Atlas Phẫu Thuật Mí Mắt Và Hốc Mắt – Jonathan Dutton (2012)

44
SEC ION E ▲ Cosmetic Blepharoplasty
FIG. 9.9. Cut the fat pedicle along the upper edge of the hemostat with scissors.
FIG. 9.10. Cauterize the fat stump completely with a bipolar electrode forceps.
FIG. 9.11. Grasp the base of the cauterized fat pedicle with a forceps below the
hemostat to prevent retraction and release the clamp. Observe the stump or
adequate hemostasis, and cauterize any residual bleeding points be ore releasing the
orceps. Alternatively, the at pedicle can be cauterized and cut without the use o a
hemostat.
FIG. 9.12. Repeat this procedure on the central fat pocket by cauterizing, cut-
ting, and inspecting the pedicle.
FIG. 9.13. Close the skin wound with a running suture of 6-0 fast-absorbing plain
gut. Fix the skin edges to orm a deep eyelid crease by passing each second or third
pass o the suture through a bite o the levator aponeurosis. Gently pull the lower skin
ap upward during closure, but take care not to evert the lid margin. Alternatively,
separate crease sutures o 7-0 chromic gut may be placed be ore closure o the skin
edges.
FIG. 9.14. When a large medial pouch is present and an M-plasty is required,
close the central V-shaped ap by pulling it slightly laterally to eliminate the
medial web. Pass an interrupted suture rom the upper to the lower wound edge and
subcuticularly through the ap tip. Close the remaining M-plasty with interrupted
sutures.
FIG. 9.15. When a large, vertical skin excision is made and the upper wound mar-
gin is signi cantly longer than the lower wound margin, a V-plasty Burow's-type
triangle is removed from the upper skin margin nasally to equalize the upper and
lower wound lengths and to prevent pouching. Make a cut superonasally in the
skin 4 to 6 mm rom the medial wound corner. Undermine the skin, pull the triangle
laterally, and excise the area o overlap.
FIG. 9.16. Close the skin with interrupted sutures of 6-0 fast-absorbing plain gut.
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
suture line three to our times daily or 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
Hematoma—T is may result rom inadequate hemostasis
o the orbicularis muscle or the transected at pedicle. I
severe, open the wound to drain clots and cauterize any
residual bleeding points.
Visual loss—T is rare event is usually caused by deep
orbital bleeding rom traction on the at pedicle dur-
ing excision. It can result in central retinal artery occlu-
sion and requires immediate opening o the wound
or decompression. I necessary, a lateral canthotomy
should be per ormed, and medical treatment or arterial
occlusion should be instituted.
Lagophthalmos—T is is caused by excessive removal o
skin and usually resolves with time. Improvement may
be hastened with vigorous massage. opical lubricants
are used until resolution occurs. I severe and persistent,
the condition may require skin gra ting or correction.
Residual redundant skin—T is is most commonly caused
by inadequate removal o skin or ailure to recognize
and correct associated brow ptosis. It can be repaired
postoperatively by secondary brow elevation or by
repeat blepharoplasty.
Asymmetric or irregular eyelid creases—T is results
rom poor placement o crease f xation sutures at the
time o closure. It can be repaired by a secondary crease
re ormation procedure that includes levator aponeuro-
sis f xation.

45
CHAP ER 9 ▼ Upper Eyelid Blepharoplasty with Fat Excision
FIG. 9.13
FIG. 9.14
FIG. 9.10
FIG. 9.15
FIG. 9.11
FIG. 9.16
FIG. 9.12
FIG. 9.9

46
FIG. 10.5. Cut through the orbicularis muscle and dissect
upward between the orbicularis muscle and the underling
orbital septum. If some fat is to be removed, open the septum
with scissors. If not, proceed to Fig. 10.7.
FIG. 10.6. If removing fat, gently hold up small amounts of
fat, cauterize across its base, and excise with scissors.
FIG. 10.7. Remove a small 1- to 2-mm strip of orbicularis
muscle from along the lower border of the incision.
FIG. 10.8. Close the skin and muscle with a running suture
of 6-0 fast-absorbing gut.
FIG. 10.1. Mark an incision line 4 to 5 mm above the upper
eyelid margin.
FIG. 10.2. Inject 0.5 mL of local anesthetic just beneath the
marked incision line.
FIG. 10.3. Incise through skin and orbicularis muscle along
the line with a scalpel blade. Control any bleeding points
with bipolar cautery.
FIG. 10.4. Elevate the skin and dissect upward between
the skin and orbicularis muscle in the subcutaneous plane
to the level of the superior edge of the tarsus.
INDICATIONS: Redundant upper eyelid skin obscuring superior visual f eld, or creation o a secondary upper eyelid old
in a patient with Asian eyelid crease anatomy.
10
Asian Upper Eyelid Blepharoplasty
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
suture line three to our times daily or 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
Lagophthalmos—T is is caused by excessive removal o
skin and usually resolves with time. Improvement may
be hastened with vigorous massage. opical lubricants
are used until resolution occurs. I severe and persistent,
the condition may require skin gra ting or correction.
Residual redundant skin—T is is most commonly caused
by inadequate removal o skin or ailure to recognize
and correct associated brow ptosis. It can be repaired
postoperatively by secondary brow elevation or by
repeat blepharoplasty.
Asymmetric or irregular eyelid creases—T is results
rom poor placement o crease f xation sutures at the
time o closure. It can be repaired by a secondary crease
re ormation procedure that includes levator aponeuro-
sis f xation.

47
CHAPTER 10 ▼ Asian Upper Eyelid Blepharoplasty
FIG. 10.1
FIG. 10.5
FIG. 10.3
FIG. 10.7
FIG. 10.4
FIG. 10.8
FIG. 10.2
FIG. 10.6

48
FIG. 11.5. Identify the soft, yellow medial and central
preaponeurotic fat pockets. Distinguish the rounded, tan,
coarsely lobulated prolapsed lacrimal gland in the temporal
one-third of the eyelid. Sometimes the gland may be covered
with a thin layer of fat.
FIG. 11.6. Place one or two 6-0 prolene xation sutures
through the lacrimal gland capsule at its inferior pole, and
reposition the gland into its bony fossa beneath the supe-
rior orbital rim.
FIG. 11.7. Pass the xation sutures through the periosteum
just inside the superior orbital rim. Tie the sutures to anchor
the gland into position.
FIG. 11.8. Proceed with a blepharoplasty if that is to be
done at this time; otherwise, close the skin with a running
suture of 6-0 fast-absorbing plain gut.
FIG. 11.1. Mark an incision line in the upper eyelid crease
from the central eyelid to the lateral canthus. If this proce-
dure is to be combined with blepharoplasty, mark the upper
incision line as described previously, on page 42. In ltrate 0.5 to
1.0 mL of local anesthetic subcutaneously.
FIG. 11.2. Pull the skin taut horizontally to prevent wrinkling
and cut along the marked line with a rounded scalpel blade.
FIG. 11.3. Tent up the orbicularis muscle with forceps to
pull it away from the levator aponeurosis, and open it with
scissors. Identify the underlying orbital septum.
FIG. 11.4. With forceps, grasp the orbital septum centrally
and pull it away from the underlying fat. Cut the septum
with scissors and open it along the length of the wound. Place
a Desmarres retractor into the upper edge of the wound to
expose the orbital fat.
INDICATIONS: Downward displacement o the lacrimal gland with lateral upper eyelid ullness.
11
Re xation of Lacrimal Gland Prolapse
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently or 24 hours. Place antibiotic oint-
ment on the suture line three to our times daily or 5 to 7
days or until the sutures are dissolved.
POTENTIAL COMPLICATIONS:
Persistent eyelid fullness—I the lacrimal gland is large,
a single f xation suture may not be su cient, and
rotation o the gland can cause one edge o it to bulge
into the eyelid. T is may not be apparent until the
patient is upright a ter surgery. It can be prevented by
slightly rocking the gland back and orth a ter place-
ment o a suture and, i necessary, placing a second
suture.

49
CHAPTER 11 ▼ Refixation of Lacrimal Gland Prolapse
FIG. 11.1
FIG. 11.5
FIG. 11.2
FIG. 11.6
FIG. 11.3
FIG. 11.7
FIG. 11.4
FIG. 11.8

50
FIG. 12.4. Grasp the orbicularis muscle along the lower
skin edge with forceps, and while holding the scissors
oblique to the skin edge, excise a 3-mm strip of muscle from
along the lower wound skin margin.
FIG. 12.5. Close the skin edges with a running suture of 6-0
fast-absorbing plain gut. If necessary, excise any redundant
skin before closure. Pass every second or third bite of the suture
through the levator aponeurosis to supratarsally x the new lid
crease. Alternatively, 3-4 interrupted sutures of 7-0 chromic can
be placed from the orbicularis muscle inferiorly to the orbital
septum, and then close the skin separately.
FIG. 12.6. At closure, the skin edges should be slightly
everted and a deep crease should be formed.
FIG. 12.1. Mark the incision line 10 to 12 mm above the
central eyelid margin. Extend the line nasally to 5 mm above
the superior punctum and temporally to 6 mm above the
lateral canthal angle. In ltrate 0.5 to 1.0 mL of local anesthetic
subcutaneously.
FIG. 12.2. Hold the lid taut horizontally to prevent buck-
ling and cut the skin with a rounded scalpel blade along the
marked line.
FIG. 12.3. Tent up the skin edges with forceps to pull the
orbicularis away from the levator aponeurosis. Cut the
muscle centrally with scissors to enter the postorbicular fascial
plane. Open the orbicularis muscle across the eyelid with scis-
sors. Do not cut the orbital septum.
INDICATIONS: Asymmetric, or absent upper eyelid crease, either primary or as a complication of eyelid surgery.
12
Reformation of the Upper Eyelid Crease
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 5 to 7 days.
POTENTIAL COMPLICATIONS:
Irregular crease—Care must be taken to maintain a uni-
form line of closure and attachment of muscle to the
orbital septum so that a smooth crease results. If the
crease appears irregular at the end of the case, the skin
suture should be removed and replaced.

