Levator aponeurosis sandwich flap for reconstruction of upper eyelid defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.     

Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft

Purpose: To review and present the results of a one-step method employing a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft for reconstruction of large upper eyelid defects after tumour surgery.Methods: This was a retrospective case-series of 8 patients who underwent reconstruction of the upper eyelid after tumour removal. The horizontal defect involved 50–75% of the lid (3 pts.), more than 75% (3 pts.), and more than 75% plus the lateral canthus (2 pts.). The posterior lamella was reconstructed with contralateral upper eyelid tarsal plate. The anterior lamella was reconstructed with a laterally based myocutaneous pedicle flap in 7 patients, leaving a raw surface under the brow which was covered with a free skin graft. In 1 patient with little skin left under the brow, the anterior lamella was reconstructed with a bi-pedicle orbicularis muscle flap together with a free skin graft.Results: All patients healed without necrosis, did not suffer from lagophthalmos, achieved reasonable cosmesis, and did not need lubricants. In one patient, a contact lens was necessary for three weeks because of corneal erosion. One patient still needs a contact lens 3 months after excision to avoid eye discomfort.Conclusion: Large upper eyelid defects can be reconstructed with a free tarsal plate graft and a laterally based myocutaneous pedicle flap in combination with a free skin graft. Two-step procedures can probably be avoided in most cases.     

Unilateral eyelid lag and retraction as sequelae of trachoma

A 42-year-old woman had a large right palpebral fissure 13 mm high with 0.5 mm of scleral show both superiorly and inferiorly due to upper and lower eyelid retraction. The upper eyelid showed eyelid lag behind the globe only during the initial ocular movement. Superior tarsal height measured 7.5 mm with palpebral conjunctival cicatrization and Arlt's line. Severe cases of trachoma may lead to contracture of the conjunctiva and deeper tissues including Müller muscle and the tarsal plate, which supports the insertion of the levator aponeurosis. Shortening of the posterior lamella and fornix contracture would explain eyelid retraction and failure of the upper eyelid to smoothly follow the globe on downgaze.     

Surgical method and results of levator aponeurosis transposition for Graves' eyelid retraction

Predictability of final eyelid height and contour following surgical correction of eyelid retraction remains problematic. We describe our surgical method and results with the distal levator aponeurosis transposition procedure for eyelid retraction. The procedure consists of disinserting the distal levator aponeurosis from the tarsal plate and excising Muller's muscle. The lateral three-fifths of the distal aponeurosis is fashioned into a flap that is disinserted laterally, rotated inferiorly 90 degrees, and attached to the tarsal plate. Distal levator transposition is useful in the management of dysthyroid retraction and in the reduction of the margin reflex distance (MRD) asymmetry between upper eyelids. However, it shares with other eyelid lowering procedures, the disadvantage of poor predictability of final MRD.     

Severe congenital horizontal tarsal kink without levator aponeurosis disinsertion

A newborn presented with congenital severe tarsal kink of the upper eyelids not caused by levator aponeurosis disinsertion. A bilateral anterior lamellar repositioning procedure was performed to correct the tarsal kink. Levator aponeurosis disinsertion was not observed as an intraoperative finding. The tarsal kink disappeared, and eyelid positions remained stable during a follow-up period of 1 year. Our case indicates that severe congenital tarsal kink may develop without levator aponeurosis disinsertion, and anterior lamellar repositioning technique is a simple and effective method of treatment.     

Vertical tarsal buckling as a complication of levator aponeurosis repair for acquired blepharoptosis

In two patients (a 60-year-old man and a 69-year-old woman) vertical buckling of the superior tarsus followed surgery to correct levator aponeurosis disinsertions for the management of acquired upper eyelid blepharoptosis. The superior tarsus rotated posteriorly and folded on itself because the sutures reattaching the levator aponeurosis to the tarsus were placed too low on the anterior tarsal plate. This complication can be prevented by placing the tarsal sutures above the vertical midpoint of the tarsus. If this complication develops, early correction is possible by revising the suture heights and keeping the tarsus flat with a symblepharon ring. This led to a satisfactory outcome in one of our cases. Late correction of vertical tarsal buckling requires excision of the buckled tarsus and repositioning the levator aponeurosis sutures. In one of our patients, an entropion developed as a result of insufficient vertical tarsal height that caused instability of the upper eyelid. The outcome was otherwise satisfactory.     

