Overview of Ptosis Correction
“Ptosis” comes from the Greek word for falling, and it’s used to describe the drooping of a body part. In this context, we’re talking about “Blepharoptosis,” which is just a fancy term for drooping of the upper eyelid.
The shape and position of our eyes, eyelids, and eyebrows play a big part in shaping our unique looks. So, when the eyelids start drooping, it can alter a person’s appearance, sometimes causing functional issues (like obstructing vision) or purely cosmetic concerns.
Droopy eyelids can occur at any age and can be triggered by a variety of factors. If someone is noticing their eyelids drooping, it’s just a symptom and not necessarily the definitive problem. Proper evaluation is crucial to identify the root cause.
There are two main classes of “droopy eyelid” conditions: true ptosis and pseudoptosis. True ptosis is then further divided based on when it appears in a person’s life. It could either be inborn (congenital) or develop later in life (acquired).
Within the “Acquired ptosis” class, there are several types such as:
1. Aponeurotic ptosis
2. Neurogenic ptosis
3. Myogenic ptosis
4. Mechanical ptosis
5. Traumatic ptosis
Aponeurotic ptosis is the most common type among adults and typically appears in middle-age. Sometimes it happens due to reasons like an eye injury, recent eyelid swelling, after an eye surgery or prolonged use of contact lenses. In such cases, the issue arises due to a disconnection or tearing of the levator aponeurosis, a muscle that helps lift the eyelid.
Neurogenic ptosis happens when the nerves controlling the muscles that lift the eyelid are disrupted. This could be caused by a third cranial nerve palsy or Horner syndrome, conditions that affect eye and eyelid movements. Treatment for these conditions can be complex due to additional risks, the first step often involves fixating the visual deviation, followed by a correction to lift the droopy eyelid.
Myogenic ptosis is the result of an issue with the levator muscle itself. Disorders like Myasthenia gravis or Myotonic dystrophy which cause muscle fatigue, weakness and can affect facial expression often result in this condition. In severe cases, it might be necessary to do correct the droopy eyelid with planned under-correction surgery.
Mechanical ptosis is caused by any external pressure on the lid, this could be from a tumor, scarring, or an issue called blepharochalasis.
Lastly, traumatic ptosis occurs when the levator muscle, which helps in lifting the eyelid, gets damaged due to either direct or indirect trauma.
It’s important to remember that these are all possible scenarios for droopy eyelids and a proper diagnosis is necessary to identify the exact cause and appropriate treatment.
Anatomy and Physiology of Ptosis Correction
The opening between your upper and lower eyelid is called the palpebral fissure. It’s shaped like an ellipse. The curve of the upper eyelid is most prominent near the nose-side of your pupil. This mark plays a key role during eyelid surgeries for the best cosmetic outcomes. Normally, the upper eyelid shields the top 1-2mm of the iris (the color part of your eye), while the lower eyelid aligns with the bottom of the iris.
When it comes to the eyelid, it is made up of different components:
1. Skin and subcutaneous (under the skin) tissue
2. Orbicularis oculi
3. Orbital septum
4. Preaponeurotic fat pad
5. Tarsal plate
6. Levator aponeurosis and Muller’s muscle
7. Conjunctiva
The skin on your eyelid is incredibly thin, the thinnest in the body to be exact. We have an eyelid crease because of how the levator aponeurosis (the tendon strengthening the main eyelid-lifting muscle) is attached to the skin.
The orbicularis oculi is a circular muscle that consists of three parts: preseptal, pretarsal, and orbital orbicularis. This muscle controls the gentle and forceful closing of your eyelid.
The orbital septum is a multi-layered, thin structure made of fibrous connective tissue. During eyelid surgery intending to fix droopy eyelids, the septum is opened to access the levator muscle. Surgeons need to be careful to not interfere with the septal attachments to the levator muscle so as to avoid making the eyelid pull too much after the operation.
The preaponeurotic fat pad is a small lump of fat that lies between the septum and the levator muscle. This fatty area is easy to locate during surgery, as applying pressure over the eye makes it protrude forward.
