perform surgical myectomy and/or aponeurotic ptosis repair before considering frontalis sling surgery. Using a pentagon technique with a silicone rod, such as the Seiff frontalis suspension set (BD-Visitec, Inc.), a generally acceptable and functional ptosis result is achieved.

Surgical Technique

Aporneurotic Ptosis Repair

The surgical technique of aponeurotic ptosis repair is routine. Patients with HFS seldom require myectomy surgery and may undergo any sort of routine technique of aponeurotic repair. It is sensible to reinforce the aponeurosis with more sutures than are used in a small-incision technique.

Patients with BEB are a bit more difficult to repair, as apraxia of eyelid opening and dystonic spasm are bilateral and make intraoperative assessment of eyelid height more difficult and postoperative assessment of eyelid position more subjective. The addition of myectomy surgery requires the administration of local anesthetic over a broad area, with resultant intraand postoperative edema (Fig. 27.5) and greater variability in eyelid position related to both edema and the possibility of anesthetic diffusion into the levator muscle. It is recommended that the ptosis repair in such patients be performed before anesthetizing more broadly for myectomy surgery.

Frontalis Sling

Frontalis sling surgery in patients with BEB may be performed with myectomy surgery, although it is generally better to perform an aponeurotic ptosis repair and myectomy initially, then reevaluate postoperatively. Even patients with severe apraxia of eyelid opening often will achieve a significant functional benefit from an aponeurotic ptosis repair and myectomy procedure and not require a frontalis sling. Frontalis sling performed with myectomy surgery will require suturing of the silicone rod to the tarsus. When performed at a later date, the silicone rod can generally be passed through supraciliary stab incisions, which is technically simpler and more predictable.

Complications

The common complications of ptosis surgery in patients with HFS and BEB are under and overcorrection, recurrence, and exposure keratitis. Patients’ eyelid position is dynamic and varies significantly throughout the treatment cycle with botulinum toxin. The baseline increased tone of the orbicularis muscle with HFS causes a ptosis that frequently corrects with botulinum toxin alone (Fig. 27.2). The lid height in such patients after ptosis repair is thus dynamic and may vary significantly throughout the treatment cycle with botulinum toxin.