51
CHAPTER 12 ▼ Reformation of the Upper Eyelid Crease
FIG. 12.1
FIG. 12.2
FIG. 12.3
FIG. 12.4
FIG. 12.5
FIG. 12.6

52
fascial connections between them. With scissors, sharply dis-
sect the ap rom the underlying tarsal plate and orbital septum.
FIG. 13.5. Tent up the orbital septum with forceps to pull
it away from the underlying fat pockets. Make a small cut
through it centrally with scissors. Open the septum to either
side along the width o the eyelid.
FIG. 13.6. Identify the lateral, central, and medial fat
pockets. Cut the delicate, brous at capsules overlying the
individual pockets and gently apply pressure on the globe to
urther prolapse the at lobules.
FIG. 13.7. Hold the herniated lateral pocket with forceps
and clamp a small, curved hemostat across the base of the
fat pedicle.
FIG. 13.8. Cut the fat along the upper edge of the hemostat and
cauterize the pedicle stump with bipolar electrode forceps.
FIG. 13.1. Mark the incision line 2 to 3 mm below the lid mar-
gin, beginning 1 mm temporal to the inferior punctum and
extending to 2 mm beyond the lateral canthal angle. Continue
the line laterally and downward in a preexisting laugh crease or a
distance o 10 to 15 mm, depending upon the amount o skin to be
excised. In ltrate 0.5 to 1.0 mL o local anesthetic subcutaneously.
FIG. 13.2. Pull the lid taut to prevent horizontal buckling and
cut the skin along the marked line with a rounded scalpel blade.
FIG. 13.3. Pull up the skin at the lateral end of the wound
with forceps and cut through the orbicularis muscle to enter
the fascial plane between muscle and periosteum of the
orbital rim. Cut through the muscle along the incision line and
continue dissecting medially in the postorbicular ascial plane.
Cauterize bleeding points with a bipolar electrode orceps.
FIG. 13.4. Gently pull the eyelid margin upward and the
skin–muscle ap downward with forceps to visualize the
INDICATIONS: Redundant lower eyelid skin with herniation o extraconal orbital at pockets.
13
Lower Eyelid Blepharoplasty
with Fat Excision

53
CHAPTER 13 ▼ Lower Eyelid Blepharoplasty with Fat Excision
FIG. 13.1
FIG. 13.2
FIG. 13.3
FIG. 13.4
FIG. 13.5
FIG. 13.6
FIG. 13.7
FIG. 13.8

54
SECTION E ▲ Cosmetic Blepharoplasty
FIG. 13.9. Grasp the fat pedicle with forceps below the hemostat. Release
the clamp and cauterize any residual bleeding points be ore releasing the orceps.
Alternatively, the at can be cauterized and cut without the use o a hemostat.
FIG. 13.10. Repeat this procedure to excise the central and medial fat pockets
and any additional lateral fat that prolapses with further pressure on the globe.
Avoid injury to the in erior oblique muscle, which passes between the medial and
central at pockets.
FIG. 13.11. Drape the skin–muscle ap upward, over the lower eyelid incision
line, and ask the patient to look upward to estimate the amount of vertical skin
to be resected. Do not remove more skin than necessary. Rarely will more than 4 to 5
mm o vertical skin have to be excised. Cut the excess skin–muscle ap with scissors.
FIG. 13.12. Pull the ap temporally and slightly upward on slight tension to
overlap the lateral skin incision. Mark and cut of the redundant lateral triangular
ap. Cauterize any bleeding points along the cut muscle sur aces.
FIG. 13.13. Place one or two deep supporting sutures of 6-0 Vicryl through the
orbicularis muscle of the temporal ap edge and into the deep subcutaneous
fascia of the upper skin incision over the lateral orbital rim.
FIG. 13.14. Close the skin with a running suture of 6-0 fast-absorbing plain gut
along the subciliary incision and with interrupted sutures along the temporal
portion of the wound.
FIG. 13.15. If a lymphedematous festoon is present and cannot be reduced
with horizontal skin–muscle ap tightening, a secondary procedure may be
performed 2 weeks later. Mark the base o the estoon with a convex line and cut
the skin and subcutaneous tissues with a scalpel blade. Dissect the skin ap rom the
underlying orbicularis muscle.
FIG. 13.16. Close the orbicularis muscle with interrupted 6-0 Vicryl sutures and
the skin edges with stitches of 6-0 fast-absorbing plain gut sutures.
POSTOPERATIVE CARE: Apply ice packs intermittently
or 24 hours. Place antibiotic ointment on the suture line
three to our times daily or 7 days or until the sutures are
dissolved.
POTENTIAL COMPLICATIONS:
Lower eyelid retraction—T is results rom mild overre-
section o vertical skin, inadvertent shortening o the
orbital septum during skin closure, or internal lid scar-
ring. It may respond to upward massage but requently
will require lysis o the septum or scar bands, or an eye-
lid tightening procedure.
Ectropion—Caused by excessive vertical resection o skin.
When mild, this may respond to vigorous massage, but
when severe it will require skin gra ting or correction.
Rounded lateral canthal angle—Results rom a lateral
incision line that is directed too in eriorly, causing
downward traction on the lateral eyelid. It can be pre-
vented by placing deep f xation sutures to vertically sup-
port the lateral eyelid. Postoperatively, the condition is
corrected with a lateral canthoplasty.
Orbital hemorrhage and visual loss—See the discussion
or Upper Eyelid Blepharoplasty (p. 46).

55
CHAPTER 13 ▼ Lower Eyelid Blepharoplasty with Fat Excision
FIG. 13.9
FIG. 13.13
FIG. 13.10
FIG. 13.14
FIG. 13.11
FIG. 13.15
FIG. 13.12
FIG. 13.16

56
fascial connections between them. With scissors, sharply
dissect the ap rom the underlying tarsal plate and orbital
septum. Continue to the in erior orbital rim and cut through
the orbicularis retaining ligaments along the anterior rim
rom medial to lateral to enter the retro Super cial musculo-
aponeurotic system (SMAS) space along the upper cheek or a
distance o about 1 cm below the orbital rim and beneath the
tear trough.
FIG. 14.5. Tent up the orbital septum with forceps to pull
it away from the underlying fat pockets. Make a small cut
through it centrally with scissors. Open the septum to either
side along the width o the eyelid.
FIG. 14.6. Carefully prolapse the lower eyelid fat pockets
by gently dissecting any brous adhesions between the
interlobular capsules, and between these and the orbital
septum. Pass 2 or 3 5-0 prolene sutures through the at
capsules along the in erior at pockets.
FIG. 14.1. Mark the incision line 2 to 3 mm below the lid
margin, beginning 1 mm temporal to the inferior punctum
and extending to 2 mm beyond the lateral canthal angle.
Continue the line laterally and downward in a preexisting laugh
crease or a distance o 10 to 15 mm, depending upon the
amount o skin to be excised. In ltrate 0.5 to 1.0 mL o local
anesthetic subcutaneously.
FIG. 14.2. Pull the lid taut to prevent horizontal buckling
and cut the skin along the marked line with a rounded
scalpel blade.
FIG. 14.3. Pull up the skin at the lateral end of the wound
with forceps and cut through the orbicularis muscle to
enter the fascial plane between muscle and periosteum
of the orbital rim. Continue cutting medially into this plane
to open the muscle along the entire skin incision. Cauterize
bleeding points with a bipolar electrode orceps.
FIG. 14.4. Gently pull the eyelid margin upward and the
skin–muscle ap downward with forceps to visualize the
INDICATIONS: Redundant lower eyelid skin with or without herniation of orbital fat pockets, associated with deepening
of the tear trough and descent of the malar fat pad.
14
Lower Eyelid Blepharoplasty
with Fat Redraping

57
CHAPTER 14 ▼ Lower Eyelid Blepharoplasty with Fat Redraping
FIG. 14.1
FIG. 14.2
FIG. 14.3
FIG. 14.4
FIG. 14.5
FIG. 14.6

58
SECTION E ▲ Cosmetic Blepharoplasty
FIG. 14.7. Drape the fat pocket over the orbital rim and pass the Vicryl suture
through the periosteum along the anterior maxillary bone 5 to 6 mm below the
orbital rim. Alternatively, the sutures can be passed through the skin and tied on the
sur ace.
FIG. 14.8. Drape the skin–muscle ap upward, over the lower eyelid incision line,
and ask the patient to look upward to estimate the amount of vertical skin to be
resected. Do not remove more skin than is necessary. Rarely will more than 4 to 5 mm
o vertical skin have to be excised. Cut the excess skin–muscle ap with scissors.
FIG. 14.9. Pull the ap temporally and slightly upward on slight tension to overlap
the lateral skin incision. Mark and cut of the redundant lateral triangular ap.
FIG. 14.10. Place one or two deep supporting sutures of 6-0 Vicryl through the
orbicularis muscle of the temporal ap edge and into the deep subcutaneous
fascia of the upper skin incision over the orbital rim.
FIG. 14.11. Close the skin with a running suture of 6-0 fast-absorbing plain gut
along the subciliary incision and with interrupted sutures along the temporal
portion of the wound.
POSTOPERATIVE CARE: Apply ice packs intermittently
for 24 hours. Place antibiotic ointment on the suture line
three to four times daily for 7 days. Remove any perma-
nent sutures after 5 to 7 days.
POTENTIAL COMPLICATIONS:
Potential complications are similar to those for Lower Eye-
lid Blepharoplasty with fat excision, page 58. Prevention
and management are as discussed previously.

