|Year : 1990 | Volume
| Issue : 4 | Page : 175-177
Modified split level lid resection in ptosis
SM Bethria, ND Patil
Dr. Rajendra Prasad Centre for Opthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
S M Bethria
Dr. Rajendra Prasad Centre for Opthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
10 patients of congenital simple ptosis having 3 to 5 mm of ptosis with variable levator action were operated. All the patients showed a good response of lid lift after instillation of phenyl ephrine drops showing the activity of Muller's muscle. With this technique the lagophthalmos was minimal and good lid folds were formed in all cases. The skin muscle lamina was not excised and was utilized for formation of lid folds which were equal in depth and dynamic in nature. However, the lid lag which is an unavoidable complication of any ptosis surgery was present in the present technique also.
|How to cite this article:|
Bethria S M, Patil N D. Modified split level lid resection in ptosis. Indian J Ophthalmol 1990;38:175-7
| Introduction|| |
The importance of Muller's muscle is now known and emphasized in the management of ptosis. Though the levator muscle is dystrophic in congenital ptosis the activity of the Muller's muscle is well documented in such cases. Harvouet and Tessier  described a type of split level lid resection in which and tarsal plate, and the levator aponeurosis along with Muller's muscle was resected, Satisfactory results of Muller's muscle and conjunctival resection were reported in well documented series by Putterman.  The true importance of Muller's muscle preservation was highlighted by Mustarde  who strongly emphasized that it should not be damaged as it could lift the lid to a large extent when compared to levator excision length by length.
We are presenting a modified split level lid resection in which good results were obtained with minimum of lagophthalmos and good and stable lid fold formation.
| Material and methods|| |
10 cases of congenital simple ptosis were operated by the modified technique. A thorough pre-operative ptosis work up of cases was done. This included apart from measurement of ptosis and levator action, the function of the Muller's muscle after instillation of 10% phenyl ephrine drops in the upper fornix. The details of the cases are given in [Table - 1].
| Surgical steps|| |
The incision was placed at the proposed site of the lid fold initially marked with the marker. The skin and orbicularis lamina was dissected and the levator muscle was clearly exposed. The levator muscle was carefully dissected from the underlying Muller's muscle and conjunctiva which was facilitated by injection of 2% lignocaine subconjunctivaliy. The horns of the ilevator were cut avoiding the damage to the lacrimal gland and reflected part of the superior oblique tendon. The tarsal plate was then excised leaving 2mm's of the terminal lash bearing part.The levator was resected for about 16 to 18 mm instead of plication depending upon the amount of ptosis and levator action. The conjunctiva, Muller's muscle and the levator were sutured back on to the remaining part of the tarsal plate. The lid fold was then formed by taking the bites from the skin-orbicularis lamina and the levator. The skin muscle lamina got infolded in the lid fold to give rise to formation of good lid fold.
| Results|| |
The details of the results are given in [Table - 2]. We found that the results were cosmetically very satisfactory specially in primary gaze. There was a minimal lagophthalmos of about 1 to 2 mm. The lid lag which was marked during early postoperative period became less at subsequent follow up. This technique gave uniformally good results in moderate as well as severe cases of congenital ptosis.
| Discussion|| |
The levator muscle is thin and dystrophic in most of the cases of congenital ptosis whereas the Muller's muscle is found to be normal. sub However,the action of Muller's muscle can be demonstrated in most of the cases of congenital ptosis by instillation of phenyl ephrine drops.  Therefore, more and more attention is really called for in assessment of Muller's muscle action and preserving it in any form of ptosis surgery. Muller's muscle is sacrificed in most of the operations for ptosis. ,,,, Also it is a common and honest observation that in severe degrees of ptosis the levator surgery even after supramaximal resection does not produce adequate results. Another unavoidable problem of any form of ptosis surgery is lagophthalmos.  The idea of split level lid resection which was popularised by Mustarde emphasized on subtotal tarsal resection, levator muscle plication, preservation of Muller's muscle along with excision of the skin and orbicularis lamina. In the present series of this modified technique of 10 cases of congenital simple ptosis, we observed undercorrection in 2 cases only. The lagophthalmos was minimal in 8 cases while in 2 cases it was 2 to 3mm during the early postoperative follow up. However, the main problem was that of lid lag which was remarkable during the early postoperative period. This was noticed in almost all the cases and was found to be reduced during the late postoperative follow up ranging from 6 months to 18 months. The lid fold was found to be symmetrical in depth and position and was of a dynamic nature. [Figure - 1][Figure - 2][Figure - 3][Figure - 4][Figure - 5]We have not observed drooping down of the lid fold as was seen in the original technique of Mustarde. [Figure - 1]
Instead of plication of the levator we have done resection as plicating the muscle made the lid more bulky and there was a bogginess felt in the lid. The levator resection did not damage the nerve supply of Muller's muscle as was proved earlier in an experimental study by Collins et al. 
The skin muscle lamina was not excised and instead a good lid fold which was symmetrical in depth and position was formed by utilizing this skin muscle lamina. While forming the lid fold care was taken to ensure that no entropion resulted on the table at the end of the operation. This modified technique works well in moderate to severe degrees of ptosis with moderate to poor levator function.
| References|| |
Harvouet, F. Tessier, P. Nouvelle technique operative anptosis. Bull. Mem.Sec. Fr. Ophthalmol. 69:239-242, 1956.
Mc Cord, C.D. Jr. An external minimal ptosis procedure - external tersoaponeurectomy. Trans. Am. Acad. Ophthalmol. and Otolaryngol. 79:683-686, 1975.
Putterman, A.M., Fett, D.R. Muller's muscle in the treatment of upper eyelid ptosis. A ten year study. Ophthalmic Surg. 7:354-360, 1986.
Mustarde. J.C. Problems and possibilities in ptosis surgery. Plast. Reconstruc. Surg. 56:381-388, 1975.
Berke. R.N. and Wadsworth. J.A.C. Histology of Levator muscle in congenital and acquired ptosis, Arch. Ophthalmol, 53:413- 428. 1955
Mustarde. J.C. Ptosis, In: Repair and reconstruction in the orbital region. Churchill Livingston. 302-311. 1980.
Fasanella, R.M., Servat, J. Levator resection for minimal ptosis : Another simplified operation. Arch. Ophthalmol. 65:493-496, 1961.
Beard, C. Ptosis. 3rd edi. St. Louis, C.V. Mosby, 154-157. 1981
Fox, S.A. Ptosis: In: Ophthalmic plastic surgery, edi. 5th Grune and Straton. 350-418, 1976.
Betharia, S.M., Grover, A.K. and Kalra, B.R. Fasanella-Servat operation a modified simple technique with quantitative approach. Brit. J. Ophthalmol. 67:58-60, 1983.
Collins, J.R.O.. Beard, C., Wood I. Terminal course of nerve supply to Mullers muscle in the Rhesus monkey and its clinical significance, Am. J. Ophthal. 87:234-246, 1979.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2]