The objectives of this lecture are:
1. Recognize different types of ptosis
2. Indications for surgery
3. Understand basic surgical techniques
4. Manage complications
Surgery location: on-board the Orbis Flying Eye Hospital in Yaoundé, Cameroon
Lecturer: Dr. Thomas Johnson, Bascom Palmer Eye Institute, University of Miami
(To translate please select your language to the right of this page)
Welcome to Orbis. I’m Dr. Tom Johnson from the USA. I’m going to give a short talk on ptosis. These are the objectives of my talk. To recognize the different types of ptosis. Be familiar with indications for surgery. Understand basic surgical techniques. And be able to manage complications.
So these are my two questions: A congenital ptosis, A, is always associated with poor levator function, B, is unilateral in about 75% of cases. C, never needs surge before age 5 years. And D, is usually associated with superior rectus muscle weakness.
Second question. Adult involutional ptosis usually has excellent levator function. B, is most commonly caused by previous eye surgery. C, is usually treated surgically by using a frontalis suspension. And the slide is cut off, but D is associated with systemic medical problems.
So let’s get started. So you have a lot of ptosis in Cameroon, I saw yesterday. It’s a very common problem. Just a little basic anatomy. There are two main retractors of the upper eye lid, the levator mys and the Muller’s muscle. This is just a diagram showing the levator muscle. You can see the levator muscle spans out over the whole inter surface of the eyelid on the tarsal plate. In most of our cases of ptosis, there’s a problem with this muscle. And most of our surgery we perform on this muscle. So there are things that look like ptosis that aren’t really ptosis. We call that pseudo ptosis. This is a patient with an ophthalmic socket. Because of the loss of the eye, the eyelid comes down. So that’s a pseudoptosis. And with the prosthesis, the eyelid comes up. This is a man with thyroid eye disease. So he has contralateral lid retraction. Lid retraction on the right. That gives his eyelid a ptotic appearance on the left. This is ha man with true ptosis, tonic eyebrows, that looks like a case of ptosis. And this is a man with dramano colossus, just excess skin that makes his eyelids look droopy also.
So in congenital ptosis, this is the first one I’m going to talk about, it’s ptosis present at birth. Or soon after birth. About 75% of cases are unilateral, on one side. Most don’t have a family history. There may be a superior rectus muscle weakness in about 5% of cases. So a small percentage of cases. And a disease called MarcusGunn Winking in about 5%.
So this is a bilateral congenital ptosis. You can see the child has a chinup position. Uses his eyebrows to lift his eyelids and has poorlyformed eyelid creases. Another kid using his eyebrows to lift up his eyelids with absent eyelid creases. So that’s a very common presentation of kids with bilateral congenital ptosis.
Key features of congenital ptosis include presence soon after birth. Lid lag on down gaze. Levator function is usually moderate to poor. And patients usually have a poorlyformed or absent lid crease. Eyelid crease. Or poorly formed or absent crease of the upper eyelid. So it can be unilateral. In this case, you can see the difference in the eyelid crease on the right compared to the left. And this child actually does use his eyebrow to lift his eyelid up on the right side. And when he looks up, you can see he has normal superior rectus function, but the eyelid does not come up much. And on down gaze, I don’t know if you can tell, but the lid is a little bit higher, so he has lid lag on down gaze. It doesn’t actually go down as well as the other side, as well as the left side. So the key thing to do when you’re deciding what kind of surgery, you want to try to figure out what type of levator function, what type of function the patient has of the muscle that we talked about.
So what I do is I immobilize the eyebrow, so he’s not using his eyebrow. I have him look down, and in kids usually you have to have them look at some type of object toy or a sticker to get them to look down. You can see it reads it reads “55” here. And then when he looks up I get him to look up he goes up 5 millimeters, from 55 to 50. So 5 millimeters of function. So later on we’ll talk about why that is important and how that helps you decide what type of surgery to perform.
I always try to see if the patient has a Bell’s phenomenon. So I have him squeeze his eyes and see if his eye goes up. Because this will let me know if the patient may have problems with exposure of this cornea after surgery. So the path physiology, the reason patients have this, is because this is an isolated dystrophy of the levator muscle. The normal muscle fibers are replaced with fat tissue and fibrous tissue. I promise this is the only pathology slide I’m going to show.
