encountered in the preoperative assessment. Identifying and understanding the unique anatomical features of the specific gender and/or ethnicity is important. However, much more important is the communication between patient and surgeon to determine what the goals and expectations of eyelid surgery are.

References

1.Odunze M, Rosenberg DS, Few JW. Periorbital aging and ethnic considerations: a focus on the lateral canthal complex. Plast Reconstr Surg. 2008;121:1002–8.

2.Odunze M, Reid RR, Yu M, Few J. Periorbital rejuvenation and the African American patient: a survey approach. Plast Reconstr Surg. 2006;118:1011–8.

3.Stewart JM, Carter SR. Anatomy and examination of the eyelids. Int Ophthalmol Clin. 2002;42:1–13.

4.Doxanas MT, Anderson RL. Oriental eyelids – an anatomic study. Arch Ophthalmol. 1984;102:1232–5.

5.Flowers RS. The art of eyelid and orbital aesthetics: multiracial surgical considerations. Clin Plast Surg. 1987;14:703–21.

6.Kim MK, Rathbun JE, Aguilar GL, Seiff SR. Ptosis surgery in the Asian eyelid. Ophthal Plast Reconstr Surg. 1989;5:118–26.

7.Yi SK, Paik HW, Lee PK, et al. Simple epicanthoplasty with minimal scar. Aesthetic Plast Surg. 2007;31:350–3.

8.Yen MT, Jordan DR, Anderson RL. No-scar Asian Epicanthoplasty: a subcutaneous approach. Ophthal Plast Reconstr Surg. 2002;18:40–4.

Abstract  Blepharoptosis is one of the most common age-related changes of the upper eyelids. It is frequently present in patients undergoing upper eyelid and facial rejuvenation. If the plan is to combine ptosis repair with other procedures, these additional procedures may impact which ptosis procedure is selected.

Blepharoptosis is one of the most common agerelated changes of the upper eyelids. It is frequently present in patients undergoing upper eyelid and facial rejuvenation. If the plan is to combine ptosis repair with other procedures, these additional procedures may impact which ptosis procedure is selected.

Techniques for ptosis correction are well described elsewhere in this book, with each procedure having its own merits and drawbacks. Although underor overcorrection of the ptotic lid is likely to be the most common complication, contour abnormalities of the eyelid margin may be even more disconcerting to the patient, particularly the cosmetic patient, and can be more difficult to correct. The Müller’s muscle– conjunctival resection (MMCR) and Fasanella– Servat (FS) procedures described in previous chapters are reliable for eyelid elevation in suitable patients. MMCR and FS reportedly carry a lower incidence of postoperative eyelid margin

A.J. Cohen (*)

Private Practice, The Art of Eyes, Skokie, IL, USA e-mail: acohen@theartofeyes.com

contour abnormalities than levator advancement surgery since the attachments between levator aponeurosis and the anterior tarsal plate are left intact. However, the small incision, minimal dissection levator resection procedure (see chapter 19 on this procedure) may also accomplish the same goal of preserving many of the levator– tarsus attachments.

The external levator advancement technique is widely used. Some will argue that this approach is preferred when blepharoplasty or other procedures are concomitantly performed since only one incision is necessary. Furthermore, in patients with ptosis who desire ocular adnexal rejuvenation, external levator advancement allows for access to other periocular structures, including the upper eyelid skin and fat, lacrimal gland, subbrow fat pad, eyebrow, corrugator supercilii and procerus muscles, brow depressors, forehead, and midface. The ultimate decision regarding which ptosis surgery technique to use will be dictated by the surgeon preference, clinical findings (such as degree of ptosis, levator function, response to phenylephrine, status of the eyelid crease), need for access to periocular structures, and patient preference and expectations.

Regardless of which ptosis procedure is utilized, it is important to be aware that the following procedures may be performed via an upper eyelid crease incision:

1. Eyelid crease formation or repositioning in cases of crease asymmetry.

2. Lacrimal gland suspension for cases of lacrimal gland prolapse or prominence.

3. Removal of excess skin, orbicularis oculi muscle, and fat in the upper eyelid, i.e., upper blepharoplasty and orbicularis myectomy.

4. Lateral canthopexy or canthoplasty to tighten the eyelids and/or reposition the lateral canthus. One may attain satisfactory access to the lateral canthal tendon and lateral orbital rim through the lateral portion of the upper eyelid incision. Lateral canthopexy may be used to address horizontal eyelid laxity, lateral canthal dystopia, rounding of the lateral canthal angle, or involutional blepharophimosis. Disinsertion of the lateral canthal tendon allows for complete mobilization of the lateral retinaculum to achieve greater tightening of a very lax eyelid and a larger degree of freedom to move and refixate the tendon.

