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References—With Key Annotated References
1. Codner MA, Day CR, Hester TR, et al. Management of mundane to complex blepharoplasty
problems. Perspect Plast Surg 15:15, 2001.
2. Shorr N, Cohen MS. Cosmetic blepharoplasty. Ophthal Clin North Am 4:17, 1991.
3. Lisman RO, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 15:309, 1988.
4. Heine JB, Hueston JT. Blindness after blepharoplasty: Mechanism and early reversal. Plast Re-
constr Surg 61:347, 1978.
5. Gradinger GP. Problems and complications in lower lid blepharoplasty. In Kaye BL, Gradinger
GP, eds. Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face.
St Louis: Mosby, 1984, p 252.
6. Rees TD, Aston SJ, Thorne CM. Blepharoplasty and facialplasty. In McCarthy JG, ed. Plastic
Surgery. Philadelphia:WB Saunders, 1990, p 2320.
7. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: Guidelines for surgery? Plast
Reconstr Surg 68:249, 1981.
8. Jelks GW, McCord CD Jr. Dry eye syndrome and other tear lm abnormalities. Clin Plast
Surg 8:803, 1981.
9. Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morphology in predicting
dry eye syndrome after blepharoplasty. Plast Reconstr Surg 82:618, 1988.
10. Wilkins RB, Hunter GJ, McCord CD, et al, eds. Oculoplastic Surgery, 2nd ed. New York:
Raven, 1987, p 451.
11. Horton CE, Murphy JB. Secondary blepharoplasty. In Kaye BL, Gradinger GP, eds. Symposium
on Problems and Complications in Aesthetic Plastic Surgery of the Face. St Louis: Mosby,
1984, p 264.
12. McCord CD, Doxanas MT. Browplasty and browpexy:An adjunct to blepharoplasty. Plast Re-
constr Surg 86:248, 1990.
13. McKinney P, Mossier RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg
15:141, 1991.
14. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast
Reconstr Surg 96:354, 1995.
With aging, the periorbital area reveals progressive exposure of underlying skeletal anatomy com-
pared with the areas of the lower face, where thicker soft tissues cover underlying bony landmarks.The
author describes a technique to preserve lower eyelid fat and advance it beyond the infraorbital rim.
This procedure is especially suggested in secondary procedures correcting overresection of orbital fat or
deformities resulting from malar augmentation.
15. McCord CD. The correction of lower lid malposition following lower blepharoplasty. Plast
Reconstr Surg 103:1036, 1999.
Lower eyelid malposition is the most common complication after lower eyelid blepharoplasty.When
malposition occurs, it is imperative to correct it using the most ef cient method.The author presents
methods for correcting both minor and severe cases.
16. Carraway JH, Mellow GC. The prevention and treatment of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg 85:971, 1990.
Ectropion and scleral show are the most common complications after lower lid blepharoplasty.This ar-
ticle discusses preoperative evaluation, operative techniques, postoperative treatment, and postoperative
measures to prevent ectropion after blepharoplasty.
17. Tenzel RR. Surgical treatment of complications of cosmetic blepharoplasty. Clin Plast Surg
5:517, 1978.
18. Nesi FA, Katzen LB, Li Vecchi JR. Complications of blepharoplasty. In Smith B, Della Roca R,
Nesi F, et al, eds. Ophthalmic Plastic and Reconstructive Surgery. St Louis:Mosby, 1987, p 732.

19. McCord CD, Boswell CD, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg 112:222,
2003.
Surgeons performing aesthetic or reconstructive surgery procedures on the lower lid or midface through
the lower lid should be comfortable with canthal anchoring procedures (canthoplasty and canthopexy).
This article discusses the principles involved in canthal support for patients undergoing aesthetic and
reconstructive surgery, variations in surgical techniques required to perform canthal anchoring in a va-
riety of patients, the signi cance and techniques of canthal anchoring as they relate to aesthetic and
reconstructive lower lid surgery, and the effect of canthal anchoring on the function of the upper and
lower lids and eyelid ssure shape.
20. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 20:417, 1993.
21. Carraway JH, Den MJ. Re nements in ptosis surgery using frontalis sling technique. Operative
Tech Plast Reconstr Surg 1:113, 1994.
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1. Lower eyelid massage for postoperative blepharoplasty tightnesss is performed
in what direction?
a. Inward and upward
b. Pinch and pull the lower lid away from the eye
c. Lateral stretching
d. Downward stretching
2. When orbital hemorrhage is suspected, examination should include all of the
following except:
a. Assessment of visual acuity
b. Fundoscopic examination
c. Tonometry to exclude elevated intraocular pressure
d. Schirmer test
3. Which is the most common residual fat pad after blepharoplasty?
a. Upper medial
b. Lower medial
c. Lower lateral
d. Lower middle
4. What is the best procedure to correct lower eyelid scar contracture?
a. Tarsal wedge excision
b. Tarsal strip
c. Cartilage graft versus Medpor implant
d. Lower lid sling
5. Placement of a Medpor implant in the lower lid should be in what anatomic
plane?
a. Just deep to the skin
b. Just deep to the orbicularis oculi muscle
c. Deep to the capsulopalpebral fascia
d. Inline with the conjunctiva
6. The following is true regarding the Schirmer test in secondary blepharoplasty:
a. It is not helpful in individuals with a history of use of antihistamines and
arti cial tear substitute
b. If the tear secretion is less then 10 to 12 mm, the lids may be inadequately
functioning
c. Is best performed without topical anesthetic in the eye
d. Excessive tearing occurs when the Schirmer test is performed under top-
ical anesthesia
e. Most secondary blepharoplasty cases demonstrate lacrimal gland hypose-
cretion
R EVIEW QUESTIONS

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7. The treatment of retrobulbar hematoma includes all of the following except:
a. Administration of acetazolamide (Diamox) or mannitol
b. Removal of sutures
c. Release of the lateral canthal tendon
d. Patch, head elevation, and observation
e. Placement of a cottonoid wick into the hematoma site
8. All of the following can cause postblepharoplasty ectropion except:
a. Excessive skin removal
b. Excessive fat removal
c. Laxity of the orbital septum
d. Damage to the orbicularis oculi muscle
e. Proptosis
9. The best approach to the lower lid for correction of lower lid retraction is:
a. Transconjunctival approach
b. Infraciliary approach
c. Combined transconjunctival and lateral canthotomy
d. Lateral conthotomy approach
e. Infraorbital approach
10. Which of the following would be contraindicated in lower lid laxity with
proptosis?
a. Wedge excision tarsectomy
b. Tarsal strip procedure
c. Lateral canthopexy
d. Lateral canthoplasty
e. Fascial sling

(Trang không có chữ)

481
Lower blepharoplasty has been called one of the most challenging procedures in
plastic surgery and is also one of the most commonly requested and performed
aesthetic procedures. With the increase in the number of procedures performed,
there is also an increase in the incidence of postblepharoplasty complications. To-
day there are two evolving trends in blepharoplasty: (1) toward more aggressive
techniques to maximize the aesthetic outcome and (2) toward more conservative
techniques to minimize the risk of complications. This has created a dichotomy
with the pendulum swinging between the two sides with techniques such as trans-
blepharoplasty subperiosteal midface lifts on one side and “no-touch” blepharo-
plasty using a transconjunctival approach and skin pinch or laser resurfacing on the
Reoperative Lower Lid Blepharoplasty
Mark A. Codner and M. Keith Hanna
C ha pter 18
Reoperative Problems
Lid malposition
Infection
Ectropion
Retrobulbar hematoma
Dry eyes
Corneal abrasion/ulceration
Scarring
Chemosis
Lateral canthal dehiscence
Visual problems/visual loss
Bleeding
To go too far is as bad as to fall short.
Confucius

Lockwood’s ligament
Lateral canthal tendon
Arcuate expansion
Inferior tarsal muscle
Müller’s muscle
Posterior reflection
of medial canthal tendon
Lacrimal sac fossa
Anterior reflection
of medial canthal tendon
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other. Lid retraction and ectropion are the most common complications that occur
after lower blepharoplasty and the most common causes for reoperative surgery.
Interestingly, these complications occur after all techniques from both ends of the
spectrum.
Transconjunctival lower blepharoplasty does not, in fact, eliminate the risk of lid
malposition, as some of the original publications suggest, and as shown in the pa-
tient above. Because complications after lower blepharoplasty cannot be entirely
eliminated, the goal of surgical techniques is to minimize the risk.Therefore, rather
than blaming a particular blepharoplasty technique or, even worse, blaming the sur-
geon, the risk factors that might predispose certain patients to complications should
be recognized before surgery.
Knowledge of the anatomy supports the hypothesis that untreated posterior lamel-
lar tarsoligamentous laxity is the primary cause of lid malposition. Patients with
minimal laxity often require lateral canthopexy, whereas patients with signi cant

