Focal

Points
Clinical Practice
™

Perspectives VO LU ME X X XV
N U MB ER 5
MAY 2 01 7

Surgical Management of Ptosis and

Brow Ptosis
Richard C. Allen, MD, PhD, FACS Clinicians’ Corner Consultants
Eric A. Cole, MD, FACS
Allan E. Wulc, MD, FACS
Focal Points Contents
Editorial Review Board
Eric P. Purdy, MD, Bluffton, IN
Editor-in-Chief; Oculoplastic, Lacrimal, and Orbital Surgery Introduction 1
Lisa B. Arbisser, MD, Sarasota, FL
Cataract Surgery Dermatochalasis 1
Deeba Husain, MD, Boston, MA
Brow Ptosis 2
Retina and Vitreous
Katherine A. Lee, MD, PhD, Boise, ID Ptosis 7
Pediatric Ophthalmology and Strabismus
W. Barry Lee, MD, FACS, Atlanta, GA Congenital Ptosis 7
Refractive Surgery; Optics and Refraction
P. Kumar Rao, MD, St. Louis, MO
Ptosis in the Adult 10
Ocular Inflammation and Tumors
Conclusion 13
Sarwat Salim, MD, FACS, Milwaukee, WI
Glaucoma Podcast Discussions 13
Elmer Y. Tu, MD, Chicago, IL
Cornea and External Disease Clinicians’ Corner 14
Billi S. Wallace, MD, Smithville, MO
Neuro-Ophthalmology Suggested Reading 19

Education Secretaries and Staff

Louis B. Cantor, MD, Senior Secretary for Clinical Education
Christopher J. Rapuano, MD, Secretary for Lifelong Learning
and Assessment
Dale E. Fajardo, Vice President
Susan R. Keller, Acquisitions Editor
Kim Torgerson, Publications Editor
D. Jean Ray, Production Manager
Debra Marchi, Administrative Assistant

Reviewers and Contributing Editor

for This Module READ MORE This icon in text denotes additional
Eric P. Purdy, MD, Editor for Oculoplastic, Lacrimal, and ONLINE content accessible in your digital
Orbital Surgery module.

Christine C. Nelson, MD, Basic and Clinical Science Course To access videos or podcasts in selected modules,
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Committee for Education

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Financial Disclosures. Lisa B. Arbisser, MD:
(C) Bausch + Lomb (2014), Mynosys (2016),
Smart Vision Labs (2016, 2017); (C, O) Mynosys
(2017). Edward K. Isbey III, MD: (C) Allscripts,
Medflow (2015); (S) Alcon Laboratories, Bausch +
Lomb (2015). W. Barry Lee, MD, FACS: (C) Shire
(2015–2017); (L) Allergan (2015), Bausch + Lomb
(2014–2017), Bio-Tissue (2016). Eric P. Purdy, MD:
(L) Alcon Laboratories (2014). P. Kumar Rao, MD:
(S) Regeneron Pharmaceuticals (2017). Sarwat
Salim, MD, FACS: (L) Alcon Laboratories (2014).
Elmer Y. Tu, MD: (C) Seattle Genetics (2014–2016);
(S) Eversight (2017). Allan E. Wulc, MD, FACS: (C)
Galderma (2016, 2017); (O, P) Apogee Aesthetics
(2016, 2017).
The following contributors state that they have
no financial interest or other relationship with the
manufacturer of any commercial product discussed
in their contributions to this module or with the
manufacturer of any competing commercial product:
Lisa B. Arbisser, MD; Stephen R. Klapper, MD;
Christine C. Nelson, MD; James A. Savage, MD (2015).
Eric P. Purdy, MD; Sarwat Salim, MD, FACS (2015–2017).
Eric A. Cole, MD, FACS; Billi S. Wallace, MD (2016,
2017). Richard C. Allen, MD, PhD, FACS; Deeba
Husain, MD; Katherine A. Lee, MD, PhD; Kim
Torgerson (2014–2017).
C = consultant fees, paid advisory boards, or fees for
attending a meeting
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S = grant support or other financial support to the
investigator for all sources
Copyright ©2017 American Academy of
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publication may be reproduced without written
permission.
Learning Objectives
Upon completion of this module, the
reader should be able to:
1 
Name the steps in the evaluation of a
patient with dermatochalasis, ptosis,
and/or brow ptosis.
2 
Describe the surgical options available
for the treatment of brow ptosis.
3 
Describe the surgical options available
for the treatment of ptosis.
4 
Identify the surgical complications of
upper blepharoplasty, ptosis, and brow
ptosis procedures.
Introduction
Management of “droopy lids” constitutes a large part of
most oculoplastic surgeons’ practices. However, as straight-
forward as the concept may seem, “droopy lids” encompass
a large spectrum of possible etiologies and treatment
options. The goal of this module is to assist the oculoplastic
surgeon and the comprehensive ophthalmologist in
understanding the relationships connecting blepharoptosis
(ptosis), dermatochalasis, and brow ptosis, and in choosing
the most appropriate intervention for the patient.
Overall, the most common etiology of “droopy lids”
is age related: involutional changes encompass most issues
noted in brow ptosis, ptosis, and dermatochalasis. These
findings may coexist, and the treating physician needs to
recognize the relative contribution of each condition and
address the distinct anatomical findings in view of the
patient’s goals. Frequently, the contribution of one or more
of these conditions does not require surgical correction,
especially if one is much more severe than the other.
However, the physician must discuss with the patient the
main complaints and goals so that a satisfactory outcome
can be obtained. In addition, one must also be cognizant
of less common conditions that may require specific
treatment plans.
Dermatochalasis
Dermatochalasis refers to redundant skin and subcutane-
ous tissue in and around the eyelids, frequently the
upper eyelids. (Lower eyelid dermatochalasis is not a
subject of this module.) The evaluation of upper eyelid
dermatochalasis assesses the medial fat pad, preaponeurotic
fat, lacrimal gland, and associated structures, including
the eyelashes and eyebrows. Patients often note difficulty
with peripheral vision, skin draping onto the eyelashes,
“puffiness” or “swelling” of the upper eyelids, and cosmetic
concerns (eg, difficulty applying eyelid and eyelash
makeup). Dermatochalasis is usually symmetric and has a
gradual onset over several years. An onset over months or
significant asymmetry should raise clinical suspicion and
prompt further evaluation, particularly for any condition
that causes periorbital edema, such as thyroid eye disease.
Significant dermatochalasis typically presents after the fifth
decade. Earlier age of onset, especially with cyclic relapsing
and remitting episodes of periorbital edema, should raise
the suspicion of blepharochalasis syndrome, a rare familial
variant of angioneurotic edema.
Examination of the patient with upper eyelid dermato-
chalasis centers on the identification of the amount and type
of redundant tissue. The brow position should be determined
(see “Brow Ptosis”), and a ptotic brow, if present, should be
manually normalized to help determine the actual severity of
dermatochalasis. The distance from the upper eyelid margin
to the corneal light reflex—or margin–reflex distance 1
(MRD1)—should be documented to identify underlying
ptosis and to determine whether it is primary ptosis or
secondary to dermatochalasis or brow ptosis. The orbicularis
strength, eyelid closure, and status of the cornea and tear
film should be evaluated. Any patient with compromised
eyelid closure, severely dry eyes, or corneal disease should
be counseled about the possibility of a surgical procedure
causing or worsening dry eye symptoms. Functional versus
cosmetic concerns should be documented. Preauthorization
criteria for insurance are satisfied by preoperative examina-
tion, visual field testing, and photographs.
Upper Eyelid Blepharoplasty
Upper eyelid blepharoplasty is commonly used to correct
dermatochalasis, whether for cosmetic or functional
purposes. The surgical procedure has evolved over the
years. Currently, there is a trend toward excising skin only
and leaving underlying orbicularis (especially in younger
patients or patients predisposed to dry eye). Many surgeons
will excise the lateral orbicularis to aid in brow elevation,
similar to applying botulinum toxin to this area. There
is also a trend toward conserving preaponeurotic fat and
excising the medial fat pad. Any lacrimal gland prolapse
should be identified preoperatively, so that the gland can be
repositioned intraoperatively.
The procedure has many possible complications. Early
postoperative hemorrhage can be potentially blinding;
this is most common in patients with iatrogenic or innate
coagulation abnormalities and cases where there was fat
manipulation. Other potential complications include over-
correction, undercorrection, eyelid or crease asymmetry,
unsightly scar, dry eye, and infection. These are potential
complications of any of the surgical procedures discussed
Richard C. Allen, MD, PhD, FACS, is a professor, Department
of Head and Neck Surgery, Section of Ophthalmology, at MD
Anderson Cancer Center, in Houston, Texas.
Focal Points Module 5, 2017 1
in this module. One frequently overlooked complication of
upper blepharoplasty is brow depression; if skin is removed
below the brow, the brow will descend (Figure 1). This
descent may be ever so slight, but potentially noticeable.
This highlights the importance of recognizing brow ptosis
preoperatively and addressing brow malposition at the time
of blepharoplasty surgery. Video 1 demonstrates upper
blepharoplasty.
1. Upper Blepharoplasty
VIDEO
TECHNIQUE. Upper eyelid blepharoplasty involves mark-
ing the eyelid crease (or the proposed eyelid crease) and then
marking the amount of excess skin to be excised. A main
goal is symmetry—patients will notice asymmetry more
than they will undercorrection. For the beginning surgeon,
it is wise to tend toward being conservative. In general, one
should not necessarily excise the same amount of skin on
each side, as much as leave the same amount postoperatively,
because it is common for patients to start with some
asymmetry. A general rule for preparing a woman patient
for surgery is to mark an eyelid crease somewhere around
8–10 mm above the eyelid margin, and, for a man, 6–8 mm
above the margin. There should be adequate skin for closure,
and a general rule is to leave 20 mm of skin between the
a can result in varying degrees of brow ptosis, depending
b presence of lagophthalmos in many of these patients, as
Figure 1 ​Dermatochalasis. a. Preoperative
evaluation shows dermatochalasis with brow
descent. b. After upper blepharoplasty,
additional brow descent is noted.
2 Focal Points Module 5, 2017
eyelashes and the inferior eyebrow cilia. This can sometimes
be difficult to identify in patients who manicure their
brows, and the junction between thin eyelid skin and thick
eyebrow skin can be used in place of the inferior brow cilia.
The cutting instrument of the surgeon’s choice can be used,
including but not limited to a blade, monopolar cautery,
laser, and thermal cautery. Sutures and methods of closure
vary. Many surgeons prefer a running 6-0 monofilament
suture that is removed at a 1-week postoperative visit.
Brow Ptosis
Brow ptosis refers to a depression of the eyebrows, most
commonly from involutional changes. Brows are very
important: by looking only at someone’s brows, one can
often determine the person’s gender, age, and mood.
Typically, female brows are arched in contour, peaked more
laterally, and usually rest above the superior orbital rim.
Male brows tend to be flatter and often at or below the level
of the superior orbital rim. With age, the brows descend
due to gravity, involutional changes in the underlying
supportive structure, and loss of deep tissue volume. Often
the temporal portion of the brow is the first area to descend,
because the frontalis muscle does not extend lateral to the
temporal fusion line. Brow height can also be understood
by looking at the interplay between the brow elevators and
the brow depressors. The main brow elevator is the frontalis
muscle. Brow depressors include the corrugator, procerus,
depressor supraciliaris, and orbicularis muscles. The
strength and tension of these muscles should be determined
when examining the height and contour of the brows.
The diagnosis of brow ptosis can be challenging in
that brow heights vary between individuals. Even though
there are discussions on ideal brow height, some brows are
naturally higher in some individuals and lower in others;
examination of previous photos or photos of younger rela-
tives is often helpful (Figure 2), as familial characteristics play
an important role in an individual’s baseline brow position.
The most common cause of brow ptosis is age related.
However, a compromised seventh cranial nerve (CN VII)
on the severity of the palsy. Usually a CN VII palsy will be
unilateral; however, there are rare causes of bilateral CN VII
nerve palsies that can be difficult to diagnose, due to the
symmetry. Bilateral CN VII nerve palsies are associated
with other facial muscle weakness, so the evaluation of
brow ptosis should also include assessment of the facial
musculature. Other causes of bilateral brow ptosis include
progressive supranuclear palsy and various muscular
dystrophies. It is important to be aware of the concomitant
any upper eyelid or brow elevation surgery can worsen the
ocular exposure.
As with dermatochalasis, one should be vigilant of
dry eye preoperatively. A brow elevation procedure may
temporarily worsen existing eye dryness. When choosing