5. A weakening procedure of the corrugator supercilii and procerus muscles to alleviate glabellar frown lines. A superior dissection plane posterior to orbital portion of the orbicularis oculi muscle will expose the obliquely horizontal corrugator supercilii muscle. Care should be taken to avoid injury to the supraorbital neurovascular bundle when dividing and/or resecting the corrugator muscle. The vertical procerus muscle can be safely divided “blindly” in the midline.

6. Eyebrow fat pad sculpting. In certain patients, such as Asians, the subbrow fat extends down into the upper eyelid and contributes greatly to the fullness of the eyelid. This subbrow fat, which lies anterior to the orbital septum and has a prominent fibrous component, should not be confused with the preaponeurotic fat that flows freely behind the septum. Thyroid eye disease patients often display hypertrophy of the brow fat pad, which may benefit from debulking to restore a more aesthetically desirable upper eyelid appearance.

7. Internal eyebrowpexy with or without resorbable fixation devices. While browpexy has limited ability to elevate the brow position, it may be particularly useful in stabilizing brow position to prevent brow descent after ptosis repair or upper blepharoplasty.

8. Subperiosteal elevation of the central forehead via inferior release. A horizontal incision

is made in the periosteum just above the superior orbital rim, allowing for subperiosteal release of the central portion of the forehead within the boundaries of the temporal lines of fusion.

9. Superior repositioning of the suborbital orbicularis oculi fat (SOOF) and malar fat pads, i.e., midface lift, may be performed to a limited degree through an upper eyelid crease incision. Through the lateral end of an extended upper eyelid incision, the lateral portion of the SOOF may be approached and mobilized by releasing the orbitomalar ligament. The SOOF is then suspended from the lateral orbital rim and the deep temporal fascia.

There is often confusion between ptosis and dermatochalasis by patients and inexperienced clinicians, and patients may assume that “too much skin” is the cause of their “droopy eyelids.” If excess skin is overhanging the eyelashes, then it is necessary to gently raise the brows to lift the skin out of the way to assess the eyelid margin position and determine the true marginreflex distance. If only upper blepharoplasty is performed, and concurrent ptosis is not addressed, there is an increased likelihood of ending up with an unhappy patient. It is essential that the clinician educate the patient how to achieve the goals that the patient has set forth, assuming those goals are realistic. In addition, in terms of managing patient expectations, it is important to forewarn the patient of the possible need for additional surgery to achieve the desired outcome. One should bear in mind that ptosis surgery may “produce” excess upper eyelid skin. This results from eyelid elevation and descent of the brows since there is no longer any need for compensatory brow elevation. The surgeon must take these issues into consideration when deciding whether or not to remove skin, and how much skin to resect, at the time of ptosis repair.

While the elderly patient with a functional eyelid malposition may be quite tolerant of certain expected postoperative issues such as bruising and swelling, younger and aesthetically oriented patients may react more strongly. In addition to withholding any drugs and herbal supplements that may promote bleeding for the appropriate

amount of time preoperatively, ­certain patients opt to take oral homeopathic Arnica montana. Despite these measures and judicious intraoperative cautery, some patients may still develop significant periocular bruising. A cover-up makeup may be used to conceal this, as well as pulsed dye laser in cases of more severe ecchymosis [1]. It is important to avoid direct sunlight exposure to bruised and red areas since that may lead to hyperpigmentation that may gradually resolve over time or can be managed with bleaching agents, such as hydroquinone.

Compared with functional patients, there is even greater pressure on the surgeon for the aesthetic patient to have a positive surgical experience. That may be enhanced by the use of bicarbonate in the local anesthetic mixture and IV sedation. Intraoperative IV dexamethasone may have a beneficial effect on postoperative nausea and edema. It is helpful to elevate the head of the bed and initiate ice compresses as soon as possible after completion of the procedure, even in the operating room. In some

patients who may be more prone to edema, one may also consider a short course of oral corticosteroids postoperatively.

Patients often ask whether vitamin E ointment applied following surgery will improve the ultimate cosmetic appearance of the wound. There is no consensus in this regard, and a significant incidence of contact dermatitis due to the ointment has been reported [2, 3]. It might be safest to just use an emollient, such as Aquaphor (Beiersdorf Inc., Wilton, CT).

References

1.DeFatta RJ. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11:99–103.

2.Baumann LS, Spencer J. The effects of topical vitamin E on the cosmetic appearance of scars. Dermatol Surg. 1999;25:311–5.

3.Zampieri N et al. A prospective study in children: Preand post-surgery use of vitamin E in surgical incisions. J Plast Reconstr Aesthet Surg. 2010;63(9):1474–8.