12.1 Patient History Leading to the Specific Problem

A 65-year-old woman had one previous blepharoplasty 3 years prior to presentation (Fig. 12-1). The patient noted progressive painless ptosis of her right upper lid after the procedure, obstructing her visual axis and causing cosmetic deformity. The patient desired ptosis repair to improve the appearance of her eyelids as well as her visual function. She was a breast cancer survivor status post mastectomy, but otherwise healthy without significant medical issues.

12.2 Anatomic Description of the Patient’s Current Status

This patient demonstrates a common problem with postseptal dissection and fat excision during blepharoplasty. Accidental injury to the levator palpebrae superioris during blepharoplasty will lead to postoperative ptosis.

12.3 Analysis of the Problem

Careful preoperative patient evaluation is critical to the surgical success and prevention of postoperative complications in blepharoplasty. The most common cause of permanent postblepharoplasty blepharoptosis is inadequate preoperative patient evaluation and identification of ptosis. Preoperative measurement of the palpebral fissures in primary gaze, margin-reflex distance, and levator function may reveal blepharoptosis and guide appropriate surgical intervention.

The levator palpebrae superioris merges with the preseptal orbicularis oculi muscle near the inferior half of the skin muscle excision during blepharoplasty. Aggressive upper eyelid dissection may damage supratarsal lid crease fibers from the levator aponeurosis to the skin (Fig. 12-2). Posterior dissection during postseptal fat removal may lead to levator damage as well. The septum may be sutured to levator during closure. If injury is noted at the time of surgery, it is corrected immediately.

Transient postoperative ptosis is typically due to mechanical restriction of levator action caused by eyelid edema. Postoperative hematomas, however, may lead to restricted levator function and subsequent fibrosis, leading to permanent levator function deficits. Therefore, if ptosis first presents 2 weeks postoperatively, it is monitored over 3 months for spontaneous resolution.

Management of postoperative ptosis requires evaluation of the type and degree of ptosis present, which will guide surgical intervention. Pertinent history includes age and timing of onset, prior eyelid or periocular trauma or surgery, swelling, contact lens use, and presence of other ocular, systemic, neurologic, or muscular symptoms. Examination of eyelid function involves measurement of palpebral fissures in primary gaze, margin-reflex distance, and levator function. Levator advancement is the procedure of choice in most cases with moderate to severe ptosis, abnormal or poorly formed eyelid creases, or minimal improvement with Neo-Synephrine testing. As an alternative, a posterior approach such as a Müller muscle resection is ideal in cases with ptosis with positive neosynephrine test and normal eyelid creases.