14.1 Introduction

The recognition of ptosis in the postoperative period after cosmetic blepharoplasty may present an unwelcome finding for patients and surgeons.

Incidence data are lacking but qualitatively the phenomenon has been described as common; thus, a preemptive avoidance strategy, alongside a repertoire of corrective techniques, is likely to be worthwhile. A previously unrecognized ptosis should still prompt careful ophthalmic examination, including pupil and motility, to exclude a new-onset neurogenic cause for a ptosis such as a Horner’s syndrome.

Upper lid dermatochalasis warranting blepharoplasty rarely manifests in absolute isolation to other periocular involutional changes. The aesthetic continuums of the eyebrow and eyelid both influence the lid margin position and degree of dermatochalasis, so each must be evaluated prior to blepharoplasty. The detection of a small concurrent brow or eyelid ptosis prior to blepharoplasty, even if not considered clinically significant to initially require surgery, warrants discussion with the patient at the outset.

Should ptosis be subsequently recognized postoperatively, the contribution of eyebrow, eyelid, and involutional skin changes must be reassessed in order to correctly target a surgical solution.

14.2 Prevention

“An ounce of prevention is worth a pound of cure” offers an applicable adage to focus our initial attention on preventable causes.

Prevention involves both the preoperative assessment, to exclude brow or eyelid pathology that would benefit from concurrent correction alongside upper lid blepharoplasty surgery, and surgical techniques, to avoid exacerbating or introducing an iatrogenic ptosis.

14.2.1 Preoperative Prevention

At initial assessment, the surgeon should be aware of previous procedures and concurrent aesthetic interventions, such as recent botulinum toxin, especially where designed to elevate the brow position, thus masking an underlying ptotic brow.

In our experience, at least two preoperative assessment visits are preferred, both for the patient’s preparation and to give the surgeon more than one opportunity to detect subtle pathology, analyze photographs from the previous clinical visit, and discuss patient expectations.

Preoperative photographs allow static preoperative clinical scrutiny and provide a medical record (Fig. 14-1). A standardized photographic system described by Coombes et al, and utilized in our practice, improves objectivity and also opposes frontalis overaction, helping assess the contribution of the brow to upper lid dermatochalasis.

14.3 Brow Stability

Involutional brow descent, especially laterally, is a classically cited aging characteristic. The temporal fusion line of the forehead marks an attenuation of the frontalis muscle, the primary brow elevator. The lateral orbicularis oculi coupled with involutional tissue descent can thus act to depress the brow with limited opposition lateral to the temporal fusion line.

Although some authors have shown limited or no postblepharoplasty brow descent, a series from Prado et al, including 45 patients, used quantitative pre- and postoperative digital analysis to demonstrate consistent lateral brow descent after upper lid blepharoplasty. Our preference to promote lateral brow stability is to excise a strip of orbicularis that is much broader laterally, described by Widgerow as an “orbicularis wedge” (Fig. 14-2). This deliberately weakens the lateral brow depressive forces, promoting a neutral or potentially elevated postoperative lateral brow.