Upper eyelid levator surgery

Many people may have congenital ptosis, which can make people look tired and older than their peers. If people want to have a better image, they need to solve the problem of ptosis first. How can we solve the problem of ptosis? You can consider having an upper eyelid levator muscle surgery, which has good results. Here is a detailed introduction to this surgery.

Levator palpebrae superioris shortening is suitable for:

Any congenital, senile, traumatic or other types of ptosis with a levator palpebrae superioris muscle strength of more than 4mm.

Preoperative preparation

1. The shortening amount cannot be calculated mechanically based on the amount of sag. For those with the same amount of ptosis but different muscle strength, after the same amount of shortening, the one with weaker muscle strength will not be able to raise the upper eyelid to the same extent as the one with stronger muscle strength. Therefore, the determination of the amount of shortening is mainly determined by the strength of the muscle.

(1) If the levator palpebrae superioris muscle is strong, the shortening will be less; otherwise, the shortening will be greater.

(2) Types of ptosis: Congenital ptosis has a greater amount of shortening, senile ptosis should be much less, and traumatic ptosis is between congenital and senile ptosis and should be close to congenital ptosis.

(3) Degree of droop: The greater the droop, the greater the shortening; the less the droop, the less the shortening.

(4) Elasticity of the levator palpebrae superioris muscle: If the levator palpebrae superioris muscle is found to have good or relatively good elasticity after cutting off the external and internal angles during surgery, it means that part of the ptosis is caused by the external and internal angles being too tight, which restricts the movement of the upper eyelid. In this case, the expected shortening can be reduced by 1 mm.

(5) The degree of correction required: People with progressive extraocular muscle paralysis are prone to exposure keratitis if their vision is corrected to the level of a normal person. For patients without Bell phenomenon or upper eyelid hysteresis, correction should also be conservative.

Generally, to correct 1mm of sagging, 4 to 6mm of shortening is required. For patients with congenital ptosis with a muscle strength of 4mm, it needs to be shortened by 20 to 24mm; for patients with a muscle strength of 5 to 7mm, it needs to be shortened by 14 to 18mm; for patients with a muscle strength of more than 8mm, it needs to be shortened by 10 to 12mm.

For senile ptosis, the shortening should not exceed 10mm, while for congenital ptosis it should not be less than 10mm.

Berke proposed that for congenital ptosis of one eye, the height of the upper eyelid corrected by surgery varies with different muscle strength.

The following describes transcutaneous shortening of the levator palpebrae superioris muscle.

This method exposes the anatomical landmarks clearly and the amount of shortening is easy to adjust. If eyelid notch, inversion or poor eyelid curvature is found during the operation, it is convenient to deal with. This surgical procedure is currently the most commonly used one.

2. Preoperative examination In addition to the routine systemic examination before surgery, local eye examination includes the following:

(1) Visual acuity (corrected visual acuity) and refraction: Although ptosis itself rarely causes amblyopia, it is often accompanied by an imbalance of the extraocular muscles or abnormal development of the eyeball, which may cause amblyopia. Therefore, visual acuity and refraction measurements should be performed on every cooperative child.

(2) Degree of ptosis: including measurement of palpebral fissure height, the amount of cornea covered by the upper eyelid, eyebrow-lid distance, and levator palpebrae superioris muscle strength.

① Measure the palpebral fissure: Use the thumb of one hand to press the patient's brow arch, and use the other hand to hold a ruler in front of the patient's eyes. Ask the patient to look forward, upward, and downward, measure the height of the palpebral fissure respectively, and compare the two sides.

②Measure the amount of cornea covered by the upper eyelid: avoid looking up or using the frontal muscle when measuring. When looking straight ahead normally, the upper eyelid margin covers 2mm of the upper cornea. If it covers 6mm, the amount of droop is 4mm. Based on the measurement results, ptosis is divided into three types: mild (1-2mm), moderate (3mm) and severe ptosis (4mm or more).