The levator aponeurosis consists of two layers that include smooth muscle

PURPOSE: To investigate the two-fold structure of the levator aponeurosis, which is partly composed of independent smooth muscles. MATERIALS AND METHODS: Fifteen upper eyelids of 12 Asian postmortems, with age at death ranging from 72 to 91 years, were examined. In 9 eyelids, posterior lamella tissue of the upper eyelid was removed to observe the stratified structures of the levator aponeurosis. Six full-thickness eyelids were used to observe the attachment site or the continuity between the levator aponeurosis and its surrounding tissues. The eyelids were incised perpendicularly in the center of the eyelid; samples were stained with Masson trichrome and antismooth muscle actin antibody and examined microscopically. RESULTS: Masson trichrome staining demonstrated the two-layered nature of the levator aponeurosis. The anterior layer was characterized by thick, robust fibrous tissue, and the posterior by thinner fibrous tissue. Although both layers contained muscle structures, the posterior layer contained more than the anterior. Immunostaining with antismooth muscle actin antibody revealed that the muscle in both layers was smooth muscle. The anterior layer continued to the orbital septum and the submuscular fibroadipose tissue; the posterior layers, located in front of Müller muscle and its tendon, attached to the anterior inferior one-third of the tarsus. Part of the anterior layer went through the orbicularis oculi muscle and attached to the subcuticular tissue. CONCLUSIONS: The levator aponeurosis is stratified, consisting of two layers than contain smooth muscle components in their proximal portions. It pulls mainly the preaponeurotic fat and anterior eyelid lamella. This partially regulates the tension of the eyelid and contributes to the ordered movement of the upper eyelid.     

The levator aponeurosis consists of two layers that include smooth muscle

PURPOSE: To investigate the two-fold structure of the levator aponeurosis, which is partly composed of independent smooth muscles. MATERIALS AND METHODS: Fifteen upper eyelids of 12 Asian postmortems, with age at death ranging from 72 to 91 years, were examined. In 9 eyelids, posterior lamella tissue of the upper eyelid was removed to observe the stratified structures of the levator aponeurosis. Six full-thickness eyelids were used to observe the attachment site or the continuity between the levator aponeurosis and its surrounding tissues. The eyelids were incised perpendicularly in the center of the eyelid; samples were stained with Masson trichrome and antismooth muscle actin antibody and examined microscopically. RESULTS: Masson trichrome staining demonstrated the two-layered nature of the levator aponeurosis. The anterior layer was characterized by thick, robust fibrous tissue, and the posterior by thinner fibrous tissue. Although both layers contained muscle structures, the posterior layer contained more than the anterior. Immunostaining with antismooth muscle actin antibody revealed that the muscle in both layers was smooth muscle. The anterior layer continued to the orbital septum and the submuscular fibroadipose tissue; the posterior layers, located in front of Müller muscle and its tendon, attached to the anterior inferior one-third of the tarsus. Part of the anterior layer went through the orbicularis oculi muscle and attached to the subcuticular tissue. CONCLUSIONS: The levator aponeurosis is stratified, consisting of two layers than contain smooth muscle components in their proximal portions. It pulls mainly the preaponeurotic fat and anterior eyelid lamella. This partially regulates the tension of the eyelid and contributes to the ordered movement of the upper eyelid.     

