Upper Blepharoplasty and Aponeurotic Ptosis Repair
John B. Holds
INTRODUCTION
Blepharoplasty surgery is the central component of any midfacial restoration or rejuvenation. The procedure is often combined with brow lift surgery, ptosis repair, or other facial aesthetic procedures to enhance or achieve an appropriate aesthetic result. Upper eyelid blepharoplasty is also performed for aesthetic reasons to reduce and redrape excess skin, redefine the eyelid crease and supratarsal platform, and decrease overall fullness. In comparison, ptosis repair is a finely tuned and challenging surgical procedure that requires correct diagnosis, thoughtful planning, impeccable surgical technique, experience, and a thorough understanding of the anatomy of the eyelid. The patient’s ocular, medical, and surgical history help determine whether surgical repair of ptosis is appropriate for that individual.
Ptosis or blepharoptosis is an abnormal sagging of the upper eyelid margin. The vast majority of cases of acquired ptosis are due to a dehiscence of the levator aponeurosis. Nevertheless, the causes of acquired ptosis are diverse, and it is helpful in evaluation and treatment to classify acquired ptosis into the following: aponeurogenic, from involutional or other disinsertional changes in the levator aponeurosis; myogenic, associated with decreased levator muscle function, as seen in myasthenia gravis (MG) or congenital progressive external ophthalmoplegia (CPEO); neurogenic, as seen in third nerve palsy or Horner’s syndrome; and mechanical, associated with eyelid masses or scarring of the eyelid lamellae. Traumatic ptosis, sometimes considered a separate category, is more properly a subcategory of each of the foregoing categories.
Ptosis that causes significant superior visual field loss or difficulty with reading is considered to be a functional problem, and correction of this defect often improves a patient’s ability to perform the activities of daily living. Ptosis is considered to be a cosmetic issue when it causes a tired or sleepy appearance in the absence of a significant visual function deficit. It is particularly important for the surgeon to have a preoperative discussion with the patient to communicate the alternatives, potential risks, and benefits of surgery.
HISTORY
In evaluating the patient for upper blepharoplasty and/or ptosis repair, it is important to consider the patient’s goals and desires. An older patient with visual obstruction symptoms and no cosmetic desires is a very different patient from the patient who wants a cosmetic blepharoplasty. Both upper blepharoplasty and ptosis repair are sometimes deemed “medically necessary” as a covered service by insurance companies to decrease overhanging skin and improve superior visual fields. Patients pursuing blepharoplasty surgery should report their perception of issues including overhanging skin, prolapse of adipose tissue, and other facial aesthetic issues. All patients having eyelid surgery should be questioned about their coagulation status. Other pertinent historical queries should include the presence of thyroid eye disease, previous eye or eyelid surgery, and prior periorbital
trauma. Complaints about dry eye seldom present an absolute contraindication to upper eyelid surgery but require additional assessment, counseling, and modification of surgical technique. All patients should be queried regarding dry eye symptoms as well as other ocular history and complaints.
trauma. Complaints about dry eye seldom present an absolute contraindication to upper eyelid surgery but require additional assessment, counseling, and modification of surgical technique. All patients should be queried regarding dry eye symptoms as well as other ocular history and complaints.
In the patient with ptosis, one must begin with a careful history, with attention to duration and progression of ptosis, daily variation in the severity of ptosis, use of contact lenses, and any history of dry eye. The patient’s history usually distinguishes congenital from acquired ptosis. Patients with congenital or acquired blepharoptosis may be aware of a family history of the condition. Marked variability in the degree of ptosis during the day and complaints of diplopia should trigger an evaluation for ocular MG.
PHYSICAL EXAMINATION
Eyebrow position is very important, as most prospective patients considering upper blepharoplasty have some degree of brow ptosis and might benefit from a brow lift. Brow ptosis commonly worsens somewhat following blepharoplasty surgery. Attempt to define how blepharoplasty and/or brow lifting will appear postoperatively and proceed with acknowledgment from the patient of the expected outcome. Blepharoptosis or ptosis is common in patients presenting for blepharoplasty and often requires concomitant repair.
