It is important to remember that not all patients require an MRD1 of 4–5 mm postoperatively. Ptosis surgeons may consider a conservative postoperative lid height (MRD1 of 2 mm) in elderly patients and those with previous corneal surface disease, prior corneal or glaucoma surgery, orbicularis muscle weakness, or poor levator excursion. Aggressive postoperative lubrication is recommended in all patients to minimize surface dryness. In patients at risk for exposure, minimal skin and muscle or skin only should be resected at the time of ptosis surgery.

Careful use of intravenous sedation is important to make the patient comfortable, but excessive sedation can make adjustment difficult or impossible. Ideally, the patient should receive propofol just prior to local anesthetic injection and then be allowed to awaken fully. Small amounts of additional sedation or narcotic pain medication can be used to keep the patient comfortable but awake enough for accurate eyelid adjustment. A discussion preoperatively with the anesthesia service is helpful to avoid overor under-sedation.

Postoperative Factors

Severe and prolonged swelling may result in residual postoperative eyelid ptosis. Complete resolution of the swelling is necessary to assess the surgical outcome, in terms of eyelid height and contour. Severe postoperative edema may also result in suture loosening (cheese-wiring) or breakage. Early postoperative adjustment in height or contour should not be considered if significant eyelid swelling is present [7].

Lagophthalmos, or lid retraction with lagophthalmos, may result from septal scarring or excessive shortening of the levator aponeurosis and muscle. Minimal handling of the orbital septum is encouraged. One should avoid placing any sutures through the septum, i.e., closing the septum or suturing it to the tarsal plate. In patients with eyebrow ptosis, the novice surgeon may mistake the eyebrow (sub-brow) fat pad for the preaponeurotic fat, or confuse the septum with the levator

aponeurosis. One should remember that the eyebrow fat contains fibrous septae, whereas the preaponeurotic fat does not. The orbital septum attaches to the orbital rim so that manual tugging on this layer will demonstrate firm resistance. On the other hand, one can appreciate some stretching when pulling on the aponeurosis. If there is any uncertainty, one can ask the patient to look up and down to identify levator movement or to feel a “tug” with upgaze.

Patients with postoperative lagophthalmos and lid lag on downgaze should be evaluated for septal scarring that will require surgical release if there is significant or symptomatic corneal exposure. If reduced upper eyelid excursion is noted preoperatively, significant resection of the levator may be required to achieve a “normal” eyelid height. Remember it is much better to have the eyelid remain a bit low, i.e., undercorrected, and the patient comfortable, rather than “normal” height and an uncomfortable patient.

Postoperative asymmetry in the eyelid skin crease or fold may give the appearance of residual postoperative ptosis. Careful preoperative eyelid skin crease measurements and marking may prevent this complication postoperatively. Lid crease reformation, with anchoring of the skin to the underlying levator, is necessary in some patients, especially those with reduced levator excursion.

Surgical Approach to Ptosis Reoperation

Reoperation rates following both external levator aponeurosis advancement and Müller’s muscleconjunctival resection are relatively low. The timing of revision surgery is typically determined by surgeon preference when treating both underand overcorrection of ptosis. A study published by Shore et al. indicates that both early and late revisions were successful in correcting unacceptable results following external levator advancement surgery [4]. Although early and late revision surgery was equally successful, benefits of early intervention included minimizing time to final

surgical result and ease of reoperation­ surgery due to minimal scarring. We typically perform all revision operations as an external approach through the lid crease, regardless of the initial surgical technique employed.

Several studies have suggested that resting eyelid position 1 week postoperatively in patients with minimal to moderate swelling is a good predictor of final eyelid height and outcome [8, 9]. Mild asymmetry may be observed for 4–6 weeks until all swelling resolves. Mild eyelid height asymmetry of less than 1 mm may resolve without surgical intervention or may be considered an acceptable surgical outcome.