But you can see you have normal, striated muscle and then you have all this fibrouslike scar tissue intermixed with the normal muscle. So that’s why the muscle just doesn’t work very well. The problem with congenital ptosis, the most serious problem is amblyopia, or lazy eye. This is because the droopy eyelid can block the visual axis, and it can also induce a stigmatism. So sometimes we need to fix these very early in life to allow the patient to develop normal vision.
Briefly MarcusGunn jaw winking is what’s called a synkinetic ptosis where there’s a miswiring of the nerves. The nerves that usually supply the muscles to the jaw get misdirected into the levator muscle. So when the patient moves their mouth, the eyelid comes up and down. This is a child with MarcusGunn. You can see when he’s looking right at you in primary position, the eyelid is pretty much closed. When he moves his jaw to the side of the ptosis, he’s moving his mouth this way, his eyelid is still down. But look what happens when he moves his jaw the other way. Move the jaw his eyelid actually retracts.
That’s because the nerve fibers that usually go to this muscle in the jaw get somehow misdirected into his eyelid, so he uses this muscle, these nerves fire and his eyelid goes up. So when you have something like this, it may kind of affect what type of surgery you use to protect the ptosis. And this is just him opening his mouth.
Sometimes this is also associated with the efficient elevation his sue superior rectus, like in this case. So these patients may be more at risk of exposure once you elevate their eyelid. So I’m just going to skip over this one so we can get keep moving. Blepharophimosis is another syndrome.
I don’t know if you see much of that here, but it’s an autosomal dominant disorder. So there’s three things, you have bilateral ptosis with poor function, telecanthus, increased distance between the two canthi. You get phimosis. You get tight eyelids that are short of skin. It’s usually an autosomal dominant inheritance. So this is a case, you can see, pretty severe ptosis. Increased distance between the canthi. Shortage of skin. Often times ectropion of the lower lids. And these small epicanthal folds.
So another disorder with ptosis that is very important to recognize is CPEO, chronic progressive external ophthalmoplegia. And in this case, you have a muscular dystrophy that affects the eyelid muscles as well as the extraocular muscles that move the eyes. It’s usually seen in young patients. Late childhood, early adulthood. Patients develop a severe poor function ptosis with fixed eyes that don’t move. So this is a common kind of clinical presentation. Severe ptosis, poor function. He’s using his brows to try to elevate the eyelids and the eyes just don’t move. And to I’ll go over the treatment of this, but the treatment should be very conservative because these patients are at high risk of getting corneal exposure.
So we usually just try to do surgery to just clear the visual axis, so the patients can see out and relax their brows. And KaernsSayre is this disease associated with retinal abnormalities and heart abnormalities. So patients with CPEO should always have a cardiac workup to make sure they don’t have the hard conduction abnormalities.
And myasthenia is another type of ptosis that can be acquired. It’s an autoimmune disease. The extra ocular muscles and levator are often affected first. It can be associated with systemic myasthenia. Myasthenia all over the body. So patients may have problems with walking, raising their arms, chewing, swallowing. The ptosis is usually variable. And there are different tests you can use. You can do an ice test where you put ice on the photonic eyelid to see if it comes up. Or you can do what you call a “Tensilon test” where you inject edrophonium Tensilon into the vein and see if the eyelid come up. And you can also do a blood test to see if there’s antibodies to acetylcholine receptors.
So it’s important to recognize all these types of neurogenic ptosis, because, again, the treatment of these is going to be different than the treatment for the myogenic or levatorassociated ptosis.
So if you have ptosis with pupillary problems, think of third nerve palsy can cause a ptosis. You see patients have a dilated pupil. Horner’s syndrome, a problem with the sympathetics. They can have a myotic pupil. Probably the most common type of ptosis I see in my practice and one that we’re going to be working on in the local hospital on Thursday is what’s called aponeurotic ptosis.
Remember I showed that diagram of the aponeurosis that is attached to the tarsal plate? This just becomes separated and the whole muscle retracts upward. It usually occurs just with agerelated changes. It can also occur after eye surgery, such as cataract surgery, glaucoma surgery, retinal surgery.
The key features are, a moderate ptosis with usually accelerometer function, an elevated lid crease, and increased excursion on downgaze. That’s the absence of lagophthalmos. The eyelid actually goes down farther on the ptotic eye side than the normal side. The eyelid actually comes down on down gaze.
So this is a typical case. And this is kind of similar to the lady we saw yesterday. You can see this patient has bilateral, left greater than right, moderate ptosis, elevated eyelid crease. And when you test his function, it’s excellent from down to up gaze. And excellent function usually means 15 millimeters of excursion. Thank you.
