Color Atlas of Cosmetic Oculofacial Surgery

In retracted lids with very prominent eyes,
insertion of a spacer is needed to lengthen the lid
upward – now, most commonly, Alloderm is used
(Figs 9.25–9.28).
155
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.25 Insertion of spacer (Alloderm).
Figure 9.26 (A) A patient with prominent eyes
and lower lid retraction. (B) After insertion of
spacer.
A
B
A
B
9.2

There is a higher revision rate in reconstructive
cheeklift patients. Among 44 consecutive cases, 38%
required more than one surgery and almost 10%
required more than two operations.
To correct postoperative problems related to
cheeklift, the following are often needed:
■ anchoring;
■ vertical recruitment; and
■ insertion of spacer.
156
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.27 Correction by simple spacer
insertion. (A) Before and (B) after correction.
Figure 9.28 Correction by spacer insertion
and secondary vertical cheeklift. (A) Before and
(B) after correction.
A
B
A
B

157
Chapter 10
Laser Blepharoplasty of the
Upper Eyelid
Jemshed A Khan
Patient Selection
The goal of cosmetic upper eyelid blepharoplasty in
the Caucasian patient is usually to improve appear-
ance by reducing the gravitational and age-related
redundancy, descent, and herniation of the upper eye-
lid tissues. Many other age-related changes also exist
but are much more difficult to address. These include
loss of skin elasticity, flaccid skin and orbicularis,
eyelash thinning and shortening, pigmentary changes,
loss of subcutaneous and eyebrow fat, descent of the
lid crease and fold, and textural skin surface changes.
One should examine and document common concur-
rent conditions including eyelid ptosis.
Patient selection considerations (Figs 10.1 & 10.2):
primary problem is redundant upper eyelid skin,

■
orbicularis, and oftentimes, fat
no significant eyelid margin malposition

■
satisfactory eyebrow position

■
satisfactory lacrimal gland position.

■
Figure 10.1 (A) Excellent candidate for upper eyelid blepharoplasty.
Primary problem is isolated redundancy, descent, and herniation of the
upper eyelid tissues.
b
Figure 10.1 (B) Same patient after upper eyelid blepharoplasty.
A
B

158
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Figure 10.3 Clinical pathway for laser blepharoplasty of the upper eyelid. (Reproduced with permission from Chen WP. Oculoplastic surgery: the
essentials. New York L Thieme; 2001:176.)
Upper blepharoplasty
Asymmetric
folds
Reset both
lid folds at
same height
ROOF
descent
ROOF
debulking or
forehead/brow lift
Brow
ptosis
Forehead/
brow lift
Glabellar
furrow
BOTOX® or
procerus/corrugator
excision/denervation
Underlying
ptosis
Müllerectomy
or levator
resection
Excess skin
and muscle
Skin, muscle
blepharoplasty
Herniated
fat
Skin, muscle, fat
blepharoplasty
Figure 10.2 Poor candidate for upper eyelid blepharoplasty,
given underlying eyebrow asymmetry.

159
Patient Selection
The margin reflex distance (MRD) obtained with
eyebrows manually raised (referred to as MRDb) is
highly predictive of the post-blepharoplasty MRD.
Balloting the globe while lifting the eyebrow and exam-
ining the superior sulcus helps determine which fat
pads should be resected. Any pre-existing eyebrow
ptosis, eyelid ptosis or nasal webbing should be docu-
mented and emphasized to the patient (Figs 10.4 &
10.5). While the brows are manually raised (and the
superior sulcus is examined for evidence of herniating
nasal and preaponeurotic fat pads) one should also
search for lacrimal gland prolapse (Fig. 10.6). Finally,
the extent of lateral hooding and retro-orbicularis
oculi fat (ROOF) should be noted.
Search for lagophthalmos by having the patient
passively close their eyelids as if sleeping (Fig. 10.7).
Slit-lamp corneal evaluation, rose Bengal or fluores-
cein epithelial staining or Schirmer tear help screen
for dry eye patients. An ocular examination including
Bell’s phenomenon testing and cranial nerve VII test-
ing may help document any pre-existing ophthalmic
pathology. At this point, the surgeon should have a
clear understanding of the patient’s expectations, sur-
gical risk factors, and underlying anatomic eyelid
changes. With this information, the surgeon may now
proceed to negotiate a surgical plan that safely meets
the patient’s needs and expectations.
Figure 10.4 With the eyebrows in a normal position one cannot
determine from the MRD whether or not there is also an underlying eyelid
ptosis.
Figure 10.5 With the eyebrows manually elevated, one can determine
from the MRDb that there is also a relative eyelid ptosis.
Figure 10.6 While the brows are manually raised, the superior sulcus is
examined. Note evidence of herniating nasal fat pad and lacrimal gland
prolapse.
Figure 10.7 Demonstration of lagophthalmos.

160
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Laser Instruments, Safety, Selection,
and Parameters
Useful instruments include a millimeter ruler, 0.3mm
toothed platform forceps, needle holder, stitch scissors,
and hemostat. Metal globe shields or guards will be
needed. Bipolar or other cautery device is also necessary.
Since there is a combustion hazard associated with
CO2 laser use, the patient should be draped with wet
cloth towels. The superb hemostasis achieved by the
CO2 laser is due to the zone of coagulative and
thermal injury created by the laser (Fig. 10.8).
Please see Chapter 11 for discussion of CO2 laser
parameters and laser safety.
Figure 10.8 Histopathological examination of CO2
laser eyelid incision. Note the purple zone of thermal
injury surrounding the laser-created tissue cleft. (Image
courtesy of Brian Biesman, MD).
CO2 laser (10,600nm)
Focused spot size of 0.3mm or less

■
Wattage setting usually around 6–7 W

■
Continuous wave or pulsed setting

■
Articulated arm beam delivery

■

161
Surgical Steps
Surgical Steps
1. Mark the proposed upper eyelid crease
When marking the eyelid skin for excision, always
remember that the inferior border of the skin incision
usually becomes the postoperative eyelid crease. If the
inferior incisions are misplaced or asymmetrical, then
the final results will be askew. Therefore, careful
initial skin markings are critical. In Caucasian eyelids,
the inferior incision is usually marked 9 to 11mm
superior to the central eyelid margin, 4mm superior to
Figure 10.9 An inked millimeter calibrated caliper is
used to mark the medial aspect of the upper eyelid
crease 4mm superior to the punctum.
Figure 10.10 An inked millimeter calibrated caliper is
used to mark the central aspect of the upper eyelid
crease 9–11mm superior to the eyelid margin.
the upper punctum, and 6mm superior to the
lateral canthal angle (Figs 10.9 & 10.10). These
markings are usually lower in Asian or Oriental eye-
lids and higher when one desires a higher lid crease
and fold. The female eyelid usually has a higher arched
crease compared to the male eyelid. In the Asian eye-
lid, be certain that the incision height and curvature is
a natural extension of any pre-existing epicanthal
folds. The eyelid crease (and inferior marking) usually
curves somewhat downwards as it extends towards
the medial canthus and lateral canthus.
10.1
10.2

162
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
2. Determine the safe amount of skin removal
with pinch technique
Perfectly symmetrical skin markings are the founda-
tion upon which the success of the remainder of the
operation rests. Any asymmetry will carry forward in
the operation and adversely affect the final outcome.
With the patient supine, determine the amount of
skin removal using pinch or other techniques (Fig.
10.11). While pinching, be certain that the lids can
passively close. This should prevent postoperative
lagophthalmos due to excessive skin removal. The
medial extent of removal is superior to the punctum
Figure 10.11 Pinch technique: the inferior jaw of the forceps engages the
inferior skin mark.
Figure 10.12 Redundant skin is gathered between the forceps jaws.
Care is taken that no lagophthalmos is induced and the superior resection
margin is inked.
Figure 10.13 Specially designed ambidextrous ‘Khan Ink and Pinch’
forceps for blepharoplasty skin marking. Note square atraumatic jaws are
offset from the forceps shafts to allow gathering of redundant skin. Minute
tip serrations engage the inferior crease. Calibrated millimeter markings
help ensure symmetry. (Courtesy of Storz Instrument Co., St. Louis, MO,
USA).
but should be moved laterally when there is a ten-
dency to medial canthal webbing. The tendency
towards nasal webbing may be determined preopera-
tively: gently pinch the lateral walls of the nasal
bridge and tug inferiorly. By observing the medial
canthal area for webbing during this maneuver, one
can judge the tendency to webbing. The lateral extent
of removal is often determined by hooding and may
be limited by the lateral orbital rim. Ink the margins
for resection (Fig. 10.12) and then remeasure with
calipers to ensure perfect symmetry. A pinch forceps
is shown in Fig. 10.13.