If minimal overcorrection exists following levator aponeurosis advancement surgery, conservative management with eyelid “massage” can result in some improvement in eyelid height. Ask the patient to close the eye. While placing inferior traction on the closed upper eyelid, the patient looks upward, thus stretching the levator aponeurosis and muscle. Eyelid massage can be started as early as the second postoperative week, when the risk of wound dehiscence is greatly reduced.

If significant eyelid retraction and prominent lagophthalmos with significant corneal exposure are present at 1 week postoperatively, early surgical revision is indicated. At 1 week, the majority of postoperative eyelid edema has resolved, tissue planes are easily identified, and scar tissue formation is minimal, making revision surgery at this time relatively easy. The levator suture(s) may be cut from either an external or a transconjunctival approach to drop the upper eyelid. We prefer reopening the wound, identifying the suture resulting in the abnormality, and cutting the suture. Using an external approach allows additional suture placement if contour is disrupted when suture lysis is performed.

Postoperative abnormalities in contour (i.e., peaking and temporal flare) may be addressed from an external approach by moving or adding a suture to change the eyelid shape. If significant contour abnormality exists in patients with minimal to moderate swelling, early intervention is indicated [10]. The natural “peak” (high point) of the upper eyelid margin typically corresponds

to the medial aspect of the pupil; however, some patients have relatively flat eyelid contour, and in unilateral ptosis surgery cases, contour symmetry should be the goal.

Residual ptosis following levator advancement or Müller’s muscle-conjunctival resection requiring reoperation can be performed through a “mini” external approach through a small incision in the lid crease or previous incision. Inspecting for a broken or cheese-wire suture and repeating the aponeurosis advancement can be performed as early as 4–6 weeks following the initial surgery, giving ample time for residual edema to resolve. Some surgeons opt for reoperation following levator advancement using posterior approach repairs. This has not been our approach, however.

Patients with persistent lagophthalmos that exhibit signs of septal scarring on clinical exam require reoperation. If there is no evidence of corneal compromise, revision surgery should not be performed prior to 4–6 months following the initial operation, allowing scar tissue remodeling to complete. The lid crease should be opened, exposing the entire septum. Septal scarring should be released along the entire length of the levator and excised. Occasionally, we place Kenalog in the dissection planes at the time of revision surgery to decrease the inflammatory response and minimize scar tissue formation following reoperation.

Summary

Recognizing preoperative, intraoperative, and postoperative factors increasing the likelihood of surgical failure is essential to improve the success of ptosis operation. As always, patient education and reasonable goals and expectations are important to achieve a good postoperative result and a satisfied patient. Careful preoperative measurements (MRD1 and levator excursion) and preoperativerecognitionofpreexistingocularconditions (such as lagophthalmos) and eyelid disorders (such as floppy eyelid syndrome) help to avoid potential problems. Meticulous hemostasis and

careful dissection of surgical planes minimize intraoperative adjustment difficulties and postoperative scarring. In the best of hands, occasional cases that require reoperation are expected. Timing and technique for reoperation vary among ptosis surgeons, without a definitive consensus.

References

1.Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External levator advancement vs. Muller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005;140(3):426–32.

2.Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123–8.

3.Berlin AJ, Vestal KP. Levatory aponeurosis surgery: a retrospective review. Ophthalmology. 1989;96: 1033–6.

4.McCulley T, Kersten RC, Kulwin DR, Feuer WJ. Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis. Ophthal Plast Reconstr Surg. 2003;19:388–93.

5.Shore JW, Bergin DJ, Garrett SN. Results of blepharoptosis surgery with early postoperative adjustment. Ophthalmology. 1990;97:1502–11.

6.Erb MH, Kersten RC, Yip CC, Hudak D, Kulwin DR, McCulley TJ. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg. 2004;20(6):418–22.

7.Tucker SM, Verhulst SJ. Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology. 1999; 106(3):517–22.

8.Wladis EJ, Gausas RE. Transient descent of the contralateral eyelid in unilateral ptosis surgery. Ophthal Plast Reconstr Surg. 2008;24(5):348–51.

9.Linberg JV, Vasquez RJ, Chao GM. Aponeurotic ptosis repair under local anesthesia: prediction of results from operative lid height. Ophthalmology. 1988;95:1046.