59
CHAPTER 14 ▼ Lower Eyelid Blepharoplasty with Fat Redraping
FIG. 14.9
FIG. 14.7
FIG. 14.8
FIG. 14.10
FIG. 14.11

60
FIG. 15.5. Grasp the eyelid margins with toothed forceps on
each side of the initial vertical cut. Pull the lateral margin toward
the nose and the medial margin toward the temple so the medial
margin overlaps the lateral one. When slight tension is encountered,
mark the amount o medial eyelid margin to be resected.
FIG. 15.6. With a scalpel blade, make a vertical cut through
the tarsus and the conjunctiva at the overlap mark.
FIG. 15.7. With scissors, complete the pentagonal excision
by cutting diagonally through the lower lid retractors from
the bottom of the vertical cut to the lowermost corner of the
previously cut lateral incision. Cauterize all bleeding points.
FIG. 15.8. Place a 6-0 silk vertical mattress suture through
the tarsus at the lid margin but do not tie it. ake care
to align the suture so that the eyelid margin approximates
without a step-of .
FIG. 15.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skin–muscle ap as described in Figs. 13.1–13.4
(page 55).
FIG. 15.2. Open the orbital septum and excise the lateral,
central, and medial fat pockets as described in Figs. 13.5–
13.10 (pages 55–56).
FIG. 15.3. With two toothed forceps, grasp the eyelid and
pull it away from the globe. With a pointed scalpel blade,
pierce through the eyelid rom the conjunctival side just below
the tarsal plate at the lateral third o the lid. Pull the blade
upward toward the lid margin to complete the vertical cut.
FIG. 15.4. Cut through the capsulopalpebral fascia and
conjunctiva with scissors, beginning at the lower edge
of the vertical incision and extending diagonally in an
inferomedial direction. T e greater the horizontal width o lid
to be resected, the more this diagonal cut is angled medially.
15
INDICATIONS: Redundant lower eyelid skin, with or without herniation o orbital at pockets, combined with horizontal
eyelid laxity.
Lower Eyelid Blepharoplasty with
Eyelid Shortening

61
CHAP ER 15 ▼ Lower Eyelid Blepharoplasty with Eyelid Shortening
FIG. 15.1
FIG. 15.5
FIG. 15.2
FIG. 15.6
FIG. 15.3
FIG. 15.7
FIG. 15.4
FIG. 15.8

62
SEC ION E ▲ Cosmetic Blepharoplasty
FIG. 15.9. Place a second interrupted 6-0 silk suture through the outer lid margin
at the lash line and leave it untied.
FIG. 15.10. With gentle upward traction on the marginal sutures to atten and
align the wound, pass three interrupted 6-0 Vicryl sutures horizontally through
the partial thickness of the tarsus to reapproximate the cut edges. T e sutures
should not extend onto the conjunctival sur ace. ie the Vicryl sutures to rmly
oppose the tarsal plate.
FIG. 15.11. Tie the silk marginal sutures and adjust the tension so that the wound
edges are slightly everted. Leave the ends o these marginal sutures 2 cm long. Place
several additional Vicryl sutures as needed to close the retractors below the tarsus.
FIG. 15.12. Drape the skin–muscle ap over the lid and ask the patient to look
upward. Mark the amount o overlap along the lid margin. Be certain there is no ver-
tical tension on the ap. Cut the excess skin and muscle rom along the upper border
o the ap.
FIG. 15.13. Pull the ap laterally and mark the amount of overlap of the tempo-
ral wound edge. Cut the excess skin and muscle with scissors.
FIG. 15.14. Place one or two deep supporting sutures of 6-0 Vicryl through the
orbicularis muscle laterally and then through the deep fascial tissues at the lat-
eral orbital rim for vertical support.
FIG. 15.15. Close the subciliary skin incision with a running stitch of 6-0 fast-
absorbing plain gut. Place several interrupted sutures across the lateral part o the
skin ap incision.
FIG. 15.16. Tie the long ends of the marginal silk sutures to the skin with one or
two interrupted stitches below the eyelid margin to keep them from abrading
the cornea.
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
suture line three to our times daily or 7 to 10 days. Leave
the eyelid margin sutures in place or 10 to 14 days.
POTENTIAL COMPLICATIONS:
Complications are the same as or Lower Eyelid Blepharo-
plasty with Fat Excision (page 58). In addition:
Notching of the eyelid margin—T is may be caused by
poor apposition o the eyelid margins, gaping o the
wound, or step-of . Critical alignment is essential, and
the marginal sutures should be tightened enough to
cause slight eversion o the skin edges.

63
CHAP ER 15 ▼ Lower Eyelid Blepharoplasty with Eyelid Shortening
FIG. 15.9
FIG. 15.10
FIG. 15.11
FIG. 15.12
FIG. 15.13
FIG. 15.14
FIG. 15.15
FIG. 15.16

64
FIG. 16.4. Split the eyelid along the gray line laterally
with ne scissors to separate the anterior skin–muscle
lamella from the posterior tarsus–conjunctiva lamella for a
distance of 5 to 10 mm, depending upon the amount of lid
shortening required. Continue this separation down to the
in erior border o the tarsus.
FIG. 16.5. With a scissors, cut the lower eyelid retractor
from the inferior border of the tarsus beneath the split
portion of the lid.
FIG. 16.6. Remove a thin strip of marginal epithelium from
the split portion of the lid using a scissors.
FIG. 16.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skin–muscle ap as described in
Figs. 13.1–13.4 (page 55).
FIG. 16.2. Open the orbital septum and excise or redrape
the fat pockets as described in the previous procedures on
lower eyelid blepharoplasty (pages 55–63).
FIG. 16.3. Pull the eyelid medially to straighten the lat-
eral canthal ligament. Make a horizontal cut through the
lateral canthal angle to per orm a lateral canthotomy to the
orbital rim. Transect the in erior crus o the ligament. Grasp
the edge o the lower eyelid and pull gently to con rm that all
attachments are ree.
16
INDICATIONS: Redundant lower eyelid skin, with or without herniation of orbital fat pockets, combined with eyelid
laxity due to lateral canthal ligament redundancy.
Lower Eyelid Blepharoplasty with
Lateral Canthopexy

65
CHAPTER 16 ▼ Lower Eyelid Blepharoplasty with Lateral Canthopexy
FIG. 16.5
FIG. 16.1
FIG. 16.4
FIG. 16.2
FIG. 16.3
FIG. 16.6

66
SECTION E ▲ Cosmetic Blepharoplasty
FIG. 16.7. Lay the anterior face of the tarsal strip over the at face of a forceps
handle for stability, and gently scrape the conjunctival epithelium from its pos-
terior surface with a scalpel blade. Cut of the redundant remnant o the lateral
canthal ligament, leaving a bare strip o tarsus measuring approximately 3 to 4 mm
wide and 4 mm long.
FIG. 16.8. Pass a 4-0 Vicryl or Mersilene suture on a small half-curved needle
through the tarsal strip from outside to inside and then through periosteum just
inside the lateral orbital rim. To be certain that a rm periosteal bite is achieved,
pull up on the suture and observe the head move slightly. Tie the suture rmly.
FIG. 16.9. Pull the skin–muscle ap laterally and mark the amount of overlap at
the temporal wound edge. Cut the triangular wedge with scissors.
FIG. 16.10. Reform the canthal angle with an interrupted suture of 6-0 fast-
absorbing plain gut through the upper and lower lid margins. Close the orbicularis
muscle and skin with multiple interrupted sutures o 6-0 plain gut.
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days or until the
sutures are dissolved.
POTENTIAL COMPLICATIONS:
Potential complications are the same as for Lower Eyelid
Blepharoplasty (page 58).
In addition:
Rounded lateral canthal angle—T is results from failure
to reform the canthus by suturing the lateral upper and
lower eyelids together at the lateral canthal angle.
Canthal angle dystopia—T e lateral lower lid margin can
stand away from the globe if the periosteal anchoring
suture is not placed inside the lateral rim. T is is corrected
by repositioning the suture or later by repeating a lateral
tarsal strip procedure.

67
CHAPTER 16 ▼ Lower Eyelid Blepharoplasty with Lateral Canthopexy
FIG. 16.7
FIG. 16.9
FIG. 16.8
FIG. 16.10

68
17
capsulopalpebral fascia. In this case, open the septum with scis-
sors to reveal the orbital fat.
FIG. 17.6. Reverse the Desmarres retractor by placing the
blade inside the wound to expose the fat pockets. Cut open
the ne interlobular fascial capsules and apply gentle pressure
to the globe to further prolapse the fat. Hold the lateral fat
pocket with forceps and apply a curved hemostat across its
base.
FIG. 17.7. With scissors cut the fat along the upper edge of
the clamp and cauterize the pedicle with bipolar electrode
forceps. Hold the pedicle below the hemostat, release the clamp,
and inspect the cut surface for residual bleeding. Alternatively,
the fat can be cauterized and cut without a hemostat. Excise the
central and medial fat pockets in similar fashion. Alternatively,
some of the fat may be redrapped to ll in a deep tear trough as
in Figs. 14.6–14.7, pages 61–62).
FIG. 17.8. Reverse the Desmarres retractor to evert the lid
margin and expose the wound. Reattach the cut edges of the
capsulopalpebral fascia and Müller’s muscle with a running
stitch of 6-0 plain gut. T e lid may be splinted with strips of
tape below the tarsus and extended to the temple and nasal
bridge.
FIG. 17.1. In ltrate the lower eyelid subcutaneously
with 0.5 to 1.0 mL of local anesthetic. Evert the eyelid and
in ltrate subconjunctivally along the proximal tarsal border.
FIG. 17.2. Pass a 4-0 silk traction suture horizontally
through the tarsus at the eyelid margin. Stay within the
tarsus to avoid injury to the lashes.
FIG. 17.3. Doubly evert the eyelid over a Desmarres
retractor to expose the internal palpebral surface. With
toothed forceps, tent up the conjunctiva, Müller’s muscle, and
the capsulopalpebral fascia 3 to 4 mm below the lower edge of
the tarsus temporally. With scissors, cut a buttonhole through
them.
FIG. 17.4. Open the conjunctiva, Müller’s muscle, and the
capsulopalpebral fascia along the horizontal length of the
eyelid but do not extend medial to the inferior lacrimal
punctum.
FIG. 17.5. With forceps pull the capsulopalpebral fascia
upward and away from the everted eyelid, and dissect
it from the orbital septum to the orbital rim. If the ini-
tial incision was placed too close to the tarsus, the orbital
septum may be re ected toward the globe along with the
INDICATIONS: Lower eyelid herniated orbital fat without dermatochalasis; fat herniation in thyroid orbitopathy;
patients with known history of keloid formation.
Transconjunctival Excision of Lower
Eyelid Herniated Orbital Fat
POSTOPERATIVE CARE: Apply iced compresses intermit-
tently for 24 hours. Place antibiotic ointment on the inferior
palpebral conjunctiva three to four times daily for 7 days.
POTENTIAL COMPLICATIONS:
Sunken, hollow appearance—T is is usually the result of
excessive resection of orbital fat so that a concave con-
tour is present above the orbital rim. Do not apply more
than gentle pressure on the globe during resection, and
do not put excessive traction on the fat pedicles. In some
cases redrapping of the fat beneath the tear trough will
provide a more aesthetically pleasing lid-cheek contour.
Asymmetry—T is is caused by unequal resection of fat
on the two sides. Save the fat from each side and care-
fully compare the volume taken from each fat pocket
before closure. T e exception is in cases where initial
asymmetry of fat herniation is noted and marked pre-
operatively.
Lower eyelid retraction and scleral show—T is is seen
rarely but may result from inadvertent shortening of the
orbital septum during closure. Care should be taken to
cut open and to close only the capsulopalpebral fascia.
If the septum was opened to reach the fat pockets, it
should be left without closure.