The tarsal plate is a dense piece of connective tissue that forms the structural skeleton of the eyelid. Within it are the Meibomian glands, which provide oils for the tear film that keeps your eyes moisturized.
The Levator Palpebrae superioris (LPS) muscle is essentially the main lifter of your eyelid. It starts at the back of the eye socket and moves forward, changing direction from horizontal to vertical at the roof of the eye socket, forming a tendinous sheath known as the levator aponeurosis. A connective tissue called Whitnall’s ligament acts as a pulley for the LPS muscle, which lies about 10-12mm above the tarsal plate.
Muller’s muscle is a smooth muscle controlled by the sympathetic nervous system. It supports the Levator Palpebrae superioris muscle in lifting the eyelid, contributing to about 2mm of the lift.
The conjunctiva is the innermost layer of the eyelid. It’s a smooth tissue that continues over the front surface of the eyeball. It contains cells known as goblet cells, which play a crucial role in keeping your eyes moist by secreting a lubricating fluid.
Why do People Need Ptosis Correction
Many people opt for a type of surgery called ptosis correction because their vision gets blocked or they lose some of their side vision due to a drooping eyelid. A frequent complaint is a feeling of heaviness in the eyelids. Aside from these functional issues, a good number of individuals choose this surgery for aesthetic reasons. This is because a drooping eyelid can make someone look tired all the time.
When a Person Should Avoid Ptosis Correction
There are certain conditions where individuals may face hurdles, such as:
1. Having severe dry eyes
2. Experiencing myogenic ptosis, which is a disease characterized by drooping of the upper eyelid due to muscle weakness, like in the case of chronic progressive external ophthalmoplegia. For these patients, if they plan to undergo surgery to correct the drooping, a less invasive procedure that focuses on improving vision should be chosen.
3. Having a poor Bell’s phenomenon – this is a protective mechanism where your eye rolls upwards when you close your lids. If this reflex isn’t working properly, it can create issues.
4. Suffering from ptosis linked with the oculomotor nerve palsy, a condition that can lead to drooping of the eyelid and other eye movement problems.
5. Having Myasthenia gravis, a disease that causes muscle weakness. Before planning any surgery, these people should be treated with medication like anticholinesterase agents which help improve muscle strength.
Equipment used for Ptosis Correction
For a successful drooping eyelid (ptosis) surgery, the surgeon only needs a few things. These include a set of specific eye surgery tools, a local anesthetic (a medication to numb the area) that has epinephrine, a pen for marking the skin, and a measuring scale. The epinephrine in the anesthetic helps to reduce bleeding during the operation.
Preparing for Ptosis Correction
Before surgery to fix drooping eyelids (a condition known as ptosis), doctors perform a thorough check up. This check up includes discussing the patient’s health history and carefully examining them. This step is very important as it can increase the success of the surgery.
The doctor must discuss the surgery process with the patient so that they understand it well. This discussion includes explaining the goals of the surgery, the surgical technique, size of the cut to be made, and how the scar will look like after surgery. The doctor may also show the patient before and after surgery pictures of other patients to give them a clear idea of what results to expect.
Patients who will undergo a less invasive approach should be shown the expected results. It’s important that the patient is aware of the potential complications, which include overcorrection (the surgery lifts the eyelid too high), under-correction (the surgery does not lift the eyelid high enough), uneven eyelid shape, inability to fully close the eye after surgery, dry eyes, eye exposure to air (which can harm the eye), infection, and the possibility for the drooping to come back after surgery. The patient should formally agree to proceed, indicating that they understand and accept these potential risks.
Before the surgery, the doctor will take pictures of the patient’s eyes. These pictures are not ordinary ones; they are taken with a flash in various direction of gaze including straight, with closed eyes, looking up, looking down and at an angle. These photos serve as a reference for the doctor to compare with the photos taken two months after the surgery.
How is Ptosis Correction performed
The history of ptosis surgery is indeed an extensive one. Ptosis, meaning a drooping upper eyelid, has seen various surgical techniques for corrections over the years. In the early times, doctors simply tried to remove the excess skin on the upper eyelid. Later on, in the 1800s, doctors attempted to lift the eyelid to the brow using dissolvable sutures. These were eventually replaced by more durable materials like silk sutures, and even silicone rod slings in the 1960s, which seemed to reduce some of the difficulties associated with ptosis.
