Ptosis Blepharoplasty Treatment & Management

Blepharoptosis is one of the most challenging of the commonly encountered oculoplastic problems. The goal of ptosis surgery is to recreate as nearly perfect an anatomic result as possible by elevating the position of the lid or lids and by creating a lid fold, if necessary. In addition, special attention is given to the contour and symmetry of the lids.

A thorough understanding of the goals and limitations of ptosis surgery is important, and the patient should be fully aware of these before surgery is planned. Particularly in congenital ptosis, when factors inherent to the anatomic defect pose limitations to the surgical results, the expectations and goals of the surgery must be discussed carefully with the patient and/or the parents preoperatively. A defective levator muscle, whose function is abnormal or absent preoperatively, cannot be restored surgically. The lid level can be changed, but dynamic limitations of the affected muscle persist postoperatively, and these may result in significant lid lag and lagophthalmos. Often the best result that can be hoped for is a normal lid level and contour when the eyes are in the primary position. In adult-acquired ptosis, surgery may result in inappropriate eyelid closure, exacerbation of a preexisting tear deficiency, and secondary exposure keratopathy.

In a survey of its members, The Aesthetic Society found that 97.4% of the responding surgeons who performed ptosis repair most often employed levator advancement or plication. ^[6]

General anesthesia is necessary for all children. Local anesthesia is adequate for adults and is much preferred for some types of ptosis. Adequate anesthesia can be obtained with a simple subcutaneous injection of 1.5-2 mL of anesthetic across the breadth of the lid. Intraorbital injection is not necessary, and if patient cooperation is desirable for setting the lid height, avoid injection behind the orbital septum. This type of injection avoids levator akinesia, thus allowing the levator muscle to function normally intraoperatively. The maintenance of levator function is an essential part of some ptosis procedures. It allows demonstration of the redevelopment of normal lid function in patients who have aponeurotic defects and is a valuable guide in patients with other syndromes in which the amount of levator resection cannot be judged accurately from preoperative measurements. Plain lidocaine (2%), lidocaine with epinephrine, or a lidocaine-bupivacaine mixture are all satisfactory.

Under general anesthesia, the congenitally ptotic lid may appear less ptotic; therefore, marking the lid prior to anesthetizing the patient is wise, since the possibility exists of inadvertently operating on the wrong eye.

In a study by Guo et al in which upper lid ptosis was corrected via the Müller aponeurosis composite flap advancement approach, the investigators found comparable postsurgical results with either local, general, or sedative anesthesia. The investigators reported that postoperatively, the marginal reflex distance–1 and corneal exposure area for local, general, and sedative anesthetics were 3.28 mm and 75.4%, 3.01 mm and 73.4%, and 3.62 mm and 74.0%, respectively. ^[7]

Frontalis sling (modified Crawford technique)

Although many variations of technique and materials for the frontalis sling procedure exist, generally surgeons agree that autologous fascia lata or preserved fascia lata (as a second choice) placed as a double rhomboid, single rhomboid, or triangular sling from the frontalis to the lid produces the best result. Other materials, such as catgut, collagen, Prolene, silicone, stainless steel, silk, skin, Supramid, sclera, tantalum, tarsus, and recently Mersilene mesh, umbilical vein, tendon, and other new synthetics, have been tried. Most of these materials have resulted from a search for substitutes that are effective, easily available, inexpensive, easily placed and removed, and involve few complications. Perhaps most importantly, the hope was that these would be useful in infants or young children when autologous fascia was not available.

Many of these materials have clear disadvantages, and the author does not recommend their routine use. The primary problems include early and late failure due to absorption, stretching, fracture, or cheese wiring, as well as infection that may require removal of the foreign body, which may be difficult or impossible with Mersilene mesh. To date, none of these materials have matched fascia lata in effectiveness and safety.

Clearly, in some circumstances fascia lata may not be necessary, for example, in a young infant with congenital ptosis felt to be of traumatic origin or caused by a hemangioma and in whom a temporary lid elevation may be desired or in an adult with dry eyes and severe myogenic ptosis in whom a temporary and easily reversible procedure may be performed to assess the patient's tolerance to lid elevation.

The author recommends Supramid or Prolene suture in children and Prolene or perhaps a silicone band in adults; this may be placed in an adjustable fashion. Whatever material is used, the principle of the suspension is the same (ie, the frontalis muscle, which normally elevates the brow, is used to elevate the lid).

