Levator advancement for congenital ptosis
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This is Richard Allen at the University of Iowa. This video demonstrates a ptosis repair in a pediatric patient with approximately 2 to 3 millimeters of ptosis and 6 to 8 millimeters of levator function. A levator resection/advancement will be performed in this case. A small blepharoplasty has been marked and a 15 blade is used to make an incision along the markings. The needle tip cautery is then used to excise a flap of skin and orbicularis muscle. The orbital septum is identified. The septum in children is always thick. Dissection is carried out through the septum with the goal of identifying the preaponeurotic fat. Palpation on the globe shows prolapse of the fat. Dissection is then carried out over the preaponeurotic fat until it is encountered. Dissection is then carried out between the preaponeurotic fat and the underlying levator aponeurosis. This is performed superiorly towards Whitnall's ligament. The amount of levator exposed depends upon the amount of advancement needed. Additional dissection is performed. In this case, 20 millimeters of resection will be performed. This is marked with a marking pen. The thermal cautery with 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 Mueller's muscle. Some surgeons will prefer dissecting under the Mueller's muscle. In this case, dissection is carried out superiorly with Wescott scissors along the surface of the conjunctiva above Mueller's muscle. A double-armed 5-0 nylon suture is placed partial thickness through the anterior surface of the tarsus. The suture is then placed through the levator aponeurosis at the markings. As one can see, this is just inferior to Whitnall's ligament. The other arm of the suture is placed. A temporary tie is then performed and the height and contour of the eyelid is inspected. The contour has a lateral droop. Therefore, an additional suture will be placed laterally. The initial suture placed is tied permanently. The redundant levator aponeurosis is excised with the thermal cautery. The second suture is then placed laterally to address the lateral droop. I think it's important in pediatric ptosis patients to pay attention to the lateral droop. Usually, more than one suture is needed to give an appropriate contour. The contour appears to be appropriate. The temporary tie is converted to a permanent tie. The incision will then be closed by incorporating the levator aponeurosis into the closure. This is performed in order to re-create the lid crease. This is performed with approximately 5 sutures along the length of the eyelid. Often, when a suture is placed, it will need to be left untied so that the adjacent suture can be placed. Again, the skin is engaged followed by the cut end of the levator aponeurosis, followed by the other edge of the skin. At the conclusion of the case, the eyelid appears be in good position with a good contour. The patient will follow-up in one week for reevaluation.