Blepharoptosis: Evaluation, Techniques, and Complications

Blepharoptosis: Evaluation, Techniques,and ComplicationsSyed M. Ahmad, M.D.,2 and Robert C. Della Rocca, M.D.1,2,3

ABSTRACT

Blepharoptosis (ptosis) is one of the most common eyelid disorders encoun-tered in ophthalmology. A detailed history and exam are crucial in the evaluation of apatient presenting with ptosis. This provides the correct guidelines for surgicalplanning. The appropriate surgical technique is usually determined by the degree ofptosis and levator function. The surgeon should have an armamentarium of severaldifferent techniques for the management of ptosis. This article will detail a modifiedapproach to the traditional tarsomyectomy (Fasenalla-Servat procedure) and also discussthe levator advancement. Despite the proper preoperative evaluation and meticulousattention to technique, the ptosis surgeon may still encounter postoperative complica-tions. The ability to manage the array of possible complications truly distinguishes theptosis surgeon.

KEYWORDS: Ptosis, blepharoptosis, levator advancement, Fasenalla-Servat

procedure, tarsomyectomy, frontalis suspension

Blepharoptosis, also referred to as ptosis, is thedrooping or abnormally low position of one or bothupper eyelids with the eyes in primary gaze. Ptosis is acommon condition resulting from the dysfunction of oneor both upper eyelid retractors. Most commonly thiscondition is acquired secondary to involutional changes,but this condition may also be secondary to a congenitalcause. Depending on the degree of ptosis, presentingsymptoms may range from an asymptomatic subtlecosmetic defect to significant visual deficits. There arenumerous etiologies of ptosis with varying anatomicpathologies and associations with underlying systemicdisorders. Different classification schemes have beendeveloped based on severity (levator function), anatomy,and age of onset.1,2 A classification system based onunderlying abnormality is shown in Table 1.3 Identifi-

cation of the underlying pathogenesis is paramount foroptimal treatment and surgical planning.

CLASSIFICATION

Aponeurotic

Aponeurotic or involutional ptosis is the most commontype of ptosis. In this type of acquired ptosis, the levatormuscle is normal but a dehiscence, attenuation, ordisinsertion of the levator aponeurosis from the anteriorinferior third of the tarsal plate leads to an abnormal lidposition. This type of ptosis is characterized by normallevator function, elevated lid crease, thinning of theoverlying skin, and a deep upper lid sulcus. The patientusually presents with a slowly progressive mild to severe

1Department of Ophthalmology, The New York Eye and Ear Infir-mary, New York, New York; 2Department of Ophthalmology,St. Luke’s-Roosevelt Hospital Center, New York, New York; 3Depart-ment of Ophthalmology, New York Medical College, New York,New York.

Address for correspondence and reprint requests: Robert C. DellaRocca, M.D., 310 East 14th Street, New York, NY 10003.

Oculoplastic Surgery; Guest Editors, Robert C. Della Rocca, M.D.,David A. Della Rocca, M.D.

Facial Plast Surg 2007;23:203–216. Copyright # 2007 by ThiemeMedical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel: +1(212) 584-4662.DOI 10.1055/s-2007-984561. ISSN 0736-6825.

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ptosis of unknown duration. It may occur as apart ofnatural age-related changes or secondary to ocular sur-gery (e.g., cataract surgery), long-term daily contact lenswear, chronic inflammation, or trauma.

Myogenic

Myogenic ptosis may be either congenital or acquired.Most commonly, patients with the congenital diseasehave a levator maldevelopment or dysgenesis secondaryto infiltration with fibrous and/or adipose tissue. It ischaracterized usually by a severe ptosis with poor levatorfunction, absent lid crease, and lid lag or ‘‘hung up’’appearance on down gaze. Other cases of myogenicptosis may be caused by local or diffuse muscular disease.They are characterized by poor levator function, pres-ence of the upper eyelid crease, and absence of lagoph-thalmos. Myasthenia gravis is an acquired conditionwith a marked variability or fluctuation of ptosisthroughout the day. It is a disorder of the neuromuscularjunction with a deficiency of acetylcholine receptors.Acquired myogenic ptosis can also be found in myotonicdystrophy, chronic progressive external ophthalmoplegia(CPEO), and oculopharyngeal dystrophy.4,5

Neurogenic

Neurogenic ptosis develops from a deficit along theinnervation pathway. Both Horner’s syndrome and thirdnerve palsies may have either a congenital or acquiredpresentation. Myasthenia gravis has a later onset. The

presentation of an acute onset ptosis should alert thesurgeon to the possibility of an associated emergentneurological condition and thus warrants a thoroughneurological evaluation. Congenital Horner’s syndromecauses an interruption of sympathetic innervation toMuller’s muscle and results in a mild ptosis. AcquiredHorner’s syndrome can be secondary to vascular, neo-plastic, or traumatic insult along the sympathetic path-way. Associated signs include ipsilateral miosis andanhidrosis. Decreased pigmentation of the iris and areolaare additional findings seen only in congenital forms ofHorner’s. Third nerve palsies can be secondary to a vastnumber of insults and can include both acquired andcongenital presentations.