③Measure the eyebrow-lid distance: When looking straight ahead, the distance between the lower edge of the eyebrow and the upper eyelid edge is 18.09±1.95mm for normal people.

④Measure the levator palpebrae superioris muscle strength: ask the patient to look straight ahead, and the examiner uses the thumb to press the eyebrow arch horizontally backward to cut off the connection between the frontalis muscle and the upper eyelid. Ask the patient to look down as hard as possible. At this time, the zero point of the measuring tape should be level with the center of the upper eyelid margin. Then ask the patient to look up as hard as possible. The range of motion is the levator palpebrae superioris muscle strength. It includes the action of Müller's muscle and the action of the upper eyelid to move upward by 0 to 2 mm. In normal people, when the frontalis muscle is not used, the average range of upper eyelid movement, i.e., the range of activity of the levator palpebrae superioris muscle, is 13.37±2.55mm. The strength of the levator palpebrae superioris muscle is generally divided into three levels: the upper eyelid movement range is 8mm for good ones, 4-7mm for medium ones, and 0-3mm for weak ones.

(3) Function of the superior rectus muscle and other external eye muscles: Lift the upper eyelids of both eyes and let the patient move both eyes in different directions. Compare the two eyes with each other to observe the function of the external eye muscles and the superior rectus muscle. If there is paralysis of the superior rectus muscle or incomplete paralysis, so that the Bell phenomenon disappears, it is not advisable to correct ptosis first. The dysfunction of the superior rectus muscle or extraocular muscles should be treated first.

(4) Extraocular muscle balance measurement: Lift the upper eyelids of both eyes and move the eyeballs in various directions to observe whether they are coordinated and whether there is strabismus or diplopia.

(5) Ask the patient to do chewing exercises: to exclude Marcus Gunn phenomenon.

(6) Appearance of eyelids and palpebral fissures: The normal position of the upper eyelid fold is 2 to 3 mm away from the eyelid margin at the inner and outer canthi, and 3 to 4 mm away from the eyelid margin at the central part. Slightly lower in older people. During surgery, attention should be paid to the position of the upper eyelid fold and bilateral symmetry.

(7) Measurement of tarsal plate width: Especially in cases that have undergone surgery, the eyelid should be turned over to measure the height from the eyelid margin to the upper edge of the tarsal plate.

(8) Whether there is upper eyelid hysteresis: Upper eyelid hysteresis refers to the inability of the upper eyelid to move downward when the eyeball moves downward.

(9) Other examinations:

① Neostigmine test: exclude myasthenia gravis.

② Epinephrine and cocaine cotton pad test: If the palpebral fissure is wide and the test is positive, sympathetic ptosis can be ruled out.

③Corneal sensation test: check whether the cornea has other unhealthy conditions.

④Müller muscle function test: Use 10% phenylephrine to point the superior fornix, and the upper eyelid can be raised, indicating that the Müller muscle is functional.

(10) Take a frontal photograph of the face before surgery for reference during surgery.

Anesthesia and positioning

Surface anesthesia and local infiltration anesthesia. Additionally, frontal nerve block anesthesia was given.

Surgical procedures

1. Use methylene blue to draw the upper eyelid fold of the operated eye. The upper eyelid fold of the operated eye should be consistent with the curvature and distance from the eyelid margin of the upper eyelid fold of the contralateral healthy eye. If the contralateral healthy eye has no upper eyelid fold, an upper eyelid fold plasty should be performed simultaneously with the operated eye.

2. Make a traction suture at the junction of the middle and outer 1/3 and the middle and inner 1/3 of the eyelid margin using 1-0 sutures. The upper eyelid is everted to expose the superior fornix conjunctiva.

3. Inject 0.5 ml of 2% lidocaine under the conjunctiva of the fornix. On the one hand, it has an anesthetic effect, and on the other hand, it separates the Müller muscle from the fornix conjunctiva. The needle should be inserted shallowly during injection.