a b
Figure 2 ​Dermatochalasis. a. 65-year-old
woman shows upper eyelid dermatochalasis
and possible brow descent. b. Patient’s 32-year-
old daughter exhibits that the brow height
is normally low. This panel demonstrates
the usefulness of examining younger family
members to determine the normal anatomical
position of the brow. Much of what is seen in
part a is also related to deflation.
the appropriate procedure, the surgeon should have multiple
options, and treatment should be individualized to the patient.
Direct Browplasty
Direct browplasty (supraciliary browlift) delivers predict-
able results. This procedure is best for older patients who
have significant brow ptosis that is mostly temporal. In
addition, it is good for patients who want a simpler surgical
procedure and will be less bothered if the scar is noticeable
(Figure 3). In this procedure, an incision is made just above
the cilia of the brow, or above the brow in an advantageous
forehead crease. Extending the incision medially is difficult,
so this lift is best for temporal brow ptosis. Some believe it
is best for women, since an arched contour is attained with
the temporal incision, but men do well with the procedure,
and the resulting scar is easier to conceal due to the denser
hairs of the male brow. Although this is not thought to be
a cosmetic lift, the incisions may heal surprisingly well.
Video 2 demonstrates direct browplasty.
2. Direct Browplasty
VIDEO
TECHNIQUE. A marking is made above the brow or in
a good crease or furrow above it. The amount of brow
ptosis is determined by lifting the portion of the brow that
appears ptotic. The amount of needed brow elevation is
measured and a marking is made above the initial marking,
a
b
Figure 3 ​Patient before (a) and after (b) a direct
browplasty and upper blepharoplasty.
corresponding to the amount of ptosis needing to be cor-
rected. In general, it is uncommon to take much less than
10 mm and more than 15 mm, unless it is associated with a
CN VII palsy. The marking is incised with a #15 blade, and
the skin and subcutaneous fat are resected. Care should be
taken to avoid dissection around the supraorbital nerve. The
defect is then closed with deep interrupted 4-0 polyglactin
sutures, followed by a running 5-0 polyethylene suture.
Closure techniques and suture choices vary among surgeons.
Browpexy
A browpexy procedure “pushes” the brow superiorly. While
a browplasty lifts though the excision of tissue above the
brow (“pulling” the brow superiorly), a browpexy is usually
performed though a blepharoplasty incision, with dissection
to release the attachments of the brow and various manipu-
lations to alter the position of the brow. The popularity of
browpexy procedures waxes and wanes. The advent of the
transblepharoplasty Endotine device (Endotine TransBleph,
Advantech Surgical; Torquay, Devon, England) in the
early 2000s resulted in renewed interest in the procedure;
however, long-term results showed unimpressive amounts
of sustained brow elevation. The lack of standardization
and quantification, and the postoperative pain that patients
often noted associated with the device, was also discourag-
ing. The procedure seemed to be best suited for men who
had a smooth forehead, a high hairline, and an insignificant
amount of ptosis. Most surgeons appreciated the procedure
as a brow stabilizer, without significant lift. The introduc-
tion of the Ultratine TransBleph has lessened some of the
concerns regarding postoperative pain.
Focal Points Module 5, 2017 3
 Several years ago, the external browpexy was intro-
duced with some early enthusiasm. Some surgeons found
it difficult to pass the suture from an external incision
and were unimpressed with the results. It was perceived
that significant subcutaneous dissection was needed, as
well as elevation of the brow fat. The quantitated internal
suture browpexy, or a “chicken brassiere” technique, was
then developed. A “brassiere” suture attaches the superior
blepharoplasty incision to the periosteum of the superior
orbital rim. Some surgeons were reluctant to perform
this procedure, due to fears of lagophthalmos. A safer
modification of the internal browpexy suspends the deep
brow soft tissue (superior to the orbicularis oculi) to the
superior orbital rim periosteum in a controllable fashion,
allowing assessment and adjustment intraoperatively. This
can be performed with nonabsorbable suture (such as
polypropylene) in 1 or 2 broad mattress sutures to provide
more sustained brow stabilization.
This procedure seems to function well as a brow
stabilizer. Its use has decreased the number of endoscopic
browlifts in the hands of some surgeons. The ideal patient
for this procedure has minimal brow ptosis and will
undergo a concurrent blepharoplasty (Figure 4). Video 3
demonstrates an internal suture browpexy.
3. Internal Suture Browpexy
VIDEO
a should be identified and marked. Sometimes it is better and
b
Figure 4 ​Patient before (a) and after (b) a
transblepharoplasty internal suture browpexy
and upper blepharoplasty.
4 Focal Points Module 5, 2017
TECHNIQUE. Dissection is carried out along the surface of
the orbital septum to the superior orbital rim, then carried
out in a preperiosteal fashion above the superior orbital rim
for 15–20 mm. This dissection is lateral to the supraorbital
neurovascular bundle and extends laterally to the lateral
orbital rim. A 4-0 polyglactin suture is used to engage the
periosteum 12–15 mm superior to the superior orbital
rim at the level of the peak of the brow. This suture then
engages the soft tissue (usually the brow fat) superior to
the superior edge of the blepharoplasty incision, the same
amount as was measured from the superior orbital rim to
the preperiosteal pass. This essentially places the superior
edge of the blepharoplasty incision near the superior orbital
rim. After the internal browpexy has been completed, the
blepharoplasty incision is closed in a typical fashion.
Indirect Browplasty/Mid-Forehead Lift
The indirect browplasty (mid-forehead lift) is an option
for some patients with significant medial brow ptosis and
a deep furrow in the forehead that is replaced with a less
noticeable scar. At present, the procedure is less frequently
performed, but some patients are good candidates. The
patient must realize that there may be a noticeable scar
across the middle of the forehead.
The procedure is predictable, can lift the entire brow,
and can be performed under minimal anesthesia. Patients
should have significant furrows in which the scar can be
hidden. This procedure should usually be reserved for men,
as many women will not accept the forehead scar. Wearing
bangs across the forehead can help mask the scar. Video 4
demonstrates the procedure.
4. Mid-Forehead Browplasty
VIDEO
TECHNIQUE. The amount of lift that is needed is
determined medially and laterally. The supraorbital and
supratrochlear nerves are marked. A good forehead crease
less noticeable to use different creases on each side of the
forehead that do not connect centrally. This breaks up the
scar and may make it less noticeable. Ideally, an additional
parallel crease above the first one that is marked can be
used for the second marking. This then turns 2 creases into
1 scar. The area is anesthetized, and incisions are made with
a blade along the markings. Extending the incision deeper
than the subcutaneous fat may result in paralysis of por-
tions of the frontalis muscle. Dissection should be avoided
laterally in the normal anatomical location of CN VII or
medially around the supraorbital nerve. There may be
loss of some sensation above the incisions; however, this
typically is recovered over 6 months. The resulting defect is
then closed with deep 4-0 polyglactin sutures, followed by
5-0 polypropylene sutures in the skin.
Pretrichial Browplasty
The pretrichial browlift is a very effective procedure that
can elevate the entire brow. It is best reserved for women
who have elevated hairlines, wear bangs, and will not be
bothered by loss of sensation above the incision. Hypes-
thesia is temporary in most patients and scalp sensation
typically returns in 4–6 months, but may be permanent in
some patients. This lift is in between a mid-forehead lift and
a coronal lift. An incision is made at the hairline, following
its contour.
The scar of the pretrichial incision will heal well with
time (Figure 5). It will not be optimal for the first month
or so, but it is almost imperceptible later. Patients should
be counseled that they will need to cover the scar with
their bangs or with makeup. This procedure will lower the
hairline. Video 5 demonstrates pretrichial browplasty.
5. Pretrichial Browplasty
VIDEO
TECHNIQUE. A marking is made at the hairline, extending
laterally beyond the temporal fusion line. An incision is
made along the marking in a saw-tooth manner to hide a
linear scar. Dissection is then carried out in the subgaleal/
preperiosteal plane medial to the temporal fusion line to
a level 2 cm above the superior orbital rim. Below this
level, the dissection continues subperiosteal to the superior
orbital rim to release the attachments of the brow to the
a b
c d
orbital rim and expose the supraorbital neurovascular
bundle. Lateral to the temporal fusion line, dissection
is carried out along the surface of the deep temporalis
fascia. The temporal fusion line is then lysed between the
medial and lateral dissections. This results in the forehead
being completely mobile. The brows are elevated, and the
overlapping soft tissue at the incision is marked. This will
usually measure at least 15 mm but not much more than
20 mm. The soft tissue is then excised, and the resulting
defect is closed with deep interrupted 4-0 polyglactin
sutures, followed by interrupted 5-0 polyethylene sutures
in a vertical mattress fashion. A dressing is placed around
the head using a gauze bandage roll followed by an elastic
self-adhering dressing. This dressing should not be too
tight, as there have been reports of scalp necrosis due to
overzealous dressings.
Endoscopic Small-Incision Browplasty
The endoscopic small-incision browplasty was developed
to give a result like a coronal lift, but without the excision
extending ear-to-ear across the top of the head. It is
currently the most popular cosmetic lift. Because it is not
as strong as the coronal lift, it should be considered a less
effective and somewhat temporary solution.
This lift works best on women with a thin scalp. The
thicker the forehead and scalp, the less the effect from
this lift. A direct, pretrichial, or coronal browplasty would
usually best serve a patient with more severe brow ptosis.
The advantages of this lift are that the incisions are small
and the patients heal quickly. The disadvantages are that it
will raise the hairline and is not as effective as the incisional
Figure 5 ​Patient before
(a) and 8 months after
(b) a pretrichial browplasty
with upper eyelid
blepharoplasty and ptosis
repair (Müller muscle–
conjunctival resection).
c, d. Appearance of the scar
1 month and 8 months after
surgery.
Focal Points Module 5, 2017 5
techniques. However, for women with thin skin and mild
brow ptosis, it works well along with a blepharoplasty
(Figure 6). Potential complications include damage to the
sensory (V-1) and motor (facial) nerves. With experience,
this procedure can also be performed without the aid of an
endoscope. Video 6 demonstrates the procedure.
6. Small-Incision Browplasty
VIDEO
TECHNIQUE. Four small incisions are made in the
hair-bearing scalp: 2 vertical incisions are placed at the
level of the peak of the brow, 1 or 2 cm above the hairline,
2 cm in length; 2 horizontal incisions are made to straddle
the temporal fusion line, approximately 2 cm above the
hairline temporally. These incisions should be perpendicu-
lar to an imaginary line extending from the ala of the nose
to the lateral canthus. The main purpose of the endoscopic
browplasty is to create a subperiosteal dissection plane
medial to the temporal fusion lines to the superior orbital
rim. The endoscope is used mainly around the supraor-
bital neurovascular bundle to make sure this is not injured.
This dissection plane is performed through the 2 vertical
incisions. An additional dissection plane is performed
lateral to the temporal fusion line, on the surface of the
a head from ear to ear. Dissection can then be performed in
b
Figure 6 ​Patient before (a) and after (b) an
endoscopic browplasty with upper blepharoplasty.
6 Focal Points Module 5, 2017
deep temporalis fascia to the lateral orbital rim. This
dissection needs to be beneath the superficial temporal
fascia, where the frontal branch of the facial nerve lies.
The dissections on either side of the temporal fusion line
are then connected by lysing the conjoint tendon. This
is done with long Metzenbaum scissors, with or without
the endoscope. This is a similar dissection as with a
coronal incision, but without the direct visualization. The
endoscope is used to avoid injury to the supraorbital nerve
and the facial nerve.
After all attachments are released, then the forehead
needs to be lifted, a task that involves a multitude of fixa-
tion devices and procedural details. An Endotine forehead
device is easy to use and has a broad fixation. The device is
placed through each of the vertical incisions and popped
into the bone into holes that have been drilled. The entire
forehead is then elevated and suspended from the barbs on
the device. It is difficult to overcorrect in this procedure.
The incisions straddling the temporal fusion line are then
used to lift temporally. This can be done with superficial
temporalis plication or excision of scalp. Other methods of
fixation include bone tunnels with suture fixation or a long
14 mm screw from which the scalp can be secured (lifted
firmly and staples placed to hold it).
Coronal Browplasty
The coronal browplasty was once considered the cosmetic
lift to which all others are compared. It is a strong lift and
can address the entire extent of the brow. However, it is a
more extensive surgery than the other procedures discussed
here, with greater dissection and a larger incision. The
advantages of this lift are that it is strong, long lasting, and
can lift along the entire extent of the brow. The disadvan-
tages include longer operative time, elevation of the hairline,
extensive dissection, permanent scalp numbness, alopecia,
and the scar along the top of the head, which can sometimes
be noticeable, especially if it affects the way the hair parts.
Overcorrection is more common with coronal browlifting
than with the other brow elevation procedures.
TECHNIQUE. An incision is made across the top of the
a subgaleal or subperiosteal plane medial to the temporal
fusion line. Lateral to the temporal fusion line, dissection is
performed along the surface of the deep temporalis fascia.
This dissection is performed down to the superior orbital
rim and lateral orbital rim. The supraorbital nerves are
identified and preserved. This allows mobilization of the
entire forehead. The desired amount of lift is determined,
and the corresponding amount of scalp is excised. Closure
can then be performed with deep 3-0 polyglactin sutures,
followed by staples.
Weakening of Brow Protractors
Since the position of the brow is partially dependent on
an interplay between brow depressor and brow elevator
muscles, one way to aid in brow elevation is to weaken the