Miscellaneous

Other miscellaneous causes include traumatic ptosissecondary to penetrating or blunt injury. Penetratinginjuries involving the levator muscle or aponeurosis mayrequire repair to correct the ptosis. However, ptosis fromblunt injury should be allowed the chance to sponta-neously resolve.6 A 6-month observation period is ap-propriate prior to contemplating surgical intervention.Eyelid neoplasms (e.g., neurofibromas or hemangiomas)can cause a weighing down of the upper eyelid leading toa mechanical ptosis. Chronic cicatrizing changes mayalso contribute to a ptosis.

Pseudoptosis

Pseudoptosis refers to a group of disorders that may givethe false impression of a ptosis. Resolution of theapparent ptosis is usually achieved if the primary disorderis addressed. Conditions with deficient orbital volumesuch as enophthalmos, anophthalmos, phthisis bulbi,microphthalmos, and fat atrophy may result in a pseu-doptosis. Treatment should be directed at addressingorbital volume rather than a ptosis repair. Dermatocha-lasis, redundant upper eyelid skin, may cause visualobstruction from overhanging skin. Dermatochalasismay be best addressed with a blepharoplasty. Othercauses of pseudoptosis include retraction of the contrala-teral upper eyelid in conditions such as thyroid eyedisease. Contralateral proptosis and hypotropia mayalso give the illusion of ptosis.

UPPER EYELID ANATOMYA basic review of the anatomy of upper eyelid will beaddressed but a detailed understanding using anatomictexts is encouraged and is crucial for the ptosis surgeon.The upper eyelid is a mobile, multilayered structurethat has the vital function of protecting the globe. It ishelpful to visualize the anatomy by dividing the eyelidinto an anterior and posterior lamella. The anterior

Table 1 Etiologies of Ptosis

Congenital ptosis

Myopathic

Blepharophimosis

Neurologic

Synkinetic ptosis

Homer’s syndrome

Third cranial nerve palsy

Acquired ptosis

Aponeurotic

Trauma, postsurgical, allergy, contact lens wear

Myopathic

Myasthenia gravis

Chronic progressive external ophthalmoplegia

Myotonic dystrophy

Neurologic

Homer’s syndrome

Third cranial nerve palsy

Mechanical

Mass lesions

Posttraumatic

Pseudoptosis

204 FACIAL PLASTIC SURGERY/VOLUME 23, NUMBER 3 2007

lamella is comprised of skin and orbicularis muscle, andthe retractors, tarsal plate, and conjunctiva make up theposterior lamella. In primary position the upper eyelidrests at the superior corneal limbus in children and 1 to2 mm below in adults. The eyelid margin peaks at ornasal to the pupil.

The skin of the eyelid is among the thinnest in thebody and unique in having no subcutaneous fatty layer. Itis a pliable, dynamic structure and important topograph-ically in delineating natural and dynamic landmarks.Underneath the skin lies the orbicularis oculi muscle,which serves as the main protractor of the eyelid.1 Theorbicularis is a thin sheet of concentrically arrangedmuscles divided into pretarsal, preseptal, and orbitalparts. Contraction of the orbicularis oculi is provided bycranial nerve VII and results in the closure of the eyelid.The thick orbital portion of the orbicularis extendssuperiorly and plays an important role in forced eyelidclosure. The preseptal portion overlies the orbital septum.In between is a fibroadipose layer that is continuous withthe eyebrow fat pad. The ptosis surgeon should becognizant that significant amounts of fat behind thislayer may falsely mimic the appearance of preaponeuroticfat.7,8 The pretarsal orbicularis is firmly adherent to theunderlying tarsal plate. The orbital septum is a multi-layered fibroconnective tissue membrane that arises froma condensation of tissue at the orbital rim known as thearcus marginalis.9 It is continuous with the periosteum.The orbital septum and the levator aponeurosis join �2to 5 mm above the superior tarsal border. Directly behindthe septum lies the preaponeurotic fat pad.

The levator palpebrae superioris and the sympa-thetically innervated Muller’s muscle (aka superior tarsalmuscle) are the two retractors of the upper eyelid.10 Thelevator palpebra is a striated muscle that is innervated bythe superior division of cranial nerve III. The levatormuscle is�40 mm long and originates in the orbital apexfrom the lesser wing of the sphenoid. It continuesanteriorly and at Whitnall’s ligament its directionchanges from a horizontal to a vertical orientation tobecome the aponeurosis inferiorly. Although consideredthe aponeurosis belowWhitnall’s ligament, muscle fiberscan still be noted within it. The aponeurosis is 14 to20 mm long and is joined by fibers of the orbital septum.The aponeurosis inserts primarily onto the anteroinferiorthird of the superior tarsus with the strongest attach-ments 3 mm from the lid margin.11 The levator aponeu-rosis also sends attachments to the skin forming theupper eyelid crease. The levator aponeurosis complexserves as the primary elevator of the upper eyelid. TheMuller’s muscle, a sympathetically innervated smoothmuscle, has its origins from the undersurface of thelevator muscle. It is �12 to 14 mm in length and insertson the superior border of the tarsal plate. It acts as anadjunct elevator, lifting the upper eyelid by �2 mm.When the action of Muller’s muscle is affected, as in

Horner’s syndrome, a mild ptosis results. The superiortarsal plate measures �10 mm in height and 25 to30 mm in horizontal dimension and is composed ofdense connective tissue. Within the tarsal plate lie thesebaceous secreting meibomian glands. Above the tarsalplate lies the peripheral marginal arcade; this serves as alandmark between the levator aponeurosis and Muller’smuscle and may be clearly visible in cases of dehiscence.

