Ptosis is known as an eyelid condition characterized by weakness in the eye elevating muscle. Usually, people who suffer from ptosis have droopy eyelids, often making the patients appear sleepy, tired and even harsh. The droopy eyelids hinder the amount of color aspect shown in the eyes, making them appear exhausted. This operation is necessary for many Asian patients whether they are elderly, or patients who seek a more radiant and vibrant appearance. There are also a handful of patients who have undergone inadequately performed double eyelid surgeries, and thus need revision to their asymmetric eyes.
This disorder can affect one eye or both. Ideally, the lid position should allow 80 to 90% of the color aspect of the eye (iris) to be visible. In most cases, a patient showing anything less is considered to have ptosis. Some physical problems associated with this disorder are headaches due to eye and brow strain, inability to read for prolonged periods of time, as well as forehead wrinkles. These symptoms are related to patients with severe ptosis. However, patients with mild to moderate ptosis do not exhibit these symptoms apart from forehead wrinkles. Patients with mild ptosis may appear tired while those with moderate ptosis have a harsh appearance.
Types of Ptosis
There are two main types of ptosis–congenital ptosis and acquired ptosis (also referred to as senile ptosis). The two types of ptosis are not mutually exclusive of the other. The spectrum of the type of ptosis a patient can have can range from borderline to severe or in some cases a combination of the two. A skilled surgeon must be able to distinguish such differences in order to correctly diagnose patients and determine the most suitable surgical technique for the ptosis correction.
Congenital ptosis is due to an intrinsic muscle disorder. This disorder results in cellular degeneration and fat infiltration of the eye muscle responsible for raising the eyelid.
The severity of this disorder can range from the eye(s) being significantly shut to having to lift one’s brows in order to keep the eye(s) open.
Ptosis can be hereditary, as patients can be born with the condition. Treatment is especially important for infants as it causes loss of vision, which leads to impaired brain development. Adolescents that develop this disorder will begin to appear sleepy. Many times young ptosis patients will lift their brows as a way to raise their eyelids. This strains the forehead muscle, and eventually the patients will become tired of the continuous strain of lifting their brows. Some patients will accept their conditions and live with smaller, droopier eyes, while some patients seek treatments. Congenital ptosis is a progressive disease and even after correction surgery, revision corrections are likely to follow.
Acquired ptosis typically develops in elderly adults, but there have been cases where it has developed in patients even in their early 30s. Many of these patients begin to notice a decrease in the size of their eyes mainly due to drooping eyelids. Unlike congenital ptosis, acquired ptosis can be due to severe tearing and stretching of the levator muscle.
About Ptosis Repair
Vertical eye enlargement increases the amount of color aspect of the eyes that is shown to correct sleepy eyes.
Vertical eye enlargement widens the eye vertically so as to remove any upper visual obstruction experienced by the patient due to weak eyelid elevating muscle. There are two conventional methods to achieve a vertically enlarged eye. The first method is double eyelid surgery, or Asian eyelid surgery. The second method is called upper blepharoplasty, which involves removal of excess skin on the upper eyelid.
The basic principle of double eyelid surgery is the anchoring of the eyelid skin to the eye elevating muscle. By doing this, additional weight is placed on the eye elevating muscle. Ptosis patients, due to their weaker eye muscle, cannot tolerate this additional weight placed on their eye elevating muscle (levator aponeurosis). Therefore, prior to undergoing double eyelid surgery or revision double eyelid surgery, it is imperative this condition be diagnosed and corrected at the time of surgery. Otherwise, patients will not get the best results that they desire.
Despite the conventional methods described, the most effective method is a very complex procedure called ptosis repair. This process involves tightening of the muscle that elevates the upper eyelid, or the eye elevating muscle so that it has more power and effectiveness in opening the eyes.
It is an extremely delicate process which requires immense amounts of dexterity and extensive knowledge and skill.
The tightening process concerns a fragile area with many layers of fine tissue and a considerable amount of blood vessels. It also requires the surgeon’s ability to gauge how much tightening or loosening is required on the eye elevating muscle. Dr. Kim has successfully executed numerous ptosis repair surgeries for various purposes. He performs them regularly for elderly patients who experience visual obstruction due to excessive eyelid hooding, and for patients who need it for double eyelid surgery.
