eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Upper Lid Ptosis Surgery: Treatment

Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Coauthor(s): Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Jan 30, 2008

Treatment

Surgical Therapy

Surgical therapy is the only effective management for ptosis of the upper lid. As indicated, many different surgical techniques are available for ptosis correction.

Minimal incision approaches have been described to correct aponeurotic laxity by Freuh et al.9 This anterior approach uses minimal dissection, is faster than traditional approaches, and can be just as efficacious in the properly selected patient.

Extended upper blepharoplasty incisions are more appropriate in patients with significant lateral hooding in addition to ptosis. Har-Shai and Hirshowitz described an incision along the supratarsal fold extending past the lateral canthus and cephalad toward the eyebrow.10 This technique also facilitates cosmetic improvement and fat resection if needed.

Preoperative Details

This is the authors' preferred method of correction. Preoperative makings should be performed with the patient in the upright position. The meridian of the eyelid should be marked on both the affected and unaffected side. The supratarsal fold also should be marked. Both planned incisions should be infiltrated using 1% lidocaine with epinephrine.

Intraoperative Details

The authors' preferred method of ptosis correction can be performed in conjunction with facial rejuvenation. A standard upper blepharoplasty incision with conservative skin excision is used to obtain exposure; however, a limited incision approach (ie, less than a centimeter) can also be used and has been presented with good results. 

Plication of the levator aponeurosis is performed using 6-0 clear nylon sutures. The suture is placed as a horizontal mattress stitch plicating only the aponeurosis and avoiding the tarsus to prevent lifting the eyelid from the globe or notching the lid margin. The superior portion of the suture is placed in the aponeurosis 4-8 mm above the superior tarsus. The inferior portion of suture is placed in the aponeurosis just above the tarsal plate. The amount of plication used was determined by the elevation of the lid gained with the plication. Usually 1 mm of lid margin elevation is obtained with 3 mm of plication. Most patients were corrected to a level at the superior limbus or 1 mm below. Many patients are corrected using a single suture placed at the vertical axis of or just medial to the pupil. Additional sutures can be placed medial or lateral to this central stitch.

Postoperative Details

No dressing is required; however, application of cool packs decreases swelling and bruising as well as postoperative discomfort. Instructions on corneal protection and the use of artificial tears are essential, as with any periorbital surgery. Skin sutures can be removed on postoperative day 4 or 5.

Follow-up

Follow-up care is performed over a period of several weeks to allow swelling to resolve. Postoperative photographs allow objective evaluation of surgical results.

Complications

Complications include difficulty closing the eyes, eye irritation, and contour irregularity and asymmetry. Although undercorrection of ptosis is one of the most common complications, it is not associated with corneal problems such as exposure or drying. Rather, the cosmetic appearance is not optimized because some ptosis is still present in the operated eye. This problem cannot be corrected without an additional plication of the levator.

In addition to asymmetry, significant overcorrection can lead to serious problems, such as corneal exposure, drying, and ulceration. In these severe cases, it is critical to protect the cornea using artificial tears, ophthalmic ointment, and taping of the eyelid. If eyelid excursion is limited by scar adhesions or lagophthalmos persists, surgical lysis of adhesions may be required. However, asymmetry and contour irregularity will improve significantly with massage therapy alone.

Meticulous hemostasis is essential to prevent hemorrhagic complications. Acute bleeding into the globe is a sight-threatening emergency, which requires immediate re-exploration and decompression. Residual hematoma within the eyelid can cause excessive fibrosis, chronic edema, and persistent lid irregularities.

Other complications following ptosis correction or upper eyelid surgery include reduced vision, corneal abrasion, entropion, loss of eyelashes, or diplopia. Subconjunctival edema or "chemosis" occurs more frequently but resolves spontaneously within a few weeks and can be treated with ophthalmic steroids.

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References
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References

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Further Reading

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Keywords

blepharoptosis, upper lid blepharoplasty, ptosis correction, levator plication, upper lid ptosis surgery, upper lid ptosis, ptosis surgery

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Contributor Information and Disclosures

Author

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

Coauthor(s)

Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham
Luis O Vasconez, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Head and Neck Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, and American Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine
Neal R Reisman, MD, JD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Medical Quality, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, Lipoplasty Society of North America, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center
R Edward Newsome, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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