In other patients, surgery may be required because recurrent ptosis may occur following even well-placed Botox injections. Eyelid-opening apraxia is also an indication for surgery. Many patients elect surgery because they do not look forward to a hundred or more cycles of Botox injections during their remaining life expectancy. There is a study at the University of Minnesota that is seeking to recruit 30 patients for this treatment. Anticholinergic and other medications taken by mouth may extend the time between treatments or help with the lower face spasms.
Most patients abandon the pills due to bothersome side effects.
Cosmetic blepharoplasty alone is insufficient because it does not remove enough of the squeezing muscle to reduce the effectiveness of eyelid closure. Our laboratory has extensively studied the anatomy and physiology of the eyelid and we do not believe that cosmetic blepharoplasty will provide anything but very short-term relief. Patients will continue to require Botox injections at about the same preoperative frequency. Limited myectomy of the upper eyelids with blepharoplasty and possibly a ptosis operation will generally give a pleasing cosmetic result and remove enough of the orbicularis oculi muscle and elevate the eyelid sufficiently to reduce the long term dependency on Botox injections of the upper eyelids. Most patients will still require Botox injections of all 4 eyelids but will find them more effective because there is less muscle to be stimulated by the overactive nerves.