As we approach middle age, there is a natural tendency for the upper lids to droop due to the weakening of the levator muscle and aponeurosis. Many patients in this age group who present for cosmetic blepharoplasty would benefit from ptosis repair, even though the lids do not droop enough to cause an interference with vision. By lifting the lids a couple of millimeters, the eyes will have a more youthful appearance. In these patients, an "eye lift" should probably be a combination of skin and fat removal with levator advancement.
1) Line outlining the upper lid crease incision and the mark to orient the placement of the suture through the tarsus.
However, some patients have had a blepharoplasty or have minimal excess skin but a cosmetically unacceptable lid droop. For these patients, ptosis repair alone is enough to solve the problem.Using radio waves allows the surgeon to minimize bleeding while doing the dissection. This gives better visualization of the anatomy, thereby making the levator aponeurosis easier to find. Radiosurgery also causes minimal damage to surrounding structures. Not only does the surgeon benefit from a less difficult surgery, but also the patient heals more quickly and with less discomfort because of less bleeding and injury to surrounding tissues.
2) Double armed 6-0 silk is passed through the anterior tarsus about 3 mm below its border.
I draw lines to outline the blepharoplasty incisions or, if only ptosis repair is to be done, I draw a single line about 10 mm above the lash line. This is where the lid crease should be. With the patient sitting up, I also mark the area in the lid that is directly above the pupil in primary gaze. I use this mark for a guide in passing the 6-0 silk suture through the tarsus. (See Figure 1.)
Using the Ellman Dual Frequency Surgitron, I make my skin incision using the A-10 Needle on a Cut setting. This allows for a fine incision with minimal scarring. The skin muscle flap is removed with the Empire Needle on the Hemo setting to give better hemo-stasis. Fat can also be resected at this stage. If a blepharoplasty is not done, a 1 cm incision is made where the lid crease should be.
Ptosis repair is now begun. I continue dissection in order to expose the pre-aponeurotic fat, below which lies the whitish levator aponeurosis. It is usually 8 to 10 mm inferior to superior dimension. The] ]superior end blends with the levator muscle. In the older individual, this muscle may be very thin or filled with adipose tissue. Once the levator aponeurosis is exposed,I penetrate the orbicularis muscle about 1 cm above the lash line and look for the superior, anterior tarsus. I try to leave the superior vascular arcade intact and remove the ssue from the superior 3 mm of the tarsus.
3) Suture is tied in a loop over levator aponeurosis.
By having the patient sit up and open the eyes, and using the pre-placed mark, I can judge exactly where the top of the arch of the upper lid should be. It is very difficult to make this judgment with the patient lying down. I use one 6-0 silk suture with a fine needle, and pass one end of the double-armed suture through the tarsus in a line where the top of the arch should be. (See Figure 2.) This suture should not penetrate tarsal conjunctiva. I pass the two arms of the suture through the aponeurosis about 1 mm below the attachment with the levator muscle. I tie the suture in a loop and ask the patient to sit up. (See Figure 3.) I adjust the suture until the lid height is satisfactory. My end point is where the lid looks best. If the epinephrine in the anesthetic has raised the lid, that effect has to be considered.
4) Wound closure.
Once the lid height and curve are satisfactory, I secure the silk suture. I do not remove the excess advanced levator aponeurosis since it is incorporated in the skin closure. I use a running 7-0 Prolene suture that is passed through the advanced levator aponeurosis to create a lid crease. (See Figure 4.) I advise the patient to apply antibiotic ointment to the wound for one week.
5) Pre-op ptosis repair.
In my opinion, this technique has several advantages. Radiosurgery allows for less bleeding during the procedure. Hence, there is better visualization of the anatomy and less time spent controlling bleeding. With less bleeding, post-op bruising is diminished and healing is faster (see Figures 5 and 6) with less discomfort than there otherwise would be.
6) Ten days post-op ptosis repair (no skin removal).
Using a single suture takes less time than multiple sutures. Since 6-0 silk dissolves very slowly, there should be ample time for good scar formation to occur between the levator and the tarsus before the silk disappears. This technique has worked well for me for the past several years and in hundreds of cases.