傳統(tǒng)前徙步驟附加技術(shù)矯正重度上瞼下垂課件

ShiHengBRAVOUAestheticPlasticHospitalAdjunctiveTechniquestoTraditionalAdvancementProceduresfortreatingSevereBlepharoptosisShiHengAdjunctiveTechniques2PlasticandReconstructiveSurgeryApril2014Volume133,Number42PlasticandReconstructiveSu3Tocreateamorephysiologic（生理性的）

eyelidopeninginpatientswithsevereblepharoptosis(瞼下垂),theauthorsusedlaminapropriamucosaofconjunctiva（結(jié)膜的瞼板固有粘膜）,whichcontinuestothecheckligamentofthesuperiorfornix(上穹窿的check韌帶),inadditiontolevatoraponeurosisandMüller’smuscleasacompositeflap.

Inpatientswithepicanthalfolds（內(nèi)眥贅皮）

withassociatedtelecanthus（內(nèi)眥間距過大）,theauthorsalsoperformedepicanthoplastywithmedialcanthaltendonshortening.Background3Tocreateamorephysiologic（4451.Superiorrectusmuscle.2.Levatormuscle.3.ConjoiningofSRMwithlevatormusclesheath.4.Tenon'scapsule.5.Suspensoryligamentofsuperiorfornix.6.Whitnall'sligament.7.Frontalismuscle.8.Browfatpad.9.Orbitalorbicularis.10.Arcusmarginalis.11.Orbitalseptum.12.Preaponeuroticfatpad.13.Preseptalorbicularis.14.Postorbicularisfascia.15.Levatoraponeurosis.16.Superiorconjunctivalfornix.17.Müller'smuscle.18.Conjunctiva.19.Superiortarsus.20.Pretarsalorbicularis.51.Superiorrectusmuscle.腱膜前脂肪Pre-aponeuroticfat眶隔前脂肪Pre-septalfat瞼板前脂肪Pretarsalfat眼輪匝肌下脂肪retro-orbicularisoculifat(ROOF)

sub-orbicularisoculifat(SOOF)6腱膜前脂肪Pre-aponeuroticfat6778MethodsFiftyblepharoptosispatients(85eyelids)withadegreeofptosisofgreaterthan4mmunderwenttheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctiva

asacompositeflap.Twenty-one(42percent)ofthosepatientsalsounderwentsplitV-Wepicanthoplastyandplicationofthemedialcanthaltendonforepicanthalfoldswithassociatedtelecanthus.Degreeofptosisandlevatorfunctionweremeasuredpreoperativelyandpostoperatively.8MethodsFiftyblepharoptosis9ResultsCompleteornear-completecorrectionofptosis(degreeofptosis,<1mm)wasachievedin54eyelids(63.5percent)andmildresidualptosis輕度殘余下垂

(degreeofptosis,1to2mm)wasobservedin22eyelids(25.9percent)inpostoperativefollow-upafter6months.Themostcommoncomplicationwasreoperation,whichwasdonein15eyelids(17.6percent)becauseofincompletecorrection.9ResultsCompleteornear-comp10ConclusionsTheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositewaseffectiveinthetreatmentofsevereblepharoptosiswithlevatorfunctionof2to7mm.Thetechniqueproducedelevatingmotionofthephysiologiceyelidinasuperior-posteriordirection.Therewerenoseriouscomplications,suchaslong-termlagophthalmos（瞼閉合不全）

