25.1 Introduction

Floppy eyelid syndrome (FES), initially described in 1981, ¹ is characterized by chronic eye irritation due to increased laxity of the eyelids that can be easily everted by applying minimal traction (Fig. 25.1). The etiology of FES is multifactorial with depletion of elastin fibers and upregulation of matrix metalloproteinases. ² The superior tarsus is flaccid, malleable, rubbery, and easily everted, especially in the temporal area. Aponeurotic blepharoptosis, eyelash ptosis, and entropion or ectropion are commonly found causing visual obstruction and ocular irritation (itching, redness, mucous discharge, foreign body sensation, and photosensitivity). FES is associated with obstructive sleep apnea (OSA), obesity, papillary conjunctivitis, and keratoconus. ³ Sleep apnea evaluation is warranted in patients with FES due to the morbidity and mortality associated with OSA.

In mild cases, FES is most often treated with topical agents such as artificial tears and lubricating ointment at bedtime combined with eyelid shielding or taping.⁴ In moderate cases, conservative treatment can be combined with an eyelid tightening procedure with a full-thickness wedge resection. Severe cases of FES often require multiple procedures, including full-thickness wedge resection, aponeurotic advancement, and eyelash ptosis repair. Full-thickness wedge resection alone may correct horizontal eyelid laxity, eyelid ptosis, and eyelash ptosis.

With progressive symptoms, multiple surgical strategies are used to address eyelid laxity and blepharoptosis with good short-term success rates but some tendency to relapse over months to years. Surgical correction of blepharoptosis or horizontal lid tightening alone may be not successful if not combined. For 24 years, the senior author has treated this condition by combining upper lid tightening at the canthal angle with upper eyelid ptosis repair. Horizontal laxity is addressed by lateral shortening and reinserting the lateral canthal tendon to the orbital rim. Aponeurotic ptosis is corrected with anterior levator advancement/reinsertion. Eyelash ptosis is corrected by rotational crease fixation sutures.

25.2 Goals of Intervention/Indications

• 
  

  Elevate eyelid to improve visual obstruction due to ptosis.

  
  
• 
  

  Decrease ocular irritation and discomfort due to FES.

  
  
• 
  

  Relief from eyelid taping and patching at bedtime.

25.3 Informed Consent

• 
  

  Include risks and benefits (as above).

  
  
• 
  

  Discussion of need for revision surgery due to recurrence, undercorrection, or overcorrection. Overcorrection is extremely rare.

25.4 Contraindications

• 
  

  Medical status precluding surgery.