Operative Technique in Plastic Surgery – Kevin C.Chung

but these can be filled with periorbital fat when necessary.
REFERENCE
1. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii muscle resection
through blepharoplasty incision. Plast Reconstr Surg. 1995;95(4):691-696.

25
CHAPTER
Indications and Techniques
for Hairline Lowering
Warwick J. S. Nettle and Yumiko Kadota
DEFINITION
■ The ideal length of the female forehead should be approximately one-third of
the length of the face (FIG 1).1–4
■ Forehead length should typically be 5.5 to 6 cm from the eyebrows to the
anterior hairline.2,4,5 This varies depending on eyebrow position and overall
facial size.
■ The forehead may be elongated congenitally, due to hairline recession with
aging or iatrogenic causes, such as coronal incision brow lift.1,4
■ A high hairline, or large forehead, causes the upper third of the face to be
disproportionately larger than the middle and lower thirds.
■ Young women find that a high hairline masculinizes their faces.4
■ Hairline lowering utilizes a posterior scalp advancement flap.1,3–6
ANATOMY
■ The hairline is an extended area consisting of various zones and borders that
frame the face.7
■ The frontal hairline has an irregular border that extends from temple to temple.
■ The transition zone is the anterior border of the frontal hairline where soft,
small hairs are found.7
■ The defined zone is immediately behind the transition zone, where the hairs
become coarser and denser.7
■ The midfrontal point is the midline, most anterior point of the hairline. This
is where the “widow’s peak” is, if it exists in the patient.
■ The frontotemporal angle is the point where the frontal hairline meets the

temporal hairline.7 This angle is the angle of temporal hair recession, routinely
found in males and sometimes found in females.
■ The layers of the scalp from superficial to deep are
■ Skin: the thickest in the body and most hair-bearing
■ Dense connective tissue where the blood vessels run
■ Occipitofrontalis muscle
■ Galea aponeurotica between occipitalis and frontalis muscles. This
aponeurosis blends with the temporalis fascia laterally, just above the
zygomatic arch.
■ The subgaleal space of loose areolar tissue provides a plane for scalp
mobility.
■ Scalp blood supply
■ Blood supply to the scalp derives from external and internal carotid artery
branches, which anastomose freely with each other.
■ Scalping does not cause necrosis of the underlying skull, which receives
blood supply from the middle meningeal artery.
■ The external carotid artery gives rises to the occipital, posterior auricular, and
superficial temporal arteries.
• The occipital artery runs from the apex of the posterior triangle of the neck
to supply the posterior scalp to the vertex.
• The posterior auricular artery supplies the scalp behind the ear.
• The superficial temporal artery is a terminal branch of the external carotid
artery and supplies the skin over the temporalis fascia and scalp.
■ The supraorbital and supratrochlear arteries derive from the internal carotid
artery and supply the forehead and anterior scalp to the vertex.
■ Scalp sensation
■ The greater occipital nerve (posterior ramus of C2) runs with the occipital
artery and supplies the posterior scalp to the vertex.
■ The posterior scalp is also supplied by the third occipital nerve (posterior
ramus of C3).
■ The lesser occipital nerve (anterior ramus of C2) runs with the posterior
auricular artery and supplies sensation to the skin behind the ear.
■ The skin of the temple is supplied by the auriculotemporal and
zygomaticotemporal nerves.
■ The forehead and anterior scalp are supplied by the supratrochlear and
supraorbital nerves, which run with the corresponding arteries.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Suitable candidates3–5 have
■ High hairline
■ Good, healthy hair
■ Lack of cowlicks (posterior exiting hairs)
■ Good scalp mobility (measured by the ability of the scalp to rock back and
forth on the skull)
■ Absence of scalp disease and previous scalp surgery
■ No history of stress-induced or unexplained hair loss
■ No family history of progressive hair loss
SURGICAL MANAGEMENT
■ Hairline lowering is a day procedure, of about 2-hour duration.
■ The major steps are as follows:

FIG 1 • A. Frontal view showing ideal facial proportions,
undulating incision along current hairline (blue),
posterior incision extensions (green), and proposed
incision for inferior and anterior advancement of new
hairline (red). B. Oblique view showing the same
markings as (A), plus the superior nuchal line, a very
minor ridge or crest on the posterior skull bone
(occipital bone) that provides attachment for the
sternocleidomastoid and trapezius muscles, as well as
the occipital belly of the occipitofrontalis muscle. C.

Overhead view.
■ The hairline is surgically advanced anteriorly using a posterior scalp
advancement flap, to meet the proposed new hairline (FIG 2A–D).
• It is easier to advance the central anterior hairline (narrow flap) than the
whole frontal hairline (broad flap).
■ The ellipse of the forehead skin between the pre-existing and new lower
hairline is excised (FIG 2C).
■ The scalp is secured in its advanced position to the underlying bone with
sutures through converging outer cortical bone tunnels, Endotines, or other
fixation devices (FIG 2C).
Preoperative Planning and Positioning
■ Marking of the existing and new proposed hairlines is made preoperatively
with the patient standing or sitting up.
■ The marking of the frontal hairline should be in an irregularly undulating
fashion, which resembles the natural hairline and helps with camouflage of
the incision (FIG 3A).3–5
• This marking is just posterior to the fine hairs of the anterior hairline but
before the coarse hairs of the defined zone become denser.3–5
■ If needed, the incision is made as lateral as possible, to allow for lateral as
well as central advancement, and to avoid recession at the frontotemporal
angle (temporal recession).
■ The proposed new, lower hairline traces the superior marking (FIG 3B).
■ The level is marked according to the patient’s desires while taking into
consideration the pre-existing scalp mobility.
■ Usually 2.5 cm of scalp advancement is not difficult with a moderately
mobile scalp.5
■ The incision continues posteriorly bilaterally, in a shape similar to the arms
of a pair of spectacles (FIG 3C).
■ The patient is positioned supine, on a head ring at the superior most end of the
table.
■ Surgery is performed under general anesthesia or local anesthesia with
sedation.3–5