Preoperative counseling must realistically inform the patient of the ability of surgery to modify all of these features as well as the risk of more common complications. Evaluation of the patient presenting for eyelid surgery should, if possible, include a slitlamp examination. A careful reporting of ocular and dry eye symptoms along with notations regarding eyelid position and function are a basic minimum. A basic Schirmer’s secretion test (after anesthetic) is simple to perform and may be worthwhile to document. In preoperative examination and counseling, it is helpful to demonstrate to the patient with a mirror the degree to which the surgeon believes overhanging skin will be improved with blepharoplasty surgery (or worsened with ptosis repair without blepharoplasty surgery) and to note and point to adipose tissue pads that can be reduced. The limits of upper blepharoplasty are stressed, especially in regard to medial and lateral skin redundancy, which is often noted postoperatively and commonly requires a brow lift to improve. Patients undergoing surgery for medical indications require specific documentation of visual complaints, a desire for surgery, and reversible superior visual field loss on standardized perimetry. All patients must have facial photography with multiple views.
Physical examination of the patient with ptosis includes five clinical measurements. Although it is ideal to record these numbers in all patients considering blepharoplasty, these are critical measurements in evaluating the patient with ptosis:
Margin reflex distance
Vertical palpebral fissure height
Position of the upper eyelid crease
Levator function (upper eyelid excursion)
Presence of lagophthalmos
The physician can record these data by using a drawing showing the cornea, the pupil size, and the position of the upper and lower eyelids in relation to these structures (Fig. 1.1). The margin reflex distance (MRD1) is the distance from the upper eyelid margin to the corneal light reflex from a penlight held at the level of the examiner’s eye on which the patient is fixating in primary position. MRD1 is single most important measurement in describing the amount or severity of a ptosis. In severe ptosis, the light reflex may be obstructed by the eyelid and therefore have a zero or negative value. Retraction of the lower eyelid (scleral show) should be noted separately as the margin reflex distance 2 (MRD2). The MRD2 is the distance from the corneal light reflex to the lower eyelid margin. The sum of the MRD1 and the MRD2 should equal the vertical height of the interpalpebral fissure.
 FIGURE 1.1 Important measurements in ptosis surgery: MRD1, margin reflex distance 1 from papillary light reflex to the upper eyelid margin; MRD2, margin reflex distance 2 from papillary light reflex to the lower eyelid margin; PF, palpebral fissure, sum of MRD1 and MRD2; LC, eyelid crease, often measured in downgaze, as overhanging upper eyelid skin may cover the true eyelid crease. |
The distance from the upper eyelid crease to the eyelid margin is measured. Because the insertion of fibers from the levator muscle into the skin contributes to formation of the upper eyelid crease, high, duplicated, or asymmetric creases may indicate an abnormal position of the levator aponeurosis. In the typical Caucasian eyelid, the upper eyelid crease is 8 to 9 mm in males and 9 to 11 mm in females. The crease is usually elevated in patients with involutional ptosis and is often shallow or absent in patients with congenital ptosis. The upper eyelid crease is lower or obscured in the Asian eyelid, with or without ptosis. Levator function is estimated by measuring the upper eyelid excursion from downgaze to upgaze with frontalis muscle function negated. Finally, the patient should be evaluated for lagophthalmos.
Clinical features of a patient with acquired aponeurosis disinsertion consist of good levator function, higher than normal eyelid crease, and a ptotic eyelid that assumes a lower position on down gaze. If a history consistent with MG is obtained, tests for fatigability as well as an edrophonium (tensilon or enlon) test should be performed. The examiner should be cognizant of the frequency of bilateral ptosis that is more apparent on one side. Because of the equal innervation to both levator muscles, correcting only one upper lid may result in worsening the appearance of ptosis on the opposite side. This phenomenon follows Hering’s law and is especially frequent in aponeurogenic ptosis.
INDICATIONS
Upper eyelid blepharoplasty indications
Reduce the overhanging skin causing visual obstruction or cosmesis
Define the supratarsal fold and eyelid crease
Smooth contour and reduce prolapsed adipose tissue
Lid ptosis, secondary to aponeurosis compromise
Raise the eyelid margin to a visually functional position
Correct asymmetry of the lid height
Improve symmetry of the eyelid crease and supratarsal fold
If blepharoplasty or ptosis repair is being performed for functional indications, it is vital to document the severity of ptosis with office notes and measurements, facial photographs, and formal visual field testing, showing the superior visual field constriction produced by the ptosis. It is also helpful to have photographs and notes available for reference at the time of surgery. After trauma, it is prudent to wait 6 months before eyelid surgery, as function may improve during that time. In MG, or any medical or neurologic condition that may undergo remission with therapy, it is wise to delay surgery until the condition is stable and optimally controlled.