EVALUATION OF THE PTOSIS PATIENT

History

A detailed history and exam are crucial in the evaluationof a patient presenting with ptosis. This aids in deter-mining the proper etiology and also allows the surgeonto individualize treatment. Ultimately, this optimizessurgical results, helps avoid recurrences from inappro-priate treatment, and minimizes the risk of postoperativecomplications.

As with any condition, a good clinical historyshould be elicited. Patients should be questioned aboutcoexisting systemic conditions, onset of any new symp-toms, and any history of prior trauma. Prior ocularhistory of eyelid disorders, previous surgery includingany recent administrations of botulinum toxin, andcontact lens wear should be noted. The patient’s historyshould usually distinguish between a congenital versusan acquired ptosis. Sometimes it is may be difficult forpatients to give an accurate onset for the ptosis. Patientsshould be encouraged to bring in driver’s license, iden-tification cards, and old photographs to help elucidatethe history. Friends or family members may also beenlisted in determining onset. Most patients report anincreasing ptosis at the end of the day or when fatigued.Attention should be paid when a marked fluctuation ofptosis throughout the day is reported. This variation mayindicate the presence of myasthenia gravis and requirefurther workup. A recent report has also suggested thedevelopment of a myasthenia-like syndrome resulting inptosis with the use of inhibitors of 3-hydroxy-3-methyl-glutaryl-CoA reductase or statins.12 These drugs areused in the treatment of hypercholesterolemia. Certainlywith the prevalence of these medications, the surgeonshould be aware of this possible association and inquireabout statin use in cases of new onset ptosis. Symptomsof ocular irritation may suggest a reactive ptosis. Thepossibility of keratoconjunctivitis sicca or dry eyes shouldbe kept in mind not only for the purposes of determiningetiology but also to understand that these conditions maybe exacerbated with surgery. Coexisting double visionshould alert the surgeon to the possibility of an under-lying myopathic or neurological process.

Patients should also be questioned about anybleeding diatheses and the use of anticoagulants. Pa-tients on warfarin are usually asked to discontinue four

BLEPHAROPTOSIS: EVALUATION, TECHNIQUES, AND COMPLICATIONS/AHMAD, DELLA ROCCA 205

doses or 5 days prior to elective surgery. Aspirin shouldbe discontinued 2 weeks prior to surgery. Nonsteroidalanti-inflammatory drugs, which are reversible plateletinhibitors, should be stopped 1 day prior to surgery.

Examination

The physical examination should be directed to clarify-ing the etiology of the ptosis and guiding preoperativesurgical planning to the most appropriate surgical pro-cedure. All cases of ptosis should be quantified by fourimportant measurements: interpalpebral fissure height,upper lid margin to corneal reflex distance, levatorfunction, and upper lid crease position. These measure-ments should be assessed and recorded with the patientlooking in primary position, prior to and after admin-istration of phenylephrine 2.5% and with frontalismuscle action relaxed or negated. Photographs are es-sential for patient education, preoperative planning,medicolegal reasons, and insurance purposes.

The interpalpebral fissure height is measuredcentrally with a millimeter ruler (Fig. 1). This measure-ment represents the vertical aperture height from thelower eyelid to the upper eyelid. The normal heightaverages 10 mm with the range from 8 to 12 mm inadults. Any abnormal changes in the position of thelower eyelid should be noted.

The upper lid margin to corneal reflex distance isknown simply as the marginal reflex distance (MRD1).A penlight is used to illuminate the cornea. The corneallight reflex is observed and the distance between thecornea and the upper lid margin is recorded (Fig. 2). Thenormal MRD1 is between 4.0 and 4.5 mm. Thiscorresponds to the upper eyelid resting at or slightlybelow the superior corneal limbus. When the degree ofptosis is severe and the upper lid obstructs the corneallight reflex, the measurement will assume a negativevalue. The recording of a negative measurement is

performed by lifting the eyelid until one is able to seethe corneal reflex and noting the amount of lift. Gradingof ptosis is mild when the reflex isþ 1.5 mm, moderatewhenþ 0.5 mm, and severe for measurementsbelow� 0.5 mm. This measurement is one of the mostreliable ways to grade the degree of ptosis as it isindependent of variations in the position of lower eyelid.