163
Approximately 1.5–2.0mL of anesthetic solution is
injected subcutaneously via a 30-gauge needle into
the mid-portion of each eyelid. The raised subcutane-
ous bleb of anesthetic is then digitally massaged medi-
ally and laterally. Waiting 10 to 20 minutes allows
the epinephrine to create a hemostatic effect, although
this is not necessary with CO2 laser blepharoplasty
since the laser seals smaller vessels (Fig. 10.14).
When incising the skin and orbicularis, be very careful
of the levator aponeurosis which may be directly beneath
the orbicularis at the inferior incision (Fig. 10.15).
Surgical Steps
3. Excise the skin and orbicularis to expose
the orbital septum
Local anesthesia with or without intravenous seda-
tion provides adequate patient comfort for blepharo-
plasty. Sublingual diazepam (5.0mg tab) helps reduce
anxiety when the procedure is performed entirely
under local anesthesia. The local anesthetic consists
of 2% lidocaine hydrochloride (Xylocaine with epine-
phrine 1:200 000) mixed 1:1 with 0.75% bupivacaine
hydro chloride (Marcaine). For better diffusion of
anesthetic, hyaluro nidase (Wydase) is often added.
Figure 10.14 Final appearance of skin marked for excision.
Figure 10.15 Left upper eyelid. Incision of the skin and orbicularis. Keep the beam perpendicular to the skin surface and repeat passes with wound
gently spread until through the orbicularis. Note the distinctive reddish-brown color of the orbicularis muscle, and the pale septum visible between the
divided orbicularis edges. Be very careful of the levator aponeurosis, which may be directly beneath the orbicularis at the inferior incision.
A
B
10.3
10.4
10.5
10.6

164
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Figure 10.16 Left upper eyelid. Excise the skin–
muscle ellipse. Apply strong traction and
countertraction to develop surgical plane. Stay in the
plane of the postorbicularis fascia, being careful to
avoid transecting the levator inferiorly.
Figure 10.17 Left upper eyelid following excision of
the skin–muscle ellipse. Note the clean surgical
dissection with minimal heme. The expanse of the
orbital septum is clearly visible, as are the orbicularis
edges.
The author usually excises skin and orbicularis
as a single specimen, but separate layered excision is
also acceptable. One may excise just skin and spare
the orbicularis muscle to reduce the risk of lagoph-
thalmos. When excising the skin–muscle ellipse,
apply strong traction and countertraction while
developing the surgical plane. Stay in the plane of
the postorbicularis fascia, being careful to avoid
transecting the levator aponeurosis inferiorly (Figs
10.16 & 10.17).

165
Surgical Steps
4. Incise the septum and expose and excise
the central fat pad
The central preaponeurotic fat of the upper eyelid is
removed in less than half of patients. When the fat pad
is excessive and requires excision, the overlying orbital
septum must be divided before the central fat can pro-
lapse. The orbital septum is opened laterally or nasally.
Figure 10.18 Left upper eyelid. Buttonhole the orbital septum laterally or
nasally. As much as possible, keep the laser pointed tangential or away
from the globe. Ballot the globe and inspect to visualize the underlying
postseptal fat pocket. Buttonhole the septum until fat prolapses freely.
Buttonhole the septum until fat prolapses freely. It is
often helpful to ballot the globe in order to inspect and
visualize the underlying (preaponeurotic) postseptal fat
pocket (Fig. 10.18). The entire horizontal width of the
exposed septum may then be divided (Fig. 10.19).
Figure 10.19 Left upper eyelid. Divide the entire horizontal width of the exposed septum over a backstop such as a dripping wet cotton-
tipped applicator or metal guard.
A
B
10.7

166
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Be sure to identify the exposed upper eyelid fat pad
and underlying levator muscle. Grasp the fat pad with
forceps and bluntly strip it free of the underlying leva-
tor muscle and aponeurosis (Fig. 10.20). Excise the
central fat pad to the level of the orbital rim or
Whitnall’s ligament. The fat pad may be excised
across a closed hemostat, or divided against a back-
Figure 10.20 Left upper eyelid. Identify the exposed
upper eyelid fat pad and underlying levator muscle.
Grasp the fat pad with forceps. Bluntly strip it free of
the levator muscle and aponeurosis.
Figure 10.21 Excise the fat pad to the level of the
orbital rim or Whitnall’s ligament. The fat pad may be
excised across a closed hemostat, or divided against
a backstop. Avoid the lacrimal gland laterally.
stop. Avoid the lacrimal gland laterally (Fig. 10.21).
Adequate hemostasis is important because of the
caliber of vessels associated with the fat pocket. Be
careful to avoid the supraorbital neurovascular bundle
located adjacent to the medial aspect of the central
fat pad – the supraorbital notch is often a palpable
landmark.

167
Surgical Steps
Figure 10.22 Left upper eyelid. Hemostat jaws are opened to bluntly
spread the fascia over the nasal fat pad. The globe is then balloted to
bring the fat pad forward. An ‘X’-shaped incision is made over the nasal
fat pad and deepened until fat prolapses.
5. Mobilize and excise the nasal fat pad
The nasal fat pad is excised in most cosmetic blepha-
roplasty patients. Bluntly spread the fascia over the
nasal fat pad with hemostats. Ballot the globe to bring
the fat pad forward. Make an ‘X’-shaped incision over
the bulging septum and underlying nasal fat pad.
Deepen the incision until fat prolapses (Fig. 10.22).
Grasp and immobilize the protruding knuckle of fat
and then use a cotton-tipped applicator to bluntly
Figure 10.23 The prolapsing fat pad is grasped and immobilized and a cotton-tipped applicator is used to bluntly strip away tissues retaining the
nasal fat pad. The base of the nasal fat pad may require local anesthesia injection for pain control. The fat pad is divided over a hemostat or metal
backstop, and the wound inspected for residual fat.
Figure 10.24 Appearance of surgical field following fat pad excision.
Note the levator muscle and aponeurosis, as well as the ROOF tissues
overlying the orbital rim.
strip away tissues retaining the nasal fat pad (Fig.
10.23). Do not forcefully tug on the nasal fat pad as
this may tear deeper vessels at the base of the pad. The
base of the nasal fat pad usually requires supplemen-
tal local anesthesia injection. The fat pad may be
excised across a closed hemostat, or divided against a
backstop. Again, adequate hemostasis is important
because of the caliber of vessels associated with the fat
pocket (Fig. 10.24).
A
B
10.8

168
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Figure 10.25 Candidate for ROOF excision. Note the
redundant lateral tissue.
6. Excision of ROOF fat if necessary
If necessary, the retro-orbicularis oculi fat (ROOF)
may be excised. This is usually helpful in patients
with overhanging, thick, redundant eyebrow tissues
obscuring the lateral half of the orbital rim (Figs
10.25 & 10.26).
Figure 10.26 Patient following ROOF excision. Note
the definition of the lateral superior orbital rims.
10.9

169
Surgical Steps
Figure 10.28 Care is taken to leave a layer of loose
tissue overlying the periosteum.
Figure 10.27 The ROOF tissue is reflected in the avascular supraperiosteal plane.
A
B
To excise ROOF, grasp the orbicularis of the upper
wound edge. Trim the orbicularis and underlying
ROOF flush with the skin edge. Reflect the ROOF
from the deep connective tissue overlying the orbital
rim (Fig. 10.27). Do not expose bare periosteum
because the skin may become adherent after surgery
(Fig. 10.28). This is a bloody dissection, so be pre-
pared to cauterize any bleeders.