CONTRAINDICATIONS
Surgical contraindications in upper eyelid surgery include the patient with inappropriate expectations, medically unstable patients including patients with recent (within 6 months) placement of a heart stent whose anticoagulation cannot be held for any period of time, and prior surgery and co-existing medical or ocular conditions that create unnecessary and unacceptable surgical risk. Dry eye syndrome or the patient prone to exposure keratopathy due to impaired protective mechanisms must be seen as relative or absolute contraindications to blepharoplasty and/or ptosis repair, depending on the severity of the clinical findings and the indication for surgery.
PREOPERATIVE PLANNING
Patients should discontinue aspirin and other anticoagulants, herbal medications, and antiplatelet agents 3 to 7 days preoperatively. This is best done in consultation with the patient’s primary care physician and offers an excellent opportunity to ensure that no acute or chronic medical condition poses an issue with surgery. The vast majority of patients undergoing blepharoplasty or ptosis surgery can be done under a local or sedated local anesthetic. Four lid blepharoplasty or additional procedures, such as brow or face lift, may require a general anesthetic.
SURGICAL TECHNIQUE
Upper Blepharoplasty
With the patient sitting upright, mark the incision with a fine-tipped surgical marker before entering the operating room. The eyelid crease is first marked, extending medially and laterally. An appropriate amount of skin
for excision is then marked. Asymmetry in the amount of overhanging skin or the total amount of upper eyelid skin are more apparent with the patient upright and can be compensated with asymmetric excision. If brow lift surgery is to be performed, one should first perform the brow lift and then recheck the blepharoplasty excision intraoperatively after the brow lift to ensure excessive excision is not performed. Use the patient’s natural eyelid crease to guide the positioning of the lid crease incision. The highest point in the central eyelid is generally at 8 to 11 mm height near the nasal aspect of the pupil (Fig. 1.2). The patient’s desires also guide positioning of the lid crease, with the female crease generally 1 to 2 mm higher than the male crease. After marking the highest point in the eyelid crease centrally, a smooth downward curve is made to 4 to 5 mm above the upper punctum medially and 5 to 7 mm above the lateral canthal angle. Medial to the medial mark a smooth upward curve may be made, never extending medial to the canthal angle. Laterally, the incision never extends beyond the orbital rim where the skin thickens 12 to 16 mm lateral to the canthal angle. Amounts of skin for excision vary from a few mm up to 2 cm vertically. If attempting to maximize the effect of blepharoplasty, a good guide is to ensure that at least 20 mm of skin (pretarsal plus infrabrow vertical extent) remains postoperatively between the lashes and the inferior aspect of the eyebrow. Marks can be made 10 to 15 mm inferior to the inferior aspect of the brow laterally, smoothly tapering toward the medial and lateral ends of the lid crease incision. It is reasonable to use a smooth forceps to gently pinch together the skin proposed for excision. A slight degree of induced lagophthalmos and eversion of the lashes when gently pinching the eyelid skin together is generally desirable, and a significant degree of lagophthalmos suggests an overly aggressive excision.
for excision is then marked. Asymmetry in the amount of overhanging skin or the total amount of upper eyelid skin are more apparent with the patient upright and can be compensated with asymmetric excision. If brow lift surgery is to be performed, one should first perform the brow lift and then recheck the blepharoplasty excision intraoperatively after the brow lift to ensure excessive excision is not performed. Use the patient’s natural eyelid crease to guide the positioning of the lid crease incision. The highest point in the central eyelid is generally at 8 to 11 mm height near the nasal aspect of the pupil (Fig. 1.2). The patient’s desires also guide positioning of the lid crease, with the female crease generally 1 to 2 mm higher than the male crease. After marking the highest point in the eyelid crease centrally, a smooth downward curve is made to 4 to 5 mm above the upper punctum medially and 5 to 7 mm above the lateral canthal angle. Medial to the medial mark a smooth upward curve may be made, never extending medial to the canthal angle. Laterally, the incision never extends beyond the orbital rim where the skin thickens 12 to 16 mm lateral to the canthal angle. Amounts of skin for excision vary from a few mm up to 2 cm vertically. If attempting to maximize the effect of blepharoplasty, a good guide is to ensure that at least 20 mm of skin (pretarsal plus infrabrow vertical extent) remains postoperatively between the lashes and the inferior aspect of the eyebrow. Marks can be made 10 to 15 mm inferior to the inferior aspect of the brow laterally, smoothly tapering toward the medial and lateral ends of the lid crease incision. It is reasonable to use a smooth forceps to gently pinch together the skin proposed for excision. A slight degree of induced lagophthalmos and eversion of the lashes when gently pinching the eyelid skin together is generally desirable, and a significant degree of lagophthalmos suggests an overly aggressive excision.
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