FIG 2 • A. The extent of subgaleal undermining, not
only of the proposed scalp flap but also of the scalp and
forehead 2 to 3 cm in addition to the scalp flap. The
blue line is the undulating incision along the current
hairline; the green lines are posterior incision
extensions; the red line is the proposed new hairline,
and the pink area is the limit of subgaleal scalp
elevation. B. Elevation of the scalp away from the
underlying skull. This occurs as far posteriorly as the
superior nuchal line. Rake retractors are used to

elevate the scalp flap. The scalp and forehead are
undermined 2 to 3 cm lateral to the lateral incisions and
anterior to the proposed new hairline. The strip of
forehead skin to be excised remains in situ until the flap
is advanced anteriorly. C. The undermined scalp is
advanced anteriorly with the help of rake retractors.
Bilateral bone holes (converging external cortical bone
holes) that have been drilled are used with sutures to
keep the scalp flap advanced. The undersurface of the
scalp flap has galeotomies (incisions in the galea),
which help it to stretch and reach further anteriorly. The
strip of hairless forehead skin is excised and discarded
prior to inset of the advanced flap. D. End result with
hairline lowered by scalp flap. Insetting is accomplished
with deep dissolvable sutures with staples laterally and
sutures anteriorly. The undulating hairline is preserved.
FIG 3 • A. Undulating irregularly irregular incision line
marking at the existing hairline. The incision will be just

posterior to this. B. Markings for the new proposed
hairline are drawn on the forehead to match the
undulating existing hairline marking. The two lines meet
laterally to outline the ellipse of skin to be excised. C.
Marking for the incision is extended posteriorly, in a
shape similar to the arms of a pair of spectacles.
T E C H N I Q U E S
■ Local Anesthesia
■ Local anesthesia (ropivacaine/marcaine/lignocaine) with epinephrine is used
for both hemostatic and intraoperative and postoperative analgesic effects.
■ The local anesthesia is injected at the brow to anesthetize the supraorbital and
supratrochlear nerves (TECH FIG 1A).3
■ Then it is injected along the existing and proposed new hairlines (TECH FIG
1B) and posteriorly in a circumferential manner, which produces a
vasoconstrictive, pseudotourniquet effect (TECH FIG 1C).3–6

TECH FIG 1 • A. Local anesthetic is injected to block
the supratrochlear and supraorbital nerves. B. Local
anesthetic with epinephrine is injected along the
incision lines. C. Local anesthetic with epinephrine is
injected along the posterior incision line in a
circumferential pattern toward the superior nuchal line
using a spinal needle. Meeting the local anesthetic from
the contralateral side produces a pseudotourniquet
effect.
■ Incision and Dissection
■ The incision anteriorly is made in a trichophytic beveled manner using a no.
15 blade.1,3,4 This denudes or de-epithelializes hair follicles along the length of
the anterior incision (TECH FIG 2A,B).

■ It is just posterior to the forehead-scalp junction, posterior to the transition
zone, just anterior to where the thicker hair of the defined zone starts.
■ The incision is deepened to the subgaleal level with a no. 10 blade, in the same
beveled manner (TECH FIG 2C), and transitions to become parallel to the hair
follicles for the posterior extensions.3
■ The incision is extended posteriorly parallel to the hair follicles (TECH FIG
2D).
TECH FIG 2 • A. The undulating existing hairline
incision is made posterior to the markings, just posterior
to the fine hairs of the transition zone. The incision is
made in a beveled, trichophytic manner denuding
follicles of the anterior scalp. B. Beveled incision
causes the hairless forehead skin to overlap the
denuded hair follicles of the anteriorly advanced scalp
flap. Some of the denuded follicle hairs will exit the
forehead skin anterior to the incision line, helping to
camouflage the incision line. C. The initial incision is
made with a no. 15 blade but deepened with the same

bevel using a no. 10 blade. D. The incision is extended
posteriorly parallel to the hair follicles.
■ Flap Elevation
■ The scalp is raised posteriorly in a subgaleal plane using a no. 10 blade with
the aid of multipronged rake retractors (TECH FIG 3A).
■ Digital dissection is then used to further dissect this flap posteriorly (TECH
FIG 3B).
■ The Iconoclast helps to elevate this flap in the subgaleal plane in the difficult
to reach portion, as far posteriorly as the superior nuchal line (TECH FIG
3C,D).
■ The scalp laterally and forehead anteriorly are undermined in the subgaleal
plane to facilitate tension-free closure.
■ A sponge is placed in the recess between the skull and the raised flap for
hemostasis (TECH FIG 3E).
■ Subgaleal undermining continues for 2 to 3 cm lateral to the posterior
extension incisions and 4 to 5 cm anterior to the anterior incision line.
■ The midline of both the skull and galea of the scalp flap is marked with a
marking pen to ensure symmetry when the flap is advanced later (TECH FIG
3F).
■ Outer cortical converging bone tunnels are made in the anterior skull, 4 to 5
cm from the midline, to attach the scalp once it has been advanced (TECH FIG
3G,H).1,3,6
■ Endotines or other fixation devices can be used if desired.4,5

C F HI

TECH FIG 3 • A. Initially the scalp is elevated in the
subgaleal plane using a 10 blade with traction from rake
retractors. B. Digital dissection in the subgaleal plane is
used as the skull curves toward the neck. C,D. The
Iconoclast is a spreading instrument used for subgaleal
dissection posteriorly to the superior nuchal line. The
instrument facilitates scalp flap elevation in the hard to
reach posterior sections of the scalp. E. A sponge is
placed in the scalp-skull recess to aid hemostasis. F. A
marking pen is used to mark the midline of the skull and
the scalp flap. This facilitates even and accurate scalp
flap advancement. G. The periosteum of the scalp is
elevated to expose the bone of the underlying skull, and
markings for outer cortical bone holes are made on the
anterior skull, equidistant from the midline. H.
Converging external cortical bone holes are drilled.
■ Galeotomies
■ To achieve further advancement, galeotomies are made in the anterior to
midscalp using an angled ophthalmic blade (TECH FIG 4A,B).4,5
■ Galeotomies must be made superficial to the underlying scalp vessels to
preserve the scalp blood supply (TECH FIG 4C).4,5
■ Four or five galeotomies may be made, each of which generally advances the
scalp a further 2 to 3 mm. They are generally made 1.5 to 2 cm apart.3

TECH FIG 4 • A. Markings are made for galeotomies,
which allow further scalp advancement. B. An
angulated fine ophthalmic blade is used to perform the
galeotomies. Care is taken to avoid going too deep
which could damage hair follicles and scalp blood
supply. C. Stretching of the scalp separates the
galeotomies, facilitating scalp lengthening and
advancement.
■ Scalp Advancement
■ The sponge is removed, and the scalp is advanced (TECH FIG 5A,B).
■ The scalp is maintained in the advanced position by a suture through the bone
tunnels, attached gently to the galea (TECH FIG 5C–E).
■ With the posterior scalp flap stabilized in the advanced position, excessive
tension on the resulting incision closure is avoided.
■ Adjustments may now be made in the markings of the proposed new hairline

(TECH FIG 5F).
■ The new hairline is incised in a similar beveled fashion to the original incision
(TECH FIG 5G).
■ This beveled incision allows the forehead skin to slightly overlap the
advanced scalp.
■ This facilitates growth of some hairs from the denuded scalp follicles
through the forehead skin anterior to the incision line.1,3,4,5
■ The hairless forehead skin is removed (TECH FIG 5H,I).