69
CHAP ER 17 ▼ ransconjunctival Excision of Lower Eyelid Herniated Orbital Fat
FIG. 17.3
FIG. 17.4
FIG. 17.1
FIG. 17.2
FIG. 17.5
FIG. 17.6
FIG. 17.7
FIG. 17.8

70
SECTIONF
Brow Ptosis
B
row ptosis results rom sagging o orehead skin and loss
o ascial support to the eyebrows. It is a common f nding
in the aging ace and requently accompanies laxity o other
periorbital structures such as eyelid skin, acial retaining liga-
ments, and canthal ligaments. Recognition o signif cant brow
ptosis is essential to the success o other cosmetic procedures
involving the upper eyelid. A downward displacement o the
eyebrows can accentuate the degree o redundancy in upper
eyelid skin. A simple blepharoplasty designed to reduce this
excess skin will pull the brow urther downward and shorten
the brow-to-eyelid margin cle t, thereby producing a cosmeti-
cally displeasing result. Brow ptosis may result in a pseudo-
blepharoptosis, which cannot be adequately repaired with
standard aponeurotic advancement.
Several procedures are available or the correction o
brow ptosis. T e choice depends upon a number o actors:
(1) the sex o the patient and there ore the desired brow
contour; (2) the relative position o the brows; (3) the den-
sity o brow cilia; (4) the presence o associated de ormities
such as lateral rhytids and prominent transverse glabel-
lar olds; (5) the height o the scalp hairline or presence o
male pattern baldness. Each procedure has its advantages
and disadvantages, and selection o the most appropriate
operation must be individualized or each patient. In gen-
eral, the direct brow li t and the endoscopic orehead li t
are the most use ul procedures.
T e direct brow li t allows some shaping o the f nal
brow contour. In particular, it acilitates segmental brow
elevation i needed temporally or medially by customizing
the shape o the excised skin ap. T e direct approach is
better or the correction o asymmetric de ects in brow
position and especially or unilateral brow ptosis associated
with seventh nerve palsy. In general, however, it results in
a somewhat eminine arched contour. Complications are
minimal and healing is rapid.
A signif cant disadvantage o the direct brow li t proce-
dure is a scar at the upper border o the brow. With care-
ul orientation o the incision, meticulous layered closure,
and eversion o the wound edges using vertical mattress
sutures, the resultant scar can be camou aged very sat-
is actorily in most individuals. Scarring is more visible
in patients with thin eyebrows. T e operation does little
to eliminate deep orehead and glabellar creases and lat-
eral rhytids. Although the incision can be carried later-
ally beyond the brow or medially across the nasal bridge,
these procedures leave ar more conspicuous scars, and the
lateral incision risks injury to the temporal branch o the
acial nerve.
T e temporal orehead li t may be use ul in patients with
lateral brow droop and prominent lateral canthal rhytids.
T is application, however, is limited and does not correct
ptosis in the medial one-hal o the brow. Another disad-
vantage is the resultant elevation o the temporal hairline,
which some patients may f nd objectionable.
When deep mid orehead rown lines and glabellar olds
are present, a orehead li ting procedure is better. T e mid-
orehead li t places the incision line within a prominent
horizontal orehead crease. Although the scar is impossible
to completely camou age, when deep urrows are already
present, the resulting scar can be relatively inconspicuous.
T e procedure has the advantage o allowing attening o
glabellar olds along with elevation o the brows. Precise
contouring o the brows, however, is not possible.
T e endoscopic orehead li t provides elevation o the
orehead, brows, and temples with camou age o the inci-
sion scars above the hairline. T e procedure has the added
advantage o allowing interruption o the procerus and
corrugator muscles, which are responsible or horizontal
glabellar urrows. One disadvantage is the elevation o the
hairline and the inability to precisely sculpture the brow
contour. In addition, it cannot be per ormed on balding
male patients.
Newer procedures include brow f xation either with dis-
solvable polymer tines implanted into the rontal bone, or
with sutures f xed to periosteum. While these procedures
work well to f xate the brow against gravity descent, they
do not elevate the brows more than about 1 cm at most.
T e timing o brow elevation, whatever the procedure,
is critical. It must be done be ore blepharoplasty so accu-
rate estimation o redundant eyelid skin to be resected can
be determined. Both procedures can be per ormed at the
same surgical sitting.
Direct brow and transblepharoplasty endotine f xation
is usually per ormed under local inf ltrative anesthesia. T e
endoscopic orehead li t can be per ormed under general
or local anesthesia. In the latter case, a supraorbital and
supratrochlear nerve block with inf ltration along the inci-
sion lines is adequate.
SUGGESTED FURTHER READING
Browpexy
Cohen BD, Rei el AJ, Spinelli HM. Browpexy through the upper lid: a new
technique o li ting the brow with a standard blepharoplasty incision.
Aesthet Surg J. 2011;31:163–169.
Massry GG. T e external borwpexy. Ophthal Plast Reconstr Surg. 2012;
28:90–95.

Direct Brow Lift
Bamer HO. Frown disf gurement and ptosis o eyebrows. Plast Reconstr
Surg. 1957;19:337–340.
Booth AJ, Murray A, yres AG. T e direct brrw li t: e cacy,
complications, and patient satis action. Br J Ophthalmol. 2004;88:
688–691.
Brennan HG. Correction o the ptotic brow. Otolaryngol Clin North Am.
1980;13:265–73.
Connell B. Brow ptosis—local resections. In: Aston SJ, ed. T ird Interna-
tional Symposium of Plastic and Reconstructive Surgery of the Eye and
Adnexa. Baltimore, MD: Williams & Wilkins; 1982.
Johnson CM Jr, Anderson JR, Katz RB. T e brow-li t. Arch Otolaryngol.
1978;105:124–126.
yers AG. Brow li t via the direct and trans-blepharoplasty approaches.
Orbit. 2006;25:261–265.
Webster RC, Fanous N, Smith RC. Blepharoplasty: when to combine it
with brow, temple, or coronal li t. J Otolaryngol. 1979;8:339–343.
Trans-blepharoplasty Endotine Brow Fixation
Berkowitz RL, Ap elberg DB. Preliminary evaluation o a ast-absorbing
multipoint f xation device. Aesthet Surg J. 2008;28:584–589.
Chowdhury S, Malhotra R, Smith R, Arnstein P. Patient and surgeon
experience with the endotine orehead device or brow and orehead
li t. Ophthal Plast Reconstr Surg. 2007;23:358–362.
Hönig JF, Frank MH, Knutti D, de La Fuente A. Video endoscopic-assisted
brow li t: comparison o the eyebrow position a ter Endotine tissue
f xation versus suture f xation. J Craniofac Surg. 2008;19:1140–1147.
Langsdon PR, Williams GB, Rajan R, Metzinger SE. ransblepharoplasty
brow suspension with a biodegradable f xation device. Aesthet Surg J.
2010;30:802–809.
Stevens WG, Ap elberg DB, Stoker DA, Schantz, SA. T e endotine: a new
biodegradable f xation device or endoscopic orehead li ts. Aesthet
Surg J. 2003;23:103–107.
Endoscopic Forehead and Brow Elevation
Angelos PC, Stallworth CL, Wang D. Forehead li ting: state o the art.
Facial Plast Surg. 2011;27:50–57.
Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow
li t. Plast Reconstr Surg. 2010;126:1e–17e.
Dailey RA, Saunly SM. Current treatments or brow ptosis. Curr Opin
Ophthalmol. 2003;14:260–266.
Georgescu D, Anderson RL, McCann JD. Brow ptosis correction: a com-
parison o f ve techniques. Facial Plast Surg. 2010;26:186–192.
Patel BC. Endoscopic brow li ts uber alles. Orbit. 2006;25:267–301.
Romo III, Yalamanchili H. Endoscopic orehead li ting. Dermatol Clin.
2005;23:457–467.
Watson SW, Niamtu J III, Cunningham LL Jr. T e endoscopic brow and mid-
ace li t. Atlas Oral Maxillofac Surg Clin North Am. 2003;11:145–155.
71
SEC ION F ▼ Brow Ptosis