4. Make a 5 mm long longitudinal incision on the inner and outer conjunctiva of the fornix. Use blunt-tipped scissors to reach under the conjunctiva, separate the fornix conjunctiva from the Müller muscle, insert an elastic band, and pass through the inner conjunctival incision.

5. To reposition the eyelid, cut the skin and subcutaneous tissue deep into the tarsal plate at the line drawn with methylene blue on the skin (3 to 5 mm away from the eyelid margin), and use scissors to separate the orbicularis oculi muscle on the tarsal plate until the entire length of the tarsal plate and the levator palpebrae superioris aponeurosis attached to its front are exposed.

6. Cut the aponeurosis longitudinally above the upper edge of the tarsal plate near the lateral canthus.

7. Use muscle forceps to clamp the Müller muscle, levator palpebrae superioris aponeurosis and orbital septum, and lock the muscles.

8. Cut the orbital septum, levator palpebrae superioris aponeurosis and Müller muscle between the upper edge of the tarsal plate and the muscle forceps, and pull out the exposed elastic band.

9. Continue to separate upward in front of the aponeurosis and below the Müller muscle, cutting the external and internal corners.

10. Expose the Whitnall ligament by dissecting it upward in front of the aponeurosis and separate the aponeurosis from the ligament. Pull the muscle forceps downward to test the muscle elasticity. 2 mm above the levator palpebrae superioris muscle cutting line, make three sutures and tie them separately, and cut along the predetermined levator palpebrae superioris muscle cutting line with straight scissors.

11. Sew three levator palpebrae superioris mattress sutures (already ligated) to the tarsal plate respectively, tighten the sutures and tie a slipknot, observe the height and curvature of the upper eyelid and adjust them. When satisfied, ligate and fix the levator palpebrae superioris muscles to the tarsal plate.

12. Cut off a thin strip of orbicularis oculi muscle on the lower lip of the skin incision, and cut off a strip of excess skin on the upper lip of the incision.

13. All sutures used to suture the skin should pass through the tarsal plate to form an upper eyelid fold.

14. If the prolapse of the conjunctiva in the fornix is ​​obvious, use 3-0 silk thread to insert the needle through the fornix conjunctiva, pass through the upper eyelid skin, and make three pairs of mattress sutures. If the palpebral fissure is not completely closed, use No. 0 thread to make Frost sutures near the lower eyelid margin to close the palpebral fissure and fix the sutures to the forehead with tape. The conjunctival sac was coated with antibiotic ointment and bandaged unilaterally.

Points to note during surgery

1. When injecting anesthetic into the fornix, be careful not to inject it too deep to avoid injecting the anesthetic into the Müller muscle.

2. Before surgery, the amount of muscle to be removed should be estimated based on the patient's age, levator muscle strength, amount of ptosis, etc. During surgery, the thickness and elasticity of the levator muscle should be taken into consideration as the main basis for removal.

This operation is both a levator muscle resection and an advancement surgery.

1. Change the dressing daily and pay attention to the condition of the cornea.

The lower eyelid traction sutures were removed after 2.3 days.

Skin sutures were removed after 3.5 to 7 days.

Before any ptosis correction surgery is completed, the curvature of the eyelid margin and the degree of correction must be carefully checked. If it is found to be unsatisfactory, it must be adjusted immediately and patiently, such as the traction of each arm of the fascia strip, the suture position of the fascia or the levator palpebrae superioris muscle or the frontalis muscle on the tarsal plate, etc., until the adjustment is satisfactory.

The following situations that occur after surgery should be treated separately.

1. Insufficient correction is often seen in patients with congenital ptosis with weak muscle strength and shortened levator palpebrae superioris muscles. As for frontalis suspension, insufficient correction may occur due to insufficient suspension height or fascial slippage. Fascial slippage is caused by excessive contraction of the orbicularis oculi muscle and is common in uncooperative children.

The key to preventing undercorrection is to perform a detailed examination before surgery and choose the appropriate surgery based on the examination results. Never use one surgical method to treat ptosis caused by different muscle strengths and different reasons.

