Overview of Blepharoplasty Ptosis Surgery
Blepharoplasty is a general term for a surgical procedure that fixes issues with the eyelids. These issues could be problems with the way the eyelids look or work, or both. This surgery is often done for cosmetic reasons to make the eyes look more appealing. It involves removing or repositioning extra skin and fat.
The most common issue addressed by this surgery is droopy upper eyelids, a condition known as ptosis. In such cases, surgeons often perform a combined procedure that adjusts the levator aponeurosis, a muscle that helps the eyelid move. This is repositioned on the tarsal plate, the dense connective tissue that gives the eyelid its shape. The height of the eyelid is then adjusted, and excess skin and fat are removed to create a more youthful look.
However, sometimes this surgery is done not just for cosmetic reasons, but also because the condition of the eyelid is affecting the patient’s vision. This could be caused by too much fat in the upper eyelid, abnormally enlarged orbicularis (eyelid muscle), loose skin, or droopy eyelashes.
The main cause of droopy upper eyelids is levator dehiscence. This is when the levator muscle separates from where it’s supposed to be, and this often happens with age. But it can also happen due to infections, injuries, tumors, or inflammation. Other less common causes include conditions such as myasthenia gravis (a neuromuscular disease that causes weakness in the skeletal muscles), trauma, tumors, birth defects, nerve damage or a condition known as Horner syndrome.
Before the surgeon attempts a repair, it’s important to make sure that the levator dehiscence is the actual cause of the droopy lid. If the levator muscle is not functioning well or not functioning at all (less than 4 mm of movement), adjusting it might not provide enough lift to the eyelid. In such cases, a different technique known as a frontalis sling is used, which involves using a synthetic material to connect the eyebrow muscle to the eyelid, helping it move better.
Anatomy and Physiology of Blepharoplasty Ptosis Surgery
The top lid of your eye is made up of several layers. Starting from the outside and moving toward the inside, these are: skin, the orbicularis muscle, a tissue wall called the orbital septum, fat pads known as pre-aponeurotic fat, the levator muscle, Muller’s muscle, a stiff plate of connective tissue called a tarsal plate, and finally a smooth, thin layer called the conjunctiva.
The layer of fat, known as pre-aponeurotic fat, is often called a surgeon’s friend during eyelid surgery. This is because it is located right in front of the levator muscle, which controls the movement of the eyelid. As long as the surgeon works in front of these fat pads, they can perform their task without harming the important muscle that helps open and close your eye.
Why do People Need Blepharoplasty Ptosis Surgery
Ptosis surgery, a procedure to correct a drooping upper eyelid, is considered when a person’s vision is affected by the eyelid’s position. Common complaints from people with this condition include losing peripheral (side) vision or having to look through their eyelashes because of the drooping eyelids. Some people even find that they see better when they manually lift their eyelids with their fingers or use their forehead muscles to raise their eyebrows.
Having excessive skin on the upper eyelids can also create similar vision problems. This is because the extra skin can hang over the edge of the eyelid, obstructing vision like a lowered window shade. To confirm the loss of peripheral vision, doctors may carry out a vision field test, known as perimetry.
If the drooping eyelid or excessive skin is causing a loss in the field of vision, health insurance may cover the cost of the correctional surgery as long as the doctor provides proof of the visual issues caused by the ptotic (drooping) upper eyelid or excessive eyelid skin.
When a Person Should Avoid Blepharoplasty Ptosis Surgery
Surgery to correct droopy eyelids, known as ptosis surgery, may not be a suitable option for some people due to risks linked to their eye health, especially the cornea (the clear, round dome covering the front of the eye). Certain medical conditions including thyroid eye disease, gradually worsening outward turning eyes, or the loss of involuntary eyelid closure (Bell’s phenomenon) can make a person more susceptible to a condition called exposure keratitis (inflammation of the cornea due to dryness) after the surgery. This means these patients need more cautious treatment plans.
Assessing for dry eye is crucial since the risk of worsening dry eye symptoms post-surgery needs to be identified. Also, if there’s a chance a patient might have a condition called myasthenia gravis (which causes weakness in the skeletal muscles), they need to undergo certain medical investigations including tests for specific proteins (acetylcholine receptor antibodies) and another test called the tensilon test.
If myasthenia gravis is confirmed, patients are recommended to try a medication called Mestinon before deciding on surgery. This highlights the importance of a thorough check-up before undergoing surgery for droopy eyelids not only to rule out other causes of the condition but also to identify any potential risk factors.
Imaging of the eye sockets using CT scans should be done if any abnormality such as thyroid eye disease or a tumor in the eye region is suspected. An examination using a slit lamp (a microscope used by eye doctors) is necessary to detect conditions like corneal erosions or dry eye.
Who is needed to perform Blepharoplasty Ptosis Surgery?