72
18
FIG. 18.4. Complete the superior incision by cutting a
beveled edge parallel to that of the inferior incision.
FIG. 18.5 Dissect a skin ap by cutting the fascial
attachments in the subcutaneous plane. T e dissection can
be deeper medially and laterally, but remain above the frontalis
muscle in the region over the supraorbital nerve. Cautiously
cauterize bleeding points, and lay a cottonoid sponge with
epinephrine in the wound.
FIG. 18.6. Close the subdermal layer with sutures of 5-0
Vicryl. Except in cases of facial nerve paralysis, do not x this layer
to the periosteum because it will limit dynamic brow movement.
FIG. 18.7. Close the skin with vertical mattress sutures of
5-0 prolene, and evert the wound margin approximately
1 mm to prevent a depressed scar when healed.
FIG. 18.8. Apply antibiotic ointment to the suture
line and wrap the brow and forehead in a 2-inch-wide
circumferential compression bandage.
FIG. 18.1 With the patient upright, elevate the brow to the
desired position, and then allow the brow to relax. Measure
the distance (x) between the central upper brow margin in the
ptotic position and elevated position. Repeat the measurement
medially and laterally. T is represents the width of skin to be
removed from above the brow.
FIG. 18.2. Mark a fusiform incision pattern with the inferior
line just at the uppermost row of brow hairs, and the supe-
rior line an appropriate distance above the brow as deter-
mined in Figure 18.1 T e medial and lateral extent of the
incision should not continue beyond the eyebrow. T e exact
shape of the area to be excised and its location, for example,
lateral part of the brow only, are determined by the pattern of
the ptosis. For reference, mark a small line where the supraor-
bital neurovascular bundle exits from the supraorbital notch.
Inject local anesthetic subcutaneously along the incision lines.
FIG. 18.3. With a rounded scalpel blade, make a beveled cut
through the skin along the inferior incision line. Orient the blade
to cut parallel to the direction of hair follicles, which may vary along
the length of the brow but in general are oriented downward as they
exit from the skin. As the blade passes over the area of the supraor-
bital neurovascular bundle, make the cut more super cial.
INDICATIONS: Involutional or paralytic brow ptosis.
Direct Brow Elevation
POSTOPERATIVE CARE: Leave the compression bandage
in position or 24 hours. A ter removal, apply antibiotic
ointment to the suture line three to our times daily or 7 to
10 days. Remove the skin sutures a ter 10 days.
POTENTIAL COMPLICATIONS:
Visible scar—Failure to cut the incision line parallel to the hair
sha ts may result in truncation o the lash ollicles and loss o
several rows o cilia adjacent to the incision line. T e result-
ing scar will then lie several millimeters rom the new supe-
rior brow margin, thus making camou age more di cult. A
wide scar is the result o excessive tension on the skin caused
by inadequately placed dermal and subdermal sutures. Fail-
ure to evert the skin edges may result in a depressed scar.
Asymmetry—Brow ptosis is requently asymmetric and
must be corrected or when planning the incisions.
Care ul preoperative measurements taken while the
patient is in the upright position with a relaxed brow
will minimize this complication.
Poor brow contour—Some degree o arching is inevitable
with this operation because o the inability to elevate the
medial and lateral corners as much as centrally. Some
males may f nd this objectionable. With greater degrees
o elevation, the two brow incisions can be joined across
the midline to prevent this de ormity, although doing so
will result in a more obvious glabellar scar.
Adynamic brow—T is is a result o suturing the wound to
the periosteum. Only the subcutaneous tissue, dermis,
and epidermis should be reapproximated. T e excep-
tions are the paralytic brow with poor rontalis tone and
cases o mild blepharospasm, where periosteal f xation
is help ul.
Supraorbital anesthesia—T is complication is caused by
injury to the supraorbital nerve branches, which inter-
digitate among the superf cial rontalis muscle f bers as
they extend over the orbital rim rom the supraorbital
notch or oramen. Care must be taken to keep the inci-
sions shallow in this region.

73
CHAP ER 18 ▼ Direct Brow Elevation
FIG. 18.1
FIG. 18.5
FIG. 18.2
FIG. 18.6
FIG. 18.3
FIG. 18.7
FIG. 18.4
FIG. 18.8

74
19
FIG. 19.1. Mark an incision line in the upper eyelid crease
from above the superior punctum to the lateral canthus.
Pull the skin taut to prevent buckling and cut along the marked
line with a scalpel blade.
FIG. 19.2. Tent up the orbicularis muscle with forceps
to pull it away from the levator aponeurosis and orbital
septum, and open it with scissors. Identify the underlying
orbital septum.
FIG. 19.3. Follow the orbital septum superiorly by dis-
secting just beneath the orbicularis muscle to the superior
orbital rim.
FIG. 19.4. Cut through the superior orbicularis muscle
retaining ligaments to fully expose the orbital rim. Take care
not to injure the supraorbital nerves.
FIG. 19.5. Make a horizontal cut through periosteum along
the rim from just lateral to the supraorbital notch to the
lateral canthal angle. With a Freer elevator, lift the periosteum
from the underlying frontal bone from the orbital rim upward
for a distance of about 4 cm. Make a 1-cm vertical cut through
the edge of periosteum at the medial and lateral extents of the
dissection to allow better elevation of the brow.
FIG. 19.6. Using the drill bit that comes with the
TransBleph Endotine kit, drill a hole into the frontal bone
at the junction of the middle and lateral thirds of the brow,
and about 1 cm above the orbital rim. Push the Endotine
into the drilled hole so that the at wings lie at against the
forehead and the tines are directed upward.
FIG. 19.7. Drape the cut edge of the periosteum superiorly
over the tines to aid in xation, and push the orbicularis
muscle onto the tines for xation. If desired, a xation suture
can be used to anchor periosteum to the Endotine.
FIG. 19.8. If there is still some redundant skin on the
upper eyelid, a skin or skin muscle blepharoplasty can be
performed at this time (see Upper Eyelid Blepharoplasty,
pp. 42–45). Otherwise, close the upper eyelid skin incision
with a running suture of 6-0 fast-absorbing plain gut. Be careful
not to disturb the brow xation.
INDICATIONS: Mild to moderate brow ptosis, especially lateral brow droop, exaggerated by gravity.
Transblepharoplasty Endotine Brow
Fixation
POSTOPERATIVE CARE: Place a 2-inch gauze head roll
around the head over the brows to maintain pressure on
the Endotines or 48 hours. Apply iced compresses to
the eyelids intermittently or 24 hours. A ter the roll is
removed place antibiotic ointment on the suture line three
to our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Hematoma—Bleeding is sometimes encountered rom
beneath the periosteal f ap, especially i the dissection
is carried too ar laterally onto the super cial temporal
ascia and over temporalis muscle. It usually subsides by
placing a cottonoid pack with epinephrine into the sub-
periosteal space or a ew minutes.
Scalp and forehead anesthesia—Numbness occurs with
injury to the neurovascular bundle during dissection
along the superior orbital rim. It can be avoided by
being care ul not to extend the dissection to the supra-
orbital notch. Sensation is usually reestablished within
6 to 8 months.
Pain at the Endotine site—Pain or tenderness some-
times results around the Endotine xation site i there
is inf ammation or pressure at the lateral deep branch
o the supraorbital nerve. T is usually resolves with
time, but in severe cases, the Endotine may have to be
removed.
Palpable Endotine—In patients with thin skin, the Endo-
tine can sometimes be palpable just above the lateral
brow even with the shorter 3.0-mm tines. Patients
should be warned o this possibility. T is resolves a ter 6
to 8 months when the tine dissolves.

75
CHAPTER 19 ▼ Transblepharoplasty Endotine Brow Fixation
FIG. 19.1
FIG. 19.5
FIG. 19.2
FIG. 19.6
FIG. 19.3
FIG. 19.7
FIG. 19.4
FIG. 19.8

76
20
FIG. 20.1. Mark a central incision about 1 cm in length
and positioned 1 cm above the hairline in the midsagittal
plane. Mark two similar paracentral incisions parallel to, and
about 4.5 cm lateral to, the midline mark. Mark a 3-cm inci-
sion line laterally, below the lateral temporal fusion line and
oriented perpendicular to the lateral eyebrow. Incise the three
central lines with a scalpel blade through the galea and perios-
teum. Incise the lateral temporal lines to the level of the super-
cial temporal fascia. T e latter is identi ed as a loose tissue
that moves easily over the deep fascia lying on the temporalis
muscle.
FIG. 20.2. T rough the central incision, incise periosteum.
Pass a periosteal dissector beneath periosteum and separate
it from the underlying frontal bone around each of the three
central incisions.
FIG. 20.3. Continue to elevate periosteum posteriorly
for about 8 to 10 cm, laterally to the superior tempo-
ral fusion lines, and forward to about 1 cm above the
supraorbital rim. T rough the lateral temporal incisions,
elevate the super cial temporal fascia from the deep fascia
through a small incision. Medially, break through the tempo-
ral fusion line to join the subperiosteal space over the frontal
bone.
FIG. 20.4. Pass an endoscope and a periosteal dissector
into two of the scalp incisions. Cut through periosteum
horizontally with the sharp edge of the dissector about
1 cm above the orbital rim and continue the dissection in
the supraperiosteal plane forward under direct visualization.
Carefully visualize the supraorbital neurovascular bundle.
FIG. 20.5. Release the superior orbicularis retaining the
ligament along the superior orbital rim with a dissector.
Expose the corrugator and procerus muscles near the midline,
and with a grasping forceps, cut or disinsert these muscles to
release the glabellar xation.
FIG. 20.6. Drill a hole at the anterior edge in each of the
paracentral incisions with the Endoscopic Brow Endotine
drill bit. Snap the Endotine into the hole with the tines
oriented posteriorly. Alternatively, use another xation device
of your choice.
FIG. 20.7. Lift the scalp and forehead up with a large
double-pronged skin hook and pull it backward. Engage the
scalp onto the tines for xation.
FIG. 20.8. Close the three central incisions with surgical
staples.
INDICA IONS: Brow and orehead ptosis, especially with medial brow droop associated with horizontal glabellar olds
and orehead creases.
CON RAINDICA IONS: Balding males or patients with a receding hairline.
Endoscopic Forehead Elevation

77
CHAP ER 20 ▼ Endoscopic Forehead Elevation
FIG. 20.1
FIG. 20.5
FIG. 20.2
FIG. 20.6
FIG. 20.3
FIG. 20.7
FIG. 20.4
FIG. 20.8

SEC ION F ▲ Brow Ptosis
78
FIG. 20.9. In the lateral incisions, further open the super cial temporal fascia
(S F) with scissors or scalpel. ake care not to injure the super cial temporal artery.
FIG. 20.10. Using a small Metzenbaum scissors or an elevator, dissect between
the super cial and deep temporal fascias inferiorly and gently separate them.
FIG. 20.11. Continue the dissection to the temporalis fossa and lateral brow.
FIG. 20.12. Pass a 4-0 double-armed Mersilene suture through the under surface
of the S F with multiple locking throws. Pull the lateral temporal skin ap upward
to elevate the lateral brow, and pass the two needles of the suture through the deep
temporal fascia and tie the two ends to each other.
FIG. 20.13. Overlap the posterior temporal skin ap and mark the excess to be
removed. Excise the excess skin with a scalpel blade.
FIG. 20.14. Cauterize the skin edges as needed.
FIG. 20.15. Close the temporal incisions with surgical sutures.
POS OPERA IVE CARE: Apply antibiotic ointment lib-
erally along the staple lines and place a f rm head dressing
or 48 hours. Place topical antibiotic ointment on the inci-
sions three to our times daily or 7 to 10 days. T e staples
are removed a ter 10 days.
PO EN IAL COMPLICA IONS:
Hematoma—T is results mainly rom the cut muscles.
Meticulous hemostasis is mandatory be ore closure.
Small hematomas will resolve without treatment. Larger
ones can be aspirated once they lique y. Rarely, open
drainage will be required.
Scalp anesthesia—Numbness occurs with injury to the
supraorbital nerve during dissection along the superior
orbital rim. Sensation is usually reestablished within 6
to 8 months.
Alopecia—T is can be seen along the incision lines when
excessive cautery is applied. Secondary resection o the
bare area can be per ormed a ter stretching loosens the
skin.
Palpable Endotine—In patients with thin skin, the Endo-
tine can sometimes be palpable on the scalp even with
the shorter 3.0-mm tines. Patients should be warned o
this possibility. T is resolves a ter 6 to 8 months when
the tine dissolves.
Frontalis muscle weakness or paralysis—T is results
rom injury the the seventh nerve while elevating the
S F over the temple and lateral brow. Extreme care
must be taken and the dissection done under direct
endoscopic observation.

