Boston Wilmington ShanghaiThe following material was used by Accdon LLC during an oral presentation and discussion. Without the accompanying oral comments, the text is incomplete as a record of the presentation. This document contains information and methodology descriptions intended solely for the use of client personnel. No part of it may be circulated, quoted, or reproduced for distribution outside this client without the prior written approval of Accdon LLC.NOTICE: Proprietary and ConfidentialCopyright 2013 Accdon LLC, All Rights ReservedShi HengBRAVOU Aesthetic Plastic Hospital Adjunctive Techniques to Traditional Advancement Procedures for treating Severe Blepharoptosis2Plastic and Reconstructive Surgery April 2014 Volume 133, Number 43l To create a more physiologic（生理性的） eyelid opening in patients with severe blepharoptosis (睑睑下垂), l the authors used lamina propria mucosa of conjunctiva（结结膜的睑睑板固有粘膜）, which continues to the check ligament of the superior fornix (上穹窿的check韧带韧带 ), l in addition to levator aponeurosis and Mllers muscle as a composite flap. l In patients with epicanthal folds（内眦赘赘皮） with associated telecanthus（内眦间间距过过大）, the authors also performed epicanthoplasty with medial canthal tendon shortening.Background451. Superior rectus muscle. 2. Levator muscle. 3. Conjoining of SRM with levator muscle sheath. 4. Tenons capsule. 5. Suspensory ligament of superior fornix. 6. Whitnalls ligament. 7. Frontalismuscle. 8. Brow fat pad. 9. Orbital orbicularis. 10. Arcus marginalis. 11. Orbital septum. 12. Preaponeurotic fat pad. 13. Preseptal orbicularis. 14. Postorbicularis fascia. 15. Levator aponeurosis. 16. Superior conjunctival fornix. 17. Mllers muscle. 18.Conjunctiva. 19. Superior tarsus. 20. Pretarsal orbicularis.腱膜前脂肪 Pre-aponeurotic fat 眶隔前脂肪 Pre-septal fat 睑板前脂肪 Pretarsal fat 眼轮匝肌下脂肪 retro-orbicularis oculi fat (ROOF) sub-orbicularis oculi fat (SOOF)678Methodsl Fifty blepharoptosis patients (85 eyelids) with a degree of ptosis of greater than 4 mm underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva as a composite flap. l Twenty-one (42 percent) of those patients also underwent split V-W epicanthoplasty and plication of the medial canthal tendon for epicanthal folds with associated telecanthus. l Degree of ptosis and levator function were measured preoperatively and postoperatively.9Resultsl Complete or near-complete correction of ptosis (degree of ptosis,4 mm) for this study. The 50 patients (85 eyelids) underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite flap. l Twenty-one of 50 patients (42 percent, 42 eyelids) had epicanthal folds with associated telecanthus and therefore underwent epicanthoplasty and shortening of the medial canthal tendon.18Operative Techniquel The double eyelid incision line is marked on the upper eyelid 6 to 9 mm above the lid margin, depending on the personal preference of patients without double eyelids.l Modified V-W plasty is designed on the skin medial to the epicanthal folds of patients with blepharoptosis and epicanthal folds with associated telecanthus.l Epicanthal folds with associated telecanthus are corrected before ptosis correction is performed. l The operation is usually performed with the patient under local anesthesia with intravenous or oral sedation.1920Correction of Severe Blepharoptosisl An incision is made along the double eyelid mark after subcutaneous infiltration with 1% lidocaine with 1:100,000 epinephrine.l Epinephrine is omitted during deeper injection to prevent stimulation of the Mllers muscle.l The upper anterior surface of the tarsal plate and the orbital septum are exposed after excision of pretarsal soft tissue.l The orbital septum is cut at its lowest part and the protruding orbital fat is partly excised to expose the levator aponeurosis.l Tetracaine（丁卡因） eye drops are applied to the cornea（角膜）, and corneal eye protectors are applied to the globe.The levator aponeurosis, Mllers muscle, and lamina propria mucosa of conjunctiva are then detached carefully from the superior tarsal border and underlying conjunctival epithelium with sharp iris scissors with the help of these three traction sutures.Injection of pure lidocaine into the superior portion of the tarsus facilitates the detachment of the Mllers muscle and the lamina from the superior tarsal border and the conjunctival epithelium by causing the tissues to balloon up slightly.In some cases, dark cornea is visible through the conjunctival epithelium. The detached levator aponeurosisMllers musclelamina propria mucosa composite flap is advanced onto the anterior surface of the tarsus. 21222324RESULTSl Fifty patients (85 eyelids) with ptosis greater than 4 mm were operated on (Table 1). Of these patients, 38 (76 percent) had congenital ptosis and 35 (70 percent) had bilateral ptosis. Of the 35 pati