A landmark in ptosis surgery is the Levator resection. This surgery was first done in the 1800s by a surgeon named Bowman, and later developed by other surgeons. It was continuously perfected over the years. This surgery works by shortening the levator muscle, which is responsible for lifting the eyelid. If this muscle doesn’t work properly, it leads to ptosis.
Surgeons Everbush and Wolf in the late 1800s made popular the front or skin approach for ptosis correction. They believed that this approach provided a clearer view of the levator aponeurosis – the part of the levator muscle connected to the eyelid – thereby making the operation more effective.
Nowadays, the most commonly used surgeries for ptosis in adults are Levator repair, which uses the front approach, and Muller’s muscle conjunctival resection, which uses the back approach. Choosing which type of surgery depends on the patient’s specific circumstances, such as the severity of their ptosis.
These detailed procedures can sometimes be overwhelming, but let’s try to simplify one, namely Levator Aponeurosis Advancement. This procedure mainly deals with correcting ptosis due to an impaired levator aponeurosis, usually caused from stretching or thinning of this muscle. The surgery begins by first marking on the upper eyelid where the incisions will be made. Then, local anesthesia is used to numb the area to be operated. Once the patient is ready, the surgeon makes the incision and begins removing the hindering parts. Afterwards, they re-attach the levator aponeurosis to the tarsus, another muscle that supports the eyelid, using a special stitch. After ensuring the eyelid is now at a good position, the surgeon closes up the incision with stitches.
Overall, the complexity of this topic underscores the importance of good communication between doctor and patient. Patients should always feel comfortable asking their doctor questions to better understand their medical condition and treatment options.
Possible Complications of Ptosis Correction
After eye-lid surgery, you might experience some issues such as undercorrection, overcorrection, eye dryness or exposure keratopathy, shape mismatch or eyelid contour defects and extra tissue or conjunctival prolapse.
Undercorrection is when the surgical adjustments were not made enough, making the eyelid appear less corrected due to swelling. However, you don’t need to worry if you notice this issue right after your surgery. It usually resolves as the swelling goes down. If it continues to persist, additional surgery might be needed to rectify it.
Overcorrection means that too much adjustment was made during the surgery. It is often seen after surgery for a drooping lid condition known as aponeurotic/involutional ptosis. Mild overcorrection shortly after the operation can often be managed by exercises that involves looking downward and gently pulling on the eyelashes a few times a day. However, serious cases will require immediate correctional surgery.
Lagophthalmos and exposure keratopathy refer to complications where you may not be able to completely close your eyes and an increased risk of the eye getting dry. This is something you’ll be counselled on before your surgery. After the surgery, you can manage it by using a lot of moisturizing eye drops. For severe cases, a follow-up surgery might be done to reduce the height of the lid.
Another possible issue after eyelid surgery is eyelid contour defects. These are shape changes in your eyelid due to improper placement of sutures (or stitches), during the surgery. With time and some eyelid exercises, minor shape displeasing can resolve on their own. But for persistent or severe cases, another surgery to place the sutures correctly might be needed.
Sometimes, after the surgery, the tissue that lines the inner surface of eyelids (the conjunctiva) might bulge out causing conjunctival prolapse. This issue can be resolved using lubricants or through surgery, if the bulge is quite substantial.
Eyelash ptosis is a condition where the eyelashes droop or tilt inwards, usually due to excessive handling during the surgery. This can be adequately corrected with further minor surgery.
A granuloma or a small lump that forms at the stitch site can also occur after the surgery. This lump can be removed surgically and the stitch that has caused the lump will also need to be taken out.
What Else Should I Know About Ptosis Correction?
Correcting droopy eyelids (a condition known as ptosis) helps improve your vision and also enhances your physical appearance. This procedure gets rid of the heavy feeling in your eye. Many people find that they look and feel younger after the treatment, which adds to their overall happiness and quality of life.