laxity may require a lateral canthoplasty. In addition to lateral canthal support, or-
bicularis suspension should be performed to support the anterior lamella.This fun-
damental principle of two-point xation of the anterior lamella and the posterior
lamella signi cantly reduces the risk of complications.
All blepharoplasty techniques are complex, technically demanding procedures with
little margin for error. Patients present with lid malposition and ectropion from
our own practices and are also referred from other practices. In addition to the pre-
vention of complications in primary cases, the purpose of this chapter is to provide
a logical sequence for both conservative and surgical correction of complications af-
ter lower lid blepharoplasty in secondary cases. Unfortunately, patients and surgeons
may nd themselves needing to revisit the reconstructive procedure to correct a se-
rious sequela after what began as a cosmetic endeavor.
Successful and predictable techniques should be used to turn the sit-
uation around and restore the shape and position of the eyelid. The
most common technical error is to perform “too little” in an attempt
to quickly satisfy an unhappy patient.
PATIENT EVALUATION
The goal of primary blepharoplasty is to restore a more youthful appearance to the
periorbital area while minimizing complications. Minimizing the risk of complica-
tions begins with the preoperative evaluation. Objective assessment of speci c dis-
ease processes and physical ndings will help identify patients who are at high risk
for complications. These ndings have been used in the development of an algo-
rithm to determine which surgical procedures to perform.1
The goal of reoperative lower blepharoplasty is to restore the shape of the eyelid to
the preoperative appearance while correcting the functional problems caused by
corneal exposure. The first consideration when evaluating a patient with com-
plaints after blepharoplasty is to reassure the patient that corrective revision sur-
gery is possible and can be performed. Many patients are devastated by the appear-
ance of their eyes as well as the discomfort associated with corneal exposure. It is
very important to restore hope through reassurance. If a colleague performed the
initial procedure, the patient should be given the option to return to the previous
physician. Most patients usually have had secondary procedures that were unsuc-
cessful because the approach was insuf ciently aggressive. Lateral tarsorrhaphy and
canthopexy without a lower lid spacer are the most common attempts that have
been made, usually without success. Although suture tarsorrhaphy can temporize
some of the symptoms associated with corneal exposure and can reduce chemosis,
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it cannot generally correct lid malposition. In addition, reoperative lower lid surgery
for lid malposition is much more complicated than primary lower blepharoplasty
and is associated with a higher rate of revision. In our own practice, the incidence
of reoperative surgery after primary procedures is less than 5%, whereas the inci-
dence after secondary corrective procedures is approximately 25%.
Tarsal plate
Lid retractors
Scar contracture
Septum
(middle lamella)
Skin
Muscle
Skin shortage
Anterior lamella
Posterior lamella
Patients need to understand that their eyelid position can be improved, but this
will often require more than one operation. Retightening the lateral canthal angle
is the most common tertiary procedure required after revision surgery.This should
be explained to the patient, as well as that in any surgery complications can result
from scarring, hematoma, and the downward retractive forces of healing that occur
after blepharoplasty. Lid malposition is not commonly caused by the removal of too
much skin—this is the most common misconception that patients may use to point
blame toward the surgeon. If a patient chooses not to return to the previous sur-
geon or if you feel that the surgery is beyond the scope of that practice, then you
should discuss alternative treatment plans with the patient. As a matter of courtesy,
communication with the primary surgeon should be considered.
In the initial evaluation the surgeon determines what technique was performed, the
timing of the procedure, and any known complications that may have occurred af-
ter surgery, such as hematoma, excessive swelling, or chemosis. Determining the
cause of the patient’s complaints should be the primary goal when evaluating a
postblepharoplasty complication. A thorough history and physical examination
LID RETRACTION

should be obtained for diagnostic purposes as well as for medicolegal documenta-
tion.This is also a time to develop a relationship with the patient, who probably ex-
hibits a wide range of emotions.When obtaining the history of the patient’s com-
plaints, the surgeon should ask speci c questions about eyelid function as well as
appearance:Is there any visual impairment, tearing, dry eyes, irritation of the cornea
or sclera, blinking function, or a sensation of a foreign body or “sand” in the eye?
The surgeon’s questions should explore any predisposing medical conditions that
would increase a patient’s risk for complications after eyelid surgery, such as pem-
phigus, rosacea, Graves’disease, benign essential blepharospasm, dry-eye syndrome,
and certain neuromuscular disorders such as myasthenia gravis.2 All of these disor-
ders increase the risk of complications after blepharoplasty.
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The physical examination should include evaluation of visual acuity, testing of the
extraocular muscle, and assessment of the protective mechanisms of lid closure and
for Bell’s phenomenon.The extent of lagophthalmos should be measured.When a
patient complains of irritation, dry eye, or foreign-body sensation, a slit-lamp exam-
ination should be considered to reveal possible corneal abrasion or ulceration. Fluo-
rescein eyedrops will appear uorescent when viewed with an ultraviolet light at an
area of corneal epithelial injury. A pattern of dryness should be evaluated, which ap-
Lid snap-back test
Bell’s phenomenon

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Complaints of dry eye should also be evaluated with a Schirmer’s test, which mea-
sures baseline tear production.3 A Schirmer’s test using an anesthetic should be per-
formed in patients presenting for primary blepharoplasty with symptoms of dry
eye, which are most commonly elicited by a history of contact lens intolerance.
This test is conducted by rst placing a topical anesthetic (tetracaine) in the eye to
avoid irritation and stimulation of excess tearing.The fornix is dried with a tissue,
and the test strip is placed in the lateral part of the lower lid fornix and left in place
for 5 minutes.The patient should be instructed to look forward to avoid a corneal
abrasion while the strips are in the lateral fornix, which can injure the cornea if the
patient looks to the side.Tear secretion of less than 10 mm at 5 minutes is consid-
ered abnormal; such a patient is at increased risk for corneal dryness. Therefore
conservative brow lift and/or upper blepharoplasty should be performed to mini-
mize lagophthalmos as well as to prevent lower lid malposition. Secondary cases
should include close inspection of the lower lid, which should also be examined for
entropion, ectropion, rounded lateral canthus or phimosis, canthal webbing, im-
proper alignment of the lower lid margin, shortening of the horizontal aperture, in-
creased scleral show, and lid tone.
Lower lid laxity should be carefully evaluated before primary blepharoplasty. Tar-
soligamentous laxity can be determined by the snap test or the pinch test.The snap
test is accomplished by pulling the lower lid down and releasing it. Normal tone is
present when the lid retracts to the globe immediately.
pears as a transverse linear band across the lower part of the cornea that corre-
sponds to the degree of lagophthalmos. Although this pattern of exposure can be
treated with liberal ophthalmic antibiotic ointments and patching at night, a deeper
corneal ulcer should be cause for immediate referral to an ophthalmologist for
evaluation because of the risk of superinfection, scarring, and perforation.

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Although ectropion most commonly involves the central and lateral aspect of the lid
margin, isolated medial ectropion warrants additional discussion. Medial ectropion
displaces the inferior punctum away from apposition to the globe, resulting in im-
The pinch test is performed by distracting the lower lid away from the globe and
measuring the distance.These tests help determine the type of lateral canthal tight-
ening procedure that should be performed. Lid distraction of 1 to 2 mm indicates
good tone and requires minimal lower lid tightening or a preventative canthopexy
depending on the blepharoplasty technique. Canthopexy should be considered for
moderate laxity demonstrated by 3 to 6 mm of distraction, and canthoplasty is rec-
ommended for lid distraction greater than 6 mm.4 Patients with lid retraction or ec-
tropion should be similarly evaluated. In addition, the lid should be pushed in a
superior direction with the index nger in the midpupillary line to evaluate pos-
terior lamella scar contraction. If the eyelid appears to have excess skin that can be
stretched at least to the level of the pupil but is restricted by the posterior lamella,
which prevents the lid from being elevated to the level of the pupil, then these pa-
tients have primary posterior lamella retraction of the lower lid.This requires release
of the posterior lamella and lid spacer. On the other hand, if the lid is limited by the
skin, the primary problem is a shortage of anterior lamellar skin, which is com-
monly present with actinic damage. In addition to a lid spacer, this problem re-
quires a cheek advancement to recruit skin into the lower lid or a skin graft.

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paired lacrimal drainage. Patients will often present with epiphora, in contrast to the
symptoms of dry eye often associated with ectropion.Furthermore,medial ectropion
requires additional techniques to reposition the inferior punctum against the globe.
A medial canthoplasty and fascia suspension of the tarsoligamentous sling are the
most successful methods for correcting a medial ectropion. Although lateral can-
thoplasty and lower lid spacer grafts are effective for correcting central and lateral ec-
tropion, correction of medial ectropion may be inadequate with these techniques.
The function of the eyelids should be examined by asking the patient to blink to
determine whether the patient can completely close the eyelids during normal
blinking. The three types of blink should be evaluated: involuntary, voluntary, and
forced. These different blinking mechanisms recruit additional orbicularis muscle
heads recruiting pretarsal, preseptal, and orbital orbicularis bers, respectively. Al-
though the upper lid orbicularis functions to create the majority of the blink mech-
anism, the lower lid is a dynamic structure that also moves superiorly and medially
with each blink. Furthermore, the lower lid orbicularis deep heads contribute to the
lacrimal pump, which can also be impaired with ectropion. If the lid cannot be
closed, the physician must then determine whether this is caused by edema, de -
ciency of skin, scarring, or lateral canthal dehiscence.
With dehiscence or loosening of the lateral canthus, the eyelid is not well anchored
to the lateral orbit, and orbicularis contraction during blinking will cause nasal mi-
gration and rounding of the lateral canthus or “ sh-mouthing” of the eyelids.5 This
has a signi cant impact on the ability of the lids to close. The normal dynamic
component of lid closure is impaired. In addition to lateral canthal support to re-
store lid shape, bony xation of the entire lateral canthal mechanism, including the
lateral canthal tendon to the upper lid, is required to restore functional closure.

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Upper lid crease
Upper lid fold
Canthal tilt
Lateral canthus
Lower lid crease
Eyelid-cheek junction
Upper lid sulcus
Medial canthus
Nasojugal groove
The anatomic relationship between the lateral and medial canthus is termed the
canthal tilt.The most common nding is a positive lateral canthal tilt, when the lat-
eral canthus is 1 to 2 mm superior to the level of the medial canthus. Another good
visual reference to eyelid shape is the amount of exposed sclera on each side of the
cornea, the nasal and lateral scleral triangles.The lateral scleral triangle is normally
larger and more pointed than the nasal scleral triangle. Any deviation from these vi-
sual keys of the “normal” eyelid shape may indicate the need for a lateral canthal
tightening procedure. For secondary cases, it is vitally important to have patients
provide a photograph of their eyelid shape before the complication. Careful analy-
sis of the patient’s lid shape usually reveals the desired outcome by the patient. Cor-
rection of severe ectropion may tighten the lower lid to elevate the position, which
may result in a lid that is more straight or more tight than before surgery. Thus a
gentle S-shaped curve of the lower lid may not be possible, and this should be dis-
cussed in detail with the patient before corrective lid surgery.
The shape of the eyelid is also an important consideration when evaluating a post-
blepharoplasty patient. The margin of the lower lid most commonly is positioned
at or just above the inferior limbus.
Negative canthal tilt
Positive canthal tilt

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Another extremely important aspect of the preoperative assessment is measuring
globe position or eye prominence. Many surgeons have discussed the importance of
recognizing eye prominence preoperatively as well as the increased incidence of
complications after blepharoplasty in patients with prominent or morphologically
prone eyes.3,5-12 A Hertel exophthalmometer can be used to provide an objective
measurement of the globe position in relation to the lateral orbital rim.
Canthal Fixation Point
Normal eye prominence (15-17 mm)
At pupillary line
4 mm inside lateral orbital rim
Exophthalmic placement (>17 mm)
More superior and anterior
Enophthalmic placement (<15 mm)
More inferior and posterior
Prominent eye
Deep-set eye

