Fig. 11.9 Bilateral prolapsed temporal lacrimal gland. The prolapse is more evident on the right side

Fig. 11.10 Surgeon’s view of a prolapsed lacrimal gland. Black arrow points to lacrimal gland. (Photograph courtesy of Guy Massry, MD)

prolapsed (Fig. 11.9). It is estimated that a minimum of one out of ten patients have unilateral or bilateral prolapsed lacrimal glands [28]. The upper lid has no lateral fat pad, but if a prolapsed lacrimal gland is mistaken for this, it can be inadvertently resected (Fig. 11.10). The lacrimal gland sometimes prolapses posterior to a lateral extension of the preaponeurotic (central) fat pad. This can also lead to mistaken excision or damage if/when the central fat pad is resected. Prior to excision of fat in the temporal lid, it is important to identify if the lacrimal gland is present. This will prevent inadvertent injury to the gland.

11.3.3.1 Medical Management

When lacrimal gland tissue is mistakenly excised there is an increased risk of dry eye syndrome [29]. Medical treatment of resultant dry eyes is discussed within the “dry eye syndrome” section of this chapter (eyelid lubrication with tears, lubricants, punctual occlusion, etc.).

11.3.3.2 Surgical Management

Recognition and protection of the lacrimal gland is crucial in maintaining normal of tear production. When the gland is prolapsed, it is possible to improve the contour of the eyelid

Fig. 11.11 Disruption of the levator aponeurosis during upper blepharoplasty resulting in left upper eyelid ptosis

while still protecting the integrity of the lacrimal gland. Resuspension of a prolapsed lacrimal gland is possible and adds to the cosmetic outcome of upper blepharoplasty. A 4–0, nonabsorbable polypropylene suture (Prolene, Ethicon, Somerville, NJ) can be passed through the capsule surrounding the lacrimal gland. The suture is then passed through the periosteum of the lacrimal gland fossa and secured. Generally, one or two sutures are sufficient for resuspension. Alternatively, there are surgeons who resect portions of the lacrimal gland; however, this greatly increases the risk of dry eye syndrome and should typically be avoided [30].

11.3.4 Ptosis

Ptosis present after blepharoplasty is often due to preexisting ptosis that is “unmasked” after surgery. New onset of ptosis is typically transient in nature and related to postoperative edema weighing the lid down. Ptosis may also occur if the levator aponeurosis sustains injury during blepharoplasty (Fig. 11.11). Anesthetic toxicity to the levator muscle and internal scarring of the surgical site has also been implicated in postoperative ptosis [31].

Postoperative ptosis is closely monitored and measured. As long as there is continued improvement, eyelid repositioning surgery should be deferred. However, if significant ptosis develops immediately after surgery, without significant lid edema, or if there is poor levator excursion, and no improvement of lid position with conservative therapy (see below), an injury to the elevator muscle or aponeurosis is suspected.

11.3.4.1 Medical Management

When ptosis is caused by persistent eyelid edema or presumed to be due to local anesthetic, the patient should be reassured and instructed to continue with the standard postoperative care. If cosmesis is a concern, the edema can be treated with increased ice application, elevation of the head at nighttime, oral diuretics with potassium replacement (Lasix, 40 mg daily), and oral steroids. If there is no improvement of ptosis with resolution of edema, then surgical exploration should be considered.