O R I G I N A L A R T I C L E

Orbicularis Plication for PtosisA Third Alternative

DALJIT SINGH, MS, DSc

The surgery involves exposure of the orbicularis oculimuscle via a skin flap starting near the upper orbital mar-gin then progressing downward. The orbicularis oculifibers near the lid margin are then joined to the proximalorbicularis fibers and the skin flap is sutured back to nor-mal position. Over 9 years, 265 operations have beenperformed on a wide variety and severity of ptosis. Thetechnique is a viable addition/alternative to the existingmethods of ptosis surgery.

A B S T R A C T

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R E P R I N T SDaljit Singh, MD, Dr. Daljit Singh Eye Hospital, 1-Radha Soami Road, Amritsar-143002, India. E-mail: RJFugomd@fugoblade.com.

Dr. Singh is from the Dr. Daljit Singh Eye Hospital, Amritsar, India.

The author has stated that he does not have a significant financial interest orother relationship with any product manufacturer or provider of services dis-cussed in this article. The author also does not discuss the use of off-label prod-ucts, which include unlabeled, unapproved, or investigative products ordevices.

Submitted for publication: 6/1/06. Accepted: 6/12/06.

Annals of Ophthalmology, vol. 38, no. 3, Fall 2006© Copyright 2006 by ASCO All rights of any nature whatsoever reserved. 1530–4086/06/38:185–193/$30.00. ISSN 1558–9951 (Online)

INTRODUCTIONThe most important cause of ptosis is poor levatorfunction, which is usually a congenital problem. Themost logical way to treat this pathology is to strengthenthe levator muscle via a suitable length resection.However, when levator function is poor and the mus-cle is fibrotic, little is to be gained by this approach.The next best alternative is a non-levator solution,i.e., frontalis suspension with strips of fascia lata.Following surgery for severe ptosis using any ofthese techniques, the level of the lid may be broughtto an acceptable level for the primary position, but itsdynamic functions cannot be normalized because thefibrotic levator muscle and the strips of fascia lataare totally inelastic in nature. As a result, in the operated cases, lid lag occurs and more importantlylagophthalmos, which may produce exposure keratopathy (1).

This article presents the first ever report on a non-traditional, second non-levator surgical alternative totreat ptosis. The procedure involves a wide exposure ofthe orbicularis oculi muscle followed by its plication,such that the distal orbicularis fibers (near the lid mar-gin) are joined to the proximal fibers (near the orbitalmargin). This procedure is termed “orbicularis plica-tion.” It has been in use since 1996. The most importantfinding is that it not only works, but it also does notcause lagophthalmos.

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TECHNIQUE

Anesthesia

GeneralGeneral anesthesia is reserved for the pediatric patients.Under general anesthesia, local infiltration with lidocainewith epinephrine is also performed. This not only helps indissection, but also there is minimal postoperative pain,which is an important consideration for pediatric patients.

LocalUsing a 27-gage needle, 8–10 mL of 2% lidocaine withepinephrine is injected subcutaneously in the upper lid(Fig. 1). The aim is to create an edematous cleavagebetween the skin and the orbicularis muscle. The skinalso is lifted and stretched, which facilitates surgicaldissection. The infiltration with the anesthetic agentextends from the lid margin to the orbital margin.

Step of the Operation

Exposure of the Orbicularis Oculi MuscleA skin-deep curved incision with its convexity towardthe upper orbital margin is created with the central high-est point of the convexity about 5–7 mm from the orbitalmargin. The incision line slopes gently toward both endsof the incision. The ends of the incision are kept awayfrom the lid margin by at least 7–8 mm.

The skin is carefully separated from the underlyingorbicularis oculi muscle close to the incision line. It isthen progressively undermined and separated, right upto the lid margin. During the process of underminingand separation of the skin, the tip of the blunt curvedcorneal scissors is kept directed toward the skin, so thatthe orbicularis muscle is not excessively injured or carriedalong with the skin. A clean dissection in the right planeminimizes oozing of blood. At times, a few bleeding

Figure 1—Balloning the skin with subcutaneous lidocaine.

