The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

At the opposing end of the spectrum, the imperfect patient is one with thicker, sun-
damaged skin, which clearly will not “pinch” well. In these patients, it is best to plan
the surgery so that the skin will have the least distortion from local anesthetic and
to apply the pinch conservatively. Just as with patients with very thin skin, a thick-
skinned patient will equally benefit from a staged second pinch procedure.
Because a dramatic skin resection can be done with this approach, the surgeon must
be cautious when applying the pinch to a patient with equally significant redundant
fat, because some of this skin must remain to redrape the now less convex lower
eyelid. Again, these patients can always undergo a simple second pinch procedure
at a later date.
Pertinent Anatomy
The essence of the pinch technique embodies a key anatomic principle: to violate
the eyelid anatomy as little as possible, and if it is compromised by age or genetics,
to repair it. Between the transconjunctival approach and the pinch, the pinch touches
and takes only what it needs to—the skin—leaving behind the critical neuromechan-
ical support: the orbital septum and the orbicularis muscle and its attendant nerves.
As for the canthopexy, the key anatomic principle is to keep it simple. Because the
lateral canthus truly comprises several components and is not easily identified as a dis-
tinct structure, the canthopexy has to become a kind of maneuver “on faith“: you
can only really feel its presence. That is, rather than trying to dissect and visualize
the canthal tissues themselves, the surgeon need only grasp and pull whatever tissue
is present in the area to know the “right stuff” has been captured. Then it simply be-
comes a matter of manipulating this anchor thoughtfully to perform an individual-
ized canthopexy.
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Part VI  Eyelid Surgery

Preoperative Assessment
History
There are several critical historical points to be gleaned, including a history of eye
dryness, tearing, or the need for drops; allergies; Graves’ disease; prior eyelid sur-
gery; and previous injection of tissue fillers.
Physical Examination
The preoperative physical examination should include the same components as for
any blepharoplasty. However, the difference is that because the pinch allows one to
modify the surgery to match the patient’s problem, the value of a detailed analysis
is even more rewarding.
The critical elements to evaluate are listed in the box.
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
Critical Factors to Assess in the Physical Examination
 The extent of the redundant skin: If necessary, a second pinch procedure can be
planned in advance. This is particularly relevant in a patient with significant “active”
skin: exaggerated wrinkling on animation.
 The extent of the redundant fat: Depending on the volume of excess, more or less skin
should be pinched to ensure that enough skin is left behind.
 The degree of lid laxity and attendant scleral show (as evaluated by a snap test): This
can be treated efficiently with a stitch canthopexy.
 The level of the lateral canthus (canthal tilt): The canthal position can be adjusted rel-
atively precisely with a stitch canthopexy.
 The vector angle of the globe to the malar (positive/neutral/negative): This aids the
surgeon in the design of the best application of the pinch and canthopexy components
of the surgery.

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Part VI  Eyelid Surgery
Photography
There are several tenets to be followed for photographic evaluation of the eyelids
and documentation of the results.
Prevent Parallax Error
Parallax refers to the apparent displacement or difference in the apparent position
of an object viewed along two different lines of sight, such as occurs because the lens
of a camera and the viewfinder see the subject from a slightly different position. Thus
photographs must be taken with the patient and surgeon seeing “eye to eye”; that
is, there should be no height discrepancy that could distort the appearance of the
posture of the lower eyelid in relation to the globe.
This problem can be manifested when either the patient is not level or the camera
is not level. These effects can mask or exaggerate the actual eyelid position.
Patient tipped up
Patient tipped down
Patient level
Camera high
Camera low
Camera level
THE PARALLAX EFFECT

Beware of the Moro Reflex
977
Chapter 32  Lower Eyelid Pinch Blepharoplasty
When a tighter photo of just the eyelids is to be taken, some patients, anticipating
the flash’s effect, may widen their eyes dramatically. If this is noted, pulling the cam-
era back to include a full-face picture should correct the distortion.
Follow the Dermatologist’s Credo
To accurately document the effects of the pinch procedure, progressively closer pic-
tures of the face should be taken, from full face to just wrinkles at the lower eyelid.
Control the Patient’s Emotions
There is a place for both active and passive photographs of a patient’s lower eyelid.
Photos should be taken of the patient smiling to define the extent of muscle-skin
excess.
Close-up with Moro
Full face without Moro
Close-up preoperative photo
Close-up postoperative photo

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Part VI  Eyelid Surgery
Often orbicularis wrinkling is the patient’s primary concern, and any correction of this
problem is a true measure of a technique’s efficacy.
On the other hand, a smile can camouflage an eyelid posture or a scleral show prob-
lem.
Compare the Present With the Past
The patient should be asked to bring photographs from the past (such as college or
wedding photos or well-focused candid photos). The insight gained from reviewing
such historic images is invaluable not only for observing changes in the character-
istics of the periorbital area but also in our attempt to recapture the patient’s char-
acteristic expression or persona.
Patient Education
A patient with significant wrinkling must be informed that a second pinch blepharo-
plasty should be considered, depending on the salutary effects of the first procedure.
The goals and actions of a canthopexy should be explained, because the palpebral
fissure will become more almond shaped.
Patient smiling preoperatively
Patient smiling postoperatively
Patient’s smile hides scleral show
Patient at rest with scleral show

Planning and Technique
Particularly when first attempted, the pinch procedure is best conducted with infil-
tration of as little local anesthetic as possible. With deeper sedation or general anes-
thesia, it is both possible and ideal to use no local infiltration. This consideration is
critical, because it allows the surgeon to most accurately judge and pinch the skin
excess without the potential distortion caused by aggressive local infiltration.
Surgical Plan
1. If a local anesthetic must be used, place it in the lower eyelid in the region of the
future pinch.
2. Conduct the upper eyelid blepharoplasty, leaving the wound open.
3. Complete the transconjunctival portion of the lower blepharoplasty.
4. Perform a stitch canthopexy through the upper-outer eyelid wound.
5. Close the upper eyelid wound.
6. Perform the lower eyelid pinch procedure and close the wound.
Marking
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
The first step is to mark a guiding “pinch line” along the lower eyelid, representing
the uppermost margin of the future excision. Medially, this line is usually placed
within a few millimeters of the ciliary margin, continuing in a straight line laterally,
deliberately leaving a progressively enlarging triangular island of intact skin of 4 to
5 mm in minimum height below the lateral eyelid margin. This maneuver further
discourages scleral show by lessening the purse-string–like scar contracture that may
occur with a curvilinear incision hugging the ciliary margin. However, the latitude
of this line can be modified, depending on the location and quality of the excess skin.
That is, the pinch line can be moved up or down on the eyelid to facilitate maximal
skin removal. If the skin is noticeably thicker, the pinch line should be moved far-
ther away from the ciliary margin to help prevent scleral show.
2
32-1 Pinch
blepharoplasty

