The approach can be anteriorly through the intended skin crease position or posteriorly through the conjunctiva. The amount of levator resected is based on both the degree of ptosis and the levator function. The levator is identified and freed from underlying tissues and shortened by between 12 to 30mm. In larger resections the lateral and medial horns of the muscle are divided to allow the muscle to be advanced sufficiently. The resected muscle is then reattached with about three sutures to the anterior, superior surface of the tarsus. The skin crease is reformed by incorporating a bite of the lower edge of the levator muscle in the skin wound.
Internal Whitnall sling - Where there is marked ptosis and levator function is not good (5mm or less) the levator can be slung over Whitnall's ligament which acts as an internal suspension for the lid. This gives very little lid movement post operatively.
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