(see above) as there can be symmetric undercorrection. However, undercorrection can cause asymmetry.

Overcorrection (too much tissue excised) can lead to significant problems (see lagophthalmos). It can be common for the novice blepharoplasty surgeon to underresect skin as the complications associated with overresection are far more significant.

11.5.5.1 Medical Management

If undercorrection is the problem, the patient is treated as previously described for postoperative asymmetry. If an overcorrection occurs with corneal exposure, aggressive ocular lubrication with drops and ointment, eyelid massage, and possibly punctal occlusion are initiated.

11.5.5.2 Surgical Management

Once swelling has resolved and eyelid stability has been reached, surgical revision can be planned. In undercorrections, it is important to assess if there is sufficient anterior lamella to be excised so as not to cause lagophthalmos or brow ptosis. In cases of overcorrection, an FTSG is the only option to improve both function and cosmesis. This is discussed in the previous section on lagophthalmos.

11.6Unrealized Patient Expectations

Unrealized patient expectations can lead to significant patient dissatisfaction after surgery, and may be the most difficult problem to resolve. A good result to surgery is when the patient is happy. As such, prevention is the best solution. It is critical that the surgeon understands the underlying motivations for which the patient is seeking surgery, and that those expectations can be met. For example, a patient who wants redundant eyelid skin removed and less protrusion of the eyelid fold can benefit from upper eyelid blepharoplasty. However, periorbital dynamic wrinkles, true lid ptosis, brow ptosis, and a deep sulcus will not be addressed with only upper blepharoplasty. It is incumbent upon the surgeon to identify any unrealistic expectations prior to performing surgery. If the patient is unwilling to modify his or her expectations, surgery should not be performed.

11.7Conclusion

Upper eyelid blepharoplasty is a commonly performed surgery for both aesthetic and functional reasons. It is a generally safe and reliable procedure with high patient satisfaction. However, like all surgery, there are a myriad of potential postoperative complications. Most of these complications can be avoided with proper patient evaluation and counseling, preoperative planning, and sound intraoperative technique.

On occasion, adverse events occur in the best of hands under normal circumstances. The surgeon must be prepared to manage such events to prevent potential permanent loss of vision (i.e., orbital compartment syndrome), and deal with less severe but still stressful issues (dry eye, lagophthalmos, asymmetry, etc.). The preoperative assessment is crucial to exclude unrealistic patients, and those whose risks prevent proceeding with surgery.

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Key Points

•Patients presenting for blepharoplasty may have concurrent true eyelid ptosis.

•If present, ptosis should be evaluated and pointed out to each patient, and its repair discussed.

•Aponeurotic/involutional ptosis is the most common etiology encountered.

•The surgeon should be aware of the medical conditions which cause ptosis (myasthenia gravis, Horner syndrome, etc.) which require further workup before proceeding with surgery.

•Dry eye status and corneal protective mechanisms must be evaluated before surgery to prevent potentially significant postoperative complications.

•A thorough knowledge of eyelid anatomy and significant experience with eyelid surgery are prerequisites for successful surgery.

•Levator ptosis repair is performed with blepharoplasty through the same eyelid incision.

•The preaponeurotic fat is a useful surgical landmark as it lies behind the orbital septum and anterior to the levator aponeurosis – the critical anatomic structure identified in surgery.

•The surgical outcome is maximized when patients are awake.

•Intraoperative adjustments in eyelid height and contour are a normal part of surgery.

•Patients should be counseled preoperatively about the potential for postoperative revision of under/overcorrections.

12.1Introduction

When evaluating the potential upper eyelid blepharoplasty patient, it is important to determine whether a component of true eyelid ptosis is present, and whether or not it should be addressed [1]. For example, if a patient has mild ptosis, but is primarily bothered by upper eyelid fullness (excess skin/muscle and fat), he/she may only chose to undergo blepharoplasty. Alternatively, marked dermatochalasis may mask significant ptosis, which can become more apparent postoperatively if not corrected. In this instance, ptosis correction may be desired. Even if ptosis is not to be addressed surgically, its presence should be pointed out to the patient before surgery with a mirror or photos, so that there are no surprises after surgery.

There are varied etiologies of ptosis [2–4], and their discussion is beyond the scope of this chapter. The most common form of ptosis is involutional, or aponeurotic in nature [2, 3]. If an etiology other than typical involutional ptosis is suspected, further workup by a specialist (oculoplastic surgeon, neuro-ophthalmologist) is recommended before proceeding with surgery. Also, there are two basic approaches to ptosis repair: an anterior (transcutaneous) approach with levator aponeurotic advancement (with or without resection) [5], or a posterior approach [6], which is discussed in detail in Chap. 13. For the purpose of this chapter, I will focus on involutional ptosis and levator aponeurotic ptosis repair only.

M.E. Hartstein (*)

Clinical Associate Professor, Department

of Ophthalmology and Division of Plastic Surgery,

St. Louis University School of Medicine, St. Louis, MO, USA

Director, Oculoplastic Surgery, Department of Ophthalmology, Assaf Harofeh Medical Center, Beer Yaacov, Israel

e-mail: mhartstein@earthlink.net

12.2Ptosis Repair: Which Approach?

When ptosis is identified, and correction is planned, a decision on which surgical procedure to perform is important. As stated above, there are two standard ways to address upper eyelid ptosis: an anterior transcutaneous approach involving levator advancement and reattachment, or a variety of posterior eyelid approaches. Posterior ptosis surgery can be accomplished by a graded resection of Muller’s muscle/conjunctiva,