1、Plastic and Reconstructive Surgery April 2014Volume 133,Number 42l To create a more physiologic（生理性的）（生理性的）eyelid opening in patients with severe blepharoptosis(睑下垂睑下垂),l the authors used lamina propria mucosa of conjunctiva（结膜的睑板固（结膜的睑板固有粘膜）有粘膜）,which continues to the check ligament of the superior
2、 fornix(上穹窿的上穹窿的check韧带韧带),l in addition to levator aponeurosis and Mllers muscle as a composite flap.l In patients with epicanthal folds（内眦赘皮）（内眦赘皮）with associated telecanthus（内眦间距过大）（内眦间距过大）,the authors also performed epicanthoplasty with medial canthal tendon shortening.Background341.Superior rec
3、tus muscle.2.Levator muscle.3.Conjoining of SRMwith levator muscle sheath.4.Tenons capsule.5.Suspensory ligament of superior fornix.6.Whitnalls ligament.7.Frontalismuscle.8.Brow fat pad.9.Orbital orbicularis.10.Arcus marginalis.11.Orbital septum.12.Preaponeurotic fat pad.13.Preseptal orbicularis.14.
4、Postorbicularis fascia.15.Levator aponeurosis.16.Superior conjunctival fornix.17.Mllers muscle.18.Conjunctiva.19.Superior tarsus.20.Pretarsal orbicularis.5腱膜前脂肪 Pre-aponeurotic fat眶隔前脂肪 Pre-septal fat睑板前脂肪 Pretarsal fat眼轮匝肌下脂肪 retro-orbicularis oculi fat(ROOF)sub-orbicularis oculi fat(SOOF)67Methods
5、l Fifty blepharoptosis patients(85 eyelids)with a degree of ptosis of greater than 4 mm underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva as a composite flap.l Twenty-one(42 percent)of those patients also underwent split V-W epicanthop
6、lasty and plication of the medial canthal tendon for epicanthal folds with associated telecanthus.l Degree of ptosis and levator function were measured preoperatively and postoperatively.8Resultsl Complete or near-complete correction of ptosis(degree of ptosis,4 mm)for this study.The 50 patients(85
7、eyelids)underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite flap.l Twenty-one of 50 patients(42 percent,42 eyelids)had epicanthal folds with associated telecanthus and therefore underwent epicanthoplasty and shortening of the m
8、edial canthal tendon.17Operative Techniquel The double eyelid incision line is marked on the upper eyelid 6 to 9 mm above the lid margin,depending on the personal preference of patients without double eyelids.l Modified V-W plasty is designed on the skin medial to the epicanthal folds of patients wi
9、th blepharoptosis and epicanthal folds with associated telecanthus.l Epicanthal folds with associated telecanthus are corrected before ptosis correction is performed.l The operation is usually performed with the patient under local anesthesia with intravenous or oral sedation.1819Correction of Sever
10、e Blepharoptosisl An incision is made along the double eyelid mark after subcutaneous infiltration with 1%lidocaine with 1:100,000 epinephrine.l Epinephrine is omitted during deeper injection to prevent stimulation of the Mllers muscle.l The upper anterior surface of the tarsal plate and the orbital
11、 septum are exposed after excision of pretarsal soft tissue.l The orbital septum is cut at its lowest part and the protruding orbital fat is partly excised to expose the levator aponeurosis.l Tetracaine（丁卡因）（丁卡因）eye drops are applied to the cornea（角膜）（角膜）,and corneal eye protectors are applied to th
12、e globe.20The levator aponeurosis,Mllers muscle,and lamina propria mucosa of conjunctiva are then detached carefully from the superior tarsal border and underlying conjunctival epithelium with sharp iris scissors with the help of these three traction sutures.Injection of pure lidocaine into the supe
13、rior portion of the tarsus facilitates the detachment of the Mllers muscle and the lamina from the superior tarsal border and the conjunctival epithelium by causing the tissues to balloon up slightly.In some cases,dark cornea is visible through the conjunctival epithelium.The detached levator aponeu
14、rosisMllers musclelamina propria mucosa composite flap is advanced onto the anterior surface of the tarsus.212223RESULTSl Fifty patients(85 eyelids)with ptosis greater than 4 mm were operated on(Table 1).Of these patients,38(76 percent)had congenital ptosis and 35(70 percent)had bilateral ptosis.Of
15、the 35 patients who had bilateral ptosis,eight exhibited eyelid asymmetry of more than 1 mm.l Patient ages ranged from 12 to 89 years(mean age,35.7 years).24The degree of ptosis among the 85 eyelids ranged from 4 to 8 mm.Seventy-seven eyelids(90.6 percent)had 4 to 5 mm of ptosis,and eight(9.4 percen
16、t)had more than 6 mm.Levator function among the 85 eyelids ranged from 7 to 2 mm.Fifty-five eyelids(64.7 percent)had fair levator function(7 to 5 mm).In primary cases,the advanced composite flap was resected at less than 5 mm(mean,3 mm).In revision cases caused by incomplete correction of ptosis,the
17、 composite flap was further advanced and resected by about 3 mm.25All patients were followed postoperatively for 6 months to 9 years(Table 2).Complete correction of ptosis(degree of ptosis,1 mm)was obtained in 54 eyelids(63.5 percent),and mild residual ptosis(degree of ptosis,2 mm)was seen in 22 eye
18、lids(25.9 percent).In the nine eyelids with moderate residual ptosis(degree of ptosis,3 mm),two patients(four eyelids)underwent autogenous fascia lata（自体阔筋膜）suspension to the frontalis muscle because of poor levator function.The remaining patients refused the procedure.26The most common complication
