The main disadvantage of this technique is the high rate of lagophthalmos causing exposure keratopathy. Plication of distal orbicularis fibers to the proximal fibers via a skin flap [21] was described in order to overcome the lagophthalmos issues and achieved good results irrespective of the disorder, showing few complications and no lagophthalmos.

Maximal Levator Resection

Maximal levator resection is a better surgical alternative to frontalis suspension in the treatment of severe congenital ptosis whether unilateral or bilateral. It provides a better cosmetic result and the recurrence rate is less than with frontalis suspension [22]. Complete transsection of the medial and lateral horns of the levator aponeurosis with preservation of the Whitnall’s ligament is the most important surgical step in mobilizing the levator muscle. Satisfactory eyelid elevation (generally considered to be a difference of less than 1 mm between both eyelid fissures) can be achieved with this technique [23]. Possible complications of sacrificing the medial and lateral horns of the levator aponeurosis include: damage to the superior oblique tendon, severing the lacrimal gland or lacrimal gland ductules, sacrifice of accessory lacrimal glands, goblet cells, meibomian glands, conjunctiva, and loss of support to the lacrimal glad and temporal eyelid. These could be avoided by incising the medial horn slightly temporally and the lateral horn slightly medially. Maintenance of normal tear film is especially important in congenital ptosis surgery where postoperative eyelid lag and lagophthalmos are expected [22, 23].

preserves levator muscle, Müller’s muscle, and Whitnall’s ligament without altering the structures that produce the three-layer tear film. It is best suited for severe unilateral ptosis in which the opposite fissure height is 9 mm or less and levator function of the ptotic eyelid is 3–5 mm [24]. This technique is believed to be anatomically and physiologically superior to “maximal levator resection” with similar long-term results. More recent results have shown that the addition of a 5-mm superior tarsectomy provides an additional elevation of 1–1.5 mm.

Summary

The traditional approach for correcting ptosis is the use of frontalis suspension procedures for cases with poor levator function, and any of the other methods, depending on margin to reflex distance (MRD), for cases with good levator functions.

Minimal ptosis is best corrected using MMCR, but Fasanella–Servat and levator surgery are also viable options.

With moderate ptosis, levator aponeurosis surgery is usually applied. Levator muscle surgery may be preferred for moderate ptosis with fair levator function. For severe ptosis, levator function and the surgeon’s personal preference dictate the choice of surgical procedure, where levator resection and frontalis suspension surgery are the most recommended options.

In general, the success of the procedure depends on the skill and experience of the surgeon; however, even in the most experienced hands, under or overcorrection, asymmetry, and contour deformity are not so uncommon.

Whitnall’s Sling

In “Whitnall’s sling” technique, only the levator aponeurosis is resected, preserving Whitnall’s ligament and its attachments. This surgery

References

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4.Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External levator advancement vs Müller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005;140:426–32.

5.Pang NK, Newsom RW, Oestreicher JH, Chung HT, Harvey JT. Fasanella-Servat procedure: indications, efficacy, and complications. Can J Ophthalmol. 2008; 43:84–8.

6.Skibell BC, Harvey JH, Oestreicher JH, Howarth D, Gibbs A, Wegrynowski T, et al. Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair. Ophthal Plast Reconstr Surg. 2007;23:367–71.

7.Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol. 2001;119:687–91.

8.Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140:877–85.

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Abstract  The purpose of this chapter is to discuss­ the risk factors for ptosis surgery failure. Preoperative assessment to identify patients with marginal reflex distance < 0 mm, poor levator excursion, and preoperative eyelid laxity should be performed. Treatment of eyelid laxity with lateral canthoplasty or full-thickness wedge resection should be performed prior to ptosis surgery. Intraoperative swelling, bleeding, and excessive sedation may negatively influence revision outcome and should be recognized. If significant corneal exposure and lagophthalmos exist postoperatively, early intervention is necessary. If undercorrection exists, surgical revision should be delayed to allow complete resolution of postoperative swelling.