TECH FIG 5 • A,B. After the sponge is removed from
the scalp-skull recess, rake retractors are used to
advance the posteriorly based scalp flap. C. A suture is
placed through the external cortical bone holes of the
anterior skull. D,E. This suture attaches to the galea of
the scalp flap and anchors the advanced scalp flap
under limited tension. F. The proposed new hairline is
checked against the leading edge of the advanced
scalp flap. Any adjustments to the proposed hairline
markings can be made at this time. G. The new hairline
incision is made in a similarly beveled manner to the
existing hairline incision. H,I. The ellipse of hairless
forehead skin is removed.

■ Scalp Fixation and Wound Closure
■ The remainder of the procedure requires accurate insetting of the advanced
scalp flap with dissolvable deep sutures (3-0 and 4-0 Monocryl). Tension is
avoided (TECH FIG 6A,C).
■ Interrupted or running 6-0 Prolene sutures are used anteriorly (TECH FIG
6B).
■ Staples are used laterally (TECH FIG 6D).
■ The patient’s hair is washed with hydrogen peroxide and then saline or water
(TECH FIG 6E).
■ The hairline is covered with a light foam dressing, using a 10-cm conforming
stretch bandage under minimal tension (TECH FIG 6F).
TECH FIG 6 • A. Dissolvable deep sutures under
minimal tension are used to inset the advanced flap. B.
The bevel used allows the denuded follicles of the scalp
flap to slip deep to the hairless forehead skin. C.
Interrupted or continuous Prolene sutures are used
anteriorly. These will be removed between
postoperative days 5 and 7.

PEARLS AND PITFALLS
Indications
■ Follicular unit grafts are better for deep temporal recession.
■ Cow licks (posterior exiting hairs) make incision camouflage more
difficult.
■ A two-stage procedure utilizing a scalp tissue expander may be
necessary for patients with tight scalps or very high hairlines or
where the desired anterior hairline advancement is more than 3 cm.
Flap
elevation
■ The Iconoclast is an instrument that allows subgaleal scalp
elevation in the difficult to reach posterior scalp recesses.
Scalp
advancement
■ A narrow central scalp flap is easier to advance than a broad flap of
the whole frontal hairline. However, most female patients desire a
rounded hairline without temporal hairline recession.
■ Broad flaps have a higher incidence of lateral incision line tension
and minor incision line hair loss.
Scalp
fixation
■ Outer cortical converging bone holes allow stabilization and
fixation of the scalp flap in an anterior position.
■ Excessive tension must be avoided.
Wound
closure
■ Dissolving deep sutures allow tension-free closure of the incision
lines.
■ Overlap of the incision line denuded scalp follicles by hairless
forehead skin is desired.
POSTOPERATIVE CARE
■ The dressing is removed on postoperative day 1.
■ Patients are able to shower and wash their hair from day 1 with warm water
and a mild soap/shampoo.
■ Patients are instructed not to blow-dry or brush their hair.
■ Alternate staples and Prolene sutures may be removed at day 5 or 6.
■ Remaining staples and Prolene sutures are removed on day 7 or 8.
■ Most patients are back at work within a week or so.
■ Patients are instructed to avoid the following:
■ Tasks that cause a Valsalva maneuver, such as heavy lifting or straining
■ Trips to the hairdresser/coloring hair for 6 weeks
■ Hot hairdryers/scalding hot showers

■ Tight caps and constricting helmets
OUTCOMES
■ Reliable hairline advancement with immediate results4
■ Good alternative to hair grafting—mobilizes many thousand follicular units4
COMPLICATIONS
■ Visible scars
■ Hyperpigmented or hypopigmented scars
■ Scalp numbness and dysesthesia
■ Hair loss
■ Telogen effluvium (“stress” or “shock” hair loss)2,4,5
■ Incision line alopecia (especially with broad scalp advancement)
■ Patchy scalp alopecia2–6
■ Hairline aesthetic/shape issues
■ Need for scar revision/need for hair grafts to finesse scars4
■ Scalp necrosis5
■ Future hair loss with progressive scar visibility
REFERENCES
1. Guyuron B, Rowe DJ. How to make a long forehead more aesthetic. Aesthet
Surg J. 2008;28:46-50.
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in
forehead rejuvenation. Plast Reconstr Surg. 2014;134(3):426-435.
3. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg.
1999;103(1):224-236.
4. Ramirez AL, Ende KH, Kabaker SS. Correction of the high female hairline.
Arch Facial Plast Surg. 2009;11:84-90.
5. Kabaker SS, Champagne JP. Hairline lowering. Facial Plast Surg Clin North
Am. 2013;21:479-486.
6. Guyuron B, Behmand RA, Green R. Shortening of the long forehead. Plast
Reconstr Surg. 1999;103:218-223.
7. Shapiro R, Shapiro P. Hairline design and frontal hairline restoration. Facial
Plast Surg Clin North Am. 2009;21:351-361.

26
CHAPTER
Section VIII: Upper
Blepharoplasty
Techniques for Upper
Blepharoplasty
Steven M. Levine
DEFINITION
■ Surgery is the standard treatment to address the aging upper eye.
■ The aging upper eye can be broken down into excess skin and excess fat.
ANATOMY
■ Relevant anatomy pertains to the layers of the upper eyelid: notably, the skin,
the orbicularis oculi muscle, and the preaponeurotic fat (central fat pad and
medial/nasal fat pad).
■ The lacrimal gland is located laterally and deep to the preaponeurotic fat pad.
This gland can become ptotic and be confused as redundant fat.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Beyond the usual history, to make sure a patient is an acceptable candidate for
facial plastic surgery, certain physical findings should be noted.
■ Ptosis should always be noted. Ptosis repair is not being addressed in this
chapter.
■ The eyes should be studied carefully to note the exact location of the excess or
“hooded” skin.
■ Ask for photographs of the patient when younger to note whether the upper
lids were always “full.”
■ This will avoid hollowing out a patient who is used to having full lids.

