Minimal Lash Ptosis

The lash ptosis is addressed after the excess skin is removed (to address concurrent dermatochalasis), and the levator is advanced in cases of blepharoptosis. Interrupted bites of 6–0 chromic sutures are used to attach skin to the deep levator aponeurosis just above the superior tarsal border. It is important to note that as the sutures are tightened, often the subsequent sutures are more difficult to place; therefore, we often preplace the sutures prior to tying them down to ensure that each one is appropriately placed. The number of sutures placed depends on the size of the incision; however, we typically place five to six sutures in each eyelid. The preplaced sutures are then tied down and any remaining skin gaps are closed with 6–0 fast-absorbing gut suture. The careful attention to closure, by ensuring the incorporation of the levator aponeurosis, accomplishes two goals. First, it reforms the lid crease, and second, it causes enough of a vertical traction on the anterior lamella to improve the angle of the eyelash orientation. We aim for slight overcorrection, as the lashes are expected to drop slightly in the postoperative period.

Moderate to Severe Lash Ptosis

These cases can be challenging to correct and therefore require a more powerful procedure to improve the vertical vector forces on the lash base. Again, in cases of either acquired or congenital blepharoptosis, we prefer to address this first. Once we have the lid height in the desired position and just prior to closure, we address the lashes. For moderate cases, we like to use a polygalactin double-armed 5–0 or 6–0 horizontal mattress suture through the upper third of the tarsus and exit just above the lash base. These sutures are placed along the same level of the tarsus across the eyelid and exit in the same position immediately above the lash base to ensure symmetric elevation across the lashes. Once tied down, the closure of the skin is completed with a running 6–0 fast-absorbing gut suture.

For more severe cases of lash ptosis, we employ a similar technique as described above with a couple of modifications. Instead of using a dissolvable suture, we like to use a permanent suture, such as silk and remove it around postoperative week 6 to minimize the chance of postoperative descent. In addition, we reinforce the vertical traction by closing the skin similar to that described for minimal lash ptosis.

In patients with FES, the lash ptosis is corrected with a horizontal tightening procedure. The authors’ preference is to use a full-thickness pentagonal wedge resection at the junction of the lateral ¼ and medial ¾ of the eyelid. The eyelid is closed using standard marginal and layered closure techniques. In our experience, rarely will floppy eyelid patients need additional rotational suture techniques as described above. Lash ptosis secondary to cicatricial entropion needs to be corrected by treatment of the underlying etiology having caused, or causing, the cicatricial changes. Once the cicatrix has stabilized, or if protection of the ocular surface warrants sooner intervention, surgery can be undertaken. The approach depends on the severity of the cicatrix, but usually requires incisional relaxation of the cicatrix and placement of a spacer graft. If the anterior lamellar anatomy has not been chronically disrupted, the lash ptosis may resolve; however, residual lash ptosis may need to be addressed secondarily using one of the above procedures.

In all of our techniques we aim for mild to moderate overcorrection, as the lash angle is expected to drop slightly in the postoperative period.

Conclusion

Lash ptosis is associated with various conditions, and the etiology of the lash ptosis may be secondary to the underlying condition, i.e., congenital or acquired blepharoptosis, FES, etc. Preoperatively, it is important to document the severity of the lash ptosis and grade it accordingly in order to determine­ the best surgical technique to employ.

The combined approach of addressing the underlying condition along with the severity of the lash ptosis will lead to an improved outcome and the greater likelihood of a satisfied patient.

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