Figure 9-1. After subcutaneous infiltration, a 4–0 double-armed silk traction suture is placed at the central upper lid margin and secured to the surgical drape below with a hemostat. The suture is placed through the gray line at the lid margin to avoid the marginal arcade, thereby preventing unnecessary bleeding. When secured inferiorly, this traction suture puts all eyelid structures posterior to the orbicularis muscle on tension, while allowing the anterior lamella to be mobilized. The skin is incised along the previously marked lid crease with a scalpel.

Figure 9-2. The orbicularis is tented anteriorly with a toothed forceps, and its full-thickness is incised centrally with a Westcott scissors oriented perpendicularly.

Figure 9-3. It is a key maneuver in this technique to make a full-thickness incision through the orbicularis muscle, as this avoids unnecessary bleeding from multiple cuts into the muscle and permits identification of the avascular posterior orbicular fascial plane (needle).

Figure 9-4. One blade of a scissors is then passed bluntly into the avascular plane, and the incision is completed medially and laterally. The superior edge of the incision is retracted upward with a skin hook, and the disinserted edge of the levator aponeurosis can oftentimes be identified through the translucent postorbicular fascia. The postorbicular fascia is recognized as a delicate layer overlying the aponeurosis. In this fascial plane, vertically oriented peripheral nerve fibers can sometimes be seen. Further dissection is required to expose the levator aponeurosis.

While retracting the superior edge of the incision with a double-pronged skin hook, gentle pressure is applied on the globe. With retrograde orbital pressure, the preaponeurotic fat pad bulges forward to tent up the orbital septum.

Figure 9-5. A horizontal incision is made with a Westcott scissors to buttonhole the orbital septum above its fusion with the aponeurosis. The incision should be directed superiorly to avoid transecting Müller’s muscle or the conjunctiva. This allows the preaponeurotic fat to herniate through the buttonhole. The entire orbital septum is then opened by placing one blade of the scissors behind the orbital septum and extending the incision medially and laterally.

The foregoing maneuvers are important to identify the preaponeurotic fat pad and to avoid making iatrogenic defects in the aponeurosis.

Figure 9-6. The skin and orbicularis muscle are retracted with a forceps. The preaponeurotic fat pad (indicated by the top needle) is the key anatomic landmark in this surgery, since the levator aponeurosis is located immediately beneath this structure (lower needle). Müller’s muscle lies immediately under the levator aponeurosis. In cases of repeated operation, trauma, or in eyelids infiltrated by tumor, such as neurofibroma, the preaponeurotic fat pad may be the only identifiable structure.

Figure 9-7. The preaponeurotic fat pad is retracted superiorly with a Desmarres retractor, and fine attachments to the underlying levator aponeurosis are lysed with a Westcott scissors.

Figure 9-8. The disinserted edge of the levator aponeurosis is grasped with forceps. When the patient is asked to look superiorly, the surgeon can feel the force generated against the forceps, confirming the structure to be the aponeurosis. The Whitnall’s ligament can be seen at the superior limit of the aponeurosis (needle tip). Frequently, the disinserted edge of the aponeurosis can be recognized.

Figure 9-9. A strip of pretarsal orbicularis muscle, at the superior margin of the tarsus, is excised by bluntly undermining with a Westcott scissors, thus baring the anterior surface of the tarsal plate. In ptosis cases in which the levator aponeurosis is intact, the appropriate amount of aponeurosis is resected with Westcott scissors. In patients in whom a rarefaction or dehiscence of the aponeurosis is present, it is important to excise the rarefied area to create a free healthy muscle edge for anchoring onto the tarsal plate.

If the aponeurosis has been disinserted, the disinserted edge is grasped with a forceps and sutured to the anterior surface of the tarsal plate. If there has been no obvious disinsertion, the aponeurosis is then detached from the upper border of the tarsal plate. The peripheral vascular arcade in Müller’s muscle helps to identify this structure. If bleeding occurs in this plane, one should pick up the tissue with the bipolar tip before cauterizing, thereby preventing thermal injury to the underlying cornea.

Figure 9-10. Once the full expanse of the aponeurosis has been separated from the tarsal plate and the appropriate amount of aponeurosis resected, it is then reattached onto the upper midportion of the tarsal plate with a 5–0 polyglactin 910 (Vicryl) suture on a spatula needle. A spatula needle facilitates a partial-thickness tarsal pass; the lid may be everted to confirm that full-thickness passes have not occurred. Full-thickness tarsal sutures should be avoided to prevent buckling of the tarsal plate and corneal abrasion. The first suture is placed just medial to the pupil, which is the highest point of the normal eyelid. The aponeurosis should be advanced and firmly fixed to the tarsus with a temporary tie first. “Tucking” of the aponeurosis does not result in a permanent correction, as no raw surfaces are opposed. The aponeurosis should be resected in all cases, except a complete disinsertion, to create a healthy, strong edge to suture to the tarsus. If the aponeurosis is advanced too low on the tarsal plate, eversion of the eyelid margin may occur.

Figure 9-11. After the central suture placement, additional sutures are placed medial and lateral to the central suture to adjust eyelid contour and height.

Figure 9-12. The lid height should be overcorrected about 1 to 1.5 mm at surgery to compensate for anesthetic paralysis of the orbicularis and to counteract a slight postoperative fall. When local anesthesia is used, the lid height and contour should be evaluated while the patient sits upright on the operating table. Eyelash position and the lid crease should be evaluated at the same time. Once the lid height and contour are judged to be satisfactory, additional sutures are used to firmly secure the aponeurosis to the tarsal plate. The eyelid is then everted to look for any exposed sutures on the tarsoconjunctival surface.