Normal measurement is 15 to 17 mm,13 a deep-set or enophthalmic eye is less than
15 mm, and a prominent or exophthalmic eye is greater than 17 mm. Determin-
ing this value preoperatively is important, because it establishes the level at which
the lateral canthal xation should be placed to obtain the optimal aesthetic result
and avoid postoperative lid malposition. Eyelid position varies directly with globe
prominence because of the dynamic forces exerted on the lid by the globe. For ex-
ample, patients with Graves’exophthalmopathy develop signi cant globe exposure.
Although the upper lid retracts superiorly because of the direct retraction of
Müller’s muscle, the lower lid descends from the force of the globe because of in-
creasing globe prominence secondary to extraocular muscle enlargement. When
lateral canthopexy is performed, globe prominence is a variable that determines
appropriate suture placement. In patients with normal eye prominence, the lateral
canthus should be anchored at the approximate level of the pupil and 4 mm inside
the lateral orbital rim. In patients with exophthalmos, the canthal suture should be
placed in a more superior and anterior position to avoid inferior “clotheslining” of
the lid against the globe.The placement of the lateral canthus in the enophthalmic
eye should be shifted downward and more posterior to the orbital rim to avoid
anterior displacement of the lower lid.5,9,10
In summary, the fundamental aspects of lateral canthal support vary depending on
the clinical scenario. Patients undergoing primary lower transconjunctival blepharo-
plasty or transcutaneous blepharoplasty with minimal lid laxity are candidates for
simple lateral canthopexy. Lower blepharoplasty in patients with signi cant lid lax-
ity and more aggressive transblepharoplasty midface lifts may require lateral cantho-
plasty. Secondary cases of lid malposition or ectropion require a reconstructive re-
operative approach including a lid spacer. The surgeon must often consider drill
hole canthoplasty to reattach the lateral canthus to the bone rather than to the peri-
osteum after one failed canthoplasty because of a lack of adequate periosteum.
PROCEDURAL CAVEATS
Historically, lower eyelid laxity was managed with the Kuhnt-Szymanowski tech-
nique, which was performed with a central lid excision and has more recently been
modi ed to include a lateral margin excision preserving the lateral commissure.14
The original technique has been abandoned for the most part because of compli-
cations, including central lid notching and worsening of lateral canthal dehiscence,
since no bony xation was performed.Treatment of lower lid laxity has evolved to-
ward lateral tightening of the tarsoligamentous sling with bony xation.The lateral
tarsal strip, which was originally used in reconstructive cases such as senile and par-
alytic ectropion, was later applied to cosmetic blepharoplasty.15-19 Presently, lateral
canthal tightening procedures are being increasingly used as routine components in
blepharoplasty.4,20 The lateral canthoplasty is a reliable technique with predictable
results when the basic principles of precise anatomic xation are followed.
As previously mentioned, the normal position of the lower lid is at or 1 mm above
the inferior corneoscleral limbus for most patients. When performing lateral can-
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thal tightening procedures in primary cases, the surgeon’s goal should be to preserve
the natural preoperative position of the lid. If the lower lid is placed too high, an ab-
normal canthal tilt will result in an overcorrected “surgical” appearance.Therefore,
at the conclusion of the lateral canthal tightening, the lid’s position should be sim-
ilar to its preoperative position, with appropriate tension allowing at least 1 mm of
lid distraction away from the globe. It should be easy to retract the lid with forceps
superiorly over the cornea to the level of the pupil to ensure that the lower lid has
not been tightened too much.9,21
Some patients with exophthalmometer measurements greater than 20 mm actually
require lengthening of the lower lid to prevent undue tension while placing the lid
in the proper position. Lid lengthening is accomplished by using suture interposi-
tion or a periosteal ap to span the distance from the lateral canthus to the lateral
orbital rim. In some patients with prominent eyes, this distance may be up to
10 mm. Suture interposition lengthens the lid by leaving several millimeters of su-
ture between the lateral canthus and the lateral orbital rim. In patients with ex-
treme proptosis, a periosteal ap can be used for additional length and support.This
ap is based at Whitnall’s tubercle on the orbital rim and elevated from lateral to me-
dial.The free lateral edge is then rotated 180 degrees and sutured to the tarsal plate
of the lower lid as a neocanthal tendon.10,22,23 Often in reoperative cases, the sur-
geon will encounter the fact that the periosteum will not support canthal xation
sutures—it has lost its integrity as a result of scarring and damage.The periosteum
of the lateral rim is less reliable in secondary cases. In such cases, drill hole xation
is performed to anchor the lateral canthus directly to the bone of the orbital rim.
For mild lower lid retraction, canthoplasty can be combined with recession of the
inferior retractors (capsulopalpebral fascia), which can be accomplished through an
anterior or posterior approach. Release of posterior lamellar scarring results in 1 to
2 mm of superior lid correction when combined with lateral canthal support.
When this maneuver fails to correct more signi cant lid retraction, spacer grafts
are generally required. Posterior lamellar spacer grafts have been reliably used as the
gold standard for the correction of postblepharoplasty lower lid malposition.10,24-27
Hard palate, cartilage, AlloDerm, Dermaplant, and Enduragen and other autoge-
nous, allergenic, and alloplastic grafts have been used for this purpose. Each spacer
has unique advantages and disadvantages.
Periosteal ap
Lateral canthoplasty

Ear cartilage has been preferred as the autogenous ma-
terial of choice over the years. Rather than using con-
ventional conchal cartilage, which is thick and curved,
the scaphoid cartilage is easily harvested through a pos-
terior approach. The cartilage is more thin yet durable
and is less curved, which reduces the visibility of the
graft through the thin lower lid skin muscle ap. The
primary disadvantage to ear cartilage is that even
scaphoid cartilage can warp over time and the grafts can
be palpable or visible over time. Ear cartilage is very use-
ful for treatment of severe ectropion and signi cant lid
retraction, such as in Graves’exophthalmopathy, when a
substantial graft is required. Although hard palate is a
popular autogenous graft alternative to ear cartilage, the donor site is less well tol-
erated by patients. Pain, bleeding, and slow healing are the most common mor-
bidities encountered with use of the hard palate graft. However, graft visibility oc-
curs at a lower incidence compared with ear cartilage.
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Autogenous tensor fascia lata should be
used for medial ectropion correction and
can be combined with spacer grafts for the
correction of frank ectropion. Dermis fat
grafts can be used for a dual purpose: as a
posterior lamellar spacer and to correct in-
fraorbital hollowness from overresection of
lower lid fat.
Allergenic spacer grafts have been used and
offer the advantage of no donor site mor-
bidity. AlloDerm is an acellular human
dermal matrix that has been used for the
past several years. Despite early enthusiasm
and success with AlloDerm, many patients
experienced long-term resorption and re-
currence of lid malposition. In part, this
was caused by the use of thin AlloDerm
sheets;success rates have improved with the
use of thicker AlloDerm grafts. Enduragen
is a sterile, acellular porcine dermal matrix that is used for posterior lamellar spacer
grafts similar to AlloDerm. Enduragen has a greater thickness than AlloDerm grafts
and appears to undergo limited resorption. The disadvantages include the risk of
prolonged swelling from in ammation, infection, or extrusion. Alloplastic posterior
lamellar spacer grafts have been used.

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Limited experience with Medpor sheets has shown effective correction but in-
creased risk of long-term exposure because of the rigidity of the material, necessi-
tating removal, compared with allergenic spacer grafts.
Evolving trends advocate the use of spacers in primary blepharoplasty to support
the lid in patients with very prominent eyes and may be considered in patients
with exophthalmometer measurements greater than 20 mm and signi cant scleral
show. The signi cant increased risk in this patient population for lid malposition
justi es the prophylactic use of spacer grafts at the time of primary blepharoplasty.
The spacer is placed in the posterior lamella between the tarsal plate and the cap-
sulopalpebral fascia through a translid or transconjunctival approach.26 An approach
similar to the management of patients with Graves’exophthalmopathy is used.
Additional lower lid support may be required in patients with prominent eyes be-
cause of the increased dynamic forces that encourage inferior displacement of the
lower lid. This extra support can be obtained by creation of an orbicularis sling,