■ The lateral extent of the excess should be noted and care taken to include that
tissue in the resection (even if it falls beyond the lateral orbital rim).
■ The tarsal insertion should be marked to represent, approximately, the inferior
aspect of the surgical excision.
SURGICAL MANAGEMENT
■ Surgery should be performed in an accredited operating room.
■ An upper blepharoplasty can be performed under local anesthesia with or
without sedation or general anesthesia.
Preoperative Planning
■ The author requires all patients to be seen by an ophthalmologist and have a
Schirmer tear test preoperatively.
■ Consideration should be given as to whether the surgeon believes the patient
will require fat to be removed.
■ If the operation is “skin only,” it is easier to perform under local anesthesia.
■ The patient should be marked while sitting upright.
■ It is important to end the medial extent of resection prior to the medial canthus
to avoid creation of a web.
■ A “pinch test” should be performed on the estimated skin resection to ensure
the surgery will not create a lagophthalmos.
■ Use a ruler to ensure the markings are roughly equal on both sides.
■ Measure the distance from the lash line to the inferior aspect of resection and
the distance from the lateral canthus to the lateral extent of the resection (FIG
1).
■ The author rarely removes fat from the upper lid.
■ That said, the medial or nasal fat compartment is more commonly full and
can benefit from fat removal.
■ The globe is balloted to accentuate the excess fat, and a decision is made
preoperatively as to where fat will be removed and how much.
■ Fat is not removed indiscriminately. The surgeon should know roughly how
much fat he or she plans to excise.

FIG 1 • A and B. The planned resection is marked in the
standing position and then checked again on the
operating table ensuring the accuracy of the markings.
■ Discussion of scar placement, complications, and expected healing time
should be reviewed with the patient.
Positioning
■ The patient is supine on the procedure table.
■ Usually, the head of bed is slightly elevated.
■ The authors prefer to sit for maximum stability.
Approach
■ Approach is dictated by the decision to remove skin, muscle, and/or fat.
■ If only fat is being removed, a small stab incision is made to access the fat.
No further incision is required.
■ If skin is being removed, a small stab incision through the muscle and
septum is made. The author does not favor an “open sky” technique.
T E C H N I Q U E S
■ Upper Blepharoplasty
■ After 1% lidocaine with epinephrine 1:100 000 is infiltrated into a
predesigned excision pattern, at least 8 minutes is allowed to pass to allow for
vasoconstriction (TECH FIG 1A).

■ The skin is excised using a no. 15 blade and the muscle is kept intact (TECH
FIG 1B).
■ If fat is to be removed, the globe is balloted to accentuate the excess fat, and
sharp scissors are used to penetrate the muscle septum. The fat is then
exposed through the small stab incision.
■ Care is taken to remove only fat considered excess. Often, this is the size of
an eraser head. (Note: this is where the surgeon’s personal aesthetic sense
comes into play. The key is to know how much fat you intent to remove
before you do so.)
■ A Bovie electrocautery is use to obtain hemostasis (TECH FIG 1C).
■ The skin is closed from medial to lateral with a running 5-0 subcuticular
nylon (TECH FIG 1D).
■ If necessary, the closure is reinforced with either running or interrupted 6-0
nylon on the skin.
TECH FIG 1 • A. Administration of local anesthesia. B.
Skin excision. C. Meticulous hemostasis is essential.
D. Closure.
PEARLS AND PITFALLS
Markings
■ Mark the patient’s tarsal crease preoperatively. This is more
challenging when the patient is supine.
Lateral
tissue
removal
■ Do not leave excess lateral tissue. There is often a fear of extending
the upper blepharoplasty incision beyond the orbital rim; however,
this scar heals very well. This is also the area where patients are
likely to complain of residual excess.

Fat
removal
■ Do not over-resect fat. A surgeon can adversely change a person’s
appearance by converting the person from an individual with full
upper lids to one with hollow upper lids.
Maintaining
symmetry
■ Measure both eye markings to ensure symmetry. Scars at different
heights on the lid need to be avoided.
Eye exam
■ A preoperative ophthalmologist exam may seem overly cautious, but
in the event of a problem, it is very useful to have a consultation
performed prior to surgery.
POSTOPERATIVE CARE
■ Steri-Strips are placed over the incisions.
■ Cool packs are also used to reduce swelling.
■ Strict blood pressure control is enforced postoperatively.
■ Patients are instructed no lifting or bending for 2 weeks.
■ At 48 hours, the medial end of the running suture is trimmed to below the
level of the skin to prevent inclusion cyst formation.
■ If skin sutures were used, they are removed within 4 days.
■ The author prefers to keep the running subcuticular suture in for 7 to 9 days.
■ All patients are seen by the surgeon 48 hours after surgery.
OUTCOMES
■ An upper blepharoplasty is a highly reliable and predictable operation.
■ Scars are usually well concealed (including the extent beyond the lateral
orbital rim).
COMPLICATIONS
■ Bruising and bleeding are the most common complications.
■ The surgeon must be cognizant of the creation of a retrobulbar hematoma.
This is exceedingly rare if fat is not removed.
■ On occasion, a second surgery is required to trim excess skin, but this is
favored over removing too much tissue.

27
CHAPTER
Transpalpebral Corrugator
Resection
Ji H. Son, Ali Totonchi, and Bahman Guyuron
DEFINITION
■ Glabellar frown lines develop as a result of the contraction of the corrugator
supercilii muscles and thinning of the overlying skin.
■ Resection of these muscles corrects the deep furrowing and is usually
accomplished through upper blepharoplasty incisions.
ANATOMY
■ Frontalis muscle: elevates the eyebrows and causes transverse wrinkling of the
forehead. Its contraction provides a constant, cranially directed force vector on
the eyebrows.
■ Orbicularis oculi muscle: depresses the eyebrows. The two main portions of
this muscle are orbital and palpebral.
■ Corrugator supercilii muscle: thin, long, hexagon-shaped muscle located at the
medial end of the eyebrow, deep to frontalis and orbicularis oculi muscles.
Corrugators pass between the orbicularis oculi and insert into the deep surface
of the forehead skin.
■ Depressor supercilii: a thin muscle that extends from the medial canthus area
to the subcutaneous plane above the eyebrows.
■ Procerus muscle: pulls the glabella area skin caudally. The procerus originates
from the caudal portion of the nasal bones and inserts into the dermis between
the eyebrows, which makes it a major stabilizer of the eyebrows. Hyperactivity
of this muscle causes transverse lines in the glabellar area and the nasal root.
■ Supraorbital nerve: exits the supraorbital notch or foramen 2.7 cm from the
midline and runs with an associated artery.
■ Supratrochlear nerve: located 1.7 cm from the midline and 0.8 cm anterior to