Insertion of the levator aponeurosis and Müller's muscle on the tarsus: a cadaveric study in caucasians

Purpose: To elucidate the insertion of the levator aponeurosis and Müller's muscle on the upper eyelid of Caucasians through cadaveric study. Methods: Sagittal full thickness sections of 11 cadaveric upper eyelids in Caucasian (7 right and 4 left; age range, 78–101 years old at death; age average, 87.7 years old) were prepared and stained with Masson's trichrome. The specimens were examined microscopically to discern the configuration of the levator aponeurosis, Müller's muscle and tarsus. Main outcome measures were the position of insertion of the levator aponeurosis and Müller's muscle onto tarsus. Results: In all 11 specimens, the levator aponeurosis inserted onto the distal tarsal plate, reaching the level of the marginal arterial arcade. The extension of Müller's muscle in 4/11 specimens (36.4%) surpassed the superior margin of the tarsal plates, but did not reach any further down the tarsus than its upper third; in the remaining seven specimens (63.6%), Müller's muscle attached to the superior aspect of the tarsal plate. Conclusions: This study from Caucasian cadavers suggests that fibres from the levator apponeurosis extends down to the distal portion of upper eyelid tarsus, with majority of Müller's muscle insertion being onto the superior aspect of the tarsal plate.     

Free tarsal graft combined with skin transposition flap for full-thickness lower eyelid reconstruction

We present the surgical outcome in a series of 4 patients with large full-thickness eyelid defects after basal cell carcinoma excision. The patients underwent reconstructive eyelid surgery using autogenous free tarsal grafts combined with a skin transposition flap from the upper eyelid. Two female and 2 male patients ranging in age from 44 years to 85 years were treated. In all 4 cases, posterior lamellae were reconstructed using a free tarsal graft, and the outer lamella was developed with a transposition skin flap from the upper eyelid. The skin flap provided adequate vascular support in all cases. Follow up of 10 months to 20 months showed a good outcome in all patients. Reconstruction of full thickness eyelid defects after extensive tumor excision requires reforming of the anterior and posterior lamella. Whereas the Hughes or Cutler Beard techniques for eyelid reconstruction require a 2-step approach with occlusion of the eye for at least 1 week, reconstruction with a free tarsal graft is a 1-stage procedure and does not entail eye occlusion. Autogenous tarsus as a free graft proves to be a simple procedure for posterior lamella substitution in lower eyelid surgery, especially in combination with a skin transposition flap from the upper eyelid.     

Modified tarsal resection operation for congenital ptosis with fair levator function

PURPOSE: There are many options for surgical repair of congenital ptosis with fair levator function. The authors review their 10-year experience with an en bloc resection of tarsus, Müller muscle, and conjunctiva in conjunction with graded levator aponeurosis advancement (a variation of the tarsectomy operation). METHODS: This is a retrospective case series that reviews all cases of ptosis repair performed at West Virginia University from 1994 to 2004 using the "modified tarsal resection method." Thirty patients with congenital ptosis and fair levator function were identified. Follow-up ranged from 6 weeks to 8 years. Charts were reviewed for type of ptosis, pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications. RESULTS: In patients with congenital ptosis and fair levator function, the average preoperative upper eyelid margin to reflex distance was 0.0 mm and the average postoperative upper eyelid margin to reflex distance was 2.8 mm. Twenty-five of 30 (83%) patients were deemed to have a "good" surgical outcome. The amount of tarsus-Müller muscle resection reliably predicts the amount of eyelid elevation. The only complications to date have been transient lagophthalmos with exposure keratitis. CONCLUSIONS: In the authors' hands, an en bloc resection of tarsus, Müller muscle, and conjunctiva combined with levator aponeurosis advancement reliably produces excellent results in the treatment of fair levator function congenital ptosis, superior to their previous experience with isolated maximal levator aponeurosis advancement.     

Transplantation of Eyebank Sclera in the Cutler — Beard Method of Upper Eyelid Reconstruction

A modification of the Cutler-Beard, or bridge flap, technique for upper eyelid reconstruction using donor sclera for tarsal replacement was performed in 26 patients with follow-up ranging from eight months to nine years. Because the flap advanced from the lower lid normally contains little or no tarsus, donor sclera is inserted between the conjunctiva-lower lid retractor and the skin-muscle layers and is fixed medially and laterally to the tarsal remnants and to the levator aponeurosis superiorly in order to provide substance and stability to the upper lid. Use of donor sclera for tarsal replacement has provided a more normal appearance and greater stability to the reconstructed upper lid. No infection, shrinkage, or rejection has occurred.     