Sequencing of Procedures
The sequence of operative steps is critical. If an upper blepharoplasty is planned as
well, it should be conducted first, with wound closure delayed until after a can-
thopexy but before the lower eyelid pinch. Thus the lateral upper eyelid wound is
available for the canthopexy, and any lower eyelid skin redundancy that may be
treated with closure of the upper eyelid takes place before the pinch procedure. On
the other hand, if only a lower blepharoplasty is to be performed, to accomplish a
pexy a 10 to 15 mm counterincision may be made in the lateral upper eyelid along
the path of an upper blepharoplasty.
Operative Technique
After the markings, the surgeon applies any local anesthetic early and judiciously to
minimize the amount of local swelling and maximize its resolution. The transcon-
junctival portion of the procedure is best conducted preceding a possible canthopexy,
lest the surgeon have difficulty distracting or even undoing the tightened eyelid. The
canthopexy should be performed before the lower eyelid pinch procedure, because
the potential lateral lift of the pexy can treat some of the lower eyelid excess. As for
the lower eyelid, the excess fat is trimmed as indicated and the wound reapproxi-
mated at its midsection with a 6-0 fast-absorbing catgut suture.
The upper eyelid portion of the blepharoplasty is then performed as premarked. The
excess skin and as indicated, excess muscle, are resected. Then the underlying or-
bital fat is treated, if necessary, with electrocautery and/or excision. Before closure
of the upper eyelid wound, the lateral stitch canthopexy is performed.
I distinguish two kinds of canthopexy to consider and design: prophylactic and ther-
apeutic. The choice is primarily determined by two factors: the position of the lat-
eral canthus and the posture and tone of the lateral lower eyelid. If the lateral can-
thus is at or above the horizon and/or the lower eyelid tone is mildly weak without
scleral show, a prophylactic pexy is in order. If instead the lateral canthus is below
the horizon and/or the lower lateral eyelid tone is weak with scleral show, a thera-
peutic lateral canthopexy should be performed. Clearly, there is always a gray zone
in this arbitrary categorization: there are patients with a normal neutral canthal cant
who could have an aesthetic improvement with a slight elevation of the lateral can-
thus, and as such the canthopexy could be considered not only prophylactic but ther-
apeutic as well. This nuance is particularly relevant in a patient who in youth had
an almond-shaped eye.
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Part VI  Eyelid Surgery

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Chapter 32  Lower Eyelid Pinch Blepharoplasty
In either case, the procedure is conducted through the lateral aspect of an upper bleph -
aroplasty incision. First, using the Bovie, a segment of approximately 1 cm of the
superolateral inner orbital rim is exposed, with great care to preserve the integrity
of the periosteum.
Then a subfascial/submuscular “tunnel” is created between the orbital rim and the lat-
eral canthus using round-tipped iris scissors.
A very fine, curved mosquito clamp is passed down the tunnel, and its very tip is
used to capture the lateral canthal tissue.
If a prophylactic canthopexy is planned, the mosquito clamp tip is passed up to the
orbital rim to determine the ideal pexy location, which will at once modestly tighten
the lower eyelid and maintain the canthal angle. If a therapeutic pexy is desired, the

mosquito clamp is manipulated as needed to produce the desired correction of the
eyelid posture and/or canthal position. If necessary, the canthal tissues, still within
the grasp of the mosquito, can be gradually released with a scissors or Bovie. This
maneuver should be conducted with the mosquito on tension so that the surgeon
can proprioceptively conduct adequate liberation of the canthus. At most, a partial
release is all that is necessary to properly treat the majority of eyelids and thwart
overcorrection.
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Part VI  Eyelid Surgery
The canthopexy is sutured in place by taking a double bite of the captured canthal
tissue with a 5-0 clear nylon suture and securing this tissue to the periosteum within
the orbital rim. The canthopexy is shown before and after it is secured. If desired,
transparent scleral protectors may be used, or those shown may be removed, to fa-
cilitate placement of the pexy stitch.
The surgeon can evaluate the efficacy of the pexy on eyelid tone by conducting an
immediate distraction test. An intraoperative distraction test is shown before and
after the canthopexy. The canthal position can also be assessed by sitting the patient
upright. NOTE: The suture should be reapplied if the desired lid tightening or can-
thal positioning effect has either not been achieved or is exaggerated.

Then, using a pair of fine Adson-Brown forceps, the subciliary skin is progressively
pinched along the premarked line into a standing “wall” of skin. The endpoint should
be the maximal effacement of wrinkled skin resting primarily below while preserv-
ing a normal posture of the eyelid margin above.
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
With a forceps producing linear traction and a straight pair of scissors, the wall is
amputated at its base.
The appropriate amount of skin has been removed
if the wound edges are close to each other or just
kissing. The wound may be opened to electrocoagu-
late any small bleeding vessels and is then closed with
a 7-0 running nylon suture. No taping or other sup-
port of the eyelids is necessary.
Pinch Blepharoplasty

Postoperative Care
Patients are started on iced cotton eye soaks during the surgery itself. If the eyes are
iced meticulously, there will be less swelling and bruising. The patient performs this
same icing routine continually for the first 48 hours, with intermittent breaks to
avoid anxiety. Thereafter, icing can be used for comfort as needed.
As an additional proactive effort to encourage faster healing, patients undergo in-
office ultrasonic therapy and lymphatic massage within the first postoperative day
or two. This is continued for two more sessions over the subsequent week or so. This
modality is a natural adjunct to the pinch blepharoplasty’s goal of a faster recovery.
In addition, herbs (Arnica montana and bromelain) to reduce bruising and swelling
are given for the first 2 weeks postoperatively. Stitches are removed at 5 days, and
no supportive tape is applied. At 2 weeks after surgery, the patient may gradually
return to routine exercise over the subsequent 4 weeks.
At 6 months or more after the initial procedure, a planned repinch may be performed.
It is usually performed with a local anesthetic and the addition of diazepam (Val-
ium) as necessary. If the patient has lost some of the effect of the first canthopexy or
still has a significant amount of redundant skin, planning a repeat canthopexy is
prudent.
Problems and Complications
The gratifying essence of the pinch technique is that its entire premise is built on the
goal of preventing the routine problems and complications seen with the traditional
approach. Thus scleral show and residual eyelid wrinkling are very rare occurrences.
However, some issues unique to the pinch blepharoplasty should be noted. If a non-
absorbable nylon-type suture is used for the canthopexy, its knot can sometimes be
seen postoperatively in a very thin-skinned patient and may need to be clipped. If
the pinch is electively performed slightly lower on the eyelid, where the wrinkles of-
ten rest, the scar may initially be more visible; however, these scars do uniformly
mature inconspicuously. In a patient with a significant amount of excess skin who
specifically asks for or prefers a scar aligned with the eyelash, they should be in-
formed of the reduction in wrinkle removal that may result.
When conducting the canthopexy, if there is excessive manipulation of the tissues,
a chemosis covering the lateral white triangle of the globe may result. This problem
is usually self-limiting but should be supported with lubricating or medicinal eye-
drops. To obviate this nuisance effect, it is best to deliberately capture the pexy ma-
terial with your first bite.
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
Finally, if performed too aggressively, the canthopexy will produce an overly cor-
rected result. Usually the effect will improve over time. On the other hand, if the
pexy is not harnessed adequately, the patient may be left with a canthal or lid de-
formity. The best preventive maneuver is to critically assess and redo the pexy if nec-
essary in the first place.
Outcomes
The spirit of this modification of the lower blepharoplasty is defined by a triad of
maneuvers: (1) the deliberate preservation of the eyelid’s integrity with a transcon-
junctival incision, (2) the mindful alignment of the lower eyelid with respect to the
globe and canthus with the application of the canthopexy, and, pivotally, (3) the pro-
ficient excision of the redundant skin with the mastery of the pinch technique.
These examples demonstrate the extent of skin excision possible with pinch tech-
nique, averaging 8 to 12 mm. In addition, the patient usually has less bruising and
swelling and heals more rapidly.
The typical early appearance of a postoperative patient is shown at 5 days and at
7 days. Together these efforts consistently deliver a salutary removal of redundant
skin of the eyelid while still safeguarding its posture. In fact, with greater comfort
performing the stitch canthopexy, the surgeon can often go one step further and cre-

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Part VI  Eyelid Surgery
ate a subtle, more aesthetic shape to the otherwise normal lower eyelid. On the other
hand, particularly in a morphologically challenging patient, the canthopexy may de-
finitively correct the attendant canthal deformity. Additionally, the application of
the repinch procedure, best planned for before the first pinch is performed, has re-
liably contributed to even more satisfying results.
Results
The following cases were chosen to demonstrate the power of the pinch procedure
given various patient presentations—from the best to the more difficult blepharo-
plasty candidates.
The Older Patient
This 68-year-old woman is shown preoperatively and 1 year after an upper and
lower pinch blepharoplasty. Lower eyelid aging was corrected and a normal eyelid
posture was ensured.
This 53-year-old woman with the classic stigmata of aging would previously have
undergone a routine blepharoplasty with CO2 laser or chemical resurfacing. Instead,
upper and lower pinch blepharoplasties with prophylactic canthopexies were per-
formed. She is seen preoperatively at age 53, in a historic photo at age 23, and post-
operatively at age 54, with an attractive, youthful eyelid posture restored.