the supraorbital nerve and runs with associated artery.
PATHOGENESIS
■ Glabellar frown lines (vertical or oblique) develop due to the
contraction/hyperactivity of the corrugator and depressor supercilii muscles
and the thinning of the overlying skin.
■ The overactive procerus muscle can result in horizontal lines in the radix area.
HISTORY
■ Corrugator supercilii muscle resection is traditionally done using open or
endoscopic forehead lift approaches. The senior author first introduced the
transpalpebral approach in 1993.1
■ This chapter will focus on the transpalpebral resection only. Other techniques
are discussed in different chapters in this textbook.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A comprehensive analysis of the face, hairline position, brow position and
arch, forehead length, width, contour, soft tissue quality, and rhytids will aid in
selection of the procedure that will best serve the patient.
■ The upper face length is approximately one-third of the entire face.
■ Frontalis compensation is extremely common, and it is crucial to eliminate it
for a more accurate judgment about the eyebrow position by asking the
patient to smile or close the eyes tightly and then open them just enough to
see the examiner, making every effort to avoid upward motion of the
eyebrows.
■ The uncompensated position of the eyebrows is at the supraorbital rim in
males and slightly above it in females, with its apex at the lateral limbus of
the eye.
■ The evaluation of the forehead rhytids is recommended in repose, smiling,
and frowning.
■ The best candidates for transpalpebral corrugator resection are:
■ Patients who have proper lateral eyebrow position with hyperactive
corrugator muscles2–4
■ Patients who are undergoing endoscopic forehead rejuvenation and
blepharoplasty concomitantly
■ Patients with male pattern baldness, on whom incisions must be limited
further laterally to avoid visible scars in the forehead area

■ Patients with long foreheads, who would not wish to have a forehead
shortening procedure
■ Patients with proptosis and overactive glabellar muscle where elevation of
the eyebrows needs to be avoided, which would otherwise expose the
proptosis more and have an adverse effect on the patient’s face
■ Similarly, patients with eyelid ptosis who decline eyelid ptosis correction
whereby elevation of the eyebrows would enhance the ill effects of existing
ptosis on the periorbital congruity3,4
■ Patients with documented frontal migraine headaches without the temporal
component5
IMAGING
■ Imaging is not indicated for transpalpebral corrugator resection, unless there is
a clear reason such as mass or lesion in the area or frontal migraine headaches
with the retrobulbar component.
NONOPERATIVE MANAGEMENT
■ Botulinum toxin A or fillers injection: These would be appropriate for
temporary reduction of corrugator hyperactivity or contour deformity for those
who are not ready to undergo surgery.6
■ Fat injection: Limited indication for the patient with permanent and static
wrinkles, where the results are long lasting but less predictable than injectable
fillers. Fat injection is indicated on patients who are not ready to undergo more
invasive procedures.
SURGICAL MANAGEMENT
■ The main objective of transpalpebral corrugator resection is to resect the
hyperactive corrugator and depressor supercilii muscles through the upper
blepharoplasty incisions as thoroughly as possible to correct the deep
furrowing lines in a lasting manner.
Preoperative Planning
■ An AP photograph of the patient’s forehead in repose and while frowning in a
standardized fashion is recommended for analysis and postoperative
comparison. Any asymmetry needs to be noted and discussed with the patient.
■ General medical conditions including hypertension and hyperglycemia, as well
as smoking cessation, are imperative to be addressed prior to surgery to
minimize wound healing complications.

■ Risks, benefits, and expectations need to be clearly discussed with the patient
prior to surgery, with specific attention to risk of anesthesia, asymmetry,
incomplete resolution of glabellar frown lines, and paresthesia in the
supraorbital and supratrochlear regions.
Approach
■ The surgery can be done under general or monitored anesthesia care (MAC).
■ After positioning the patient supine and prior to anesthesia, the supratarsal
crease is marked as the incision line.
■ If a concomitant blepharoplasty is intended, the entire blepharoplasty incision
is designed.
■ Otherwise, the medial half or third of a blepharoplasty incision is used.
T E C H N I Q U E S
■ Incision and Dissection
■ The upper eyelids and the lower forehead area as well as glabellar area are
injected with mixture of 1% lidocaine with 1:100 000 epinephrine mixed
with 0.5% of Naropin using a 30-gauge needle generously.
■ Incision is made on the upper eyelid in supratarsal crease (TECH FIG 1A)
and taken through the orbicularis muscle (TECH FIG 1B).
■ Skin hooks are placed at the skin edges to retract the skin and orbicularis
muscle cephalically.
■ Dissection is started in the plane between the orbicularis muscle and the
orbital septum while staying immediately under the orbicularis muscle and
aiming toward the supraorbital rim. Initially, the dissection is done with a
cautery for an extent of 5 to 10 mm (TECH FIG 1C) and is then continued
using Metzenbaum scissors (TECH FIG 1D).

TECH FIG 1 • A. Upper eyelid incision using
conventional blepharoplasty incision. B. Incision down
to the orbicularis muscle. C. Dissection between the
orbicularis muscle and the orbital septum. D.
Continuation of dissection between the orbicularis
muscle and the orbital septum until depressor
supercilii is visualized. (From Guyuron B.
Transpalpebral corrugator resection: 25-year
experience, refinements and additional indications.
Aesth Plast Surg. 2017;41:339-345.)
■ Removal of the Corrugator and Depressor
Supercilii Muscle
■ After elevation of the skin and the orbicularis muscle, a thin layer of the
depressor supercilli muscle overlying the darker and more friable corrugator
supercilli muscle comes into view; it is dissected (TECH FIG 2A) and

removed (TECH FIG 2B).
■ Upon removal of the depressor supercilii muscle, a branch of the
supraorbital nerve piercing the corrugator supercilli muscle is identified and
followed deep into the muscle using a mosquito hemostat (TECH FIG 2C).
■ The supraorbital nerve is deeper and bigger than the supratrochlear nerve.
■ The corrugator muscle is lifted to identify and protect the main nerve
branches above the periosteum (TECH FIG 2D).
■ The caudal portion of the muscle is isolated and removed first using
coagulating cautery (TECH FIG 2E), followed by the cephalic segment.
■ The remaining portion of a muscle is removed in a piecemeal fashion using
the cautery as thoroughly as possible, including a lateral segment of the
procerus muscle, the end point being the exposure of the fat in the
subcutaneous plane.
■ If the intention of the surgery is to treat frontal migraine headaches, the
supratrochlear and supraorbital arteries are removed as well. If the nerve and
vessels pass through a foramen, a foraminotomy is carried out using a 2-mm
osteotome or a rongeur while protecting the orbital content (TECH FIG 2F).
TECH FIG 2 • A. Corrugator supercilii is dissected. B.
Corrugator supercilii is removed. C. Branch of the
supraorbital nerve is identified and followed deep in
the muscle using a hemostat. D. The same nerve
branch is identified above the periosteum and
protected. E. Corrugator supercilii caudal to the nerve