The levator function directly determines the typeand the amount of surgery that needs to be performed(Table 2). It is assessed with the compensatory action ofthe frontalis muscle elevation negated. This is accom-plished by firmly securing one’s thumb over the browwhile measuring the excursion of the upper eyelid frommaximal down gaze to the maximal up gaze position(Fig. 3). It is sometimes helpful to take an average ofmeasurements. Levator function may be classified asexcellent (13 to 15 mm), good (8 to 12 mm), fair (5 to7 mm), and poor (4 or less).8

The upper eyelid crease is measured as the dis-tance between the central lid crease to the lash marginwith the eyelid in down gaze (Fig. 4). A high lid creasesuggests an underlying aponeurotic dehiscence. An ab-sent lid crease is frequently encountered in congenitalptosis.

Sympathomimetic agents such as 2.5% phenyl-ephrine should be used to stimulate Muller’s muscle.After instilling two drops and waiting 5 minutes, inter-

Figure 1 The interpalpebral fissure height is measured cen-trally. The zero is aligned at the level of the lower eyelid marginand distance measured to the upper eyelid margin. The inter-palpebral fissure height is 10 mm in this schematic. Figure 2 Marginal reflex distance (MRD1) measurement. The

zero mark of the millimeter rule is aligned with the corneal lightreflex and the distance to the upper eyelid margin is measured.The MRD1 is 4 mm in this schematic.

Table 2 Classification of Levator Function

Classification Levator Function (mm)

Excellent 13–15

Good 8–12

Fair 5–7

Poor < 4


palpebral fissure height and MRD1 are rechecked. If aresponse is observed, the patient is a good candidate for aposterior lamellar repair. The 2.5% phenylephrine testalso gives important information in cases of asymmetricor unilateral ptosis. Hering’s law of equal innervationstates that agonist muscles such as the bilateral levatormuscles receive equal innervation.13 If undetected priorto surgery, a postoperative drop may occur in the con-tralateral eyelid. If prior to surgery this drop is observedafter the instillation of phenylephrine, a bilateral surgeryshould be contemplated.

A complete ophthalmic examination must beperformed on every patient with ptosis with particularattention paid to the following parts of the exam. Anexternal examination should note coexisting brow ptosisand the presence and amount of dermatochalasis. Pre-existing eyelid scars may indicate prior surgical proce-dures or a history of trauma. Ptosis secondary to eyelidlesions, palpable masses, or proptosis must be deter-mined. Everting the upper eyelid should be performedparticularly to assess the feasibility of a Fasanella-typeprocedure. A careful pupillary exam with the presence ofan irregular, miotic, or mydriatic pupil may indicate acoexisting neurological condition. A motility examshould be conducted with attention paid to the presenceof a Bell’s phenomenon, activated superior rectus func-tion during inhibited levator function. The Bell’s phe-nomenon is checked by asking the patient to close theeyes while the examiner gently pries the eyelid open tocheck the position of the globe. Determining what partof the globe lies within the interpalpebral fissure isimportant if there is incomplete eyelid closure. Thepresence of strabismus or diplopia requires furtherworkup.

An anterior segment examination should note thepresence of conjunctival inflammation, filtering blebs, orkeratopathy. A full dry eye exam should be conducted ifany evidence of keratopathy exists. A retinal exam maybe needed to check for pigmentary changes if thediagnosis of CPEO is suspected.

In children presenting with ptosis, a cycloplegicrefraction should be conducted to measure for astigma-tism and to determine if any amblyopic potential existsor may develop.

Goldmann or Humphrey visual fields are per-formed to document disability secondary to ptosis.Additional ancillary studies may be ordered in caseswhere systemic causes of ptosis are suspected. Thesemay include a serum assay for acetylcholine antibodiesand edrophonium chloride (Tensilon) test to detect amyasthenic patient. In patients with CPEO, an electro-cardiogram, electroretinogram, electromyography, or amitochondrial assay should be considered. In cases ofHorner’s syndrome or third nerve palsies, appropriatecomputed tomography or magnetic resonance imagingscanning of the brain, spine, or chest may be warranted

Figure 3 Levator function measurement. The zero mark isaligned with the upper eyelid margin with the patient looking infar down gaze. The patient is then asked to look up. The totalexcursion of the upper eyelid is recorded. The levator function is11 mm in this schematic.

Figure 4 Upper lid crease position. The zero mark is alignedwith the upper eyelid margin. The distance to the lid crease isnoted. The measurement is 7 mm in this schematic.


SURGICAL TECHNIQUEMany surgical techniques have been described for therepair of ptosis. The ptosis surgeon should be comfort-able with a variety of different techniques. This allowsfor the selection of the most appropriate technique foreach individual patient.