Figure 2—Reflection of the skin leading to the exposure of theorbicularis in muscle up to the lid margin.

Figure 3—Plication suturing of the upper and the lowerorbicularis muscle fibers, showing the central plication sutureonly.

Figure 4—Two orbicularis plication muscle sutures havebeen added on both sides of the central suture, which isshown in Fig. 3.

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points will need to be cauterized with a bipolar radio-cautery or hemostased with the non-cauterizing FugoBlade™ (Medisurg Ltd., Norristown, PA).

The reflection of the skin flap is best done with a ×6head worn magnification. It gives a degree of freedomof movement that is not possible with an operating

microscope. One can look under the skin flap and carryout the dissection with confidence. Bright illuminationwith a 5–6 cm diameter is obtained from the operatingmicroscope. This light transilluminates the skin andhelps to identify and separate the orbicularis fibers fromthe skin. In addition, a hand-held light is sometimesrequired to sometimes directly illuminate under the skinflap for better visualization.

The making of the skin flap exposes the arches oforbicularis oculi fibers. They are circularly disposed,dark pink in appearance, and a number of blood vesselsof various sizes are seen coursing over them (Fig. 2).

Plication of the Orbicularis MuscleVanadium stainless steel (VA 316) 80-µ suture attached toan atraumatic needle is used for plication. The first sutureis applied in the middle of the incision field. The needle ispassed under a 2-mm strip of the orbicularis close to thelid margin. The same needle then lifts a 2-mm strip of theorbicularis muscle toward the orbital margin. The selec-tion of the proximal site varies according to the degree ofptosis. It is placed closer to the superior orbital margin incases of severe ptosis. When the central suture is tied, thelid margin is seen to rise (Fig. 3). The cornea is hereinexposed. At this stage the cornea is covered with a thicklayer of visco-elastic material like methylcellulose. A reefknot is used. The ends of the suture are cut close to theknot with a stout scissors. A single suture produces anangulation in the lid margin. To produce a natural lookinglift to the entire lid, one or two sutures are applied oneither side of the central suture (Fig. 4).

At the end of plication, the following can be noted:

1. The lid margin rises to expose the cornea. If thepatient looks straight ahead, the lid margin mayappear in the vicinity of the upper limbus.

Figure 5—The skin flap created by surgical dissection isherein anchored to the orbicularis fibers with three 80-µstainless steel sutures.

Figure 6—Excision of excess skin is demonstrated.

Figure 7—The margin of the skin incision is shown closedwith interrupted skin sutures.

Figure 8—Using two fingers, the upper lid is pusheddownward to demonstrate that the eye is easily closed withminimal force.

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2. The reflected skin flap looks much bigger than theraw area that needs to be closed.

3. The upper lid margin may in some cases show a ten-dency to stand away from the eyeball.

Managing the Palpebral Skin FlapThe loose skin flap is fixed as follows:

1. The under-surface of the skin is sutured to the pli-cated orbicularis muscle at three points with singlethrow sutures. This prevents the skin from hangingdown (Fig. 5).

2. A 2- to 3-mm strip of excess skin is excised from thebottom of the incision flap (Fig. 6).

3. The skin flap is closed with 10–12 single throw, verysuperficially applied, 80-µ vanadium steel sutures(Fig. 7).

Closing the EyeThe upper lid is gently pushed downward in order toclose the eye (Fig. 8). When pressure is released, theeyelid moves up, revealing the elasticity of movement.The eyelid is carefully closed, with a sterile eye patchtaped over the eyelid. Recently, we have preferred topass a stout nylon suture for tying the two lids together.

Postoperative Management

AdultsThe eye is opened after 24 hours. The patients areinstructed to close the eye frequently. A pad and bandageis applied when the patient feels tired of exercising theorbicularis. The eye is bandaged if it is seen to remain openduring sleep. These precautions are to be followed for afew days until the eye closes spontaneously during sleep.

Infants and ChildrenThe eye is opened after 48 hours. The parents are instructedto carefully watch the blinking and closing of the eye andto comply with local medication use and eye protection. Ifthe eye remains partially closed during sleep, it is ban-daged. If the child is co-operative, pad and bandage areapplied for 2–3 hours during the day. This precaution isrequired for 1 week to 10 days.