which consists of orbicularis muscle suspension to the lateral orbital periosteum
and deep temporal fascia.24 Many surgeons appreciate the need for canthopexy but
overlook the need for resuspension of the skin muscle ap.The traditional approach
of removing a small strip of skin and muscle and gently pushing the ap back up
to the lid margin and closing the incision in a tension-free position is simply not
enough to prevent lid malposition or ectropion in most patients. Even when a can-
thopexy is performed, based on the anatomy, this only addresses posterior lamellar
support.The skin muscle ap must be resuspended to support the anterior lamella
at a point separate from the canthal support suture. This is required to control lid
position during the postoperative period when downward forces occur from
swelling and scar contraction.The skin muscle ap is sutured to the periosteum of
the lateral orbital rim just lateral to the canthopexy suture. Patients with signi cant
skin shortage may require a supraperiosteal or subperiosteal cheek-lift procedure to
recruit additional skin in a vertical direction. In the most severe cases of skin short-
age, a full-thickness skin graft may be required.The best donor site for this purpose
is the upper eyelid; however, if this is not available or is inadequate, the retroauric-
ular or supraclavicular areas can be used as donor sites.
Although exophthalmos predisposes patients to increased risk of lid malposition
because of lid retraction, patients with enophthalmos are at risk for different com-
plications. Overcorrection of canthal support is advocated and tolerated in patients
with prominent eyes because the force of the globe on the lid will allow the lid to
descend to the approximate preoperative position. However, a deep-set eye exerts
little force on the globe; therefore overcorrection should be avoided. In addition,
the patient is at risk for anterior displacement of the lid away from the globe. Can-
thal xation should be deep (more posterior) within the orbital rim to prevent lid
separation away from the globe. Horizontal lid shortening during the lateral can-
thoplasty may be required in these patients in the face of signi cant lower lid lax-
ity. Patients with deep-set eyes require a more inferior canthal xation point com-
pared to patients with prominent eyes to avoid superior lid malposition.13
COMPLICATIONS
Lower blepharoplasty has been called one of the most dif cult procedures in the
practice of aesthetic surgery.The complications that can occur after blepharoplasty
range from a subtle change in eye shape to frank ectropion with corneal ulceration.
The primary goals of blepharoplasty should be prevention of these complications.
Reoperative blepharoplasty is based on the recognition and correction of these
problems. Additional complications include infection, bleeding, retrobulbar hema-
toma, delayed healing, scars, epiphora, dry-eye syndrome, chemosis, lagophthalmos,
corneal abrasion, visual problems, and vision loss. Complications most commonly
encountered after lower blepharoplasty include excessive orbital fat excision and
lower lid malposition. Occasionally, underresection of fat occurs, which requires
reoperation for correction. The lateral fat pad in the lower lid is the most com-
monly under resected fat pad after blepharoplasty. A bulge may appear in this lat-
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eral area more visible in upgaze necessitating secondary removal. The most com-
monly underresected fat pad in the upper lid is the nasal fat pad. Secondary correc-
tion can be performed with a transconjunctival approach to the nasal fat pad,
thereby avoiding another external incision.
A lateral bulge in the upper lid after upper blepharoplasty is most
commonly a ptotic lacrimal gland. This should not be resected; how-
ever, resuspension can be performed simply by suturing the lateral
horn of the levator to the arcus marginalis.
Sutures should not be placed in the gland, because there is no true capsule.The up-
per lid should be closed with a retractor before suture placement to avoid impaired
closure which can occur if the levator lateral horn is sutured to the rim in the open
position. Overresection of fat in the lower lid can also lead to suboptimal aesthetic
results by giving the appearance of sunken, hollow eyes as a result of lower lid con-
cavity and orbital rim prominence. Although the current trends in blepharoplasty
support less fat removal than in the past, conservative fat removal continues to be
an important part of achieving the ideal aesthetic result.The abandonment of fat re-
moval altogether seems excessive and may result in suboptimal results for a signif-
icant group of patients with periorbital fat excess. Additional techniques such as
septal reset, arcus marginalis fat repositioning, and septal plication have been de-
scribed with acceptable results and complication risks. One should be mindful of
the anatomy and appreciate that the septum is connected to the orbital rim at one
end and the lower lid margin at the other.Therefore forces that tighten the septum
will also pull the lid toward the orbital rim. The key to avoiding overresection of
orbital fat during primary blepharoplasty is that the septum should be widely opened
or removed and the fat should be delicately sculpted flush with the orbital rim
rather than pulling, clamping, and cutting orbital fat pads in a manner reminis-
cent of performing an appendectomy. Secondary blepharoplasty often requires the
addition of fat in to the orbit to correct orbital hollowness. Free fat grafts, dermal
fat grafts, fat injection, ller injection, and suborbicularis oculi fat (SOOF) lift can
all be used with success. The fundamental principle is to add volume to the de -
cient soft tissue coverage overlying the inferior orbital rim.
The most common complication after lower blepharoplasty is lower lid
malposition.28 There are many causes of lower lid retraction, including
excessive resection of skin and muscle, scar contraction, and excessive
edema. However, most of these complications are the result of inade-
quate recognition and management of lower lid laxity.
This highlights the importance of a thorough preoperative evaluation as previously
mentioned. Traditional blepharoplasty techniques that do not include lateral can-

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Reoperative Lower Lid Blepharoplasty
Chemosis is a frequent complication after primary and secondary lower blepharo-
plasty. Chemosis is conjunctival edema caused by general periorbital edema from
lymphatic obstruction after periorbital surgery. Chemosis is also caused by con-
junctival exposure and dryness from postoperative lagophthalmos.Treatment con-
sists of liberal use of ophthalmic ointment, including a steroid as well as eyedrops
and patching the eye closed at night. Severe chemosis that is slow to respond can
also be improved with gentle pressure with an ace wrap during patching the eye.
In addition to patients who may be dissatis ed with the aesthetic result after bleph-
aroplasty, lid retraction can cause signi cant functional impairment such as abnor-
mal tear lm coverage of the cornea, corneal dehydration, and eventually exposure
keratopathy. Therefore, when scleral show or ectropion occurs after blepharo-
plasty combined with inadequate corneal protection con rmed by eye pain and
slit-lamp examination, immediate treatment should be considered to avoid cor-
neal exposure. Conservative management includes liberal use of eyedrops and oph-
thalmic ointment during the day with patching or bandage contact lenses at night.
The patient should be instructed to begin with lid massage with the patient push-
ing the lower lid superiorly to reduce the edema and stretch the super cial and
deep tissues.
thal support report a 15% to 20% incidence of lower lid malposition.29 In our expe-
rience, this rate can be signi cantly reduced by the addition of lateral canthopexy
and orbicularis suspension techniques as a routine part of lower blepharoplasty.

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Marginal tarsorrhaphy with a 6-0 nylon through the lid margin lateral to the
cornea can be performed in the of ce with the use of local anesthetic and may
help protect the cornea temporarily until edema resolves and de nitive surgical
correction can be performed.Very small amounts of steroids may also be injected
as a conservative management option; however, caution should be exercised be-
cause of the possibility of subcutaneous atrophy and hypopigmentation.Therefore
small amounts of Kenalog 10 injected through a transconjunctival approach to
avoid skin changes should be considered.
Corrective Procedures for Lower Lid Retraction
Canthopexy


Canthoplasty


Suture interposition canthoplasty


Periosteal ap


Recession of retractors


Increasing severity
Spacer graft


Orbicularis suspension


Cheek lift


Skin graft


Timing of de nitive reoperation should be either early or late.That is, if there ap-
pear to be technical problems, such as failure of a canthopexy suture on one side
during the rst week or two after surgery with a frank ectropion that will not re-
solve quickly with conservative treatment, immediate reoperation should be con-
sidered within the rst 2 weeks. Immediate reoperation should also be considered
for impending corneal exposure, which may lead to scarring or infection.This may
save the patient from months of discomfort and inability to work. Otherwise, con-
servative treatment should continue for at least 6 weeks. The worst time to reop-
erate is at this 6-week interval because of tissue in ammation. If lid retraction has
not resolved after 6 weeks of conservative management, surgical intervention is of-

ten necessary.The surgical options that have been outlined include lateral cantho-
plasty, posterior lamellar spacer grafts, orbicularis muscle suspension, and midface lift
to recruit tissue into the lower lid to correct skin shortage, and as a last resort, skin
grafting.
TECHNIQUES
LATERAL CANTHAL TIGHTENING PROCEDURES
The degree of lower lid laxity and lid malposition should be carefully and objectively
assessed by placing anterior traction on the lower lid in the operating room and pre-
cisely measuring the distance the lid is distracted from the globe with calipers.
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For moderate laxity of 3 to 6 mm and minimal scleral show, lateral canthopexy is
adequate to control lid position. Canthopexy is performed through an anterior ap-
proach by placing a suture from the tarsal plate and lateral retinaculum to the lat-
eral orbital rim. A double-armed 4-0 Mersilene suture on a P2 needle is used to
create a horizontal mattress suture through the pretarsal muscle and tarsal plate just
medial to the lateral canthal angle. Technical failure can occur from improper su-
ture placement. If the suture is placed too lateral, the tarsal plate will not be in-
cluded in the mattress suture. If the suture is placed too medial, the lateral canthal
commissure will be distorted. If the suture is placed too anterior, the suture may de-
hisce between the tarsal plate and the pretarsal orbicularis muscle. Both needles are
then placed through the periosteum inside the lateral orbital rim beginning poste-
rior and exiting the orbit more anterior along the rim. As mentioned previously,
eye prominence dictates the exact position of placement of this suture in relation
to pupil and lateral orbital rim for proper lower lid positioning (see the table on
p. 490). Care should be taken to appropriately adjust the tension for the desired lid
position. Too much tension may result in downward displacement or inferior
clotheslining of the lid margin.

To achieve proper lid length, full-thickness exci-
sion of redundant lower lid margin is performed.
A double-armed 4-0 Mersilene suture on a P2
needle is placed in the cut edge of the tarsus from
superior to inferior taking care to ensure vertical
alignment to avoid tarsal rotation. Again, both
arms of the suture are placed in the periosteum
inside the lateral orbital rim at a position dictated
by the patient’s preoperative canthal tilt.
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For patients with signi cant lower lid laxity of at least 6 mm of anterior lid distrac-
tion, lateral canthoplasty is generally required. A lateral canthoplasty is performed
using a canthotomy incision with straight iris scissors through the lateral commis-
sure with selective division of the inferior limb of the lateral canthal tendon while
preserving the superior limb to the upper lid. An inferior cantholysis is then di-
rected medially through the conjunctiva and capsulopalpebral fascia below the in-
ferior arcade. This provides wide mobilization and release of the posterior lamella
and lateral retinaculum for precise lid repositioning.
Lid resection

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Chapter 18
Reoperative Lower Lid Blepharoplasty
After adequate positioning of the lower lid, a 6-0 nylon suture is used to precisely
align the margin of the upper and lower lids at the lateral canthus to prevent post-
operative canthal webbing. This alignment suture is placed in the gray line of the
upper and lower lid to ensure the normal lid relationship.
SUTURE INTERPOSITION/ PERIOSTEAL FLAP
FOR LID LENGTHENING
Patients with exophthalmos may require lower lid lengthening to prevent excessive
tension during placement of the lid in the proper position. Lengthening can be ac-
complished by using suture interposition or a periosteal ap. A small amount of
lid lengthening can be accomplished by suture interposition between the canthal
tendon and the lateral orbital rim. The permanent suture and scar tissue maintain
support of the lower lid. The periosteal ap is a rectangular strip of periosteum
based laterally at Whitnall’s tubercle and hinged on the edge of the orbital rim at
the level of the pupil.The ap is angled so that it is superiorly based to elevate the
lid in the proper direction.The ap should be based high enough on the orbital rim
to ensure upward, lateral, and posterior vectors to reposition the lid margin. The
distal end of the ap is sutured directly to the tarsal edge with 4-0 Mersilene.
Alignment suture
Gray line

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DRILL-HOLE FIXATION
Lateral orbital rim
In reoperative cases, the periosteum will often not support canthal xation sutures
because of scarring and damage. In these cases, the lateral canthus is anchored di-
rectly to the bone of the orbital rim with drill hole xation. The desired lateral
canthal position is marked with methylene blue on the lateral orbital rim. Single or
double drill hole xation can be performed by placing the drill holes 3 to 4 mm
lateral to the orbital rim and approximately 4 mm inside the orbital rim.With dou-
ble drill hole xation, each arm of the canthoplasty suture is placed through a dif-
ferent hole and then can be tied directly over the bony bridge between the holes.
In single drill hole xation, both arms of the canthoplasty suture are placed through
the same hole and sutured to the temporalis fascia. Both techniques are effective.
The single drill hole is more commonly used for lower lid malposition correction
and the double drill hole for xation of the upper and lower lid such as impaired
upper lid blink caused by phimosis or medial migration of the lateral canthal angle.