170
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
7. Closure of incision
Initial ‘air knot’
Close the skin incision with running 5-0 Prolene suture
on a tapered needle. Absorbable suture is avoided in
laser eyelid blepharoplasty because the tensile strength
is not maintained long enough to reliably avoid dehis-
cence. To aid in the removal of non-absorbable Prolene
eyelid sutures, one should begin the incision with an
‘air knot’ and end with a slip knot. This technique
avoids the discomfort associated with cutting any
knots close to the skin surface (Fig. 10.29).
Figure 10.29 (A) An ‘air knot’ is used at the beginning of closure. It is started by passing the 5-0 Prolene through a small skin bite. (B) The wooden end
of a cotton-tipped applicator is placed over the skin bite. (C) The two suture ends are tied over the wooden end of a cotton-tipped applicator as a
simple square knot. (D) The wooden tip is removed. The knot is well away from the skin surface, thereby allowing relatively painless removal by severing
either half of the loop. (Images courtesy Dylan Yu, MD)
A
B
C
D
10.10
10.11

171
Surgical Steps
Incision closure and final slip knot
After the initial air knot, the incision is closed as
follows. Take only superficial running dermal bites
(0.5mm depth) across the eyelid using a tapered needle
to reduce bleeding from the vascular orbicularis.
Other options include recreating the eyelid crease by
placing three stitches through dermis of the upper skin
edge or the orbicularis and then through the surface
of the levator aponeurosis or tarsus along the superior
tarsal border. Deeper (1.5mm depth) and wider bites
are taken lateral to the outer canthal angle to prevent
dehiscence (Fig. 10.30).
Figure 10.30 (A) Note the ‘air knot’ at the beginning of the closure. The bites are dermal only and the orbicularis is avoided to reduce bleeding.
The tapered needle also significantly reduces bleeding. (B) To begin the slip knot, the terminal suture end is looped over the needle holder tip. The loop
is grasped with forceps, the needle holder released, and the suture distal to the loop is grasped. (C) The suture distal to the loop is pulled backwards
through the loop with the needle holder. Using forceps to stabilize the loop aids in this procedure. (D) The closure is completed with the simple slip knot
tied above the skin surface. When removing the suture postoperatively, the external loop of the medial ‘air knot’ is cut, the running suture is cut midway
across the lid, and the two ends are pulled out. There is no need to cut the slip knot. Note the wider and deeper bites lateral to the canthal angle.
(Images courtesy Dylan Yu, MD)
A
B
C
D

172
Chapter 10: Laser Blepharoplasty of the Upper Eyelid
Final appearance and postoperative care
At the conclusion of the case one should be able to
see the intended degree of surgical improvement
(Fig. 10.31 A & B). It may be helpful for the patient
to see the immediate appearance as well since posto-
perative swelling will worsen the appearance over
several days.
Ointment is applied to the incision and to the infe-
rior cul-de-sac if the patient is not blinking fully. Stitches
are left in for 7–15 days. No patches are placed.
Postoperative instructions include frequent ice
packs, erythromycin ointment to the incision once
daily, elevating the head at night or sleeping in a
recliner, and avoiding strenuous activity for 1 week.
A
B
Figure 10.31 (A) Patient prior to laser upper eyelid blepharoplasty. (B) Same patient immediately following laser upper eyelid blepharoplasty with ROOF
tissue excision.

173
Chapter 11
CO2 Laser Transconjunctival Lower
Blepharoplasty and Fat
Repositioning
Jemshed A Khan
Patient Selection
Transconjunctival laser blepharoplasty is ideal for
addressing isolated lower eyelid fat pad herniation
(Fig. 11.1). Compared to other approaches, the
Figure 11.1 (A) Excellent candidate for transconjunctival blepharoplasty. Primary problem is isolated to lower eyelid fat pad herniation. (B) Same patient
following transconjunctival blepharoplasty.
transconjunctival technique avoids any cutaneous
stitches or incisions, disrupts neither the orbicularis
layer nor its motor innervation, and affords a remark-
ably brief convalescence.
A
B

174
Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
However, the transconjunctival technique does not
address common concurrent eyelid conditions such as
eyelid laxity, wrinkles, festoons, malar edema and folds,
tear trough deformity, and suborbicularis oculi fat
(SOOF) descent (Fig. 11.2). The transconjunctival
approach is often combined with other procedures to
address any of the previously listed concurrent condi-
tions, and may be modified to allow repositioning of the
lower eyelid fat pads to address tear trough deformities
(Fig. 11.3).
It is important to determine preoperatively the rela-
tive extent of fat prolapse when the patient is upright.
For example, some patients may have only nasal fat
pad prolapse and not require any other fat pad
removal. In others, one fat pad may herniate more
than another, so these findings should be noted ahead
of time and may be referred to during surgery.
When tear trough deformity is a concern, this may be
addressed through fat repositioning which is discussed
in the supplemental steps at the end of this chapter.
Figure 11.3 Clinical pathway for laser blepharoplasty of the lower eyelid.
Lower blepharoplasty
Horizontal laxity
or rounded
lateral canthus
Lower lid tightening
(e.g. tarsal-strip
procedure)
Tear-trough
deformity
Tear trough
implant or fat
repositioning
Lower lid retraction,
malar fat descent
on cheek
SOOF lift and/or
hard palate mucosal
graft and/or skin graft
Crow’s
feet
BOTOX® and/or
resurfacing
and/or filler
Festoon and/or
malar bags
Skin/muscle bleph,
and/or resurfacing
and/or direct excision
Skin
wrinkles
Resurfacing
or skin/muscle
blepharoplasty
Herniated
fat only
Transconjunctival
blepharoplasty
Figure 11.2 Poor candidate for transconjunctival blepharoplasty, given
significant eyelid wrinkles and festoons.
Patient selection
■ Primary problem is lower eyelid fat pad herniation
■ No significant eyelid margin malposition
■ Satisfactory lower eyelid skin without significant
wrinkling
■ Satisfactory midface continuum
■ No significant tear-trough deformity

175
Laser Selection and Parameters
Laser Selection and Parameters
Incisional CO2 lasers suitable for blepharoplasty are
available from several manufacturers including
Lumenis (formerly the medical laser division of
Coherent Inc. and Sharplan/ESC) and Nidek. Each
company uses a slightly different CO2 delivery system
and actual incisional parameters vary accordingly. A
small spot size of 0.3mm or less is important to reduce
the zone of thermal injury. CO2 lasers that use a hol-
low waveguide (rather than an articulated) arm to
transmit the beam from the laser tube to the handpiece
are not recommended because the exit beam is diver-
gent rather than coherent, collimated, and focused
(Figs 11.4 & 11.5) Appropriate formal didactic train-
ing in laser blepharoplasty and laser safety is essential
and is beyond the scope of this chapter. Further refer-
ences are provided.
Figure 11.4 Articulated arm. The rigid articulated arm of the UltraPulse CO2
laser delivers focused, collimated, and coherent laser energy to the handpiece.
Figure 11.5 Focused handpiece. The focused handpiece converts the
collimated output of the articulated arm into a smaller and more intensely
focused spot that is used to divide tissue.
Parameters of CO2 laser (10 600nm)
■ Focused spot size of 0.3mm or less
■ Wattage setting varies by manufacturer
■ Continuous-wave or pulsed setting
■ Articulated-arm beam delivery

176
Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
Laser Safety
Laser safety is crucial because of the numerous hazards
associated with unsafe laser blepharoplasty (Fig. 11.6).
The surgeon must acquire appropriate knowledge,
Table 11.1: Safety issues for laser blepharoplasty.
Globe protection
Metal interpositional shield or scleral shield
Tissue protection
Metal backstop or hemostat
Tissue protection
Appropriate laser, laser settings and laser focus
Laser reflection hazard
Antireflection treatment of metal instruments
Combustion hazard
Use wet drapes
Operator smoke hazard
Use smoke evacuator and laser masks
Operator ocular hazard
Wear wavelength-appropriate laser-safe goggles
Governmental standards
Follow OSHA and State standards
motor skills, and laser-safe instrumentation before
embarking upon laser blepharoplasty (Fig. 11.7; Table
11.1). Complete discussion of this issue is beyond the
scope of this chapter. For further information, see
Reference 3.
Figure 11.7 Safety instruments used during CO2 laser blepharoplasty
have an antireflective finish. Instruments (right to left) include Westcott
scissors, micro needle holder, pair of matte-finish Desmarres retractors,
modified Khan–Jaeger laser eyelid plate, ‘propeller’ laser backstop,
Castroviejo 0.5mm platform tying forceps, pair of metal scleral guards,
laser handpiece, and hemostat. Top: Bipolar cautery forceps. Bottom:
Laser blepharoplasty clamp.
Figure 11.6 Corneal injury caused by CO2 laser during blepharoplasty
procedure.

