• Primary goal: Elevation of a drooping (not baggy) upper eyelid
• Secondary goals: (May be performed in conjunction with blepharoplasty)
• Special anatomy: Review: The levator muscle begins in back of the eye and turns into a tendon (the aponeurosis) as it enters the eyelid. Most cases of adult-onset ptosis are the result of thinning or tearing of the levator aponeurosis. Less commonly, rare muscle diseases such as myasthenia gravis may cause the muscle itself to become paralyzed (requiring far different operations from those discussed here.)
• Anesthesia: Local anesthesia with minimal sedation is mandatory to allow for active patient cooperation during surgery
• Operative technique: Through an upper eyelid crease skin incision, the blepharoplasty is carried out as described above to the point through and including the removal of fat. Now on good display, the levator aponeurosis can be inspected by the surgeon (surgery photos). The aponeurosis is "tucked" using non-dissolving sutures. The surgeon must be careful not only to create a smooth lift for the droopy lid, but also to match the one upper eyelid to the other upper eyelid and to restore the normal curve to the lid margin (which becomes flattened with ptosis).
• Variations: Less commonly and at the option of the surgeon, ptosis may also be repaired by several different operations performed from the back side of the eyelid ("Müller's muscle-conjunctival resection" and "Fasanella-Servat procedure") in conjunction with blepharoplasty from the normal skin approach. While such posterior approaches work well in ptosis repair performed as an isolated procedure, the advantage of using these less precise operations in lieu of a direct levator tuck once the eyelid is open is hard to appreciate.
• Advantages: If a patient suffers from a combination of both baggy eyelids and drooping eyelids (ptosis) yet only the bagginess is addressed, the final result will be disappointing.
• Limitations: Ptosis repair does not interfere with blepharoplasty surgery but may prolong recovery. Because the tissue being operated upon is defective, the reoperation rate is higher than with cosmetic blepharoplasty and is about 1 in 6 per eyelid.
• Care and recovery: As described in Section Four. In addition, the upper eyelid may not fully "express" the lift until all of the internal inflammation has disappeared. In most cases, it takes about three to six weeks for the effect of a ptosis repair to become fully apparent, but longer recovery periods (3-6 months) may be experienced. For this reason, the decision to reoperate should not be made prematurely.
• Risks and complications: See Chapter 28: Blepharoplasty Risks - Complications. In addition, ptosis repair may be complicated by overcorrection and undercorrection, irregularities of lid shape, and asymmetry between the two sides.
• Comments: Ptosis repair is a delicate and very precise operation, and any surgical shortcomings will be readily visible For this reason, many patients with ptosis choose to have their combined blepharoplasty-ptosis repairs performed by surgeons specializing in both cosmetic and corrective eyelid surgery.
• Photos