X X
X X
X position. MRD1 is the distance between the upper eyelid
X X
Figure 7 ​Diagram showing the location for
injection of botulinum toxin for weakening the
brow protractors (corrugator, procerus, and
lateral orbicularis). (Courtesy of ForeverLee/
Shutterstock.com.)
depressors (protractors). This would include the orbicularis,
procerus, and corrugator muscles. Surgically, one can do
this through the blepharoplasty incision or the endoscopic,
pretrichial, or coronal incision. As noted earlier, it is often
reasonable to be a bit more aggressive in excising lateral
orbicularis during the blepharoplasty to help in elevation of
the lateral brow.
Realistically, the easiest and most predictable way to
weaken the brow protractors is with injection of botulinum
toxin into the lateral orbicularis under the temporal brow.
Injection of 2.5 units botulinum toxin A on each side is a
good starting point. One should not inject more medial
than the lateral orbital rim. The most common risk with
this injection is causing ptosis, due to diffusion of the
toxin into the levator muscle. It is best to start low with
the toxin dose and stay lateral. Regarding the procerus and
corrugator muscles, complications are less likely—usually
5.0–7.5 units of botulinum toxin A injected into each cor-
rugator and 5 units into the procerus will suffice (Figure 7).
Volume Restoration for Brow Elevation
Aging is a process of deflation and descent. Sometimes
deflation plays a major role in brow descent. This aspect of
brow descent has been gaining a lot of attention recently.
The area to reinflate is the brow fat inferior to the temporal
portion of the brow. Loss of volume in this area results
in loss of support for the brow. Inflating this area has an
elevating effect on the brow. This can be performed with a
dermal filler or autologous fat injection.
Ptosis
Ptosis (blepharoptosis) refers to the upper eyelid margin
being low. This can be difficult to define—eyelid position in
one person might be too high; in another person, it might
constitute ptosis. The MRD is the primary measurement
used to define the height of the upper eyelid in relation to
the center of the pupil.
Eyelid measurements are generally considered as the
“vital signs” of the eyelids. Palpebral fissure height (PF) is
the distance between the peak of the upper eyelid margin
and the lower eyelid margin with the eyes in primary gaze
margin and the corneal light reflex with the eyes in primary
gaze position. MRD2 is the distance between the lower
eyelid margin and the corneal light reflex with the eyes in
primary gaze position. Thus, MRD1 + MRD2 = PF.
Lagophthalmos is present when space exists between
the upper eyelid margin and lower eyelid margin when the
patient is attempting eyelid closure. Levator function (LF)
is the excursion of the upper eyelid margin from downgaze
to upgaze with the brows fixed and head immobilized. Lid
crease (LC) is the distance from the upper eyelid margin
to the eyelid crease. The LF and LC measurements are
important when evaluating a patient with ptosis.
The measurements are made with a millimeter ruler,
with the patient looking straight ahead, usually at the
light of a Finhoff transilluminator. An MRD1 of 2 mm or
less is thought to represent clinically significant ptosis. In
patients with dermatochalasis, the MRD1 could be normal,
but extra skin may hang down over the eyelid margin.
The distance between the edge of the extra skin (rather
than the eyelid margin) and the corneal light reflex should
also be measured. Surgeons have used various ways to
represent this—using “MRD (skin)” or “pseudo MRD” can
help delineate the difference between this and the MRD1
measurement. Many patients have both ptosis and dermato-
chalasis and will therefore have abnormal MRD1 and MRD
(skin) measurements.
In categorizing ptosis patients, it is important to
differentiate congenital ptosis from adult-onset ptosis (see
“Ptosis in the Adult”).
Congenital Ptosis
Congenital ptosis is present from birth. In rare cases, birth
trauma may be the cause, but most of these birth trauma–
related cases rarely present to the surgeon because they
resolve spontaneously. Congenital ptosis has historically
been considered a myogenic form of ptosis, but now there is
evidence that the levator muscle is not innervated correctly
during development in many of these patients. Many
ophthalmologists now favor the term congenital cranial
dysinnervation disorder (CCDD) to generally categorize
any child who has a dysinnervation of one or more cranial
nerves.
Several factors need to be considered when a child has
congenital ptosis: bilateral or unilateral ptosis; severity; any
variation with jaw movement, eating, or nursing; amblyopia;
strength of the levator muscle; and associated conditions.
Bilateral and unilateral congenital ptosis are distinctly dif-
ferent clinical problems. Although it seems counterintuitive,
bilateral congenital ptosis is easier to treat than a unilateral
case. Usually, there will be no ocular preference in bilateral
Focal Points Module 5, 2017 7
symmetric ptosis, so surgery will not be performed early
unless the ptosis is amblyogenic or causing an abnormal
head position (usually a backward head tilt). In that case,
then it will usually be significant enough to require a fronta-
lis sling, which works better bilaterally than unilaterally.
A pediatric ophthalmologist should evaluate every
child with congenital ptosis not simply to evaluate the
patient for amblyopia, but also to ensure there is no
strabismus or motility issue and to check for any significant
refractive error. The strength of the levator muscle can
be difficult to determine in a young child. In general, the
amount of ptosis is inversely correlated with the strength
of the levator muscle in a child. Also, a more distinct eyelid
crease is reflective of a stronger levator muscle.
In bilateral ptosis, the surgery preference rests upon
the amount of ptosis and the strength of the levator muscle.
In general, the more severe the ptosis and the weaker the
levator muscle, the more likely the patient would be best
served with a frontalis sling. In addition, if the patient lifts
the brows to see, that is also an indication that a frontalis
sling will likely succeed.
In unilateral ptosis, there is a recent trend toward push-
ing a levator advancement or resection to its limits rather
than using a primary frontalis sling. The main issue is that it
is sometimes difficult to get children with unilateral ptosis
to use their brow to elevate the sling. Part of the issue is
that the side with the ptosis will usually not be the patient’s
dominant eye, or there may be amblyopia. If the child raises
the brow on the side of the ptosis preoperatively, it is a good
sign that a frontalis sling may work. If a unilateral sling is
performed, the parents will need to patch the contralateral
eye at least part-time until the age of 9 to make the child
want to use the sling. The goal of a levator resection is to
raise the eyelid not necessarily to symmetry, but out of the
amblyogenic range. Later in life, the height of the eyelid can
be refined.
Frontalis Sling Procedures
There are many choices with respect to frontalis sling
materials. For very young children, a nylon monofilament
suture is useful. For children older than 1 year of age, many
surgeons prefer donor fascia or a silicone rod. Recently,
more surgeons are leaning toward use of a silicone rod at
earlier ages. After the age of 4 or so, autogenous fascia can
be harvested, which is still the gold standard.
Surgery is performed under general anesthesia for a
frontalis sling in children. A single rhomboid configuration
has gained in popularity, regardless of the sling material.
Five principles are important to follow for optimal results:
tarsal fixation of the sling, retroseptal placement of the
sling, no fat excision, minimal (if any) skin incision, and
incorporation of the levator aponeurosis into the skin
incision.
FRONTALIS SUSPENSION/SLING. The upper eyelid
crease is marked along with a conservative blepharoplasty,
so that at least 18 mm of skin remains between the inferior
8 Focal Points Module 5, 2017
brow cilia and upper eyelid margin. Three markings
are then made above each brow: 1 medial, 1 lateral, and
1 halfway between these 2, approximately 1 cm above them,
preferably in an advantageous wrinkle. These areas are
infiltrated with local anesthesia.
A #15 blade is used to make a stab incision in each brow
marking. A hemostat is used to bluntly dissect each of these
incisions. An incision is then made along the blepharoplasty
marking, and a flap of skin and orbicularis is removed.
The orbital septum is opened, and the levator aponeu-
rosis is exposed. The levator aponeurosis is dissected from
the anterior surface of the tarsus. The silicone frontalis
sling is then sutured to the anterior surface of the tarsus
1 or 2 mm inferior to the superior border of the tarsus with
3 interrupted 5-0 polyester fiber sutures placed partially
through the anterior surface of the tarsus. The ends of
the silicone sling are then placed posterior to the orbital
septum to exit out the medial and lateral brow incisions.
Each end of the sling is then placed to exit out the central
brow incision. The sleeve that comes with the sling (or a
270 Watzke sleeve) is cut in half, and each half is placed
over the slings.
The patient is placed in a sitting position, and the sling
is tightened to attain an appropriate height and contour. The
patient is then placed in the supine position. A 5-0 polyester
fiber suture is then placed around the sling inferior to the
most inferior sleeve. A second 5-0 polyester fiber suture
is then placed around the most superior half of the sleeve.
The redundant portion of the frontalis sling is cut, and the
sling is placed under the subcutaneous tissue through the
superior incision.
The brow incisions are then closed with 5-0 fast-
absorbing gut suture placed in a vertical mattress fashion.
The eyelid incisions are then closed with the same suture,
which engages a skin edge, followed by the disinserted end
of the levator aponeurosis, followed by the other skin edge.
Levator Resection and Advancement
For mild-to-moderate congenital ptosis, Table 1 is useful for
determining how much levator should be excised. Table 2
presents the intraoperative eyelid height desired, depending
on the preoperative upper eyelid excursion. In general,
it is uncommon to overcorrect pediatric patients with
congenital ptosis, especially if they have 3 mm or more of
ptosis. With reoperations, overcorrection is more of a risk,
probably due to increased internal fibrosis and adhesions.
EXTERNAL LEVATOR ADVANCEMENT. An incision
is made at the level of the eyelid crease or the proposed
eyelid crease, keeping in mind that the measured lid crease
will often rise after the surgery. Dissection is carried out
through the orbicularis muscle to the orbital septum.
The orbital septum is then opened and the underly-
ing preaponeurotic fat is identified and dissected from
the underlying levator aponeurosis/muscle. The levator
aponeurosis is then dissected from the anterior surface of
the tarsus and dissection is then carried out between the
Table 1. Estimation of Levator Resectiona
AMOUNT OF PTOSIS UPPER EYELID EXCURSION AMOUNT OF RESECTION
2 mm (mild) 0–5 mm (poor) 22–27 mm
6–11 mm (fair) 16–21 mm
12 or more (good) 10–15 mm
3 mm (moderate) 0–5 mm (poor) Maximum (30 mm)
6–11 mm (fair) 22–27 mm
12 or more (good) 16–21 mm
4 mm or more (severe) 0–5 mm (poor) Maximum (30 mm)
6–11 mm (fair) 25–30 mm
12 or more (good) 25–30 mm
a
Recommended resection amount of the levator muscle for patients with congenital ptosis, dependent on the amount of ptosis and the strength of the levator muscle
(levator function/excursion). From Beard C. Congenital ptosis. Ptosis. 1976;91–115.

