Final comments from the panel

Sarith Makuloluwe
Anterior aponeurosis advancement approach for correction of ptosis needs to be part of every Oculoplastic surgeon’s toolbox. It is a tried and tested method, allowing detailed anatomical scrutiny, the ability to appreciate degenerative change and subsequent adjustment of the procedure to compensate for this. With this in mind, I believe medialised bites of the mobilised healthy aponeurosis, using a non-absorbable suture, is a critical step in achieving good clinical outcomes in even the most challenging case.

Christina Lim on posterior white line advancement
Ptosis surgery can be challenging, as it is not a condition where one surgical technique fits all. Posterior white line advancement is an effective and highly successful procedure that avoids tissue removal or septal disturbance, providing unique access to the posterior layer of the levator aponeurosis. I highly recommend this technique as a valuable and versatile tool that every oculoplastic surgeon should have under their belt for managing a variety of ptosis cases.

Don Kikkawa
Mueller’s muscle conjunctival resection is a predictable and reliable method to correct mild to moderate acquired ptosis. If needed, it can be combined with skin excision in patients with dermatochalasis. No intraoperative adjustments are necessary and all decisions about resection amount are made preoperatively.

Comments from Ben Parkin on anterior white line advancement
Less is more: leave the orbital septum and the conjunctiva intact! One can easily reach the same plane as a posterior approach from a skin crease incision. When done correctly, there is no risk of conjunctival trauma, corneal abrasion, meibomian gland damage, dry eye, loss of mullers innervation or peaked upper lid profile and only a single suture. 

Intra-operative tips:
I would recommend using a corneal shield. I find Electrocautery helpful for the dissection, but one can use cold steel and cautery. Use a traction suture and lift tissues to aid dissection. Apply inferior traction on mullers, to place suture through resulting fold in the aponeurosis and into anterior upper tarsus 2-3mm from the upper border (taking a wide bite, centred at the position of the pupil in primary gaze). I recommend a monofilament suture to minimise inflammation.

Email benparkin@icloud.com for video or if you have any further questions.