Category: eye

WHAT IS PTOSIS?

Eye Cross Section – Double Eyelid – Blepharoplasty – Ptosis

• Ptosis (blepharoptosis) is the abnormally low (droopy) position of the upper eyelid margin due to a weakness in the lifting mechanism. This mechanism consists of muscle (levator palpebral superioris) and its soft tissue extension (levator aponeurosis)
• It must be differentiated from dermatochalasis. In this condition, excessively lax upper eyelid skin causes a droopy appearance rather than the true weakness of the lifting mechanism of the eye.
• Blepharoptosis can also co-exist with dermatochalasis.
• Patients with blepharoptosis or dermatochalasis has tired looking eyes even though they have adequate rest. They usually use their forehead muscles to assist in lifting up the upper eyelids resulting in persistent frownlines. Thus, seeking droopy eyelid treatment is vital.

Ptosis Vs Dermatochalasis

	Blepharoptosis	Dermatochalasis
Diagram	Blepharoptosis	Dermatochalasis
Mechanism	Droopy lid due to weakness in the lifting mechanism of eyelid.	Droopy lid due to excessive eyelid skin.
What covers the limbus?	Ciliary margin (eyelash margin)	Skin edge of redundant upper eyelid skin
Age group	All age	Older age
Associated disorder	Both conditions can co-exist
Medical claims	Considered medical condition	Considered cosmetic condition

*Limbus – Junction between the cornea and the sclera (the black and the white of the eye)

ASSESSMENT OF BLEPHAROPTOSIS

• Blepharoptosis is assessed based on two parameters :
  • Degree of blepharoptosis – the severity of blepharoptosis
  • Levator function – the residual lifting ability of the upper eyelid opening mechanism

DEGREE OF BLEPHAROPTOSIS

There are two methods to measure the severity of blepharoptosis

1. Amount of upper lid droop or descent (over the limbus)

Blepharoptosis Assessment – MRD

2. Marginal Reflex Distance

• • Most accurate method to measure degree of blepharoptosis
  • It is a vertical distance between the pupillary light reflex and the eyelid margin.
  • Types of MRD :
    • MRD1
      • Distance from the pupil center to the upper eyelid
      • Blepharoptosis present if MRD1 < 4 mm
    • MRD2
      • Distance from the pupil center to the lower eyelid
      • Lower lid retraction if MRD2 > 6 mm

	Lid Descent over Upper Limbus	MRD1
Degree of Blepharoptosis	Ptosis Assessment by Coverage of Limbus	Blepharoptosis Assessment by MRD
Mild	1-2 mm	3-4 mm
Moderate	3 mm	2 mm
Severe	> 4 mm	1 mm

LEVATOR FUNCTION

• The levator palpebral superioris is the main muscle responsible for eye opening.
• To measure the residual lifting ability of the upper eyelid opening mechanism, the patient is asked to look downwards and then upwards while immobilizing the brow. The amount of eyelid movement is called levator excursion and this reflects levator function.
• The levator function and degree of blepharoptosis determine the type of corrective surgery to be done.

Table of Levator Function Assessment

Levator Excursion	Levator Function
Levator Function Test – Lid Closed Levator Function Test – Lid Open	Good : >10 mm
	Fair : 5-10 mm
	Poor : 0-5 mm

SUITABLE CANDIDATES FOR PTOSIS CORRECTION SURGERY

• Patient with established blepharoptosis.
• Patient with blepharoptosis concomitant dermatochalasis. 