is lifted and removed using cautery, medially and then
laterally. F. If the intention of the surgery is to treat
frontal migraine headaches, the supratrochlear and
supraorbital arteries are removed due to their roles in
compressing the nerve, and if the nerve and vessels
pass through a foramen, a foraminotomy is carried
out. (From Guyuron B. Transpalpebral corrugator
resection: 25-year experience, refinements and
additional indications. Aesth Plast Surg. 2017;41:339-
345.)
■ Fat Grafting and Closure
■ The upper eyelid nasal (medial) fat pad is gently isolated and injected with
small amount of lidocaine with 1:100 000 epinephrine and removed with
cautery (TECH FIG 3A).
■ For the patient without protruding medial fat pads, 1 to 2 cc of fat is
harvested from the abdomen and injected in the area.
■ Fat graft or injection will prevent the depression resulting from a thorough
removal of the muscles, minimize the potential for the recurrence of the
frown lines by avoiding the reattachment of the muscle to the skin, and
rejuvenate the glabellar area by restoring the naturally lost volume because of
aging.
■ After fat harvest, it is flattened and placed in the corrugator site and fixed to
the underlying periosteum using a 6-0 Vicryl suture to avoid any depression
and to restore the lost glabellar volume to the site (TECH FIG 3B).
■ The skin incision is closed using a 6-0 plain gut in a subcuticular fashion.

TECH FIG 3 • A. Isolated fat graft. B. The fat is
flattened and placed in the corrugator site and fixed to
the underlying periosteum using a 6-0 Vicryl suture.
(From Guyuron B. Transpalpebral corrugator
resection: 25-year experience, refinements and
additional indications. Aesth Plast Surg. 2017;41:339-
345.)
PEARLS AND PITFALLS
■ Inadequate removal of the muscle will result in irregularities and flaws mostly during
animation.
■ Only the lateral fibers of the procerus muscle are removed because complete or
almost complete removal of the procerus muscle can cause excessive elevation of the
medial eyebrows, resulting in an aesthetically displeasing outcome.
■ The depressor supercilii muscle is commonly mistaken for the corrugator muscle. The
latter is darker, more pliable, and located deeper and medial to the former. The goal of
the surgery is complete or near complete removal of the muscles between the
orbicularis muscle/skin and the periosteum.
■ Some patients with established skin wrinkles may require fat injection or graft to the
central portion of the glabella and laser surfacing to obtain optimal results.
POSTOPERATIVE CARE
■ Head elevation for the first few days along with the use of a cold compress

during the first 24 hours of surgery will help with edema and ecchymosis.
■ Patients are instructed not to apply pressure on the glabellar area for a few
days.
■ Ophthalmic ointments help prevent dryness of the incisions, corneal abrasion,
and exposure keratitis.
OUTCOMES
■ Long-term satisfaction is usually very gratifying as long as the muscle is
removed thoroughly (FIG 1A,B).
FIG 1 • Before (left) and 1 year after (right)
transpalpebral corrugator resection. A. In repose. B.
animated expression. (From Guyuron B. Transpalpebral
corrugator resection: 25-year experience, refinements
and additional indications. Aesth Plast Surg.
2017;41:339-345.)
COMPLICATIONS

■ The most common complication of transpalpebral corrugator resection is
anesthesia/paresthesia of the forehead, which is often temporary.
■ Early recurrence of glabellar furrowing may occur if the corrugator muscle is
not adequately resected or is not replaced with fat graft. If the fat graft is not
secured in place, it can migrate caudally causing excessive upper eyelid
fullness.
■ Patients who undergo transpalpebral corrugator resection with blepharoplasty
experience more ecchymosis, compared with those who have blepharoplasty
alone.
REFERENCES
1. Guyuron B. Corrugator supercilii muscle resection through blepharoplasty
incision, ASPRS (ASPS) Annual Meeting, New Orleans, Louisiana, September
1993.
2. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg. 1995;95:52-60.
3. Guyuron B. Michelow BJ, Thomas T. Corrugator supercilii muscle resection
through blepharoplasty incision. Plast Reconstr Surg. 1995;95:691-696.
4. Guyuron B. Corrugator supercilii resection through blepharoplasty incision.
Plast Reconstr Surg. 2001;107:604-605.
5. Guyuron B, Varghai A, Michelow BJ, et al. Corrugator supercilii muscle
resection and migraine headaches. Plast Reconstr Surg. 2000;106(2
suppl):429-434.

28
CHAPTER
Technique for Ptosis
Correction
Ashley A. Campbell, Christopher C. Lo, and Richard D.
Lisman
DEFINITION
■ Blepharoptosis, or ptosis, is the abnormally low position of the upper eyelid in
primary gaze. Ptosis is classified by its etiology as congenital, involutional,
neurogenic, myogenic, and mechanical.
ANATOMY (FIG 1)
■ In normal eyelid anatomy, the upper eyelid retractors are the levator muscle
(innervated by cranial nerve III) and the Mueller muscle (innervated by the
sympathetic system).
■ The levator muscle extends from the lesser wing of the sphenoid just above the
annulus of Zinn to Whitnall ligament; at this point, it transitions to become the
levator aponeurosis.
■ The lid height is determined by the attachment of fine strands from the levator
aponeurosis to the pretarsal skin and orbicularis muscle.
■ The upper eyelid fold is subsequently created by the overhanging skin, fat, and
orbicularis muscle superior to the crease.
■ Mueller muscle originates from the undersurface of the levator aponeurosis to
the superior tarsal margin. It provides about 2 mm of elevation to the upper lid.
■ The upper eyelid tarsus is a dense plate of connective tissue that acts as
structural support to the eyelids. It measures 10 to 12 mm in the vertical
dimension.
PATHOGENESIS
■ The most common type of ptosis is involutional (also referred to as
aponeurotic).

■ This occurs gradually with age and is thought to be related to dehiscence of the
levator from its attachment to tarsus.
■ Involutional ptosis may be related to contact lens use, prior eye or periocular
surgery, eye rubbing, and chronic ocular allergy. These all produce a levator
dehiscence.
NATURAL HISTORY
■ Involutional ptosis typically presents as a gradual decrease in lid height over
time.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient’s primary complaint is often eyelid height or crease asymmetry and/or
a gradual decrease in the size of the palpebral aperture.
■ This often produces the complaint of a tired appearance in patients presenting
for aesthetic correction.
■ Visual symptoms include superior visual field loss and even central loss of
vision in severe cases.
■ This often presents with highly elevated/arched eyebrows with deep frontalis
contraction in an involuntary attempt to open each aperture. Less commonly,
the patient may present with a chin-up posture in an involuntary attempt to
look out from under the resultant “canopy effect.” If long standing, neck pain
or postural problems can result.