general, one should be wary of using an MMCR to address

Table 2. Intraoperative Eyelid Heighta
UPPER EYELID SUPERIOR CORNEAL
EXCURSION COVERAGE BY UPPER EYELID
0–5 mm (poor) 0 mm (eyelid margin at
superior limbus)
6–11 (fair) 2 mm
12 or more (good) 4 mm
a
Berke’s method of desired intraoperative eyelid height during a levator resec-
tion surgery in patients with congenital ptosis, based on the preoperative upper
eyelid excursion (levator function).
levator aponeurosis and the underlying Müller muscle. A
double-armed 5-0 nylon suture on a spatula needle is then
placed partially through the anterior surface of the tarsus,
approximately 2 mm inferior to the superior border of the
tarsus just nasal to the center of the pupil. Each arm of the
suture is then placed through the underside of the levator
aponeurosis, and a temporary tie is performed.
The patient is placed in the sitting position and the
height and contour of the eyelid are inspected. The patient
is then placed supine, and any appropriate adjustments
of the suture on the tarsus are made to alter the contour.
Eyelid height can be adjusted by altering the placement of
the suture in the levator aponeurosis. The patient is again
placed in the sitting position. If the appropriate height and
contour of the eyelid has been attained, the patient is placed
supine, and the temporary tie is converted into a permanent
tie. The redundant portion of the levator aponeurosis can be
excised, and the incision is closed with placement of sutures
that incorporate a portion of the levator aponeurosis to
create an eyelid crease. Sutures used can be a nonabsorbable
or an absorbable monofilament material; many surgeons
prefer a 6-0 polyethylene suture.
Posterior-Approach Ptosis Surgery
Success has been reported using a Müller muscle-con-
junctival resection (MMCR) for congenital ptosis cases. In
more than 2 mm of ptosis. Part of the issue is that the
levator muscle is weak. If an MMCR is actually an internal
levator advancement, then an 8.5 mm resection would
do very little in a patient with subnormal levator strength
(12 mm or less). If the patient has convincingly excellent
levator strength (eg, levator function of ≥15 mm) and at
most 2 mm of ptosis, then an MMCR may be appropriate,
as in a congenital Horner syndrome.
MÜLLER MUSCLE–CONJUNCTIVAL RESECTION.
The amount to be resected is determined preoperatively,
depending on the patient’s response to the instillation
of phenylephrine 2.5% drops. A 4-0 silk suture is placed
through the upper eyelid margin, and the eyelid is everted
over a Desmarres retractor. Additional local anesthetic can
be placed at this point. Two marks are made with cautery
or a marking pen, corresponding to the middle third of the
tarsus. Calipers are placed on half the proposed resection
amount, and marks are made corresponding to this
amount superior to the previously placed marks. A toothed
forceps is used to grasp the conjunctiva and presumed
Müller muscle and placed on traction. A Putterman clamp
is used and placed at the superior border of the tarsus. A
6-0 chromic suture is then placed in a mattress fashion
along the edge of the Putterman clamp. A #15 blade then
excises along the clamp (“metal on metal”). The suture is
tied. A bandage contact lens is placed on the eye, followed
by antibiotic drops.
Conditions Associated With
Congenital Ptosis
A final issue to consider in congenital ptosis is whether
there is any association with other abnormalities. Associ-
ated forms of congenital ptosis include blepharophimosis,
ptosis, epicanthus inversus syndrome (BPES), Marcus Gunn
jaw-winking ptosis, congenital fibrosis of the extraocular
muscles, and congenital myasthenic syndromes. Treating
these conditions is beyond the scope of this module.

Focal Points Module 5, 2017 9

 In the United Kingdom, surgeons have had success in
convincing parents to have surgery done on both sides (Beard
procedure) for unilateral congenital ptosis, and typically for
Marcus Gunn jaw-winking ptosis. In this situation, the leva-
tor on the normal side is extirpated so that ptosis is induced
on that side as well, and then treated with a bilateral frontalis
sling. This allows the child to raise both brows to elevate both
eyelids, rather than depending on them to raise one brow.
Many surgeons in the United States have difficulty convinc-
ing parents to approve this more aggressive procedure.
Ptosis in the Adult
Adult-onset ptosis is categorized into one or more of the
following categories: aponeurotic, myogenic, neurogenic,
and mechanical (Bartley Frueh classification). Aponeurotic
ptosis refers to a dehiscence, atrophic thinning, stretching,
or disinsertion of the levator aponeurosis. The aponeurosis
is the tendon portion of the levator and inserts into the
anterior surface of the tarsus 1 or 2 mm below the superior
border of the tarsus in Caucasians. With age, the aponeu-
rosis is thought to stretch, dehisce, or disinsert, resulting in
ptosis (there is some controversy as to the true etiology of
involutional ptosis). In this type of ptosis, the levator should
be of normal strength (LF >12–15 mm), the eyelid crease
should be high, and the ptosis will be worse with downgaze.
These patients will sometimes report that the ptosis
bothers them most as they try to read, due to their looking
down during this activity. Other common risk factors for
aponeurotic ptosis include long-term contact lens wear,
previous ocular surgery, chronic manipulation or rubbing of
the eyelid (as observed in chronic allergic ocular disorders),
and corticosteroid injection around the area.
Levator-Based Surgery
If the aponeurosis is stretched, then the appropriate proce-
dure would be to shorten the aponeurosis. This is generally
referred to as levator-based surgery. There are a few different
levator-based surgeries. A levator advancement refers to
disinsertion of the levator aponeurosis from the anterior
surface of the tarsus, dissecting between the aponeurosis
and the underlying Müller muscle, and resuturing the
aponeurosis to the tarsus to advance it. Another surgery is a
levator resection; in this surgery, the dissection is performed
under the Müller muscle, and then both the levator and
Müller muscle are shortened and advanced to the tarsus.
Finally, a levator plication is performed by not disinserting
the aponeurosis, but rather placing sutures through the
tarsus followed by sutures into the aponeurosis so that the
levator aponeurosis is folded over itself.
The determination as to what procedure to perform
is the surgeon’s preference. In each of these surgeries in an
adult, the patient is placed in the sitting position intraopera-
tively to determine if the eyelid is in the appropriate position.
An appropriate eyelid position is determined by the height
and contour of the eyelid margin. This is the most challeng-
ing part of the management of ptosis. Studies have shown
10 Focal Points Module 5, 2017
that the reoperation rate in ptosis patients can be as high as
10%. Video 7 demonstrates external levator advancement.
There are several “pearls” for performing levator-based
surgery. Limiting the volume of local anesthetic avoids
introducing mechanical issues from the anesthetic. Using
epinephrine in the local anesthetic to decrease bleeding
is helpful, but the eyelid should be slightly overcorrected
intraoperatively due to the temporary elevating effect of
the epinephrine on the Müller muscle. Identification of the
preaponeurotic fat is critical, because dissecting it from the
underlying levator aponeurosis ensures that one is in the
correct dissection plane. The suture should be placed on the
tarsus just medial to the pupil to place the peak of the eyelid
in the appropriate position. The beginning surgeon should
be aware that levator-based surgery takes considerable
practice. Even in experienced hands, achieving consistent
results can be challenging.
7. External Levator
Advancement
VIDEO
POSTERIOR-APPROACH PTOSIS SURGERY. This
procedure refers to incisions on the inside of the upper
eyelid to elevate the eyelid. There are basically 2 posterior-
approach options: the Fasanella–Servat procedure and
Müller muscle–conjunctival resection (MMCR). The
Fasanella-Servat procedure excises some of the tarsus at
the time of the surgery. This particular type of posterior-
approach ptosis surgery has lost popularity for numerous
reasons. Shortening the tarsus vertically compromises the
meibomian glands. Also, shortening the tarsus results in
a very unstable tarsus if one must reoperate later with a
levator-based procedure or a frontalis sling. In addition,
the shortened, unstable upper eyelid tarsus can later lead to
upper eyelid entropion in some patients.
However, MMCR (Video 8) has regained popularity
in addressing less than or equal to 2.5 mm of ptosis. The
surgery was popular in the 1970s and fell out of favor in the
1980s and 1990s. Lately surgeons have again embraced this
surgery as a predictable, easy surgery in appropriate situa-
tions: 2.5 mm or less of ptosis, good levator function, and a
good response to phenylephrine drops. During the ptosis
evaluation, a drop of 2.5% phenylephrine is placed in the eye
on the side of the ptosis. A second drop is given 10 seconds
later. After 5 minutes, the position of the eyelid is checked.
If it attains a normal position from the drop, an 8.5 mm
resection would be appropriate. If the eyelid is higher or
lower than what would be desired, then less or more of a
resection would be performed (Figure 8). In general, not
much less than 6 mm (for about 1 mm of ptosis) nor more
than 9.5 mm (for a response from the phenylephrine drop
that is 1 mm less than would be desired) is resected.
The advantages of MMCR are that it is weak relative
to external levator surgery, will not produce a significant