Crawford popularized the use of the patient's own fascia lata and developed a fascia lata stripper that bears his name. He has also devised a method for storing human fascia sterilized by radiation. Physicians have used this material since 1969, and it has produced results nearly comparable to those with autologous fascia. Crawford found a recurrence of ptosis in approximately 10% of more than 300 patients in whom this procedure was performed over a 20-year period when preserved fascia was used. For this reason, he uses autologous fascia in all but infants and elderly people. To avoid the necessity of harvesting fascia, the author generally uses the preserved material and reserves the autologous fascia for patients in whom it is unavailable or when a previous sling has failed.

Using a sling for unilateral ptosis produces a cosmetic blemish on downward gaze because the motion of the lid is restricted when following the downward movement of the globe; however, excellent cosmetic results can often be obtained with the unilateral sling. The patient can learn to move one side of the brow to set the lid level close to that of the unaffected side and can ease the brow on downgaze to minimize asymmetry. Use of a bilateral sling is now accepted in patients with unilateral ptosis or with unilateral jaw-winking phenomenon to give symmetry to the 2 lids. This is felt by some to be cosmetically pleasing and to give coordination to the movements of the lids as they follow the globe in the up and down positions.

Frontalis suspension for the surgical correction of poor levator function congenital ptosis has been a matter of debate in the last decade, but recently progress has been made. A study by Bernardini et al highlights the relevant keystones regarding sling material, surgical steps, and approach that can improve functional and esthetic results, while minimizing risk to the eye. ^[8]

A Chinese study indicated that in severe congenital ptosis, the success of treatment using the frontalis muscle transfer technique depends on the preoperative quality of frontalis muscle function, with the investigators finding that patients whose frontalis muscle had a preoperative excursion of greater than 7 mm tended to have better correction outcomes than did those whose frontalis muscle had an excursion of 7 mm or less (91.2% sufficient correction vs 63.2%, respectively). ^[9]

Harvesting fascia

Children older than 3-4 years are usually large enough to allow harvesting of fascia. If in doubt, use preserved fascia or an alternate material. To obtain fascia for use in the modified Crawford technique, place the fascia lata of the leg on stretch by slightly bending the knee and turning the knee inward and the heel outward. Place a pillow beneath the hip and between the legs with a piece of adhesive tape across the lower leg to hold the knee in position.

Provide routine surgical preparation to the skin of the lateral surface of the thigh from the knee to the upper portion of the thigh, and apply the adhesive portion of a sterile plastic sheet (eg, 3-M #1060) with the hole 2.5 inches above the knee. Make a 1.5- to 2-inch horizontal incision 2.5 inches above the joint and carry it down through skin, subcutaneous tissue, and fat to the fascia, which can be seen as a white, glistening, heavy tissue with fibers running parallel to the axis of the leg. Control superficial bleeding with cautery. Use 2 skin rakes to give exposure.

Pick up the fascia with Adson skin forceps and make a 1-cm full-thickness incision through and perpendicular to the fascial fibers (horizontal). Then, make 2 vertical cuts (parallel to the fascial fibers) at the ends of the horizontal incision and extend them toward the hip for approximately 2 cm. This mobilizes the ends of the fascia so it can be threaded into the Crawford stripper (Storz #N-4298). Tie a 4-0 black silk suture in this end of the fascia to aid in threading and holding the fascia as the stripper is passed up the tendon, directed on a line from the head of the fibula or lateral tibial condyle to the iliac crest. The stripper has sharp lateral cutting edges.

After the cut is well started, the fascia splits along the parallel fibers with relative ease. Pass the stripper along the tendon for 20-25 cm; the lever is closed to cut the fascia at this point, and the stripper and fascia are withdrawn. Close the subcutaneous tissue of this incision with 4-0 chromic catgut and close the skin with an end-on mattress suture of 4-0 silk, nylon, or Prolene. Apply an elastic bandage to the thigh for 2 days for hemostasis.

The patient's activities are restricted for several days because, occasionally, a late hemorrhage occurs; however, very little postoperative reaction or pain is experienced from the thigh. Remove the skin sutures after 8 days. Place the excised fascia strip on a board and pin it to hold it on stretch. Remove any clinging fat or subcutaneous tissue. Split the strip of fascia, approximately 8 mm wide, for its full length, taking great care to separate the fibers with straight scissors and cutting across as few as possible. This gives 2 excellent strips 3-4 mm wide and 20-25 cm long, which is enough to perform the procedure on both lids.

