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.     

Aeolus Press awards first Orbit Medal to Gabe M. Bleeker Gabe

Congenital upper lid retraction is a rare anomaly in which one or both eyelids are abnormally elevated. Unilateral involvement in males is the most frequent presentation. An intrinsic disorder of the levator or Muller muscle is the most likely etiology, since neurological, systemic, or orbital abnormalities have not been described. The authors describe two cases of congenital upper lid retraction. The levator muscle from one patient and an age matched control were examined histologically and ultrastructurally. The lid retraction and control specimens demonstrated similar fiber diameters, similar amount of connective tissue between fascicles, and absence of inflammatory cells or intercellular edema. Electron microscopy of the lid retraction specimen showed small areas of Z-line streaming and myofibrillar disarray which were not demonstrated in the control specimen. The significance of these ultrastructural findings is unclear, since they have been reported in some healthy young subjects, as well as in several muscle disorders.     

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.     

Anatomy and surgery of the levator aponeurosis in senile ptosis

The authors performed an anatomical and histological study on eight eyelids to define the lower insertions of the levator muscle. Twenty-nine cases of senile ptosis are presented in which levator aponeurosis surgery was successful. All patients were operated under local anesthesia. The authors used an aponeurotic repair when an aponeurosis dehiscence was identified during surgery (12 cases). The preoperative clinical appearance of all of these patients was typical and suggested the presence of a defect in the aponeurosis. In the 17 other cases the authors used aponeurosis tucking. This technique is easy and rapid and can be performed on very old patients. Histological anomalies of the aponeurosis were found out from biopsies. There is an anatomical analogy between the upper and the lower lid, and equally between senile ptosis and senile entropion, characterized by laxity or disinsertion of the lower lid retractor. One patient with a disinsertion of the aponeurosis and of the lower lid retractor is presented.     

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.     

改良提上睑肌缩短术矫正上睑下垂

目的:探讨改良提上睑肌缩短术矫正上睑下垂的效果。方法:保留提上睑肌腱膜与上睑的连接方式不变,采用提上睑肌腱膜复合瓣与缩短的提上睑肌腱膜吻合术矫正19例20眼上睑下垂。结果:术后4～10mo随访,治愈18例19眼,欠矫1例1眼,无过矫病例。结论:改良提上睑肌缩短术与常规手术比较有改进,术后的睑缘高度易保持在上方角膜缘,弧度与健侧对称自然,不易形成眼角畸形,能较好提高矫治效果。     

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.     

Accessory levator muscle slips of the levator palpebrae superioris muscle

Background:  Accessory levator muscle slips may be associated with congenital eyelid retraction or blepharoptosis. Nevertheless, congenital retraction of the upper eyelid is a poorly defined entity about which little is known. Because of the clinical importance of the accessory levator muscle slip of the levator palpebrae superioris muscle, this study aimed to describe the morphological appearance of this variation in human adult orbits.
Methods:  This study was undertaken in 60 orbits of 30 embalmed adult human cadavers, 17 men and 13 women, between the ages of 38 and 87 years at death. All cadavers were embalmed in 4% formalin solution.
Results:  Three accessory levator muscle slips of the levator palpebrae superioris muscle were identified. One of these arose laterally from the origin of the levator palpebrae superioris muscle. At its anterior end, it divided into two parts, the main superior and a smaller inferior accessory. The second had an accessory levator fibromuscular slip. It arose medially from the origin of the levator palpebrae superioris and lost its muscular character after a short course. The third arose from the origin of the levator palpebrae superioris as a thin flat muscle.
Conclusions:  Although many variations of the levator palpebrae superioris muscle have been reported in fetuses, investigation and demonstration of these may be more important in children and adults for ophthalmic surgery. We believe that detailed knowledge regarding the morphological appearance of an accessory levator muscle slip of the levator palpebrae superioris muscle may be useful for successful outcomes in ophthalmic surgery.     

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.     

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.     

Müllers MUSCLE-CONJUNCTIVAL RESECTION PTOSIS PROCEDURE

The Müllers muscle-conjunctival resection procedure is a relatively simple means of relieving upper eyelid ptosis. Candidates for the operation are chosen by placing several drops of 10% phenylephrine hydrochloride into the upper ocular fornix. If the upper lid elevates close to a norma! level after five minutes, the patient is selected for the operation. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and müllers muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and müllers muscle to the superior tarsal border, and then the tissues held in the clamp are resected.
The müllers muscle-conjunctival resection has advantages over the Fasanella procedure, because tarsus is preserved, and over the levator aponeurosis advancement and tuck procedures, because the results are much more predictable.     

先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

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.     

术中提上睑肌肌张力评估后单纯提上睑肌缩短术的临床疗效观察

目的 探讨根据术中对提上睑肌肌张力评估采取的单纯提上睑肌缩短术对儿童重症先天性上睑下垂的疗效方法 对169例(216只眼)重症先天性上睑下垂患儿,根据术中实际提上睑肌肌张力的评估,设计手术方式及手术量,其中143例(182只眼)行单纯提上睑肌缩短术,结果 169例(216只眼)术后6个月至2年随访,上睑缘位置均在瞳孔以...     

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.     

Advances in the diagnosis and treatment of ptosis

PURPOSE OF REVIEW: The surgical correction of blepharoptosis, both congenital and acquired, has been intensively examined and reported on for many years. This paper reviews recent publications on basic science, evaluation, technique modifications, and innovative materials in the care of ptosis patients. RECENT FINDINGS: The frontalis suspension technique is a commonly performed surgical correction of congenital blepharoptosis, used widely in the repair of ptosis with poor levator function. The repair typically includes using either tissue such as autologous or banked fascia lata or permanent suture material. The procedure involves connecting the motor unit (frontalis muscle) and the upper eyelid. Authors have recently reintroduced the technique of a dynamic frontalis muscle flap tunneled into the eyelid that directly attaches to the tarsal plate.Patients presenting with symptomatic blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. Multiple groups have tended toward a minimally invasive approach directed specifically at the levator aponeurotic defect. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results. SUMMARY: Surgical correction of congenital blepharoptosis may be performed with autologous fascia lata, cadaveric allograft, or permanent suture material. The use of a frontalis muscle advancement flap is elegantly designed; however, its role in clinical practice remains to be defined. Advancement of the levator aponeurosis for senile blepharoptosis may be preformed via a minimally invasive small incision approach. Patients benefit with decreased operative time, edema, ecchymosis, and recovery times.     

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.     

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.     

提上睑肌中央腱膜切断术治疗甲状腺相关眼病上睑退缩

目的：评估提上睑肌中央腱膜切断术矫正甲状腺相关眼病上睑退缩的临床疗效。方法：对35例52眼以上睑退缩为主要表现的静止期甲状腺相关眼病患者采用提上睑肌中央腱膜切断术矫正退缩的上睑,并观察其临床疗效。结果：术后所有患者上睑退缩均得以矫正,自觉症状不同程度减轻或消失。结论：提上睑肌中央腱膜切断术能有效矫正甲状腺相关眼病的中度上睑退缩。