn’t have very good levator function. Now, I can get very good symmetry in primary position if I do a unilateral sling. The one disadvantage is in downgaze, they’re gonna have some lid lag. Now, that lid lag does get better over time. But I can see that this lid is overcorrected. So on the other hand, this is a patient after bilateral slings. He has better symmetry in downgaze, but you really don’t spend your time interacting with the public by looking down at your shoes. You’re looking straight ahead. And in that case, this is usually not very apparent. What I tell parents is I tell them — listen. If you decide that you would want to have me come back and do the second eye later on, I can do it. But let’s just operate on the one side first, and see what you think. But I have never had a parent come back and ask me to do the second side. So I generally do one side. The reason that I really prefer to do one side — the very first case I did — because I was trained to treat unilateral congenital ptosis with poor function — to treat that with bilateral slings. The very first patient I did that on ended up with exposure keratopathy and a corneal ulcer on her good side. The side that had had no ptosis, preoperatively. And I said… Hm. I don’t like that. So I’ve been doing unilateral slings, and have had very good patient acceptance. Again, here’s a patient preoperatively. This is where I want to adjust him at the time of surgery. I reform the eyelid crease. And we get good elevation and good symmetry, postoperatively, with good closure. Now, as I said, the one downside is downgaze. All right. So what do we do with a patient with poor function ptosis but no recruitment of the brow? In that case, we have to do a frontalis sling. I misspoke. A supramaximal levator resection. Because we can’t do a frontalis sling. Now, this does result — can lift the eyelid well, but it results in more lagophthalmos. So if a patient has no Bell’s reflex, I don’t want to use this. And we cannot use it if there’s aberrant innervation of the levator, like a Marcus-Gunn or a congenital third nerve, because we’ll just exacerbate that. So here’s an example of a patient. He has decreased ptosis, but he’s not really recruiting the frontalis. No frontalis recruitment on this side. And in this case, he has a good Bell’s phenomenon. I’m going to have to go ahead and try and do a levator resection instead. We’ll make a skin incision through skin and orbicularis. We’re gonna open the orbital septum, and then we’re going to expose the preaponeurotic fat, which is just behind the septum. After I’ve done that, I disinsert the levator aponeurosis from the tarsal plate, and then I want to pull it forward. And here’s Whitnall’s ligament here, that I’m looking at. I’m gonna pull it forward, to expose as much of it as I can. And I make a cut through Whitnall’s on this side and a cut on this side, and that allows me to advance as much levator muscle as possible. You can see here’s the superior fornix. And we can see conjunctiva over the cornea here. And then I’m gonna amputate all of this levator aponeurosis, levator muscle, and I’m gonna suture this edge to the superior border of tarsus here. We’re going even higher now. Here you can see where we have the actual fattily infiltrated levator muscle. And in this case, I’m taking about 25 millimeters of levator muscle, and I’m going to amputate it. First I prepass sutures through it. And then I suture it to tarsal plate. And you can see this gives me a pretty good lid height and contour. And then I cut off all the levator muscle that I resected. And here’s this same patient, preoperatively. And this is after surgery. He has good height. He has some lagophthalmos. But he can tolerate this reasonably well. Another example. This little girl. Decreased levator function. But she doesn’t really recruit her frontalis on this side. And this is after a unilateral levator supramaximal resection. Now, you can get overcorrection with these patients. Over time, however, I generally want to get overcorrection, because over time it will tend to drop, as we can see here. So a little bit of overcorrection early on is not bad. Undercorrection does not generally get better, and usually means we have to go back and do a reoperation. So again, the large majority of ptosis is gonna be levator aponeurotic, in which case we do an aponeurotic advancement. If there’s good levator function, we can either do aponeurotic advancement or Mullerectomy. If there’s poor or aberrant function, we either have to do a frontalis sling or a supramaximal levator resection. So that is a summary of the options we have for ptosis repair. And at this point, I think I’m going to take a look and see what questions our audience may have about this. About ptosis repair. One question that was posed two weeks ago was whether or not to use a Frost suture, a suture through the lower eyelid, and tape it to the eyebrow. I don’t do that. All you need to do is have the patient’s family make sure that they vigorously lubricate the eye — even if it’s wide open. If they vigorously lubricate every 2 to 3 hours, I’ve never had a patient develop a corneal ulcer afterwards. And trying to see that patient back postoperatively and get that Frost suture out again is a real hassle. So I don’t use Frost sutures. So at this point, let’s see if there are any other questions that any of our participants might have. They’re telling me I still have no open questions. Okay. Now I have a question. Do you intraoperatively adjust the lid position, depending on the pre-op levator action? Yes. Thank you for asking that. Yes, for sure. If I have a patient who has poor levator function, I