Procedure

Make 3 stab incisions in the brow down to the periosteum with a No 15 Bard-Parker knife. Make the lateral incision 0.5 cm above the orbital rim (at the upper border of the eyebrow) and 0.5 cm temporal to a line drawn perpendicularly above the lateral canthus. The second incision is made 0.5 cm above the orbital rim, perpendicular to the center of the lid, and the third incision is made 0.5 cm above the orbital rim and 0.5 cm nasal to a line drawn perpendicular to the inner canthus. Always make the lateral incision first because the brow is fairly vascular, and if the nasal and middle incisions are made first, the blood flows over the operative site, making the lateral incision difficult. Place a Halsted hemostat in the base of each incision and spread to create a wide base for the location of the knot of fascia. Pressure over the 3 incisions provides hemostasis.

Place a 4-0 black silk traction suture in the tarsus and pass the needle in and out of the gray line in the center of the lid. Place a Storz lid plate (#E2504), which has a knurled knob at the end, under the lid, and fasten the traction suture to the knob to put the lid on constant stretch. A protective contact lens may also be used to protect the eye, but the author finds the lid plate more flexible. Make 3 horizontal stab incisions, 2 mm long, in the upper lid 1 mm above the cilia line through the skin and pretarsal muscle to the tarsus. Place the temporal incision 3 mm from the medial canthus, the middle incision in the center of the lid, and the nasal incision 3 mm from the medial canthus.

With the lid plate in place, insert an empty Wright needle (Storz #E954) into the middle brow incision to the depth of the periosteum. Pass it across the orbital rim without incorporating periosteal fibers of the linea alba. Direct the needle inferiorly and posteriorly to pass behind the orbital septum and then superficially into the lid anterior to the tarsal plate to emerge through the middle lid incision. Thread the fascia through the needle until the center of the strip is reached. Then withdraw the needle, pulling the doubled fascia through the middle incision and out the middle brow incision. Cilia must not be pulled into the tract with the fascia, since this increases the possibility of infection. Cut the double fascia at the needle, making 2 strips of equal length that are used to produce the double rhomboids.

Insert the empty Wright needle into the temporal lid incision and pass it beneath the skin to the middle lid incision. Thread the end of one fascial strand through the needle and withdraw it toward the temporal lid incision. Direct the empty needle from the temporal brow incision downward and out through the temporal lid incision in the same fashion as it was placed through the central brow and lid incisions. The fascia is then drawn through the temporal brow incision. Pass the empty needle from the temporal brow incision to the middle brow incision, and thread the opposite end of the same fascial strand through the needle and pull it out through the temporal brow incision.

This procedure produces a temporal rhomboid, and the tension on the 2 ends elevates the lateral half of the lid. The same steps are carried out in the same order to complete the medial rhomboid, using the second strip of fascia in the middle and nasal incisions of the brow and lid. By using the 2 strands of fascia in this fashion, the middle, temporal, and nasal portions of the lid can be controlled to produce a good lid contour that is slightly higher in the nasal third than in the temporal third. Both strands of fascia are pulled tightly enough to produce a good lid fold and to elevate the lid so it crosses the upper limbus with the eye in the primary position.

If bilateral ptosis is present, perform the procedure on both lids during the same operation to produce symmetry. Grasp the ends of the fascia projecting from the nasal brow incision with small Halsted clamps, and place a single tie with the fascia pulled as tightly as necessary. As mentioned, tie the sling so that the upper lid crosses the globe at the upper limbus in the primary position at the time of operation.

Some postoperative relaxation always occurs, usually 1-2 mm, which puts the lid at approximately the correct position. The author has found that overcorrection is difficult in these situations, and generally the fascia is pulled as tightly as possible. Suture the knot firmly with 4-0 chromic catgut suture or 5-0 Vicryl, using multiple passes to prevent slippage. The author has found placement of a second tie in the fascia unnecessary, since slippage does not occur if the single fascial throw is adequately sutured in place. In addition, deleting the second loop considerably reduces the bulk of the knot in the brow incisions.

