Ptosis Repair in Aesthetic Blepharoplasty




A straightforward approach to ptosis in a patient interested in aesthetic blepharoplasty is presented. Beginning with an explanation of how ptosis often becomes apparent after an aesthetic surgery of the upper lid, this article describes functional anatomy of the eyelid relevant to ptosis, and discusses the various causes of ptosis, examination of the patient presenting with a drooping lid, aspects the surgeon should be aware of from the patient’s perspective of this problem, and surgical options and techniques. The author describes in step-by-step detail external levator aponeurosis resection, pretarsal aponeurosis resection, Müller muscle–conjunctival resection, the complications that can arise with these procedures, and aftercare required.


Key points








  • Upper eyelid ptosis is not an uncommon finding during evaluation for blepharoplasty surgery.



  • A detailed examination of eyelid position is critical in recognizing ptosis before performing blepharoplasty surgery.



  • Missing a preexisting ptosis can lead to an unhappy patient even if blepharoplasty surgery is performed successfully.



  • The surgeon must be aware of the multiple causes of ptosis and how to rule out potential pathologic processes that can be associated with ptosis.



  • The most common etiology of ptosis is involutional, related to attenuation of the levator aponeurosis tendon.



  • A clear understanding of eyelid anatomy is essential to successful ptosis repair.



  • There are 2 standard techniques for the repair eyelid ptosis: an external levator resection and a posterior-approach Müller muscle–conjunctival resection.



  • The surgeon should be prepared to manage dry-eye–related symptoms, as these can easily occur after ptosis repair.



  • Revisional ptosis repair is far more common and complex than revision blepharoplasty surgery.






Introduction


Upper blepharoplasty is one of the most common cosmetic procedures performed today. Eyelid changes associated with age include dermatochalasis, fat herniation, and lax/redundant orbicularis muscle. Blepharoplasty can be performed to selectively remove excessive skin, muscle, and fat from the eyelid. Often, patients with dermatochalasis also have upper eyelid ptosis, which is a lowered position of the eyelid margin when the eye is in primary position. A normal eyelid rests in a position where the eyelid margin is approximately 3.5 to 4.5 mm above the central pupil. An upper eyelid is considered to have functional ptosis when the upper lid margin rests 2.5 mm or less from the center of the pupil. Ptosis should be repaired at the time of blepharoplasty surgery. If not, ptosis is often more apparent after surgery because it is unmasked by the lid debulking inherent to blepharoplasty. In addition, the patient does not know that their lid droop is due to ptosis. If ptosis is undiagnosed and apparent after blepharoplasty, the patient will be unhappy and feel surgery was not successful.


There are 2 muscles responsible for elevating the upper lid, the levator palpebrae superioris and the Müller muscle. Their location in the eyelid is posterior to the orbital septum and deep to the eyelid fat pads, which is important because the fat pads act as an anatomic landmark or barrier to the surgeon as to where these vital eyelid-elevating muscles are. In turn, this allows a level of protection from inducing ptosis during upper blepharoplasty surgery by avoiding surgical manipulations deep to the fat pads. When performing stand-alone upper-lid blepharoplasty these muscles should be left undisturbed. Because they are deeper structures of the eyelid, correcting concurrent ptosis while performing blepharoplasty surgery requires a more detailed knowledge and familiarity with upper eyelid anatomy. In addition, ptosis correction is more challenging, complex, and time consuming than blepharoplasty alone, and can result in additional postoperative complications such as abnormalities in eyelid height and contour.


There are 2 standard surgical options to address ptosis in conjunction with blepharoplasty.



  • 1.

    An anterior approach is performed by resection and advancement of the levator aponeurosis through the same incision that is used for the blepharoplasty procedure.


  • 2.

    Conversely, a Müller muscle–conjunctival resection is performed from the posterior aspect of the eyelid.



Levator surgery is more complex and time consuming, and requires the cooperation of the patient. The posterior approach is easier and more appropriate to the less experienced ptosis surgeon if the patient is a good candidate. Both procedures are reviewed here in detail.




Eyelid anatomy


A detailed description of eyelid anatomy is found in the article by Lam and colleagues elsewhere in this publication. Reviewed here is the relevant anatomy specific to ptosis repair. A general concept is that the various tissue layers of the eyelid are different if a cross section were to be taken beneath the eyelid crease as opposed to above the eyelid crease.


Starting anteriorly, one finds the following layers:



























Below the Crease Above the Crease
Skin Skin
Orbicularis muscle Orbicularis muscle
Tarsus Orbital septum
Conjunctiva Orbital fat
Levator aponeurosis tendon
Müller muscle
Conjunctiva


As the eyelid-elevating muscles exist primarily above the crease, the balance of ptosis surgery occurs at this level, and understanding eyelid anatomy in this area is the foundation of attaining good surgical results.


Levator Palpebrae Superioris Muscle


The levator palpebrae superioris muscle provides the majority of muscle elevation of the upper eyelid. It is a striated muscle that arises from the lesser wing of the sphenoid at the orbital apex, and is approximately 40 mm in length. It passes anteriorly in a common muscle sheath with the superior rectus muscle. It is innervated by the superior division of cranial nerve (CN) III. The levator transitions from muscle to aponeurosis tendon about 15 to 17 mm above the superior tarsal border. The aponeurosis inserts into the anterior and superior aspects of the tarsal plate. It also sends attachments through the pretarsal orbicularis to the skin to form the upper eyelid crease.


