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Congenital ptosis levator advance surgery

This narrated video demonstrates an anterior approach levator advance procedure for the correction of congenital ptosis. It discusses relevant aspects of the anatomy of the levator muscle as well as skin crease reformation.



Congenital Ptosis, Levator Advance



In congenital ptosis, the skin crease is often less pronounced or absent as in this case, presumably because of the reduced function or insertions of the muscle 다운로드. The crease is marked at 8mm centrally, 5mm above the lateral canthus and 4mm above the medial canthus

A blepharoplasty is not being undertaken as there is no skin redundancy.


The skin is incised.

A high temperature cautery or hot wire is being used for dissection.

The tarsal plate is exposed 다운로드. Identifying the dissection plane to the tarsal plate can be more difficult with the cautery than scissors, but the haemostatic effect is a big advantage. If the skin and orbicularis are grasped and retracted inferiorly and away from the globe, one can usually see a small pucker deep to the orbicularis, through where dissection will lead to the tarsal plate 복음성가 무료.


Dissection at the lower end of septum exposes the inferior end of the levator aponeurosis. This is inferior to the pre-aponeurotic fat pad which although a useful landmark for ptosis surgery does not need to be exposed to identify the inferior end of the aponeurosis.


The posterior surface of the retractors is dissected free from the underlying conjunctiva. One can either dissect between levator and Mullers to create a levator flap or between Mullers and conjunctiva to create a flap consisting of both retractors 윈도우10 1803 다운로드. While there is no evidence to guide the choice, intuitively it seems prudent to use both retractors in congenital ptoses given the reduced levator function and sometimes a levator only flap does not appear to adequately elevate the lid.


The lateral horn is the fan like extension of levator aponeurosis that attaches to the lateral retinaculum and lateral tubercle just inside the orbital rim 다운로드. It is transected at angle of 45 degrees medially and superiorly which avoids the lacrimal ductules. This allows levator to advance more freely

Similarly the medial horn which passes over superior oblique tendon and attaches to the posterior portion of the medial canthal tendon and the posterior lacrimal crest, is partially transected.


A quick check of the lid contour and the position of its peak aids suture placement.

A double ended 6-0 vicryl suture is passed partially thickness in the tarsal plate 다운로드. The lid is everted to ensure it is not full thickness.

Each of the two needles is passed from the posterior to the anterior surface of the levator.

The suture is tied on a bow and the lid position checked.


The lid is marginally too high. The sutures are placed a couple of millimetres lower on the levator aponeurosis 다운로드. The lid position is better. The levator has not been advanced a huge amount and just a small amount of its terminal end and adjoining orbicularis is resected.


This patient had no skin crease on this side. In this case, the orbicularis of the inferior incision edge is being sutured to the terminal end of the levator aponeurosis in a few places 다운로드. This is thought to create a soft or less dense skin crease. This contrasts with the more widely used technique in Caucasian eyes of including a small bite of levator in the skin closure. There is very limited evidence for different skin crease reformation techniques and their outcomes in Caucasian eyes, but there are theoretical downsides to including levator in the skin closure 다운로드. Firstly it may be at greater risk of slipping with resultant loss of the skin crease or change in its position because of the repeated pull on the closure from blinking. Secondly it is contrary to usual surgical teaching to include some internal tissues between skin edges. Finally, electron microscopy studies have questioned whether there are indeed slips of levator that attach to skin slui exe. The skin is closed with a running 6-0 suture.


Paediatric Endoscopic DCR

This narrated video focuses on the challenges of and surgical technique for paediatric endoscopic DCR surgery.

DCR is sometimes required for paediatric congenital or acquired nasolacrimal duct obstruction. Paediatric Endoscopic and external DCR have similar success rates of around 83-96%.

The anatomy and technique of endo DCR in general is explored in more detail in other videos on this website 다운로드.