orlidlag（眼球遲滯）.10ConclusionsTheadvancement11Severeptosispresentsadifficultconditionbecauseasignificantamountofeyelidexcursionisrequiredtocorrectit.Inaddition,incongenitalptosis,levatormusclefunctionisoftenpoor.Wedefinesevereptosisasthedegreeofptosisgreaterthan4mm,asdescribedbyIsaksson.11Severeptosispresentsadi12Frontalissuspensioniscommonlyperformedtobypasstheissueofpoorlevatormusclefunction.However,therearemanydrawbacksassociatedwithfrontalissuspension,suchaslagophthalmos,lidlag,liddistortion,andunnaturaleyelidmovementinasuperiordirectionfollowingoveractionofthefrontalismuscle.Holmstr?mandSantanellireportedonsuspensionoftheeyelidtothecheckligamentofthesuperiorfornixincongenitalblepharoptosis.12Frontalissuspensioniscom13Thecheckligamentofthesuperiorfornix（上穹窿）,whichemanatesfromthesheathsofthelevatorandsuperiorrectusmusclesandfromTenon’scapsule,containscollagenfibers,elastinfibers,andsmoothmusclefibers.Superficialanddeepextensionsofthecheckligamentcontinuetothesuperiorconjunctivalfornixandconjunctiva.ThischeckligamentwasconfirmedbyLukasandcolleaguesandHwangandcolleaguesastheintermusculartransverseligament（肌間橫韌帶）

andconjointfascialsheath（CFS，聯(lián)合筋膜鞘）,respectively.13Thecheckligamentofthesu141415Kakizakiandcolleaguesclassifiedtheconjunctivaintolaminapropriamucosaofconjunctivaandconjunctivalepithelium.ThelaminapropriamucosaofconjunctivaislocatedjustposteriortotheMüller’smuscleandhasarichvascularplexus.ThelaminaisasthickasMüller’smuscleandinsertsontotheposteriorhalfofthesuperiortarsalborder.Thelaminacontinuesproximallytothecheckligamentandisthoughttohaveasuspensoryeffectontheuppereyelid.15Kakizakiandcolleaguesclas16Weusedthelevatoraponeurosis,Müller’smuscle,andlaminapropriamucosaofconjunctiva

inthetreatmentofsevereblepharoptosis.Incasesofepicanthalfoldswithassociatedtelecanthus,epicanthoplastyandmedialcanthaltendonshortening（內(nèi)眥韌帶縮短）wereperformedsimultaneouslytoenlargethepalpebralopeningandtoreleasethetensionoftheuppermedialeyelidskinandtetheringfold,whichimpedes（阻止）theactionofeyelidelevation.16Weusedthelevatoraponeuro17PATIENTSANDMETHODSBetweenJanuaryof2004andSeptemberof2012,werecruited50Koreanpatientswithsevereblepharoptosis(degreeofptosis,>4mm)forthisstudy.The50patients(85eyelids)underwenttheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositeflap.Twenty-oneof50patients(42percent,42eyelids)hadepicanthalfoldswithassociatedtelecanthusandthereforeunderwentepicanthoplastyandshorteningofthemedialcanthaltendon.17PATIENTSANDMETHODSBetween18OperativeTechniqueThedoubleeyelidincisionlineismarkedontheuppereyelid6to9mmabovethelidmargin,dependingonthepersonalpreferenceofpatientswithoutdoubleeyelids.ModifiedV-Wplastyisdesignedontheskinmedialtotheepicanthalfoldsofpatientswithblepharoptosisandepicanthalfoldswithassociatedtelecanthus.Epicanthalfoldswithassociatedtelecanthusarecorrectedbeforeptosiscorrectionisperformed.Theoperationisusuallyperformedwiththepatientunderlocalanesthesiawithintravenousororalsedation.18OperativeTechniqueThedoub191920CorrectionofSevereBlepharoptosisAnincisionismadealongthedoubleeyelidmarkaftersubcutaneousinfiltrationwith1%lidocainewith1:100,000epinephrine.EpinephrineisomittedduringdeeperinjectiontopreventstimulationoftheMüller’smuscle.Theupperanteriorsurfaceofthetarsalplateandtheorbitalseptumareexposedafterexcisionofpretarsalsofttissue.Theorbitalseptumiscutatitslowestpartandtheprotrudingorbitalfatispartlyexcisedtoexposethelevatoraponeurosis.Tetracaine（丁卡因）