The Younger Patient
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
This 36-year-old patient presented with modest wrinkling. She underwent only a
lower pinch blepharoplasty with full correction, as seen 2 years postoperatively, ob-
viating the need for laser or other resurfacing intervention.
Orbital Groove
This 42-year-old woman, who requested upper and lower blepharoplasty, demon-
strated significant asymmetrical excess of both fat and skin. The pinch blepharo-
plasty allowed an equally asymmetrical excision and a salutary effacing of the deep
orbital groove, as seen 14 months postoperatively.
Problem: Anatomy
This 45-year-old patient had morphologically challenging anatomy: a triad of a large
globe, a negative orbital vector, and lateral canthal cant (left and center). In addi-
tion to an upper blepharoplasty, she underwent a therapeutic canthopexy and pinch
lower blepharoplasty that corrected both the depressed canthus and the eyelid prob-
lem itself, as shown 18 months postoperatively (right).

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Part VI  Eyelid Surgery
This 58-year-old patient had a spectrum of poor “design” issues: negative cheek and
lateral canthus angles and scleral show. He is seen 16 months after upper and lower
blepharoplasties with pinch and therapeutic canthopexies (right).
This 63-year-old patient had poor morphology and significant, albeit asymmetric
redundancy at the lower eyelids, and proper scleral show. He underwent an upper
and aggressive lower pinch blepharoplasty with an asymmetrical canthopexy. He is
shown preoperatively and (below) with results at 7 days and at 6 months.
Problem: Anatomy

Problem: Redundant Skin
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Chapter 32  Lower Eyelid Pinch Blepharoplasty
This 52-year-old woman had considerable excess crêpey skin. Two years after an
upper and lower pinch blepharoplasty, she demonstrates essentially complete re-
moval of the redundant skin; good eyelid posture has been maintained.
This 73-year-old woman was an ideal patient for a pinch blepharoplasty. The photo
series reveals the pathway to relatively complete repair of lower eyelid aging. The
patient is shown intraoperatively, demonstrating the prodigious pinched wall of skin
and wound, with preservation of an attractive eyelid posture. The 1-year postoper-
ative view confirms the rewarding improvement.

Problem: Persistent Skin Excess Requiring
a Repinch Procedure
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Part VI  Eyelid Surgery
This 56-year-old patient presented with advanced sun-damaged skin at the eyelids,
so a second pinch procedure was planned. She underwent an upper and maximal
lower pinch blepharoplasty with canthopexy. At 6 months postoperatively she demon-
strated persistent excess in the upper and lower eyelids.
A revision was performed, with reexcision at the upper and repinch at the lower eye-
lids. The repinch roll and extent of repinch wound at approximately 10 mm are
shown.
The patient is seen in a historic photo at age 20 and 1 year after the repinch surgery,
demonstrating reasonable success at recapturing her youthful look.
Preoperative
6 months after first blepharoplasty with canthopexy
At age 20
1 year after repinch procedure

Repinch Procedure
991
Chapter 32  Lower Eyelid Pinch Blepharoplasty
This 72-year-old woman illustrates the power of the repinch procedure. The staged
surgery was performed at approximately 6 months. The patient is shown preoper-
atively and 6 months after the first pinch procedure.
The intraoperative views demonstrate the second pinch roll, the wound kissing, and
the pinch wound.
The patient is shown 4 days after the second pinch procedure and 1 year later.

This 68-year-old patient is seen in close-up views of progressive correction: preop-
eratively, following the first pinch blepharoplasty, and following the repinch surgery,
each result 6 months apart.
Concluding Thoughts
One could say that these modifications empower the surgeon to tame and command
greater control of the lower eyelid. Personally, I have found the effects of this tech-
nique quite gratifying: I have both a newfound serenity when approaching the lower
eyelid with this more reliable means for preventing surgical stigmata and a satisfac-
tion with the results because of the more comprehensive eyelid correction that can be
realized.
The procedure’s advantages are particularly manifested when one is confronted by
challenging morphology. As an endorsement of the efficacy of the pinch blepharo-
plasty, I have not performed a skin-muscle flap lower blepharoplasty in more than
12 years. The pinch blepharoplasty has eliminated the need for lower eyelid resur-
facing in most cases.
In addition, we have abolished the proverbial “therapeutic” postoperative taping. I
now perform more canthopexies intelligently and excise more skin confidently. The
results of these efforts have included consistently faster patient recovery, more ac-
curate canthal and eyelid positioning, and what is most important, significantly im-
proved aesthetic outcomes.
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Part VI  Eyelid Surgery

Clinical Caveats
 The surgeon should infiltrate the local anesthetic as early and minimally as pos-
sible. The less distortion of the tissues, the more accurate and facile the pinch ma-
neuver will be. This is particularly germane at the start of a surgeon’s learning
curve. To this end, it is often helpful to sedate the patient more deeply just before
the pinch procedure.
 The addition of a stitch canthopexy is a preoperative decision predicated on eval-
uation of both the position of the lateral canthus and the posture and tone of the
lower eyelid. The action of the canthopexy may be classified as either prophylac-
tic (elderly, prominent globe, malar hypoplasia, or “negative” lateral canthal po-
sition) or therapeutic (laxity or scleral show).
 Generally, if a patient is deemed to be a candidate for a lower blepharoplasty, at
least a prophylactic canthopexy should probably be performed. Thus almost every
patient now undergoes a canthopexy. In effect, the stitch canthopexy, when judi-
ciously harnessed, empowers the surgeon to take full advantage of the pinch pro-
cedure and perform the most complete removal of redundant skin.
 Both the pinch blepharoplasty and the stitch canthopexy techniques have a no-
table learning curve. During this evolution, the surgeon should be aware that it is
deceivingly easy to “overpinch” or “overpexy.” As a layer of protection initially,
it is prudent to pinch a few millimeters farther away from the lash margin com-
pared with the traditional incision. This scar consistently heals imperceptibly. Also,
when conducting a stitch canthopexy, the surgeon should have a low threshold
for replacing the stitch if an overcorrection is perceived; it may not “settle” enough
on its own postoperatively. Likewise, the pexy should be reattempted if an under-
correction is noted.
 The pinch portion of this technique can easily be repeated with the patient under
local anesthesia to treat any residual crêpey skin.
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Chapter 32  Lower Eyelid Pinch Blepharoplasty