a
b material enabling closure and the ability to adjust the sling
Figure 8 ​Müller muscle–conjunctival resection
(MMCR). a. Patient with left upper eyelid ptosis.
b. After instillation of phenylephrine. c. Four
months after left 8.5 mm MMCR.
overcorrection, and will maintain a normal contour. As to
contraindications for MMCR surgery, the relative weakness
of the procedure should be respected, so it should not
be used for more significant ptosis. Realistically, it should be
reserved for aponeurotic ptosis or a Horner syndrome with
2.5 mm or less of ptosis. Although success has been reported
in patients with a compromised ocular surface (including
patients with previous penetrating keratoplasty and glaucoma
filtering blebs), many surgeons believe that the resection of
conjunctiva with the mucus-producing goblet cells places
patients at increased risk for significant ocular irritation,
ocular surface disease, and exacerbation of dry eye syndrome.
8. Müller Muscle–Conjunctival
Resection
VIDEO
Myogenic Ptosis
Adult-onset myogenic ptosis is associated with chronic
progressive external ophthalmoplegia (CPEO), oculo-
pharyngeal muscular dystrophy (OPMD), or myotonic
dystrophy. Otherwise, it is sometimes related to congenital
ptosis that was not previously treated. Congenital ptosis
in an adult patient should be a relatively stable condition
and can be treated per the amount of ptosis and levator
muscle strength. CPEO, OPMD, and myotonic dystrophy
are progressive forms of ptosis (secondary to a dystrophy
of the levator muscle) and are best treated with silicone
frontalis suspension. The issue with these progressive
forms of myogenic ptosis is that levator-based procedures
eventually fail, and then the more surgery that is done on
these eyelids, the more the eyelid closure is compromised.
Some surgeons advocate an aggressive blepharoplasty as a
treatment, but eliminating the excess skin also eliminates
the chance of producing an eyelid crease, thus leading to
a poor cosmetic result. A silicone sling works very well on
these patients and has the advantage of the elasticity of the
later (Figure 9). Video 9 demonstrates a bilateral silicone
frontalis sling procedure.
9. Bilateral Silicone
Frontalis Sling
VIDEO
Ptosis Due to Myasthenia Gravis
Ptosis from a problem at the neuromuscular junction is
due to myasthenia gravis. Myasthenia should be suspected
in any patient with acquired ptosis, especially if he or
she has a subnormal levator function, acute or subacute
onset, diplopia, significant variability in eyelid position,
orbicularis oculi muscle weakness, other symptoms of
generalized muscle weakness, or a history of thyroid eye
disease. Most patients with ptosis report worsening of
their eyelid malposition at the end of the day; however,
myasthenic patients may experience variation in the ptosis
during the day. Uniquely, patients with myasthenia may
give a history of episodes of complete ptosis, which is
rarely observed in other causes of ptosis. Eliciting fatigue
in the clinic is very helpful. Having the patient fixate on a
superior target and observing if one or both eyelids descend
will test for fatigability. Additional diagnostic tests and
signs for myasthenia gravis include the identification of a
Cogan eyelid twitch, the ice test, the sleep test, and various
serological investigations.
A Cogan eyelid twitch refers to the situation in which
the patient looks down for 3–5 seconds followed by
refixation to primary position. In doing this, the upper
eyelid will show a transient retraction (or twitch) during the
period of refixation before returning to its ptotic position.
In the ice test, the palpebral fissure is measured and
a bag with ice is placed over the eyelids for 2 minutes.
After the ice is removed, the palpebral fissure should be
remeasured within 10 seconds. Patients without myasthenia
Focal Points Module 5, 2017 11
 Figure 9 ​Patient with
chronic progressive external
ophthalmoplegia who
underwent previous levator a b
advancement procedure
2 years ago. a. She now
has recurrent ptosis.
b. Same patient 6 months
after silicone frontalis
suspension. c. Patient with
oculopharyngeal muscular
dystrophy before silicone
frontalis suspension. d. Four
months after. c d
will have no change in the palpebral fissure height. Patients
with myasthenia respond to the ice test with an increase in
palpebral fissure height of 2 mm with an 80% sensitivity
and 100% specificity.
The sleep test refers to having patients gently close their
eyes for 10 minutes followed by opening of the eyes. In some
patients with myasthenia gravis the ptosis will temporarily
improve.
Lastly, testing for antibodies to the acetylcholine receptor
can be useful; these antibodies are present in 80%–90% of
patients with generalized myasthenia gravis and 50%–75%
of patients with ocular myasthenia gravis.
If myasthenia is diagnosed, the patient needs to know
that this is a potentially fatal condition, and they need ex-
amination and treatment by a neurologist. Once maximum
improvement is achieved with medical therapy, surgery
can be considered for residual ptosis. Levator advancement
surgery may be effective for mild-to-moderate ptosis. More
advanced cases may require combined levator–Müller
muscle advancement or a silicone frontalis sling procedure.
Neurogenic Ptosis
The most common neurogenic causes of ptosis include
third cranial nerve palsy and Horner syndrome. The main
issue with third nerve palsy is the strabismus. Some third
nerve palsies are secondary to trauma and should be
given 6 months to recover before surgery is considered.
In nontraumatic cases of third nerve palsy, neuroimaging
studies are important, especially if pupillary involvement
is present, to rule out an intracranial aneurysm or tumor.
Close collaboration with a strabismus surgeon is helpful
to determine if it will be possible to provide good ocular
alignment. Otherwise, it is sometimes acceptable to allow
the ptosis to provide occlusion to prevent diplopia. Usually
a frontalis sling will be necessary (silicone rods are the
preferred choice).
12 Focal Points Module 5, 2017
Horner syndrome is very effectively treated with MMCR.
For mild unilateral ptosis, attention should be paid to the
pupils. The patient should be asked about previous neck
surgery, and checked for pulmonary symptoms and Horner
syndrome. The latter is easily missed. Any unexplained
Horner syndrome needs to be fully evaluated for the
underlying etiology.
Mechanical Ptosis
Mechanical ptosis refers to a ptotic lid due to a mass or
chronic edema. This can be caused by a tumor, a foreign
body (traumatic or iatrogenic), or inflammation. It is very
important to look for a mechanical etiology in children,
especially if there is a temporal drooping of the upper
eyelid. It is easy to assume that a patient has congenital
ptosis when the problem is a mass, such as a plexiform
neurofibroma in the lateral upper eyelid and anterior
orbit. Usually, capillary hemangiomas are more obvious.
In adults, a mass is also usually obvious. Amyloid on the
conjunctival surface of the upper eyelid is easy to miss—
so it is important to evert the upper eyelid in all patients,
but especially those with ptosis. Also, superior orbital
lymphomas often cause ptosis in adult patients.
Pseudoptosis
Pseudoptosis refers to the situation in which an upper
eyelid is low relative to the contralateral upper eyelid, but
the patient has other factors, such as strabismus, orbital
disorders, or contralateral eyelid problems, that are causing