Tarsomyectomy (Fasanella-Servat Procedure)

The tarsomyectomy is effective in the management ofmild to moderate amounts of ptosis (usually 2 mm orless) in the presence of good to excellent (8 mm or more)levator function and no response to topical 2.5% phenyl-ephrine eyedrops.14 However, because the effects ofphenylephrine mimic the end results of this surgery, itmay also be used with a positive response to phenyl-ephrine.1 This procedure’s main advantage is that it istechnically simple and predictable. This is an excellentprocedure in young patients with mild lid asymmetry.Other patients may benefit, such as patients with lateacquired hereditary ptosis, patients with Horner’s syn-drome, and in some cases patients with myopathic ptosiswhere elevation of the lid for functional purposes is moreof a concern than cosmetic purposes. This procedure isavoided by some surgeons due to difficulties in control-ling eyelid contour, resulting in the peaked appearancepostoperatively. This complication relates specifically tothe incorrect placement of the hemostats intraopera-tively. Other disadvantages of this procedure are the lossof normal tarsus, meibomian glands, and accessorylacrimal glands and destabilization of the eyelid. Thisprocedure should be performed with caution in patientswith keratitis sicca or cicatrizing conjunctival disease as itputs them at a higher risk of exacerbating these con-ditions.

SURGICAL TECHNIQUE

After the placement of a protective corneal shield, localanesthesia is obtained by injecting a dilute solution ofsodium chloride and xylocaine 2% with epinephrine1:100,000 (9:1) into the upper eyelid. The use of adilute solution along with a 30-gauge needle decreasespatient discomfort during the initial injection. This isfollowed immediately by the injection of a 1:1 solutionof xylocaine 2% with epinephrine 1:100,000 and mar-caine 0.5%. A total volume of 1 to 2 mL should be usedso to allow for patient cooperation during the proce-dure. Then a double-armed 4–0 silk suture is passedfull-thickness near the lower border of the tarsus and isused to provide traction and stabilize the eyelid. Theeyelid is everted and 0.5 mL of a 1:1 solution ofxylocaine 2% with epinephrine 1:100,000 and marcaine0.5% is injected subconjunctivally superior to the uppertarsal border (Fig. 5). Traditionally, a 5–0 Prolenesuture on a P3 needle is passed full-thickness fromthe external surface of the lid aimed just above the

tarsus. The authors have modified this technique. In-stead, a 23-gauge needle is passed from a point justsuperior to the upper, central border of the tarsus full-thickness through the eyelid medially. The needle exitssuperior to the medial aspect of the tarsus. The 5–0Prolene suture is fed into the 23-gauge needle and theneedle retracted backward full-thickness through theskin (Fig. 6). A curved clamp is then placed andencompasses the tarsus, palpebral conjunctiva, andMuller’s muscle with the tip of the clamp angulatedslightly toward the eyelid margin. The correct position-ing of the clamp is essential to avoid contour defects.The authors find the use of two clamps simultaneouslyto be cumbersome and dependent on assistancethroughout the procedure. The authors choose to useone clamp at a time (Fig. 7). Care should be taken wheneverting the eyelid to not push the skin and orbicularisinto the crease and excise a full-thickness defect intothe eyelid. The 5–0 Prolene suture is then passedserpiginously at 15-degree angle beneath the curvedclamp, carrying out the passage of the suture from thenasal to the temporal aspect (Fig. 8). Once the suturehas passed to the most temporal aspect of the hemostat,the clamp is removed and Westcott scissors are used tocut only the crushed tissue (Fig. 9). The clamp is nowpositioned from temporal end of the tarsus, includingthe same amount of tarsus, conjunctiva, and Muller’smuscle. Care should be taken not to incorporate thelacrimal gland when clamping the temporal aspect. The5–0 Prolene suture is then passed beneath the clamp,extending laterally. Crushed tissue is again removedwith Westcott scissors now excising the whole tarsus(Fig. 10). The needle is cut off and a 23-gauge needle isused again in externalizing the passage of suture to thecentral third of the eyelid adjacent to the initial sutureexit site (Fig. 11) The suture is then tied while observ-ing the position of the upper eyelid (Fig. 12)

Figure 5 The eyelid is everted and 0.5 mL of a 1:1 solution ofxylocaine 2% with epinephrine 1:100,000 and marcaine 0.5% isinjected subconjunctivally superior to the upper tarsal border.


The postoperative regimen should include lu-bricating drops. It is also advised that a fox shield beworn at night for the first 2 to 3 nights. Edema andhematoma formation may make it difficult to appre-ciate the full correction for 1 to 2 weeks. A regimen ofcool compresses for 2 days followed by warm com-presses helps to shorten the recovery period. The onlytime the eyelid is everted in the first 2 weeks is to cutsutures for the management of contour abnormalities.The Prolene suture may be removed at 1-week followup.

Posterior Muller’s Muscle/Conjunctival

Resection (Putterman Mullerectomy Procedure)

This is an alternative procedure for minimal ptosis(2 mm or less), good levator function, and a positiveresponse to the administration of 2.5% phenylephrineeyedrops.1,15,16 It is a technically difficult procedure withlimited amount of eyelid lift. This procedure is appro-priate in patients who respond well to phenylephrine andvery effective in patients with Horner’s syndrome. Smallamounts of under- or overcorrection of eyelid heightwith the phenylephrine test are compensated at surgeryby varying the resection.

