Thank you so much for these clear explanations. Do you thing it would be possible to post a video of a full surgery with a posterior approach ? It would be extremely helpful... I hope you'll continue to send new videos. I very often watch them before going to the OR...
Hi Sander, the brow lift was with a pre-trichial ellipse excision, direct subperiosteal elevation and with two prolene loops passed through small stab incisions above the brow at the site of the marks anchored at the periosteum at the superior edge of the wound. It works for some hair styles! In others the scar is too prominent. Best wishes. Ric
Thanks for the excellent presentation! I just have a question about the insertion of the levator's aponeurosis. AAO BCSC books mention that the aponeurosis is more firmly attached on the inferior part of the tarsal plate and looser on the superior part. So is it right to re-attach the aponeurosis on the upper part of the tarsus to get that physical contour?
Hi Moayad, when Putterman described his technique in the 1970s it was new and groundbreaking. It remains an excellent technique, and is worth noting in the evolution of posterior approach ptosis surgery. It has it's place, unlike Fasanella-Servat, which is no longer acceptable. Our understanding of posterior approach has however continued to evolve over the last 50 years, and in particular over the last 10 years. A simple levator aponeurosis advancement is now the posterior technique of choice. Simple, easy, needs no extra kit, repeatable and easy to understand. The knowledge and appreciation of the anatomy remains king. Best wishes. Ric
hello dear dr. Caesar thank you for your nice presentation, I am big fan of yours a question please, in the first example of anterior unilateral ptosis, MRD is approximately 0 and the patient as it looks by the photo seems to be a little bit exotropic and hypotropic guided by corneal reflex, so could a Horner's cause such features?
@@usamaali-nh3xi Aha, you're talking about the patient at 21 mins. Pre and post. I'm very impressed by how observant you are! There is indeed as slight exo and hypo and I'm embarrassed to say that I know why. Based on the pupil this could be a Horners, as I suggest in the video, but it isn't - the left eye is a false eye! The subtle clue is the visible edge at the plica. You are Sherlock usamaali Holmes. I missed it when I was choosing pre and post ptosis photos for my video. It is a very impressive false eye to be fair :) Best wishes! Ric
I also have a question for the posterior approach : when you dissect the Muller Muscle, you explain that you reach the levator aponeurosis. But I read that Muller Muscle inserts on the Whitnall ligament. So how can you reach the aponeurosis ?
Hi Moimeme1512. For simplicity in this video I've stopped discussing the anatomy at the point where the conjunctiva, Mullers and levator all merge, as this is the practical end point for most ptosis surgery. As you continue to advance superiorly from the levator aponeurosis you will reach the Whitnall ligament. Tracking the Mullers will first lead you to the undersurface of the levator aponeurosis, and this "White Line" is key for posterior approach surgery. Best wishes. Ric
Hi Hisar. In the first instance I would open the top wound, find the silicone and tighten it over the sleeve and resuture. If the problem is inadequate frontalis movement some training and practice can help, but the results can be underwhelming. (Always worth checking a patient isn't using botulinum toxin to have a smoother forehead!). Best wishes. Ric
Hi David. I've just really zoomed in on the image and I think you are right! Ha. Pseudo Horner's via fixed pupil on a glass eye! What a great glass eye. I'm very impressed by your powers of observation. Sherlock Holmes was based on an ophthalmologist. That could be you. Best wishes. Ric
So happy you are publishing video again!
Thank you so much. As far one of the best teachers ever.
Thank you you are one of the best teacher and gentleman that I have ever seen BEE SUCCEED.
Thank you so much for these clear explanations. Do you thing it would be possible to post a video of a full surgery with a posterior approach ? It would be extremely helpful... I hope you'll continue to send new videos. I very often watch them before going to the OR...
very informative , it helps me a lot to understand the surgical approachs
thanks a lot
Thank you for the explanation, now i know that i have Ptosis, but this video give me the courage for repair it!
Thank you for this presentation
Love it!
Thank you so so much doc 💓 💖 🎉😊. 😅
Very clear and informative.
Great presentations!
Hope you post new videos! It has been a while.