an eyelid to be low relative to the contralateral upper eyelid.
Hypertropia may result in an eye that is supraducted rela-
tive to the eyelid, but when the eye is forced into primary
position, the eyelid position becomes normal. Also, a large
hypotropia can cause pseudoptosis, because the eyelid is
following the hypotropic eye downward in its infraducted
position.
 Enophthalmos may also result in the appearance of
ptosis. It is very important to pay attention to the axial
position of the eye and perform Hertel measurements.
Finally, a retracted contralateral upper eyelid may
result in the appearance of ptosis. This is often observed in
early thyroid eye disease, in which a patient presents with
“ptosis” of a single upper eyelid, but actually has retraction
of the other upper eyelid. This can be very difficult to
determine, and sometimes an apparent retraction can be
caused by a contralateral ptosis. In this situation, the ptotic
eyelid is usually on the side of the patient’s dominant eye,
resulting in raising the ptotic eyelid, which in turn results
in contraction of the contralateral lid, as stated in Hering’s
law. In situations of trying to determine true ptosis versus
contralateral retraction, it is useful to instill phenylephrine
on the ptotic side to see if the contralateral side then relaxes.
Holding the relatively ptotic lid up manually while examin-
ing the position of both upper eyelids can also demonstrate
this phenomenon.
but they may not wish to undergo the additional time or
expense of multiple surgical procedures or a potentially
longer recovery. Regarding compliance, it is always good
to decide whether the patient will be able to follow the
postoperative instructions that are necessary for a successful
surgical result. Surgeon experience may be a factor in
choosing the surgical procedure for the patient, but should
not put the patient through a procedure that is not in his or
her best interest.
Podcast Discussions
You are invited to hear author Richard C. Allen, MD, PhD,
FACS, and Eric P. Purdy, MD, editor-in-chief and editor for
Oculoplastic, Lacrimal, and Orbital Surgery, discuss key
topics of this module. To tune in, simply scan the QR codes
with a QR app on your digital device.

Preoperative Topics

Conclusion
PODCAST

In general, the conditions of dermatochalasis, brow

ptosis, and ptosis are seen in combination in patients with Patients Who Need
Combined Procedures
an involutional etiology. As the treatment choices for PODCAST
dermatochalasis are limited, the choice of ptosis and brow
ptosis repair will depend on the patient’s goals and compli-
Findings in Older Patients
ance with postoperative instructions, and the surgeon’s Regarding Tissue Laxity
experience and skill with various surgical techniques. Some PODCAST
patients may be better served by more extensive surgery,

Focal Points Module 5, 2017 13

Clinicians’ Corner
Eric A. Cole, MD, FACS, and Allan E. Wulc, MD, FACS, weigh in with
their clinical perspectives on “Surgical Management of Ptosis and
Brow Ptosis.” Clinicians’ Corner consultants respond to questions
without reading the module or each other’s responses.
1. How do you approach the patient with dry
eyes and blepharoptosis?
Dr. Cole: A patient with pre-existing dry eye syndrome
is at significant risk for potential complications after
blepharoptosis surgery. Examples include keratopathy, due
primarily to increased tear evaporative loss, and risk of
lagophthalmos and corneal exposure. Patients with mild
dry eye and minimal symptoms typically tolerate ptosis
surgery well. In patients with moderate-to-severe dry eye, I
attempt to diagnose the cause or causes of the patient’s dry
eye and optimize its treatment prior to performing ptosis
surgery. Patients with aqueous tear deficiency benefit from
interventions such as use of preservative-free artificial
tears, cyclosporine ophthlamic emulsion (Restasis), and
punctal plugs prior to surgery. Patients with significant
meibomian gland dysfunction benefit from therapies such
as warm compresses, artificial tears, eyelid scrubs, and
topical agents with anti-inflammatory properties. In my
area, patients frequently suffer from ocular rosacea, and
they also benefit from low-dose doxycycline medications.
I have not found treatments of the meibomian glands with
intense pulse light therapy (IPL) or LipoFlow (TearScience,
Morrisville, NC) to be significantly more effective than
warm compresses alone.
Once tear function has been optimized, we discuss
the pros and cons of correction of their visually significant
ptosis and their need for a long-term commitment to
continue these therapies after surgery. In patients who elect
to undergo surgery, I often employ the internal levator
advancement procedure for ptosis, as I have found that
this procedure minimizes risks of overcorrection and
lagophthalmos. In patients who are not candidates for
this procedure or are also in need of a blepharoplasty, I
perform an orbicularis-sparing external levator advance-
ment procedure with intraoperative adjustment and try
to undercorrect the postoperative margin–reflex distance
1 (MRD1) slightly. Older patients with lower eyelid laxity
or inferior scleral show often benefit from a horizontal
tightening procedure simultaneously to improve their tear
pump mechanism.
14 Focal Points Module 5, 2017
Dr. Wulc: While dry eye is not a contraindication to
ptosis repair, patients with a diagnosis of dry eye should
be approached conservatively. All our patients fill out the
ocular surface disease index questionnaire (OSDI), and
approximately 10% of patients in our practice present with
mild to moderate dry eye as defined by the OSDI score.
Preoperatively, the ocular surface should be optimized.
Management might include treatment of pre-existing
blepharitis and use of artificial tears, gels, oral supplements,
punctal plugs, and/or Restasis. In our area, several special-
ists interested primarily in dry eye have access to diagnostic
tools and additional treatments, and we often refer patients
with severe dry eye for treatment prior to surgery.
If the patient has symptomatic severe dry eye, including
blurred vision and/or photophobia, and exhibits signs
such as corneal staining, then consideration to perform
conservative surgery, or to avoid surgery, must be made in
conjunction with the patient, making him or her fully aware
of the risks.
If lower eyelid retraction in the dry eye patient
accompanies ptosis, the lower eyelid may be elevated
simultaneously with the upper ptosis repair, thus maintain-
ing palpebral fissure width as the area of functional vision
is translocated, minimizing additional postoperative surface
exposure.
We prefer an external repair approach for ptosis in dry
eye patients because of the theoretic possibility of interfer-
ing with accessory lacrimal gland function, and because of
the ease of postoperative adjustment of aponeurotic repair
when necessary. We attempt to avoid overcorrection and
often settle for undercorrection. If simultaneous upper
Eric A. Cole, MD, FACS, is a fellowship-trained oculofacial
plastic and reconstructive surgeon at Cole Aesthetic Center in
Silverdale, Washington.
Allan E. Wulc, MD, FACS, is an oculofacial cosmetic surgeon
with a practice in Plymouth Meeting, Pennsylvania. Dr. Wulc
is an associate clinical professor of ophthalmology at the
University of Pennsylvania, and an adjunct clinical associate
professor of otolaryngology at Temple University.