Introduction

Ptosis surgery is among the most common procedures performed by oculoplastic surgeons. Acquired ptosis may be corrected by an external or internal approach. Severe ptosis of greater than 3 mm, in patients with moderate to good levator excursion (LE, defined as the distance the upper eyelid travels from extreme downgaze to extreme upgaze, measured in millimeters), requires an

J. Melicher (*)

Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, OH, USA

e-mail: jmelicher@cincinnatieye.com

external approach with levator aponeurosis advancement. Müllers muscle-conjunctival resection is traditionally used to treat mild to moderate ptosis of 2 mm or less, although it has successfully been employed with 3 mm or greater ptosis. Frontalis suspension is required for patients with poor levator excursion. Most patients undergoing eyelid ptosis repair have satisfactory results. However, even the most experienced eyelid surgeon will have a few patients with unsatisfactory results. Honest, critical eyelid surgeons will agree that very few ptosis repairs have “perfect” height and contour.

The reoperation rates for ptosis repair in the literature vary. A recent study performed by Simon et al. reports a reoperation rate of 18% for external levator advancement and 3% for Müllers muscle-conjunctival resection surgery [1]. The overall success rates of external levator aponeurosis advancement surgery reported in the literature vary from 70% to more than 95% [2–4]. The largest study to date evaluating approximately 1,000 patients who underwent external levator advancement surgery for acquired ptosis with good levator excursion had a reoperation rate of 8.7% [3].

Both eyelid height and contour are important considerations. A patient with satisfactory eyelid height may complain about irregularities in the eyelid shape. Careful contour adjustments should be performed at the time of ptosis correction to decrease the likelihood of reoperation. Even with careful intraoperative adjustments, eyelid abnormalities in height and contour (nasal or temporal flare or droop and areas of peaking) may require

revision surgery. This chapter identifies factors increasing the likelihood of ptosis surgery failure and surgical approaches to ptosis reoperation.

Factors Increasing Ptosis Surgery

Failure

Understanding our patient’s goals for surgery is very important in achieving success with ptosis correction. Educating patients on the difference between dermatochalasis and eyelid margin height and illustrating to the patient how the presence of brow ptosis worsens upper eyelid dermatochalasis are very important. Many patients do not recognize eyelid or brow ptosis, but notice the presence of dermatochalasis. It is important to educate the patient regarding how the eyebrow, the skin fold, and the eyelid margin may contribute to a “droopy eyelid.” Equally important is understanding the patient’s cosmetic concerns, any functional difficulties, and the overall postoperative expectation.

Preoperative Factors

Several preoperative measurable eyelid characteristics have been noted in the literature to be risk factors for increased likelihood of reoperation following ptosis surgery. Marginal reflex distance (MRD1, defined as the distance between the corneal light reflex and the upper eyelid margin, measured in millimeters) of less than 0 mm, decreased levator excursion, and the presence of Hering’s law dependency are all predictors of over or undercorrection with ptosis surgery [3]. All three factors should be taken into consideration with preoperative surgical planning and in the informed consent process.

Hering’s law dependency can be identified by instilling 10% phenylephrine in the superior fornix of the ptotic eye, in the case of unilateral ptosis, or the more ptotic eye, in the case of bilateral ptosis. The presence of a decrease in the contralateral MRD1 indicates that Hering’s effect

is present. If Hering’s effect is suspected, the phenylephrine test should be performed. If prominent Hering’s dependency is found, bilateral ptosis surgery should be performed.

Additionally, the presence of eyelid laxity or floppy eyelid syndrome should be noted at the time of preoperative evaluation. Significant laxity can result in problems with contour adjustment intraoperatively. Surgeons may consider treating eyelid laxity with full-thickness wedge resection or lateral canthopexy prior to surgery to improve the overall success of ptosis correction. Wedge resection can result in some elevation of the eyelid margin and should be performed at least 3–6 months prior to ptosis repair.

Intraoperative Factors

Intraoperative factors influencing the success of ptosis surgery include bleeding, swelling, impaired levator function due to local anesthetic effect, unrecognized eyelid laxity, an excessively sedated patient, and scarring from injury or previous eyelid procedures. Shorter operative time tends to make ptosis correction easier. Careful use of intravenous sedation can make the patient comfortable, facilitating eyelid surgery, while too much sedation can interfere with intraoperative eyelid height. Severe intraoperative lagophthalmos may limit the amount of advancement possible.