R ELEASE OF LOW ER LID R ETRACTORS
Mild cases of lower lid retraction can be improved simply by releasing the lower lid
retractors, capsulopalpebral fascia, and the posterior lamellar scarring. In this proce-
dure the retractors of the lower lid are divided along the entire lid margin below
the level of the inferior arcade either from an anterior or posterior approach. Lower
lid elevation of 1 to 2 mm can be expected with this maneuver. After release of the
lower lid retractors, a lateral canthoplasty should be performed to elevate the lid
margin to the desired position.
SPACER GRAFTS
When release of the lower lid retractors is not adequate to correct more signi cant
retraction, spacer grafts will be required. Mild cases of lid retraction or ectropion
can be corrected with an acellular dermal matrix such as AlloDerm, which is hu-
man dermis, or Enduragen, which is porcine dermis. The thickness of these aller-
genic and xenografts varies; the thickest available graft is recommended, which is
approximately 1 mm. Despite success with an extensive series of patients, long-
term follow-up reveals that all acellular grafts undergo some gradual resorption,
which may predispose the patient to long-term recurrence, particularly when thin
grafts are used.
503
Chapter 18
Reoperative Lower Lid Blepharoplasty
2 mm
Scleral show
6 mm
AlloDerm
Before

After
A formula for the width of the dermal grafts is double the amount of lid retraction.
That is, if a patient has 2 mm of scleral show, a graft at least 4 mm in width should
be designed.The length of the graft is the entire length of the lid margin, which is
approximately 30 mm. The graft is sutured superiorly to the tarsal plate and infe-
riorly to the released edge of the lid retractors. An additional advantage of the use
of dermal grafts is the graft can be sutured directly to the lateral rim after it is su-
tured in the posterior lamella.The graft functions as an additional posterior lamel-
lar sling.
ALLODERM FORMULA

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Although dermal grafts have been used with considerable success, more serious
cases of ectropion may require a different approach.
Ear cartilage has been found to be the most effective graft in the long
term with no appreciable resorption. Scaphal cartilage is preferred to
conchal cartilage because it is less curved and less bulky.
The graft can be harvested through a
posterior auricular curvilinear incision
parallel to and approximately 5 mm from
the edge of the helix. Once the peri-
chondrium is elevated and the cartilage is
exposed, the desired graft size is marked
and incised with a scalpel and then com-
pleted with scissors, removing a full-
thickness graft. Care should be taken to
preserve at least a 5 mm cartilage bridge
at the helix to ensure the integrity of the
helix and prevent an iatrogenic Stahl’s ear deformity or collapsed helical rim. Metic-
ulous hemostasis should be obtained to avoid postoperative hematoma, which can
also cause donor site deformity. The cartilage graft is then shaped approximately
4 mm in width and 15 to 20 mm in length.The graft is sutured into the posterior
lamella after release of the capsulopalpebral fascia as discussed previously. A 5-0
double-armed chromic is used to suture the cartilage just below the tarsal plate
and inferior arcade to the inferior edge of the released fascia at the level of the or-
bital rim.The lateral canthoplasty is then performed at the completion of the car-
tilage spacer graft.
Another autologous material that can be used as a spacer graft is the hard palate.
Grafts from the hard palate have minimal resorption and therefore do not need to
be made excessively large.The vertical dimension should approximate the amount
of lower lid retraction. The graft should be harvested between the median raphe

Orbitomalar ligament
Orbital fat
SOOF
and the alveolar process avoiding the greater palatine artery.The mucosa and sub-
mucosa are harvested while the underlying fat and periosteum are preserved on
the hard palate donor site to aid in healing. Any adherent fatty tissue is removed in
a manner similar to thinning a skin graft. The donor site is left open to heal by
secondary intention, with remucosalization occurring within a week.
The hard palate graft is sutured in the posterior lamella between the tarsal plate
and the capsulopalpebral fascia similar to the technique described for the ear car-
tilage graft through an anterior transcutaneous or posterior transconjunctival ap-
proach. To avoid corneal irritation, buried sutures should be used in the superior
border of the graft with 5-0 chromic sutures.The superior edge of the graft is su-
tured to the tarsus and the inferior edge is sutured to the conjunctiva and the in-
ferior retractors. All spacer grafts, including cartilage and allogenic grafts, can be in
direct contact with the globe without a conjunctival ap for coverage. Reepithelial-
ization also occurs within a week, and corneal irritation is minimal because the
majority of the graft is not in contact with the cornea. Although conjunctival lin-
ing is not necessary for a static graft in the lower lid, full-thickness defects of the up-
per lid do require conjunctival or mucosal lining to prevent corneal irritation be-
cause the upper lid graft moves continuously over the cornea during blinking.
MIDFACE LIFT AND O RBICULARIS SUSPENSION
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Chapter 18
Reoperative Lower Lid Blepharoplasty
Although overresection of skin is not the most common cause of ectropion, a skin
shortage can result after scar contraction of the posterior lamella and to a lesser de-
gree of the anterior lamella. If preoperative evaluation demonstrates that additional
anterior lamella is required, a cheek lift can be used to recruit tissue into the lower
lid frequently obviating the need for skin grafting.A cheek lift is performed through
a subciliary incision elevating a skin-muscle ap in the preseptal plane taking care to
preserve a 4 to 5 mm strip of pretarsal orbicularis on the lid margin.Laterally the peri-
osteal attachments of the orbicularis are released by dissection in the preperiosteal
plane.The orbitomalar ligament is divided at the inferior orbital rim, which mobi-
lizes the orbicularis and the SOOF pad. The dissection continues inferiorly in a
plane super cial to the periosteum when a super cial cheek lift is planned.
Zygomatico-
temporal nerve
Zygomatico-
facial nerve
Infraorbital nerve

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PART III
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Super cial cheek lift can be performed in secondary cases to release the anterior
skin muscle ap at the level of the orbital rim with dissection proceeding 1 to 1.5
cm inferior to the orbital rim.The advantages of the super cial cheek lift are that
the zygomaticofacial nerve is preserved and the SOOF is elevated over the orbital
rim.There is less postoperative swelling compared to a subperiosteal cheek lift.The
super cial cheek lift can also be used in primary cases to improve the lid-cheek
junction and correct the tear-trough deformity. Preservation of the periosteum al-
lows the orbital fat to be sutured to the periosteum inferior to the orbital rim for
the redistribution of orbital fat.
Orbitomalar
ligament
Zygomatic
cutaneous
ligament
Before
After
Zygomatico-
temporal nerve
Zygomatico-
facial nerve
Infraorbital nerve
Before
After
Orbitomalar
ligament
Zygomatic
cutaneous
ligament
More severe cases of anterior lamellar shortage require a subperiosteal cheek lift to
recruit additional tissue into the lower lid.The subperiosteal cheek lift is also per-
formed through a transcutaneous lower blepharoplasty incision.The periosteum is
divided at the level of the orbital rim.A periosteal elevator is used to dissect the peri-

osteum inferiorly to the level of the alar base. The infraorbital neurovascular bun-
dle is preserved although the zygomaticofacial nerve is usually divided. The peri-
osteum is released in a U-shaped distribution to elevate the malar fat pad. This
more aggressive degree of dissection elevates additional skin and muscle, which is
suspended to the lateral orbital rim and temporalis fascia to take tension off the
lower lid. The subperiosteal cheek lift is also used in primary aesthetic cases. This
technique should be considered when elevation of the malar fat pad and correction
of malar bags is desired. Super cial dissection is less effective in correcting these
problems.
Correction of skin shortage and restoration of lid position are the two primary
goals of reoperative lid surgery.The cheek lift can be used to correct severe lid re-
traction. If there is an additional shortage of skin after midface elevation, a full-
thickness skin graft should be performed to span the de ciency between the ele-
vated skin edge after suspension to the temporalis fascia and the corrected lid
margin after lateral canthoplasty and lid spacer.The full-thickness skin graft should
be placed on a vascularized bed that includes the septum and posterior lamella.
Overlap of the avascular spacer should be avoided. Suspension of the orbicularis
muscle augments lower lid support and provides xation for vertical elevation of
the midface.
CONCLUSION
Lower blepharoplasty can be safely performed with predictable aesthetic results and
acceptable risks. Appreciation of the anatomy supports an anatomic approach to
primary blepharoplasty and secondary reoperative surgery. The best way to mini-
mize complications is through careful preoperative planning to identify high-risk
patients before surgery so that surgery can be avoided or surgical technique can
be applied to prevent complications. Anatomic, morphologic, and physiologic char-
acteristics have been presented in this chapter that are known to contribute to poor
outcomes. Preoperative recognition of these factors will facilitate the formulation
of a comprehensive operative plan. An individualized approach to blepharoplasty is
important to maximize results and minimize complications.The aesthetic goal is a
more youthful appearance with correction of fat pads, skin and muscle excess, and
tear-trough deformity.The functional goal is less measurable;in fact, it is often im-
perceptible.That is, a well-performed blepharoplasty and canthoplasty should result
in a natural eyelid shape similar to the preoperative shape with no appreciable
symptoms of dryness.
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The key to primary lower lid surgery is preservation of eyelid shape and position
while achieving the aesthetic goals.

