External Levator Advancement

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Article initiated by:

David S. Wu, MD, Sruti S. Akella, MD

All contributors:

Wesley Schwind, David S. Wu, MD

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Surgical Therapy

CPT 67904; Repair of blepharoptosis; levator advancement, external approach

Background

External levator advancement (ELA) is a commonly employed technique for upper eyelid aponeurotic ptosis correction. This procedure advances the levator palpebrae superioris (levator) aponeurosis to the superior tarsus, effectively shortening the levator muscle to improve the position and cosmesis of the ptotic eyelid.

An anterior (external) approach to ptosis repair was first described by Everbusch in 1883 as a levator plication to treat congenital blepharoptosis. However, the modern understanding of ELA is attributable to Jones, Quickert, and Wobig in 1975, who introduced the idea that acquired ptosis was caused by disinsertion or dehiscence of the levator aponeurosis and could therefore be treated by repositioning the aponeurosis (i.e., advancement), a theory which was later histologically proven by Dortzbach and Sutula in 1980.

Since then, ELA has undergone several innovations, including by Liu (1993) who introduced a single suture advancement and by Meltzer et al. (2001) who introduced an adjustable suture. The small incision approach that is widely practiced today was described in 1999 by Lucarelli and Lemke, with subsequent modifications by Baroody et al. and Frueh et al. in 2004.

Patient Selection

Indications and Surgical Planning

In preoperative assessment, a thorough history should first be obtained to distinguish aponeurotic ptosis from neurogenic, myogenic, and mechanical ptosis, including record of previous eye or eyelid surgery, contact lens wear, trauma, dry eye disease, glaucoma, and medical comorbidities (e.g., bleeding disorders, smoking, chronic illness).

Once a diagnosis of aponeurotic ptosis is established, the severity of ptosis, degree of compensatory brow elevation present, eyelid excursion, and need for concomitant blepharoplasty or brow surgery are factored into determining candidacy for ELA.

Eyelid measurements should include Margin Reflex Distance 1 (MRD1), levator function, and eyelid crease height. Levator function is measured as the total vertical excursion of the upper eyelid from the maximum downgaze to the maximum upgaze position while the brow is immobilized to prevent frontalis recruitment. Patients with levator function of at least 5 mm or greater are generally thought to be good candidates for ELA, though most patients with true aponeurotic ptosis will have a levator function of at least 10mm .

In cases of unilateral or asymmetric ptosis, a positive Hering’s Law test whereby manual lift of the ptotic eye causes a decrease in the MRD1 of the fellow eye, should also be noted pre-operatively. When concomitant blepharoplasty or brow surgery is anticipated, an anterior approach such as ELA also gives the surgeon flexibility to address several issues through the same incision.

Contraindications

• Ptosis requiring further evaluation, observation, or medical treatment, including untreated myasthenia gravis or traumatic ptosis of less than 3-6 months’ duration.
• Poor Bell's phenomenon, pre-existing lagophthalmos, or orbicularis weakness (relative contraindications).
• Poor levator function (e.g. 0-4 mm).

Surgical Technique

This procedure is conducted under monitored anesthesia care or local anesthesia, as patient cooperation during surgery is critical to successful outcomes.

Preoperatively, the eyelid crease is marked. In most cases, the patient’s natural eyelid crease can be used. However, in instances of severe levator dehiscence resulting in a high or indistinct crease, the provider may mimic the contralateral unaffected eyelid crease or, if both eyelids are affected, the surgeon may place the marking 8-10mm above the lash line. Care should be taken to preserve a natural, often lower crease in East Asian patients. If a simultaneous blepharoplasty is being performed, this will be marked out in the standard fashion. The skin is then infiltrated with the surgeon’s preferred local anesthetic mix, usually with epinephrine to cause local vasoconstriction and minimize bleeding.

A skin incision is made along the previously marked eyelid crease. If a blepharoplasty is also being performed, skin is excised at this stage. Dissection is continued posteriorly through orbicularis oculi and orbital septum until the landmark of preaponeurotic fat is seen. Further dissection is carried out to separate the preaponeurotic fat from the underlying levator aponeurosis.

At this stage, the aponeurosis can then be disinserted from the tarsus with sharp dissection, thus creating a free leading edge of the levator aponeurosis.

Once the aponeurosis is successfully isolated, one or two double-armed partial-thickness sutures are placed horizontally through the superior border of tarsus. The lid may be everted to confirm that the suture is not full-thickness through tarsus and will therefore not rub on the cornea. Each arm of the tarsal suture is then passed through the levator aponeurosis and a temporary tie is placed.

At this stage, it is advisable to sit the patient up and assess eyelid height and contour. If the eyelid looks too low, the suture may be repositioned more superiorly on the aponeurosis to the level of Whitnall’s ligament. Conversely, if the eyelid appears retracted, the suture may be loosened until the appropriate height is observed.

Once the result is acceptable, the temporary ties are then converted to permanent ties. Closure is accomplished per surgeon preference. At this point, the leading edge of levator aponeurosis can be incorporated into the skin closure to reform a dynamic eyelid crease.

Intraoperative view of the levator aponeurosis from the surgeon's point of view. The Desmarres retractor is pushing back pre-aponeurotic fat and the levator muscle and aponeurosis are seen. Image courtesy of Dr. Sruti S. Akella, MD, MBA

Surgical Variations

Minimally Invasive Approach

Small incision ELA was introduced by Lucarelli and Lemke in 1999, shortening the standard technique of a 20-22 mm full-length crease incision to 8-10 mm. In this approach, every layer including the septum is still opened, and satisfactory height and contour were achieved in 25 of 28 lids (89%). Using a similar approach, Baroody et al. reported fewer reoperation rates in a sample size of 118 lids, where 4 overcorrections and 3 undercorrections were reported.

Lateral Horn Incision for Severe Involutional Blepharoptosis

In severe involutional ptosis, a lateral horn incision may be employed to increase advancement. In a retrospective cohort of sixty-nine patients who underwent levator advancement surgery for involutional blepharoptosis between 2020 and 2023, 32 patients (preoperative MRD1 0. 5 mm) who underwent lateral horn incision were compared to 37 patients (preoperative MRD1 1.0 mm) who did not. In the lateral horn incision group, the levator aponeurosis was advanced 4.3  mm more caudally and 3.1 mm more medially, with no significant differences in postoperative MRD1 between the two groups (2.8 mm versus 3.0 mm).

Outcomes

Outcomes of conventional repair are generally favorable, with revision rates between 8.7 and 9.5% based on existing literature. In other reports, the success rate of unilateral ELA for congenital blepharoptosis at 6 months has been reported at 74%, with 19% of cases reported as under corrections and 7% as overcorrections.

Complications

• Under/overcorrection
• Asymmetry/contour defects
• Lagophthalmos
• Exposure keratopathy
• Infection
• Bleeding/hematoma
• Anesthesia risks