Levator Aponeurotic Advancement Procedure

This technique results in the shortening of the levatorcomplex. It is used in cases of fair to good levatorfunction.17

SURGICAL TECHNIQUE

The eyelid crease is outlined with a marking pen. If aclearly defined crease does not exist, the crease shouldbe drawn out at 8 to 10 mm above the central lid margin(slightly higher in women and slightly lower in men)with a gradual tapering above the lateral canthus andthe punctum medially. Excess upper eyelid skin ismarked above the lid crease using a pinch technique.

Figure 6 (A–C) A 23-gauge needle is passed externally full-thickness toward the medial aspect the eyelid just above the tarsus. Theneedleless end of a 5–0 Prolene suture is fed into the 23-gauge needle and the needle retracted backward full-thickness through theskin.

Figure 7 The use of one clamp at a time is less cumbersomeand can be easily manipulated by one surgeon.


Local anesthesia is administered prior to prepping thepatient by injecting a dilute solution of sodium chlorideand xylocaine 2% with epinephrine 1:100,000 (9:1) intothe upper eyelid. This is followed immediately by theinjection of a 1:1 solution of xylocaine 2% with epi-nephrine 1:100,000 and marcaine 0.5%. Again care istaken not to inject excessively as this limits patient

cooperation during the procedure. A 4–0 silk tractionsuture is placed in the central upper lid margin toprovide traction. An incision is made over demarcatedline with a no. 15 blade. An en bloc skin-muscle flapmay be then excised, exposing the plane between thesuborbicularis fascia and the septum (Fig. 13). Adelicate posterior dissection is performed across theorbital septum. Dissection along the suborbicularisplane leaves a relatively bloodless field. An incisioninto the septum exposes the preaponeurotic fat(Fig. 14). Fat excision can be performed if needed. Itis helpful to gently dissect using either a monopolarcautery with a Colorado tip needle or Wescott scissors.Afterward, a Desmarres retractor is used to expose theunderlying aponeurosis. The aponeurosis is fan shapedand often glistens (Fig. 15). Dissection is then per-formed inferiorly to adequately expose the tarsus. Theleading edge of levator should be visualized around thelevel of the peripheral arcade above the superior tarsalborder. Tissue around the vascular arcade should behandled gently to avoid hematoma formation. Once theaponeurosis has been mobilized, double-armed 6–0 silkon a G-6 needle is passed partial-thickness horizontallythrough the anterior surface of the central tarsus in amattress fashion (Fig. 16). This suture should be passed�3 mm below the superior tarsal border. The sutureends are brought up through the levator and tied with asingle throw (Fig. 17). Placement of the suture willdepend on the amount of levator function. Generallyspeaking, 6 to 10 mm of resection will often yieldsufficient lid elevation. After the central suture isplaced, the patient is asked to open the eyes so thatthe surgeon may check contour and height. Once thedesired result has been achieved, the suture is com-pletely tied off; then the medial and lateral sutures areplaced in a similar fashion (Fig. 18). The lid should beeverted to check that all passes have been only partial-thickness through tarsus. The skin incision can beclosed with a 6–0 fast-absorbing gut or monofilament.Lid crease formation can be achieved with alternatingdeeper bites through the levator aponeurosis (Fig. 19).

Figure 8 (A,B) The 5–0 Prolene suture is passed serpiginously at a 15-degree angle beneath the curved clamp, carrying out thepassage of the suture from the nasal to the temporal aspect.

Figure 9 Once the suture has passed to the most temporalaspect of the hemostat, the clamp is removed and Westcottscissors are used to cut only the crushed tissue.

Figure 10 Once the passage of the suture is completed,crushed tissue is again removed with Westcott scissors nowexcising the whole tarsus.


An antibiotic-steroid ointment is applied over thewound.

Postoperatively, the patient should continue theantibiotic-steroid ointment three times daily. It is alsoadvised that a fox shield be worn at night for the first 2 to3 nights. A regimen of cool compresses for 2 daysfollowed by warm compresses helps to shorten the

recovery period. The skin suture may be removed at3- to 5-day follow-up.

FRONTALIS SUSPENSION TECHNIQUESThe frontalis suspension technique is reserved for patientswith poor levator function (0 to 4mm) and intact frontalismuscle.18,19 It is the most commonly performed proce-dure in cases of congenital myogenic ptosis and externalophthalmoplegia. This technique involves elevating theeyelid by suspending the tarsus to the frontalismuscle. It isusually performed bilaterally and considered in unilateralcases with compensatory elevation of the brow.

A variety of sling material has been used. Au-togenous fascia lata is useful in children and carrieswith it a low risk of infection but requires the harvest-ing of tissue from a second operative site. Donor fascialata obviates the need for a donor site but is at risk formaterial failure and has a small rate of disease trans-mission. Silicone rods are useful in older patientsand are readily available and easily adjusted.19 Becauseof their elasticity, eyelid closure is easier with this

Figure 11 (A,B) The needle is cut off and a 23-gauge needle is used again in externalizing the passage of suture to the central third ofthe eyelid adjacent to the initial suture exit site.

Figure 12 The suture is tied while observing the position andcontour of the eyelids.

