Levator Recession

Abstract

Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Indications

Upper eyelid retraction is the most common ophthalmic sign of thyroid eye disease. Levator recession is generally performed after the patient has already had an orbital decompression and strabismus surgery, if indicated. Although not an exhaustive list, other, less common causes of upper lid retraction include postsurgical (levator advancement/resection surgery, blepharoplasty), pseudoretraction (response due to contralateral ptosis), progressive supranuclear palsy, Parkinson’s diseases, Parinaud syndrome, aberrant regeneration of oculomotor nerve, and cranial nerve VII palsy. Mild cases of retraction can sometimes be observed and treated medically with ocular lubrication. However, if evidence of exposure keratopathy develops, surgery is generally recommended. Levator recession surgery can be performed from an internal or an external approach, with or without a spacer graft, and with or without hang-back sutures. The hang-back sutures are left untied so that the levator muscle can be easily tightened postoperatively if there is significant overcorrection (ptosis). We will discuss the external approach with and without hang-back sutures.

Essential Steps

• 1. Incision marking followed by injection of local anesthetic

• 2. Placement of a protective corneal shield

• 3. Incise the skin

• 4. Dissect through the orbicularis muscle and orbital septum

• 5. Identify the levator aponeurosis underneath the central fat pad

• 6. Perform a stepwise disinsertion of the levator muscle–Müller’s muscle complex from the superior edge of the tarsal plate, starting temporally

• 7. Dissect the levator and Müllers muscle away from the underlying conjunctiva

• 8. Check the height and contour of the eyelid

• 9. If full thickness eyelid recession is performed, carefully incise the conjunctiva similarly to the levator–Müller’s muscle complex

• 10. If hang-back sutures are used, three 6-0 Prolene sutures are passed in a reverse horizontal mattress fashion through the levator muscle and left untied, externalized through the skin incision

• 11. Close incision with running or interrupted sutures

• 12. Removal of the corneal shield

Complications

• Persistent lagophthalmos

• Infection

• Hemorrhage

• Scarring

• Wound dehiscence

• Overcorrection (eyelid retraction)

• Undercorrection (residual ptosis)

• Asymmetric eyelid contour

Template Operative Dictation

Preoperative diagnosis:

Upper eyelid retraction on the (right/left/bilateral)

Procedure:

Levator recession (right/left/both) eye(s)

Postoperative diagnosis:

Same

Indication:

This ____-year-old (race) (male/female) had developed (bilateral/unilateral) (exposure keratopathy/foreign body sensation/corneal ulceration) over the past ____ (months/years) and on clinical evaluation was found to have (bilateral/unilateral) upper eyelid retraction. A detailed review of risks and benefits of the procedure(s), as well as treatment alternatives, was discussed with the patient. Following this, the patient elected to undergo the procedure(s) and informed consent was obtained.

Description of the procedure:

The patient and operative site(s) were identified in the preoperative area, and the (right/left/both) eyelid incision(s) was (were) marked with a surgical marking pen. The patient was then taken to the operating room and placed supine on the operating room table. Monitored conscious sedation was administered by the (hospital/surgery center) anesthesia department. Topical anesthetic, proparacaine was placed into the (right/left) eye. The patient was then prepped and draped in the usual sterile fashion for oculofacial plastic surgery. A time out was performed verifying correct patient, procedure, site, positioning, and special equipment prior to starting the case. Local anesthetic consisting of ______ was injected into (right/left/both) upper eyelid(s). A corneal shield was placed in the (right/left/both) eye(s).

A caliper was used to measure a lid crease incision of ___ mm on the (right/left) upper eyelid. A #15 Bard-Parker blade was used to make an incision through the skin and orbicularis muscle. Wescott scissors and 0.3 forceps were used to dissect through the remaining orbicularis fibers until the orbital septum was identified. The septum was then opened revealing the underlying pre-aponeurotic fat pad and levator aponeurosis. Using Wescott scissors and beginning temporally, the levator aponeurosis and underlying Müller’s muscle were disinserted from the tarsal plate. The levator–Müller’s muscle complex was then carefully dissected away from the underlying conjunctiva. The corneal shield was then removed from the (right/left) eye. The height and contour of the eyelid was then checked by having the patient open and close (his/her) eyes. The corneal shield was replaced and the dissection was carried medially until the desired height and contour of the upper eyelid was achieved.

If full thickness eyelid recession was performed:

Despite near maximal recession of the levator and Müller’s muscle, there was still some residual retraction. The Wescott scissors were used to incise the conjunctiva at the level of the previous levator–Müller’s muscle recession. This incision was carried nasally until the desired height and contour of the eyelid was achieved.

If hang-back sutures were placed:

Once the levator aponeurosis was completely disinserted from the tarsal plate, 6-0 Prolene sutures were placed in a reverse horizontal mattress fashion through the levator muscle, partial thickness through the tarsal plate, and left untied with their tails pointing inferiorly and externalized through the skin incision. _ 3 _ of these sutures were passed along the horizontal length of the eyelid. The skin was then closed with interrupted 6-0 plain gut sutures. The free ends of the untied prolene hang-back sutures were secured to the eyelid with steri strips in order to avoid irritating the eyes.

If a bilateral levator recession was performed:

Attention was then turned to the opposite eye. A caliper was used to measure a lid crease incision of ___ mm on the (left/right) upper eyelid. The same exact dissection and procedure mentioned previously was applied in an identical manner. Special care was taken to ensure a symmetric appearance of both eyelids.

The corneal shield(s) was (were) then removed from the (right/left/both) eye(s). Antibiotic ophthalmic ointment was instilled into the (right/left/both) eye(s) and on all suture sites. The patient tolerated the procedure well and was then taken back to the recovery area in stable condition.