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经皮上睑下垂手术：提肌腱膜和Müller肌前徙术（英）

2012-04-10 15:48阅读：

http://blog.sina.cn/dpool/blog/u/1253983307

Transcutaneous Blepharoptosis Surgery: Simultaneous Advancement of the Levator Aponeurosis and Müller’s Muscle (Levator Resection)
Kazunami Noma,1 Yasuhiro Takahashi,2 Igal Leibovitch,3 and Hirohiko Kakizaki*2
1Noma Eye Clinic, Kokutaiji, Naka-ku, Hiroshima 730-0042, Japan
2Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
3Division of Oculoplastic and Orbital Surgery, Department of Ophthalmology, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
*Address correspondence to this author at the Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi 480-1195, Japan; Tel: +81-561-62-3311; Fax: +81-561-63-7255; E-mail: cosme@d1.dion.ne.jp

Received April 15, 2010; Revised June 25, 2010; Accepted July 19, 2010.
This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
Abstract
Transcutaneous blepharoptosis surgery with simultaneous advancement of the levator aponeurosis and Müller’s muscle (levator resection) is a popular surgery which is considered effective for all types of blepharoptosis except for the myogenic type. Repair of ptosis cases with good levator function yields excellent results. A good outcome can be also obtained in cases with poor levator function, however, in such cases; a large degree of levator advancement may be required, which may result in postoperative dry eyes, unnatural eyelid curvature and astigmatism. These cases are therefore better treated with sling surgery. With the right patient selection, the levator resection technique is an effective method for ptosis repair.
Keywords: Transcutaneous blepharoptosis surgery, levator aponeurosis, Müller’s muscle, levator resection.
INTRODUCTION
Blepharoptosis surgery is one of the most popular operations in the field of ophthalmic plastic and reconstructive surgery. The specific surgical method for repairing blepharoptosis is selected according to the degree of eyelid droopiness and the preoperative levator function [1]. There are 3 categories of surgical approaches to blepharoptosis surgery; transcutaneous [2], transconjunctival [3] and sling surgery [4]. The transconjunctival approach is mainly used in cases of mild to moderate ptosis with a good response to the phenylephrine test [5]. The transcutaneous approach can be applied to all types of ptosis except for the myogenic type, in which sling surgery may be best suitable [6]. Ptosis cases with levator function of 4 mm or more are usually repaired by levator resection [1], whereas sling surgery is used in cases of levator function under 4 mm [7].
There are several techniques for blepharoptosis repair which are done through a transcutaneous incision; simultaneous advancement of the levator aponeurosis and Müller’s muscle (levator resection) [8], advancement of the aponeurosis only (lavatory advancement) [2] etc. The 2 transcutaneous techniques are widely performed, however, they are selected based on surgeons’ preferences and not based on the pathophysiology of ptosis or factors like levator function, degree of ptosis, or type of ptosis.
Müller’s muscle is believed to originate from the posterior surface of the levator palpebrae superioris (LPS) muscle [9]. More recently, modified anatomical findings regarding the origin of the levator aponeurosis and Müller’s muscle have been reported [10]. It was shown that the LPS muscle is divided into 2 branches in the periphery: the superior branch which continues to the levator aponeurosis, and the inferior branch from which Müller’s muscle originates. Although the thickness of each branch is almost identical, the superior branch tends to be thicker than the inferior branch.
Based on these new anatomical findings, the indications for ptosis surgery can theoretically be divided into the following categories:
  • Aponeurotic ptosis- requires aponeurosis advancement.
  • Cases of pathology in the Müller’s muscle (such as Horner’s syndrome) [9] - require Müller’s muscle advancement. However, as Müller’s muscle is structurally weak [11], simultaneous advancement of the levator aponeurosis is recommended.
  • Ptosis in hard contact lens user [12] (and in rare cases in soft contact lens user [13]) - as the pathology is not purely in the aponeurosis but rather in both the aponeurosis and Müller’s muscle [14], levator resection is recommended.
  • In cases of severe ptosis - levator resection or sling surgery should be performed. Although each procedure is effective irrespective of the associated pathology, comparative long term results have not been reported so far.

In this review, we present the levator resection technique and discuss the advantage and disadvantage.
THE SURGICAL TECHNIQUE
After marking a horizontal line along the upper skin crease extending to the lateral canthal commissure and about 6 to 7 mm from the upper eyelid margin, a local anesthetic solution (2 ml of 1% lidocaine with 1/100,000 epinephrine) is administered.
The skin is then incised with a number 15 blade. The subcutaneous tissue and the orbicularis oculi muscle are dissected with scissors, and the levator aponeurosis can then be visualized.
The levator aponeurosis is detached from the tarsal plate (Fig. ?11), and the levator complex, including Müller’s muscle and the levator aponeurosis, are continuously detached from the conjunctiva (Fig. ?22). Involutional change of the Müller’s muscle (thin appearance and/or fat infiltration, etc.) may be seen in some cases [15]. A negative phenylephrine test can be seen in patients with marked fatty infiltration [16].

 Fig. (1) (Upside down view: surgeon’s view) Detachment of the posterior layer of the levator aponeurosis from the tarsal plate.


Fig. (2) (Surgeon’s view) Detachment of Müller’s muscle from the conjunctiva.

The anterior aspect of the levator aponeurosis is also detached from the orbicularis oculi muscle, and the white line [17-19], which is the confluent part between the levator aponeurosis and the orbital septum, is confirmed (Fig. ?33). Of notice here is the 3-dimentional structure of the merging point between the levator aponeurosis and the orbital septum. When the orbital se

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