Figure 13 After the initial incision, dissection is carried toexpose the plane between the suborbicularis fascia and theseptum.

Figure 14 Dissection along the suborbicularis plane leaves arelatively bloodless field. Here the septum and the underlyingpreaponeurotic are visualized.


material. The downside of silicone rods is an increasedrisk of infection, extrusion, or breakage.

COMPLICATIONSPatients should have a good understanding of the ele-ments of the surgery and be informed of the complica-tions and the possible need for repeat surgeries orreadjustments. Even with proper evaluation and metic-ulous attention to technique, postoperative complicationsmay still occur. The ptosis surgeon should be cognizant ofthese complications and their proper management.

Complications of Tarsomyectomy or Posterior

Muller’s Muscle/Conjunctival Resection

EYELID CONTOUR ABNORMALITY

With the tarsomyectomy, the most common compli-cation is a contour abnormality manifesting as a‘‘peaked’’ appearance of the eyelid. This is avoided bymeticulous attention to placement of the hemostatsduring surgery as previously mentioned. If too much

tarsus is resected centrally, then a ‘‘peaking’’ occurs. Ifcentral peaking is noted intraoperatively, sutures can beplaced in the medial and lateral tarsus only. Otherintraoperative measures include a gentle massage of theeyelids to distribute the suture tension equally andloosening of the suture knot. Postoperatively, onemay snip a suture at the site of the peak and gentlysmooth out the irregularity. This is the only time theeyelid should be everted in the first 2 weeks. If too littletarsus is resected centrally, then the contour becomesflat. If this is noted, excess tarsus centrally can beexcised.

UNDERCORRECTION

Undercorrection following a tarsomyectomy or a con-junctivo-Mullerectomy can be due to a variety of fac-tors.20,21 Undercorrection may result secondarily whenthere is too little resection of the posterior lamella. Itmay also result if the one of these procedures is chosenimproperly to repair a severe ptosis. If the lid is evertedin the first week, a postoperative wound dehiscencemay also lead to undercorrection. Undercorrectionmay be managed with a repeat tarsomyectomy. Repeat

Figure 15 (A,B) The levator is identified lying below the preaponeurotic fat.

Figure 16 (A,B) Once the tarsus has been exposed, a double-armed 6–0 silk suture should be passed �3 mm below the superiortarsal border. The eyelid should be everted to ensure the passage of partial-thickness bites into the tarsal plate.


tarsomyectomy should be done cautiously as too muchresection can lead to lid instability. Most cases of under-correction can be managed with a levator advancementor resection.

OVERCORRECTION

Overcorrection is rare as these procedures usually onlyresult in 2 mm of elevation. Overcorrection may bemanaged with eyelid massage four times a day for thefirst month postoperatively. Suture adjustment can betried, or alternatively a levator recession or Muller’smuscle recession can be performed.

KERATITIS

Postoperative keratitis is a common problem and may besecondary to exacerbation of a dry eye state, lagophthal-mos, suture keratopathy, or granuloma formation. Thesecan be treated with a combination of artificial tears andlubricating ointments. Suture keratopathy is rare if thesuture is performed in a buried fashion as describedearlier. Otherwise, medical management and earliersuture removal is another option. Pyogenic granulomas,though rare, can develop. These can be excised withtopical anesthesia or may respond to a trial of topicalsteroids.

Complications of Levator Surgery

UNDERCORRECTION

Undercorrections are more common than overcorrec-tions.17 Undercorrections may result from inadequateresection of the levator, insufficient advancement, loos-ening of sutures or dissolution of absorbable sutures, andlarge postoperative hematomas. If patients have goodlevator function, a repeat levator surgery can be per-formed; otherwise, a frontalis sling may be more appro-priate in those with poor levator function.

OVERCORRECTION

Overcorrection is much rarer and can be treated with acombination of lubricants if keratopathy exists. Massag-ing the eyelid downward may be beneficial in the earlypostoperative period. If no improvement occurs andthere are functional or cosmetic concerns, a levatortenotomy or levator recession can be performed.

EYELID CONTOUR ABNORMALITY

Eyelid contour abnormalities are a result of unevenplacement of the sutures that attach the levator to thetarsus. Traditionally three sutures (medially, midpupil-lary line, laterally) placed 2 to 3 mm below the superior

Figure 17 (A–C) Both ends of the double-armed suture are brought up through the advanced levator and tied with a single throw.


tarsal border and 3 to 4 mm apart will provide an optimalresult. If a contour defect is present in the early post-operative period, suture replacement can be performed.

EYELID MALPOSITIONS

Entropions can occur after large resections with short-ening of the posterior lamella. Downward massage is

initially used, after which surgery can be contemplated ifthe problem persists. Ectropions can occur with a highfixated crease after a large resection. A surgical proceduremay be needed.