eyelid blepharoplasty is performed along with the ptosis
repair, less than the expected amount of skin is resected and
no orbicularis muscle is removed, to attempt to maintain
normal eyelid closure.
Postoperatively, patients with dry eye must be treated
with aggressive topical therapy and observed carefully for
worsening of dry eye signs and symptoms. In the rare case
where the dry eye patient becomes more symptomatic after
ptosis repair, and after exhausting additional dry eye treat-
ment methods, an external levator advancement ptosis repair
has the advantage of being reversed as a minor procedure.
2. How do you decide whether to perform
an internal or an external approach to
involutional ptosis repair? If you perform a
transconjunctival procedure, do you prefer the
Fasanella–Servat technique or a Müller muscle–
conjunctival resection (MMCR)? Which ptosis
clamp do you find most useful?
Dr. Cole: I decide whether to perform an internal versus
external ptosis procedure based upon the patient’s response
to testing using 2.5% phenylephrine. In patients with a good
response (MRD-1 of 3 mm or greater after phenylephrine),
I usually perform an internal ptosis repair. I have found that
neither the type of ptosis (acquired versus congenital) nor
the severity of the ptosis is important in this decision. If the
patient responds favorably to phenylephrine testing, he or
she is usually a good candidate for internal ptosis repair. I
use the procedure described by Dr. Allen Putterman and
favor his style of clamp. I find the procedure quick, easy,
and extremely predictable. I am not a proponent of the
Fasanella–Servat procedure, as it involves partial excision
of the tarsal plate. Excision of a portion of the tarsal plate,
while effective in elevation of the ptotic eyelid, can result
in eyelid instability if future ptosis procedures, such as an
external levator resection, become necessary for the patient.
In patients who do not favorably respond to phenylephrine
or need a simultaneous blepharoplasty, I use the external
approach to ptosis repair, with levator aponeurosis advance-
ment or resection.
Dr. Wulc: The phenylephrine test is a maneuver used
in routine ptosis evaluation. Originally described with
10% phenylephrine instilled into the affected eye, I use a
2.5% solution and assess the eyelid position at 10 minutes.
A phenylephrine-responsive patient will often benefit
from an internal approach, such as an MMCR, and can
obtain predictable results. The phenylephrine test is also
clinically useful if an external repair is contemplated. In the
patient undergoing an external approach, local anesthetic
with epinephrine injected in a phenylephrine-responsive
patient will produce intraoperative elevation of the eyelids,
interfering with intraoperative assessment. In these patients,
a compensatory overcorrection of the ptosis should be
performed (by approximately 1.5 mm).
Clinicians’ Corner
In the presence of dermatochalasis and steatoblepha-
ron, if an eyelid crease anomaly needs to be addressed and
if there is an intention of dealing with these issues, I will
employ an external approach. If the patient has had a prior
internal approach, has a cicatrizing conjunctival disorder,
or has had glaucoma surgery or is being considered for
glaucoma surgery, I will also employ an external approach.
When performing an internal approach, my preference
is to perform an MMCR. I believe that this procedure spares
the meibomian glands, which are inevitably transected
with the Fasanella–Servat procedure. Furthermore, if a
future external approach is necessary, because of the lack
of success of the internal approach due to persistent ptosis
or recurrent ptosis, it is much more difficult to perform an
external repair when the tarsus has been vertically chal-
lenged with a previous Fasanella–Servat procedure. Eyelid
abnormalities, such as peaks or unnatural upper eyelid
contours, are common in this group of patients, and I have
often found it necessary to add additional tissue (dermis or
contralateral tarsus when available) to support the elevation
and to maintain a natural eyelid shape.
My preferred ptosis clamp with the internal procedure
is the 6-pin titanium Putterman clamp.
3. How do you counsel the patient with brow
ptosis who is only aware of and referred for
management of eyelid malposition?
Dr. Cole: I am frequently referred patients for manage-
ment of eyelid malposition who actually suffer from
eyebrow ptosis either as an isolated condition or concur-
rently with eyelid ptosis. I carefully explain to patients, as
they look into a mirror in primary gaze, what the effect of
each of the separate procedures would accomplish both
functionally and aesthetically. Once I am sure that patients
understand the interrelationship of the eyelid–eyebrow
complex and have a reasonable expectation of the potential
aesthetic and functional outcomes, I let them make an
educated decision as to which procedures or combinations
of procedures they feel would be of the most benefit. In
my practice, most women with eyebrow ptosis or temporal
eyebrow hooding elect to have their eyebrows repositioned
surgically to improve their functional and/or aesthetic
outcome. Correction of the eyebrow ptosis can occur in
conjunction with eyelid surgery or as an isolated surgical
procedure, depending upon the patient’s needs and
aesthetic expectations. In general, most men in my practice
choose not to proceed with eyebrow repositioning surgery
unless functionally necessary, due primarily to potential
complications such as facial feminization or poor scar
camouflage due to male pattern hair loss.
Dr. Wulc: The patient who is referred and unaware of his
or her brow malposition is a daily visitor to my practice.
The patient who comes in for an eyelid lift often pulls the
brow upward, stating that vision is improved with this
Focal Points Module 5, 2017 15
Clinicians’ Corner
maneuver. The patient thinks that this maneuver mimics
the effects of eyelid surgery. I quickly point out that this is
not the procedure that he or she will be undergoing if eyelid
surgery alone is performed: they are mimicking the effects
of a brow lift.
Many patients with brow ptosis inevitably believe
that the removal of excess skin from the eyelids will both
improve their appearance and relieve the hooding that
exists because of ptosis of the tail of the brows. In fact,
ptosis repair and/or blepharoplasty may accentuate or even
worsen the brow ptosis, because the demand for frontalis
action may diminish after the eyelid issues are addressed.
I often counsel these patients that they may be dissatisfied
with the aesthetic aspects of their surgery if a browlift is
not performed. Postoperatively, this group of patients often
thinks that not enough skin was removed with the original
procedure, and the patients think they need a secondary
blepharoplasty to remove more skin.
In our office, we have an album of pre- and postopera-
tive photos of patients who have undergone blepharoplasty
and/or ptosis repair, with and without brow surgery, to
allow the patient to better understand this management
conundrum. This album also includes examples of patients
with brow and eyelid ptosis who elected to have eyelid
surgery alone, and then who underwent brow ptosis surgery.
This way the patient can see the aesthetic transition as each
element was individually addressed. Often—but not always—
there is an “aha” moment where the patient understands how
the brow is intimately involved in eyelid aesthetics.
Most patients with upper eyelid ptosis and brow ptosis
who are referred because of visual symptoms, such as
altitudinal field loss, are improved from a visual standpoint
without brow lift surgery. A subgroup of these patients,
however, will be unhappy with their appearance after
functional upper eyelid surgery. While it is easy to diagnose
these 2 conditions when they occur simultaneously, it is
difficult to predict the individual patient’s level of postop-
erative satisfaction.
If, after counseling these patients, I am convinced a
browlift will be necessary from an aesthetic standpoint
and if the patient declines a browlift, I ask for a signed
informed consent stating that a browlift was advised. This
maneuver has helped me remind the dissatisfied patient in
the postoperative period that the interrelationship between
brow and upper eyelid aesthetics was discussed.
4. Which materials do you use for frontalis
sling procedures?
Dr. Cole: In general, I perform frontalis sling procedures
only in patients with severe congenital ptosis who have a
Berke levator function less than 4 mm. In patients with
4–8 mm of levator function, I prefer procedures such as the
“supermaximal” external levator resection. Typically, I will
use a silicone frontalis sling for adult patents and a banked
fascia product for children. I base this choice on the ease
16 Focal Points Module 5, 2017
with which the silicone sling can be adjusted in the office with
local anesthesia, if symptomatic dry eye or lagophthalmos
develops in an adult patient. Children are more able to
tolerate lagophthalmos and do not develop keratopathy as
readily, when compared to adult patients. I do not harvest
autogenous fascia in children, as this leaves an unsightly
scar on the lateral aspect of the thigh and has no proven
benefit regarding the longevity of the sling. Because I
have had a higher incidence of inflammatory reactions to
products made of Gore-Tex, requiring secondary interven-
tions, I have discontinued use of this material for frontalis
sling procedures.
Dr. Wulc: When performing autologous fascia repair, I
often use temporalis fascia. It is easily harvested, proximate
to the operative field, abundant, regenerates, and can be
reharvested if necessary. I employ a modification of the
suspension approach described by Dailey, Wilson, and
Wobig. I have no experience with banked fascia, but many
of my colleagues use it and are satisfied with it. For exog-
enous slings in adults, I use the Seiff silicone suspension set
(Beaver-Visitec, Waltham, MA). These are most helpful in
cases of myopathic or neuromyopathic ptosis, especially in
the presence of concomitant ophthalmoparesis, as the repair
can be adjusted at any point postoperatively to address an
undercorrection or an overcorrection.
5. What are the primary advantages and
disadvantages of different methods of fixation
in endoscopic forehead lifting?
Dr. Cole: I have used many of the products commercially
available for brow fixation in endoscopic brow and
forehead lifting, including sterile self-tapping dissolvable
screws and anchors, removable self-tapping screws,
and Endotine devices (Advantech Surgical; Torquay,
Devon, England). I believe that if the eyebrow, forehead,
and posterior scalp are properly released during the
endoscopic browlift, the type of fixation used is of minimal
importance, as all these devices are extremely effective. The
major issue is the product cost, which can be significant,
especially if you are performing the surgery for functional
purposes in a private ambulatory surgery center. Years
ago, I switched to the bone bridge device developed by
Dr. Sykes at the University of California Davis. This
product is reusable, easy to use, low cost, and extremely
effective, requiring only suture for fixation. The use of this
device also limits potential foreign body reactions and
patient dissatisfaction due to the temporary palpability of
most implants.
Dr. Wulc: It is impossible to achieve fixation of the
forehead unless a complete periosteal release is performed
at the supraorbital rim, and a lateral release is performed
beyond the inferotemporal crest ligament at least to the
level of the sentinel veins. The release is more important