Thank you for the excellent presentation. How did you perform the brow lift on the left side in het unilateral posterior ptosis female patient?
Hi Sander, the brow lift was with a pre-trichial ellipse excision, direct subperiosteal elevation and with two prolene loops passed through small stab incisions above the brow at the site of the marks anchored at the periosteum at the superior edge of the wound. It works for some hair styles! In others the scar is too prominent. Best wishes. Ric
Thanks for the excellent presentation! I just have a question about the insertion of the levator's aponeurosis. AAO BCSC books mention that the aponeurosis is more firmly attached on the inferior part of the tarsal plate and looser on the superior part. So is it right to re-attach the aponeurosis on the upper part of the tarsus to get that physical contour?
Please can you do a video for blepharoplasty approach
I was hoping to see you explain more about the posterior approach in particular Putterman’s technique
Hi Moayad, when Putterman described his technique in the 1970s it was new and groundbreaking. It remains an excellent technique, and is worth noting in the evolution of posterior approach ptosis surgery. It has it's place, unlike Fasanella-Servat, which is no longer acceptable. Our understanding of posterior approach has however continued to evolve over the last 50 years, and in particular over the last 10 years. A simple levator aponeurosis advancement is now the posterior technique of choice. Simple, easy, needs no extra kit, repeatable and easy to understand. The knowledge and appreciation of the anatomy remains king. Best wishes. Ric
@@riccaesar very helpful. Thanks Ric
hello dear dr. Caesar
thank you for your nice presentation, I am big fan of yours
a question please,
in the first example of anterior unilateral ptosis, MRD is approximately 0 and the patient as it looks by the photo seems to be a little bit exotropic and hypotropic guided by corneal reflex,
so could a Horner's cause such features?
Hi. The first case was a simple involutional. The second was a Horners. The pupil is usually the sign that alerts you to Horners. Best wishes. Ric
@@riccaesar aren't the first two photos for the same patient? Pre and post op?
@@usamaali-nh3xi Aha, you're talking about the patient at 21 mins. Pre and post. I'm very impressed by how observant you are! There is indeed as slight exo and hypo and I'm embarrassed to say that I know why. Based on the pupil this could be a Horners, as I suggest in the video, but it isn't - the left eye is a false eye! The subtle clue is the visible edge at the plica. You are Sherlock usamaali Holmes. I missed it when I was choosing pre and post ptosis photos for my video. It is a very impressive false eye to be fair :) Best wishes! Ric
Please show us the brow lift
I also have a question for the posterior approach : when you dissect the Muller Muscle, you explain that you reach the levator aponeurosis. But I read that Muller Muscle inserts on the Whitnall ligament. So how can you reach the aponeurosis ?
Hi Moimeme1512. For simplicity in this video I've stopped discussing the anatomy at the point where the conjunctiva, Mullers and levator all merge, as this is the practical end point for most ptosis surgery. As you continue to advance superiorly from the levator aponeurosis you will reach the Whitnall ligament. Tracking the Mullers will first lead you to the undersurface of the levator aponeurosis, and this "White Line" is key for posterior approach surgery. Best wishes. Ric
@@riccaesar Thank you very much for your reply and your explanations. Your videos are invaluable for surgical training.
Any suggestion in performing ptosis surgery revision due to inadequate lifting after frontalis sling suspension surgery?
Hi Hisar. In the first instance I would open the top wound, find the silicone and tighten it over the sleeve and resuture. If the problem is inadequate frontalis movement some training and practice can help, but the results can be underwhelming. (Always worth checking a patient isn't using botulinum toxin to have a smoother forehead!). Best wishes. Ric
please make one on ECTROPION please please
Dear Waleed - as if by magic - th-cam.com/video/IlHxBdIU-fw/w-d-xo.html
Best wishes
Ric
Eu também tenho um olho caído!😞
Patient at 21:36 might have a glass eye? (post-enucleation?)
Hi David. I've just really zoomed in on the image and I think you are right! Ha. Pseudo Horner's via fixed pupil on a glass eye! What a great glass eye. I'm very impressed by your powers of observation. Sherlock Holmes was based on an ophthalmologist. That could be you. Best wishes. Ric