eyedropsareappliedtothecornea（角膜）,andcornealeyeprotectorsareappliedtotheglobe.20CorrectionofSevereBlepharThelevatoraponeurosis,Müller’smuscle,andlaminapropriamucosaofconjunctivaarethendetachedcarefullyfromthesuperiortarsalborderandunderlyingconjunctivalepitheliumwithsharpirisscissorswiththehelpofthesethreetractionsutures.InjectionofpurelidocaineintothesuperiorportionofthetarsusfacilitatesthedetachmentoftheMüller’smuscleandthelaminafromthesuperiortarsalborderandtheconjunctivalepitheliumbycausingthetissuestoballoonupslightly.Insomecases,darkcorneaisvisiblethroughtheconjunctivalepithelium.Thedetachedlevatoraponeurosis–Müller’smuscle–laminapropriamucosacompositeflapisadvancedontotheanteriorsurfaceofthetarsus.21Thelevatoraponeurosis,Mülle2222232324RESULTSFiftypatients(85eyelids)withptosisgreaterthan4mmwereoperatedon(Table1).Ofthesepatients,38(76percent)hadcongenitalptosisand35(70percent)hadbilateralptosis.Ofthe35patientswhohadbilateralptosis,eightexhibitedeyelidasymmetryofmorethan1mm.Patientagesrangedfrom12to89years(meanage,35.7years).24RESULTSFiftypatients(85eyThedegreeofptosisamongthe85eyelidsrangedfrom4to8mm.Seventy-seveneyelids(90.6percent)had4to5mmofptosis,andeight(9.4percent)hadmorethan6mm.Levatorfunctionamongthe85eyelidsrangedfrom7to2mm.Fifty-fiveeyelids(64.7percent)hadfairlevatorfunction(7to5mm).Inprimarycases,theadvancedcompositeflapwasresectedatlessthan5mm(mean,3mm).Inrevisioncasescausedbyincompletecorrectionofptosis,thecompositeflapwasfurtheradvancedandresectedbyabout3mm.25ThedegreeofptosisamongtheAllpatientswerefollowedpostoperativelyfor6monthsto9years(Table2).Completecorrectionofptosis(degreeofptosis,<1mm)wasobtainedin54eyelids(63.5percent),andmildresidualptosis(degreeofptosis,<2mm)wasseenin22eyelids(25.9percent).

Inthenineeyelidswithmoderateresidualptosis(degreeofptosis,3mm),twopatients(foureyelids)underwentautogenousfascialata（自體闊筋膜）

suspensiontothefrontalismusclebecauseofpoorlevatorfunction.Theremainingpatientsrefusedtheprocedure.26AllpatientswerefollowedposThemostcommoncomplicationwasincompletecorrectionofptosis.Reoperationwasperformedin15eyelids,withfurtheradvancementofthecompositeflap.In41eyelids(48percent),lagophthalmosof1to2mmandmildlidlagwerepresentforthefirstfewmonthspostoperativelybutwereseentoresolveafter6months,exceptinthreepatientswhowerelosttofollow-up.Minorcomplications,suchaschemosis(結(jié)膜水腫),ecchymosis（瘀斑）andcornealirritation（角膜刺激）,werewellrecoveredbyconservativetreatmentssuchaseyelubricants（潤滑劑）.27Themostcommoncomplicationw28Fig.4.A49-year-oldmanpresentedwithbilateralcongenitalblepharoptosis.(Above,left)Preoperativestraight-aheadgaze.(Above,right)One-yearpostoperativeresultsafteradvancementofthecompositeflap.

(Below)Closureofeyes.28Fig.4.A49-year-oldmanp292930Fig.6.A26-year-oldmanpresentedwithbilateralcongenitalblepharoptosisandepicanthalfoldsassociatedwithmoderatetelecanthus.(Above,left)Preoperativestraight-aheadgaze.(Above,right)Two-yearpostoperative

