Aesthetic blepharoptosis correction with release of fibrous web bands between the levator aponeurosis and orbital fat

Abstract

BACKGROUND: Blepharoplasty remains one of the most frequent operations in Asia. The most common complaint of Asian patients is a limitation of eye opening, and a substantial proportion of patients have puffy eyelids, supratarsal folds in the upper eyelid, and a narrow palpebral fissure, thus exhibiting a tired and sleepy appearance. To correct these features, an accurate understanding of upper eyelid anatomy is essential, especially concerning the levator aponeurosis, orbital fat, and orbital septum.

METHODS: After a strip of orbicularis oculi muscle was removed through usual transcutaneous blepharoplasty incision, we excised the submuscular soft tissue to expose the fusion line of the septum and the levator aponeurosis. Blunt dissection was carried out between the levator aponeurosis and the orbital fat. During dissection, a three-dimensional fibrous web connecting the orbital fat and levator aponeurosis, and continuing to just behind the Whitnall ligament, was observed in all patients. All of the connections with these fibrous bands were resected during the procedure using a Steven scissors while controlling bleeding. After this dissection, we reevaluated the degree of blepharoptosis in the upright position and checked the function of the levator palpebral muscle. We observed that mild and subclinical blepharoptosis was corrected without manipulation of the levator aponeurosis or the Müller muscle.

RESULTS: Of the 32 patients evaluated, 22 were women and 10 were men. All of our patients had mild or subclinical blepharoptosis (<2 mm). The levator function was excellent or good in all patients. Most of these patients (29/32, 87.5%) were satisfied with the outcome after this operation.

CONCLUSIONS: The authors found that fibrous web bands between levator aponeurosis and orbital fat limit movement of the levator aponeurosis, which is a cause of eye opening limitation. In the current study, subclinical and mild blepharoptoses were corrected by releasing these fibrous bands without manipulating the levator aponeurosis or the Müller muscle. This method has been shown to be highly effective in correcting mild ptosis and can be applied during most surgical blepharoptosis techniques.