A contribution to the histological and topographical anatomy of the aponeurosis of the levator palpebrae superioris and of the tarsal muscle in the normal lid and in blepharoptosis

Eight normal upper lids were examinated histologically with special regard to the aponeurosis of the levator and of the tarsal muscle (Müller's). The aponeurosis originates from the levator muscle within the orbit (behind the septum orbitale) and inserts at the upper anterior surface of the tarsal plate. The tarsal muscle originates from the levator muscle and inserts at the upper tarsal border. It is a smooth muscle containing many small blood vessels. Fifty-six specimens of tissue resected in operations for blepharoptosis were examined histologically. They consist of parts of the tarsal muscle and of the aponeurosis of the levator and of fat tissue without pathological changes.     

Lower eyelid full-thickness vertical lengthening.

Two cases of lower eyelid retraction caused by loss of full-thickness eyelid components were successfully treated with a tarsal-confunctival flap and skin graft procedure. One patient also had upper eyelid retraction, which was decreased by excising Müller's muscle and recessing the levator aponeurosis simultaneously with the lower eyelid surgery.     

Eyelid suspension with a transposed levator palpebrae superioris muscle

In patients with severe Marcus Gunn jaw-winking, ablation of the synkinetic eyelid movement requires surgical removal of a significant portion of the levator complex (muscle and aponeurosis). As an alternative to removing this tissue completely, the levator muscle can be transected approximately 25 mm above its tarsal plate insertion. The distal levator muscle and aponeurosis can then be used as a suspensory material to suspend the eyelid to the eyebrow.     

Ultrasound biomicroscopy of the levator aponeurosis in congenital and aponeurotic blepharoptosis

PURPOSE: To evaluate and measure the thickness of the levator aponeurosis by ultrasound biomicroscopy in congenital dysmyogenic and aponeurotic blepharoptosis. METHODS: Forty-four upper eyelids of 22 patients who had unilateral blepharoptosis were evaluated by ultrasound biomicroscopy. The patients ranged in age from 13 to 69 years (mean, 35.4 +/- 20.2 years). Fourteen patients were male and 8 patients were female. Seven patients had congenital dysmyogenic blepharoptosis and 15 patients had aponeurotic blepharoptosis. Imaging was performed with a 50-MHz transducer. The thickness of the levator aponeurosis was measured centrally at the upper border of the tarsus. RESULTS: The levator aponeurosis was imaged in all eyelids except for one eyelid with aponeurotic blepharoptosis. The mean thickness of the levator aponeurosis was 0.39 +/- 0.10 mm in the ptotic eyelid and 0.42 +/- 0.09 mm in the control eyelid of the patients with congenital dysmyogenic blepharoptosis (p = 0.043). The mean thickness of the levator aponeurosis was 0.26 +/- 0.05 mm in the ptotic eyelid and 0.36 +/- 0.04 mm in the control eyelid of the patients with aponeurotic blepharoptosis (p = 0.001). The thickness of the levator aponeurosis was correlated with the palpebral fissure height (p = 0.013, r = 0.644) in aponeurotic blepharoptosis. The thickness of the levator aponeurosis was correlated with the levator function (p = 0.033, r = 0.795) in congenital dysmyogenic blepharoptosis. CONCLUSIONS: The thickness of the levator aponeurosis can be measured with ultrasound biomicroscopy. The most common pathology in aponeurotic blepharoptosis is thinned-out aponeurosis. The levator aponeurosis of the ptotic eyelid is thinner than the normal eyelid in congenital ptosis.     

Levator aponeurosis disinsertion in congenital entropion of the upper eyelid.

