will appear grossly elevated and should not be used as the desired goal (it will soften and descend with time). If the eyelash position as well as crease depth and position is deemed appropriate, the suture is secured with its ends left long enough for removal postoperatively. A higher crease can be created by placing a superiorly placed horizontal bite through the levator. Alternatively, a lower crease can be created by placing the suture more inferiorly along the levator. A second and third fixation sutures are aligned with the medial limbus and halfway between the lateral limbus and the lateral canthus, respectively. These fixation sutures can be adjusted intraoperatively if needed. The skin is then approximated with a loosely running, nonlocking 6–0 nylon suture. All sutures are removed a week after surgery. Figure 14.13 illustrates a patient before and 18 months after the described procedure.

14.6.5 Postoperative Care

Cold compresses are applied to the lids for the first 48–72 h to reduce edema. Ophthalmic antibiotic ointment is applied twice daily. The patient returns between the fifth and seventh postoperative day for suture removal. Occasionally, the patient may experience weakness in eye opening caused by eyelid edema or temporary levator aponeurosis dysfunction. This typically resolves within 1–2 months of surgery. Frank ptosis with poor lid excursion beyond the immediate postoperative period can signify levator injury requiring exploration. Pretarsal edema may persist for months and sometimes up to a year. This requires preoperative counseling and postoperative reassurance. Narrow, rectangular-shaped eyeglasses can camouflage some of the postoperative edema, which tends to lead to a noticeable high crease. The crease