Complications of Frontalis Suspension

OVERCORRECTION

Patents with congenital ptosis and poor levator functionare rarely overcorrected with a sling procedure. Over-correction can be repaired easily in the early postoper-ative period by opening the brow incisions and adjustingthe sling to the desired lid height or by instructing thepatient to massage the eyelids in a downward fashion.Undercorrection is the most common complication. Ifrecognized early, the eyebrow incisions are opened andthe sling tightened as needed to adjust the lid height.21

Lagophthalmos is an expected side effect of thisprocedure. Most patients will have difficulty closingtheir eyelids at night. Patients can be medically managedwith aggressive lubrication and lid taping at night asneeded. Silicone rods will allow the eyelid to close moreeasily because of their elastic nature.

Figure 18 (A) The patient is asked to cooperate with lid opening and closure. Once the desired result has been achieved, the suture iscompletely tied off, then the medial and lateral sutures are placed in a similar fashion. (B) Resection. (C) Dissection of excess fat mayalso be performed as needed.

Figure 19 The skin incision can be closed with attention beingdirected to form a lid crease.


CONCLUSIONThe visual impact of ptosis can be significant for thepatient. The negative psychosocial impact of an abnor-mal eyelid position should not be discounted especiallyin young children and teenagers.

A detailed knowledge of eyelid anatomy coupledwith a comprehensive history and exam are the prereq-uisites for proper surgical planning. Even in the mostexperienced hands, meticulous attention to techniquereduces but does not completely eliminate postoperativecomplications. It is mandatory for surgeons who performptosis surgery to be able to sufficiently manage thepossible complications also.

REFERENCES

1. Arthurs BP, Della Rocca RC. Entropian. In: Della RoccaRC, Bedrossian EH Jr, Arthurs BP, eds. Ophthalmic PlasticSurgery: Decision Making and Techniques. New York:McGraw-Hill; 2002:77–89

2. Frueh BR. The mechanistic classification of ptosis. Oph-thalmology 1980;87:1019–1021

3. Dortzbach RK, McGerick JJ. Diagnosis and treatment ofacquired ptosis. In: Focal Points 1984 Clinical Modules forOphthalmologists. American Academy of OphthalmologyModule 10; pp. 2–9

4. Kearns TP. External ophthalmoplegia, pigmentary degen-eration of the retina, and cardiomyopathy: a newlyrecognized syndrome. Trans Am Ophthalmol Soc 1965;63:559–625

5. Lessell S, Coppeto J, Samet S. Ophthalmoplegia in myotonicdystrophy. Am J Ophthalmol 1971;71:1231–1235

6. Eyelid Malpositions and Involutional Changes. In: Basic andClinical Science Course Sec 7. American Academy ofOphthalmology; pp. 189–203

7. Meyer DR, Linberg JV, Wobig JL, McCormick SA.Anatomy of the orbital septum and associated eyelid

connective tissues. Ophthal Plast Reconstr Surg 1991;7:104–113

8. Gausas RE. Technique for combined blepharoplasty andptosis correction. Facial Plast Surg 1999;15:193–201

9. Putterman AM, Urist MJ. Surgical anatomy of the orbitalseptum. Ann Ophthalmol 1974;6:290–294

10. Lemke BN. Anatomy of the ocular adnexa and orbit. In:Smith BC, Della Rocca RC, Lisman RD, Nesi FA, eds.Ophthalmic Plastic and Reconstructive Surgery. Vol 1. St.Louis, MO: CV Mosby; 1987:3–74

11. Stasior GO, Lemke BN, Wallow IH, Dortzbach RK.Levator aponeurosis elastic fiber network. Ophthal PlastReconstr Surg 1993;9:1–10

12. Ertas FS, Ertas NM, Gulec S, et al. Unrecognized side effectof statin treatment: unilateral blepharoptosis. Ophthal PlastReconstr Surg 2006;22:222–224

13. Gay AJ, Salmon ML, Windsor CE. Hering’s law, thelevators, and their relationship in disease states. ArchOphthalmol 1967;77:157–160

14. Fox SA. Modified Fasanella-Servat procedure for ptosis.Arch Ophthalmol 1975;93:639–640

15. Putterman AM, Urist MJ. Upper eyelid retraction afterglaucoma filtering procedures. Ann Ophthalmol 1975;7:263–266

16. Putterman AM, Fett DR. Muller’s muscle in the treatment ofupper eyelid ptosis: a ten-year study. Ophthalmic Surg1986;17:354–360

17. Berlin AJ, Vestal KP. Levator aponeurosis surgery: aretrospective review. Ophthalmology 1989;96:1033–1036

18. Crawford JS. Repair of ptosis using frontalis muscle andfascia lata: a 20-year review. Ophthalmic Surg 1977;8:31–40

19. Leone CR Jr, Shore JW, Van Gemert JV. Silicone rodfrontalis sling for the correction of blepharoptosis. Ophthal-mic Surg 1981;12:881–887

20. Carroll RP. Preventable problems following the Fasanella-Servat procedure. Ophthalmic Surg 1980;11:44–51

21. Dortzbach RK. Ophthalmic Plastic Surgery: Prevention andManagement of Complications. New York: Raven Press;1994:65–90


Blepharoptosis: Evaluation, Techniques, and Complications

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