177
Anatomic Landmarks and Surgical Tips
Arcuate expansion
Lateral fat pad
Central fat pad
Figure 11.9 The arcuate expansion sometimes constrains the central
and temporal fat pads.

Clinical pearls
■ Recommended instruments (Storz Instrument Co., St
Louis, MO, USA) include a Khan–Jaeger Laser Eyelid
Plate, Castroviejo O.5 mm toothed platform tying
forceps, Desmarres retractor (dull finish), bipolar
cautery, hemostat (fine curved), protective metal
scleral contact lens.
■ The inferior oblique can always be located between
the nasal and central fat pads.
■ If the fat is restrained between the central and lateral
fat pads, look for and divide the anteriorly located
fibrous band of tissue (arcuate expansion).
■ The lateral fat pad is easier to remove once separated
from the underlying lower eyelid retractor.
Anatomic Landmarks and Surgical
Tips
The location of the inferior oblique muscle should be
clearly envisioned prior to embarking upon transcon-
junctival blepharoplasty. The inferior oblique is relia-
bly located in the cleft or separation between the nasal
and central fat pads (Fig. 11.8). The inferior oblique
muscle originates from the periosteum adjacent to the
proximal bony nasolacrimal duct and passes inferior
to the nasal fat pad and superior to the central fat
pad. Arising from the inferior oblique is an expansion
of connective tissue that sometimes restrains the con-
tiguous fat of the central and lateral fat pads. This
tissue, termed the arcuate expansion, may be divided
if necessary (Fig. 11.9).
Central Fat Pad
Inferior Oblique
Nasal Fat Pad
Figure 11.8 Inverted view of left lower eyelid. Inferior oblique muscle is reliably located in the cleft or separation between the nasal and central fat pads.
B
A

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
Surgical Steps
1. Prolapse the inferior fat pads and fornix
Adequate prolapse and exposure of the conjunctival
fornix is an essential prelude to successful transcon-
junctival incision (Fig. 11.10). The key to this step is
to ballot the globe so as to prolapse the fat and
conjunctiva anteriorly whilst simultaneously having
the assistant retract the lower eyelid margin with two
fingers. Retraction of the lower eyelid margin requires
that the pads of the assistant’s fingers be placed directly
upon the eyelid margin itself in order to exert sufficient
inferior traction. When performed successfully, a liberal
horizontal roll of prolapsing fat and overlying con-
junctiva will present itself quite reliably and visibly.
The use of the titanium Khan–Jaeger plate allows one
to ballot the globe posteriorly in order to prolapse the
fat anteriorly whilst also protecting the globe.
Figure 11.10 Demonstration of proper
technique for fully prolapsing the inferior
fornix. Note ballottement of globe and
positioning of assistant’s fingers on the
eyelid margin. Globe may be balloted
posteriorly with Jaeger plate or metal
scleral contact lens. Assistant retracts
lower eyelid margin with two fingers.
11.1
11.2

179
Surgical Steps
Essential steps
■ Begin at the inferior border of the lateral tip of the
caruncle
■ Continue laterally
■ Stay 4mm below the base of the tarsal plate
■ Continue to within 2mm of the lateral canthal angle
■ Angle the beam towards the inferior the orbital rim
2. Incise the conjunctiva
Conjunctival incision placement is important in order
to efficiently expose the three underlying fat pads
while avoiding unintended injury to surrounding
structures. The medial landmark for incision place-
ment is the inferior border of the lateral tip of the
caruncle. The incision is carried laterally while staying
4mm inferior to the tarsus and carried laterally where
it curves towards the lateral canthal angle (Fig. 11.11).
Alternatively, the incision maybe carried along the
apex of the ridge of bulging tissue. This more poste-
rior approach allows quicker and more direct access
to the bulging fat pads, but also results in more chem-
osis of the bulbar conjunctiva.
Figure 11.11 Inverted view of right lower eyelid. Note that incision originates from the inferior border of the caruncle, extends laterally 4.0mm inferior to
the lower edge of the tarsal plate, and extends to the lateral canthal angle.
A
B
11.3

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
3. Expose the orbital septum
After carrying the incision deeper until it spreads
open, one may either continue the incision deeper
while angling towards the orbital rim, or bluntly
dissect the orbicularis off the orbital septum with a
cotton-tipped applicator (Fig. 11.12). With the
former approach, one will often automatically
expose the three fat pads of the lower eyelid, in
which case surgical Step 4 may be omitted, except
that it is still advisable to divide the lateral fat pad
from the underlying lower eyelid retractors as
described below.
Figure 11.12 The incision is deepened
with the laser until it can be spread
open with blunt dissection.
Essential steps
■ Carry the incision deeper until it spreads open,
exposing the septum
■ Place a Desmarres retractor
■ Grasp the inferior conjunctival wound edge with
0.5mm toothed forceps
■ Spread the wound farther open by sweeping a
cotton-tipped applicator inferiorly across septum
11.4

181
Surgical Steps
4. Incise the septum over the nasal, central,
and lateral fat pads
It is important to free each of the fat pads from any
encumbering structures. Specifically, the overlying
orbital septum must be divided for each fat pad before
the fat can prolapse freely (Fig. 11.13). The lateral fat
pad may be more difficult to mobilize because the
overlying septum may be adherent to the inferior lat-
eral orbital rim.
Make a horizontal incision
over the central fat pad
Make an ‘X’-shaped
incision over the bulging
nasal fat pad
Separate the lateral fat pad from the underlying
lower eyelid retractors
Nasal fat pad
■ Ballot the globe to bring the fat pad forward
■ Make an ‘X’-shaped incision over the nasal fat pad
■ Deepen the incision until fat prolapses
Central fat pad
■ Ballot the globe to bring the fat pad forward
■ Make a 10–12mm horizontal incision over the central
fat pad
■ Place the incision 2–3mm superior to the inferior
orbital rim
■ Deepen the incision until fat prolapses
Lateral fat pad
■ Expose the lateral fat pad
■ Divide the fat pad from the underlying lower eyelid
retractors
■ Incise the overlying orbital septum
■ Divide the arcuate expansion if necessary (fibrous
anterior band separating the central and lateral fat
pads)
Figure 11.13 Inverted view of left lower eyelid.
Separate incisions are placed over each fat pad.
11.5
11.6
11.7

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
5. Mobilize each fat pad
Nasal and central fat pads
The nasal and central fat pads generally prolapse
quite easily (Figs 11.14 & 11.15). It is important to
be aware of large vessels in the base of the nasal fat
pad. An encircling fibrous band is often found at the
Figure 11.15 The central fat pad is mobilized through a horizontal
incision.
Central fat pad
■ Incision parallel and superior to the bony orbital rim
■ Grasp prolapsing fat with forceps
■ Do NOT tug anteriorly on the fat pad
■ Use a cotton-tipped applicator to strip away tissues
retaining the inferior aspect of the central fat pad
Figure 11.14 The nasal fat pad is mobilized with forceps and cotton-
tipped applicator.
Nasal fat pad
■ Base of nasal fat pad may require supplemental local
anesthesia injection
■ Do NOT tug anteriorly on the fat pad
■ Use a cotton-tipped applicator to strip away tissues
retaining the nasal fat pad
base of the nasal fat pad and may be bluntly stripped
away. The inferior oblique muscle may be reliably
located along the inferior and lateral edge of the
nasal fat pad. The broad-based central fat pad is
freed via a horizontal incision that is both parallel
to the inferior orbital rim and 3–4mm superior to
the rim.