However, the fascia is extremely slippery, and the ends must be fastened securely with suture material. The ends of the fascia are left long, projecting from the wound. Grasp the knot with the Halsted clamp and push it into the base of the incision so that it is well buried. Tie the fascia projecting from the temporal brow incision similarly. The temporal rhomboid usually is not tied quite as tightly as the nasal one in order to obtain proper lid contour. Examine the lids for symmetry.

Grasp the tarsal plate with two Adson skin forceps and pull the lid down into the proper position to produce a good curve without any peaking. This pulling on the lid actually sets the fascia in the desired position. If any notching or irregularity of the lid is present, pull it out by grasping the tarsus firmly with Adson forceps and pulling the lid margin to its proper place to equalize the pull of the vertical components of the sling.

When satisfied with the height of the lid, bury the projecting ends of the fascia by pulling them horizontally within the brow tract with the Wright needle from the nasal and temporal incisions toward the middle incision. In this procedure, the fascia should be inserted only slightly into the eye of the needle so it pulls free as the needle is drawn across the brow. If enough of the end of the fascia is left so that it projects from the middle wound, cut it off so that the buried portion lies deep and retracts into the incision. Close the brow skin incisions with 2-3 7-0 chromic catgut sutures placed very superficially. The lid incisions need not be closed. If the lid is picked up off the globe by elevating the brow, the fascia likely has not been placed behind the orbital septum superiorly. Patrinely and Anderson emphasized this well-recognized consideration in 1986. If this situation is detected, the fascia should be replaced prior to final suturing.

At the end of the procedure, a Frost suture of 6-0 black silk is usually placed, allowing closure of the eye(s) by fastening the lower lid to the forehead with adhesive strips. Some patients have fared well using ointment liberally once discharged. In this situation, emphasize to the patient or parents that large amounts of ointment are necessary, since the eye is most at risk of exposure during the first 24-48 hours when the lids are sore and closure is poor. If a Frost suture is placed, dress the eye with antibiotic ointment and a pressure patch for 24 hours.

Anterior approach for levator resection

At the level of the lid crease, make a 2-cm skin incision with a scalpel. If no lid crease is present, carefully place the skin incision to match the lid crease on the contralateral side. Use skin hooks to gently spread and elevate the skin edges, and divide the orbicularis muscle using fine, sharp scissors. Meticulous control of bleeding is essential at this point and throughout the procedure. Wet-field cautery gives excellent control and minimal reaction, but a fine hot-tip cautery also works well.

Perform dissection superiorly, posterior to the orbicularis in the preseptal space, until orbital fat can be identified through the intact orbital septum. Put slight pressure on the globe; this causes the orbital fat to prolapse, making the identification easier. The orbital septum is then divided with a horizontal incision for the length of the skin incision. The orbital fat, orbital septum, and skin are retracted superiorly with a Desmarres retractor. The levator tendon is thus exposed and is identified generally as a glistening white membrane.

In patients with severe congenital ptosis and very poor levator function, the levator tendon is very thin and is easily damaged with rough manipulation. Great care should be taken in its handling since a shredded tendon becomes difficult to repair. Make a small buttonhole in the levator tendon at the level of the inferior wound margin over the upper third of the tarsal plate and divide the tendon with scissors across the tarsus for the width of the incision.

The Müller muscle is then identified as a slightly reddish-brown and friable structure immediately beneath the levator tendon. A relatively large marginal vessel generally overlies the retrotarsal margin and serves as a good landmark of the Müller muscle, especially in cases of levator dehiscence, in which identification of the dehisced edge of tendon at the retrotarsal margin can be difficult. Gently elevate the levator aponeurosis with fine forceps while dissecting it with blunt-tip scissors from the underlying Müller muscle.

In cases of mild-to-moderate ptosis, dissection up to the origin of the Müller muscle from the undersurface of the levator muscle is generally sufficient to allow adequate levator resection. In cases of severe ptosis, the origin of the Müller muscle may be divided from the undersurface of the levator using a hot-tip cautery as a cutting instrument. The levator muscle may be held with a ptosis clamp if desired. With the muscle on stretch, the levator horns can be identified and divided.

In some cases, the Whitnall ligament may serve as a check ligament to the levator and also can be divided. If Müller muscle has been divided from the levator muscle, it then can be resutured to the belly of the levator muscle with an absorbable suture as far proximally as possible with the levator tendon on stretch. This effectively advances the levator tendon and muscle without resection or folding of the Müller muscle.