79
CHAP ER 20 ▼ Endoscopic Forehead Elevation
FIG. 20.12
FIG. 20.9
FIG. 20.10
FIG. 20.11
FIG. 20.13
FIG. 20.14
FIG. 20.15

80
SECTIO G
Blepharoptosis

tosis o the upper eyelid is a common malposition in both
children and adults. Its consequences vary rom a mild
cosmetic blemish to severe visual disability and unctional
blindness. T e etiologies o upper eyelid ptosis are numerous
and are o ten associated with other anatomic or physiologic
conditions.
Any approach to the treatment o ptosis must be based
on an accurate assessment o its cause. Without such
knowledge, even the most enthusiastic and per ectly exe-
cuted surgical operation could be unsuccess ul. T e f rst
step in understanding the diverse causes o ptosis is devel-
oping an unambiguous classif cation system that re ects
mechanistic principles. Un ortunately, some older classif -
cations have in part been burdened by unnatural group-
ings based on ortuitous associations rather than on true
etiologic actors. Some groupings, such as congenital,
acquired, or traumatic ptosis, convey little use ul in orma-
tion, and similar etiologies are seen in all three groups.
T e ollowing mechanistic classif cation allows a more
natural grouping o disorders responsible or ptosis and
provides a more appropriate basis or its management.
Clearly, in many cases o ptosis, good medical judgment
will demand more complete clinical evaluation or modif -
cation in surgical correction.
Neurogenic Ptosis. T is group includes ptosis
resulting rom dys unction o the oculomotor nerve. T e
pathologic process may be anywhere rom its central nuclei
to the peripheral branches o its superior division within
the orbit. Etiologies include vascular lesions, ischemic
in arction, demyelinating diseases, toxic e ects, in ectious
processes, tumors, and trauma. Similar processes may
a ect the sympathetic innervation to Müller’s muscle, thus
resulting in Horner’s syndrome. Also included here are the
synkinetic ptoses such as the Marcus Gunn jaw wink syn-
drome and misdirected third nerve f bers.
In all cases o neurogenic ptosis, except the synkinetic
group and Horner’s syndrome, there is an innervational
def ciency in levator muscle unction. T is can vary rom
mild to pro ound. T ere may be associated neurologic f nd-
ings, either on examination or by history, that suggest a more
serious condition. Surgical correction o the ptosis should
in all cases be de erred until its cause has been thoroughly
investigated and the condition has stabilized. T erapy must
be individualized and may be achieved with any appropri-
ate ptosis operation. Levator muscle unction will remain
de ective despite reestablishment o adequate eyelid height.
Myogenic Ptosis. In myogenic ptosis, the de ect is
in the striated levator muscle. Similar disorders a ecting
Müller’s sympathetic muscle are not known. By ar, the
most common cause is a congenital developmental dys-
trophy, accounting or hal o all cases o ptosis. Rarely a
similar dystrophic development o the levator muscle is
associated with a genetic dysmorphic syndrome such as
blepharophimosis syndrome. Some cases o adult pto-
sis appear to be the result o an acquired myopathy that
combines poor levator muscle unction, atty inf ltration,
and f brous replacement o muscle f bers. A similar, late-
acquired myopathy occurs as a hereditary disorder. Con-
genital f brosis o extraocular muscles is usually associated
with myogenic ptosis. Other rare causes include chronic
progressive external ophthalmoplegia (CPEO), myotonic
dystrophy, and oculopharyngeal muscular dystrophy.
Myasthenia gravis may properly be included among
both the neurogenic and myogenic classif cations, although
it is most requently associated with the latter. oxic myo-
genic ptosis is reportedly a result o prolonged use o cor-
ticosteroids and mascara. raumatic injury to the levator
muscle may produce a myopathic dys unction that gener-
ally resolves spontaneously.
Determination o a myogenic cause or ptosis may alert
the surgeon to potentially li e-threatening conditions,
such as CPEO. Conditions such as myasthenia gravis also
demand very di erent consideration, and surgery is gener-
ally delayed until stable medical therapy is certain.
Surgical correction o myogenic ptosis is indicated when
the condition is stable. T e choice o procedure depends
upon the degree o residual levator muscle unction and
the nature o associated dys unctions. Surgical intervention
in some patients, or example, where Bell’s phenomenon
may be severely de ective, requires a ar more conservative
approach or modif cation o technique.
Aponeurot ic Ptosis. De ects in the mechanical link-
age between the levator muscle and tarsal plate are grouped
as the aponeurotic ptoses. Involutional redundancy o the
aponeurosis is the most common cause o adult-acquired
ptosis and requently accompanies senile degeneration o
other periorbital tissues. T inning and dehiscence o the
aponeurosis are also seen as aging phenomena, as is rank
disinsertion, although the last is much less common. Sepa-
ration o the aponeurosis rom the tarsus is seen requently
with trauma, both congenital and adult, and ollowing
repeated bouts o eyelid edema.
In aponeurotic ptosis, the levator muscle is usually
completely normal, and unction is excellent. Correction
is directed at shortening the aponeurosis or reattaching it
to the tarsal plate. Similar surgery can also yield grati ying

results in some cases o neurogenic and myogenic ptosis
where unction is good, in spite o the act that the patho-
logic process does not reside with the aponeurosis itsel .
Mechanical Ptosis. In mechanical ptosis, there is
a physical obstruction impeding eyelid elevation in the
presence o an otherwise normal levator muscle and ocu-
lomotor nerve. Eyelid mass lesions, such as abscesses and
tumors, and skin or conjunctival scarring can restrict lid
movement. Dermatochalasis and brow droop may put
excessive weight on the lid, resulting in a secondary pto-
sis. Orbital lesions requently present with ptosis when the
levator and superior rectus muscles are involved. T e cor-
rection o mechanical ptosis is directed f rst at the cause.
Any residual ptosis may then be corrected with other surgi-
cal techniques designed to elevate the lid.
Pseudoptosis. T is is a poorly def ned group o unre-
lated disorders resulting in ptosis and caused by de ects
in posterior eyelid support, changes in ocular position, or
counter e ects o the protractor muscles. Loss o orbital
volume seen with microphthalmos, phthisis bulbi, enucle-
ation, and traumatic at atrophy result in sagging o support
to the levator muscle and Whitnall’s ligament, with associ-
ated ptosis. Correction may require orbital so t tissue vol-
ume augmentation or repositioning rather than standard
ptosis repair. Hypotropia and ptosis are requently related
because o both anatomic and physiologic mechanisms.
Correction o the strabismus requently also corrects the
ptosis. Blepharospasm, either primary or secondary to ocu-
lar sur ace irritation or iritis, can increase protractor orce
against the levator muscle, resulting in a pseudoptosis.
Eyelid retraction rom thyroid orbitopathy or sympathomi-
metic drugs can cause a pseudoptosis o the contralateral
eyelid because o reduced central output and Hering’s law o
equal innervation. In all these conditions, treatment clearly
is not directed at the levator muscle or its aponeurosis with-
out f rst attending to the primary pathologic process.
TIE T EV LU TIO
Evaluation o the ptotic patient should include an attempt
to determine the precise etiology. Once other treatable dis-
eases have been ruled out, attention is directed at repair o
the ptosis. T e most important criterion in selecting a suc-
cess ul surgical procedure is levator muscle unction. T is
must be measured with extreme care because in the poor
unction range, even a di erence o 1 or 2 mm may result
in the choice o an inappropriate operation.
Levator muscle unction is measured as maximum eyelid
margin excursion rom extreme downward gaze to extreme
upward gaze positions. T e rontalis muscle must be immo-
bilized with the examiner’s f nger at the brow to eliminate
its contribution to lid elevation. T is is especially important
in children. By convention, more than 12 mm o unction is
considered excellent, 8 to 11 mm is good, 5 to 7 mm is air, 3
to 4 mm is poor, and 0 to 2 mm is considered absent.
Minimal degrees o ptosis up to 3 mm with good leva-
tor muscle unction may be corrected with any number o
procedures. T e tarsoconjunctival resection procedure is
simple to per orm and provide good results. However, it
sacrif ces the upper portion o the tarsus and accessory lac-
rimal glands, and in most cases, it ails to correct the source
o the pathologic process, namely the redundant levator
aponeurosis. T e posterior Müller’s muscle–conjunctival
resection preserves the tarsus and accessory glands and
specif cally does not address any de ects in the aponeuro-
sis. Nevertheless, it provides good lid elevation and pre-
dictable results. During the preoperative evaluation, 10%
phenylephrine drops are instilled in the eye. A ter 10 min-
utes, the lid position is noted. I the position is normal, an
8-mm resection is planned. I it is slightly less than normal,
9 mm is resected. I it is slightly more than normal, a 7-mm
resection is anticipated. I the test does not elevate the lid
to within 1 to 2 mm o normal lid position, an alternative
procedure should be selected.
T ere are a number o other ptosis operations, many
o which require a greater knowledge o eyelid anatomy.
Most, such as the external tarsoaponeurectomy, the
A- rame Müller’s muscle aponeurectomy, and the split-
level tarsectomy–tarsoaponeurectomy, o er little advan-
tage over the simpler aponeurotic advancement procedure.
In most cases with air to good levator muscle unction,
ptosis can be corrected easily with aponeurotic advance-
ment or repair. Although most appropriate or acquired
aponeurotic ptosis, this procedure also works well in
cases o congenital, other myopathic, and neurogenic pto-
ses. T is operation allows accurate adjustment o eyelid
height and contour, especially when per ormed under local
anesthesia.
Some air- unction ptosis cases may respond to maxi-
mum aponeurosis advancement up to Whitnall’s ligament.
However, most will require a levator muscle resection pro-
cedure. T is may be per ormed through a transcutaneous
or transconjunctival route, although the ormer is easier
or the beginning eyelid surgeon.
In levator muscle resection surgery, an estimate o the
amount o muscle to be removed should be made preop-
eratively. T e quantitative data below derive rom the col-
lective experience o many surgeons and have provided
predictable results. With very poor levator muscle unc-
tion, the estimate is less accurate. T e ollowing approxi-
mate resections are recommended:
Ptosis
Levator Muscle
Function
Levator Muscle
Resection
1–2 mm
good (8+ mm)
10–13 mm
3 mm
good (8+ mm)
14–17 mm
3 mm
air (5–7 mm)
18–22 mm
4+ mm
air (5–7 mm)
23–26 mm
4+ mm
poor (3–4 mm)
27+ mm
Additional intraoperative adjustment is made according to
the Berke method, which is based on the degree o expected
postoperative all or elevation in the lid position. With this
81
SEC ION G ▼ Blepharoptosis