Müller Muscle


The Müller muscle is a smooth, autonomically innervated muscle that originates from the levator muscle, approximately 15 mm above the superior tarsal border. It is found just posterior to the levator aponeurosis, and is intimately associated with the conjunctiva on its posterior surface. The peripheral vascular arcade lies on the anterior surface of the Müller muscle and acts as an anatomic landmark to the location of the muscle, which attaches to the superior tarsal border.


Orbicularis Oculi Muscle


While the 2 retractors of the eyelids (eyelid-opening muscles) already described are the basis of ptosis surgery, the protractor of the eyelids, the orbicularis oculi muscle, is also important in ptosis and blepharoplasty surgery, as maintaining its function is critical to lid closure, blink, and corneal integrity. The orbicularis oculi is a sphincter-like muscle that overlies the orbital rim and eyelids, and functions to close the upper and lower lids. It is separated into an orbital and palpebral segment. The palpebral segment is further subdivided into a preseptal and pretarsal component. The muscle is innervated by CN VII, and postoperative weakness results in a paretic/paralytic lagophthalmos. The muscle lies just beneath the skin, with its terminal portion visible as the gray line on the eyelid margins.


Orbital Septum


Posterior to the preseptal orbicularis is the orbital septum, a fibrous connective-tissue structure that lies just anterior to the orbital/eyelid fat pads. It arises at the superior arcus marginalis and extends to insert on the levator aponeurosis in Caucasians. The orbital septum inserts lower (on to tarsus) in Asian eyelids, thus allowing the eyelid fat to sit lower than in Caucasian lids. In part this leads to the fuller appearance of Asian lids and lower or indistinct eyelid crease. The orbital septum is a critical structure in eyelid surgery, as it defines the division of the eyelid proper from the orbit. Violation of the orbital septum (a necessary step in levator advancement ptosis surgery) exposes orbital fat and the underlying levator aponeurosis.


There are 2 fat pads in the upper eyelid. The nasal fat is lighter, denser, and in continuity with deeper orbital fat, because the levator aponeurosis does not separate the nasal fat from the extraconal and intraconal orbital fat, which is also why nasal fat can be approached transconjunctivally. The central fat is also called preaponeurotic fat, as it lies anterior to the levator aponeurosis. It is more yellow, less dense, and separated from deeper orbital fat by the levator aponeurosis. In the lateral upper lid there is no fat pad (as opposed to the lower lid). In the upper eyelid this space is occupied by the lacrimal gland.


Tarsus


The tarsus is a dense fibrous connective tissue that provides the structured framework and form of the eyelids. It averages 10 mm in height in the upper lid and 4 to 5 mm in the lower lid. It tends to be taller in females and shorter in Asians (7–8 mm). The tarsus is the attachment point for the levator aponeurosis (on its anterior surface) and Müller muscle (at its superior edge). When performing levator ptosis repair, the tarsus is exposed and the levator aponeurosis reattached to its anterior surface. In posterior-approach ptosis surgery the tarsus is seen through the conjunctiva, but left undisturbed. Rather, the conjunctiva and Müller muscle are resutured to its superior extent. The tarsus contains numerous sebaceous adnexal structures called meibomian glands, which provide the outer layer of the tear film to prevent tear evaporation. Approximately one-third of the tarsus lies medial to an imaginary vertical line drawn through the pupil, and two-thirds lies lateral to this point.


Vascular System in Eyelids


The eyelids contain a rich vascular supply, formed from an anastomosis of the external and internal carotid arteries. The 2 branches of this system in the upper lid are the marginal and peripheral arcades. The marginal arcade lies just above the lid margin and the peripheral arcade just above the tarsus. Visualization of the peripheral arcade is very helpful in identifying the Müller muscle when approached through the skin, because it runs on its surface 1 to 3 mm above the superior border of the tarsus. Müller muscle can be infiltrated by fibrofatty tissue, making it difficult to identify. In these cases the peripheral arcade is a very helpful landmark. The marginal arcade runs 3 mm above the eyelid margin on the anterior tarsal surface. It is important to avoid disturbing the marginal arcade during surgery because this can lead to excessive bleeding, bruising, lash loss, trichiasis, lid notches, and other deficits of the eyelid margin.




Eyelid anatomy


A detailed description of eyelid anatomy is found in the article by Lam and colleagues elsewhere in this publication. Reviewed here is the relevant anatomy specific to ptosis repair. A general concept is that the various tissue layers of the eyelid are different if a cross section were to be taken beneath the eyelid crease as opposed to above the eyelid crease.


Starting anteriorly, one finds the following layers:



























Below the Crease Above the Crease
Skin Skin
Orbicularis muscle Orbicularis muscle
Tarsus Orbital septum
Conjunctiva Orbital fat
Levator aponeurosis tendon
Müller muscle
Conjunctiva


As the eyelid-elevating muscles exist primarily above the crease, the balance of ptosis surgery occurs at this level, and understanding eyelid anatomy in this area is the foundation of attaining good surgical results.