Excessive bleeding or ecchymosis at the time of surgical correction may result in significant eyelid swelling that make adjustments difficult, or less accurate, during external levator aponeurosis advancement surgery. Slow injection of local anesthesia with epinephrine with a 30-gauge needle just under the skin should be used to minimize any bruising that may occur even before the skin incision. In most cases 1.0 cc of local anesthetic per eyelid is all that is necessary. Excessive injection contributes to eyelid swelling and potential weakening of the levator. Allow 5–10 min for the epinephrine effect to provide hemostasis prior to the skin incision. Cutting tools including the Colorado microdissection

needle, thermal cautery, Ellman radiofrequency, or the CO2 laser are useful to minimize bleeding during the skin incision and deeper dissection. Careful dissection of the aponeurosis from the underlying vascular Müller’s muscle should be performed to minimize bleeding and bruising within Müller’s muscle. Performing this dissection with high temperature battery cautery is helpful to decrease the risk of Müller’s muscle hemorrhage. If bleeding occurs, immediate tamponade with a cotton tip applicator or digital pressure followed by bipolar cauterization of the bleeding vessel will minimize the swelling induced by the hemorrhage. If significant hemorrhage and swelling occur intraoperatively, the surgeon may need to make adjustments based on the amount of levator aponeurosis resected on the contralateral side or consider the degree of swelling in unilateral surgery and adjust the suture placement accordingly. If significant intraoperative hemorrhage is encountered, surgery may need to be aborted and the eyelid position adjusted a week later in the office, once swelling has deminished.

In unilateral ptosis and asymmetric bilateral ptosis cases, Hering’s law dependency may result in contralateral eyelid drooping that makes reliable intraoperative adjustment more difficult. A study published by Wladis and Gausas in 2008 illustrated in a small number of patients that Hering’s law dependency, although not demonstrated preoperatively, was present at the time of surgery, resulting in a mean intraoperative droop of greater than 2 mm in the contralateral eyelid height. They suggest raising the operated eyelid to the preoperative height (MRD1) of the contralateral side to achieve postoperative symmetry. The Hering’s effect resolved postoperatively in all the 12 patients studied [5]. Preoperative testing for Hering’s law dependency does not reliably predict postoperative contralateral eyelid height according to Erb et al. [6]. Their study states that approximately 5% of patients undergoing unilateral ptosis repair require contralateral ptosis correction within 1 year.

Although infrequently encountered in our practice, cases of bilateral, asymmetric ptosis may present an intraoperative surgical challenge.

These patients must be carefully evaluated for Hering’s law dependency preoperatively and the levator function should be carefully assessed. This unique subgroup of patients may be best treated with the most ptotic lid being surgically corrected first, postoperative assessment of the height of the contralateral lid, and if necessary surgical intervention for the contralateral lid 2–3 months after the first surgery.

Unrecognized upper lid laxity may be encountered at the time of surgery and is exacerbated by the absence of orbicularis muscle tone following the injection of local anesthesia. Patients with eyelid laxity may require more than one suture to secure the aponeurosis to the tarsal plate to avoid contour abnormalities or eyelid margin peaking postoperatively. Severe eyelid laxity also predisposes to eversion of the tarsus, which can be alleviated by moving the sutures higher on the tarsal plate. Ideally, excessive laxity should be corrected with a separate surgical procedure prior to ptosis correction. Simultaneous wedge resection and ptosis repair should be avoided in these patients. Wedge resection requires additional local anesthesia, resulting in a decrease in levator tone and excursion and can make adjustment of eyelid height and contour more difficult intraoperatively. Horizontal lid tightening surgery should be performed at least 6–8 weeks prior to ptosis correction to allow appropriate time for healing and re-evaluation of eyelid position as wedge resection surgery often will lift the lid slightly, resulting in some ptosis correction.

Intraoperative qualitative assessment of lagophthalmos is challenging for eyelid surgeons. We typically ask ourselves: How much intraoperative lagophthalmos is too much at the time of ptosis surgery? Several preoperative factors should be considered to minimize exposure issues postoperatively. If the patient has robust orbicularis function, a good Bell’s phenomenon and a healthy tear film, more aggressive lid elevation and greater intraoperative lagophthalmos can be tolerated. Once orbicularis tone improves following surgery, lagophthalmos should resolve, or at least improve, in most patients.

Patient goals and expectations should be considered during the informed consent process.