FIG 1 • Normal anatomy of the upper eyelids.
FIG 2 • Marginal reflex distance is measured from the
central corneal light reflex to the upper eyelid while the
patient sustains a neutral gaze in primary position.
■ Pertinent questions to ask in the patient’s history include onset of ptosis, a
history of trauma, a history of contact lens wear, prior surgery or botulinum
toxin injections, fluctuations in the eyelid height, diplopia, and any associated
systemic manifestations.

■ Ocular history, especially including the history of dry eyes, should be
obtained.
■ Old photographs are useful in determining onset and degree of prior ptosis.
■ Important aspects of the physical examination include the following:
■ Margin reflex distance (MRD): measured from the central corneal light reflex
(usually the center of the pupil) to the upper eyelid margin. Normal
measurement is 3 to 4 mm. In ptosis patients, this is reduced (FIG 2).
■ Palpebral fissure (PF): measured from the lower to upper eyelid margin in the
midpupillary axis. Normal measurement is 8 to 10 mm. In ptosis patients, this
is reduced.
■ Levator function (LF): measures the upper eyelid excursion from extreme
downgaze to extreme upgaze while the brow is neutralized (FIG 3). This is
critical in determining what ptosis repair technique is most appropriate.
Normal measurement is 14 to 16 mm, and a value less than 5 mm indicates
that either congenital blepharoptosis or acquired neurogenic etiologies need to
be investigated prior to ptosis correction.
■ Lid crease height (LC): should evaluate shape and height. In the case of
involutional ptosis, the LC is often elevated as the levator muscle is
disinserted from its attachment to the tarsus.
■ Bell phenomenon: the involuntary upward movement of the eye on lid
closure. This needs to be assessed to determine the degree of corneal
exposure should there be any lagophthalmos postoperatively.
■ In asymmetric ptosis, Hering law should be evaluated by mechanically lifting
one ptotic eyelid and observing the contralateral eyelid positional change.
■ Pupillary examination should be performed to assess symmetry and reactivity
in light and dark to rule out a Horner syndrome.
■ Humphrey visual field testing performed with and without taping of the upper
eyelid can be performed to demonstrate a superior visual field defect that is
often present in patients with severe ptosis.
IMAGING
■ Imaging is not typically required in the ptosis workup, unless there is any
indication of a myogenic or neurologic etiology for ptosis.
■ If the patient describes any variation in the amount of ptosis throughout the
day or any double vision, a myogenic cause of ptosis (such as myasthenia
gravis, chronic progressive external ophthalmoplegia, and myotonic dystrophy)
should be considered. In this case, a referral to neuro-ophthalmology for

further lab testing is indicated.
■ If there is any evidence of unilateral ptosis in the context of a meiotic pupil
(suggesting a Horner syndrome) or abnormal eye movements (suggesting a
cranial nerve III palsy), a referral to neuro-ophthalmology for further workup is
also indicated.
DIFFERENTIAL DIAGNOSIS
■ Congenital ptosis
■ Myogenic
■ Myasthenia gravis
■ Chronic progressive external ophthalmoplegia
■ Myotonic dystrophy
■ Neurogenic
■ Horner syndrome
■ Cranial nerve III palsy
■ Mechanical
■ Traumatic
■ Dermatochalasis/blepharochalasis
FIG 3 • To clinically evaluate levator function, measure
the upper eyelid excursion in millimeters from extreme
downgaze to upgaze with the brow relaxed or

neutralized by the examiner’s hand.
SURGICAL MANAGEMENT
■ Many operative techniques have been described for the correction of
involutional ptosis associated with moderate or good levator function. These
include levator reinsertion, mullerectomy, and the Fasanella-Servat procedure.
■ Here, we describe the modified Fasanella-Servat procedure, which is our
procedure of choice out of many for aesthetic patients who obviously demand
the most symmetry and have a good tear film and tear production. It is also
possible to perform this ptosis correction in conjunction with other aesthetic
procedures, and it does not require the patient’s cooperation.
Preoperative Planning
■ Prior to surgery, a careful ophthalmic examination should be performed
particularly to assess for any evidence of dry eye disease, as there is a risk of
increased early postoperative dry eye.
■ If there is evidence of dry eye, history of laser in situ keratomileusis (LASIK),
or a poor Bell phenomenon, a conservative ptosis correction should be
considered. This is usually a conservative levator reattachment procedure.
■ If there is asymmetric ptosis, Hering law of central and equal innervation to
the levator muscles should be considered, as unilateral ptosis correction on the
more ptotic-appearing side could then unmask ptosis on the normal-appearing
eyelid.
Positioning
■ A typical blepharoplasty incision site is marked in the preoperative holding
area with the patient seated or in a semireclined position.
■ Upon arrival to the operating room, the patient is placed in the supine position,
and either monitored sedation or general anesthesia is used.
■ Tetracaine ophthalmic drops are placed in each eye.
■ Protective corneal shields covered with ophthalmic ointment are placed over
both eyes.
■ 2% lidocaine with 1:100 000 epinephrine is injected into both upper eyelids to
achieve local anesthesia.
Approach

■ The various approaches to consider in mild-moderate ptosis repair include
levator reinsertion, mullerectomy, and the modified Fasanella-Servat. In this
text, the modified Fasanella-Servat procedure will be further elaborated.
T E C H N I Q U E S
■ Modified Fasanella-Servat Procedure
■ A no. 15 blade is used to incise the skin in the previously made
blepharoplasty mark.
■ The skin and orbicular oculi muscle are removed with curved Steven
scissors.
■ Hemostasis is obtained with unipolar cautery and epinephrine-soaked
pledgets.
■ The orbital septum is incised along the extent of the incision.
■ Any excess central or medial fat is judiciously resected with the Colorado
needle tip.
■ The orbicularis muscle is contoured with the same device.
■ Two symmetrically sized and shaped curved hemostat clamps are chosen for
the tarsoconjunctival resection. The pair should be matched with care, as
these will ultimately create the eyelid contour (TECH FIG 1A,B).
■ The upper eyelid is everted, and a small (2 mm), medium (4 mm), or large (6
mm) tarsoconjunctival resection is delineated with the clamps. It is
anticipated that 1 mm of lift is achieved with a small resection, 2 mm for a
medium resection, and 3 mm for a large resection.
■ The clamps are placed so that the largest resection occurs over the medial
aspect of the pupil in primary gaze.
■ At least 4 mm of residual tarsus and conjunctiva on the upper eyelid is
required to avoid lid destabilization and potential entropion.
■ A 5-0 nylon suture on a P-3 needle is loaded backhand and passed from
inside the upper eyelid wound centrally and directed laterally to exit at the
posterior aspect of the clamp (TECH FIG 1C).
■ The suture is passed in a running, buried fashion, just posterior to the
clamps, medially to laterally (TECH FIG 1D,E). It is important that each
suture pass begins in the previous suture hole, thereby burying the suture. If

