eyelid postoperatively. Children are especially at risk for postoperative bleeding since they are more prone to falling or running into objects or rubbing the operative eye. Patients should be advised to avoid sleeping face down for at least 1 week after surgery, as it can increase pressure and possibly cause direct trauma to the surgical site.

Infection

Risk of infection after eyelid surgery is low given the rich blood supply of the face. Although the risk is small, an infection can have devastating consequences if it migrates postseptally into the orbit. At the very least, it causes discomfort,

swelling, and delayed healing. The septum may have been intentionally or inadvertently violated surgically and provide a path for spread of infection. Certain patients, such as diabetics, smokers, and those on chronic immunosuppressive medications, are at greater risk of infection and require closer monitoring and patient education regarding wound care. Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly prevalent in recent years, likely exacerbated by the excessive use of antibiotics. Any site of possible infection postoperatively should be monitored very closely for the onset of cellulitis or an abscess. The wound may need to be incised and drained, with cultures sent for identification and sensitivities. The patient should be started on broad-spectrum

oral antibiotics. Several oral agents have been reported to be effective against MRSA. These include trimethoprim/sulfamethoxazole, clindamycin, rifampin, and doxycycline [15]. If the clinical signs do not improve, or if there are signs of orbital involvement, the patient should be hospitalized and started on intravenous vancomycin. Currently, there are no recommendations regarding preoperative antibiotics for patients with history or colonization of MRSA, nor is there a recommendation for usage of routine prophylactic systemic antibiotics in the garden-variety, sterile ptosis procedure.

Corneal Abrasion/Ulceration/

Perforation

When performing levator advancement or resection, partial-thickness tarsal sutures should be used at all times to prevent suture perforation through to the conjunctival surface. Inadvertent full-thickness sutures that are exposed through the conjunctiva can cause corneal abrasion or ulceration. It is a prudent practice to evert the upper eyelid after placement of the tarsal sutures to be certain that no sutures are exposed on the inside of the upper eyelid. Avoidance of exposed sutures can be more challenging in those patients with very thin tarsal plates. In addition, we advocate the use of intraoperative corneal protectors to prevent accidental corneal puncture during tarsal suture placement.

Conclusion

Although ptosis repair may seem straightforward, all surgeons are likely to encounter complications due to the structural complexity, nuances, and intricacies of ptosis surgery. In addition to being well versed in each technique of ptosis repair, a thorough understanding of potential complications, focusing on prevention and management, is essential for every ptosis surgeon.

References

1.Cetinkaya A, Brannan PA. Ptosis repair options and algorithm. Curr Opin Ophthalmol. 2008;9(5):428–34.

2.Spahiu K, Spahiu L, Dida E. Choice of surgical procedure for ptosis correction. Med Arh. 2008;62(5–6):283–4.

3.Ahmad SM, Della Rocca RC. Blepharoptosis: evaluation, techniques, and complications. Facial Plast Surg. 2007;23(3):203–15.

4.Whitehouse GM, Grigg JR, Martin FJ. Congenital ptosis: results of surgical management. Aust N Z J Ophthalmol. 1995;23(4):309–14.

5.Cates CA, Tyers AG. Outcomes of anterior levator resection in congenital blepharoptosis. Eye. 2001;15 (Pt 6):770–3.

6.Dortzbach RK, Kronish JW. Early revision in the office for adults after unsatisfactory blepharoptosis correction. Am J Ophthalmol. 1993;115(1):68–75.

7.Lee MJ, Oh JY, Choung HK, Kim NJ, Sung MS, Khwarg SI. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three-year follow-up study. Ophthalmology. 2009;116(1):123–9.

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(5):877–85.

9.Pang NK, Newsom RW, Oestreicher JH, Chung HT, Harvey JT. Fasanella–Servat procedure: indications, efficacy, and complications. Can J Ophthalmol. 2008;43(1):84–8.

10.Kakizaki H, Zako M, Ide A, Mito H, Nakano T, Iwaki M. Causes of undercorrection of medial palpebral fissures in blepharoptosis surgery. Ophthal Plast Reconstr Surg. 2004;20(3):198–201.

11.Park DH, Kim CW, Shim JS. Strategies for simultaneous double eyelid blepharoplasty in Asian patients with congenital blepharoptosis. Aesthetic Plast Surg. 2008;32(1):66–71.

12.Kikkawa DO, Kim JW. Asian blepharoplasty. Int Ophthalmol Clin. 1997;37(3):193–204.

13.Wolfley DE. Preventing conjunctival prolapse and tarsal eversion following large excisions of levator muscle and aponeurosis for correction of congenital ptosis. Ophthalmic Surg. 1987;18(7):491–4.

14.Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of post blepharoplasty orbital hemorrhage and associated visual loss. Ophthal Plast Reconstr Surg. 2004;20(6):426–32.

15. Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA, and Participants in the Centers for Disease Control and Prevention-Convened Experts. Strategies and clinical management of MRSA in the community. Summary of an Experts’ Meeting Convened by the Centers for Disease Control and Prevention. March 2006.

Abstract  Patient satisfaction is dependent on more than just a favorable anatomic result. Good communication with the patient during the entire process is essential, making certain that you have the opportunity to hear and address the patient’s concerns and to be sure that the patient and you are “on the same page.” This chapter provides invaluable advice regarding how to optimize the sur- geon-patient relationship and increase the chances of a happy patient postoperatively.

Surgeons recognize results of ptosis surgery as being unpredictable and therefore a source of patient dissatisfaction. Many ophthalmologists, as well as other surgeons with the knowledge and technical skill to perform ptosis surgery, avoid it because they do not like to deal with unpredictable results and unhappy patients. Yet those who perform ptosis repair on a routine basis proclaim that ptosis correction yields great patient satisfaction. How is it that some patients who have a marginal result are happy and others who may have achieved a very reasonable result are so unhappy? The answer is that successful ptosis surgeons manage patient expectations and guide their patients through the surgical experience with compassion and understanding. They anticipate and manage problems as the problems arise and help patients control their frustration and remain patient as they treat such things as asymmetry,

J. Shore (*)

Texas Oculoplastic Consultants, Austin, TX, USA e-mail: jshore@tocaustin.com; jshore@austin.rr.com

abnormal contour, underand overcorrections, lagophthalmos, discomfort, and dry eye, to name a few. They explain to patients the unpredictable nature of ptosis surgery. They intervene at appropriate intervals and choose appropriate adjustments to enhance results when needed. They very carefully inform their patients that results cannot be promised and that even in the best hands, the desired outcome cannot be achieved every time.

Ptosis surgery humbles the surgeon. I have been performing ptosis surgery for 31 years and may have done as many as 10,000 ptosis operations during that time. I do not believe that I am any better at achieving anatomic success today than I was 5 years after completing fellowship training. I think I have happier ptosis patients now than earlier in my career – not because I am better at technical execution or because I quit tackling difficult cases. I believe it is because I am better at matching patients to procedures and managing patient expectations than in the past. Experience has given me a better feel for the problems encountered during and after ptosis surgery. Over time, one learns how to anticipate and identify problems more quickly and develop better judgment concerning the appropriate time to adjust the eyelid position and contour or intervene in other ways to enhance results. Also, I am better at communicating to patients what to expect when things are not working out, as I now have a better feel for what the final result will be than I did years ago. Patients want to know their surgeon has seen and can manage complications and unsatisfactory results that occur with ptosis correction. Reasonable patients hope for, but do not expect, perfect results. They