PURPOSE: To present a patient with congenital entropion of the upper eyelid caused by levator aponeurosis disinsertion. METHODS: Case report. RESULTS: Surgical correction of the levator aponeurosis disinsertion corrected the upper eyelid entropion. CONCLUSIONS: Congenital upper eyelid entropion may be caused by levator aponeurosis disinsertion and treated effectively by repairing the anatomic defect.     

Internal vertical shortening for the correction of diffuse or segmental postoperative blepharoptosis

In a series of 18 patients operated on because of postoperative eyelid contour abnormalities or small to moderate amounts of diffuse blepharoptosis, a technique of internal vertical shortening produced consistently reliable results. A cosmetically acceptable result was achieved in 17 of 18 patients (95%); only one of 18 (5%) showed no improvement. In cases of overcorrected upper eyelid retraction secondary to thyroid ophthalmopathy, 11 of 11 patients had cosmetically acceptable results. In those with blepharoptosis or eyelid contour abnormalities secondary to other causes, six of seven patients (84%) had cosmetically acceptable results. In our technique of internal vertical shortening, a predetermined amount of conjunctiva and overlying scar tissue or levator aponeurosis is removed. The resection uses a posterior approach to remove tissue from the superior tarsal border upward.     

Ultrasound biomicroscopy of the upper eyelid structures in normal eyelids

PURPOSE: To evaluate the normal upper eyelid structures quantitatively and qualitatively using ultrasound biomicroscopy (UBM). METHODS: Sixteen upper eyelids of 16 healthy subjects with no eyelid problems were evaluated with UBM. The orbicularis oculi muscle, levator aponeurosis, Müller muscle-conjunctival complex, and tarsus were imaged centrally just above the tarsus, and the tarsus was imaged just above the eyelid margin. The thickness of these structures was measured primary gaze. The measurements of levator aponeurosis and Müller muscle-conjunctival complex were repeated in upgaze. RESULTS: Of 16 patients, 8 were men and 8 were women. Eight were more than 40 years old and eight were younger. Orbicularis oculi muscle and Müller muscle-conjunctival complex were echo-dense, while levator aponeurosis and tarsus were echo-lucent. The mean thickness was 0.74 +/- 0.11 mm for orbicularis oculi muscle, 0.44 +/- 0.67 mm for levator aponeurosis, 0.91 +/- 0.15 mm for tarsus, and 0.38 +/- 0.64 mm for Müller muscle-conjunctival complex. There was no significant difference in the thickness of these structures between the patients younger than 40 years old and older patients, or between male and female patients (p > 0.05). In upgaze, the increases in thickness of levator aponeurosis and Müller muscle-conjunctival complex were a mean of 53% and 32%, respectively. CONCLUSIONS: UBM is an easy, non-invasive test used to visualize normal eyelid structures. It can be used in the diagnosis and follow-up of eyelid problems. The normal upper eyelid structures showed no significant differences based on age or gender.     

Acquired ptosis secondary to vernal conjunctivitis in young adults

PURPOSE: To establish a relation between prolonged severe vernal conjunctivitis and upper eyelid ptosis. METHODS: The study consisted of 12 patients between the ages of 19 and 32 years with acquired ptosis who presented in our clinic between September 2001 and February 2005. Potential factors responsible for acquired ptosis were investigated in all patients, with specific attention to the history and severity of vernal conjunctivitis. RESULTS: We found vernal conjunctivitis to be the identifiable cause in 8 men and 4 women with acquired ptosis. There was neither contact lens usage nor trauma or ocular surgery history in their medical records. The blepharoptosis was caused by levator disinsertion and recession of the aponeurosis. The pathology improved in each case after reattachment of the aponeurosis to the superior tarsal border. CONCLUSIONS: These findings suggest that prolonged severe vernal conjunctivitis may induce a lower position of the upper eyelid and eventually lead to ptosis through levator disinsertion that is similar to involutional ptosis. We believe that chronic inflammation of the upper eyelid with giant papillary conjunctivitis and persistent rubbing of the eyelids may be responsible for the development of this pathology.