A type of eyelid surgery, blepharoplasty or ptosis surgery, often requires a team of medical professionals. This team usually includes someone called a scrub tech, who assists the surgeon during the operation, and a circulating nurse, who does important tasks like fetching instruments and ensuring the environment is safe. Additionally, a nurse anesthetist (who administers an anesthesia or medicine to numb the pain) should be present, along with an anesthesiologist (a doctor who specializes in pain relief during and after surgery). A key part of the process is constantly watching over the patient, to make sure the procedure is as safe as possible.
Preparing for Blepharoplasty Ptosis Surgery
Before any surgery to address droopy eyelids, or ‘ptosis’, it is crucial that doctors conduct an initial evaluation. This is done to make sure the cause of the drooping is related to the muscle (the levator muscle) responsible for lifting the eyelid. They’ll also confirm that strengthening this muscle (or ‘levator advancement’) will indeed fix the problem. Before going ahead with the surgery, doctors also need to make sure that the patient doesn’t have additional conditions like tumors, a neuromuscular problem called myasthenia, or severe dry eye conditions that could complicate the procedure.
How is Blepharoplasty Ptosis Surgery performed
Before the operation, it’s necessary the patient is examined a second time. The operation will take place on the eyelid, but it’s important to mark out where everything is while the patient is sitting, to maintain the correct brow and eyelid levels. The surgery is known as a Blepharoplasty and it can be performed on its own or along with a ‘ptosis repair’, a procedure to fix drooping of the upper eyelid. Based on this, we’ll mark out where any excess skin needs to removed.
In the operating room, the patient is put into a drowsy state through light sedation, without fully putting them ‘under’ as an active response to instruction is needed. A combination of painkillers and a substance called hyaluronidase (which helps the other drugs spread more effectively) are injected into the skin over the bone structure that makes up the eye socket. The patient’s face is then properly prepped and covered appropriately for surgery.
The skin cut is made along the upper eyelid and any bleeding is quickly managed. The surgeon is then able to see and cut down through muscles until they reach a sheet of tissue (orbital septum) that holds everything in place. Depending on the patient’s age and the current state of their eyelid, some muscle may need to be removed. Gentle pressure on the eyeball reveals the layer of fat just underneath that sheet of tissue. This layer of fat and the next underlying tissue layer (levator aponeurosis) are separated gently, and the surgeon can then proceed to expose another tough, fibrous sheet (the tarsal plate) by removing more muscle. This whole process is done carefully to avoid any injury.
Distinguishing the tarsus from other tissue components can be tricky, so everting the eyelid or flipping it inside out can reveal it. Once identified, the tarsus is handled carefully using a non-absorbable thread to hold everything in the right position. When this is done, the patient’s eyelid is closely inspected to make sure no injury has taken place or any adjustment is needed relating to the height or the shape of the eyelid. The patient can then be asked to open their eye to evaluate these. Any adjustments will be made as needed and once everything is satisfactory, the patient is free to rest while the surgeon continues their work.
The level of the patient’s sedation may be increased to relieve discomfort as the operation continues. The surgeon takes care not to remove the lacrimal gland which is situated far to the side in the eye socket. This gland is different from other tissue as it appears paler and sometimes pink. If the lacrimal gland is accidentally shifted, it can be stitched back in the appropriate location. The surgeon will then remove any excess skin and muscle over the wound. The area of the skin incision is then closed with absorbable stitches and a combination of steroid and antibiotic is applied over the operation site to prevent infection.
The patient’s eye is then patched overnight and ice packs applied to help with any swelling.
Possible Complications of Blepharoplasty Ptosis Surgery
One common issue after eyelid surgery is an uneven height or shape of the eyelids. This can generally be corrected with a follow-up surgery. However, a severe complication called an orbital hemorrhage, which is basically severe bleeding in the eye socket, could lead to blindness if not immediately identified and treated. If the bleeding is serious enough, it could compress the optic nerve (the nerve that sends visual information from the eye to the brain) and cause vision loss.
Quickly opening the surgical wound and draining the blood should solve the issue, but it’s essential that it’s identified quickly. If this happens, patients usually report a lot of pain. Therefore, if you’re experiencing severe pain after this surgery, it’s necessary to get checked out quickly. If the pressure in the eye becomes too high due to a hemorrhage, the surgical wound needs to be promptly opened and the excess blood drained to avoid long-term damage to the optic nerve.
While post-surgery infections are rare, orbital cellulitis, a type of eye socket infection, can occur since the orbital septum (a thin tissue barrier in the eye socket) is opened during surgery. Infections can be treated with heat and the right systematic antibiotics, as chosen by the doctor. To lower the chances of infection, your surgeon might irrigate the site of the surgery with a solution containing the antibiotic gentamycin.
What Else Should I Know About Blepharoplasty Ptosis Surgery?
Patients see improvements in their appearance and eye functionality from a combination of ptosis and blepharoplasty treatments. In these procedures, the eyelids are lifted to a natural position which enhances side vision. It also gives the eyes a rejuvenated look, giving them a younger appearance.
