24.1 Introduction

Many patients who present for upper blepharoplasty have ptosis that may or may not be evident to the patient. Usually, the ptosis is minimal (2 mm or less) and the levator excursion is within normal limits (>10 mm). When performing blepharoplasty, there are various methods for simultaneous ptosis repair, including Müller’s muscle–conjunctival resection (MMCR), Fasanella–Servat, or levator aponeurotic repair.

24.2 Clinical Evaluation and Indications for Surgery

The initial exam should evaluate visual acuity, ocular surface health, presence or absence of dry eye, extraocular motility, and the anterior segment. Brow position, amount of dermatochalasis, and distribution of herniated orbital fat should be noted. The margin reflex distance 1 (MRD1) should be assessed. Levator excursion, Bell’s phenomenon, amount of lagophthalmos, and degree of lower lid laxity are also documented. Though not uniformly performed during the upper eyelid ptosis consultation, the margin reflex distance 2 often provides helpful information to the oculoplastic surgeon.

After the initial assessment outlined above, a phenylephrine test is performed on patients undergoing evaluation for ptosis correction. A drop of phenylephrine is placed on the ocular surface of the ptotic eye or eyes. It is important to document an MRD1 prior to drop installation. The patient is reexamined 5 minutes after installation of phenylephrine, and the MRD1 is documented in both eyes. An elevation of 2 mm or more in the medicated eye is considered a positive response and indicates that an MMCR is a good option for ptosis repair. A negative phenylephrine test indicates that an MMCR is not viable, and the patient would be better served with either a Fasanella–Servat procedure or levator repair. In the case of a negative phenylephrine test, the Fasanella–Servat procedure is a good option if the amount of ptosis is 2.5 mm or less on each side. If the ptosis is greater than 2.5 mm or the ptosis is exceedingly asymmetric, levator repair is preferable.

Though ptosis is often bilateral, there are cases in which the ptosis initially appears unilaterally. In these patients, a positive phenylephrine test in the ptotic eye may induce a contralateral ptosis in the fellow eye due to Hering’s law of equal innervation. The development of contralateral ptosis should be assessed and documented. Consideration should be given to bilateral repair in these instances, and the type of surgical procedure and amount of correction should be determined according to previously discussed algorithms.

It is important to consider patient age and ability to cooperate intraoperatively. A poorly cooperative patient would not be an ideal candidate for levator repair, as this is best done with the patient’s cooperation under local or monitored anesthesia care. Patients who desire general anesthesia are better served with an MMCR or Fasanella–Servat combined with upper blepharoplasty as these procedures require no intraoperative patient cooperation.

24.3 Combined Müller’s Muscle–Conjunctival Resection and Blepharoplasty

This procedure can be performed under local, monitored, or general anesthesia. No patient cooperation is required. The amount of Müller’s muscle and conjunctiva to resect is determined according to standard nomograms (see Chapter 21), and no adjustment is made when performed in conjunction with blepharoplasty. Prior to administering anesthesia, the pupillary axis is marked on the upper eyelid with the patient in a seated position. The amount of skin to be resected is marked. Local anesthesia is injected. The order of repair is arbitrary; we prefer performing the MMCR first. The procedure is performed in a standard fashion (see Chapter 21). The blepharoplasty is best performed as a skin-only excision, preserving the underlying orbicularis muscle. The medial and central fat pads can be accessed through a medial buttonhole. Care must be taken not to cut the MMCR suture when performing the upper blepharoplasty. No patch is necessary postoperatively.

24.4 Combined Fasanella–Servat and Blepharoplasty

This procedure can also be performed under local, monitored, or general anesthesia. No patient cooperation is required. The amount of tarsus to resect is determined according to standard nomograms (see Chapter 23), and no adjustment is made when performed in conjunction with blepharoplasty. The eyelids are marked as previously described. The Fasanella is performed in a standard fashion and can be performed prior to or after the blepharoplasty (see Chapter 23). We prefer performing the Fasanella first. During blepharoplasty, again, the orbicularis muscle is preserved to avoid dry eye and allow for adequate eyelid closure. Care must be taken not to cut the Fasanella suture. No patch is necessary postoperatively.