183
Surgical Steps
Lateral fat pad
The lateral fat pad is the most difficult to mobilize
because it is adherent to the lower eyelid retractors
and covered by a sometimes thick septum that is
densely adherent to the inferior lateral rim (Fig.
11.16). Exposure is further compromised by the lat-
eral canthal tendon. In the lateral aspect of the lateral
pad there are often blood vessels that may bleed pro-
fusely. Therefore, exposure is maximized by excising
any dense overlying septum and also freeing the fat
pad from the underlying lower eyelid retractors. Even
when properly mobilized, a deeper pad or further lat-
eral fat may only become evident after first removing
the presenting lateral fat and balloting the globe.
Figure 11.16 (A & B) The arcuate expansion is a fibrous band obscuring the tip of the underlying laser probe.
Essential steps
■ The lateral fat may come out in two layers
■ The lateral fat pad is adherent to the underlying lower
eyelid retractors
■ Sharply divide the lateral fat pad from the underlying
retractors
■ Lateral pad may be restrained by the arcuate
expansion
■ Divide arcuate expansion if necessary
Lateral fat pad
Lower eyelid retractors
Figure 11.16 (C) The posterior face of the lateral fat pad is adherent to
the lower eyelid retractors.
A
B
C

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
6. Excise each fat pad flush with the orbital rim
Nasal and central fat pads
One can achieve remarkable postoperative lower
eyelid symmetry by using the symmetric positions of
the paired inferior orbital rims. Therefore, it is
important to use the bony inferior orbital rim as the
sole landmark when deciding exactly where to
transect the herniating lower eyelid fat. One can
immobilize the herniating fat with a hemostat which
rests upon the orbital rim. Thus assured, one can
proceed with excision of the fat. Other methods
include piecemeal excision of the protruding fat.
After excising the protruding fat, it is important to
immediately ballot and see if any more fat comes
forward easily.
Figure 11.17 Demonstration of a moist cotton-tipped applicator
employed as a backstop for laser division of the nasal fat pad.
Essential steps
■ Transect each fat pad flush with the inferior orbital rim
■ Use a metal Desmarres, moist cotton-tipped
applicator, or hemostat as a backstop
■ The central fat pad prolapses easily and generally
presents little difficulty
Figure 11.18 The central fat pad is divided by CO2 laser over a clamped hemostat.
A
B

185
Surgical Steps
Lateral fat pad
Positioning a hemostat properly in the tight lateral
area requires diligence and experience. It is not uncom-
mon to find that more fat prolapses immediately fol-
lowing the first excision. Also, there may still be a
residual temporal bulge of fat that requires further
division of the septum. Therefore, diligence and
patience are necessary to achieve adequate temporal
fat excision (Fig. 11.19). Since the fat pads contain
vessels, the author always cauterizes the pedicle stump
with additional bipolar cautery to reduce the risk of
postoperative hemorrhage.
Figure 11.19 The lateral fat pad is
transected flush with the inferior orbital
rim and requires use of a metal
Desmarres, moist cotton-tipped
applicator, or hemostat as a backstop.

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
7. Reposition the eyelid and ballot to look for
any residual bulging fat
Balloting is an important final step. Oftentimes, one
may find residual fat that was overlooked earlier in
the procedure (Fig. 11.20). Such fat may not come
forward until later in the procedure because it had
been constrained by cautery or clamping of the over-
lying fat.
Essential steps
■ Ballot by applying firm pressure against the globe
■ Examine the contours of both lower eyelids
■ Look for any bulging or asymmetry
■ Excise further fat as needed
■ Look for and cauterize any bleeding points
Figure 11.20 Finger pressure is
applied to the protective shield in order
to retropulse the globe and prolapse
forward any residual excess fat.
11.8

187
Surgical Steps
8. Closure
Postoperatively, the patient is instructed to avoid signifi-
cant lifting or straining for several days. Written instruc-
tions are given that include the warning signs of retrobulbar
hemorrhage. Antibiotic ointment is applied to the inferior
fornix each evening, and contact lenses are not used for 1
week. Only a small amount of ointment is placed in the
fornix so as to avoid ointment entering the incision and
Figure 11.21 Appearance at end of
procedure.
Essential steps
■ Tug upwards on the eyelid to prevent inversion or
overriding of the wound
■ No suture is used
■ Remove eye shield
■ Place ointment
■ Reassure patient
causing ointment granulomas. Icepacks are used for 7
days and the patient is instructed to elevate the head of the
bed for 1 week when sleeping. Oral and topical cortico-
steroids are prescribed only when patients develop signifi-
cant postoperative chemosis or eyelid edema. Patients are
warned of postoperative complications and instructed to
check visual acuity every 2 hours for the first 24 hours.
They are generally seen 9 to 14 days following surgery.

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Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
6. (Addendum) Supplement step 1: fat pad
repositioning
Developing the supraperiosteal pocket
In the case of tear trough deformity, one may decide to
reposition rather than excise the nasal and/or central
fat pads, Additional blunt dissection is carried infer-
iorly over the cheek and beyond the lower border of
the tear trough to create a pocket for the fat (Fig. 11.22).
Figure 11.22 Bilateral tear trough deformity. The
blue area indicates the extent of blunt pocket
dissection necessary to accommodate the nasal
and central fat pads. The green area indicates the
tear trough. The arrows show that the dissection
pocket must extend well beyond the inferior
border of the tear trough.
This pocket should be superficial to the periosteum,
but deep to the orbicularis muscle. Dissection may
be performed with cotton-tipped applicators and by
blunt spreading with scissors. Some bleeding is
always encountered, so visualization, illumination,
retraction, and bipolar cautery are all helpful.
Alternatively, a subperiosteal dissection plane may
be used.

189
Surgical Steps
Figure 11.23 The nasal fat pedicle has been
developed by partially severing the base so that it
can easily fill the dissection pocket.
Figure 11.24 Several bites of 5-0 double-armed
Prolene suture are passed through the inferior
edge of the fat pedicle. (Image courtesy of
Dylan Yu, MD)
Developing the fat pedicles
The fat pedicles are developed in a manner that allows
them to be draped over the inferior orbital rim and
advanced into the dissection pocket so as to fill the
overlying tear trough (Fig. 11.23).
After the nasal and central fat pads have been pro-
lapsed forward, the base of the central and/or nasal
fat pads is partially incised so as to release the fat
without overly compromising its blood supply. It is
important that the fat is mobilized without tugging on
the oblique muscle.
In order to prepare the fat pedicle for placement, sev-
eral bites of 5-0 double-armed Prolene suture are passed
through the inferior edge of the fat pedicle (Fig. 11.24).

190
Chapter 11: CO2 Laser Transconjunctival Lower Blepharoplasty and Fat Repositioning
Positioning the fat pads in the dissection pocket
The double-armed sutures are passed into the dissec-
tion pocket and externalized inferior to the tear
trough. This ensures that the fat is properly positioned
underneath and beyond the inferior edge of the tear
Figure 11.25 Nasal fat pad positioning. The needle holder is positioned
deep in the dissection pocket. The tissue is tented up and blanched from
the pressure of the needle tip.
Figure 11.26 Nasal fat pad positioning. The second arm of the 5-0
Prolene is externalized. One can see on the opposite eyelid that both the
nasal and central double-armed sutures have already been tied down.
Figure 11.27 The central fat pad is prepared for repositioning. Note the
externalized sutures from the nasal fat pad repositioning. (Image courtesy
of Dylan Yu, MD)
trough (Figs 11.25–11.27). Proper suture placement is
challenging. It is helpful to place a Sewell retractor
into the pocket first, and then pass the loaded needle
holder beneath the metal retractor.

