Ptosis repair and 4-lid blepharoplasty: postoperative course

By Joseph Walrath, MD | Nov 29, 2014 | Blepharoplasty, Cosmetic, Ptosis

The preoperative evaluation, postoperative course, and 3 month result of a patient are described in this post.


This patient complained that her upper lids are interfering with her vision.  As can be seen below, the upper lid on the right is actually below the center of the pupil.  The left upper lid is also quite low, within the pupil itself.


Testing was done in the preoperative visit, which demonstrated that vision indeed was adversely effected, to the level required by Medicare. It was therefore appropriate to submit upper eyelid surgery to Medicare for coverage.

In addition. this patient complained about her lower eyelid appearance.  We discussed fat transfer across the “trough” beneath the lower lids, just under the bags, with the goal being to smooth the transition between the lower eyelids and the cheeks. Additionally, she manifested relatively loose lower lids, and this was factored into the operative plan.

During the consultation, we discussed that she would also benefit from full face laser and facelift for the lower face, and I offered to refer her for these services to one of my associates, but she decided not to pursue that treatment.

The final surgical plan was:

  • Lift both upper lids (insurance)
  • Remove excess tissue from both upper lids (included with insurance portion)
  • Bilateral lower blepharoplasty with fat transfer, lateral canthoplasty, and skin flap (cosmetic)

One week later, she returned for suture removal:


Small cheek sutures are visible — those are the fat transfer sutures.  The other sutures are still visible.  Below, sutures are being removed — this should not be a painful process!


At 3 months, she is seen below:


For reference, her preoperative photo again: