With the 5–0 nylon now loaded normally in a forehand fashion, a horizontal bite is placed through the levator at the approximate lower edge of exposed levator again aligned at the midpupil. Next, with the 5–0 nylon loaded in a backhand fashion, the final throw of the needle is placed through the lower skin edge again aligned with the midpupil. The patient is then asked to open his/ her eyes after one suture knot to determine proper eyelash position. The eyelashes should be slightly everted, and that should be the endpoint that is desired. The crease height will appear grossly too high and should not be used as the desired endpoint. If the eyelash position is deemed appropriate, the remaining four square knots are thrown to anchor the suture knot. The same technique is undertaken on the contralateral side and symmetry of the creases is noted and can be adjusted as need be. A higher crease is created by placing the horizontal bite through the levator more superiorly and lowered by placing the suture more inferiorly along the levator.

With the initial fixation suture placed bilaterally and symmetry observed, the two remaining fixation sutures per side can be placed in the same fashion. The second fixation suture is aligned with the medial limbus and the third fixation suture positioned halfway between the lateral limbus and the lateral canthus. Additional fixation sutures can be used as needed to fine-tune any perceived asymmetry.

a

Fig. 51.7 (a) Preoperative patient. (b) One week postoperative following a full incision procedure. (c) Four weeks postoperative. (d) Six months postoperative

The skin is then approximated with a running, nonlocking 7–0 nylon suture.

51.4 Postoperative Care

Postoperative care is straightforward consisting of icing the eyelid areas for the first 48–72 h and cleansing the incision line twice daily with hydrogen peroxide and dressing it with Bacitracin ointment for the first postoperative week. The patient returns on the seventh postoperative day to have all sutures removed, i.e., the three fixation sutures per side (5–0 nylon) and the running skin closure (7–0 nylon). At times the patient may complain of difficulty opening his or her eyes due to either excessive edema and/or temporary levator dysfunction that can disappear over the first several days but can linger even up to 3–6 weeks following the procedure. The patient is reassured that it often takes a full year to achieve a natural crease configuration owing to persistent pretarsal edema that can linger for many months (Fig. 51.7). Narrow, rectangular-shaped eyeglasses can camouflage some of the exorbitant edema in the immediate postoperative period; and, for female patients, mascara can be used to help hide the abnormal height of the crease during the initial few months following the surgery.

b