Annotated Bibliography
Dinner MI, Glassman H, Artz JS. The “no flap” technique for lower-lid blepharoplasty. Aes-
thetic Plast Surg 16:155-158, 1992.
In a case report, the authors described the first lower blepharoplasty with a skin pinch in
combination with the transconjunctival approach.
Parkes M, Fein W, Brennan HG. Pinch technique for repair of cosmetic eyelid deformities.
Arch Ophthalmol 89:324-328, 1973.
This is the first description in the medical literature of the pinch technique for skin re-
moval. However, the approach negated some of the benefit of the pinch, because Parkes
divided the orbicularis muscle to access the fat.
Ristow B. Transconjunctival blepharoplasty. In Cohen M, ed. Mastery of Plastic and Recon-
structive Surgery, vol 3. Boston: Little Brown, 1994.
Ristow included the concept of a direct excision of skin in conjunction with a transcon-
junctival blepharoplasty. Rather than pinching the redundant skin, it was measured,
marked, and excised in a fashion akin to the traditional upper eyelid skin removal.
Suggested Readings
Jelks G. No touch blepharoplasty. In Cardoso de Castro C, ed. Midface Surgery. Philadel-
phia: Elsevier/Saunders, 2009.
Kim EM, Bucky LP. Power of the pinch. Ann Plast Surg 60:532-537, 2008.
Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg 115:1405-1412; dis-
cussion 1413-1414, 2005.
Rosenfield LK. A safe technique with superior results. Aesthetic Surg J 27:199-203, 2007.
Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty: the transconjunc-
tival approach. Clin Plast Surg 20:317-321, 1993.
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Part VI  Eyelid Surgery

Ptosis Surgery in the
Blepharoplasty Patient

CLINTON D. MCCORD, JR., FOAD NAHAI
CHAPTER 33

E
yelid ptosis, or abnormal drooping of the eyelid, is a condition frequently en-
countered during aesthetic and reconstructive eyelid surgery. Failure to iden-
tify this problem preoperatively or to incorporate correction of this condition into
the operative plan will compromise the ultimate result. This chapter focuses on adult
ptosis resulting from acquired dehiscence of the levator aponeurosis and the type of
levator surgery that is most effective for a patient seeking blepharoplasty. For this
group of patients, the primary goal of surgical correction is on repair of the levator
aponeurosis. Ptosis may be repaired alone or in combination with upper lid bleph -
a ro plasty. Although the correction of lid droopiness is the primary goal in ptosis sur-
gery, other important related issues include eye protection and identification of any
underlying pathologic process requiring diagnosis and treatment. Sudden-onset pto-
sis with neurologic signs of pupillary abnormalities and ocular motility should alert
the surgeon to underlying neuromuscular problems, such as myasthenia gravis,
Horner’s syndrome, and third nerve paresis. A patient with these signs should un-
dergo neurologic evaluation.
Pertinent Anatomy
Levator Dehiscence
Levator dehiscence is an abnormality or thinning and stretching in the levator
aponeurosis that allows a downward movement of the tarsal plate. It may occur with-
out any known predisposing cause or may occur following direct trauma, such as
acute swelling from a bee sting or a “black eye.” Levator dehiscence is known to oc-
cur following an ocular procedure, such as cataract surgery, and is thought to be ex-
acerbated by wearing rigid gas-permeable contact lenses. Any significant edema can
cause levator dehiscence in predisposed individuals. Levator muscle function and
elasticity are normal in these patients, and there is no lagophthalmos in downgaze.
The characteristic clinical appearance of ptosis as the result of aponeurotic dehis-
cence is good to excellent levator function, a high lid crease, and thinning of the eye-
lid tissues above the tarsal plate. In some cases the high lid crease may be obscured by
dermatochalasis.
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Part VI  Eyelid Surgery

These patients demonstrate various examples of levator dehiscence. The patient on
the left has bilateral levator dehiscence, whereas the patient on the right demonstrates
levator dehiscence following cataract surgery.
Landmarks of the Levator Complex
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
Musculo-
aponeurotic
junction
Muscular levator
Levator
aponeurosis
Whitnall’s ligament
Tarsus
The three major attachments of the levator Müller’s complex are illustrated in the
schematic of upper eyelid anatomy. These attachments include:
1. Müller’s muscle, inserting into the upper tarsal border
2. Aponeurosis attachments to the anterior tarsus, inserting into the lower third
of the anterior tarsus
3. Additional extensions of the aponeurosis that penetrate the orbicularis mus-
cle, inserting into the skin and creating the lid crease
In a patient with involutional ptosis, the anterior tarsal attachments of the aponeu-
rosis are defective because of stretching and disinsertion, thus causing lengthening
of the lid and ptosis. Some of the lid crease attachments of the aponeurosis tend to
remain intact, and the persistent attachments to the skin cause the migration of the
lid crease to a higher level. An additional anatomic change that occurs in patients
with involutional ptosis is dehiscence of the medial horn, which causes a lateral dis-
placement of the upper lid tarsal plate.

This cross section of the upper eyelid shows normal attachments of Müller’s muscle
and levator aponeurosis (left). Aponeurotic dehiscence with retraction of the lid crease
is illustrated (right).
The accompanying dehiscence of the medial horn of the levator causes outward mi-
gration and a lateral shift of the tarsal plate so that the peak of the tarsal plate, which
is normally centered above the pupil, is shifted temporally. If one performs surgery
on the levator so that the maximum pull of suturing is at the peak curvature of the
tarsal plate, the result will be consistent temporal overcorrections and “flare.”
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Part VI  Eyelid Surgery
Levator muscle
Tarsus
Müller’s muscle
High lid
crease
Retracted attachments
Normal levator attachments
Normal
lid crease
position
Levator muscle
Normal
medial horn
Levator
aponeurosis
Degenerated
medial horn
Normal
Lateral tarsal shift
Tarsus
The levator is shown on frontal view. Normal structures and landmarks can be seen
(left). The lateral shift of the tarsal plate as a result of dehiscence of the medial horn
and supportive structures of the upper lid is demonstrated (right).

This woman with involutional ptosis is shown with markings placed on the eyelids
in line with the peak curvature of the tarsal plate superiorly. With her eyes open, lat-
eral displacement of the peak of the tarsal plate is evident as a result of release of
the medial horn on the ptotic side.
Levator function is characteristically good to excellent in these patients. In some pa-
tients, however, ptosis may rarely be caused by levator weakening from fatty degen-
eration of the levator muscle rather than from aponeurotic thinning. This uncom-
mon occurrence is thought to represent another subgroup within the etiologic factors
of involutional ptosis. In many cases of acquired ptosis, diagnostic testing is needed
to rule out neurologic or myopathic disease.
Preoperative Assessment
Obtaining a detailed medical history is essential. The surgeon should ask for a list
of medications the patient takes, about any previous history of trauma, previous oc-
ular surgery, instances of severe eyelid swelling, any bee, hornet, or wasp stings, or
a family history of ptosis. Symptoms such as double vision or difficulty in swallow-
ing should be evaluated. Old photographs of the patient sometimes reveal a ptosis
that was not recognized at an earlier age, and this may be the only clue that the pto-
sis is congenital.
In the absence of any history or indicators in old photographs, the dynamic behav-
ior of the lid may provide clues about the cause. If the lid is stiff, with lagophthal-
mos on downgaze in the ptotic eye, a congenital cause is very likely. However, leva-
tor muscles that have been scarred by trauma, inflammation, or previous surgery
may also be stiff, and lagophthalmos in downgaze may be present in these patients
and may make it difficult to establish the cause of ptosis.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient

Ptosis correction procedures always produce some postoperative stiffness of the up-
per lid. If the eye retains its moisture with an adequate tear film and good protective
rotary eye movements are present, the patient should tolerate mild degrees of postop-
erative lagophthalmos. If there is impairment of eye protective mechanisms, expo-
sure problems and conditions that threaten vision may develop. Each patient should
be questioned about the presence of dry-eye symptoms and be examined for ade-
quacy of tear film and evaluation of motility, including an assessment of Bell’s phe-
nomenon. Slit-lamp examination can show inadequacy of the precorneal tear menis-
cus. In patients with suspicious symptoms, a Schirmer’s test with anesthesia should
be performed. Additional deficiencies, such as decreased corneal sensation or facial
nerve weakness, may further aggravate postoperative exposure. With the loss of one
or more eye protective mechanisms, one should reconsider a surgical procedure or,
at a minimum, the patient should be informed that a special lubricant might be nec-
essary. If the patient’s eyes are more intolerant of postoperative lagophthalmos, punc-
tal plugs or actual reversal of the ptosis procedure may be necessary.
Almost all patients who wear contact lenses can be considered to have a normal tear
meniscus and are safe candidates for ptosis surgery, because adequate tears are es-
sential for wearing contacts. Postoperatively, soft lens wearers can resume routine
wear of their contact lenses in 1 week. Patients who wear rigid gas permeable lenses
must resume with a time buildup and are advised to get a special suction cup to assist
with lens removal postoperatively. They can usually resume normal wear after a time
but may need to modify the mechanics of their lens removal procedure.
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Part VI  Eyelid Surgery
A range of “normal” positions exists for the upper lid margin. Generally, iris color
is visible above the upper pupillary edge. In cases of unilateral ptosis, the amount of
ptosis relates to the position of the opposite normal eyelid. Subtle degrees of ptosis
may be missed and unmasked by blepharoplasty if these landmarks are not observed,
as can be seen in this patient, who, following upper lid blepharoplasty, maintained
that her ptosis had resulted from the surgery. However, a comparison of the preop-
erative and postoperative photographs clearly demonstrates the presence of ptosis
before surgery, and the condition was subsequently “unmasked” by the surgery.

Levator Function
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
Upper lid excursion, from extreme downward gaze to extreme upward gaze with the
eyebrow firmly splinted, is the accepted method of measurement of levator function.
This is measured in millimeters by placing a rule vertically in front of the eyelid.
Patients with pure aponeurotic dehiscence will have upper lid excursion of at least
10 to 12 mm. Less function than that should alert the surgeon to another possible
cause for the ptosis. Patients with congenital ptosis commonly have less than 10 mm
of levator function and, in congenital ptosis, precise measurement of the amount of
function is critical in determining the amount of levator resection needed or whether
to employ frontalis suspension.
Preexisting ptosis from levator dehiscence may be exacerbated if blepharoplasty is
performed without surgical repair of the levator. In bilateral cases the surgeon must
carefully explain to the patient what the lid position will be following surgery. Asym-
metric ptosis is common, in which a more severely ptotic eyelid on one side masks
a lesser degree of ptosis in the opposite eyelid. In this situation, an unconscious ef-
fort on the patient’s part will cause normalization of position in the less ptotic lid,
making it appear that only the more ptotic lid needs correction (Herring’s law). How-
ever, if only the more ptotic lid is corrected, the voluntary effort will cease and the
ptosis will then appear on the nonoperated side. It is important to recognize this
asymmetry and compensatory effort preoperatively by having the patient alternately
cover and uncover the eyes. Occlusion of the more ptotic eye usually allows relax-
ation of the less ptotic or nonptotic eye, revealing true ptosis. Bilateral ptosis surgery
is needed to prevent the asymmetry.

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Part VI  Eyelid Surgery
This patient exhibited levator dehiscence on the left following upper lid bleph -
aroplasty. The patient is seen (right) after levator repair and preaponeurotic fat
advancement.
Differential Diagnosis and Pseudoptosis
Many conditions mimic ptosis but are not true ptosis and should be differentiated
from it. Retraction of the opposite lid from Graves’ disease, in many cases, may sim-
ulate ptosis. Enophthalmos may simulate true ptosis, because the globe is recessed
and the upper lid migrates downward to a lower position. Contralateral exophthal-
mos may also cause an upward movement of the lid, producing a relative enophthal-
mos and ptosis on the opposite side.
This patient with Graves’ disease had unilateral upper eyelid retraction on the right
side, causing pseudoptosis on the left. Lagophthalmos of the right upper eyelid was
evident in downgaze (Von Graefe’s sign), consistent with Graves’ disease.

This patient with ptosis of the right upper lid underwent corrective surgery. A CT scan
of the right orbit revealed a mass in the lacrimal gland area consistent with lymphoma.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
This young woman had acquired ptosis of the left upper lid. The CT scan shows en
plaque meningioma as the underlying pathologic condition.
Any mechanical pressure on the lid, such as heavy skin folds, eyelid edema, or tu-
mor, can produce a downward position of the lid margin and, in many cases, may
be difficult to differentiate from a true ptosis. Guarding or squinting in the presence
of an irritative phenomenon may also simulate ptosis.
Spasm may occur with aberrant regeneration of a seventh nerve palsy, hemifacial
spasm, or benign essential blepharospasm. Abnormal closure of the eyelid may oc-
cur with regeneration of the seventh nerve following palsy or paresis. This is seen as
eyelid closure when the patient smiles or contracts his or her lower facial muscles,
and it can be misinterpreted as ptosis. In these cases of spasm closure, the lower lid
will also elevate as the upper lid comes down.

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Part VI  Eyelid Surgery
This patient had a narrowing of the left fissure with lower facial muscle contraction
(left). The patient exhibits misdirected regeneration of a left seventh nerve palsy. The
patient is seen with lower facial muscles relaxed and opening of the eyelid (right).
Congenital Versus Involutional Ptosis
In evaluating patients, one must distinguish congenital ptosis from acquired ptosis.
Surgical procedures for acquired ptosis and congenital ptosis are entirely different.
Although aponeurotic repair is effective for acquired ptosis, it usually has little ef-
fect on congenital ptosis, which is the result of a developmental dystrophy in the le-
vator muscle itself—an absence of striated muscle fibers with fibrosis. In congenital
cases, the levator muscle is inelastic and stiff and does not respond to aponeurotic
repair. Patients with acquired ptosis have a more contractive, elastic muscle. The stiff-
ness of the lid is a diagnostic sign for congenital ptosis and causes lagophthalmos in
downgaze. This can be an important diagnostic aid in the absence of history, when
one wishes to differentiate congenital ptosis from levator dehiscence. In ptosis from
levator aponeurotic dehiscence, stiffness or lagophthalmos in downgaze will not be
present. Congenital ptosis only responds surgically to graded levator resection or
frontalis suspension.

