Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus  Kiyoshi Matsuo, Shoji Kondoh, Takeshi Kitazawa, Yoshimasa Ishigaki, Niroh Kikuchi  British Journal of Plastic Surgery  Volume 58, Issue 5, Pages 668-675 (July 2005) DOI: 10.1016/j.bjps.2004.12.032 Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions

Figure 1 Hypothetical schematic diagrams of the relationships among the levator (LM), superior rectus (SR), and inferior rectus (IR) muscles, the capsulopalpebral fascia (CP), the inferior suspensory ligament of Lockwood (L), the lower eyelid, and the globe. (A) Normal eyelid without disinsertion of the levator aponeurosis from the tarsus. OS, orbital septum; LA, levator aponeurosis; ITL, inferior transverse ligament W: Whitnall's ligament; MM, Müller's muscle. (B) After the aponeurosis is disinserted from the tarsus, additional contraction of the inferior rectus muscle accompanied with the levator and superior rectus muscles displaces the superior palpebral crease (SPC) upwards and the lower eyelid downwards and the globe upwards by means of traction of the capsulopalpebral fascia and the inferior suspensory ligament of Lockwood, resulting in lower scleral show. (C, D) Advancement of the orbital septum, which is the superficial expansion of the levator aponeurosis, by vascular clips or surgery relaxes the superior and inferior rectus muscles, lessens the traction of the capsulopalpebral fascia and the inferior suspensory ligament of Lockwood, raises the lower eyelid, and lowers the globe in the orbit. British Journal of Plastic Surgery 2005 58, 668-675DOI: (10.1016/j.bjps.2004.12.032) Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions

Figure 2 A 32-year-old male patient with unilateral lower scleral show. (A, B) Temporary aponeurotic advancement by vascular clips is performed to confirm whether aponeurotic surgery will correct the global position and cause the diplopia. (C) Intraoperatively, how the disinserted levator aponeurosis slips from the tarsus is determined. The stretching of Mueller's muscle induces involuntary contraction of the bilateral levator muscles.12 (D) Aponeurotic advancement and fixation with three stitches is unilaterally performed in the right eyelid. (E, F) The right global position in the orbit is lowered immediately after the fixation and 4 months after surgery. British Journal of Plastic Surgery 2005 58, 668-675DOI: (10.1016/j.bjps.2004.12.032) Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions

Figure 3 A 30-year-old female patient with bilateral lower sclera show. (A, B) The vertical global position from the center of the cornea to the intercanthal line is measured pre-operatively without or with temporary aponeurotic advancement by vascular clips. The blue line indicates the horizontal position of the lower corneal limbus. (C) Aponeurotic advancement and fixation with three stitches (arrow) is unilaterally performed in the right eyelid. (D) The global position is measured to confirm whether unilateral aponeurotic advancement might cause unilateral downward displacement of the ipsilateral globe. The blue line on the lower corneal limbus helps to measure the global position in ptotic eyelid according to Hering's law. British Journal of Plastic Surgery 2005 58, 668-675DOI: (10.1016/j.bjps.2004.12.032) Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions

Figure 4 Changes of lower scleral show in eight patients. In the left column are pre-operative photos. In the central column are pre-operative photos with temporary aponeurotic advancement by vascular clips. In the right column are post-operative photos of the primary gaze position. The vertical level and size of the photos of each patient in the left, central, and right columns were adjusted based on the intercanthal line and the square scale. (A, B) Unilateral lower scleral show in patients with unilateral decompensated aponeurotic blepharoptosis. (C, D) Bilateral lower scleral show in patients with bilateral decompensated aponeurotic blepharoptosis. (E, F) Bilateral scleral show in patients with bilateral compensated aponeurotic blepharoptosis and the features of Mongoloid eye. (G, H) Bilateral scleral show in patients with bilateral compensated aponeurotic blepharoptosis (the goggled eye). British Journal of Plastic Surgery 2005 58, 668-675DOI: (10.1016/j.bjps.2004.12.032) Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions

Figure 5 Statistical analysis of the global position in the orbit and the degree of retraction of the lower eyelid. (A, B) Changes in pre-operative and post-operative distances form the center of the cornea to the line between the medial canthi. (C, D) Changes in pre-operative and post-operative areas enclosed by the lower lid margin and the line between the medial and lateral canthi. British Journal of Plastic Surgery 2005 58, 668-675DOI: (10.1016/j.bjps.2004.12.032) Copyright © 2005 The British Association of Plastic Surgeons Terms and Conditions