Eye protection precautions are enforced rigorously ifBell’s phenomenon is absent or if the eye is hypotropic.

Postoperative MedicationPostoperative medications include: oral broad-spectrumantibiotics for 5 days; artificial tear drops, instilled six to eight

Figure 9—A 15-year-old patient with unilateral severe ptosis and hypotropia. Left column of photos is preoperative. Right column is 6 months postoperative. Top row is up-gaze. Second row from the top is looking straight ahead. Third row from thetop is down-gaze. Bottom row shows closure of the eyelids.

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times a day for 2 months; and Neosporin®–hydrocortisoneeye ointment on the incision line twice a day for 3 months.

RESULTSDuring the past 9 years, more than 265 cases haveundergone operations. The treated eyelids belonged tothe following categories: congenital, unilateral–severe(132); unilateral–moderate (36); bilateral–severe (56);bilateral–moderate (2); Marcus Gunn ptosis–severe (21);Marcus Gunn–moderate (5); senile ptosis (4); paralyticptosis–unilateral (2); paralytic ptosis–bilateral (2); failedLPS (levator palpebrae superioris) surgery (2); andfailed brow suspension (3).

Hypotropia was seen in 17 eyes, whereas hypertropiawas present in 4 eyes. Eleven eyes had divergent squint,whereas three had a convergent squint.

The treated eyes belonged to patient age groups as fol-lows: younger than 2 years (12); 2–5 years (28); 6–10years (63); 11–15 years (42); 16–20 years (50); 21–30years (45); 31–40 years (12); 41–50 years (3); 51–60 years(5); and over 60 years (5).

The patients were followed for a minimum of 2 days toa maximum of 72 months, the average being 7 months.Sixteen patients underwent re-operation for unsatisfactory

primary surgery result. Fourteen more patients wereoffered a second operation, which they refused.

Two types of surgical problems were seen. One con-cerns the separation of the orbicularis oculi musclefrom the overlying skin. Blunt corneal scissors wereused for this purpose. The surgeon’s eye was keptfocused on the plane between the two tissues. A loss ofattention may result in splitting of orbicularis fibers,which then ended up in the skin flap. Bleeding isanother problem, which is most often the result of anexcessively deep dissection plane. Trying to dissect inthe absence of clear visibility may also cause damage tothe orbicularis muscle. The dissection is more difficultin previously operated and failed cases. Small button-holing can occur in the skin flap, which is not a seriousproblem.

One patient of congenital bilateral paralytic ptosisfailed to observe precautions as advised. This led toexposure and infective corneal ulcer in one eye. Fortu-nately, the ulcer responded to the treatment. The patientwas ultimately left with a small nebular opacity in thelower periphery of the cornea, which did not interferewith her sight.

One elderly patient showed a noticeable ectropion ofthe upper lid. This resulted from an excessive excision

Figure 10—A 65-year-old patient who sustained head trauma resulting in total ophthalmoplegia. Left column of photos is preoperative. Right column is 2 days postoperative. Top row is up-gaze. Second row from the top is looking straight ahead.Third row from the top is down-gaze. Bottom row is closure of the eyelids.

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of the loose skin. However, the patient was not aware ofthis until he was told of its occurrence. Nothing morewas done based on patient preference.

The combined results of all the categories are as fol-lows: excellent (51), good (143), fair (57), and poor(14). The result is considered excellent if the eyelidappears normal in the primary position. If a slight effortis needed to make it look normal, it is considered asgood. If moderate effort is needed to lift the lid, it isconsidered as a fair result. Below-moderate findings isconsidered a poor result. Some of the results are shownin Figs. 9–14.

Lid lag is observed in every operated eye. It appearsobvious in unilateral operated cases. The degree of lid lagtends to improve with time as the lid becomes soft andsupple. The lid lag produces asymmetry in unilateralcases.

Lagophthalmos was not seen to persist in any case.One patient with bilateral congenital third nerve paraly-sis, who since birth had never exercised her orbicularismuscle, developed a postoperative corneal ulcer becauseof exposure, as mentioned previously.