Reoperative lower lid surgery has similar goals, which unfortunately begin from a
different starting point. Rather than preservation of lid position, correction of lid
malposition and restoration of the preoperative lid shape are achieved. In addition
to the improvement in the eyelids after reoperative blepharoplasty, there is improve-
ment in the function of the eyelids and the ability to protect the cornea from ex-
posure. In summary, there is no single approach to reoperative eyelid surgery. Many
of the fundamental principles used in corrective surgery are also used in primary
blepharoplasty to avoid these problems.
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References—With Key Annotated References
1. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: A simpli ed suture
canthopexy. Plast Reconstr Surg 103:2042-2058, 1999.
A clear algorithm that de nes lateral canthal suspension as a routine part of lower blepharoplasty.
2. Codner MA, Day CR, Hester TR, et al. Management of mundane to complex blepharoplasty
problems. Perspect Plast Surg 15:15-32, 2001.
3. Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morphology in predicting
dry-eye syndrome after blepharoplasty. Plast Reconstr Surg 82:619-625, 1988.
4. Codner MA, McCord CD, Hester TR.The lateral canthoplasty. Op Tech Plast Reconstr Surg
5:90-98, 1998.
A technique article that describes how to perform lateral canthoplasty.
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237, 2003.
6. Lisman RD, Rees TD, Baker D, et al. Experience with tarsal suspension as a factor in lower lid
blepharoplasty. Plast Reconstr Surg 79:897-905, 1987.
7. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient:Bypassing the pitfalls.
Clin Plast Surg 20:213-223, 1993.
8. Wolfe SA, Kearny R. Blepharoplasty in the patient with exophthalmos. Clin Plast Surg 20:275-
283, 1993.
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Reconstr Surg 103:1036-1039, 1999.
11. Fagien S. Lower eyelid rejuvenation: Preoperative assessment and surgical planning. Presented
at the Baker-Stuzin-Baker Symposium, Miami, Feb 2000.
12. Fagien S. Facial and peri-orbital rejuvenation:Teaching course. Presented at the Annual Meet-
ing of the American Society for Aesthetic Plastic Surgery, Orlando, May 2000.
13. Hirmand H, Codner MA, McCord CD, et al. Prominent eye:Operative management in lower
lid and midfacial rejuvenation and the morphologic classi cation system. Plast Reconstr Surg
110:620-628, 2002.
A study evaluating the prominence of the globe using the Hertel exophthalmometer, which de nes an
increased risk for patients with prominent eyes.
14. Smith B, Cherubin TD. Modi cations of the Kuhnt-Szymanowski ectropion repair. In Smith
BC, ed. Oculoplastic Surgery:A Compendium of Principles and Techniques. St Louis:Mosby-
Yearbook, 1970.
15. Bick MW. Surgical management of orbital tarsal disparity. Arch Ophthalmol 75:386-389, 1966.
16. Tenzel RR.Treatment of lagophthalmos of the lower lid. Arch Ophthalmol 81:366-368, 1969.
17. Anderson RL, Gordy DD.The tarsal strip procedure. Arch Ophthalmol 97:2192-2196, 1979.
18. McCord CD, Shore JW. Avoidance of complications in lower lid blepharoplasty. Ophthalmol-
ogy 90:1039-1046, 1983.
19. Rees TD. Prevention of ectropion by horizontal shortening of the lower lid during blepharo-
plasty. Ann Plast Surg 11:17-23, 1983.
20. Flowers RS. Canthopexy as a routine blepharoplasty component. Clin Plast Surg 20:351-365,
1993.
One of the original articles supporting the use of canthopexy as part of lower blepharoplasty to min-
imize the risk of ectropion.
21. McCord CD. Lower lid blepharoplasty. In McCord CD, ed. Eyelid Surgery. Philadelphia: Lip-
pincott-Raven, 1995, p 200.

22. McCord CD. Lower lid blepharoplasty. In McCord CD, ed. Eyelid Surgery. Philadelphia: Lip-
pincott-Raven, 1995, p 273.
23. Sassoon E, Codner MA, McCord CD. Periosteal strip in secondary blepharoplasty. Presented
at the Annual Meeting of the Society for Aesthetic Plastic Surgery, Orlando, May 2000.
24. McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr
Surg 102:2471-2479, 1998.
A review of principles that emphasize the importance of orbicularis suspension during lower bleph-
aroplasty to minimize complications.
25. McCord CD. Postoperative management of complications of cosmetic blepharoplasty. In Mc-
Cord CD, Ed. Eyelid Surgery. Philadelphia: Lippincott-Raven, 1995, p 216.
26. Fagien S, Elson ML. Facial soft tissue augmentation with allogenic human tissue collagen ma-
trix (Dermalogen and Dermaplant). Clin Plast Surg 28:63-81, 2001.
27. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 20:417-425, 1993.
28. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg 85:971-981, 1990.
29. Lowry JC, Bartley GB. Complications of blepharoplasty. Surv Ophthalmol 38:327-350, 1994.
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1. When performing a primary transcutaneous lower blepharoplasty in a 60-year-
old female patient with a poor snap-back test and a negative canthal tilt, mini-
mal skin is removed, and during closure of the skin ectropion is noted.The fol-
lowing procedure should be performed:
a. Removal of the sutures and skin graft with the excised skin
b. Temporary suture tarsorrhaphy
c. Ear cartilage graft and drill hole canthoplasty
d. Closure and frost suture
e. Lateral canthoplasty and orbicularis suspension
2. When performing a secondary blepharoplasty, medial ectropion associated with
excess tearing can be corrected with:
a. Tensor fascia lata sling
b. Punctal plugs
c. Glabellar ap
d. Transnasal wiring
e. Dacrocystorhinostomy
3. Two months after a transcutaneous lower blepharoplasty, a 65-year-old male pa-
tient has severe lower lid retraction with corneal exposure, excessive tearing,
photophobia, and scleral show. The most likely anatomic cause for this nding
is scar contraction between the orbital septum and which structure:
a. The lower lid retractors
b. The orbicularis oculi muscle
c. The orbital rim
d. The tarsal plate
e. The lateral canthus
4. Correction of this complication in Question 3 should include:
a. Lid massage
b. Lid taping
c. Skin graft
d. Lid spacer graft and lateral canthoplasty
e. Suture tarsorrhaphy
5. A 50-year-old patient with a history of hypertension undergoes secondary cor-
rection of ectropion.Three hours after surgery, the patient has a painful swollen
left eye with proptosis and decreased visual acuity compared to the opposite
eye. Most appropriate management includes:
a. Ice packs and elevation
b. Ophthalmology consultation
c. Lasix and narcotics
d. An additional dose of antihypertensive medication
e. Acetazolamide, corticosteroids, and emergency canthotomy
R EVIEW QUESTIONS

513
Because the eyelid is mobile and has a vital physiologic function, ptosis surgery
demands careful preoperative evaluation and detailed postoperative follow-up to
ensure that aesthetic, anatomic, and functional restoration of the eyelid has been
accomplished.1 Obtaining excellent results with ptosis repair, particularly second-
ary repair, depends in large part on the status of the eyelid before the repair is un-
dertaken. Eyelid level, tissue integrity, function of the closure mechanism, and func-
tion of the levator muscle are extremely important in estimating the chance for
postoperative improvement.2
Preoperative conditions can strongly affect the postoperative result that can be ob-
tained. For example, if the patient has minimal levator function (3 mm) and mod-
erate ptosis (5 mm) of the affected eye, it may be impossible to achieve a normal lid
level and a satisfactorily functioning eyelid.The surgeon could probably raise the lid
Secondary Ptosis Correction
James H. Carraway, James R. Miller, and Bradley K. Lewis
C ha pter 19
Reoperative Problems
Infection
Lid edema
Dehiscence
Lid asymmetry
Corneal abrasion
Lid margin irregularities
Bleeding problems
Overcorrection
Vision changes
Undercorrection
You can observe a lot by just watching.
Yogi Berra

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to the normal level equal with that of the contralateral eye, but adequate eyelid clo-
sure would be nearly impossible, placing the patient’s vision at risk. Or, if the patient
is older and severe aging changes of the eyelid structures are occurring, particularly
the aponeurosis and distal levator muscle, ptosis surgery, even in the presence of ex-
cellent levator function, may fail. The eyelid structures may be so weak and so dif-
cult to suture that the repair may not hold and ptosis will occur.The surgeon must
avoid the temptation to achieve a perfect lid level at the expense of normal eyelid
function (for example, closure during sleep). Although a normal-appearing eyelid
will result, the lid will function poorly, possibly endangering the cornea.
In the very best of circumstances in which there is good to excellent levator func-
tion and mild to moderate ptosis with satisfactory integrity of the tissues, excellent
results can be attained in approximately 90% of cases.3 Near-perfect lid levels are
best achieved by operating on the awake or “monitored” patient in whom only
mild sedation is given to reduce anxiety. Eyelid function is well maintained in the
lying-down and sitting-up positions. Technical limitations, however, may still ob-
struct the goal of a perfect ptosis repair. For example, fascia sling and levator ad-
vancement or resection procedures in small children remain dif cult because the
obligatory requirement of general anesthesia prevents the surgeon from making in-
traoperative corrections based on patient cooperation and intact eyelid function.
However, even with adults, precise positioning of a fascia sling intraoperatively does
not always mean an ideal postoperative result is obtained. In this situation, the sur-
geon is at least able to make intraoperative adjustments in an awake and coopera-
tive patient.
Problems in healing may also hinder achieving a good result. For example, if a fas-
cia sling becomes contracted and shortens, lagophthalmos may develop, with the
eyelid remaining open during sleep, thus increasing the chance of corneal exposure
and irritation or in ammation.
Furthermore, a less than desirable outcome may result from the surgeon’s lack of
skill or judgment, in combination with one or several of the negative predisposing
features mentioned. For instance, if there is poor levator function and poor brow
function and the surgeon is unskilled or unfamiliar with the fascia sling procedure,
a suboptimal postoperative result with overcorrection or undercorrection is possi-
ble. As with all types of surgery, ptosis repair is associated with a certain percentage
of poor results.3 Reoperative ptosis surgery may be indicated in a signi cant per-
centage of ptosis repairs.
PATIENT EVALUATION
Ptosis surgery may yield a wide range of results as a consequence of the interplay
of the many factors involved with this type of surgery. For example, postoperatively
the lid level may be perfect or near-perfect, but the eye may be dry, irritated, and
unable to blink well, which could occur with an overcorrected fascia sling repair.