(Below,left)Upwardgaze.(Below,right)Downwardgaze.30Fig.6.A26-year-oldmanpr31DISCUSSION31DISCUSSIONWehavebeeninterestedintheadvancementtechniqueofusingthelevatoraponeurosis–Müller’smusclecompositeasaflapinthecorrectionofblepharoptosis,andhavereportedtheresults.Wefoundthateyelidelevationwasstilldeficientforusingthistechniqueinpatientswithsevereptosis.Aftergainingafurtherunderstandingofthedeeperconnectionbetweenthelaminapropriamucosaofconjunctivaandthecheckligamentofthesuperiorfornix,weincorporatedthelaminaintothecompositeflap。Wepostulatedthatsimultaneousadvancementofthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositeasaflapproducesstrongerpowertocorrectsevereptosis.32WehavebeeninterestedintheThelevatoraponeurosisisconnectedsuperiorlytothelevatorpalpebraesuperiorismuscle（提上瞼?。゛ndtheWhitnall’sligament,andhasfirmosseousinsertionatthemedialandlateralhorns.AdvancementofthedistallevatoraponeuroticmargindownwardonthetarsalplateraisesthetarsusdynamicallybyincreasinglevatorfunctionandstaticallybypullingontheelasticWhitnall’sligamentandshortenedlevatoraponeurosisitself.33ThelevatoraponeurosisisconMüller’smusclehasnormalfunctioneveninsevereptosisandhas2to3mmofeyelidliftingpower.Müller’smuscleisanimportantterminalattachmentofthelevatormuscletothesuperiortarsalborder,andshorteningtheMüller’smusclemayaugmentitsphysiologicrolebyincreasingthetensilestrengthofthemuscle.34Müller’smusclehasnormalfunThelaminapropriamucosaoftheconjunctivaiscontinuouswiththeelasticcheckligamentofthesuperiorfornix,andshorteningthelaminapropriamucosapullsonthecheckligament.Therefore,advancementofthesethreedistinctanatomicstructuressimultaneouslytothetarsalplateproducesintegratedpowertoraisetheuppereyelidinanaturalsuperior-posteriorvector.35ThelaminapropriamucosaoftPatientswithsevereeyelidptosisattempttousethreemusclestomaximizeeyelidopening.Theinitialattemptisbytheprimarycomponentofeyelidelevation—thelevatormuscle（提上瞼肌）.Thenextphaseofeyelidopeningthatpatientsattemptinvolvesuseofthesuperiorrectusmuscle（上直?。?/p>

tolookupward.Thethirdphaseistheuseofthefrontalismuscle（額?。?36Patientswithsevereeyelidptthecheckligamentisconnectedanteriorlytothelevatorpalpebraesuperiorismuscleandposteriorlytothesuperiorrectusmuscle.pullingthecheckligamentpullsthelevatorpalpebraesuperiorismuscleandthesuperiorrectusmuscle.37thecheckligamentisconnecteOnecanpostulate假定

thatthecheckligamentpullsthesuperiorrectusmusclemoredirectlysincetheconnectionbetweenthecheckligamentandthelevatorpalpebraesuperiorismuscleallowssomeglidingmotion,whiletheconnectionbetweenthecheckligamentandthesuperiorrectusmuscleisrelativelyfirm.38Onecanpostulate假定thatthecAnotheradvantageofusingthelevatorpalpebraesuperiorismuscle,Müller’smuscle,andsuperiorrectusmuscle,comparedwithusingjustonemuscle,isthereducedshorteningofoneparticularmuscle.Distributingtheshorteningtoothereyeelevatingmusclesandaugmentingthephysiologiccomponentofeyelidelevationallowsdecreasedeyelidshorteningtogainthesameliftingeffect.Intheory,thisshouldinducelesslagophthalmosandlidlag,asnoticedinourresults.39AnotheradvantageofusingtheInsevereptosiscorrection,thereisanincreasedchanceofpostoperativedoubleeyelidasymmetry,sinceasignificantchangeinthepositioningofthelevatoraponeurosisismadeduringptosiscorrection.Thesepatientsoftenneedrevisionalsurgeryforfoldasymmetry.Inextremecasesofsevereptosiswithverypoorlevatorfunction,werecommendthefrontalisslingmethod.Forourtechniquetobeeffective,webelievethatsomelevatorfunctionshouldexist.40Insevereptosiscorrection,t41CONCLUSIONS41CONCLUSIONSThetechniqueofadvancementofthe

levatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositeasaflapwaseffectiveinthetreatmentofsevereptosiswithpreexistinglevatorfunctionofgreaterthan2mm.Inpatientswithepicanthalfoldswithassociatedtelecanthus,epicanthoplastyandmedialcanthaltendonshorteningenlargedthepalpebralfissureopeningandeliminatedtheconstrictingfactorsthathinderuppereyelidelevation.Ourtechniqueproducedphysiologicaleyelidexcursioninasuperior-posteriordirection.Theamountofresectedadvancedcompositetissuestumpwaslessthan5mm,andtherewerenoseriouscomplications,suchaslong-termlagophthalmosorlidlag.42Thetechniqueofadvancemento434344Thankyou!44Thankyou!ShiHengBRAVOUAestheticPlasticHospitalAdjunctiveTechniquestoTraditionalAdvancementProceduresfortreatingSevereBlepharoptosisShiHengAdjunctiveTechniques46PlasticandReconstructiveSurgeryApril2014Volume133,Number42PlasticandReconstructiveSu47Tocreateamorephysiologic（生理性的）

eyelidopeninginpatientswithsevereblepharoptosis(瞼下垂),theauthorsusedlaminapropriamucosaofconjunctiva（結(jié)膜的瞼板固有粘膜）,whichcontinuestothecheckligamentofthesuperiorfornix(上穹窿的check韌帶),inadditiontolevatoraponeurosisandMüller’smuscleasacompositeflap.

Inpatientswithepicanthalfolds（內(nèi)眥贅皮）

withassociatedtelecanthus（內(nèi)眥間距過大）,theauthorsalsoperformedepicanthoplastywithmedialcanthaltendonshortening.Background3Tocreateamorephysiologic（484491.Superiorrectusmuscle.2.Levatormuscle.3.ConjoiningofSRMwithlevatormusclesheath.4.Tenon'scapsule.5.Suspensoryligamentofsuperiorfornix.6.Whitnall'sligament.7.Frontalismuscle.8.Browfatpad.9.Orbitalorbicularis.10.Arcusmarginalis.11.Orbitalseptum.12.Preaponeuroticfatpad.13.Preseptalorbicularis.14.Postorbicularisfascia.15.Levatoraponeurosis.16.Superiorconjunctivalfornix.17.Müller'smuscle.18.Conjunctiva.19.Superiortarsus.20.Pretarsalorbicularis.51.Superiorrectusmuscle.腱膜前脂肪Pre-aponeuroticfat眶隔前脂肪Pre-septalfat瞼板前脂肪Pretarsalfat眼輪匝肌下脂肪retro-orbicularisoculifat(ROOF)

sub-orbicularisoculifat(SOOF)50腱膜前脂肪Pre-aponeuroticfat651752MethodsFiftyblepharoptosispatients(85eyelids)withadegreeofptosisofgreaterthan4mmunderwenttheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctiva

asacompositeflap.Twenty-one(42percent)ofthosepatientsalsounderwentsplitV-Wepicanthoplastyandplicationofthemedialcanthaltendonforepicanthalfoldswithassociatedtelecanthus.Degreeofptosisandlevatorfunctionweremeasuredpreoperativelyandpostoperatively.8MethodsFiftyblepharoptosis53ResultsCompleteornear-completecorrectionofptosis(degreeofptosis,<1mm)wasachievedin54eyelids(63.5percent)andmildresidualptosis輕度殘余下垂

(degreeofptosis,1to2mm)wasobservedin22eyelids(25.9percent)inpostoperativefollow-upafter6months.Themostcommoncomplicationwasreoperation,whichwasdonein15eyelids(17.6percent)becauseofincompletecorrection.9ResultsCompleteornear-comp54ConclusionsTheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositewaseffectiveinthetreatmentofsevereblepharoptosiswithlevatorfunctionof2to7mm.Thetechniqueproducedelevatingmotionofthephysiologiceyelidinasuperior-posteriordirection.Therewerenoseriouscomplications,suchaslong-termlagophthalmos（瞼閉合不全）