DISCUSSIONThe only pre-requisite for orbicularis plication is anintact facial nerve and the orbicularis muscle. The tissueplane in which orbicularis plication is performed is dif-ferent than the planes in which frontalis suspension orlevator resection is done. Therefore, a less-than-satisfactoryresult of one technique can be corrected with a secondsurgery with the other technique. In the case of orbicu-laris plication, the operation can be repeated by the sametechnique.

Orbicularis oculi muscle plication has a number ofmerits:

1. The technique is simple.2. Minimal tissue manipulation and no damage to the

deeper lid structures.3. Low probability of deformities such as ectropion,

ectropion, and lid-notching resulting from this operation.

4. Except for lid lag when looking down, in unilateralcases, there is good symmetry. Lid lag tends to de-crease with time.

Figure 11—An 11-year-old child with severe bilateral ptosis. Left column of photos is preoperative. Right column is 2 days postoperative for the right eye and 1-year postoperative for the left eye. Top row is up-gaze. Second row from the top is looking straight ahead. Third row from the top is down-gaze. Bottom row is closure of the eyelids.

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5. The absence of lagophthalmos permits its applica-tion in young patients.

6. The excursion of the lid with jaw winking is re-duced, parallel with the improvement in the primaryposition of the lid.

7. The cases of paralytic ptosis are amenable to thissurgical technique.

8. In failed cases by other techniques, it has a utility.Because the other operations are performed indeeper planes, the orbicularis oculi muscle usuallyescapes damage and is available for use.

9. If an undercorrection or an overcorrection occurs, arevision can be performed with minimal trauma tothe tissues.

10. In specific cases, a part of the orbicularis can be pli-cated to overcome a segmental defect of the lid.

The choice of suture material for the purpose of orbicu-laris oculi plication is important. We have selected 80-µvanadium steel for the following reasons: it is strong; theknot does not slip and it does not absorb; it is totally inert,therefore no inflammatory changes occur around it in thetissues (that makes it easy to undo or enhance on re-opera-tion, if required); and this suture is equally good for sutur-ing the skin (the skin sutures fall out in a couple of weeks).

How much plication does one perform in an individ-ual case? In severe cases, the plication is to be donebetween the orbicularis fibers close to the lid margin andthe fibers that are about 5–8 mm from the superiororbital margin. The exact height of plication in all casesis judged clinically by keeping an eye on the position ofthe lid margin in relation to the upper limbus. I have notexperienced a single case of overcorrection. Whenever Ifeared an overcorrection, the result was an undercorrec-tion. How much trimming of the skin flap, before applyingthe skin sutures? This is a matter of clinical judgment atthe time surgery. In general, the younger the patient, theless the trimming needed. In younger patients, if no trim-ming is done, the excess skin shrinks in a few months. Ifan undesirable skin fold hangs on the lid, its excision iseasy to manage.

There are many young patients in our series. The par-ents were asked to watch lid movements and to applyartificial tears frequently during the day and to bandagethe eye at night if it remained open during sleep. Thisprecaution was necessary for the first 1–2 weeks. Noneof the operated patient had a significant problem of clos-ing the eyelid.

A word of warning about the creation of the skin flap:because a large skin flap is dissected by severing its

Figure 12—A 15-year-old patient with bilateral severe ptosis. Left column of photos is preoperative. Right column is 8 monthspostoperative for the right eye and 3 weeks postoperative for the left eye. Top row is up-gaze. Second row from the top is lookingstraight ahead. Third row from the top is down-gaze. Bottom row is closure of the eyelids.

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vascular connections to the deeper muscular and subcuta-neous tissues, it is important that the flap be so fashionedthat the chances of flap necrosis are minimized. This isdone by keeping the ends of the incision at least 8 mmaway from the lid margin. The lid may sometimesappear dark in the early postoperative period. It could bethe result of temporarily reduced vascularity of the skinflap or of the collection of some blood in the subcutaneousspace. We have not come across a case of necrosis so far.

