Fig. 30.8  (a) 12-year old male with poor function bilateral ptosis. (b) After bilateral upper lid frontalis suspension with autologous fascia lata. Note satisfac-

tory lid position in primary position. (c) With maximal with frontalis elevation, upper lid ectropion occurs

ectropion. This provides a more favorable, posteriorly and superiorly directed vector force that lessens the tendency of the lid to pull away from the globe with eyebrow elevation. An excessively lax upper eyelid increases the chances of developing ectropion, and occasionally horizontal tightening of the eyelid is warranted.

If longstanding ectropion is present after frontalis suspension, an eyelid crease incision can be made, with release of the sling’s tarsal attachments to allow the eyelid to “relax” downward. Although the tarsal attachments are lysed, the fibrous tracts that formed around the sling material (autologous or alloplastic) will continue to allow eyelid elevation with frontalis contraction.

Contour Deformity

Postoperative contour deformity is largely aesthetic in nature and rarely functionally significant. It can occur with any type of ptosis repair. In assessing the deformity, some time should be given for resolution of edema and inflammation before considering treatment, particularly if there is significant eyelid swelling. This must be

weighed, however, against the fact that as the healing process progresses, dissection becomes more difficult, i.e., it is quicker and easier to do a brief touch-up, such as repositioning the tarsal sutures, during the first 2 weeks after surgery.

Contour deformities can manifest in several ways. Peaking of the eyelid nasally, centrally, or temporally, nasal or temporal drooping, and a flat eyelid contour are all types of contour abnormalities.

Contour deformities occur most commonly following levator surgery and frontalis suspension. Improper suture placement is usually the cause of the deformities (Fig. 30.9a, b). If the sutures are placed too far apart from each other on the tarsus, it can lead to an eyelid that has a flat contour without the natural curvature of the eyelid that has its highest point just nasal to the pupil [10]. On the other hand, if the sutures are placed close to each other, the pull vector will concentrate too much in the middle leading to unnatural peaking. Length of the suture pass in the central tarsal bite can also be a factor. A horizontally long tarsal bite can also cause flattening, while a short tarsal bite can cause peaking (Fig. 30.10). Contour abnormalities are more common in patients with very thin, floppy tarsal plates and also in vertically shortened tarsal

Fig. 30.9 (a) acquired ptosis patient after

A 52-year-old female with bilateral with good levator function. (b) Same undergoing bilateral external levator

advancement. Note satisfactory lid levels but lateral peaking in left upper lid due to temporal placement of central suture

plates from prior surgery, such as a Fasanella– Servat or Hughes procedure. In these cases, a temporal tightening, lateral canthopexy can help to achieve favorable eyelid margin contour. Nasal or temporal peaking can usually be corrected by shifting the tarsal bite in the opposite direction and possibly higher on the tarsal plate.

If the contour irregularity has not resolved after some time, then conservative management such as massage or stretching can be attempted. Definitive treatment, however, usually requires reoperation to release and place the sutures at the appropriate location. If the levator is well anchored on the tarsus, then the levator must be dissected, freed, and resutured.

For mild contour defects, anterior or posterior tarsectomy on the portion of the eyelid that appears flat can be a useful technique. This technique should be reserved for patients who have

not undergone prior tarsal resection; otherwise, the patient may end up with deficient tarsus and is at risk for developing eyelid instability with any additional tarsal resection. For patients with a more severe contour deformity, opening of the wound and suture replacement is necessary. A central suture fixated from levator to the tarsus can be placed if the contour is too flat, and two sutures can be placed nasally and temporally if central peaking has occurred.

Patients undergoing the posterior lamellar approach can also develop abnormal eyelid contour. This complication usually occurs due to resection of tissue that is not centered over the pupil. This complication is best avoided by marking vertically, where the pupil is located with the upper eyelid everted prior to placing the resection clamp. This may also result from improper hemostat placement if one is using two curved

hemostats instead of the modified Putterman clamp to perform a Fasanella–Servat procedure.

In frontalis suspension, contour deformity occurs if tarsal anchor points are poorly positioned on the eyelid. Due to the variety of suspension patterns and material used, there is no uniform method to correct contour abnormality. Nonetheless, the most efficacious way to correct contour abnormalities in patients who have undergone frontalis suspension is to open the wound, release and replace the sutures at different fixation points from the original placement, and move them either temporally or nasally. Broadening the fixation point with additional sutures, depending on the contour abnormality, may also be attempted.

Lagophthalmos

Lagophthalmos is typically seen in conjunction with overcorrection but can also occur independently, particularly if there is any orbicularis oculi muscle weakness. Most patients with mild overcorrection have complete or nearly complete eyelid closure. Lagophthalmos mostly occurs with large levator resections and frontalis suspension operations. It can also occur when the levator is inadvertently sutured to a structure that is not moving in synchrony with the eyelid, such as the orbital septum or the tendon of the superior oblique or superior rectus muscle. If this is suspected, releasing the suture to exclude the septum or tendon can resolve the lagophthalmos.

