Levator advancement in a patient with a deep superior sulcus
Richard C. Allen, MD, PhD, FACS
Length: 03:42
This is Richard Allen at the University of Iowa. This video demonstrates a levator advancement in a patient with a prominent superior sulcus. This is often encountered in older patients with involutional ptosis. There is essentially no lid crease. A lid crease will be marked at approximately 8 millimeters. I think the difficulty in these patients is identifying the preaponeurotic fat which is the landmark for upper eyelid surgery. A miniscule blepharoplasty is performed. Dissection is carried out through the orbicularis muscle to identify the orbital septum. The issue here is that the levator aponeurosis will be directly under the orbital septum and there will be no pad of preaponeurotic fat. Therefore, dissection will be carried out superiorly between the orbital septum and orbicularis muscle. The orbital septum is demonstrated with toothed forceps to show its attachment to the superior orbital rim. The orbital septum is then opened and immediately one notes the levator aponeurosis under it as well as Whitnall's ligament. There is no evidence of preaponeurotic fat in this area as the preaponeurotic fat has migrated superiorly in the patient's orbit. The scant pre-aponeurotic fat is demonstrated with the Paufique forceps. Dissection is carried out between the preaponeurotic fat and the underlying levator muscle. Whitnall's ligament is demonstrated. Superior to Whitnall's is the muscular portion the levator aponeurosis. Ptosis surgery can then proceed as normally with disinsertion of 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. Again, you'll often encounter this anatomy in older patients. The patient has no history of prostaglandin use or have any other reason to have enophthalmos other than age. The thinness of Mueller's muscle is also demonstrated here. The pretarsal orbicularis muscle is dissected from the underlying tarsus to bear the tarsus. Also complicating the surgery, is the fact that this patient had a previous Fassanella-Servat procedure which compromised the integrity of the tarsus. Ptosis surgery then proceeds as would be normally performed by engaging the anterior surface of the tarsus with a double-armed 5-0 nylon suture. Again, it's important in these patients to be aware of the scant preaponeurotic fat or absence of preaponeurotic fat in the normal anatomic position.
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