191
Surgical Steps
Figure 11.28 Appearance prior to fat pad repositioning.
Figure 11.29 Appearance at the completion of procedure. Note that the
suture is gently tied on the skin surface. Bolsters may be used.
Securing the fat pads in the dissection pocket
The ends of the suture are externalized and gently tied
down on the cheek surface. These stitches are removed
1 week later. Patients should be warned of transient nodu-
REFERENCES
1. Khan JA. Ch. 8: Introduction of laser incisional
surgery. In: Biesman B, ed. Carbon dioxide lasers
in facial aesthetic and reconstructive surgery.
Baltimore: William & Wilkins; 1998: 91–97.
2. Biesman BS, Khan JA. Laser incisional surgery. In:
Roberts TL, Pozner JN, eds. Clinics in plastic
surgery/aesthetic laser surgery, vol. 27, no. 2.
Philadelphia; WB Saunders; April 2000: 213–220.
3. Khan JA, Biesman B. Carbon dioxide laser
physics, laser tissue interaction, and laser safety.
In: Biesman B, ed. Lasers in facial aesthetic and
reconstructive surgery, Ch. 1. Baltimore:
Williams & Wilkins; 1998: 1–13.
larity lasting several weeks and requiring massage, as
well as the possibility that the mobilized fat pads may
resorb (Figs 11.28 and 11.29).

193
Chapter 12
Traditionally, ptosis has been divided into either the
congenital or acquired category. In the literature there
have been publications reporting a 90% prepon -
derance of congenital ptosis versus acquired ptosis;
and yet there have also been papers reporting that
acquired ptosis constituted the majority of cases.
Obviously, the reported incidence will depend heavily
on the type of patients profiled by the observers, their
training and subspecialty inclination, their referral
pattern, and even the town that they practice in
(whether it is a younger population). This method of
classification does not immediately yield any clue as
to the origin of the particular type of ptosis, although
it tends generally to fall into those with poor to fair
levator function (congenital ptosis), and those with
good levator function (acquired ptosis). In this classi-
fication, the most prevalent form of ptosis to be
encountered in a clinical ophthalmologist’s practice
would be involutional ptosis (‘senile’ ptosis) within
the acquired ptosis group. The etiology of this form
of ptosis would include aging, stretching of the levator
aponeurotic complex, as well as postsurgical.
A more informative etiological classification deriv-
ing from the above is to categorize ptosis into the
following groups:
■ aponeurotic ptosis (from levator aponeurotic
dehiscence or rarefaction);
■ myogenic ptosis;
■ neurogenic ptosis; and
■ mechanical ptosis.
In this scheme, the traditional ‘acquired ptosis’
would fall into the involutional aponeurotic dehis-
cence type, while ‘congenital ptosis’ would be part of
the myogenic group.
Aponeurotic ptosis would include involutional
ptosis seen in elderly patients, where the levator
aponeurosis (Fig. 12.1) may have undergone rarefac-
tion or partial dehiscence along the superior tarsal
border, resulting in elongation of the length of the
muscle and a ptotic upper lid margin.
Ptosis (Blepharoptosis)
William PD Chen
Figure 12.1 Surgeon’s open-sky view of levator aponeurosis and Whitnall’s
suspensory ligament, right upper lid.

Clinical findings in involutional ptosis may include
mild to moderate ptosis, a high lid crease, and a good
to excellent levator function (greater than 10mm).
The clinician may be able to see the outline of the
cornea through the upper lid skin when the patients
close their eyelids. Intraoperatively, one may see fatty
infiltration and degenerative changes of the levator
aponeurosis, partial dehiscence of the medial portion
of the levator muscle (Fig. 12.2), and lateral shifting
of the tarsal plate (Fig. 12.3).
194
Chapter 12: Ptosis (Blepharoptosis)
Figure 12.2 Dehiscence and fatty degeneration of
the medial portion of the levator muscle in a left upper
eyelid.
Figure 12.3 Lateral migration of the tarsi in an elderly
woman.

Other causes include surgical trauma (ocular
surgery, vitreoretinal surgery, enucleation, and evis-
ceration), repeated subclinical injury to the upper lids
(including contact lens wear and recurrent periorbital
swelling), and actual traumatic injury.
Myogenic ptosis includes the broad category of
congenital ptosis, congenital ptosis with superior rec-
tus weakness (double elevator palsy), Marcus Gunn
jaw winking ptosis, blepharophimosis, myasthenia
gravis, chronic progressive external ophthalmoplegia,
and rarer entities like muscular dystrophy.
Congenital ptosis typically presents at birth (Fig.
12.4). It is thought to be an isolated dystrophy of the
levator muscle, at times manifesting as a hypoplasia of
the muscle. On clinical examination the patient may
present with mild to severe ptosis, and levator func-
tion in the poor (0–5mm) to fair (5–10mm) range. The
eyelid typically shows absence of lid crease and may
manifest lagophthalmos on downgaze. There is fre-
quently a history from the parent that the child’s
eyelids do not approximate at night during sleep,
although the cornea may be rolled up from an intact
oculocephalic reflex (Bell’s phenomenon). It may be
unilateral or bilateral, with asymmetric involvement.
195
Ptosis (Blepharoptosis)
Figure 12.4 Congenital ptosis of the right upper lid.
Note absence of crease on affected lid.

Marcus Gunn jaw winking ptosis (Fig. 12.5A) is a
peculiar condition where the patient’s ptosis appears
to be lessened when the subject moves his or her
lower jaw to the opposite side of the involved eyelid
(Fig. 12.5B). For example, a patient who has ptosis of
the right upper lid may reduce his ptosis when his jaw
is moved laterally to the left side, or the patient may
show fluctuation of his upper lid’s ptotic position as
he is having his meals (activating his masticatory
muscles innervated by the fifth nerve). It is thought
to be an aberrant innervational connection between
the levator and the fifth nerve, although the exact
location is unclear.
196
Chapter 12: Ptosis (Blepharoptosis)
Figure 12.5 (A) Marcus Gunn jaw winking
ptosis.
Figure 12.5 (B) When the jaw is moved to the
opposite side, the ptosis is relieved.
A
B

