36.1 Introduction

Over the course of a career, ptosis revision is unavoidable. While there are no definitive data on the incidence of ptosis reoperation, Bernice Brown surveyed expert eye plastic surgeons and found the rate of revision to be between 12 and 18%. ¹ The goal of this surgery is to provide eyelid symmetry with adequate eye protection to the unhappy patient.

Depending on the ptosis type, the appropriate method of surgical correction may vary (Table 36.1). In eyelids that have consecutive eyelid retraction (overcorrection), recession of the levator may be performed. In the patient who has not had many eyelid surgeries with minimal middle lamellar scarring, revision ptosis surgery can be performed through an anterior or posterior approach. ² ID#b292a160_3 ^– ID#b292a160_4 ID#b292a160_5 ID#b292a160_6 ⁷

This chapter focuses on ptosis reoperation in patients who are undercorrected, and in whom multiple eyelid surgeries has resulted in significant full-thickness scarring. Frequently, the anterior, middle, and posterior lamellar layers are scarred-down. The levator muscle and aponeurosis and Müller’s muscle may be difficult to identify. In this type of blepharoptosis revision surgery, segmental tarsectomy offers a reliable, reproducible result for minimal to moderate eyelid height and contour deformities. ⁴ ID#b292a160_5 ^– ID#b292a160_6 ⁷

36.2 Anatomical Considerations

In an eyelid that has had many previous surgeries with removal of skin, subcutaneous tissue, muscle, and orbital fat in conjunction with levator advancement or Müller’s muscle conjunctiva resection, it may be difficult to separate the eyelid layers. Scar tissue may exist between anterior, middle, and posterior lamellae. In these eyelids, it is nearly impossible to re-advance the levator and correct eyelid height deficiencies. Posterior approaches tend to be more effective. Gladstone, Bassin, and Putterman have described a posterior approach to address contour abnormalities. ^{5 ,​ 6} Reoperation with Fasanella-Servat has also been described. ^{7 ,​ 8} Here, I discuss segmental tarsal resection, first described by Henry Baylis, ⁴ and historically employed in primary blepharoptosis surgery. ^{9 ,​ 10}