Place mattress sutures of a nonabsorbable material (eg, 5-0 Mersilene, Prolene) in the anterior-superior portion of the tarsal plate, or, if some advancement is desired, perform dissection anterior to the tarsus down to the lash follicles. The mattress sutures may be placed in the anterior-inferior third of the tarsus, giving advancement of an additional 4-6 mm. The sutures are placed equally across the lid, brought out through the aponeurosis, and tied temporarily until the appropriate degree of shortening is determined.

Actual resection of the tendon is reserved until the sutures have been permanently tied and the position and contour of the lid accomplished. The lid curvature and lid level can be readily adjusted by tightening one or the other of the mattress sutures to give the ideal contour. Divide the levator tendon or muscle with scissors and ensure hemostasis. Additional sutures may be placed for reinforcement as desired. Suture the orbicularis at the inferior skin edge to the resected edge of levator tendon with several interrupted sutures. This ensures formation of a lid crease and appropriate movement of the upper lid skin fold with motion of the lid.

The skin is closed with running 8-0 black silk suture, which remains in place for 5-7 days. Absorbable sutures may be used in children, placing subcuticular or interrupted sutures of a fine material. The lower lid may be elevated with a Frost suture in the immediate postoperative period. A 4-0 or 6-0 black silk suture placed through the skin of the lower lid and taped to the brow works well.

Anterior approach for levator aponeurosis repair

Local anesthesia is preferred for anterior-approach levator aponeurosis repair because it allows documentation of levator function at the time of surgery and allows the patient to cooperate with the surgeon in setting the proper height and contour of the lid(s). Resection or advancement of a tendon with a normal muscle is likely to produce an overcorrection, and local anesthesia allows for accurate determination of lid level. Lidocaine (2%) provides adequate anesthesia for this procedure, which generally takes only about 30-40 minutes to perform. Approximately 0.5-1.5 mL of lidocaine is injected subcutaneously across the lid at the level of the lid crease. Injecting posterior to the septum is not desirable, since this paralyzes the levator muscle. The skin incision and dissection through the orbicularis are the same as for a levator resection.

If a full dehiscence has occurred, often the septum is rolled superiorly and attached to the free edge of the levator aponeurosis, making its identification difficult. In this setting, after the orbicularis is divided, the Müller muscle is the next structure the surgeon encounters. The slight reddish-brown color and the transverse peripheral vascular arcade at the retrotarsal margin readily identify this muscle. If dissection is carried superiorly for several millimeters, the septum and tendon can be identified and separated. Remember that orbital fat is a crucial landmark separating these 2 structures. Dissecting superiorly under the orbicularis and over intact septum until preaponeurotic fat can be identified may be wise. At this point, the septum can be incised and the fat retracted to identify the levator aponeurosis proximal to the dehiscence.

When a complete dehiscence occurs, the edge of the levator tendon is identifiable as a relatively thick, rolled, white structure. If the patient is asked to open his or her eye or look up at this point in the procedure, the tendon is seen to retract into the orbit forcefully. After isolation, resuture the tendon to the upper mid portion of the tarsus, but slightly nasal to the pupil in the primary position, using a nonabsorbable suture. Use 2 additional sutures to set the lid contour nasally and temporally. Temporary suture placement initially allows for demonstration of good lid level and function prior to final closure. Care in closure prevents lid contour problems.

Occasionally, the levator tendon does not have a complete dehiscence but is attenuated and elastic in nature, termed a stretchy tendon. At surgery, this can often be identified by having the patient open his or her eyes and look up, demonstrating good levator function superiorly in the orbit but with poor lid motions. In this situation, simply resuture the tendon to the upper tarsal border to produce a firm attachment of the tendon to the lid at the desired height. This sometimes requires the use of hang-back sutures.

Close the skin with 8-0 black silk sutures in the same fashion as described for levator resection. The lid fold usually reforms spontaneously, but 2-3 fine sutures attaching the orbicularis to the levator tendon ensure its reformation. The author prefers not to suture skin to the tendon because this gives an unnaturally deep crease, which is noticeable when the lids are closed. No Frost suture is required.

A light patch may be used at the surgeon's discretion, although an antibiotic ointment may suffice. The author has found that the best results are obtained with minimal anesthesia and a rapid, atraumatic procedure. Postoperatively, the lids usually remain within 1 mm or so of the level set at surgery.