19、 was incomplete correction of ptosis.Reoperation was performed in 15 eyelids,with further advancement of the composite flap.In 41 eyelids(48 percent),lagophthalmos of 1 to 2 mm and mild lid lag were present for the first few months postoperatively but were seen to resolve after 6 months,except in th
20、ree patients who were lost to follow-up.Minor complications,such as chemosis(结膜水肿),ecchymosis（瘀斑）and corneal irritation（角膜刺激）,were well recovered by conservative treatments such as eye lubricants（润滑剂）.27Fig.4.A 49-year-old man presented with bilateral congenital blepharoptosis.(Above,left)Preoperati
21、ve straight-ahead gaze.(Above,right)One-year postoperative results after advancement of the composite flap.(Below)Closure of eyes.2829Fig.6.A 26-year-old man presented with bilateral congenital blepharoptosis and epicanthal folds associated with moderate telecanthus.(Above,left)Preoperative straight
22、-ahead gaze.(Above,right)Two-year postoperative(Below,left)Upward gaze.(Below,right)Downward gaze.30DISCUSSION31We have been interested in the advancement technique of using the levator aponeurosisMllers muscle composite as a flap in the correctionof blepharoptosis,and have reported the results.We f
23、ound that eyelid elevation was still deficient for using this technique in patients with severe ptosis.After gaining a further understanding of the deeper connection between the lamina propria mucosa of conjunctiva and the check ligament of the superior fornix,we incorporated the lamina into the com
24、posite flap。We postulated that simultaneous advancement of the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite as a flap produces stronger power to correct severe ptosis.32The levator aponeurosis is connected superiorly to the levator palpebrae superioris muscle（提上睑肌）a
25、nd the Whitnalls ligament,and has firm osseous insertion at the medial and lateral horns.Advancement of the distal levator aponeurotic margin downward on the tarsal plate raises the tarsus dynamically by increasing levator function and statically by pulling on the elastic Whitnalls ligament and shor
26、tened levator aponeurosis itself.33Mllers muscle has normal function even in severe ptosis and has 2 to 3 mm of eyelid lifting power.Mllers muscle is an important terminal attachment of the levator muscle to the superior tarsal border,and shortening the Mllers muscle may augment its physiologic role
27、 by increasing the tensile strength of the muscle.34The lamina propria mucosa of the conjunctiva is continuous with the elastic check ligament of the superior fornix,and shortening the lamina propria mucosa pulls on the check ligament.Therefore,advancement of these three distinct anatomic structures
28、 simultaneously to the tarsal plate produces integrated power to raise the upper eyelid in a natural superior-posterior vector.35Patients with severe eyelid ptosis attempt to use three muscles to maximize eyelid opening.The initial attempt is by the primary component of eyelid elevationthe levator m
29、uscle（提上睑肌）.The next phase of eyelid opening that patients attempt involves use of the superior rectus muscle（上直肌）to look upward.The third phase is the use of the frontalis muscle（额肌）.36the check ligament is connected anteriorly to the levator palpebrae superioris muscle and posteriorly to the super
30、ior rectus muscle.pulling the check ligament pulls the levator palpebrae superioris muscle and the superior rectus muscle.37One can postulate假定 that the check ligament pulls the superior rectus muscle more directly since the connection between the check ligament and the levator palpebrae superioris
31、muscle allows some gliding motion,while the connection between the check ligament and the superior rectus muscle is relatively firm.38Another advantage of using the levator palpebraesuperioris muscle,Mllers muscle,and superior rectus muscle,compared with using just one muscle,is the reduced shorteni
32、ng of one particular muscle.Distributing the shortening to other eye elevating muscles and augmenting the physiologic component of eyelid elevation allows decreased eyelid shortening to gain the same lifting effect.In theory,this should induce less lagophthalmos and lid lag,as noticed in our results
33、.39In severe ptosis correction,there is an increased chance of postoperative double eyelid asymmetry,since a significant change in the positioning of the levator aponeurosis is made during ptosis correction.These patients often need revisional surgery for fold asymmetry.In extreme cases of severe pt
34、osis with very poor levator function,we recommend the frontalis sling method.For our technique to be effective,we believe that some levator function should exist.40CONCLUSIONS41The technique of advancement of the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite as a fla
35、p was effective in the treatment of severe ptosis with preexisting levator function of greater than 2 mm.In patients with epicanthal folds with associated telecanthus,epicanthoplasty and medial canthal tendon shortening enlarged the palpebral fissure opening and eliminated the constricting factors that hinder upper eyelid elevation.Our technique produced physiological eyelid excursion in a superior-posterior direction.The amount of resected advanced composite tissue stump was less than 5 mm,and there were no serious complications,such as long-term lagophthalmos or lid lag.4243Thank you!44谢谢