orlidlag（眼球遲滯）.10ConclusionsTheadvancement55Severeptosispresentsadifficultconditionbecauseasignificantamountofeyelidexcursionisrequiredtocorrectit.Inaddition,incongenitalptosis,levatormusclefunctionisoftenpoor.Wedefinesevereptosisasthedegreeofptosisgreaterthan4mm,asdescribedbyIsaksson.11Severeptosispresentsadi56Frontalissuspensioniscommonlyperformedtobypasstheissueofpoorlevatormusclefunction.However,therearemanydrawbacksassociatedwithfrontalissuspension,suchaslagophthalmos,lidlag,liddistortion,andunnaturaleyelidmovementinasuperiordirectionfollowingoveractionofthefrontalismuscle.Holmstr?mandSantanellireportedonsuspensionoftheeyelidtothecheckligamentofthesuperiorfornixincongenitalblepharoptosis.12Frontalissuspensioniscom57Thecheckligamentofthesuperiorfornix（上穹窿）,whichemanatesfromthesheathsofthelevatorandsuperiorrectusmusclesandfromTenon’scapsule,containscollagenfibers,elastinfibers,andsmoothmusclefibers.Superficialanddeepextensionsofthecheckligamentcontinuetothesuperiorconjunctivalfornixandconjunctiva.ThischeckligamentwasconfirmedbyLukasandcolleaguesandHwangandcolleaguesastheintermusculartransverseligament（肌間橫韌帶）

andconjointfascialsheath（CFS，聯(lián)合筋膜鞘）,respectively.13Thecheckligamentofthesu581459Kakizakiandcolleaguesclassifiedtheconjunctivaintolaminapropriamucosaofconjunctivaandconjunctivalepithelium.ThelaminapropriamucosaofconjunctivaislocatedjustposteriortotheMüller’smuscleandhasarichvascularplexus.ThelaminaisasthickasMüller’smuscleandinsertsontotheposteriorhalfofthesuperiortarsalborder.Thelaminacontinuesproximallytothecheckligamentandisthoughttohaveasuspensoryeffectontheuppereyelid.15Kakizakiandcolleaguesclas60Weusedthelevatoraponeurosis,Müller’smuscle,andlaminapropriamucosaofconjunctiva

inthetreatmentofsevereblepharoptosis.Incasesofepicanthalfoldswithassociatedtelecanthus,epicanthoplastyandmedialcanthaltendonshortening（內(nèi)眥韌帶縮短）wereperformedsimultaneouslytoenlargethepalpebralopeningandtoreleasethetensionoftheuppermedialeyelidskinandtetheringfold,whichimpedes（阻止）theactionofeyelidelevation.16Weusedthelevatoraponeuro61PATIENTSANDMETHODSBetweenJanuaryof2004andSeptemberof2012,werecruited50Koreanpatientswithsevereblepharoptosis(degreeofptosis,>4mm)forthisstudy.The50patients(85eyelids)underwenttheadvancementtechniqueusingthelevatoraponeurosis–Müller’smuscle–laminapropriamucosaofconjunctivacompositeflap.Twenty-oneof50patients(42percent,42eyelids)hadepicanthalfoldswithassociatedtelecanthusandthereforeunderwentepicanthoplastyandshorteningofthemedialcanthaltendon.17PATIENTSANDMETHODSBetween62OperativeTechniqueThedoubleeyelidincisionlineismarkedontheuppereyelid6to9mmabovethelidmargin,dependingonthepersonalpreferenceofpatientswithoutdoubleeyelids.ModifiedV-Wplastyisdesignedontheskinmedialtotheepicanthalfoldsofpatientswithblepharoptosisandepicanthalfoldswithassociatedtelecanthus.Epicanthalfoldswithassociatedtelecanthusarecorrectedbeforeptosiscorrectionisperformed.Theoperationisusuallyperformedwiththepatientunderlocalanesthesiawithintravenousororalsedation.18OperativeTechniqueThedoub631964CorrectionofSevereBlepharoptosisAnincisionismadealongthedoubleeyelidmarkaftersubcutaneousinfiltrationwith1%lidocainewith1:100,000epinephrine.EpinephrineisomittedduringdeeperinjectiontopreventstimulationoftheMüller’smuscle.Theupperanteriorsurfaceofthetarsalplateandtheorbitalseptumareexposedafterexcisionofpretarsalsofttissue.Theorbitalseptumiscutatitslowestpartandtheprotrudingorbitalfatispartlyexcisedtoexposethelevatoraponeurosis.Tetracaine（丁卡因）