This young woman has congenital ptosis. When she gazes downward, lagophthal-
mos is evident, and there is a higher lid position on the ptotic side because of the
stiff dystrophic levator muscle.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
Evaluation of Preblepharoplasty Patients
 Rule out other causes of ptosis.
 Evaluate both eyes for ptosis by alternately occluding each eye.
 Differentiate congenital from involutional ptosis.
 Inform the patient that ptosis surgery is imprecise.
 Inform the patient that even in the best of hands, a subsequent revision procedure may
prove necessary (revision rate 10% to 20%).
Preoperative Planning
An anatomic aponeurotic repair is the senior author’s preference for ptosis correc-
tion. As mentioned previously, patients undergoing aponeurotic surgery should have,
by selection, excellent levator function with only an aponeurotic defect or dehiscence.
Other procedures that have been used in lieu of aponeurotic surgery are Putterman’s
mullerectomy and the Fasanella tarsomullerectomy. Although we do not use the pro-
cedure, Putterman’s mullerectomy is well accepted as safe and predictable in certain
patients. It does require an additional row of stitches on the undersurface of the up-
per lid, which seems unnecessary if one is performing ptosis surgery combined with
an external upper blepharoplasty. The Fasanella-Servat procedure is still used by
some ophthalmic surgeons; however, it does involve excision of a portion of the tarsal
plate and is nonanatomic in nature. Corneal complications may occur with this pro-

cedure, and any needed reoperations are rendered much more difficult after it has
been performed. It has been generally replaced by the more anatomic, aponeurotic
repair approach to ptosis surgery for these patients, as described next.
Operative Technique
Anesthesia
Some surgeons favor performing aponeurotic repair with the use of local anesthesia
and sedation, having the patient voluntarily open his or her eyelids while the sur-
geon adjusts until the eyelids have reached the desired levels. This requires that there
be no paresis of the levator from a local anesthetic. Local anesthesia is achieved with
a supraorbital nerve block for the lid and infiltration of the eyelid crease area with
0.50 to 0.75 ml of short-acting infiltrative anesthetic placed along the site of the in-
tended lid crease, just beneath the skin, with a minimal amount in the nasal lid. In
most cases anesthesia is achieved without loss of levator function.
However, this approach can be frustrating: variations in the local anesthetic may
cause levator akynesia, an epinephrine effect on Müller’s muscle that causes inap-
propriate lid retraction, and anomalous movement with variations in depth of seda-
tion and patient cooperation. Because of these problems, we have abandoned this
method in favor of an anatomic approach with the patient under general anesthesia
or full local anesthesia.
Technique
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Part VI  Eyelid Surgery
Exposure for aponeurotic surgery
Skin marking and tissue excision are outlined. A lid crease incision is made at
the desired level, usually at the upper border of the tarsal plate (approximately 9 to
10 mm above the lash line). The desired amount of skin and muscle above the crease
can then be removed. An opening through the orbital septum must be made for sur-
gical exposure. In the aesthetic patient, we think that an “open-sky” approach is nec-
essary, with full exposure of the preaponeurotic space.

The orbital septum must be incised or partially excised, as in the open-sky technique,
to expose preaponeurotic fat, the levator aponeurosis, and the musculoaponeurotic
junction, which are the landmarks for aponeurotic repair. In some cases, the levator
aponeurosis may appear relatively intact at the upper tarsal edge; however, in many
cases it is rarefied and stretched, allowing Müller’s muscle and the superior arterial
arcade to be visible near the superior edge of the tarsus.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
The aponeurosis is marked at the superior tarsal border with methylene blue and
is incised just inside the superior edge of the tarsal plate to avoid traumatizing the
superior arcade. In aponeurotic surgery it is not necessary to disturb Müller’s mus-
cle or the superior vascular arcade, thus reducing the amount of bleeding during
the procedure.
Methylene
blue marking
tarsal edge
Aponeurosis
Superior arcade
Müller’s muscle
The anterior view of the upper lid shows dissection of the levator aponeurosis. The
cross-section depicts the structures after dissection.
After the levator has been dissected free from Müller’s muscle and the mus cu lo -
aponeurotic junction is exposed by retraction of the preaponeurotic fat, a 6-0 su-
ture, with a small cutting needle, is introduced half-thickness within (2 to 3 mm) the
upper edge of the tarsal plate. This suture is the central lifting suture and should be
placed in the exact vertical line with the pupil. This aspect is important when deal-
ing with involutional patients who have a lateral displacement of the tarsal plate.

The position of the central lifting suture in the tarsus is demonstrated above. On the
left, a more central position in a normal, youthful upper lid is shown. The image on
the right shows the position of suture placement that is usually needed in adult le -
va tor dehiscence to produce a normal contour. Alignment with the pupil is needed
because of a lateral shift of the tarsus.
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Part VI  Eyelid Surgery
On the left is an anterior view and on the right a cross-sectional view of suture place-
ment through the musculoaponeurotic junction. A double-armed suture is used,
which then can be brought underneath the levator through the junction of the up-
per edge of the aponeurosis and the levator muscle, the musculoaponeurotic junc-
tion. The central suture is the lifting suture for the upper lid, and tightening this su-
ture provides the desired elevation. Nasal and temporal sutures are rarely placed,
and if placed, serve only for contour adjustment. Approximation of the superior tar-
sus to the musculoaponeurotic junction of the levator restores the anatomic integrity
of the upper lid, resulting in correction of the ptosis.

Quantitation With the Anatomic Method
In bilateral cases, there are surgical conditions that control the final eyelid level: the
anatomic symmetry of the surgical repair, intraoperative eyelid gaping, and intraop-
erative eyelid springback tension.
Whether bilateral ptosis is symmetrical or asymmetrical, the surgery should be per-
formed with:
 Symmetrical dissection of the aponeurosis
 Symmetrical suture placement on the tarsus
 Symmetrical placement at the musculoaponeurotic junction
 Symmetrical tension on the central lifting suture knot
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
Despite attempted symmetry of surgical technique, there will be slight differences in
the tension of pull on the upper lids. These differences can be further neutralized by
loosening and tightening the tension of the central suture until the upper lid eleva-
tion produces symmetrical gapping of the eye fissure. This can be verified with caliper
measurement, as seen here, which depicts the intraoperative measurement of gapping
needed to refine the accuracy of upper lid placement.
Springback Test
Even further refinement to the upper lid may be needed. It is well known to oph-
thalmic surgeons correcting strabismus that despite symmetrical positioning of the
eye, subtle differences in tension can affect eye alignment. The same is true in ptosis
surgery, so the final adjustment on suture tension is to equalize the “springback”
between the two lids. Both upper lids are closed by forced traction with forceps
and then released to observe the velocity with which the lid “springs open” to the
gapped position. Tension on the central suture is then adjusted until the springback
is symmetrical.

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Part VI  Eyelid Surgery
True Unilateral Ptosis
The springback test and intraoperative assessment of gapping are not appropriate
in cases of unilateral ptosis; only the anatomic landmarks observed at surgery are
pertinent. There is a greater incidence of postoperative adjustment in such patients.
In many ptosis patients, regardless of the method of quantitation used, some form
of postoperative adjustment will be needed. The easiest postoperative adjustment to
make is loosening of an overcorrected lid. Most cases of mild overcorrection can be
improved by early postoperative stretching. More-persistent overcorrections can be
improved a few weeks after surgery by a simple central lid crease incision and clipping
of the central suture and adhesions, followed by massage. Undercorrections require
reoperation.
This patient with Graves’ disease is seen after levator surgery; she exhibits early signs
of overcorrection. To address the overcorrection, a program of stretching exercises
was initiated for 10 days. These exercises produced an improvement, as can be seen
in the final eyelid position. No surgical revision was required.

