Involutional Ptosis Repair and Considerations During Blepharoplasty

Involutional ptosis is the most common cause of acquired upper eyelid drooping in adults. It results from attenuation or dehiscence of the levator aponeurosis and leads to functional and cosmetic impairment, including superior visual field obstruction and psychosocial distress. The condition is often accompanied by dermatochalasis, making combined ptosis repair and upper eyelid blepharoplasty essential for optimal outcomes. This chapter reviews the anatomy and physiology of the upper eyelid, highlighting the roles of the levator palpebrae superioris and Müller’s muscle in eyelid elevation. It discusses age-related changes, including loss of skin elasticity, levator disinsertion, and brow descent, which contribute to both ptosis and dermatochalasis. The chapter provides a thorough approach to clinical assessment, focusing on critical diagnostic measures such as margin-reflex distances, evaluation of levator function, and the phenylephrine test. It also underscores the need to distinguish involutional ptosis from other etiologies, including neurogenic, myogenic, and mechanical types. Surgical management aims to restore normal eyelid anatomy by reattaching the levator aponeurosis to the tarsus. Two primary surgical approaches are commonly employed: external levator advancement and posterior Müller’s muscle–conjunctival resection (MMCR). The selection of technique is guided by the severity of ptosis, levator muscle function, and individual patient characteristics. Considerations for simultaneous blepharoplasty, including eyelid crease repositioning and management of fat herniation, are detailed to enhance both function and aesthetics. Postoperative care involves managing edema, exposure symptoms, and asymmetry, with most patients achieving improved eyelid symmetry, an MRD1 > 3 mm, and restored visual fields. By integrating anatomical understanding with precise diagnosis and surgical planning, clinicians can achieve predictable and satisfying results in the management of involutional ptosis with or without concurrent blepharoplasty.