Orbicularis oculi plication has a universal appli-cation in treating all types and severity of cases withequal ease. It works irrespective of the pathology inthe levator palpebrae superioris muscle. In most casesof severe ptosis, the levator muscle is said to befibrotic, therefore attempting maximum resection inthe hope of achieving a good result is an exercise infutility. The expected absence of muscular tissue in thepathological levator makes it impossible to achieve adegree of plasticity that is desirable in the surgery forsevere ptosis. The existing levator function is notdisturbed by orbicularis plication. In case of Marcus-Gunn ptosis, the surgical elevation of the ptotic lid

reduces the height of reflex excursion of the lid. A lid foldusually forms spontaneously after orbicularis plication.

It may or may not match the lid fold in the other eye.The excess skin may or may not be excised. In mostcases, the skin shrinks spontaneously over a period ofmonths. Sometimes an excessive skin fold may hangnear the lid margin, in which case the strip is excised.

We have not been able to develop a formula to spec-ify exactly how much plication should be performedfor a given case. Our rough guide is to watch the lidmargin in relation to the cornea during the course ofsurgery. The curvature of the upper lid margin is alsokept under scrutiny when the sutures are applied oneither side of the center. Occasionally, at the end ofsurgery, the upper lid margin seems to lift away fromthe eyeball. In such a case, a lid spatula is placed onthe conjunctival side and some pressure is appliedfrom the skin side. The procedure of orbicularis oculimuscle plication, as described previously, utilizes healthymuscle fibers to form active muscular arches betweenthe upper and the lower circular bundles. The surgi-cally corrected lid, by this method, has a degree of

Figure 13—A 20-year-old patient of unilateral severe right ptosis. Left column of photos is preoperative. Right column is 6 months postoperative. Top row is up-gaze. Second row from the top is looking straight ahead. Third row from the top is down-gaze. Bottom row is closure of the eyelids.

Figure 14—A 7-year-old patient with severe ptosis of the left eye. Lid lag is evident in the operated eye. Left column of photos is preoperative. Right column is 1-month postoperative. Top row is up-gaze. Second row from the top is looking straight ahead.Third row from the top is down-gaze. Bottom row is closure of the eyelids.

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freedom and plasticity, which is difficult to realizeafter facia lata brow suspension or after a large resec-tion of the fibrotic levator palebrae superioris muscle.

How does orbicularis plication work? It is difficult tomake a catagorical statement about this issue. It seemsthat the union of the upper and the lower orbicularisfibers produces muscular aches, which lift the upper lidwithout a conscious effort. This is perhaps true of all thesuccessful cases. The role of the plicated orbicularismuscle in lifting the ptotic lid is particularly highlightedif the levator palpebrae superioris muscle is paralyzed(Fig. 10).

At the present time, the most commonly performedprocedures are levator palpebrae superioris and browsuspension with fascia lata. A number of complicationsare possible, the most important being lagophthalmosthat can threaten the health of the cornea. If overcor-rection occurs, weakening is required, which mayrecreate ptosis. Lid may be pulled away from the eye-ball after brow suspension. The use of stored fascia latamight set up a reaction. If it is absorbed, the ptosisreturns. Other problems like entropion, ectropion, peaking,

loss of eyelashes, and uneven contour of the lid mar-gin, etc., although rare, do occur. Under- or overcorrec-tion needs complicated procedures to overcome theproblem.

Orbicularis oculi plication has been successfully usedby the author for 9 years. There have been few compli-cations as a result of this operation. Re-operation forundercorrected case can be easily performed. There aretwo important requirements for a successful operation—a meticulous skin flap and the use of 80-µ stainless steelsutures. The technique appears to be a useful additionand perhaps an alternative to the existing techniques ofptosis surgery in specific situations.

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MO: C. V. Mosby, 1981, pp. 39–76.3. Collin JRO. Ptosis. In: Manual of Systematic Eyelid Surgery.

Oxford, England: Butterworth Heinemann, 1999, pp. 41–72.4. Levine MR. Manual of Oculoplastic Surgery. Oxford, England:

Butterworth Heinemann, 1996, pp. 75–105.