Procedure Figure

An anterior approach has the advantage that excess skin can be excised where patients have co-existing dermatochalasis. Sometimes a true disinsertion of the levator aponeurosis is identified and the lower edge of the aponeurosis can then be reinserted onto the tarsal plate. In aponeurosis stretching, the aponeurosis is advanced sufficiently to eradicate the ptosis. Since the vast majority of aponeurotic ptosis occurs in adults, this surgery should be performed under local

The Underlying Levator Aponeurosis
Figure 5.5 Aponeurosis advancement with direct sutures. Separated from underlying Muller's muscle (a), and advanced on to the tarsus (b).

anaesthesia so that perioperative adjustment of the lid height can be made.

Aponeurosis tuck (Figure 5.6) - some surgeons prefer not to free the aponeurosis from the underlying tissues but to merely plicate the tendon with one or more sutures.

Adjustable sutures (Figure 5.7) - to overcome some of the unpredictability of ptosis surgery, especially in patients undergoing redo surgery or in those adults who insist on surgery under general anaesthesia, adjustable sutures can be used to attach the levator muscle or aponeurosis to the tarsal plate.These can then be advanced or recessed within 24 hours following surgery.

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