Before and After Photos
Reasons for Ptosis Correction
There are three main reasons ptosis correction is required. One is for aesthetic reasons. Patients with ptosis have their eyelids positioned below the ideal height and tend to look harsh and unfriendly. Therefore, it can hamper their day-to-day interactions with other people as a result of insecurities associated with how they appear. Another reason is dysfunctionality of their eyes, as patients who suffer from ptosis have difficulty opening their eyes and are forced to strain their brows and wrinkle their forehead. Lastly, patients seeking double eyelid surgery must undergo ptosis correction.
Without ptosis correction, the double eyelid surgery will further exacerbate or bring out their ptosis condition.
Anatomy of the Eye and Ptosis
There are two muscles that are responsible for raising or elevating the eyelid—the levator muscle and the Müller’s muscle. The levator muscle is a more superficial muscle and sits above the Müller’s muscle. These two muscles work in concert to lift the eyelid. The levator muscle is controlled by voluntary signaling, whereas the Müller’s muscle is controlled by involuntary signaling.
Patients with severe congenital ptosis have a weakening of both levator and Müller’s muscles; therefore, correction requires tightening of both muscles.
In mild to moderate cases, ptosis surgery can be performed with correction of Müller’s muscle only. In patients with acquired ptosis, correction requires the strengthening of the levator muscle or the Müller’s muscle. In this case, determining which muscle to correct is based on which muscle is dysfunctional.
Types of Ptosis Repair
Borderline ptosis can be difficult to correct with the traditional open technique, as mild ptosis requires a very fine tightening of the muscle.
The traditional method of the surgical correction of ptosis was merely the tightening of the levator muscle. This method was further advanced with the tightening of the levator as well as the Müller’s muscles, providing more efficacy. The latest advancement involves a minimally invasive technique which is done by plicating or resecting the muscle without making an incision on the skin. This method can be performed on patients with borderline to moderate ptosis.
Non-incisional ptosis correction is especially useful when the patient has had prior eyelid surgery, and would like to avoid having further incisions.
Non-incisional ptosis correction method can be useful for patients with borderline ptosis. This involves flipping the eyelid and working on the inner, deep aspect of the eyelid. The result is less traumatic to the eyelid tissue since less additional surgical incision is made. It is also helpful in creating the most natural and dynamic double eyelid fold, as the anatomy that is involved in fold formation is not disturbed.
An advancement with ptosis correction for severe ptosis involves simultaneously tightening both muscles to provide maximal eyelid functionality and durability to the ptosis repair compared to the prior method. Another advancement with severe ptosis is coupling the eye elevating muscle to the superior rectus muscle. The advantage of this technique, compared to the traditional method of elevating to the forehead, is that the eyelid mechanism is significantly more natural.
Ptosis can negatively affect the function of one’s eye(s) and one’s appearance.
Ptosis correction is an extremely challenging surgery, as it requires the patient to be fully conscious and cooperative. Thus, patients are given only local anesthesia. During correction, the patient must lift their eyes and also sit upright to determine how much weight from soft tissue is impinging the eye elevation. The surgeon must also be careful not to induce excess or asymmetric swelling during surgery; this is done only by very meticulous dissection. Furthermore, excess bleeding must also be avoided by careful dissection and avoidance of the many fine vessels. Therefore, it is equally important that your surgeon is skilled and understands the procedure thoroughly.
Ptosis or subclinical ptosis (i.e., no evidence of ptosis but results after double eyelid surgery) can also be an issue for patients who wish to undergo double eyelid surgery. When seeking ptosis correction, do your research to find a skillful and experienced surgeon.
As ptosis correction is a challenging procedure, it is imperative that your surgeon has an expertise in the comprehensive anatomy of the eyes and eye surgeries.
Ptosis repair is largely performed simultaneously with suture or incision technique double eyelid surgery. The surgery takes place under local anesthesia, with or without oral sedatives. The duration of the surgery will depend on the severity of the ptosis. The skin stitches will be removed 5-7 days after the surgery at our office. The critical swelling will subside in 1 week, and the remaining swelling will gradually subside within 8-12 weeks.