To confirm when the levator aponeurosis is disinserted and how the disinser
tion is compensated for in growing children, the earliest and latest photog
raphs of the same children were the subjects of a retrospective comparative
study regarding upward displacement of the superior palpebral crease and t
he eyeball in the palpebral fissure. Ninety-four children (48 boys and 46 g
irls) were selected from 615 patients with cleft lip and palate who were fo
llowed for more than several years at our outpatient clinic and whose 58,00
0 photographs were digitized. The earliest and latest photographs of the pa
tients were taken in primary gaze position; the former, taken at less than
3 years of age, and the latter, taken at more than 6 years of age, were sel
ected for this study. The intervals between the two photographs ranged from
3 to 14 years (mean, 9.61 years; SD, 3.11). The superior palpebral crease
moved upward parallel with the growth of the children (p < 0.0001) as well
as with the length of the growth period (p = 0.0141). The lower eyelid did
not move downward (p < 0.0001). The eyeball also displaced upward parallel
with growth (p < 0.0001) and with the length of the growth period (p = 0.03
02). The more the superior palpebral crease was displaced upward, the more
the eyeball was displaced upward (p = 0.0005). The levator aponeurosis may
be likely to disinsert from the tarsus in growing children, thus requiring
compensatory, excessive contraction of the levator muscle, which may cause
upward displacement of the superior palpebral crease. Subsequently, excessi
ve contraction of the superior rectus muscle in conjunction of the levator
muscle may rotate the eyeball upward, which may incline the head. When the
head is not inclined in the primary gaze position, compensatory contraction
of the inferior rectus muscle to maintain the horizontal visual axis may d
isplace the eyeball upward in the orbit by means of the inferior suspensory
ligament of Lockwood.