Keynote lecture at the European Academy of Facial Plastic Surgery on Ptosis Repair with Cosmetic Blepharoplasty

Keynote Lecture on Blepharoplasty with Ptosis Repair

Years ago in a letter to the New York Times I described the important relationship between aesthetic and reconstructive surgery. A solid experience in reconstruction is crucial to providing safe, optimal outcomes in aesthetic procedures. Within facial plastic surgery this is most essential in rhinoplasty (nose) and blepharoplasty (eyelid) surgery. Last week at the European Academy of Facial Plastic Surgery meeting in Amsterdam I was honored to present a Keynote Lecture on Blepharoplasty with Ptosis Repair combining a complex reconstructive procedure with our most common cosmetic procedure. I first published on this topic exactly 30 years ago and while much as changed the basic requirements remain the same- a clear understanding of the anatomy and a precise technique. I had the honor of studying with Mr. Richard Collin (a good “mate” of my mentor and friend Tony Bull) at the Moorfields Eye Hospital in London where I learned the complexities of the procedure.

Simply put, ptosis is when the eyelid margin is too low with respect to the light reflex of the pupil (MRD1). When one evaluates a patient, especially an older one, for excess skin/fat of the upper lids it is not uncommon to find an associated ptosis. Due to the way the eyelids are innervated (Herings Reflex) a ptosis on one side causes and elevation of the lid on the opposite side; therefore, what appears to be a normal opposite lid may harbor an undetected ptosis. There are many causes of ptosis but mostly in our context it is caused by a separation of the tendon (aponeurosis) of the levator muscle that lifts the lid from its eyelid attachment (tarsus). Repair at the time of blepharoplasty is straightforward in that the aponeurosis is reattached to the tarsus but there are many variables which require experience and judgment such as the amount of local anesthesia with adrenaline injected, the patient’s level of sedation, the precision of the surgery and more. With experience these factors can be considered to obtain a good lid height with a smooth contour and arch. An advancement in recent years has been the minimal incision blepharoplasty with a predetermined amount of aponeurosis to excise based on the preoperative measurements and goals. My good friend Bryan Sires from Seattle has describe this procedure well.

As more and more patients seek aesthetic eyelid surgery it is essential for surgeons to understand the functional aspects and how to combine reconstructive and cosmetic goals. In my own surgical practice I have been fortunate to learn from my colleagues in the UK and oculoplastic surgeons in the US.