This patient with bilateral ptosis underwent blepharoplasty and ptosis repair. She is
shown preoperatively and 10 days after surgery with overcorrection of the left up-
per lid. To address this problem, stretching exercises were initiated. Six weeks after
surgery, the patient’s lid had responded to the stretching exercises, and no surgical
loosening was required.
Because of the inherent imprecision of any ptosis surgery, postoperative surgical re-
visions are necessary in 10% to 20% of cases. In a series of patients operated by the
author (C.D.M.) using an anatomic approach, general anesthesia, and in conjunc-
tion with other aesthetic surgical procedures, the revision rate was lower (approach-
ing 2%), and the surgery was much less tedious for the surgeon and the patient. The
following three cases demonstrate the results of a series of patients who underwent
aponeurotic repair in conjunction with aesthetic surgery.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
Preoperative
10 days postoperatively
6 weeks postoperatively

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Part VI  Eyelid Surgery
Results
This patient is shown before and after upper blepharoplasty and lower lid midface
surgery, combined with tarsolevator repair. No postoperative adjustments were
necessary.
Upper blepharoplasty and lower lid midface surgery was used to treat this patient’s
problem. She also underwent tarsolevator repair, an endoscopic brow lift, and a lower
face lift. No postoperative adjustments were necessary.

In this patient, levator repair was done to the right upper lid, combined with a lower
lid midface lift, an endoscopic brow lift, and a lower face lift. The patient required
secondary surgical loosening of the right upper lid, which was performed as a mi-
nor outpatient procedure. With a small amount of local anesthetic placed in the cen-
tral lid crease, a small incision was made to release some of the aponeurotic attach-
ments. Postoperative stretching exercises were instituted.
Special Problems
Floppy Upper Lid in Males
Floppy upper lids more commonly occur in obese men. Severe distensibility of the
upper lid and lower lid requires a reconstructive type of canthoplasty on both up-
per and lower lids. Failure to resect any redundant upper lid will result in overlap-
ping of the upper lid and poor closure. Subtle variations of this may occur. A can-
thoplasty type procedure must be performed on the upper lids to stabilize them.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient
This obese young man exhibits ptosis with floppy lid syndrome in his primary gaze.
Distention shows dramatic loss of elasticity in the upper lid. An upper lid cantho-
plasty is needed to stabilize the lid.

Blepharochalasis Syndrome
Blepharochalasis syndrome is a rare condition that occurs in young people, usually
females, characterized by recurrent idiopathic edema of the eyelids. This results in
stretching of the skin, levator aponeurosis, and the lateral canthal tendon, and oc-
casionally in atrophy of the nasal fat pad. The patient’s ptosis is surgically correctable
with aponeurotic repair, but staged procedures are usually required, including lat-
eral canthoplasty, blepharoplasty with aponeurotic repair and dermal fat grafting to
atrophied areas.
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Part VI  Eyelid Surgery
Tissue changes resulting from the blepharochalasis syndrome are evident in this
woman. She had repeated bouts of inflammatory edema during childhood resulting
in loss of elastic tissue dehiscence of the levator, loss of the nasal fat pad, lateral can-
thal dehiscence, and crêpey skin changes. The patient was referred because of “skin
growing between her upper and lower lid.” She also has levator dehiscence in addi-
tion to canthal dehiscence.
Chronic Progressive External Ophthalmoplegia
Chronic progressive external ophthalmoplegia (CPEO) results from a progressive
muscular dystrophy that principally affects the extraocular muscles including the le-
vator muscle. Its onset can be subtle, and it may begin in childhood or adolescence,
with gradual development of ptosis. Very early cases may be difficult to recognize be-
cause of the absence of diplopia. These patients will develop progressive impairment
of ocular rotations and eye protection, and postoperative corneal exposure may be
a problem.

This woman has an advanced stage of CPEO. She is shown attempting eye rotation.
She has extremely poor levator function and very poor ocular motility and is at se-
vere risk for corneal exposure with any ptosis surgery.
Concluding Thoughts
Patients who request aesthetic eyelid rejuvenation may have associated ptosis, and
recognition of the ptosis at the initial consultation is essential. The cause must be es-
tablished and the ptosis corrected at the time of aesthetic blepharoplasty.
Clinical Caveats
 Recently acquired ptosis, in many cases, warrants neurologic evaluation.
 Congenital ptosis will not respond favorably to aponeurotic repair.
 Adequate eye protective mechanisms are more critical for patients undergoing pto-
sis surgery than for patients undergoing blepharoplasty.
 Acquired ptosis can be a sign of an underlying pathology of the lid or orbit.
 Lateral displacement of the upper tarsal plate must be surgically compensated to
achieve good postoperative contour.
 The vector of pull should be centered over the pupil.
 In bilateral cases, symmetry of surgery with fine tuning of suture tension is the
most important requirement for postoperative symmetry.
 In most patients, one suture is usually enough. Extra suturing will reshape the lid.
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient

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Part VI  Eyelid Surgery
Annotated Bibliography
Dortzbach RK, Kronish JW. Early revision in the office for adults after unsatisfactory bleph -
aroptosis correction. Am J Ophthalmol 115:68-75, 1993.
The most common complications of levator palpebrae superioris muscle blepharopto-
sis repair are undercorrection, overcorrection, and abnormalities of the eyelid contour.
Previously described nonsurgical as well as surgical methods delay the repair of such
complications and introduce the same confounding factors that can affect judgment of
the eyelid level as during the initial surgical procedure. The authors present their tech-
nique and results in 22 patients who underwent a highly predictable surgical technique
to revise unsatisfactory postoperative eyelid positions.
Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in optimizing results
in aesthetic upper blepharoplasty: a new look at the surgical treatment of mild upper
eyelid fissure and fold asymmetries. Plast Reconstr Surg 125:653-666, 2010.
The author presents a simple yet comprehensive approach to upper blepharoplasty that
considers both the youthful or desired appearance and the management of upper eyelid
asymmetries by preservation or selective treatment of the orbicularis oculi muscle and
placement of the upper eyelid crease to improve aesthetic outcomes.
McCord CD. The evaluation and management of the patient with ptosis. Clin Plast Surg
15:169-184, 1988.
The author discusses the fundamentals for evaluating and correcting ptosis for a vari-
ety of patients. He emphasizes there are many subgroups of ptosis patients that require
the ptosis surgeon to have a flexible approach and a repertoire of surgical procedures.
In a certain percentage of patients, results will remain unpredictable, and the surgeon
must always be prepared to perform revisional surgery. He also stresses that formulas
are only a starting point for each surgeon to develop individual variations to obtain the
best and most predictable ptosis correction.
Shore JW, Bergin DJ, Garrett SW. Results of blepharoptosis surgery with early postoperative
adjustment. Ophthalmology 97:1502-1511, 1990.
The authors review 157 cases (207 eyes) of blepharoptosis corrected by external leva-
tor resection and present the results. They found early or late reoperation is effective in
correcting unsatisfactory results after external levator resection. However, the benefits
of early surgery include a reduction in time to final result, the ease with which it is per-
formed, potential cost savings, and the opportunity of correcting unsatisfactory results.

