You are in: eMedicine Specialties > Plastic Surgery > EYELIDS Blepharoplasty, Upper Lid Ptosis SurgeryArticle Last Updated: Jan 30, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama Coauthor(s): Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham Editors: Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center Author and Editor Disclosure Synonyms and related keywords: blepharoptosis, upper lid blepharoplasty, ptosis correction, levator plication, upper lid ptosis surgery, upper lid ptosis, ptosis surgery INTRODUCTIONSection 2 of 11
  Upper eyelid ptosis is a drooping of the upper eyelid margin in relation to superior limbus. This problem can have significant functional and aesthetic implications. Because it can be a difficult problem to correct, a variety of procedures have been developed to address ptosis. History of the ProcedureTreatment of ptosis dates back well before 200 years. Until the early 1800s, management was limited to simple excision of skin from the upper lid. Von Graefe described a technique that resected a strip of orbicularis muscle with the skin excision. Bowman described a transconjunctival resection of the levator.1 Fansella and Servat reported resection and plication of the conjunctiva, tarsus, and levator to address mild ptosis with good levator function.2 Beard proposed a modification that used a continuous running suture rather than interrupted horizontal sutures.3 The use of fascial slings to suspend the upper lid from the frontalis muscle was originated by Payr4 and Lexer5 and later adapted by Risdon.6 Tillett and Tillett7 and McCord and Shore8 suspended the ptotic lid in a similar fashion but employed silastic strips rather than fascia. Anterior approaches to the levator using a blepharoplasty-type incision allow resection of a portion of the levator aponeurosis and tightening. Further evolution has led to techniques that use adjustable suture plication either alone or in conjunction with aesthetic blepharoplasty. ProblemUpper eyelid ptosis is a lowering of the upper eyelid margin in relation to superior limbus. Normally, the eyelid covers 1-2 mm of the upper limbus of the cornea. When the ptotic lid covers enough of the upper limbus or pupil it can result in both functional and aesthetic deformities. The severity of ptosis is classified by determining how much of the upper limbus is covered by the lid margin: mild is 2 mm, moderate is 3 mm, and severe is 4+ mm. Levator function is classified based on the distance of lid margin excursion: excellent is 12-15 mm, good is 8-12 mm, fair is 5-7 mm, and poor is 2-4 mm. FrequencyThe frequency of upper eyelid ptosis is difficult to determine. However, it is increasingly recognized in the elderly population. This is particularly true in patients who have undergone cataract extraction or lens replacement, perhaps due to stretching or disruption of the levator muscle when the eye is propped open using retractors. EtiologyThe etiology of blepharoptosis can be classified based on whether it is true ptosis or pseudoptosis, congenital or acquired, and unilateral or bilateral. True ptosis can be congenital or acquired. Congenital ptosis is associated with neurogenic or myogenic origins. Acquired causes include mechanical, traumatic, and senile lid ptosis. Pseudoptosis, the appearance of ptosis without true lid margin ptosis or levator dysfunction, can be due to severe blepharochalasia, asymmetry, or changes in ocular volume. PathophysiologyCongenital ptosis typically involves isolated myogenic dystrophy resulting in an underdeveloped levator muscle with poor functions. Congenital presentation also can include neurogenic origins such as cranial nerve (CN) III palsy and Marcus-Gunn pupil. Acquired ptosis also can be of neurogenic pathology and include acquired CN III palsy and Horner cervical sympathetic nerve palsy. In older patients, myogenic ptosis is caused by a thinning, lengthening, or, less often, disinsertion of the levator aponeurosis from the tarsal plate. In addition, acquired muscular dystrophy, progressive external ophthalmoplegia, and myasthenia gravis all can be causes of late-onset ptosis. With the exception of the neurogenic and myasthenic types of ptosis, levator function is usually good in acquired ptosis. Traumatic ptosis varies according to the location of the injury to the levator muscle or lid mechanism. Mechanical ptosis is due to a tumor, cyst, or enlarged lacrimal gland pushing down the eyelid. Pseudoptosis refers to the drooping lid skin of blepharochalasis and to the apparent ptosis seen in the postenucleation eyelid. ClinicalPtosis of the eyelids can have a subtle presentation and even go unnoticed by the patient. Presenting signs include a high tarsal fold, persistent wrinkles in the forehead due to contraction of the frontalis muscle, and asymmetric elevation of the eyebrows, greater on the affected side. In severe cases, patients complain of restricted visual fields. Patients presenting for cosmetic surgical procedures on the face also may demonstrate some degree of upper eyelid ptosis. In apparently unilateral cases, the "normal" appearing eye is checked by closing the affected one to see if a milder degree of ptosis is noted. INDICATIONSSection 3 of 11
Many techniques have been used to correct upper eyelid ptosis. Consider the degree of ptosis and levator function when weighing surgical options. Patients with poor levator function (<10 mm of excursion) and moderate ptosis (<3 mm) will likely require suspension of the lid from the frontalis muscle. Patients with poor levator function but severe ptosis (4 mm or greater) are managed with resection of a segment of the levator muscle. Patients who have good levator function (>10 mm excursion) can obtain long-term correction of the ptosis using plication of the distal levator muscle aponeurosis. Patients with minor ptosis (<2 mm) and good levator function (>10 mm excursion) are candidates for the Fasanella-Servat mullerectomy. In addition, when these patients also are undergoing cosmetic facial surgery, they can be treated successfully with transpalpebral blepharoplasty plication of the levator aponeurosis. In most of these patients with senile ptosis, simple plication of the levator may suffice. RELEVANT ANATOMYSection 4 of 11
The upper eyelid is divided anatomically into the anterior lamella, comprising skin and orbicularis muscle and the posterior lamella, which consists of the tarsus and conjunctiva. The upper eyelid is further divided by the supratarsal fold into tarsal and orbital segments of the orbicularis muscle. The supratarsal fold is formed by the insertion of the levator aponeurosis and the orbital septum on the deep surface of the orbicularis oculi. These layers, which make up the pretarsal fascia, insert into the anterior aspect of the tarsus and fix the structures of the anterior and posterior lamellas. The levator muscle, which is approximately 45 mm in length, is a skeletal muscle under voluntary control of CN III. It originates within the apex of the orbital cone and inserts on the levator aponeurosis. The levator aponeurosis extends for 12 mm superior to the supratarsal fold between the levator muscle and Müller muscle. Müller muscle is a smooth muscle under control of autonomic system, which lies beneath the aponeurosis adjacent to the conjunctiva. Failure to recognize the complex anatomy of the thin, mobile upper eyelid can lead to injury of the levator aponeurosis during cosmetic blepharoplasty while trying to locate the supraorbital fat pads. CONTRAINDICATIONSSection 5 of 11
Because ptosis correction can be performed under local anesthesia, with proper operative selection there are no specific surgical contraindications to surgery. Purely cosmetic procedures should be avoided in patients with dry eye syndrome. Patients who are undergoing concomitant procedures may require general anesthetic; in these patients, careful preoperative evaluation with regard to the degree of ptosis and planned correction is required. WORKUPSection 6 of 11
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TREATMENTSection 7 of 11
Surgical TherapySurgical therapy is the only effective management for ptosis of the upper lid. As indicated, many different surgical techniques are available for ptosis correction. Minimal incision approaches have been described to correct aponeurotic laxity by Freuh et al.9 This anterior approach uses minimal dissection, is faster than traditional approaches, and can be just as efficacious in the properly selected patient. Extended upper blepharoplasty incisions are more appropriate in patients with significant lateral hooding in addition to ptosis. Har-Shai and Hirshowitz described an incision along the supratarsal fold extending past the lateral canthus and cephalad toward the eyebrow.10 This technique also facilitates cosmetic improvement and fat resection if needed. Preoperative DetailsThis is the authors' preferred method of correction. Preoperative makings should be performed with the patient in the upright position. The meridian of the eyelid should be marked on both the affected and unaffected side. The supratarsal fold also should be marked. Both planned incisions should be infiltrated using 1% lidocaine with epinephrine. Intraoperative DetailsThe authors' preferred method of ptosis correction can be performed in conjunction with facial rejuvenation. A standard upper blepharoplasty incision with conservative skin excision is used to obtain exposure; however, a limited incision approach (ie, less than a centimeter) can also be used and has been presented with good results. Postoperative DetailsNo dressing is required; however, application of cool packs decreases swelling and bruising as well as postoperative discomfort. Instructions on corneal protection and the use of artificial tears are essential, as with any periorbital surgery. Skin sutures can be removed on postoperative day 4 or 5. Follow-upFollow-up care is performed over a period of several weeks to allow swelling to resolve. Postoperative photographs allow objective evaluation of surgical results. COMPLICATIONSSection 8 of 11
Complications include difficulty closing the eyes, eye irritation, and contour irregularity and asymmetry. Although undercorrection of ptosis is one of the most common complications, it is not associated with corneal problems such as exposure or drying. Rather, the cosmetic appearance is not optimized because some ptosis is still present in the operated eye. This problem cannot be corrected without an additional plication of the levator. In addition to asymmetry, significant overcorrection can lead to serious problems, such as corneal exposure, drying, and ulceration. In these severe cases, it is critical to protect the cornea using artificial tears, ophthalmic ointment, and taping of the eyelid. If eyelid excursion is limited by scar adhesions or lagophthalmos persists, surgical lysis of adhesions may be required. However, asymmetry and contour irregularity will improve significantly with massage therapy alone. Meticulous hemostasis is essential to prevent hemorrhagic complications. Acute bleeding into the globe is a sight-threatening emergency, which requires immediate re-exploration and decompression. Residual hematoma within the eyelid can cause excessive fibrosis, chronic edema, and persistent lid irregularities. Other complications following ptosis correction or upper eyelid surgery include reduced vision, corneal abrasion, entropion, loss of eyelashes, or diplopia. Subconjunctival edema or "chemosis" occurs more frequently but resolves spontaneously within a few weeks and can be treated with ophthalmic steroids. OUTCOME AND PROGNOSISSection 9 of 11
Levator aponeurosis plication is an effective, safe, and simple procedure to correct upper eyelid ptosis. It easily can be combined with many facial cosmetic surgery procedures. MULTIMEDIASection 10 of 11
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Blepharoplasty, Upper Lid Ptosis Surgery excerpt Article Last Updated: Jan 30, 2008 | |||||||||||||||||||||||||||||||||