So this is another patient with an abnormal ptosis on the left. And just by reattaching the levator muscle, you can completely restore their normal eyelid height and function.
And mechanical ptosis, just to complete the definitions, is just ptosis due to increased weight of the eyelid. This can be due to tumors. We saw one yesterday with hemangioma in the screening. Swelling, inflammation, hematomas after trauma. This is similar to the kid we saw yesterday with the hemangioma, causing a mechanical ptosis of the right upper lid. Once you treat the hemangioma, the ptosis will resolve on its own. This is another kid, acquired ptosis in a child. Always be suspicious in a child with acquired ptosis, because it’s unusual. It’s not usual for a child to have an acquired ptosis.
So one thing I’ve always got in the habit of doing is flipping the eyelid over any time I have a ptosis that I can’t really explain. So I flip the eyelid over and I see this cyst. Patient had this huge cystic lesion at the top of this tarsal plate. It was a cyst of the accessory lacrimal glands. So just by removing the cyst, his ptosis resolved.
And traumatic ptosis, I’ll just go over a quick one. This is a kid with a traumatic ptosis. And when we do a CT scan, you can see this patient has an orbital roof fracture. This is from falling down a flight of stairs. Another patient with a traumatic ptosis. And after the hemorrhage and so forth is resolved, this is very common in the screening day yesterday. The patient ended up with a complete ptosis with no levator function. So this patient most likely had damage to the nerve supply of the levator muscle causing the muscle to completely be nonfunctional.
And I see you have a lot of these cases in Cameroon. This is a kid that had been seen in an ER and had a lid a laceration sutured.
so he came in with a ptosis and hypotropia. The eye is down. And so we did a CT scan. You can see this patient has an orbital foreign body. And this is a coronal CT scan. And you can see the eye is pushed down with this foreign body. Does anybody know what this is? Raise your hand. Anybody have an idea what that is?
This kid developed this it happened in school. He was in school when it happened. So it’s not that it’s a pencil, yes. So this is what happened. He had been running with a pencil, and, of course, kids don’t tell you this and fell. And I have had a couple of these where the pencil has gone into the orbit, missed the eye, but has been embedded in the orbit.
And so this is just by removing the pencil. The ptosis and the hypotropia resolved. You can see. So I’m going to quickly go over some measurement and then briefly some techniques. So normal the most important measurement you take, I think, is the levator function. And the normal function is about 1520 millimeters of excursion. The normal palpebral fissure is about 10 millimeters. And the normal eyelid crease is about 811 millimeters. It’s a little bit lower in men and a little bit higher in women. This is just showing a patient with ptosis and doing visual fields.
So ptosis surgery, the main ptosis surgeries we perform are levator advancement, an internal ptosis, or conjunctival Mullerectomy, levator resection for congenital ptosis with good to moderate functions. I don’t really perform Whitnall’s Sling, so we’re not going to talk about that. And frontalis suspension for poor function Ptosis. And I use that one, the levator function is 4 millimeters or less. There’s different materials we can use. We can use fascia from the patient’s own leg, or synthetic materials such as silicone, Supramid or GoreTex.
Timing. Usually the timing is very important. If I think the ptosis is causing amblyopia, I try to re-tear it as soon as possible. If it’s not causing amblyopia, I like to wait until the child is about 45 years of age. The reasons are, kids really don’t care that their eyelid is ptotic before that time, the anesthesia risks is much less. And the tissues are better developed so it’s easier to get an excellent result. So I’m just going to go over some steps. I’m going to go over aponeurotic, just reinserting the aponeurotic first. So we mark the eyelid crease. You don’t really need a traction suture.
But make an incision with a blade, pick up the orbicularis muscle centrally. Cut down through the orbicularis to the orbital septum. And you see this orbital septum, this kind of white, shiny layer. So there’s a very nice plane you get into here. So in eyelid surgery, always try to work in these avascular planes. Once you find this plane, you put one blade in and one blade out and cut along the line to open up this plane the entire length of your incision using a scissor going one way and the other way.
Then I dissect underneath orbicularis muscle superiorly to expose the fat pad. This is your key landmark in ptosis surgery is the fat. The preaponeurotic fat. Because right underneath that fat pad you always find the levator muscle. And so once we find the fat pad, there is the orbital septum, and you gently open the orbital septum over the fat. Just stay on top of the fat and you are in a very safe plane, and you open the septum the whole length of your septum. So open this the other direction. This is the orbital septum we’re opening. And then what you can see, you can see the skin, muscle, orbital septum, fat, and underneath the fat, this is the levator aponeurosis, this white structure.
