Abstract

Objectives: Motivation of a superior, external access (“open sky exposure”) to correct upper eyelid ptosis. Outlining the importance of pretarsal wrinkle definition and eyelid skin invagination. Rationale for minimal interference with the medial or lateral horns of the levator aponeurosis, Müller’s muscle or the striated part of the levator. Avoidance of tethering by the orbital septum. Pursuing a natural curve of the eyelid border by using five resorbable sutures to attach the levator aponeurosis to the tarsus. Demonstration with representative pictures and film fragments. Introduction: The objective of upper eyelid ptosis correction generally has both a functional and an aesthetic objective. The choice between a transconjunctival and an external access is important, the latter being associated with more temporary side-effects but giving more control of the pretarsal wrinkle. The decision how much aponeurosis length is bypassed, when it is fastened to the tarsus, is delicate and pivotal. The time-proven single, non-resorbable, central stitch often leaves a less aesthetic tent shape of the eyelid border. Materials / method: Demonstration with representative pictures and film fragments. The levator palpebrae muscle belly is first identified through the upper incision line. The tarsus is exposed through the lower incision. The upper part of the levator aponeurosis is spared to a chosen length, while the rest of the tissue between the incisions is removed. The shortened levator aponeurosis is stitched to the tarsus with five poliglecaprone 6/0 sutures. The amount of bypassing depends on the cause of the ptosis as diagnosed during the surgery. The skin ends are connected to the deep suture line on closing. Results: Proper levator muscle exposure, without tissue staining by blood, is best achieved from the superior incision line. Intraoperative finding of muscle steatosis versus aponeurosis rarefaction may lead to a different treatment. A natural curve of the eyelid border can better be achieved with five sutures between the aponeurosis and the tarsus than with one single, central stitch. Muscle steatosis, may require more levator shortening on the most affected side. A symmetric restoration is often more adequate to treat levator rarefaction or dehiscence. Conclusion: The external approach provides control over the pretarsal wrinkle and skin crease, contrary to transconjunctival ptosis correction. However, the morbidity (stiffness, light irritation of the eye, prolonged oedema) is markedly higher than in conventional blepharoplasty or in transconjunctival ptosis repair. The amount of aponeurosis shortening depends on intraoperative findings. Five levator to tarsus stitches lead to a more aesthetic eyelid border curve than one, central stitch. Suturing both skin ends directly to the deep suture line can unequivocally redefine the pretarsal wrinkle.