eyedropsareappliedtothecornea（角膜）,andcornealeyeprotectorsareappliedtotheglobe.20CorrectionofSevereBlepharThelevatoraponeurosis,Müller’smuscle,andlaminapropriamucosaofconjunctivaarethendetachedcarefullyfromthesuperiortarsalborderandunderlyingconjunctivalepitheliumwithsharpirisscissorswiththehelpofthesethreetractionsutures.InjectionofpurelidocaineintothesuperiorportionofthetarsusfacilitatesthedetachmentoftheMüller’smuscleandthelaminafromthesuperiortarsalborderandtheconjunctivalepitheliumbycausingthetissuestoballoonupslightly.Insomecases,darkcorneaisvisiblethroughtheconjunctivalepithelium.Thedetachedlevatoraponeurosis–Müller’smuscle–laminapropriamucosacompositeflapisadvancedontotheanteriorsurfaceofthetarsus.65Thelevatoraponeurosis,Mülle6622672368RESULTSFiftypatients(85eyelids)withptosisgreaterthan4mmwereoperatedon(Table1).Ofthesepatients,38(76percent)hadcongenitalptosisand35(70percent)hadbilateralptosis.Ofthe35patientswhohadbilateralptosis,eightexhibitedeyelidasymmetryofmorethan1mm.Patientagesrangedfrom12to89years(meanage,35.7years).24RESULTSFiftypatients(85eyThedegreeofptosisamongthe85eyelidsrangedfrom4to8mm.Seventy-seveneyelids(90.6percent)had4to5mmofptosis,andeight(9.4percent)hadmorethan6mm.Levatorfunctionamongthe85eyelidsrangedfrom7to2mm.Fifty-fiveeyelids(64.7percent)hadfairlevatorfunction(7to5mm).Inprimarycases,theadvancedcompositeflapwasresectedatlessthan5mm(mean,3mm).Inrevisioncasescausedbyincompletecorrectionofptosis,thecompositeflapwasfurtheradvancedandresectedbyabout3mm.69ThedegreeofptosisamongtheAllpatientswerefollowedpostoperativelyfor6monthsto9years(Table2).Completecorrectionofptosis(degreeofptosis,<1mm)wasobtainedin54eyelids(63.5percent),andmildresidualptosis(degreeofptosis,<2mm)wasseenin22eyelids(25.9percent).

Inthenineeyelidswithmoderateresidualptosis(degreeofptosis,3mm),twopatients(foureyelids)underwentautogenousfascialata（自體闊筋膜）

suspensiontothefrontalismusclebecauseofpoorlevatorfunction.Theremainingpatientsrefusedtheprocedure.70AllpatientswerefollowedposThemostcommoncomplicationwasincompletecorrectionofptosis.Reoperationwasperformedin15eyelids,withfurtheradvancementofthecompositeflap.In41eyelids(48percent),lagophthalmosof1to2mmandmildlidlagwerepresentforthefirstfewmonthspostoperativelybutwereseentoresolveafter6months,exceptinthreepatientswhowerelosttofollow-up.Minorcomplications,suchaschemosis(結(jié)膜水腫),ecchymosis（瘀斑）andcornealirritation（角膜刺激）,werewellrecoveredbyconservativetreatmentssuchaseyelubricants（潤滑劑）.71Themostcommoncomplicationw72Fig.4.A49-year-oldmanpresentedwithbilateralcongenitalblepharoptosis.(Above,left)Preoperativestraight-aheadgaze.(Above,right)One-yearpostoperativeresultsafteradvancementofthecompositeflap.

(Below)Closureofeyes.28Fig.4.A49-year-oldmanp732974Fig.6.A26-year-oldmanpresentedwithbilateralcongenitalblepharoptosisandepicanthalfoldsassociatedwithmoderatetelecanthus.(Above,left)Preoperativestraight-aheadgaze.(Above,right)Two-yearpostoperative

(Below,left)Upwardgaze.(B