And this levator is separated, see? This levator here should be attached down over the tarsal plate. So you can then pull the levator down with a forceps, and, again, you can see the preaponeurotic fat and levator has this kind of white vascular portion, and then up here, more of a muscular portion. And underneath levator is Muller’s muscle. This tissue right here. This pink tissue with these blood vessels, these vertical blood vessels, is Muller’s muscle. So what we do is we’re going reattach the levator to the tarsal plate. So we place sutures through the tarsal plate in a partial thickness fashion. Because we don’t want them to rub on the cornea.
So I’m going to use a doublearmed suture placement through the tarsal plate, and then place is through the levator, place the suture through the levator muscle. And then on the table we tie these sutures with slipknots to adjust the height and contour. So you can see in this patient I’ve tied the suture, it’s a little bit too high. So then we’ll place the suture lower down in the levator to low it a little bit until we get the correct height and contour. So usually we put three sutures in, a suture over the pupil, one lateral, one medial.
Another patient with an eyelid crease incision. We can do these under straight, local anesthesia. This is just injecting some 1% lidocaine with epinephrine. And you only need about 1 cc to 1.5 ccs. We have gone through this dissection, and when we do this surgery, we remove a little bit of orbicularis muscle to actually reform a lid crease. Here’s, again, the levator mys. Here’s preaponeurotic fat, levator muscle, Whitnall’s ligament is right here. And placing partial thickness sutures through the tarsal plate. And then we can see we’ve placed these sutures through the tarsal plate and then through the levator muscle. So fat, levator muscle, sutures, and the tarsal plate.
We tie these with slipknots first. And then adjust the height and contour. And then in these older patients I also remove some skin when I do the levator advancement. So I mark out an ellipse of excess skin that I’m going to remove. So I just remove the skin. So I go medial, lateral. So the levator is reattached. Then I’m going to place sutures through skin, through levator, through skin again, to reform the eyelid crease. And then tie these sutures and then close the skin in a running fashion.
The other surgery that is very useful and will be useful for you is frontalis sling. Because I see a lot of patients here have poor function ptosis. Often due to trauma. So there are different methods of placing materials in the eyelid to lift up the eyelid. The goal of this surgery is to place sutures or material through the eyelid up to the frontalis muscle so the patient uses the muscles up here, the frontalis muscles, so elevate the eyelids.
This is a material called “Supramid” and I use this in very, very young children. It’s a synthetic material. So these are just some of the different techniques of passing either supramid, fascia, or silicone through the lid. I think this is the technique you use here. The Pentagon, correct? Yeah. So that’s a good technique. But it’s not the technique I’m used to using.
You can also use, for the material to elevate the lid, you don’t have to have this synthetic material. You can actually harvest it from the patient’s leg. And this is fascia lata, and you harvest this from the lateral thigh about 5 centimeters above the knee joint. So you make a line between the head of the fibula and the anterior/superior iliac crest. And you make an incision 5 centimeters above the knee joint. Dissect down to the fascia. And then you can use one of these instruments to actually harvest the fascia.
Or the other thing is, if you don’t have this instrument, you can make an incision inferiorly and then superiorly about 10 centimeters above and use long scissors to cut the fascia. So you don’t have to have this fascia stripper to do this.
So this is an actually adult harvesting fascia. You can see the site of the incision. So I feel the head of the fibula here. Anteriorsuperior iliac crest and make an imagery line between those two. I go from the knee joint. Go 5 centimeters up. And, of course, I shave the leg if I need to. I make an incision about 45 centimeters in length. And I try to get as long of a piece as I can. In this case I’m getting about I guess, about 13 centimeters of fascia. And this just shows what the fascia looks like when you remove it from the leg. It’s a very strong material.
I try to make it about 1 centimeter in width. If I’m doing a bilateral case, I divide it into four segments. So I carefully cut these segments to each one is about 2.5 millimeters in thickness. And, again, there are different techniques. I’ll show you. This is the Crawford technique. This is a classic technique. We have three incisions in the eyelid and two in the eyebrow and one above the eyebrow.
So you are going to pass this fascia between these incisions, bringing the fascia into these corner incisions and then up into the central brown incision. So you basically are making two triangles here and then one triangle in the brow. So this is one patient using the Crawford technique. You can see three incisions in the eyelid crease, medial brow, lateral brow, and 1 centimeter above the brow. And then always use a corneal protector. This is a fascia needle. Right fascia needle.