10.Park DH, Jung JM, Choi WS, Song CH. Early postoperative adjustment of blepharoptosis. Ann Plast Surg. 2006;57(4):376–80.

Abstract  Ptosis repair is one of the most common operations in oculofacial plastic surgery. In mild cases, eyelid ptosis can be purely cosmetic, but in severe cases, it can cause significant visual field compromise, hindering vision and resulting in amblyopia in children. Because a variety of mechanisms can cause ptosis, it is essential that the surgeon make the proper diagnosis and implement the right surgical plan to achieve the best result. Even in expert hands, however, a less than ideal result can occur. Variables exist beyond the surgeon’s control, but it is the proper recognition and management of these problems that allow for optimized outcomes even in the face of complications.

This chapter details the most frequent complications associated with the different approaches to ptosis surgery. These include: under/overcorrection, lid contour abnormalities, lid malposition, and lagophthalmos. Recommended medical and surgical solutions to deal with each specific postoperative complication are also covered.

Ptosis repair is one of the most frequent operations in ophthalmic plastic surgery. Even in the best of hands, ptosis surgery can be challenging, and

D.O. Kikkawa (*)

Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery,

Shiley Eye Center, University of California, San Diego, La Jolla, CA, USA

e-mail: kikkawa@eyecenter.ucsd.edu

results may not be perfect. Although the vast majority of procedures achieve the desired outcome with patient and surgeon satisfaction, educating the patient and family about potential side effects and complications can decrease the element of surprise postoperatively. One of the most fundamental ways to decrease complications is the selection of the proper operation for the patient; simply performing an operation that the surgeon feels most comfortable with will likely lead to suboptimal outcomes [1–3].

Due to the unpredictable nature of ptosis surgery, even the most experienced and skilled surgeon will likely face complications at some point. This chapter highlights common complications and their management.

Underand Overcorrection

Underand overcorrection constitute the majority of complications depending on the type of operation, in some studies, the frequency is as high as 20% [4]. Some colleagues feel that sitting the patient up, often several times, during surgery to assess upper lid height and symmetry will improve the likelihood of a successful outcome.

Overcorrection typically occurs after levator advancement for acquired ptosis and in patients with good levator function. It is more rare in congenital ptosis, particularly in cases with poor levator function where undercorrection is more common. Although over or under correction is not

entirely avoidable, one can reduce the incidence with careful measurement of levator function, preoperative planning, and intraoperative lid adjustments based on patient cooperation during surgery, if done under local anesthesia [5]. Many intraoperative variables exist during levator advancement surgery. These include: amount of anesthetic infiltrated, degree of patient consciousness, and amount of swelling and hemorrhage (see chapter on levator advancement surgery for more details on surgical technique). We commonly use epinephrine (1:200,000) in our local anesthetic and infiltrate more anteriorly and for hemostasis. In theory, epinephrine can stimulate Müller’s muscle causing contraction resulting in undercorrection in levator advancement and overcorrection in conjunctival Müllerectomy in conjunctival Müllerectomy, however, we keep the injection superficial and limit the amount to avoid diffusion posteriorly.

If possible, it is best to follow the patient for a minimum of 2 weeks prior to attempting repair of overcorrection. Patients can use frequent lubricants and tape their lid closed at bedtime to lessen exposure keratopathy. Conservative measures include downward massage, stretching, and asking the patient to squeeze his/her eyelids multiple times a day. If conservative measures fail and surgical repair is imminent, a frank discussion with the patient is necessary with the surgical goal of lowering the eyelid but preferably not returning the patient back to the preoperative ptotic state.

In adults undergoing levator surgery with either overor undercorrection, an early office revision (Fig. 30.1a–d) has been recommended [6]. This technique involves an office visit as early as 3–4 days postoperatively. Minimal to no local anesthetic is used, and under sterile conditions, the wound is opened. Blunt dissection easily separates the wound edge, and the levator is identified. The levator sutures are removed, replaced (advanced in the case of undercorrection and recessed in the case of overcorrection), and tied with a temporary knot. The lid height is then examined until satisfactory height of the upper eyelid is established. Once the desired height has been determined, the suture is tied permanently. Skin closure is then performed.