method, the lid margin is placed at the superior corneal
limbus when levator muscle unction is poor to air, and a
postoperative all o several millimeters is expected. With
air to good unction, the lid is placed 2 to 3 mm below the
limbus and no postoperative all is expected. Such intraop-
erative adjustment is a use ul addition to the quantitative
estimation made preoperatively. However, when epineph-
rine is present in the local, there will be some Müller’s mus-
cle stimulation so that a postoperative all o 1 to 2 mm is
typical.
T e levator muscle resection procedure described below
is a modif cation designed to achieve muscle shortening,
with preservation o Whitnall’s ligament as a suspensory
structure or the superior orbital ascial system. T e pro-
cedure also preserves Müller’s muscle, which in many con-
genital cases may be the major source o intrinsic eyelid
retraction.
In patients with no levator muscle unction, the only
operation that will achieve adequate eyelid elevation is
rontalis suspension. In this procedure, the eyelid is f xed to
the rontalis muscle at the brow. Functionally, the rontalis
muscle is used as a supplemental eyelid retractor. A variety
o suspensory materials have been advocated. Autogenous
ascia lata has proven to give good results with minimal
complications but requires secondary surgery on the leg
or harvesting o the ascia. A silicone rod has become very
popular and has the advantage o not scarring into posi-
tion, so that it can be adjusted indef nitely.
Whenever possible, all ptosis surgery should be per-
ormed under local anesthesia to allow more precise
adjustment o eyelid height and contour. In cooperative
children, local anesthesia can be used success ully as early
as 6 years o age.
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Beard C. Ptosis. 3rd ed. St. Louis, MO: Mosby-Year Book; 1981.
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Callahan M, Beard C. Beard’s Ptosis. 4th ed. Birmingham, UK: Aescula-
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Mauriello JA, Wagner RS, Caputo AR, et al. reatment o congenital pto-
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Waqar S, McMurray C, Madge SN. ranscutaneous blepharoptosis sur-
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Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement
vs Müller’s muscle-conjunctival resection or correction o upper eye-
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resection or correction o upper eyelid ptosis: relationship between
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Carroll RP. Preventable problems ollowing the Fasanella Servat proce-
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simple operation. Arch Ophthalmol. 1961;65:493–496.
Glatt HJ, Putterman AM, Fett DR. Mueller’s muscle-conjunctival resec-
tion procedure in the treatment o ptosis in Horner’s syndrome. Oph-
thal Surg. 1990;21:93–96.
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Müller muscle-conjunctival resection ptosis procedure. Ophthal Plast
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advancement by Müller’s muscle-conjunctival resection: technique
and review. Arch Facial Plast Surg. 2001;3:104–110.
Putterman AM, Urist MJ. Mueller muscle-conjunctiva resection. Arch
Ophthalmol. 1975;93:619–623.
Putterman AM, Urist MJ. Mueller’s muscle-conjunctiva resection ptosis
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Putterman AM. Müllers muscle-conjunctival resection ptosis procedure.
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Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryn-
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Waller RR. Evaluation and management o the ptosis patient. In: McCord
CD, ed. Oculoplastic Surgery. New York: Raven Press; 1981.
Weinstein GS, Buerger GF Jr. Modif cation o the Mueller’s muscle-
conjunctival resection operation or blepharoptosis. Am J Ophthalmol.
1982;93:647–651.
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Levator Resection and Supra-Whitnall’s Levator Muscle Resection
Beard C. Ptosis. 3rd ed. St. Louis, MO: Mosby-Year Book; 1981.
Berke RN. Results o resection o the levator muscle through a skin inci-
sion in congenital ptosis. Arch Ophthalmol. 1959;61:177.
Callahan M, Beard C. Beard’s Ptosis. 4th ed. Birmingham, UK: Aescula-
pius; 1990:269–270.
Craw ord JS. Congenital blepharoptosis. In: Smith BC, Delia Rocca RC,
Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Sur-
gery. Vol 1. St. Louis, MO: Mosby-Year Book; 1987.
Dutton JJ. A Color Atlas of Ptosis—A Practical Guide to Evaluation and
Management. Singapore: P. G Publishing Co.; 1988:95–119.
Mauriello JA, Wagner RS, Caputo AR, et al. reatment o congenital pto-
sis by maximum levator resection. Ophthalmology. 1986;93:466–469.
Frontalis Suspension
Chow K, Deva N, Ng SG. Prolene rontalis suspension in paediatric ptosis.
Eye. 2011;25:735–739.
Osborn SF, Sloan B. Modif ed eyelid crease approach rontalis suspension
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82

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Am Acad Ophthalmol Otolaryngol. 1959;60:672–678.
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83
SEC ION G ▼ Blepharoptosis

84
21
from the supratarsal conjunctiva to the tarsal conjunctiva
behind the clamps. Include all eyelid layers except the skin and
orbicularis muscle. ie the sutures and leave the ends long.
FIG. 21.5. R m v m
m k w . With ne forceps, tease the conjunctiva
away from the underlying tissues to reveal the tarsus, Müller's
muscle, and conjunctiva.
FIG. 21.6. 6-0 m f m k f
m w f w .
FIG. 21.7. R x m f ü '
m w , 6-0 m .
Keep the suture loops beneath the conjunctiva. At the nasal
end of the wound, pass the suture through to the skin surface.
FIG. 21.8. C m k
m . Return the lid to its normal posi-
tion. ake small bites through the skin with each end of
the chromic suture and tie the ends to themselves.
FIG. 21.1. I 0.5 mL f
b 0.5 mL
b j v b . Allow
10 minutes for hemostasis.
FIG. 21.2. f 4-0 k
m . Evert the lid over a
Desmarres retractor, using the suture for xation. T e tip of the
retractor blade should lie at the supratarsal fold.
FIG. 21.3. w v m m
3 4 mm f m b . Close
the clamps by sliding the tightening jaws over the Desmarres
retractor so that the tarsus and conjunctiva are included in the
bite. Align the clamps so that the curved tips lie closer centrally
to the superior edge of the tarsus than elsewhere.
FIG. 21.4. R m v D m . Pull the skin
and muscle away from the clamped tissue with forceps to
ensure that these layers are not included in the bite. Pass three
temporary double-armed 4-0 silk sutures through the eyelid
I DIC TIO S: Minimal ptosis o up to 2 mm with good to excellent levator muscle unction.
CONTRAINDICATIONS: Moderate to severe ptosis o more than 3 mm; air to poor levator muscle unction; associated
de ormities, such as dermatochalasis, requiring concomitant repair.
T j v R
(F -S v )
OSTO ER TIVE C RE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
globe our times daily or 7 days or until the chromic
sutures dissolve.
OTE TI L CO LIC TIO S:
Undercorrection—T is is more common when patients
are not care ully evaluated and more than 2.5 mm o
ptosis is present. T e procedure should be limited to
cases o minimal, good- unction ptosis.
Overcorrection—T is may occur i more than 3 to 4 mm
o tarsus is resected. I minimal, overcorrection requires
no treatment. I signif cant, cut the chromic sutures
a ter 3 days and massage the lid downward to gape the
wound.
Corneal abrasion—T is results rom the chromic sutures
placed across the conjunctival edges. Ophthalmic oint-
ment must be used liberally until the sutures dissolve.
Contour defects—T is is caused by uneven placement o
the clamps, ailure to leave the central tarsus longer than
the sides, or resection o too wide a segment o the tar-
sus. I peaking occurs, the central portion o the chro-
mic suture can be cut and the lid massaged downward,
beginning 3 to 4 days a ter surgery.

