Fig. 30.2  (a) A 43-year-old male with myasthenia gravis and stable bilateral ptosis on maximally tolerated medical therapy. (b) After bilateral upper lid frontalis suspen-

sion with silicone band. Right upper lid is undercorrected. (c) Immediately after office revision with tightening of the silicone band through central brow incision

Fasanella–Servat procedure following a failed Müller’s muscle-conjunctival resection with good results; however, there is a limit as to the amount of conjunctiva and tarsus that can be safely resected, and excessive resection can lead to symblepharon (see below) and tarsal instability. Patients with a failed posterior approach will likely benefit the most from levator advancement surgery (Fig. 30.3a–d).

Entropion

Entropion typically results when the posterior lamella of the eyelid has been shortened out of proportion to the anterior lamella. This can occur with almost every type of ptosis surgery. The posterior lamella is elevated superiorly, and the anterior lamella shifts inferiorly. It is the lack of everting forces that causes the lid margin to rotate inward. In addition to its cosmetic impact, entropion may result in inward eyelashes that abrade the cornea, a potentially disastrous complication

that can cause severe keratopathy and corneal ulcerationandrequirespromptattention.However, if the entropion is mild and well tolerated, it is reasonable to carefully observe the patient to see if improvement occurs spontaneously.

Avoidance of entropion is best addressed at the time of the initial operation. A large levator resection with sutures placed too high on the tarsus may promote the development of entropion (Fig. 30.4), so it is best to lower the tarsal fixation points of the sutures. If the tarsus is divided vertically into thirds, the tarsal fixation points should be located between the junction of the middle and upper thirds for the best stability and contour of the lid postoperatively (Fig. 30.5).

Anterior lamellar repositioning is another useful approach when managing postoperative upper lid entropion and preventing its occurrence. This involves dissecting skin and muscle in the pretarsal space until the lash bulbs are visible. The anterior lamella is then elevated and secured by placing multiple 7-0 absorbable sutures from the pretarsal orbicularis to a higher

Fig. 30.3 (a) A 76-year-old female with bilateral acquired ptosis. (b) After instillation of 2.5% phenylephrine showing good response. (c) Same patient after undergoing bilat-

eral 8-mm conjunctival Müllerectomy. Left upper lid is undercorrected. (d) Final lid levels after undergoing revision of left upper lid with external levator advancement

vertical level on the tarsus. This creates excellent eversion of the lid margin (Fig. 30.6). This technique is useful during both levator resection and frontalis suspension surgery. Any excess skin above the lid crease can then be removed and the skin closed in a standard fashion.

Symblepharon

Excessive scarring in a posterior approach surgery can lead to cicatricial contractures creating excessive inward pull on the eyelid which in turn can also cause entropion. Treatment is aimed at

releasing the scar, which allows the tissue to relax back to its normal configuration (Fig. 30.7a–c). In rare cases, if the symblepharon is severe enough to produce limitation of eye movement and/or binocular diplopia, placement of a mucous membrane or amniotic membrane graft may be necessary.

Ectropion

In general, ectropion occurs when there is excessive anterior and upward pull as opposed to posterior and inward tension on the eyelid. This can occur in several ways. In cases of a large levator resection, ectropion is usually due to the levator being sutured too far inferiorly on the tarsus.

Likewise, in frontalis suspension, if the sling is attached too far inferiorly or if the sling is too superficial, the lid may elevate away from the globe when the brows are raised (Fig. 30.8a–c).

Finally, if excessive skin is removed along with any ptosis procedure, full thickness shortening of the eyelid will occur and ectropion can result, which is accentuated by the elevation of the brow. This may produce symptomatic lagophthalmos that is difficult to correct surgically without replacing skin via a graft or flap.

Treatment for ectropion involves adjustment of levator or sling attachments, such that the tarsal fixation point is more superior (further away from the lid margin). With frontalis suspension, passing the sling posterior to the orbital septum (while avoiding the arcus marginalis) prior to exiting near the brow should correct the

Fig. 30.7  (a) A 69-year-old male who underwent large Müller’s muscle conjunctival resection (>10 mm) was referred for management of symptomatic entropion of the right upper eyelid. (b) On upper lid eversion, sym-

blepharon noted, causing cicatricial entropion. (c) After release of symblepharon and placement of amniotic membrane graft to rebuild fornix. Note the deepening of fornix