If the levator palpebrae superioris muscle strength is above 5mm and insufficient correction occurs after levator palpebrae superioris muscle shortening, the levator palpebrae superioris muscle shortening can be performed via the skin route 3 to 6 months after the operation after the swelling subsides, but the transconjunctival route shortening should not be performed. If the muscle strength is below 5mm, the frontalis muscle should be transplanted to the tarsal plate or the frontalis muscle suspension should be performed instead.

If the correction is insufficient after frontalis muscle suspension surgery, the suspension surgery can be repeated or the frontalis muscle can be directly transplanted to the tarsal plate.

2. Overcorrection is common in senile ptosis due to shortening of the levator palpebrae superioris muscle, which is caused by excessive resection during surgery or excessive tightening of the fascia during frontalis muscle suspension surgery.

If the levator palpebrae superioris muscle is shortened and overcorrected within 2 weeks after surgery, you can massage the upper eyelid downward with your hands, or press down the upper eyelid with your hands after closing your eyes and then try to open your eyes. Repeating this training for 2 to 3 months is often effective. Alternatively, under local anesthesia, use No. 1 thread to make a mattress suture slightly above the upper eyelid margin to pull the upper eyelid downward, which can also be effective. If the overcorrection is very obvious, the incision needs to be reopened, the levator palpebrae superioris muscle is moved back to the upper edge of the tarsal plate and then sutured. If necessary, allogeneic sclera transplantation can be used to lengthen the levator palpebrae superioris muscle.

Overcorrection of frontalis muscle suspension surgery can also be corrected in the early stages using the above-mentioned massage method or suture traction method. In the late stage, it is necessary to re-incise the upper eyelid, remove the fascia fixation line, and adjust the traction force according to the height of the upper eyelid.

3. Lagophthalmos and exposure keratitis In mild lagophthalmos (incomplete palpebral fissure closure), as long as the Bell phenomenon exists and the underlying cornea is not exposed, corneal complications will not occur. If the lagophthalmos is obvious, or the superior rectus muscle is paralyzed or accompanied by inferior oblique muscle dysfunction, resulting in exposure of the lower cornea, causing corneal epithelial dryness, shedding, or even infiltration and ulceration, emergency surgery is required to correct the lagophthalmos. Generally, the symptoms of rabbit eyes after surgery will gradually improve over time. Patients with mild corneal complications need temporary traction sutures or other corrective surgery.

4. If conjunctival prolapse is found before the end of the surgery, use No. 0 silk thread to make three pairs of mattress sutures from the dome, pass through the upper eyelid skin and ligate it. If prolapse is found after surgery, part of the prolapsed conjunctiva needs to be cut off.

5. Entropion and trichiasis may occur after various ptosis correction surgeries, especially partial inversion of the inner eyelid margin, which is mostly due to the suture of the levator palpebrae superioris muscle to the lower 1/3 of the tarsal plate.

If inversion occurs after surgery, the incision must be reopened and the attachment position of the levator palpebrae superioris muscle or fascia on the tarsal plate must be adjusted.

6. Ectropion is less common. In mild cases, the edema can be repositioned on its own after it subsides; in severe cases, the incision should be reopened, the attachment position of the fascia or levator palpebrae superioris muscle on the tarsal plate should be adjusted, and the prolapsed conjunctiva should be treated at the same time.

7. If the asymmetry of the upper eyelid fold is not corrected enough, it will be treated as undercorrected. If the correction is satisfactory, wait about 3 months after the operation, then remove the original incision scar and part of the skin of the lower lip of the incision and re-suture it.

8. Angular deformity or poor curvature of the eyelid margin may occur after frontalis muscle suspension surgery. It is often caused by uneven traction of the arms of the fascia or improper suture position on the tarsal plate. Before the end of the operation, carefully check the curvature of the eyelid margin and correct it in time if it is not ideal.