85
CHAP ER 21 ▼ Posterior arsoconjunctival Resection (Fasanella-Servat)
FIG. 21.1
FIG. 21.2
FIG. 21.3
FIG. 21.4
FIG. 21.5
FIG. 21.6
FIG. 21.7
FIG. 21.8

86
22
FIG. 22.5. Pull the clamp and enclosed tissues upward and
the overlying skin downward to con rm that the skin and
levator aponeurosis are not included in the bite. T e skin
should pull away easily. If there is resistance, remove the clamp
and replace it.
FIG. 22.6. Hold the clamp straight out and pass a
double-armed 6-0 plain gut suture through the clamped
tissues nasally, 1.5 mm behind the clamp blades. Run
one end of this suture to the temporal side of the clamp as a
mattress stitch, taking 2-mm bites.
FIG. 22.7. With a scalpel, cut the conjunctiva and Müller's
muscle between the clamp and the running mattress
suture. Remove the previously placed 6-0 silk conjunctival
marking suture.
FIG. 22.8. Replace the Desmarres retractor and run the
nasal end of the 6-0 plain suture in continuous fashion
across the wound, apposing the edges of Müller's muscle
and conjunctiva to the superior tarsal border. Bring the two
arms of the suture through the lid temporally and into a 4-mm
horizontal skin incision at the temporal edge of the supratarsal
eyelid crease. ie the ends to bury the knot below the skin.
Remove the traction suture.
FIG. 22.1. Administer a frontal nerve block, using 1 mL
of anesthetic solution without epinephrine to avoid
stimulation and distortion of Müller's muscle. Place a 4-0 silk
traction suture through the tarsus and across the lid margin,
and evert the lid over a Desmarres retractor to expose the
supratarsal palpebral conjunctiva.
FIG. 22.2. Pass a 6-0 silk marking suture horizontally
through the conjunctiva and Müller's muscle 8 mm above
the superior tarsal border (or 7 to 9 mm, depending upon
the results of the phenylephrine test). ake one bite centrally
and two additional bites 6 mm to either side.
FIG. 22.3. With toothed forceps, grasp the conjunctiva and the
part of Müller's muscle that is adherent to its undersurface.
Pull it from side to side and up and down to separate its loose
areolar connections from the levator aponeurosis. Repeat this
procedure at several positions across the lid.
FIG. 22.4. Place a toothed Müller's muscle–conjunctival
resection clamp with one blade adjacent to the superior
tarsal border and the other at the 6-0 silk marking suture.
T e clamped tissue should include 8 mm of conjunctiva
and Müller's muscle. ighten the clamp while removing the
Desmarres retractor.
INDICATIONS: Mild to moderate ptosis of up to 3 mm with good to excellent levator muscle function, especially Horner’s
neurogenic ptosis, and where the phenylephrine test shows correction with Müller’s muscle stimulation.
CONTRAINDICATIONS: Ptosis >3 mm with fair to poor function, or where the phenylephrine test fails to correct the lid
position.
Posterior Müller's Muscle–Conjunctival
Resection
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently for 24 hours. Place antibiotic ointment beneath
the upper lid four times daily for 7 days.
POTENTIAL COMPLICATIONS:
Undercorrection—T is results from failure to resect
enough tissue or from poor patient selection. If 10%
phenylephrine fails to elevate the lid to within 1 mm
of the desired level, an alternative procedure should be
selected.
Punctate corneal staining—T is may be caused by the
tarsal sutures. It is treated with liberal topical lubri-
cation and typically resolves within 1 week after the
sutures dissolve.

87
CHAP ER 22 ▼ Posterior Müller's Muscle–Conjunctival Resection
FIG. 22.1
FIG. 22.2
FIG. 22.4
FIG. 22.3
FIG. 22.5
FIG. 22.6
FIG. 22.8
FIG. 22.7

88
23
FIG. 23.5. Cauterize the muscle edges with bipolar
electrodes.
FIG. 23.6. Identify the orbital septum, which inserts onto
the aponeurosis 3 to 5 mm above the tarsus. T e yellow fat
pockets are visible through it. Hold the orbital septum with
forceps, and cut a buttonhole centrally with scissors.
FIG. 23.7. Open the septum all the way across the wound.
Carefully separate all attachments between the septum and
aponeurosis at the extreme medial and lateral sides of the inci-
sion to prevent postoperative lagophthalmos.
FIG. 23.8. With cotton-tipped applicators, brush the
preaponeurotic fat pockets upward to reveal the levator
aponeurosis. Divide the ne fascial attachments between the
fat capsules and aponeurosis with scissors, if necessary.
FIG. 23.1. Mark the incision line within the existing eyelid
crease or at a level symmetric with the opposite eyelid.
In bilateral surgery, place the incision lines 8 to 10 mm above
the lid margin.
FIG. 23.2. In ltrate 1 mL of local anesthetic along the
incision line. Wait 15 minutes for hemostasis.
FIG. 23.3. Hold the lid taut to prevent buckling and cut
the skin with a rounded scalpel blade. T e circumferential
bers of the orbicularis muscle should be visible within
the wound.
FIG. 23.4. Tent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Open the muscle nasally and
temporally to expose the underlying orbital septum and
aponeurosis.
INDICATIONS: Mild to severe aponeurotic ptosis with good to excellent levator unction. Also, mild to moderate neuro-
genic and myogenic ptosis with good unction.
CONTRAINDICATIONS: Ptosis rom any cause in which levator unction is poor or absent.
External Levator Aponeurosis
Advancement

89
CHAP ER 23 ▼ External Levator Aponeurosis Advancement
FIG. 23.1
FIG. 23.5
FIG. 23.2
FIG. 23.6
FIG. 23.3
FIG. 23.7
FIG. 23.4
FIG. 23.8

SEC ION G ▲ Blepharoptosis
90
FIG. 23.9. Note the status of the aponeurosis. It may be attached to the tarsus but
redundant, or it may be dehisced or disinserted. In the latter case, Müller's muscle
will be visible inferior to the edge of the aponeurosis, and the ne peripheral vascular
arcade will be seen running horizontally just above the tarsal border.
FIG. 23.10. Excise a strip of orbicularis muscle from the inferior skin edge to
reveal the tarsal surface.
FIG. 23.11. Pass a 6-0 prolene suture through partial thickness of the tarsus
3 mm from its upper border and above the central pupil and then through the
lower edge of the aponeurosis.
FIG. 23.12. Tie the suture in a temporary knot and ask the patient to look for-
ward with eyes open. If necessary, replace the suture upward or downward in the
aponeurosis until the eyelid margin lies 1.5 to 2.0 mm above the desired level. Some
fall in eyelid height usually will be seen within 5 to 10 minutes of suture placement.
FIG. 23.13. Place additional sutures through the tarsus and aponeurosis medi-
ally and laterally to produce a normal marginal contour. Adjust the sutures as
needed.
FIG. 23.14. If necessary, resect a strip of the skin and orbicularis muscle from
along the superior wound edge to prevent excessive overhang. Close the skin with
a running suture of 6-0 fast-absorbing plain gut or interrupted stitches of 7-0 chromic.
If the skin-muscle lamella is not xed to the tarsus and folds down over the lashes
easily, reform the eyelid crease. Except when an Asian lid is to be maintained, pass the
suture through the aponeurosis with every second or third loop to reform the eye-
lid crease. Alternatively, reform the crease by placing 4 to 5 interrupted 6-0 chromic
sutures to x the orbicularis muscle to the aponeurosis prior to closing the skin.
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
suture line our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Undercorrection—T is results rom inadequate advance-
ment o the aponeurosis or rom ailure to allow or the
expected 1- to-2 mm postoperative all in the eyelid
height. Within the f rst week, it may be corrected in the
o ce by pulling the wound open and placing the sutures
higher on the aponeurosis.
Overcorrection—T is is uncommon but is seen with
excessive advancement o the aponeurosis. I mild, it
may be corrected with vigorous downward massage
a ter 2 weeks. I overcorrection is more than 2 mm, it
can be repaired at 1 week in the o ce by pulling open
the wound and replacing the tarsal sutures lower on the
aponeurosis.
Asymmetry of the eyelid crease—T is is caused by ailure
to adequately re orm the eyelid crease or by misplace-
ment o the incision line. I the crease is too high, it will
usually all spontaneously over several months. I it is
too low, re orm the crease by opening the wound and
ref xing the skin edges. I there is an excessive overhang
o the skin obscuring the crease, resect a strip o skin
and muscle prior to closure.
Lagophthalmos—Some degree o lagophthalmos is
expected postoperatively. It almost always resolves
within a ew days. Signif cant and persistent lagoph-
thalmos may result rom inadvertent shortening o the
orbital septum by ailure to separate it rom the apo-
neurosis or by including it in the skin sutures. T is may
require opening o the wound with lysis o the septal
attachments.
Poor eyelid contour—T is is caused by uneven advance-
ment o the aponeurosis and it is prevented by care-
ul attention to the contour intraoperatively. Uneven
contour can be corrected within 1 week by pulling the
wound open with segmental advancement or recession
o the aponeurosis.

91
CHAP ER 23 ▼ External Levator Aponeurosis Advancement
FIG. 23.12
FIG. 23.9
FIG. 23.13
FIG. 23.10
FIG. 23.14
FIG. 23.11

92
24
yellowish orbital fat behind it. Hold the septum up with
forceps and cut a central opening with scissors.
FIG. 24.6. Cut open the septum across the lid, being careful
to completely separate the septum from the aponeurosis at
the medial and lateral extremes.
FIG. 24.7. With cotton-tipped applicators, brush the
preaponeurotic fat pockets upward to the level of Whitnall’s
ligament. Measure the distance from the superior border of the
tarsus to Whitnall’s ligament (X mm). Subtract this number from
the total planned resection (Y mm) to give the amount of levator
muscle to be excised above Whitnall’s ligament (Y − X mm = Z mm).
FIG. 24.8. Identify the levator muscle above Whitnall’s
ligament. Using the scissors and blunt dissection, carefully
separate the levator muscle from the underlying superior
rectus muscle and conjunctiva.
FIG. 24.1. Mark the incision line within the existing eyelid
crease or symmetric with the opposite lid. For bilateral
ptosis, place the line 8 to 10 mm above the lid margin. Inject
local anesthetic with epinephrine along the marked line for
hemostasis.
FIG. 24.2. Cut the skin with a rounded scalpel blade while
holding the lid taut to prevent buckling.
FIG. 24.3. Tent up the skin edges to pull the orbicularis
away from the levator. With scissors, cut the muscle centrally
to enter the postorbicular fascial plane.
FIG. 24.4. Open the orbicularis muscle across the entire
wound. Cauterize the muscle edges with bipolar electrodes.
FIG. 24.5. Identify the orbital septum, which inserts onto
the aponeurosis 3 to 5 mm above the tarsus, and the
INDICATIONS: Myogenic or neurogenic ptosis with air to poor levator muscle unction o 4 to 6 mm.
CONTRAINDICATIONS: Ptosis with good to excellent levator muscle unction or very poor to absent unction.
Supra-Whitnall’s Ligament Levator
Muscle Resection