Ptosis surgery - what are the pros and cons of anterior vs posterior approach, when a revision upper bleph is also required?

Question

Almost 2 years post upper bleph, which needs revision for raised lumpy scarring, high crease etc. Had consultations with 3 oculoplastic surgeons, with different opinions. I also have ptosis in both eyes. I see the advantage of (scarless) posterior ptosis repair alone. However, if the surgeon is making the eyelid incision anyway for the revision upper bleph, why not do the anterior ptosis repair through the same incision? Preferred surgeon wants to do posterior repair. I'm a contact lens wearer.

Kenneth D. Steinsapir, MD · Answer

Of course you have handicapped us by not even providing a photograph.  However, the high crease is a marker that the levator aponeurosis is disinserted in your eyelid.  That means that the mechanics that are the basis for a successful Muellerectomy (posterior approach ptosis repair) will not work-the levator is not in position and the mullerectomy will be ineffective.  The only viable option for you is to have an anterior approach upper eyelid surgery that will control the upper eyelid platform skin, lower your upper eyelid crease, revise the unsatisfactory prior scar, support your upper eyelid lashes, and repair the upper eyelid ptosis by physiologically repositioning the levator aponeurosis tendon where it belongs. The septal scar from prior surgery can be broken up and anterior orbital fat brought down from he orbit to reestablish fullness of the upper eyelid fold.  The reason why your surgeons have not proposed this is that they do not understand what is going on inside the eyelid. They are simply looking at the ptosis.  You need a comprehensive approach to the eyelid.

Mehryar (Ray) Taban, MD, FACS · Answer

The main advantage of posterior ptosis surgery is not the scarless result (although that is nice) but it is more predictable results with better eyelid contour. However, not everybody is a candidate for it and not every surgeon uses it. See following video and link.  Revision blepharoplasty can still be done while ptosis (muscle tightening) is done posteriorly.

Daniel Ezra, MD, FRCS · Answer

I think that your question is very perceptive, and this a question I regularly ask my own registrars. In a nutshell, a posterior approach ptosis is a nice procedure but only suitable for patients with an adequate skin crease. The great strength of the anterior approach is the ability to control the skin crease. Whilst one can improve the skin crease with a posterior approach procedure to a degree, a case like yours where you have previously had surgery and where there has been scar tissue would mean that you would need an anterior approach for best results. I do share your feeling on this... Common sense would render it fairly absurd to make an incision in the skin for the bleph and then another behind the lid for the ptosis repair when the whole point of the posterior approach would be to avoid a skin scar!I'm just speculating, but I wonder whether the reason you are getting contradictory advice is that the surgeon in question probably only does posterior approach and may not be comfortable with an anterior revision which is more complex. One does tend to see this bias in surgeon procedure decisions quite often.

David Cheung, MBChB, Bsc(Hons), FRCOphth · Answer

Hi Peta.  Most of my oculoplastic colleagues in the UK still go for an anterior approach as that is how most of us have been trained. Increasingly there's a vogue though for a posterior approach as the recovery time is quicker, there's reduced risk of scarring of the skin and theoretically it makes more anatomical sense. Quite a few of my colleagues do report good results for contact lens related aponeurotic ptosis (with high creases) via a posterior approach (e.g. white line advancement surgery). I personally still prefer an anterior approach as I like to reform a skin crease properly and it's just an approach I'm most happy with.  As you say it makes sense to go for an anterior approach if you need a revisional blepharoplasty anyway and seems illogical to cut through the skin and then again through the back conjunctiva. If the ptosis is very mild though then some surgeons prefer a posterior approach as they feel their results are more predictable plus they can offer adjustability post op.  Either way the most important thing is find a surgeon whom you're most comfortable with. Both approaches have their pros and cons

Ptosis surgery - what are the pros and cons of anterior vs posterior approach, when a revision upper bleph is also required?

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