摘要

Objectives: Description of an operative technique with external access (“open sky exposure”) to correct eyelid ptosis as well as severe blepharochalasis with loss of pretarsal wrinkle definition. The classic, non-resorbable central stitch between the remnant of the levator aponeurosis and the tarsus is replaced by five resorbable sutures, with the objective of obtaining a more natural-looking aspect of the eyelid border. Direct supra brow skin excision as an ancillary procedure is also illustrated. Introduction: A minority of blepharoplasty candidates presents with poor definition of the pretarsal wrinkle. As the pretarsal skin slides downwards, it becomes a part of the blepharochalasis. If the corrective surgery does not restore some degree of skin invagination on eyelid opening, there is a risk of undercorrection after simple excision, or of lagophthalmos in case of overcompensation. It is not so uncommon for degenerative ptosis to be detected in patients requesting upper blepharoplasty. Few patients are aware of the negative influence of saggy eyebrows on upper eyelids. Materials / method: The retroseptal fat and the levator palpebrae muscle belly are identified through the upper blepharoplasty incision. The tarsus is clearly exposed through the lower incision. While the assistant exerts firm traction on the eyelid border, the upper, more consistently developed part of the levator aponeurosis can be visualised and 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. Supra brow skin is excised and the defect is sutured directly. Results: The correct, deep plane of dissection to expose the levator aponeurosis can be found easier from superiorly, beginning with the muscle belly, as opposed to the confusion between multiple layers inferiorly. A gentle eyelid border curve and appropriate eyelid opening can be reconstructed by using five sutures between the levator aponeurosis and the tarsus rather than one central stitch. The medial and lateral stitches of five easily cause some eyelid tethering or border deformation, important points of attention before closure. Direct supra brow excision is straightforward to plan. 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. Suturing both skin ends directly to the deep suture line can unequivocally redefine the pretarsal wrinkle. Eyebrow lifting by direct excision is efficacious and versatile, but the visible scar may stay red for up to a year and remain slightly retracted.