Dear Sir, Numerous surgical techniques have been described for upper eyelid retraction. Our technique uses VY advancement for levator lengthening. Our technique is to recess Muller's muscle and advance the levator aponeurosis flap through a lid crease incision. We present two cases of successful upper eyelid reconstruction using VY levator lengthening, and we discuss the operative technique and its advantages. Operative technique The procedure is performed under local anesthesia. A mixture of 0.5% lidocaine and epinephrine (1:100,000) is injected with a 27-gauge needle into subcutaneous tissue. The skin and orbicularis muscle is incised along the marked double eyelid crease to expose the septum. The orbital septum is opened and any redundant preaponeurotic fat is removed to display the levator aponeurosis. If the septum is absent due to blepharoplasty, the levator aponeurosis is displayed after dissecting adhesive preaponeurotic fat. The levator aponeurosis together with the underlying Muller's muscle is separated from the tarsus and is dissected from the conjunctiva (Figure 1a). The medial and lateral horns of the levator expansion are identified and divided. A V-shaped design is then marked on the levator aponeurosis for incision (Figure 1b). After V-shaped aponeurotomy of the levator aponeurosis is performed, and the flap is transferred down and sutured with 7-0 nylon in a Y shape (Figure 1c). We used a formula modified from that reported by Piggot: I area in Y (extended distance) = 2 x (degree of retraction in mm) + 1 mm. For example, to correct a 2-mm retraction, the length of the I area would be 5 mm. The lengthened aponeurosis is sutured to the upper border of the tarsal plate with 6-0 nylon (Figure 1d). This formula gives an indication of the extended distance. However, the actual extent is decided intraoperatively by testing eyelid level and excursions. After adjusting the eyelid to its desired position, a double-eyelid crease is created.
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