So you can place the fascia through the eyelid and the needle and pull it out through the brow. And in a similar fashion, pass it between the medial and the central brow or lid incisions. So this is just having passed both fascia strips in the medial triangle and the lateral triangle, bringing the fascia out through the brow incisions. So I’ve passed the fascia through the eyelid. I brought it out this incision and that incision.
And then you can adjust the might and contour by pulling on these strips and you tie knots in the medial and lateral brow incisions. Then you bring the long pieces of fascia up through the central brow incision the central incision. And also tie it there. So this is just a patient that’s had bilateral. This is the same patient, bilateral frontalis slings.
One thing you have to keep in mind when patients have this surgery, they have lid lag on down gaze. The lid lag is on down gaze. The lid stays up when they look down. So this is the way the patient will look when they look down. And when the patient sleeps, the eyelids will be a little bit open. When the patient is sleeping the eyelids will be open a little bit.
So always warn your patients about this preoperatively before surgery. Usually children adjust very quickly to this. Adults may get some initial dryness from this. Yes, sir?
>> Can that patient blink?
>> The patient can blink. The patient can blink, but it’s they don’t blink as completely as a normal patient. So that’s the problem with this procedure, because patients do have lag up thalamus, and the eyelid stays open a little bit. So patients who already have dryness or have poor eye movements are at risk. So you may want to just undercorrect those patients. Patients that are at risk, you undercorrect them. Like that patient I showed earlier with the CPEO. I just bring the lid up to the pupil. And then you have to warn patients they may develop dryness. They may need to use artificial tears, lubricating ointment.
Patients are especially at risk if they have CPEO, myotonic dystrophy, poor bells for whatever reason. What I do in those patients is I use silicone because it’s very easy to reverse. I can take it out and the eyelid will fall back down to where it was before. Sometimes patients really want to have their eyelids lifted even though they’re highrisk patients. So I always tell them about this risk of dryness and the possible need to reverse the surgery.
So levator resection is another treatment for congenital ptosis when the levator function is good. And this is performed very similar to aponeurotic ptosis that we went over, except we actually resect a certain amount of a levator to shorten it and elevate the eyelid. So the way we do this, we find a levator similar to the aponeurotic ptosis. We have to cut the medial horn the lateral horn and the medial horn of the levator. We measure out the amount we’re going to resect. Place our sutures through the tarsal plate and through the levator, and then resect a certain amount of the levator. And there’s some formulas you can use to determine how much to resect.
So this is what’s called a “Ptosis clamp.” But you can use a small hemostat to do this. You don’t need this clamp. So, again, you can see preaponeurotic fat, levator muscle. And the levator has been separated off the underlying tissues. Medial lateral horns cut. And the levator is placed in this either this clamp or a small hemostat. Then taking a calipers, I measure the amount that I want to resect. I resect that amount and then I attach the levator to the tarsal plate. And then the rest of the surgery is exactly the same as in aponeurotic ptosis.
So you can see this is a child with congenital ptosis and moderate function. And this is after doing a levator resection. We can elevate the eyelid, and, at the same time, reform a lid crease. And to reform the lid crease, when you’re closing the skin, you place one suture to the skin. Take a small bite of the levator and another suture to the skin and place three of those. And that reforms the crease.
So that’s actually the end of this lecture. So these are the questions, again. So this is a posttest. So congenital ptosis, A, is always associated with poor levator function. B, is unilateral in about 75% of cases. C, never needs surgery before 5 years. And D, is usually associated with superior rectus weakness. So everybody click your clickers. Yes! Very good. Okay.
No, it’s associated with superior rectus weakness in only about 5% of cases. Only about 5%. And it’s not always associated with poor levator function. It can be associated with good or sometimes even excellent levator function. So that’s why we have different surgeries. If it’s poor levator function, we use that frontalis sling. If it’s good levator function, we may do a levator resection. So you can have varying amounts of levator function depending on how fibrotic the muscle is. Adult involutional ptosis, A, usually has excellent levator function. B, is most commonly caused by previous eye surgery. C, is usually treated with a frontalis suspension. And, D, is associated with a systemic disease.
Adult involutional. Also called aponeurotic ptosis. The answer is actually A. A aponeurotic ptosis usually has excellent levator function because what happens is the levator muscle is normal. It just has slipped back a little bit. So even though the eyelid is ptotic, when you test the levator function from down gaze to up gaze, usually have excellent excursion. Which is like 1520 millimeters. Usually poor function is more associated with traumatic ptosis or congenital ptosis. The involutional ptosis due to separation of the levator muscle usually has excellent function.