will try to overcorrect them. Because I know that they’re gonna tend to drop some. If I have patients with good levator function, I want to leave them — under local anesthesia, again. This is talking about doing this under local anesthesia — I’ll leave them right where I want them to be. But if they have poor levator function, and I’m doing it under local anesthesia, I will try and overcorrect them. Second question is: What is my experience with palmar tendon? The answer is I have no experience with palmar tendon. I actually imagine it would work fine. But I have never found a need for it, because it’s so easy for me to harvest fascia from the iliotibial tract. So fascia lata works the same. Next question. What of the Fasanella-Servat procedure? I tend to use Mullerectomy instead of Fasanella-Servat. But it’s almost the same operation. The only difference, in a Fasanella-Servat, you’re resecting a little bit of the superior tarsus, and a little bit of the distal levator aponeurosis, Muller’s, and conjunctiva. So I tend to leave the tarsus alone, and tend to just do a Mullerectomy myself. Okay. So… The next question is: Operating on Marcus-Gunn jaw wink. We certainly do do that. What is the indication? About the same as anything else. And that is: Early on, if it’s threatening amblyopia, I definitely want to operate it, because I have to do a frontalis sling. I’ll have to go in. I’ll disinsert the levator muscle, and I will suture it to the supraorbital rim, inside the orbit. The only reason I suture it up there is to make sure it doesn’t reattach to the eyelid. And then I will do a frontalis sling. If the patient has amblyopia, it’s really difficult, because anything I do to try and strengthen the levator is gonna make the wink worse. Now, if I have a patient where the ptosis is more prominent and the wink isn’t too bad, I can do levator aponeurotic surgery on those patients, and just tell them — because most patients do learn to control the jaw movements which lead to a wink, as they get older. If the patient is not amblyopic, then you can wait until they’re old enough to harvest the lateral rectus — I misspoke — the fascia lata. Is Berke’s table good for intraoperative lid positioning in general anesthesia? You know, I think that probably is a good thing. I generally go in with an idea of where I want the lid to be at the end of the procedure. If they have good levator function, I’d like to have it sort of splitting the pupil. If it’s intermediate, I want it sort of halfway between the superior limbus and the pupil. If it’s poor function, I want it at or above the superior limbus. But I think Berke’s table is a good thing as well. Okay. Parents often ask when full lid closure will be achieved at bedtime. My answer is: Maybe never. But it almost always gets quite a bit better after six weeks or so. So I generally tell them, for the first six weeks, almost everybody needs ointment at bedtime. And after that, most kids can taper off the lubricating ointment at six weeks. Okay. Well, I think… I don’t see any more questions in the queue here. Ah-ha. Another one. Do you do conjunctival approach levator resections? The answer is no. I really see — in my mind — no advantage to a conjunctival approach over a lid crease approach. I think it’s — the anatomy is not as clear. So I don’t do that. Now, my good friend Richard Collin, I think, still does do a posterior approach. I would say here in North America, 98% of oculoplastic surgeons will do an anterior approach to a lid crease, rather than through a conjunctival approach. And it also gives us the advantage of getting — reestablishing the eyelid crease. Okay. How do you manage blepharophimosis syndrome? That can be difficult, for sure. In congenital eyelid syndrome, we have telecanthus, we have epicanthus inversus, and ptosis. As a general rule of thumb, we have to correct the ptosis earlier, especially if it’s amblyogenic, or if we think there’s a risk of torticollis, because of neck position, but we don’t have to correct the epicanthus until they’re quite a bit older. And definitely as these kids grow, the epicanthus tends to get better. If you want to really correct the epicanthus, in my opinion, you really have to do transnasal wiring. So the soft tissue — I just do a little V to Y advancement in the medial canthus. But I do transnasal wiring to bring the medial canthus close together. And I usually wait until they’re 10 or 12 years of age to do that. The next question is: Is there an indication for Fasanella-Servat now, instead of conjunctival Mullerectomy? In my hands, I just do the conjunctival Mullerectomy. I would have no argument at all, if somebody wanted to do, you know, a Fasanella-Servat for a modest congenital ptosis, or a good function modest acquired ptosis. I just think the neosynephrine test allows me to titrate things a little bit better than the Fasanella-Servat. Okay. Well, I think our hour has come to an end. I hope this was helpful. And if there are additional questions, we can take those offline. Thank you for your attention. Oh, wait, last thing. How do you adjust the lid position under general anesthesia in resurgeries? Well, the only time I would do general anesthesia is if it were a kid. Okay? Anybody who can be done under local anesthesia I always do under local anesthesia, because it’s so much easier for me to adjust lid height and contour with them sitting upright. If it’s a child, I generally want to get it higher than it was, and that means if it’s poor function, I want to get it up at the superior limbus, under general anesthesia. Okay, folks. I think I will say goodnight to everyone, and I appreciate your attention. Bye, now.