Orbicularis plication for ptosis

Recently, Singh ^[10] suggested a novel surgery that he believes is a viable addition or alternative to the existing methods of ptosis surgery. This procedure involves exposure of the orbicularis oculi muscle via a skin flap that starts near the upper orbital margin and progresses downward. The orbicularis oculi fibers near the lid margin are then joined to the proximal orbicularis fibers and the skin flap is sutured back to normal position. Singh claims that, in over 9 years, 265 operations have been performed on a wide variety and severity of ptosis.

With levator resection or a fascia sling procedure, in which some lagophthalmos is expected, the lower lid is pulled up with a modified Frost suture to cover the cornea.

Place antibiotic ointment in the eye and apply a light patch, which should be left in place for 24 hours. Use an antibiotic-steroid ointment on the suture line during the postoperative period and in the eye to guard against possible drying. Generally, only 1-2 weeks of ointment use is necessary for complete adjustment to the new situation. The patient is seen on the first postoperative day mainly to look for exposure problems and infection. If evidence of surface drying or a persistent epithelial defect is observed, the Frost suture may be left in place until healing occurs.

Remove the sutures 5-7 days postoperatively and recheck the patient. If lagophthalmos seems severe and the patient is unable to close the eye, the lid may be taped closed at nighttime, or a bubble-shield moisture chamber may be placed for protection in addition to generous ointment application. Once the repair is stable, a final visit in 1-2 months allows evaluation of the result.

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Black Eye.

Undercorrection

Undercorrection of a ptotic lid is the most common complication. Most often, undercorrection is caused by inadequate resection of the levator tendon owing to inadequate preoperative evaluation. Occasionally, excessive hemorrhage at the time of surgery may cause the surgeon to fail to identify and resect the proper structures. Excessive hemorrhage and the resultant scarring may lead to a less mobile lid and, even in the presence of an adequate levator resection, may lead to an undercorrection. Misplaced sutures or slippage of sutures in the postoperative period may also cause this complication. These situations can usually be avoided by careful preoperative evaluation and careful surgery. Unfortunately, occasional undercorrections occur even when proper preoperative evaluation and excellent surgical technique are used.

Some investigators report an 80-90% success rate with aponeurotic surgery, but in some of the remaining 10-20%, reoperation is necessary. Significant undercorrection or overcorrection can be adjusted in the early postoperative period by opening the wound and replacing the necessary suture(s) within 48-72 hours, before significant healing has occurred.

Occasionally, the surgeon attempts to correct severe ptosis with a levator resection when a frontalis sling procedure is more appropriate. Good results may be obtained, but often a frontalis sling procedure is required later, since even very large (>25 mm) levator resections may not elevate the lids. Sometimes, the manipulations of surgery produce mild paresis of the levator muscle and the lid appears undercorrected in the immediate postoperative period but improves with time. For this reason, repeat surgery should be delayed several months.

At that time, careful evaluation of the situation and discussion with the patient or parents should be undertaken to determine if the amount of undercorrection is considered a problem to those involved and if repeat surgery is desired. If levator function is present, repeat levator resection is performed using the guidelines presented for primary resections. If levator function is poor, a frontalis sling procedure is necessary.

Undercorrection following a frontalis sling procedure is treated with repeat operation; make sure to leave the lids near the upper limbus at surgery. If available, autologous fascia is preferable in these cases.

Overcorrection

Overcorrection in moderate or severe congenital ptosis is rare. It can occur if the lid is unintentionally sutured to the Whitnall ligament or to an excessively shortened orbital septum, but it is very difficult to produce by any reasonable amount of levator resection. Overcorrection in a patient with acquired ptosis, particularly levator dehiscence, is rather easy to produce if a levator resection is performed rather than simply a repair of the dehiscence. This problem was more frequent before the pathophysiology of this type of ptosis was recognized and when the defect was treated with either anterior or conjunctival approach levator resection.

If significant overcorrection occurs, it can be adjusted in the early postoperative period (1-3 d) as described for undercorrection. Alternately, massage of the lid can be instituted in 4-5 days and can be continued for several months to ensure the maximum effect is achieved.