Blepharophimosis is typically an autosomal domi-
nant trait and includes the findings of congenital
ptosis, telecanthus, epicanthus inversus, phimosis,
and lateral displacement of the inferior punctum. For
patients with significant telecanthus, ptosis repair
usually follows repair of the telecanthus by way of
transnasal wiring. This is then followed by frontalis
suspension.
Patients with myasthenia gravis are thought to
have an immunological blockage at the level of the
neuromuscular junction, resulting in an effective
lack of acetylcholine. The ptosis is often severe, with
poor levator function. Diplopia may be present. The
evaluation consists of appropriate diagnostic assays
for neuroreceptor blocking antibodies, the Tensilon
(edrophonium chloride) test and muscle biopsy, fol-
lowed by therapeutic use of systemic medications
(Mestinon) to see if the ptosis can be improved.
Significant ptosis that is functionally disabling can
be treated with frontalis suspension utilizing an
adjustable 1mm silastic rod. It has been reported in
the literature that approximately 5–10% of myasthe-
nia patients have Graves’ disease. Ptosis may occur in
hyperthyroidism and therefore patients with Graves’
disease who manifest ptosis with poor levator func-
tion should be screened for myasthenia gravis.
Chronic progressive external ophthalmoplegia may
have a myogenic as well as neurogenic origin. The
patient may present with bilateral, severe ptosis and
absence of extraocular movements to a varying
degree in each eye, but typically does not report
diplopia. The pupillary reflexes are typically normal.
The levator function is poor. Some of these patients
may have associated involvement of the periorbital
orbicularis muscles, and some even have paresis of
the frontalis muscles of the forehead. Since these
patients have absent Bell’s protective eye movement
due to their absent extraocular movement, with a
poor orbicularis function causing poor eyelid closure,
treatment of ptosis is best managed using an
adjustable technique like the frontalis suspen sion
with a 1mm silastic rod.
Among the neurogenic ptosis category, one would
include Horner’s syndrome as well as third nerve
palsy. Horner’s syndrome can occur with involvement
of the primary, secondary, or tertiary fibers of the
sympathetic nervous system. The most often men-
tioned causes include tumors (e.g. Pancoast tumor of
the lung), trauma, aneurysms, and iatrogenically
from surgery. The manifestation includes mild ptosis
with excellent levator function, relative miosis of the
pupil, anhidrosis, and a greater degree of anisocoria
in dark as compared with light setting. Third nerve
palsy may occur with diabetes, orbital trauma,
tumors, vascular episodes, infections, as well as
neurologic emergencies. The manifestation includes
severe ptosis with poor levator function and paralysis
of the superior rectus, inferior rectus, medial rectus,
and inferior oblique. The ptotic upper lid when lifted
shows an eye in a downward and out-turned posi-
tion, due to the remaining actions of the lateral rectus
and the superior oblique muscles. Cases that do not
resolve after at least 6 months may be treated with
strabismus correction followed by ptosis repair in the
form of adjustable frontalis suspension, preferably
using a 1mm silastic rod.
Mechanical ptosis, as the name implies, may
include aging-related dermatochalasis, fatty prolapse,
presence of abnormal tissues (hemangiomas), tumors
as in plexiform neuroma of von Recklinghausen’s syn-
drome (neurofibromatosis), and patients with floppy
eyelid syndrome (pachydermoperiostosis – constella-
tion of sebaceous hyerplasia, recurrent blepharitis,
and meibomitis; thickened, engorged, and elastic
upper tarsi, and spontaneous out-turning of the tarsal
plates, especially during sleep). Mechanically, scar
bands may occur following surgery, trauma, or
idiopathic conditions like ocular pemphigoid and
Stevens–Johnson syndrome. Cicatricial reaction along
the skin as well as within the middle lamella (orbicu-
laris, orbital septum, preaponeurotic fat, levator mus-
cle) can cause a mechanical tethering of the levator
muscle, resulting in ptosis.
197
Ptosis (Blepharoptosis)

EVALUATION AND TREATMENT
Clinically, the patient’s past history as well as findings
would help one determine whether the patient has
congenital versus acquired ptosis. Evaluation should
include the following assessments, in rough order of
clinical significance:
1. levator function;
2. amount of actual ptosis and functional
impairment;
3. presence or absence of protective eye
mechanism;
4. tear functions;
5. absence or presence of lid crease; and
6. age of patient – especially in the pediatric age
group.
Levator function (LF), in general, guides the
surgeon into the following paths:
■ LF = 0–5mm – frontalis suspension procedure;
■ LF = 6–10mm – external levator resection; and
■ LF = 11mm or above – Fasanella–Servat
procedure, tarso-aponeurotic resection of
McCord, aponeurotic repair/tuck/advancement/
resection, and internal müllerectomy.
To document the amount of ptosis, the normal
upper lid margin should cover the upper end of the
cornea by 1.0 to 1.5mm. In elderly patients, this nor-
mal may be set at 2mm below the corneal limbus. If
an adult’s upper lid position covers 5mm of his or her
cornea on one eye and the other side is normally
situated at 1.5mm, the difference or net amount to
be corrected will be 3.5mm. (That is assuming
the patient is orthophoric; if the patient is not
orthophoric, strabismus surgery ought to be consid-
ered first, to correct for any vertical deviation.)
Documentation of functional impairment should be
carried out on each ptosis patient using visual field
evaluation and photography, for medicolegal as well
as insurance accountability purposes.
Absence of Bell’s phenomenon and tear function
anomaly should prompt one to be more conservative
in the overall degree of surgical repair. If a patient has
poor extraocular muscle movement (as in chronic
progressive external ophthalmoplegia), despite a
moderate levator function (LF = 5–10mm), the patient
should not have any levator or aponeurotic resection.
Instead, he or she should have an adjustable frontalis
suspension.
In the pediatric age group, a ptotic young child
without significant threat of amblyopia ought to be
conservatively managed until the age of 4 or 5 years,
at which time the measurements are more accurate
and the anesthetic risk for the child is reduced.
The presence of a lid crease in a ptotic child
with a history of relatively normal lids at birth and
onset of ptosis later on in life should indicate a need
for a lesser degree of resection of levator muscle.
Conversely, a congenitally ptotic child with good
levator function (LF >11mm) will still need a greater
degree of aponeurotic and/or levator muscle resection
than his or her normal adult counterpart, as the child’s
levator muscle is dystrophic and less responsive to
each millimeter of resection.
198
Chapter 12: Ptosis (Blepharoptosis)

Surgical Repair
For the majority of cases of acquired ptosis
seen in an ophthalmologist’s practice,
with LF ≥ 11mm
External tarso-aponeurotic resection (of McCord)
The upper lid is anesthetized from the conjunctival
side superior to the tarsus as well as from the skin
side. The tarsus is everted and the height of the tarsus
measured; this helps in placement of the lid crease
incision (the lid crease will be the lower line of
incision if some redundant skin–orbicularis is to be
excised). The skin is incised with a No. 15 Bard-
Parker-type blade. The orbicularis along the superior
tarsal border is traversed horizontally to expose the
anterior tarsal surface as well as the distal insertion
of the levator aponeurosis. McCord originally deter-
mined the amount of resection by adding 3mm to the
amount of ptosis to be corrected. For example, if one
needs to lift the lid 3.5mm, the amount to be resected
will be 6.5mm (3.5 + 3.0). It is then marked out over
the plane of the tarsus and aponeurosis, such that half
of the 6.5mm is on the aponeurosis side and the rest
is over the tarsal plate.
After making sure that a corneal protective shield
is in place, resection is carried out by first incising
through the tarsal plate with a No. 15 blade and then
cutting out the spindle-shaped segment of tarsus and
aponeurosis with sharp spring scissors. Bleeding will
be at both corners of the wound from the superior
tarsal arterioles and may be easily controlled with
bipolar wetfield cautery. A double-armed 7-0 silk
suture is used to take an anterior tarsal bite along the
central portion of the superior cut edge of the tarsus
(aligned at or just nasal to the pupillary center), then
each of the suture ends is passed through the cut
superior edge of the levator aponeurosis. Two addi-
tional double-armed sutures are similarly placed, one
medially and one laterally along the superior tarsal
border. The three sutures are temporarily tied and the
contour adjusted to effect an ideal lid shape. The
sutures are then permanently tied. The lid crease
wound may be closed with a 7-0 silk suture, or
enhanced by concurrent placement of five to six 6-0
silk sutures in a skin–aponeurosis–skin fashion.
Advantages
McCord’s technique allows for accurate placement
and design of the lid crease, removal of skin–muscle
redundancy in an elderly patient, an open view,
assessment of integrity of the levator muscle, more
accurate contouring of the palpebral fissure in case
of dehiscence of the medial horn of the levator,
and avoidance of lateral peaking, as well as medial
undercorrection of the ptosis that may often be seen
with Fasanella–Servat correction, which is a posterior
approach tarso-Müller-aponeurectomy. It may require
a greater degree of familiarity with eyelid anatomy.
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Surgical Repair

Chen’s modification – modified external
tarso-aponeurectomy of McCord
This is a very useful technique that may easily be per-
formed in conjunction with an upper blepharoplasty.
The upper lid is anesthetized from the conjunctival
side superior to the tarsus as well as from the skin
side. The tarsus is everted and the height of the tarsus
measured; this helps in placement of the lid crease
incision. The skin is incised in a full-thickness fashion
with a No. 15 blade or needle tip of a radiofrequency
unit. The orbicularis over the superior tarsal border is
then traversed horizontally to expose the anterior
tarsal surface as well as the insertion of the levator
aponeurosis. The amount of resection is determined
by adding 1mm to the actual millimeters of ptosis to
be corrected. For example, if one needs to lift the lid
2.5mm, the amount to be resected will be 3.5mm (2.5
+ 1.0). It is then marked out over the plane of the tar-
sus and aponeurosis, such that 1mm of it is over the
tarsus and the rest is over the aponeurosis (Fig. 12.6).
After making sure that the corneal protective shield
is in place, resection is carried out by first incising
through the tarsal plate with a No. 15 blade and
then cutting out the spindle-shaped segment of
tarsus and aponeurosis with a pair of sharp spring
scissors (Westcott) (Fig. 12.7). Bleeding will start at
both corners of the wound from the superior tarsal
arterioles and may be easily controlled with bipolar
wetfield cautery or radiofrequency unit.
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Chapter 12: Ptosis (Blepharoptosis)
Figure 12.6 Modified tarso-aponeurectomy: the amount of tissue to be
resected is placed, including 1mm of the superior tarsal border, across
the tarso-aponeurotic junction.
Figure 12.7 The tarso-aponeurotic tissue has been excised in a full-
thickness segment, exposing the black eye protective scleral shell
beneath.
12.1