Conversely, a repair in which the lid level is lower than the contralateral eye may of-
fer corneal protection and allow good vision but, because of the lid level discrep-
ancy, results in a poor cosmetic appearance.
Form and function must be balanced. Above all, the primary concern
should be eyelid function, because it is ultimately the basis of good
vision.
If the cornea is dry and the lid does not close well, corneal exposure during sleep
and subsequent corneal damage will occur. If postoperatively the axis of vision is
obscured by the lid because of inadequate elevation, normal vision is not possible.
If consistent and predictable surgical results are to be achieved, it is paramount that
the surgeon individually evaluate the various goals of each blepharoptosis repair.
Eyelid level is the single most aesthetically and functionally important
parameter evaluated after blepharoptosis repair.
Lid level is often the basis for patient complaints because any eyelid level discrep-
ancy based on comparison with the contralateral lid is obvious to both the patient
and physician. For instance, if the lid level of the postoperative corrected eyelid is
absolutely normal at 1 mm below the upper limbus and the contralateral lid is 2
mm below the limbus, then lid asymmetry and an apparent imperfect result are
perceived. In this situation reoperative surgery would require adjustment of the
contralateral eyelid to match the perfect lid level achieved in the now repaired (for-
merly ptotic) eyelid.
Before surgery a complete eye examination with emphasis on certain aspects of pa-
tient history and physical examination must be performed and recorded in the chart.
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Once measurements of these parameters are recorded, the result from previous sur-
gery can be critically evaluated and the possibility of success of reoperative ptosis
surgery can be estimated. If levator function is poor, results of the Schirmer test
are abnormal, and the patient is older, then attempts to raise a mildly or severely
ptotic lid are likely to result in corneal exposure and irritation, with an inability to
tolerate the newly adjusted “normal” lid level. In this case, the surgeon and the pa-
Lid level (measure ptosis)

Bell’s phenomenon
Levator function

Lower lid position
Schirmer’s test

Lagophthalmos and lid lag
Status of cornea

Visual acuity
Status of lid margin
Factors to Consider for Reoperative Ptosis Surgery

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tient must settle for a result that is compromised but nevertheless offers an im-
provement over the preoperative condition. For this reason, it is imperative to eval-
uate each of the physical signs listed in the box on p. 515 for an accurate appraisal.
The most important determinant of a successful blepharoptosis repair is levator
function. Although other physical factors contribute, it is the ability of the levator
muscle to move the eyelid that determines the level to which the eyelid can be
raised and the degree to which it can be closed during sleep.
During the evaluation process, the physician must inform the patient about the
possibility of failure of the second ptosis procedure. Given the fact that primary
ptosis repair yields only about an 80% to 90% satisfactory result, it follows that it is
less likely to achieve an excellent result after secondary blepharoptosis repair.4 The
goals of secondary surgery must be thoroughly outlined. The expectations of the
patient, risks, potential outcomes, and chance of success versus failure should be
discussed openly with the patient to ensure proper informed consent.4
COMPLICATIONS
W OUND PROBLEMS
Infection after ptosis surgery is rare. However, infection associated with the use of
homograft fascia, in combination with a wound granuloma, has been reported.5
These problems can result from a foreign body introduced into the wound during
a previous ptosis procedure. In this situation, correction requires opening the
wound and resecting the part of the fascia that is closest to the skin so that good
dermal closure can be achieved and recurrent granuloma thus prevented. The pa-
tient should also be treated with appropriate antibiotics during this period. Al-
though cellulitis is rare, it can also occur after ptosis repair, particularly in patients
who are prone to infection.
Dehiscence of a wound is more common than infection and is related to improper
wound closure or “rolling in” of the epidermis, which delays proper dermis-to-
dermis healing and allows some separation of the wound when the sutures are re-
moved.Total dehiscence of the wound can result from traumatic wound disruption
(for example, the child who falls and strikes the operative area after ptosis surgery).
Dehiscence is best managed by evacuating any hematomas and closing the wound
in a manner similar to the original closure. Sutures are removed several days later
and healing is usually noneventful.
CORNEAL ABRASION
One of the most serious complications of ptosis surgery is abrasion of the cornea.
An actual abrasion may occur during the surgical procedure when an instrument
or gauze brushes against an exposed cornea. Because corneal abrasion is more likely
to happen if the cornea has been exposed and is dry, a small amount of lubricant
should be placed into the eye before beginning ptosis surgery. In addition, if sutures
are placed on the conjunctival side of the upper lid, these sutures may cause corneal

irritation and abrasion postoperatively. Sutures irritating the eye must be removed,
the eye patched, and lubricant used until the cornea heals.
Corneal abrasion can also result from the patient rubbing the exposed cornea post-
operatively.The patient may rub the eye during sleep or immediately after surgery
when still drowsy. Small children are particularly at risk for this problem, so it is im-
portant to use restraints that maintain the arm in the extended position at the el-
bow and prevent the child from touching the eye.
BLEEDING PROBLEMS
Hemorrhage is an inconvenient but fortunately unusual problem after eyelid pto-
sis repair. If an intraoperative hematoma results from the injection of local anes-
thetic, it is best to open the orbital septum at the injection site and place a 1⁄2-inch
neurocottonoid paddie into the bleeding area to help to absorb some of the blood,
thereby decompressing the area. Adequate monitoring of intraocular pressure and
visual status are imperative at this time. Should a full retrobulbar hematoma de-
velop, administration of intravenous mannitol, acetazolamide (Diamox), and
steroids, and lateral canthotomy are indicated (see Chapter 17).
Postoperatively, bleeding can occur from the time of closure to 8 or 9 days after sur-
gery. Although it is unusual for delayed hemorrhage to occur beyond this point, it
is always a possibility.The risk of late postoperative bleeding is increased if the pa-
tient takes aspirin or engages in vigorous exercise.
Hemorrhage most often occurs several hours after ptosis repair is performed. An el-
evation of blood pressure in this period can cause a bleeding problem. One cause
of elevation in blood pressure is pain.
If pain can be lessened by prolonged analgesia, the possibility of elevated
blood pressure and resultant postoperative hematoma is diminished. For
this reason, we prefer to administer lidocaine (Xylocaine) mixed with
bupivacaine (Marcaine) for operative anesthesia, which provides a pro-
longed period of tissue anesthesia after the surgery is completed.
In addition, all hypertensive patients should be monitored closely after surgery and
postoperative pain medication should be administered in adequate doses.
When hemorrhage occurs, the patient must be returned to the operating room
immediately for wound decompression. Sutures are removed at the hemorrhage
site, the orbital septum is opened, and a slightly moistened 1⁄2-inch neurocottonoid
paddie is placed in the area.This pad serves as a wick for the blood and allows rapid
decompression of the bleeding site. Intravenous mannitol, acetazolamide, and
steroids are administered. Even a relatively short period of exposure of the eye to a
massive retrobulbar hematoma can lead to blindness. Thus one must act as rapidly
as possible to overcome the problem and prevent this complication.
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VISION CHANGES
Postoperative changes in vision can result from ointment being used in the early pe-
riod after surgery, but the patient may not be aware of this cause.Therefore it is wise
to caution the patient that the use of ointment in the eyes will cause blurring of vi-
sion and dif culty with visual acuity. In addition, some light sensitivity may be pres-
ent after ptosis repair but tends to resolve quickly and spontaneously. Furthermore,
if there is any dif culty with lagophthalmos causing exposure and even mild dry-
ing of the cornea, visual acuity may be temporarily altered. Certainly more prob-
lematic conditions such as retrobulbar hematoma or bleeding can cause distortion
of the globe, leading to temporary changes in visual acuity as well.
If a patient has blepharophimosis and very narrow palpebral ssures, this condition
may aid the patient’s vision simply by the pinhole effect lent by the encroaching
skin in the eyelids.When the lids are lifted and the skin is removed, the patient’s lens
prescription may need to be changed to accommodate and to regain visual acuity
(see p. 532).
LID EDEMA
When ptosis is corrected secondarily, more edema develops postoperatively than af-
ter the primary procedure.The edema may be extensive enough to cause stretch-
ing of some of the lid tissue, and the effect may even be irreversible.When the lid
fold is recreated, it is important that the distance between the lid crease and the lid
margin on the ptotic eyelid be the same or less than that of the contralateral eye-
lid. In addition, the skin should not be sutured to the aponeurosis, because this in-
creases lid edema. Rather, the lid crease should be formed by suturing the orbicu-
laris oculi muscle to the aponeurosis, which creates less pretarsal edema and less
stretching of that segment of skin in the pretarsal area.
Postoperatively, a patch lightly placed over the eye with some degree of pressure ap-
plied by taping can help to reduce lid edema. If such a patch is applied with pres-
sure, care must be taken not to mask bleeding or other problems that can lead to
much more serious complications. Diuretics are administered and the patient is re-
minded to sleep with the head elevated and to avoid foods that are high in salt or
contain sodium glutamate until the edema subsides.
LID ASYMMETRY
Reoperative ptosis procedures are probably most commonly performed to correct
lid asymmetry and palpebral ssure differences. Lid asymmetry means that the lid
is either too high or too low;in either case the problem must be addressed. In some

cases it is not possible to bring the lid margin up to the level desired simply because
the levator muscle is limited in some way or the patient manifests dry-eye syn-
drome and is not able to tolerate complete opening of the lid.
When the lid margin is low or the lid is retracted, reoperation may be considered
and undertaken (see pp. 536 and 537).
LID MARGIN IRREGULARITIES
When faced with postoperative lid margin irregularities, one must rst ascertain the
cause. Most often lid margin irregularity results when one area of the levator mus-
cle, aponeurosis, or fascia sling is sutured to the tarsal plate, thereby causing peak-
ing or pulling of the lid margin at that site. Instead of creating a normal arc to the
lid, this maneuver gives an effect of a high spot and forms an irregular lid shape.
Correction first requires analysis of the cause. If the patient has had a levator
aponeurosis repair and the middle part of the lid is peaked but is at the correct
level, then the lateral and medial portions of the aponeurosis must be resutured so
that the lateral and medial lid margins are elevated. If a fascia sling was used and
peaking is present, this deformity is likely caused by the xation point on the tarsal
plate being limited to a central area.The treatment of choice in this case is to spread
the lifting points away from the center and obtain lifting in the medial and lateral
areas as well as the middle part of the lid.The most common lid margin irregular-
ity is drooping of the lateral lid area, which results because of the dif culty with lift-
ing that portion of the lid in some patients.
OVERCORRECTION AND UNDERCORRECTION
Fascia Sling
In treating overcorrection of ptosis repair that was performed by a frontalis sling of
fascia lata or other materials, one must rst consider the materials used to create the
sling. If a Silastic band or Gore-Tex material was used, then the correction may be
approached superiorly from the area of the brow suspension. These materials are
smooth and can easily glide through the tissues, allowing secondary correction of
the lid level.When fascia lata is used as the sling material, the fascia heals to the sur-
rounding tissue and attaches itself to some of this tissue. This attachment makes it
more dif cult for the fascia to slide through the tissue to adjust the level of correc-
tion. However, it is possible to adjust the lid level using all of these materials by ei-
ther a direct approach or alteration of the point of insertion in the forehead or brow
area.This correction is discussed in the section on surgical technique (see p. 524).
In general, we prefer the use of autologous fascia lata for the frontalis sling, because
there is little chance of extrusion, no risk of rejection of this material, it is easy to
harvest, and donor site morbidity is minimal. Results with this technique are for the
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most part predictable; however, some contracture of the sling occasionally occurs,
elevating the lid level postoperatively.
Levator Advancement
When the levator advancement procedure has been performed and either over-
correction or undercorrection of the lid level results, it is possible to adjust the lid
level by altering the point of insertion of the levator muscle attachment to the tarsal
plate. It is best to perform this procedure with the patient under local anesthesia so
that the lid level may be assessed under monitored conditions. A minimal lid level
discrepancy after ptosis repair is not uncommon, and the patient should be cau-
tioned that it may be dif cult to establish the last millimeter of correction by the
readjustment technique. Before correction of minimal residual ptosis is undertaken,
the patient should be counseled that there is always a chance that the result may be
unchanged or worsened by the secondary procedure (see pp. 536 and 537).
Aponeurosis Repair
If the aponeurosis repair was performed under monitored circumstances and the in-
traoperative result was considered excellent, it may be dif cult to get an ideal lid
level with a secondary procedure (see technical discussion). Under usual circum-
stances, a ptotic eyelid repaired by the aponeurosis technique is usually about 1 mm
higher than the contralateral lid at the end of the operative procedure. Lid level is
most accurately assessed at the time of the original ptosis surgery while the patient
is in the operating room in the supine and sitting-up positions. In our experience,
in about 10% of the cases, despite the lid level being excellent immediately after
surgery, the long-term postoperative result may be either undercorrection or over-
correction. This phenomenon has been noted by other surgeons as well and sim-
ply demonstrates that a perfect lid level cannot be achieved in all cases, even under
monitored conditions. For either overcorrection or undercorrection, the aponeu-
rosis may be released or shortened, respectively, to adjust the eyelid level. If there is
a peaking of the lid margin after aponeurosis repair, this defect can also be cor-
rected by the techniques of release or additional ree ng of the aponeurosis. If re-
traction is present across the whole lid margin after this type of repair, we believe
that this repair should be taken down and the whole process repeated (see p. 533).
In general, the timing of reoperative ptosis surgery depends on the situation. If lid
retraction or overcorrection is present immediately after surgery, it is probably best
to proceed with reoperative ptosis repair at that time to obtain a better lid level. If
the lid level seems undercorrected, this problem is most likely caused by swelling as-
sociated with the ptosis procedure. The surgeon and patient should wait until the
swelling subsides before the degree of undercorrection and the possible need for re-
operation can truly be assessed.