Stretching the lid in a downward fashion in the immediate postoperative period can also provide some effect. The lid may be doubled over a Desmarres retractor and pulled on daily for several days, again beginning after an observation period of 3-4 days. Levator recession is required if a significant overcorrection persists several months after ptosis surgery. Preserved sclera and fascia lata have been used to lengthen the levator muscle in the same fashion as for correction of lid retraction in thyroid disease; however, levator recessions are frequently performed with no spacers, since usually only hang-back sutures suffice. Generally, the amount of recession is equal to the amount of lid retraction. Again, this procedure can be performed with the patient under local anesthesia to allow the patient's assistance in accurately setting the lid level.

Poor or improperly positioned lid crease

A poor or improperly positioned lid crease may occur if the skin incision is placed incorrectly or if the skin and orbicularis muscle are not fixated to the levator aponeurosis during the skin closure. A lid crease can be lowered by making an incision at the desired level for the new crease and then excising the intervening scar and closing the new incision. Conversely, elevating the crease is difficult, since making a new adhesion higher exposes the original scar. In that situation, lowering the crease on the contralateral side may be easier.

Peaking of the lid

Peaking of the lid rarely occurs with levator resection if the tarsus is left intact, since its width serves to stabilize the lid contour. However, if sutures are placed unevenly or if suturing is directly to the tarsus in one area and to pretarsal tissues in another, contour problems are more likely to occur. Reoperation may be necessary to obtain the best result. Operations in which the tarsus is resected partially produce a much higher frequency of lid contour problems and are therefore no longer advocated.

Exposure keratitis

Mild exposure keratitis is frequently noted for the first few weeks after surgery. This seems to cause little or no problem in children, since the epithelium soon heals and the patient readjusts to the new situation. In adults, corneal staining may persist and be significant. Tear function must be reevaluated. In general, temporary tear replacement, ointments, and lid closure at night produce adequate protection, and the problem disappears. If the problem persists, consider placement of temporary punctal plugs. Significant lagophthalmos is unusual in patients with levator dehiscence, since lid function is simply restored. Some lagophthalmos is common after frontalis sling procedures and with maximal levator resections. The parents should always be informed preoperatively that the eyes will remain open to some extent while a child is asleep and that temporary protection is necessary.

Corneal abrasion

Corneal abrasion can result from sutures inadvertently placed through the tarsus or conjunctival surface. After suture placement, evert the lid to check that a suture is not exposed. Protect the globe and cornea during dissection and suture placement and, as noted above, especially during Wright needle insertion. Consider using a contact lens corneal protector or lid plate.

Lid lag

Lid lag, like lagophthalmos, is an expected compromise of congenital ptosis surgery that must be accepted.

Infection and inflammatory reactions

Infection is extremely rare following levator surgery. It may occasionally occur with frontalis sling procedures, since an avascular, possibly foreign material is introduced. In addition, a noninfectious inflammatory reaction to implanted materials may occur. Chances of infection may be reduced by irrigating the operative site with an antibiotic solution at the end of the procedure. Take great care to avoid introducing cilia or other foreign material into the operative site during placement of the fascia. Treat infections by heat and appropriate systemic antibiotics. If some material other than fascia is placed, its removal may be necessary.

Late granulomatous inflammatory reactions can be observed around suture materials. Once a suture abscess has been excluded, treat these conservatively with warm compresses and antibiotic-steroid combination ointments if superficial, followed by steroid injection at the site, with or without removal of the inciting material and fistulous tract.

Double vision

Usually, postoperative diplopia is due to direct damage to the superior rectus muscle and sometimes the superior oblique muscle; rarely, it is due to direct nerve damage.

Usually, good-to-excellent results are obtained when these procedures are performed by experienced surgeons. ^[11]

A study by Bahceci Simsek indicated that ptosis blepharoplasty can lead to significant relief from tension-type headaches. In the study, patients with tension-type headache symptoms were treated with either standard upper eyelid blepharoplasty or ptosis repair, with the latter consisting of levator resection, Müller muscle resection, or frontalis suspension. The investigators found that for both groups of patients, mean postoperative scores on the Headache Impact Test (HIT-6) showed significant improvement over the mean preoperative scores. ^[12]

No true controversies exist regarding this surgery bar the decision of whether to operate on both eyes in severe unilateral congenital ptosis, particularly in patients affected by Marcus Gunn winking. The consensus and recent studies have demonstrated that bilateral frontalis slinging is the best option, but some surgeons remain hesitant to take this severe approach.