A double-armed 7-0 silk suture is used to take an
anterior tarsal bite along the central portion of the
cut edge of the tarsus (aligned at or just nasal to the
pupillary center), then each of the suture ends are
passed through the superior cut edge of the levator
aponeurosis. Two additional double-armed sutures
are similarly placed, one medially (over the medial
one-third) and one laterally (over the lateral one-
third) along the superior tarsal border (Fig. 12.8).
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Surgical Repair
Figure 12.8 Three double-armed 7-0 black sutures have been placed
from the anterior surface of the superior edge of the tarsus to the levator
aponeurosis. Here, a white Telfa dressing is placed under the upper lid to
show the suture placement.
Figure 12.9 The sutures have been tied and the levator aponeurotic
complex (with Müller’s muscle and conjunctiva) is firmly attached to the
tarsus, without any exposed suture knot that may irritate the underlying
cornea.
The suture placement may be adjusted up or down,
or loosened before being permanently tied (Fig. 12.9).
The lid crease wound may be closed using a 7-0 silk
suture; alternatively, it may be enhanced by concur-
rent placement of five to six 6-0 silk sutures in a
skin–aponeurosis–skin fashion, or reinforced using
three separate transcutaneous pretarsal fixation
sutures from the aponeurosis to the pretarsal inferior
skin edge.

Discussion
McCord originally proposed the use of an ‘add-on’
factor of 3mm to be added to the amount of desired
lift; and it was originally designed to lift the upper lid
margin to a point 1mm below the superior corneal
limbus. I have been setting the ideal level now in
elderly patient to 2mm below the limbus, i.e. 1mm
lower than I used to, and therefore I currently use
1mm as the add-on factor in determining the amount
of tarso-aponeurectomy.
The original method described distribution of the
resection equally over the tarsal plate and the levator
aponeurosis. I have not had to straddle equally over
the superior tarsus and then resect more than 1–2mm
of the tarsus plus levator aponeurosis since most
patients exhibit ptosis no worse than around mid-
pupil or half of their cornea (where 5mm of the
cornea is covered by the upper lid). In a situation
with 5mm of cornea being covered, to lift the eyelid
to a point 2mm below the superior limbus, the lift
factor is 3mm (5 – 2), plus the add-on factor of 1mm,
resulting in 4mm of resection. I would then choose to
include 1.0mm of tarsus and 3mm of the
distal levator aponeurosis for resection. The resected
specimen includes Müller’s muscle, levator aponeur-
osis, as well as conjunctiva. In patients whose ptosis
covers more than half of the cornea, resection using
the above formula while resecting no greater than
1mm of the tarsus seems to yield equally satisfactory
correction (Fig. 12.10).
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Chapter 12: Ptosis (Blepharoptosis)
Figure 12.10 (A) Preoperative view of an elderly woman with acquired
aponeurotic ptosis. Note the higher right upper lid crease.
Figure 12.10 (B) Postoperative view after tarso-aponeurectomy.
A
B

The effective lift from resection of these tissues is
just as effective, millimeter for millimeter, as when
actual tarsal plate is being resected (Fig. 12.11). It is
quite possible that when correcting a greater degree
of ptosis by this modified tarso-aponeurectomy, one
is farther from the superior tarsal border and is resect-
ing levator aponeurosis that is not as thinned out or
degenerated. It may also arise because elderly patients
have a weaker opposing pre septal orbicularis oculi
muscle (which is an antago nist to levator and an ago-
nist for eyelid closure), resulting in an equally effec-
tive ptosis repair when some skin, preseptal orbicularis,
and aponeurosis are resected in combination with
very minimal tarsal resection. The atraumatic fashion
with which a surgeon can handle the resection and
the inherent skill improvement with repetition no
doubt add to the predictability of this procedure.
Individual ocular and orbital factors, as well as the
relative position of the opposite eyelid of the patient,
will necessarily determine the adjustments that works
well with one’s surgical technique. This modification
preserves a major portion of the tarsus, and the ptosis
repair may be repeated as necessary in future should
the ptosis continue to recur with advancing age.
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Surgical Repair
Figure 12.11 (A) Preoperative view of an elderly man with involutional
ptosis.
Figure 12.11 (B) Postoperative view after external tarso-aponeurectomy.
A
B

Aponeurotic repair/aponeurotic tuck/aponeurotic
advancement/aponeurotic resection
These are essentially variations of exploration of the
levator aponeurosis via the anterior skin approach.
There are situations when the dehisced edge of the
levator aponeurosis is clearly detectable on explora-
tion and reapproximating it in a graded fashion on
the antero-superior border of the tarsal plate may
correct the ptosis. Some surgeons use a single 6-0 or
7-0 silk suture; others use two or three 6-0 Vicryl
sutures for this purpose. More often though, there is
true stretching, rarefaction, and secondary lengthen-
ing of the aponeurosis, and therefore a resection of at
least twice the amount of the ptosis to be corrected,
combined with reattachment, is necessary. Again, the
reattachment may be performed using three double-
armed 7-0 silk sutures as described in the section on
external tarso-aponeurectomy.
Fasanella–Servat procedure for correction of
minimal ptosis (posterior approach, from
conjunctival side)
This used to be a popular and often taught method
for correction of simple acquired ptosis, mild to mod-
erate in measurement, with LF greater than 11mm.
The upper lid is anesthetized from the conjunctival
side superior to the tarsus as well as from the skin
side. A corneal protective shell is applied. The upper
lid is everted and two curved hemostats are used to
clamp symmetrically onto a segment of the tarsus,
equal to the amount of ptosis to be corrected. It is
important to place the two instruments such that they
are evenly applied on the medial as well as the lateral
portion of the upper tarsus, that they meet in the
center and the midpoint is aligned with the physio-
logic pupillary axis. One must also be aware of any
lateral migration of the tarsal plate (easily detected
when the upper lid is everted) (Fig. 12.3), a finding
often confirmed intraoperatively in elderly patients
who may have dehiscence or fatty degeneration of the
medial portion of the levator (medial horn of the
levator) (Fig. 12.2). The tips of the hemostat clamps
should be angled closer to the lid margin near the
central portion of the lid, to avoid the common prob-
lem of central peaking. Sutures of 6-0 plain catgut
are passed in a continuous mattress fashion from the
lateral end to the medial end just above the clamps.
The tissues circumscribed by the clamps (tarsus,
Müller’s muscle, and some strands of levator aponeu-
rosis, as well as conjunctiva) are then resected using a
No. 15 blade. The clamps are then removed and the
catgut sutures are externalized onto the skin side
through the cut edge along the superior tarsal border.
They are adjusted to ensure a good lid contour and
correction of the ptosis, and are then tied.
Müllerectomy (posterior approach, from
conjunctival side)
For the patient who has 1–4mm of ptosis, good leva-
tor function, and a positive response to 2.5% or 10%
phenylephrine (lessening of ptosis after instillation of
this drop), this is a viable alternative. It involves
resection of the Müller’s muscle from a posterior
conjunctival approach and is therefore less apt to be
used in conjunction with a cosmetic blepharoplasty.
(Interested readers may refer to Putterman’s original
paper, listed in the Further Reading section.)
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Chapter 12: Ptosis (Blepharoptosis)