And it’s most commonly caused just by aging. It can be associated with eye surgery, but the more common cause is just growing older. Detached, just weakened. It’s what we call an involutional. They used to call it senile ptosis, but that has bad connotations. So nobody calls it senile, because not many patients want to be classified as senile. It’s called “Involutional.” That just means” Agerelated,” something that happens when you get older due to gravity and agerelated changes. The other thing that I see in my practice is a lot of young adults have this due to contact lenses.
Because by manipulating their eyelid to take the lens out and put it in over and over, they actually cause the muscle to disinsert. So it’s very common in young adults who have been wearing contact lenses for, let’s say, 10 years or so. Repeated trauma to the eyelid can cause those attachments to weaken and that mys toll disinsert. I think that about wraps it up. Are there any questions?
>> Please, concerning frontalis you mentioned, do you always do it bilaterally even if the ptosis is unilateral?
>> That’s a good question. No, I don’t. You know, some people teach that you should because you may have some asymmetry, but I find in my practice very few parents want their child to have surgery on their normal eyelid. I find I get into a unilateral and get pretty good symmetry in primary position. But I always warn the parents that the patient, when they look down, one eyelid may hang up a little bit. And when they sleep, one eyelid may be a little bit open.
But most people are accepting of that and would rather have that than to operate on the good lid. Because if you operate on the good lid, you have to disable the levator and then do a frontalis sling. And so you’re taking a normal eyelid and disabling it to put in a frontalis sling. That used to be the teaching for unilateral congenital ptosis is to just do both sides. It’s called the Beard procedure after Carl Beard. But most oculoplastic surgeons I know don’t do that. Unless, of course, it’s a bilateral case, you would. But if it’s a unilateral case most people these days do just one side. But that’s an excellent question. Because if you do one side, there will be some asymmetry. Always. You can never get the lids to be exactly symmetrical by doing one frontalis sling. Okay? Any other questions? That was a really good question.
I don’t really I don’t use FasanellaServat. Sometimes I’ll use a conjunctival Mullerectomy. But which is similar, but in FasanellaServat, you actually remove part of the tarsal plate. And I don’t do that. I don’t really find it’s necessary. You could do a similar procedure, conjunctival Mullerectomy, where you just remove conjunctival Muller’s muscle above the tarsal plate and that seems to work very well. I usually use that in young patients with an aponeurotic ptosis, but I would like a levator advancement, because I could adjust the lid crease. I can adjust the contour on the table. And I can remove some excess skin and I can do a little bit of a blepharoplasty with it, so I find that in most of my patients they’re happier to have all of those things done.
So I try to do that. Especially my older patients, because if you elevate their eyelid and they have excess skin, they have excess fat, elevating the eyelid actually accentuates that excess skin. So you can get the perfect height of the lid, but then you have this excess skin kind of hanging down and touching the lashes. So I like to take that out and take it out a little bit of the medial fat pad at the same time. So I do it all through one incision in most cases.
With myasthenia gravis, the prognosis is really good. What I do is I they’re usually treated with Mestinon, a medication for myasthenia. And then sometimes even on maximal treatment for their myasthenia, they may have some ptosis, but I’ll wait until they’re maximally medically improved where they cannot be improved anymore on maximal medical therapy and then I’ll treat them as a ptosis based on that. On treatment. Because, you know, they need systemic treatment anyway, and if you treat them off medication, then you’re going to overcorrect them. You want to treat them when they’re on medication.
So first I make sure that they’re maximally medically treated, and then I’ll go ahead, and I may advance the levator a little bit more if I need to. After they’re treated. That’s another question. Just about the techniques of doing a frontalis sling. The different patterns you put in the eyelid. There’s several different patterns. So you can do just a pentagon. You can do a Crawford technique, which is two basedown triangle in the lid and then a base down triangle on the forehead.
Or as I was showing my trainees yesterday, you can do a double rhomboid technique where all three incisions are in the eyebrow. Really, that’s a matter of preference. I know different doctors who are excellent oculoplastic surgeons just do it differently. Like in my hands I like to do what I called double rhomboid because I think I can adjust the height and contour better. But, again, that’s a matter of surgeon preference. It’s just like different people do it in different ways. It’s kind of what you what you learn, what you find works best in your hands. And all of them are good. You can get good results out of all the different techniques. It’s just a matter of preference.