11.3.4.2 Surgical Management

When the surgeon feels that ptosis seen after blepharoplasty is a preexisting condition that was unmasked by the excision of the redundant skin, then the ptosis may be repaired by conventional methods at a time that is convenient for the patient and the surgeon. It is best to wait for resolution of the edema and inflammation from the blepharoplasty surgery. A retrospective review of the preoperative photos may be helpful in identifying this problem.

When levator injury is suspected or unexpected postoperative ptosis does not improve with conservative management, surgical exploration is warranted. Having the patient conscious during revision, and looking up and down, helps to delineate the levator complex. Violation of the levator aponeurosis is the likely cause of ptosis. The surgical wound is opened, the levator aponeurosis is identified, and its edges and reapproximated with 7–0 Silk or Prolene suture. If the aponeurosis is disinserted from the tarsus, it should be secured to the superior border of the tarsus with the same suture. Ptosis repair is a technically challenging surgery and should be performed by someone with specialized training or experience, especially when transection of the levator muscle is suspected. Early diagnosis is important as these anatomic changes will be easier to correct in the first 2 weeks following surgery before significant wound scarring occurs.

11.3.5 Diplopia

muscle, trochlea, or tendon can be injured when dissecting or sculpting the nasal fat pad. Therefore, it is important to avoid sharp or blind dissection and/or aggressive cauterization of the nasal fat pad.

11.3.5.1 Medical Management

Initial management of diplopia is conservative. Improvement is often spontaneous and should be monitored by an ophthalmologist or someone versed in the evaluation of strabismus. Diplopia that is monocular, likely caused by tear film inadequacy, should be treated as previously outlined for dry eye syndrome. Persistent monocular diplopia requires evaluation by an ophthalmologist for potential intraocular or corneal pathology. Patients with binocular diplopia should be observed closely for continued improvement. Oftentimes, a trial of oral steroids may hasten recovery. While waiting for resolution, a pair of glasses with built-in or stick-on prisms allow better tolerance of bothersome symptoms.

11.3.5.2 Surgical Management

When binocular diplopia does not improve after a period of observation, then permanent lens prism correction or strabismus surgery is warranted. In all cases of persistent diplopia, consultation with an ophthalmologist specializing in strabismus surgery should be obtained.

11.3.6 Sulcus Deformity

As with ptosis, the presence of diplopia following blepharoplasty can be a transient or persistent complication, usually resulting from interference with extraocular muscle function. Persistent diplopia following blepharoplasty is estimated to occur in 0.003% of cases [32], with a greater incidence in lower than upper blepharoplasty [33]. Transient diplopia may be caused by edema or local anesthetic effects on the extraocular muscles [31]. Persistent diplopia is the result of injury to the extraocular muscles, their tendons, or neurovascular supply.

It is important to clinically differentiate monocular versus binocular diplopia. Monocular diplopia related to blepharoplasty is generally benign and usually caused by corneal tear film abnormality, such as seen in dry eye syndrome. Binocular diplopia is more worrisome warranting detailed assessment of ocular alignment and extraocular muscle function. Syniuta et al. [33] have shown that diplopia after upper blepharoplasty is most commonly associated with dysfunction of the superior oblique complex. The mechanism of superior oblique palsy after upper blepharoplasty is unknown, but it is believed to be related to direct trauma to the superior oblique muscle, formation of a hematoma, or anesthetic toxicity [34]. The superior oblique

Hollowing or deepening of the superior sulcus may occur from senescent orbital volume changes or iatrogenically as a result of blepharoplasty. Extensive sculpting of the orbital fat in the upper eyelid sulcus may lead to a “skeletonized” or sunken appearance (Fig. 11.12). Similarly, asymmetrical sculpting may produce an irregular contour within and between the sulci. Some patients have a preexisting deep sulcus that appears to be more prominent once eyelid skin and muscle are debulked. In all cases, the cosmetic result is undesirable and particularly so in males as it imparts a more feminine appearance.

Fig. 11.12 Hollow bilateral superior sulci after upper blepharoplasty