Levator Palpebrae Superioris Muscle


The levator palpebrae superioris muscle provides the majority of muscle elevation of the upper eyelid. It is a striated muscle that arises from the lesser wing of the sphenoid at the orbital apex, and is approximately 40 mm in length. It passes anteriorly in a common muscle sheath with the superior rectus muscle. It is innervated by the superior division of cranial nerve (CN) III. The levator transitions from muscle to aponeurosis tendon about 15 to 17 mm above the superior tarsal border. The aponeurosis inserts into the anterior and superior aspects of the tarsal plate. It also sends attachments through the pretarsal orbicularis to the skin to form the upper eyelid crease.


Müller Muscle


The Müller muscle is a smooth, autonomically innervated muscle that originates from the levator muscle, approximately 15 mm above the superior tarsal border. It is found just posterior to the levator aponeurosis, and is intimately associated with the conjunctiva on its posterior surface. The peripheral vascular arcade lies on the anterior surface of the Müller muscle and acts as an anatomic landmark to the location of the muscle, which attaches to the superior tarsal border.


Orbicularis Oculi Muscle


While the 2 retractors of the eyelids (eyelid-opening muscles) already described are the basis of ptosis surgery, the protractor of the eyelids, the orbicularis oculi muscle, is also important in ptosis and blepharoplasty surgery, as maintaining its function is critical to lid closure, blink, and corneal integrity. The orbicularis oculi is a sphincter-like muscle that overlies the orbital rim and eyelids, and functions to close the upper and lower lids. It is separated into an orbital and palpebral segment. The palpebral segment is further subdivided into a preseptal and pretarsal component. The muscle is innervated by CN VII, and postoperative weakness results in a paretic/paralytic lagophthalmos. The muscle lies just beneath the skin, with its terminal portion visible as the gray line on the eyelid margins.


Orbital Septum


Posterior to the preseptal orbicularis is the orbital septum, a fibrous connective-tissue structure that lies just anterior to the orbital/eyelid fat pads. It arises at the superior arcus marginalis and extends to insert on the levator aponeurosis in Caucasians. The orbital septum inserts lower (on to tarsus) in Asian eyelids, thus allowing the eyelid fat to sit lower than in Caucasian lids. In part this leads to the fuller appearance of Asian lids and lower or indistinct eyelid crease. The orbital septum is a critical structure in eyelid surgery, as it defines the division of the eyelid proper from the orbit. Violation of the orbital septum (a necessary step in levator advancement ptosis surgery) exposes orbital fat and the underlying levator aponeurosis.


There are 2 fat pads in the upper eyelid. The nasal fat is lighter, denser, and in continuity with deeper orbital fat, because the levator aponeurosis does not separate the nasal fat from the extraconal and intraconal orbital fat, which is also why nasal fat can be approached transconjunctivally. The central fat is also called preaponeurotic fat, as it lies anterior to the levator aponeurosis. It is more yellow, less dense, and separated from deeper orbital fat by the levator aponeurosis. In the lateral upper lid there is no fat pad (as opposed to the lower lid). In the upper eyelid this space is occupied by the lacrimal gland.


Tarsus


The tarsus is a dense fibrous connective tissue that provides the structured framework and form of the eyelids. It averages 10 mm in height in the upper lid and 4 to 5 mm in the lower lid. It tends to be taller in females and shorter in Asians (7–8 mm). The tarsus is the attachment point for the levator aponeurosis (on its anterior surface) and Müller muscle (at its superior edge). When performing levator ptosis repair, the tarsus is exposed and the levator aponeurosis reattached to its anterior surface. In posterior-approach ptosis surgery the tarsus is seen through the conjunctiva, but left undisturbed. Rather, the conjunctiva and Müller muscle are resutured to its superior extent. The tarsus contains numerous sebaceous adnexal structures called meibomian glands, which provide the outer layer of the tear film to prevent tear evaporation. Approximately one-third of the tarsus lies medial to an imaginary vertical line drawn through the pupil, and two-thirds lies lateral to this point.


Vascular System in Eyelids


The eyelids contain a rich vascular supply, formed from an anastomosis of the external and internal carotid arteries. The 2 branches of this system in the upper lid are the marginal and peripheral arcades. The marginal arcade lies just above the lid margin and the peripheral arcade just above the tarsus. Visualization of the peripheral arcade is very helpful in identifying the Müller muscle when approached through the skin, because it runs on its surface 1 to 3 mm above the superior border of the tarsus. Müller muscle can be infiltrated by fibrofatty tissue, making it difficult to identify. In these cases the peripheral arcade is a very helpful landmark. The marginal arcade runs 3 mm above the eyelid margin on the anterior tarsal surface. It is important to avoid disturbing the marginal arcade during surgery because this can lead to excessive bleeding, bruising, lash loss, trichiasis, lid notches, and other deficits of the eyelid margin.

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Nov 20, 2017 | Posted by in General Surgery | Comments Off on Ptosis Repair in Aesthetic Blepharoplasty

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