than the means of fixation. Excessive traction in the absence
of release can result in alopecia that often can go beyond the
area of the incisions.
Over the years, I have tried several approaches, such
as nonfixation after full periosteal release, externalized
screws, permanent and nonresorbable anchors, which are
sutured to frontalis, and sutureless resorbable tines, which
penetrate the soft tissues of the forehead.
Currently, obtain fixation by suturing the frontalis
muscle directly to the frontal bone in my 2 paramedian
incisions areas, made approximately 4.5 cm from the
midline and posterior to the hairline. I use a 5 mm, guarded
J-latch bit to create 2 adjoining drill holes in the anterior
table, through which I pass 2-0 absorbable sutures that
secure the frontalis to bone in buried mattress fashion. Fixa-
tion of the temporal aspect of the temporoparietal fascia to
the temporalis can be accomplished with a 3-0 absorbable
suture, but I have not found this maneuver particularly
useful, as temporal brow ptosis recurs unless a complete
release is achieved.
The tines can clip, and they can be painful if they are
placed close to sensory nerves. They have been associated
with granulomatous reactions. Anchors, if not seated
properly, can be palpable until they resorb and can be
annoying to the patient. Both these means of securing the
forehead add substantially to the cost of the procedure.
6. What is the role for the browplasty
procedure performed concomitantly with
upper eyelid blepharoplasty and/or ptosis
surgery?
Dr. Cole: I commonly perform browlifting procedures
in combination with blepharoplasty or ptosis surgery. The
combination of these procedures can safely be performed
for either cosmetic or functional indications. Patients who
have truly visually significant brow ptosis as well as visually
significant blepharoptosis benefit tremendously by the
combination. Patients who desire aesthetic improvement,
most commonly due to mild-to-moderate temporal brow
hooding or medial brow descent, are also typically very
happy with this combination of procedures. The surgeon
must be very careful not to over lift the eyebrow, as this
can result in significant lagophthalmos. The risk of this
complication can be minimized by simultaneously perform-
ing the “pinch test” of the upper eyelid dermatochalasis to
determine the amount of excess skin to be resected, while
having your assistant manually lift the eyebrow to the
desired postoperative height. The patient is then marked
in this position to determine the maximum safe potential
eyebrow height that can be achieved, while ensuring the
eyelids will still freely close after the procedure.
Dr. Wulc: Transpalpebral internal browpexy, originally
described by McCord and Doxanas in 1990, was a
Clinicians’ Corner
procedure that I greeted with great enthusiasm because
of the ease and elegance of addressing the brow through
an eyelid incision. In 1994, I compiled my results with
this technique and presented them at an International
Aesthetic Congress, and, unfortunately, found that my
long-term results with this procedure were disappointing.
The medial brow could not be elevated with this technique.
Patients who had the internal approach often complained
of palpability of the sutures and tenderness long after the
procedure, whether absorbable or nonabsorbable sutures
were employed. Recurrence of lateral brow ptosis also was a
problem in my patients.
Recently, Massry described a mini-external browpexy
performed at the time of eyelid surgery—a direct browlift
with a single suture performed through a small incision—
and I have tried this procedure in a limited number of
patients with success. Postoperatively, patients may com-
plain about pain related to the suture, and, while healing,
prominence of the suprabrow scar.
7. What is your approach to the male patient
with marked alopecia, absence of forehead
furrows, and a thin eyebrow, but with
significant brow ptosis and temporal
hooding?
Dr. Cole: Male patients with marked alopecia, absent
forehead furrows, and thin eyebrow hairs are excellent
candidates for an endoscopic brow- and forehead lifting.
The 2 central incisions can be 1–1.5 cm vertical lines and
the temporal incisions need to only be approximately
1.5–2 cm in length. With meticulous closure of these
incisions and great care with tissue manipulation, these
incisions are nearly invisible several months after surgery.
Patient satisfaction with this procedure is extremely high.
Internal eyebrow-pexy through an eyelid-crease incision is
also in option in these patients, although I have not been
able to personally achieve the degree of eyebrow eleva-
tion or patient satisfaction with this procedure as I have
achieved with endoscopic browlifting.
Dr. Wulc: Bald or balding patients represent a manage-
ment dilemma because of the theoretic risk of creating a
visible scar in someone who may already be self-conscious
about hair loss. However, I have had excellent results with
endoscopic forehead lifting in patients who are completely
bald, where there is no possibility of concealing a scar. Scars
in this location are usually inconspicuous and heal well.
Forehead incisions can be hidden in horizontal forehead
rhytids, or made in slightly irregular patterns to avoid
drawing attention to a linear scar. If a scar were to become
apparent postoperatively, it could be treated postoperatively
with fractional laser resurfacing or radiofrequency micro­
needling. Fortunately, I have not found additional treat-
ments of this sort to be necessary.
Focal Points Module 5, 2017 17
Clinicians’ Corner
8. What role do botulinum toxin (eg, Botox,
Dysport, or Xeomin) injections have in
the management of brow ptosis? What is
your preferred technique and frequency of
injections?
Dr. Cole: Botulinum toxin injections have a role in
mild-to-moderate brow ptosis in patients who are not ready
to undergo eyebrow surgery or are not currently candidates
for surgical intervention. To my knowledge, none of the
insurance carriers in my area consider botulinum treatment
for eyebrow ptosis a “covered” expense, which severely
limits its use in functional patients. I use approximately
20 units of Botox (60 units of Dysport) to maximally
weaken the eyebrow/forehead depressors (corrugators
and procerus muscles) of the glabella. I also weaken the
lateral orbital orbicularis, which has a secondary function
of pulling the eyebrows down and inward. To get maximal
browlifting with botulinum toxin injections, one should
not treat the frontalis muscle too aggressively. The goal
is to allow it to elevate the eyebrows upward without the
oppositional downward force of the weakened glabellar
muscles. I do not have set periods for patients to return for
treatment, as I find the effective duration of the treatment
18 Focal Points Module 5, 2017
can be quite different in each patient. I ask patients to
return when they feel the effects have worn off and they
desire re-treatment.
Dr. Wulc: Botulinum toxin is a useful adjunct for elevating
the brow and can be used in instances of mild-to-moderate
brow ptosis. Chemical browlifting with botulinum toxin is
unpredictable—patients should be advised that the results
are not as precise as those that can be obtained with surgery.
Contour abnormalities and undercorrections are common.
A trial of botulinum toxin to elevate the brows can be
performed to decide whether it is useful for the patient who
is not interested in a surgical browlift.
The most recent technical contribution to the
“microdroplet” botulinum toxin injections as described by
Steinsapir. This innovative technique produces a uniform
and natural elevation of the brows. Botulinum toxin is
administered to the depressor supracilii, the procerus,
the corrugator supracilii, and the orbital portion of the
orbicularis in small concentrations.
Chemical browlifting with botulinum toxin needs to
be repeated at approximately 3-month intervals. Over time,
this approach may become more expensive than a cosmetic
endoscopic browlift.
Suggested Reading
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Primary bilateral silicone frontalis suspension for good levator function
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96(6):841–5.
Anderson RL. Predictable ptosis procedures: do not go to the dark side.
Ophthal Plast Reconstr Surg. 2012;28(4):239–41.
Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol.
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comparison of two brow-lifting techniques in patients undergoing upper
blepharoplasty. Ophthal Plast Reconstr Surg. 2016;32(3):204–6.
Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External
levator advancement vs Müller’s muscle–conjunctival resection for correc-
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