Endoscopic DCR has the significant advantage in children of avoiding a skin incision with risk of scarring and does not disrupt the medial canthal tendon. It also enables visualisation of the nasal anatomy and ostium, providing the opportunity to address turbinate abnormalities, membranes, polyps and other abnormal findings 다운로드.

The nasal mucosa has already been decongested either with co-phenilcaine or cocaine soaked neuropatties. It is infiltrated with lignospan. The weight adjusted doses must be calculated pre-operatively and carefully adhered to. The safe doses are extremely low in young children.

Similarly, the maximum allowable blood loss should be calculated prior to commencing the procedure and in small children is a surprisingly small volume of blood 톰캣 7 다운로드. The use of the monopolar needle to create the nasal mucosa is of benefit in paediatric DCR as there is less bleeding than when the blade is use.

The nasal space is narrower in children than in adults. Therefore paediatric endoscopic DCR is technically more challenging than in adults. In adults narrow spaces can be improved with septoplasty, but this is contraindicated in children as it may impact on nasal growth and cosmesis 카티아 학생용 다운로드. However, although the space starts of seeming very narrow, it generally accommodates a 4mm scope comfortably after the nasal mucosa is raised and the bony ostium formation commenced. If the 4mm scope is not easily passed, or risks repeated trauma to the nasal septum, then a 2.7mm rigid 30 degree scope should be available for use.

The nasal flap is raised on a posterior base and then reflected over the middle turbinate to keep it out of the way Winxp download. Some surgeons prefer to make a much smaller nasal flap which has the advantage of needing less or no trimming to abut the posterior lacrimal sac flap, but may get in the way during surgery.

The bony ostium is formed initially mechanically with the Hajak koffler. The superior aspect is enlarged with the Malhotra nibbler. It is completed with the DCR burr 실시간티비 다운로드. As with adults the ostium in enlarged until it exposes the entire lacrimal sac, but the created ostium is smaller in children than in adults; typically around 10 x 10mm in younger children and 10mm wide by 15mm high in older children. The vertical height of the nasal cavity is smaller in children. This may increase the risk of a CSF leak if the proximity of the skull base to the surgical site is not considered 다운로드.

The thin lacrimal bone is flaked away from the lacrimal sac.

The inferior canaliculus is probed. The probe is used firstly to assess if there is any canalicular pathology, by feeling if there are any obstructions or a sensation of tightness around it. The lid must be on lateral tension whilst this is assessed, otherwise folds are easily mistaken for membranes and canalicular obstructions, which are in fact extremely rare in children 스카이림 엘더스크롤 다운로드. Secondly the probe is used to tent up the lacrimal sac to minimise the risk of trauma to the internal ostium and internal mucosal lining of the sac when it is incised with the exquisitely sharp cataract keratome.

The keratome and then hooked sickle are used to form anterior and posterior lacrimal sac flaps which are reflected anteriorly and posteriorly respectively 천재교육 교사용 cd 다운로드.

The nasal flap is trimmed to abut the posterior lacrimal sac flap. It is still too large and The is reduced further
The flaps are manipulated into a good position well clear of the internal ostium. Generally, they seem to remain where they are placed intraoperatively, so it is worth spending a bit of time ensuring they are well located and without any tension on them that might pull them out of position 왕좌의 게임 시즌 1 다운로드.
The internal ostium is checked for canalicular restriction or tightness. The role of nasolacrimal stents remains uncertain, but there does not seem to be any benefit to using them if the cause of obstruction is exclusively distal to the internal ostium, that’s to say the pathology is in the nasolacrimal duct, or lacrimal sac, which will of course be bypassed.. Omission of stents is of particular benefit in children in whom the removal of the stents may require another general anaesthetic.

Supporting literature1 2

1. Al-Nuaimi D, Inkster C, Lobo C. Paediatric powered endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2011;268(12):1823-8. doi: 10.1007/s00405-011-1605-z
2. Leibovitch I, Selva D, Tsirbas A, et al. Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol 2006;244(10):1250-4. doi: 10.1007/s00417-006-0273-y