Levator advancement #2
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This is Richard Allen at the University of Iowa.
This video demonstrates an additional example of a levator advancement.
This patient has bilateral upper eyelid dermatochalasis and left involutional ptosis. A bilateral upper eyelid blepharoplasty will be performed with a left levator advancement. The needle tip cautery is used to make an incision along the previously marked blepharoplasty markings. This patient has a naturally low eyelid crease. This is performed bilaterally. Dissection is then carried out along the surface of the orbital septum to excise a flap of skin and orbicularis muscle. Hemostasis attained with the monopolar cautery. This is then performed on the other side.
A high temperature thermal cautery is then used to make an incision through the orbital septum to expose the underlying pre-aponeurotic fat. The pre-aponeurotic fat is then dissected from the underlying levator aponeurosis and muscle to the level of Whitnall's ligament. The thermal cautery is then used to disinsert the levator aponeurosis from the anterior surface of the tarsus. Dissection is then carried out between the levator aponeurosis and the underlying Mullers muscle. This dissection is performed to the junction of the levator aponeurosis and levator muscle.
A double armed 5-0 Nylon suture on a spatula needle is then place partial thickness through the anterior surface of the tarsus 1-2 mm inferior to the superior border of the tarsus. The needle is then placed through the levator aponeurosis at the junction of the aponeurosis and levator muscle, which I think is a good starting place for ptosis repair. The other arm of the suture is then placed in the same manner and a temporary tie is placed. The patient is asked to open their eyes. In this case, the peak of the lid appears to be too medial. Therefore, the temporary tie is untied and one arm of the suture is removed from the levator aponeurosis and placed more lateral to the initial suture through the anterior surface of the tarsus, 1-2 mm inferior to the superior border of the tarsus. The suture is then placed back through the levator aponeurosis. The other arm of the suture is then removed from the initial bite through the tarsus. The suture is then placed through the levator aponeurosis and a temporary tie is placed. The patient is asked to open their eyes. The peak and height appear to be adequate. I will sit the patient up at this point to evaluate them.
The temporary tie is then converted to a permanent tie. The incision is then closed with a 6-0 Prolene suture which incorporates a bite of the levator aponeurosis. This will assist in eyelid crease formation, if desired. This will be a running suture. A small Burrows triangle is excised medially. The closure is completed. At the conclusion of the case, antibiotic ointment will be placed over the incision three times a day and the patient will return in one week for reevaluation and suture removal.