SURGICAL TECHNIQUES
There are several surgical techniques used for reoperative correction of ptosis.The
secondary procedure is often more dif cult than the primary surgery because of
scarring, loss of landmarks, loss of tissue from previous surgery, and recurrent scar
formation postoperatively.
ANCHOR BLEPHAROPLASTY
In some cases of ptosis repair, not enough attention is given to formation of an up-
per lid crease. In addition, the lid crease may be asymmetrical with that of the con-
tralateral eye and may need to be readjusted.To create a lid crease at the appropriate
level, anchor blepharoplasty can be performed (see p. 541). With this technique the
desired level of the crease is de ned and the skin incision is made at that level.The
aponeurosis is clearly identi ed, and the orbicularis oculi muscle of the distal seg-
ment of the wound is sutured directly to the aponeurosis, thus anchoring the orbic-
ularis oculi muscle tightly at that point. Once the skin closure is performed and the
lid is opened,the lid crease automatically sets itself at the level of the anchoring of the
orbicularis oculi muscle. It is not necessary to suture the distal skin edge to the
aponeurosis;this maneuver seems to cause excessive swelling of the pretarsal segment.
FASANELLA-SERVAT PROCEDURE
The Fasanella-Servat procedure is simply a tarsectomy procedure that can be per-
formed from the conjunctival surface of the lid by eversion and clamping of a hor-
izontal segment of tarsal plate and aponeurosis. Once this segment is clamped and
excised, a running suture is placed in the conjunctiva along the area of excision in
such a way that the suture will not rub against the cornea. For the patient with
minimal ptosis and excessive scarring of the lid after primary surgery, this tech-
nique may be the best choice. However, if there is lagophthalmos of the upper lid,
this condition will be made worse by the Fasanella-Servat procedure because the
inhibiting scar tissue is not released in this procedure.6,7
APONEUROSIS PLICATION AND R EINSERTION
In the case of overcorrection, one should estimate that about 3 mm of shortening
of the aponeurosis leads to about 1 mm of elevation of the lid margin. If this for-
mula is then reversed, the aponeurosis should be released 3 mm for every 1 mm of
overcorrection. If there is peaking of the lid margin after aponeurosis repair, simple
transverse transection of the aponeurosis at the point of peaking allows the aponeu-
rosis to split and separate, quickly solving the problem.
When previous aponeurosis plication or shortening by reinsertion has been per-
formed and a minor degree of ptosis still remains, in some situations further
aponeurosis plication can be performed without having to detach the aponeurosis
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from the tarsus and reinserting it. This procedure is best applied in cases in which
rm xation of the distal aponeurosis has resulted after a previous procedure. If de-
hiscence of the aponeurosis and associated ptosis have been treated previously by
plication, additional plication generally will not help. Here the problem is contin-
ued disinsertion of the distal aponeurosis: no matter how much plication is per-
formed, the distal aponeurosis will continue to disinsert, thus causing recurrent
ptosis.When plication is appropriate, about 3 mm of plication must be performed
for every 1 mm of desired lift of the lid margin, as indicated above.8-11
When aponeurosis surgery has been previously performed, it may be necessary to
perform the procedure again to attain enough lift of the upper lid. If with previous
surgery the aponeurosis was sutured to the tarsal plate, to improve the lid level the
aponeurosis must be detached from its point of insertion to the tarsal plate and re-
sutured to either a lower point on the tarsal plate or a higher point on the aponeu-
rosis or levator muscle (see p. 535). It is helpful to remember that for aponeurosis
reinsertion and plication at the time of surgery under monitored and awake con-
ditions, the repaired lid must be about 1 to 1.5 mm above the level of the con-
tralateral lid.12 Once the local anesthetic wears off, the orbicularis oculi muscle
brings the lid level down approximately 1 mm, which compensates for the slight
overcorrection.
LEVATOR ADVANCEMENT
When levator advancement has been performed and a secondary lid adjustment is
needed, the levator muscle must be detached from the tarsal plate and reattached ei-
ther proximally to the aponeurosis or distally to the tarsal plate for a distance of 4 mm
for every 1 mm of overcorrected or undercorrected ptosis (see pp. 537, 539, and
540).13 This correction is best performed with the patient under local anesthesia so
that the lid level may be accurately ascertained under monitored conditions.14 Af-
ter reinsertion, the levator muscle is reassessed; the lid level should remain about 1
mm higher than the contralateral lid. If both eyelids have been anesthetized and,
therefore, both orbicularis oculi muscles are paralyzed, the level of the corrected lid
should be perfectly equal with the contralateral lid.
SECONDARY BLEPHAROPLASTY
A secondary blepharoplasty may be indicated as part of a reoperative ptosis pro-
cedure if there is too much skin or extra folds of skin in the medial and lateral eye-
lid area. Determining the amount of skin excision necessary is usually easy because
these folds are simply overlapping portions of excessive skin. Marking these seg-
ments of skin preoperatively before the injection of local anesthetic is extremely
important, and excision of the skin and muscle folds with simple closure corrects
the problem. If secondary blepharoplasty is combined with an anchor blepharo-
plasty, usually less skin needs to be excised because the anchor technique tucks
some of the skin up into the lid crease area.

FASCIA SLING
Correction of a previously placed fascia sling can be performed by adjusting the
sling material itself (see p. 524).15 If alloplastic material was used, then it may be
possible to simply untie the sling material at its point of insertion and either tighten
or loosen the sling as necessary. For example, for overcorrected ptosis with a sling
of Gore-Tex or Silastic, the tie around the upper part of the alloplastic sling can be
loosened and the lid level allowed to come down. If the lid level needs to be ele-
vated, the sling can simply be pulled up and tightened using a similar technique.
When the sling is constructed of fascia, the fascia heals to the surrounding tissue;
therefore a different approach must be used. It is usually necessary to expose the fas-
cia sling directly at the midportion of the lid between the tarsal plate and the brow.
The fascia sling can be shortened by plicating it with a simple suture on both ex-
posed limbs. Plication is performed on a 1:1 basis so that for every 1 mm lift de-
sired, 1 mm of plication is performed. For an overcorrected fascia sling, the lid level
is dropped by disinserting the fascia sling distally and suturing it to the tarsal plate
at a slightly higher level. Again, plication is performed on a 1:1 basis, and the lid
level is dropped accordingly. Alternatively, the fascia sling can be split in a longitu-
dinal direction and then the opposite ends of the split fascia can be cut, allowing the
fascia edges to slide away from each other and the lid to fall to a normal position.
The fascia is then retied at the adjusted position. In this way a xed point of attach-
ment between the brow and tarsal plate is maintained. Relying on secondary heal-
ing between the ends of the divided sling is not advised because the scar will likely
stretch, dropping the lid level to an undercorrected position.
These procedures can be performed as primary or secondary techniques. In the
virgin eyelid the tissue planes are much more easily identi able and surgical proce-
dures can be accomplished with more nesse. In the patient who has undergone
one or more previous procedures for ptosis, the tissue planes may be very dif cult
to de ne. For example, on reentering an eyelid crease to locate the preaponeurotic
fat pad, one may immediately encounter the aponeurotic plane and enter Mailer’s
muscle or conjunctiva inadvertently.When the upper lid is operated on again, it is
important to try to locate the preaponeurotic fat pad rst and then work from that
point downward. If the reverse approach is taken, entry into the eyelid may require
the repair of the aponeurosis at the level of entry before proceeding with the actual
corrective procedure for secondary ptosis.
Correction of secondary ptosis is a dif cult surgical problem. If the primary result
was not acceptable when performed in the best of circumstances, there is a good
chance that the secondary result may fall short of the desired effect as well. On the
other hand, if a problem after the rst ptosis procedure resulted in severe overcor-
rection or undercorrection, this situation can often be corrected to nearly perfect
position with a secondary procedure.
523
Chapter 19
Secondary Ptosis Correction

524
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Patient Examples
This 9-year-old boy presented with bilateral blepharoptosis with 2 to 3 mm of left le-
vator function and essentially no right levator function. He underwent bilateral
frontalis suspension with a fascia sling. Symmetrical lid level adjustment was per-
formed intraoperatively with a satisfactory immediate postoperative result.Two days
postoperatively, lid asymmetry became apparent, with the right upper lid 1 to 2 mm
lower than left. This asymmetry may have resulted from initial undercorrection of
the right side or from slippage and downward adjustment of the fascia sling.However,
it is not uncommon to see asymmetry after fascia sling surgery for no apparent rea-
son, and it is helpful to have a mechanism for adjustment available postoperatively.
With the patient under local anesthesia, the slight lid asymmetry was corrected by
opening the central brow wound and tightening the fascia sling to a higher lid level.