Three Different Anesthesia Approaches in Blepharoptosis Surgery

Ziyi Guo, MD; David Dae Hwan Park, MD, PhD; Kisoo Park, MD; Naiqiang Guo, MD


Plast Reconstr Surg Glob Open. 2019;7(4):e2136 

In This Article

Materials and Methods


This study compared the outcomes of 101 blepharoptosis cases operated on under 3 different anesthesia approaches: general, local, and sedative anesthesia. The Müller aponeurosis composite flap advancement procedure was performed by 1 senior consultant from 2010 to 2016.

Thirty-four (60 eyelids), 38 (49 eyelids), and 29 (42 eyelids) patients received general anesthesia, local anesthesia, and sedative anesthesia, respectively (Table 1).


Preoperatively, the ptosis degree of severity and the levator and frontal muscle functions were measured. The marginal reflex distance (MRD1) and eyebrow height were recorded (Table 2).

Accurate measurements in 2-dimensional views were acquired by measuring the corneal exposure area (CEA) to record the severity of blepharoptosis.[1]

The selection of the anesthesia approach was based primarily on patients' condition (whether they could cooperate or not) and not by the preoperative MRD or levator function. Patients who can coordinate were included in the local anesthesia or sedative groups. Patients too young to cooperate were assigned to the general anesthesia group.

Anesthesia Approach

General Anesthesia Approach. General anesthesia was induced by an intravenous injection of either pentothal sodium or propofol followed by the inhalation of sevoflurane (2.5–3.5 vol%) and a 1:1 mixture of N2O:O2 at 3 L/min.[5,7,8]

Local Anesthesia Approach. A local injection of lidocaine/adrenaline with a normal saline solution (mL) (2%–4%) was performed. The maximum medication dose was no more than 4.5 mg/kg.

Sedative Anesthesia Approach. The sedatives group was based on local anesthetics with an additional intravenous injection of precedex 0.5 μg/kg/h. The medication was stopped when the patients were required to wake up.

Surgical Methods

The Müller aponeurosis composite flap advancement was used in this study. Before the operation, we measure the levator function and degree of ptosis. We decided how much advancement of aponeurosis before operation according to the degree of ptosis and the levator function. Usually, we decided 3 mm advancement Muller aponeurosis flap for 1 mm of ptosis correction. The skin crease was marked, and an upper eyelid crease incision was performed, followed by a dissection through the orbicularis. The preaponeurotic fat was identified as a guide to the levator muscle. Local anesthesia was then applied to the conjunctiva to achieve a hydrodissection effect, followed by a vertical incision through the upper transconjunctiva. The Müller muscle was separated from the conjunctiva using blunt scissors, and the Müller muscle was then detached carefully from the superior portion of the tarsus. The Müller muscle-levator aponeurosis flap was then dissected and advanced with a resection if needed. The elevated flap was fixed to the tarsal plate at the appropriate level with a 5–0 polydioxanone suture at 2 to 3 points.[1]

During operation, we adjust the lid level according to preoperative calculation. We do not use a gaping technique. But, we made a symmetrical gap in bilateral ptosis cases. We decided to resect a portion of the flap after we fix the Müller aponeurosis flap to tarsus. If the length of the remnant flap is long and over the skin incision margin, then we resect the remnant portion of the flap. How much flap excision depends on how much flap there is over the skin incision margin. The flap over the skin incision was resected.

There is no specific method to calculate the exact eye position changes in patients under general anesthesia. For adult, a recommended method is to mark the level of the superior limbus on the patient's nasal dorsum when in the primary gaze position. Otherwise, Krimsky's test result is needed to adjust the position of the upper eyelid fixation 30 min after anesthesia induction. If it is not possible to achieve both individual modification and preoperative markings according to eyes position change, the 1-mm fixation level below the superior limbus is recommended for surgical correction.[5]