exposure of the suture occurs, the patient will experience foreign body
sensation and may develop a corneal abrasion or ulcer.
TECH FIG 1 • A. Symmetrically sized and shaped
hemostat clamps with a smooth contour will result in a
smooth upper eyelid contour. B. Poor clamp selection
and positioning may result in eyelid peaking and
contour abnormalities. C. A 5-0 nylon placed on a P-3
needle loaded backhand is passed from inside the
upper eyelid wound centrally and directed laterally to
exit at the posterior aspect of the clamp. D,E. The
running 5-0 nylon suture is passed posterior to the
hemostat clamps medially to laterally in a buried
fashion. F. A tarsoconjunctival resection is performed

with a no. 15 blade using the clamps as a guide to
ensure a smooth contour. G. The ends of the 5-0
nylon suture are tied with multiple knots and left long
for easy retrieval postoperatively. This suture is
externalized through the upper eyelid blepharoplasty
wound.
■ The tarsoconjunctival resection is performed with a no. 15 blade using the
clamps as a guide, ensuring a smooth contour (TECH FIG 1F).
■ The lateral clamp is removed, and the suture is passed from the posterior
aspect of the eyelid to exit in the upper eyelid wound just adjacent to the
opposite arm of the suture. The medial clamp is then removed. Careful
attention is given to ensure that the needle with its first and last pass traverse
the entire eyelid thickness and pass through the levator as the procedure
actually reattaches a levator disinsertion to a foreshortened tarsus. The
release of the clamp adhesions with separation allows for later readjustment,
if needed, just prior to the dense scarring after postoperative days 8 to 10.
■ The suture is tied with multiple knots and left long for easy retrieval at the
time of suture removal. This suture is externalized through the upper eyelid
wound (TECH FIG G).
■ The contour of the upper eyelid should be smooth at this point. The eyelid
height, however, should not be evaluated.
■ The upper eyelid wound can be closed using whatever technique the surgeon
prefers, as long as the 5-0 nylon Fasanella-Servat suture is externalized.
PEARLS AND PITFALLS
Curved clamp
selection
■ Make sure each curved clamp is symmetric given that the curve of
the clamp will ultimately determine the curvature of the eyelid.
■ Choice of two asymmetric clamps may result in significant lid
peaking and contour abnormality.
Closure
■ Ensure that the knot is externalized through the blepharoplasty
incision to facilitate suture removal at postoperative week 1.
Burying the
■ Failure to bury the suture through the previous suture hole when

suture
running nylon suture through the palpebral conjunctiva can result
in foreign body sensation and a corneal abrasion.
■ If a corneal abrasion should develop, it is recommended to place a
bandage contact lens until the suture is removed.
■ The antibiotic/steroid drop should be changed to an antibiotic drop
alone if a bandage contact lens is placed.
Postoperative
adjustment
■ At postoperative days 5 to 7, an adjustment can be made in the
office if there is eyelid peaking, overcorrection on the surgical site,
or undercorrection on the opposite side. This involves gentle
downward tugging in the desired area of adjustment from the
lashes or eyelid margin.
FIG 4 • Female with moderate, asymmetric, right-worse-
than-left involutional ptosis, and dermatochalasis. A.
Preoperative photos. B. A 2-month status post bilateral
modified Fasanella-Servat procedure and quad
blepharoplasty with symmetric eyelid height and
contour.
POSTOPERATIVE CARE
■ Postoperatively, a topical antibiotic/steroid eye drop is recommended four
times a day for 1 week.
■ For the first 72 hours postoperatively, patients should sleep with their head
elevated and apply cold compresses.
■ Patients should be instructed to avoid heavy lifting, bending, and straining for
at least 2 weeks after surgery.
■ If the patient should develop any foreign body sensation or evidence of a
corneal abrasion, this could mean exposure of the nylon suture along the

palpebral conjunctiva. This can be managed with placement of a bandage
contact lens, which is removed at the time of suture removal. At this point, the
antibiotic/steroid drop should be changed to an antibiotic drop alone.
■ At postoperative week 1, the Fasanella suture can be removed. At this time,
adjustments can be made as necessary (FIG 4).
OUTCOMES
■ The Fasanella-Servat procedure is unique in that subtle correction of lid
contour and height asymmetries can be made in the early postoperative period.
Given that tarsus does not adhere until postoperative day 8 or 9, early
adhesions can be broken around postoperative days 5 to 7 at the time of suture
removal (FIG 5).
■ Indications for adjustment include eyelid peaking, overcorrection on the
surgical side, or undercorrection on the opposite side (FIG 6).
■ Adjustment requires a gentle downward tugging in the desired area from the
lashes or lid margins (FIG 7). Use of a cotton-tipped applicator to apply
pressure at the superior border of the tarsus separates early tarsal adhesions.
Local anesthesia or sedation is not needed.
■ In the case of bilateral surgery, readjustment is aimed at lowering the higher
lid given that the lower eyelid will secondarily elevate due to the phenomenon
of Hering law.

FIG 5 • A. Preoperative photo of a young female with
bilateral upper eyelid aponeurotic ptosis. B. Two
months after bilateral upper eyelid modified Fasanella-
Servat procedure showing improved MRD, symmetry,
and contour restoring a youthful appearance. C.
Preoperative photo of a male with unilateral aponeurotic
ptosis and compensatory left brow elevation. D.
Postoperative photo 2 months after left modified
Fasanella-Servat surgery with deviation of the left upper
eyelid. Left brow drop further contirbutes to overall
symmetry and balance of periorbital features.

FIG 6 • Aberrant contour and eyelid height are
complications of all methods of eyelid ptosis repair. With
the modified Fasanella-Servat procedure, these pitfalls
can be easily reversed with postoperative in-office
adjustments.

FIG 7 • A. A. Postoperative adjustments can be
performed prior to tarsal adhesion 5 to 7 days
postoperatively when sutures are removed and edema
subsides. B. Adjustments entail a gentle downward
tugging in the desired area from the lashes or lid
margins. C. It is common to see some blood in the tear
film after a successful adjustment.
■ In general, approximately 20% of patients require a small postoperative
adjustment. Once adjusted, nearly 100% of patients can attain a satisfactory
result.1
■ Final lid height is determined at about 14 to 21 days postoperatively or when
all the edema has fully cleared.
■ Although it is rare to need a reoperation, if an additional surgery is necessary,
it is recommended to wait at least 3 months postoperatively.2
COMPLICATIONS
■ Foreign body sensation or a corneal abrasion can occur immediately
postoperatively if there is exposure of the nylon suture through the palpebral