Suggested Readings
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cial Plast Surg 23:203-215, 2007.
Beard C. Ptosis, 3rd ed. St Louis: CV Mosby, 1981.
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1988.
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sis. Arch Ophthalmol 53:413-428, 1955.
Bernardini FP, de Conciliis C, Devoto MH. Mini-invasive ptosis surgery. Orbit 25:111-115,
2006.
Carraway JH, Tran P. Blepharoplasty with ptosis repair. Aesthet Surg J 29:54-61, 2009.
Fasanella RM, Servat J. Levator resection for minimal ptosis, another simplified procedure.
Arch Ophthalmol 65:493-496, 1961.
Giovanni PV, Giovanni Andre PV. Approach to eyebrow ptosis through the modified tech-
nique of Castanares. Indian J Plast Surg 42:58-62, 2009.
Goldberg R, Seiff S, McFarland J, et al. Floppy eyelid syndrome and blepharochalasis. Am
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Ichinose A, Tahara S. Transconjunctival levator aponeurotic repair without resection of
Müller’s muscle. Aesthetic Plast Surg 31:279-284, 2007.
Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthal-
mol 93:629-634, 1975.
Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid blepharoplasty with orbito-
malar suspension: retrospective review of 212 consecutive cases. Plast Reconstr Surg
125:315-323, 2010.
Li H, Li D, Jie Y, et al. Multistage correction of blepharophimosis: our rationale for 18 cases.
Aesthetic Plast Surg 33:576-581, 2009.
McCord CD Jr, Codner M. Ptosis: evaluation and treatment. In McCord CD Jr, Codner M,
eds. Eyelid & Periorbital Surgery. St Louis: Quality Medical Publishing, 2008.
McCord CD Jr, Seify H, Codner M. Transblepharoplasty ptosis repair: three-step technique.
Plast Reconstr Surg 120:1037-1044, 2007.
McCord CD Jr, Tanenbaum M, eds. Oculoplastic Surgery, 2nd ed. New York: Raven Press,
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Chapter 33  Ptosis Surgery in the Blepharoplasty Patient

Morax S, Touitou V. Complications of blepharoplasty. Orbit 25:303-318, 2006.
Moskowitz BK, Patel AD, Pearson JM. Aesthetic and functional management of eyelid and
orbital reconstruction. Facial Plast Surg 24:69-77, 2008.
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blepharoptosis. Arch Ophthalmol 93:619-623, 1975.
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the levator aponeurosis-Müller’s muscle complex readaptation technique: a 15-year ex-
perience. Plast Reconstr Surg 121:71-78, 2008.
Shore JW, McCord CD Jr. Anatomic changes in involutional blepharoptosis. Am J Ophthal-
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68:92-99, 1969.
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Part VI  Eyelid Surgery

Avoidance and Treatment of
Complications of Aesthetic
Eyelid Surgery

CLINTON D. MCCORD, JR., FOAD NAHAI
CHAPTER 34

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Part VI  Eyelid Surgery
A
wareness of the complications that may occur after aesthetic eyelid surgery
can help a surgeon to avoid them. In many cases, postoperative complications
are visible and obvious; however, on occasion, a patient’s result may look accept-
able from an aesthetic standpoint but eyelid dysfunction may still be present from
subtle changes in eyelid flexibility, position, or movement. For example, even mild
lower lid retraction, if accompanied by reduced upper lid closure from excessive skin
removal, can produce severe exposure problems, particularly if there are coexisting
conditions such as eye dryness or poor eye movement.
Most patients with no history of suspicious eye symptoms preoperatively, or those
with a history of a “normal” eye examination in the recent past, are generally good
candidates for eyelid surgery. It is safe to assume that contact lens wearers, because
of the adequate moisture that is required by the lenses for wear, will be tolerant of
the usual stiffness that occurs after blepharoplasty, but there may be exceptions. Pa-
tients who have suspicious symptomatology or unusual findings on an eye exami-
nation and those with a history of eye problems should be evaluated by slit-lamp
examination, tear tests, or consultation with an ophthalmologist.
Complications following blepharoplasty may be as minimal as an unfavorable scar,
as devastating as visual loss, or anything in between. The majority of complications
in between are mostly related to lid retraction and its consequences. We divide these
complications into two categories:
1. The unfavorable aesthetic result in which the basic protective mechanisms
of the eyelid are unimpaired, but the patient is realistically displeased by sur-
gical changes, or disappointed with the result, which may not have met ex-
pectations
2. Functional complications in which the patient suffers from eyelid malposi-
tion or is left with faulty eyelid mechanics so that the eyelid fails to protect
the eye
These two categories are not mutually exclusive, and both may have to be addressed.
Early complications following blepharoplasty include bleeding/hematoma and chemo-
sis. Fortunately hematomas following blepharoplasty are rather rare, in our experi-
ence less than 1%; on the other hand, chemosis is by far the most common early
complication, ranging up to 11.5% in some series. Lid retraction and its consequences
represent the majority of late complications and account for most secondary or cor-
rective procedures.

Early Complications
Hematoma
Eyelid Hematoma
Predisposing factors for hematoma following blepharoplasty are the same as those
following a face lift, including hypertension, increased venous pressure, nausea, vom-
iting, and anxiety. (See Chapter 50 for a detailed discussion.)
A hematoma confined to the preseptal area is not usually a threat to vision; how-
ever, it may affect the surgical result. With a skin-muscle flap, hematoma may result
in scarring and skin and lid retraction as it resolves. Therefore it is advisable to ag-
gressively evacuate or drain any blood collection after blepharoplasty.
Orbital Hematoma
Postseptal bleeding causing an intraorbital hematoma is a serious matter. Profuse
intraorbital bleeding may increase orbital pressure, thereby compromising optic
nerve function. If the hematoma is mild, not expanding, and produces no detectable
visual or pupillary changes, it can be treated conservatively by observation, systemic
steroids, and cold compresses. Severe bleeding producing intense orbit and pupil-
lary or visual changes is an emergency requiring urgent intervention. Immediate lat-
eral canthal lysis, removal of sutures, and evacuation of hematoma is performed at
the patient’s bedside. Time should not be wasted in trying to return the patient to
the operating room. Once the pressure has been relieved, a search is made for the
source of bleeding, which is then cauterized.
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Chapter 34  Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery
Complications Following Blepharoplasty
Unfavorable Aesthetic Results
Unacceptable scar
Residual skin excess
Overresection or underresection of fat
Overresection or underresection of
orbicularis oculi muscle
Changes in eye shape
Eyelid asymmetry
Functional Problems
Chemosis
Hematoma
Exposure problems
Infection
Lid retraction
Ptosis of the upper eyelid
Muscle palsy (most commonly the
inferior oblique muscle)
Loss of vision

An orbital hematoma is most likely to occur during the immediate postoperative pe-
riod. Therefore it is important that the patient be observed by a trained, responsi-
ble person in the recovery area. Any significant change in orbital volume or severe
pain following blepharoplasty should alert the nurse and the surgeon to the possi-
bility of an orbital hematoma. Severe eye pain in the recovery room may also signal
corneal abrasion or another ocular event. It is our practice to avoid pressure ban-
dages on the eye and to apply ice compresses intermittently.
1022
Part VI  Eyelid Surgery
Types of Hematomas and Recommended Treatment
Eyelid Hematomas
Skin-muscle flap
Observation
Skin flap
Drainage (Bard-Parker No. 11 blade or removal of stitches)
Orbital Hematomas: Mild, Without Pupillary Changes
Observation/drainage
Systemic steroids
Cold compresses
Orbital Hematomas: Severe, With Pupillary and/or Visual Changes
Remove stitches and evacuate hematoma
Large canthotomy and cantholysis
Orbital decompression if edema becomes chronic
Chemosis
Postoperatively, the conjunctiva on the surface of the eye may swell, retain fluid, and
become chemotic. If this occurs, a corresponding dry spot (dellen) forms on the
cornea. The initial cause of this swelling is likely multifactorial and may be the re-
sult of lymphatic drainage obstruction, poor eye closure with exposure, and an in-
flammatory reaction. This problem is much more likely to occur in patients who
have preexisting conjunctivochalasis (redundant conjunctiva), significant swelling,
and fluid retention postoperatively, or who do not use lubricants postoperatively.
On occasion, the surgeon may see this condition develop intraoperatively. In such a
case, the bulbar conjunctiva can be snipped in the inferior fornix without conse-
quences. If significant excision is performed, a 6-0 plain gut suture can be inserted
in the bulbar conjunctiva near the fornix.