Overcorrection can also occur after frontalis suspension. Depending on the type of material used, adjustment can range from simple to complex [7, 8]. If silicone is used, the central brow incision can be opened and the two ends loosened from the within the sleeve. If fascia or another synthetic material is used, two options exist. If early (within 1–2 months after surgery), an attempt can be made to loosen the knots at the brow attachment. If greater than 3 months after the initial surgery, the fascia becomes incorporated and it becomes very difficult to isolate the knots. Thus, in these cases, the eyelid wound can be opened and the fascia recessed from its tarsal attachment.

If overcorrection occurs with the posterior approach ptosis repairs, release of the suture and gentle downward stretch will usually help to resolve the overcorrection. However, one must be careful to avoid converting an overcorrection to an undercorrection by fully separating the internal wound during this maneuver.

In most cases of undercorrection, observation should be the initial approach. Postoperative swelling, which may restrict elevation of the eyelid, can take up to several months to resolve in certain cases. Once edema and hemorrhage subside, the lid is likely to get elevated to some degree. When considering a surgical repair of undercorrection, a fundamental decision must be made to either revise the same surgery or perform a different surgical technique. The early officebased revision can be applied to adults with mild to moderate undercorrection. However, if time has elapsed and the tissues have healed well, a complete reoperation is more likely.

Undercorrection occurs most commonly in congenital or acquired ptosis where levator function is poor or when the inappropriate type of ptosis procedure has been performed. In cases of levator resection, inadequate levator resection or postoperative loosening of the sutures (sometimes due to “cheesewiring” through a very attenuated aponeurosis) are the likely culprits. When operating on a patient with a very thin levator aponeurosis, sutures should be passed through a more robust portion of the aponeurosis more superiorly, or through Whitnall’s ligament, and one can use a hang-back suture position if

Fig. 30.1  (a) A 66-year-old female with right upper lid ptosis. (b) Patient 1 week after surgery with right upper lid symptomatic overcorrection. (c) Immediately after

right upper lid in-office levator recession. (d) Final lid levels 3 months after office revision

this results in excessive levator advancement, i.e., if overcorrection is noted intraoperatively. If there is persistent, significant undercorrection, then reoperation with additional levator resection should be considered, provided the ocular surface can tolerate it. In the case of poor levator function, if a maximal levator resection has already been performed and the patient has recurrent or persistent ptosis, then further levator resection is not an option, and either superior tarsectomy or frontalis suspension may be required. In cases of undercorrection with good levator function, readvancement of the levator is typically all that is necessary; in addition, a posterior lamellar procedure (Müller’s muscle-conjuncti- val resection or Fasanella–Servat [9]) could be considered as a secondary procedure.

Treatment for unilateral ptosis with poor levator function has been controversial, with some surgeons electing a bilateral procedure with levator weakening on the normal side, and others preferring a unilateral surgical approach. A unilateral procedure will likely have associated lid lag (with greater eyelid asymmetry noted on down-gaze on the operated side).

If undercorrection occurs following a unilateral frontalis suspension procedure, which may result from amblyopia in the ptotic eye or simply ocular dominance in the contralateral eye (such that the patient is not motivated to elevate the brow), then a bilateral frontalis suspension procedure should be considered.

In cases of undercorrection after a frontalis suspension procedure, a similar approach can be used as in the case of overcorrection. With a silicone sling the brow incision can be opened and theendstightenedwithinthesleeve(Fig.30.2a–c). In the case of fascia or other materials, if the material cannot be found and tightened, advancing the sling further inferiorly on the tarsus and reanchoring the sling with additional sutures can provide additional lift. Finally, if the suspension material is inadequate and its tensile strength has weakened, a complete revision is recommended.

In the case of posterior lamellar approaches (Müller’s muscle-conjunctival resection or the Fasanella–Servat procedure), repair of undercorrection typically involves using a different surgical approach. Some surgeons will perform a