Lagophthalmos, particularly when mild, can be tolerated quite well in the presence of a good

Bell’s phenomenon, satisfactory tear production, and a healthy cornea. However, in patients with poor protective mechanisms (poor Bell’s phenomenon or third nerve palsy) or preexisting corneal issues (due to chronic blepharitis, anterior basement membrane dystrophy, or neurotrophic keratitis, for example), lagophthalmos can be very detrimental to the ocular surface and can cause significant exposure keratopathy or corneal ulceration and perforation. If encountered early, observation is appropriate, with the use of ocular lubricants and taping of the eyelids closed during sleep, if necessary.

In cases of more severe lagophthalmos, an anterior or posterior approach levator recession is performed. If the amount of levator recession to correct the lagophthalmos passes the upper tarsal border, a hang-back suture can be utilized.

Eyelid Fold and Crease

Asymmetry of the eyelid fold and crease is probably the second most common complication of ptosis surgery, following overor undercorrection. Creation of the eyelid crease is a crucial part of ptosis surgery. In the case of unilateral surgery, efforts should be directed at matching the opposite crease. In the case of levator advancement or resection, this can be accomplished by placing sutures to attach the levator edge to the skin or orbicularis muscle at the level of the proposed eyelid crease (Figs. 30.6 and 30.11a, b). The upper eyelid skin fold, which includes the skin and the orbicularis, drapes over the crease.

Fig. 30.11  (a) A 8-year-old female after levator resection for left upper lid congenital ptosis. Note subsequent entropion and poor crease formation. (b) Same patient

after undergoing lid crease fixation and entropion repair with anterior lamellar repositioning

Most congenitally ptotic eyelids have some degree of skin excess as the chronically droopy eyelid stretches the skin. We typically include a small amount (1–2 mm) of skin excision as part of our standard levator repair in children.

Symmetry between the two eyelid creases is very important cosmetically, and it is important to make the new lid crease and fold in harmony with the ethnic background of the individual. For example, in Asian patients, levator surgery will likely result in the formation of a crease, which may or may not be the patient’s wish. This should be disclosed to the patient, but if the eyelid crease incision is kept low (5–6 mm above the lash line), the results can be very natural. One can try to avoid the creation of an inadvertently higher eyelid crease by limiting or foregoing resection of preaponeurotic fat. If the patient wishes to avoid the crease altogether, a posterior conjunctival approach is the more logical choice to correct mild ptosis. For unilateral levator surgery in an Asian patient, elevating or creating a low-lying crease on the opposite side is an excellent option for likely asymmetry that is due to the creation of a surgical crease on the operated side [11, 12].

In general, it is much easier to raise an eyelid crease than to lower one. If the surgical eyelid crease has been formed too low, then the desired place for the crease should be marked and incised. From this point, the skin and the orbicularis are undermined inferiorly down to the location of the old crease. The skin and orbicularis are then pulled up to the point of incision and sutured through the levator aponeurosis. A small amount of redundant skin can be excised before skin closure. The downside is that the lower incision scar may be visible below the new, higher eyelid crease.

If the crease has been formed too high, depending on the degree of asymmetry, several techniques can be applied. For more mild cases, soft tissue fillers or free fat injected above the crease deep to the eyelid fold provides an excellent way to enhance volume to allow the skin fold to rest lower, obscuring the elevated crease. For more severe cases with adequate skin, the new crease is marked below the elevated crease, and the intervening skin segment is excised. The orbital septum is then opened, and preaponeurotic

fat is advanced and sutured to the superior tarsal border. This fat creates a barrier to prevent the levator from readhering to the upper skin edge. Skin closure is then performed.

Conjunctival Prolapse

The superior fornix is held by the suspensory ligament, which may be inadvertently severed during larger levator resections [13]. This can lead to prolapse of the conjunctiva. Excess edema and/or a hematoma can also cause conjunctival prolapse. The superior fornix should be checked at the end of ptosis repair to look for prolapse. If present, horizontal mattress sutures can be placed through the fornix to attach the conjunctiva to the undersurface of the levator muscle intraoperatively (Fig. 30.12). If the conjunctival prolapse occurs postoperatively, conservative management with observation or repositioning of the conjunctiva with muscle hooks can be attempted under topical anesthesia in the office. If resolution does not occur with conservative measures, surgical repair is likely necessary. One option is to excise the prolapsed tissue with direct closure. The other is to place full-thickness horizontal mattress sutures from conjunctiva and exiting on the skin surface to recreate the fornix.

Hemorrhage/Hematoma

Hematomas can cause several complications including suture release and conjunctival prolapse. The most feared complication of retrobulbar hemorrhage is rare but has been described in the literature [14]. Use of anticoagulants and uncontrolled hypertension increases the risk of vision-threatening hemorrhage, and discussion should be held with the patient and his/her internist regarding the pros and cons of stopping blood thinners before surgery.

Preseptal hemorrhages are more common and can typically be observed. Bleeding and an ensuing hematoma can occur if there is trauma to the