Evaluation

Preoperative recognition of ptosis is extremely important because postoperative eyelid height asymmetry will not go unnoticed by the scrutinizing patient and the blepharoptosis is frequently more apparent after excess skin is removed. A systematic preoperative evaluation of all patients desiring cosmetic eyelid surgery identifies the presence of ptosis as well as other eyelid and upper facial maladies. The examination should also serve to thoroughly educate the patient and engender an amicable and trusting relationship between the patient and physician.

The preoperative examination entails a thorough review of the physical relationships of the patient’s entire upper face. The heights and contours of the upper eyelids are noted with the forehead and eyebrows in a relaxed, natural position. An asymmetric or heavily furrowed brow often masks the presence of ptosis. Frequently, redundant upper eyelid skin must be gently elevated out of the way to visualize the lid margin and the natural eyelid crease, which is typically elevated by an aponeurosis disinsertion.

The amount of levator function present should be recorded. Levator aponeurosis disinsertion results in ptosis with normal levator function. If the levator function measures less than 12 mm, the cause should be sought. The eyelid skin should be examined for scars from previous surgery or trauma. Any lagophthalmos should be noted, as its presence may help to identify a previously uncorrected congenital ptosis or the presence of significant internal scar tissue or symblepharon. Bilateral ptosis with poor levator function may be the only feature of a systemic condition such as chronic progressive external ophthalmoplegia. Variable ptosis and levator function are classically associated with myasthenia gravis. Conditions associated with poor levator function require specialized care, and affected patients may not be candidates for a combined blepharoplasty and aponeurotic ptosis repair.

Upper eyelid crease

Symmetry between the two upper eyelids is of paramount importance in achieving the desired cosmetic result. Correct placement of the eyelid crease incision, therefore, is one of the most important steps in the combined blepharoplasty and aponeurotic ptosis repair procedure. The central eyelid crease height should usually be 9–12 mm above the lid margin. It should taper temporally to a height of 5–6 mm above the lateral canthus and medially to 6–7 mm above the punctum. The configuration of this incision roughly corresponds to the superior border of the tarsal plate, the level at which the levator aponeurosis normally sends fibers through the orbicularis oculi muscle to the skin.

The incision continues temporally approximately 1 cm beyond the lateral canthus in a natural skin crease. One should avoid the temptation to extend the incision beyond this point in an attempt to incorporate temporal crow’s feet (rhytids) into the excision. The skin beyond the lateral orbital rim is thicker and less forgiving than eyelid skin, and the incision scar in this area may be visible for months after surgery. Rhytids in the temporal region are best addressed by an upper facial rhytidectomy and not through an ‘extended blepharoplasty’ procedure. Alternatively, Botulinum toxin A (Botox®), chemical peeling, and carbon dioxide (CO₂) laser resurfacing has proved quite effective in the treatment of temporal rhytids and are an excellent treatment option for individuals who do not require extensive skin excision.

During simultaneous aponeurotic ptosis repair, there is a tendency for the eyelid crease to establish itself lower than the originally desired height. This occurs when the surgeon must expose the tarsal plate to facilitate placement of tarsal sutures. If desired, the surgeon can counter this tendency by minimizing dissection to the superior border of the tarsal plate, by not excising any pretarsal orbicularis muscle, and by placing aponeurotic sutures at the desired eyelid crease height.

Surgical technique

The skin incision is marked superiorly to circumscribe redundant skin and orbicularis muscle tissue. The surgeon establishes the proper amount of skin and muscle that can be safely excised by placing one blade of a smooth forceps on the marked eyelid crease incision and gently pinching sufficient redundant tissue between it and the second blade of the forceps to cause the lid margin to just begin to evert. We use the extra fine point skin marker by Scanlan^TM (800-328-9458) as it has an ultra fine tip and allows precise marking. This maneuver is repeated along the length of the eyelid crease incision, and the superior extent of the incision is marked with a pen at each location (Fig. 10-1A). As a general guide, the superior limb of the incision should be at least 10–12 mm below the inferior margin of the eyebrow at the midpupillary position to ensure adequate anterior lamella remains to allow for complete eyelid closure and to prevent iatrogenic brow ptosis.

Figure 10-1 A, Ellipse of upper eyelid skin to be removed is outlined.

B, Elevation of the skin and orbicularis oculi muscle flap facilitates dissection just deep to the suborbicular fascial plane, thus helping to prevent iatrogenic damage to the levator aponeurosis.

C, The medial fat pad and redundant central fat may be conservatively sculpted by sharp excision with tenotomy scissors.

D, Alternative 1: The spontaneously disinserted edge of the levator aponeurosis is identified. The 5-0 polyglactin (Vicryl) sutures are passed vertically through the superior border of the tarsal plate and then passed through the disinserted edge of the levator aponeurosis.

E, Alternative 2: Fatty infiltration of the levator aponeurosis. No distinct disinsertion is noted.

F, Alternative 2: Excision of the pretarsal orbicularis muscle bares the superior aspect of the tarsal plate.

G, Alternative 2: The levator aponeurosis is elevated off the underlying Müller’s muscle to the desired level.

H, Alternative 2: The 5-0 polyglactin sutures are passed vertically through the superior border of the tarsal plate and then through the levator aponeurosis at the desired height.

I, Alternative 2: The redundant levator aponeurosis is excised.

J, The 5-0 polyglactin sutures are secured.

K, Skin closure with interrupted 6-0 plain gut sutures.

After the skin markings have been completed, the tissues are infiltrated with 2 percent lidocaine with 1 : 100,000 epinephrine to facilitate hemostasis, which takes place approximately 5–10 minutes following injection. No hyaluronidase is used, as it may enhance deep penetration of the local anesthetic, which may result in diminished levator function and subsequent difficulty adjusting the eyelid to the proper height.

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