DESCRIPTION OF PTOSIS CORRECTION PROCEDURE

Table of Status of Levator Function and Corresponding Ptosis Correction Procedures

• Many surgical procedures have been described for the correction of blepharoptosis tailored according to levator function.
• Common procedures performed by our surgeon is sagging eyelid correction – levator plication and levator advancement.
• The levator aponeurosis is shortened by pleating and suturing in levator plication procedure. A portion of the excess aponeurosis is removed and the free edges are overlapped and sutured together in the levator advancement procedure.
• The incisions and scar for blepharoptosis correction are similar to conventional blepharoplasty. The scar is hidden in the eyelid crease.
• However, the scope of surgery is vastly different. It is a very delicate surgery that require meticulous dissection of the opening mechanism of the eye and it takes longer duration than conventional blepharoplasty.
• During the operation patient may be required to sit up and check for symmetry of eye opening several times after correction.
• Ptosis correction ( droopy eyelid surgery )  can be combined with conventional upper blepharoplasty procedure for :
  • Incisional blepharoplasty
  • Removal of excessive upper eyelid skin
  • Removal of excessive upper eyelid fat pad
• Surgical duration: 2-4 hours
• Day Surgery (home on the same day)

ANAESTHESIA

• Combination of local anaesthesia with light intravenous sedation administration:
  • Maximal patient comfort
  • Patient able to participate in checking symmetry of eye-opening during the surgery.
• General anaesthesia:
  • At the special request of the patient.
  • Result might be affected because of the inability to check for symmetrical eye-opening.

POST OPERATIVE CARE

• Mild discomfort to be expected includes:
  • Swelling usually resolves in 1 week.
    • In rare instances swelling may take several weeks to resolve.
    • Avoid exertion and rest 30 degree head up to hasten resolution of swelling.
  • Bruising usually resolves in 2 weeks.
  • Tearing
  • Lagophthalmos
    • Incomplete eyelid closure – usually transient
    • May need lubricant eye drop or eye gel to prevent corneal desiccation (drying).
    • Eye pad may be required during sleep.
  • Post-operative medication:
    • Antibiotic ointment to be applied regularly 3-5 times a day
    • Antibiotic eye drop 3 times a day
    • Oral antibiotics
    • Analgesics (pain relief) and anti-swelling medications
  • Removal of suture at 1 week.
  • Resumption of light exercise for 3-4 weeks.
  • Refrain from wearing contact lenses up to 4 weeks post-surgery.

RISK AND COMPLICATION OF DROOPY EYELID CORRECTION TREATMENT

• Bleeding/ Haematoma (blood clot accumulation)
  • Avoid exertion post-operative.
• Infection
  • Very rare
  • Avoided by clean (sterile) technique during the surgery.
• Asymmetrical eye-opening is fairly common in the early post-operative period

FREQUENTLY ASKED QUESTION

Is asymmetrical eye-opening common after blepharoptosis correction?

• This is a common occurrence and it is usually transient. The eye will take a short while to adjust to its new eyelid opening position.
• Many patients have pre-existing asymmetrical height of the globe of the eye, the size of eye-opening, the amount of extra skin and fat in the eyelids, and the distance between the brow and upper lid.
• Due to all these factors, asymmetry can still result despite best efforts during surgery.

Is it common to perform ptosis surgery (sagging eyelid correction surgery) in only one eye?

• Although blepharoptosis may be unilateral (exist in one eye) it is common to suggest a correction in both eyes because ptosis correction in one eye can affect the eye-opening of the opposite (unoperated) eye. During the consultation, Dr Ng would explain why this is affected by the complex nature of equal innervation of both eyes (Hering’s law).

COST OF DROOPY EYELID SURGERY

• Blepharoptosis correction is considered medical and financial assistance by medical insurance is possible provided a set of strict criteria are met. These criteria include special test e.g. visual field testing by an eye specialist.
• The amount of reimbursement by the insurance company is determined on a case-by-case basis by their assessment team.

During your consultation, our plastic surgeon will explain the most common causes of ptosis, sagging or droopy eyelids, and recommend the most suitable droopy eyelid correction surgery and treatment methods for you.

ASIAN VS CAUCASIAN EYELIDS

Caucasian Double Eyelid vs Oriental Single Eyelid

• The levator aponeurosis is part of the opening mechanism of the eye and which is closely related to the tarsal plate. It sends multiple slips of dermal (skin) extension which pulls on the pretarsal upper eyelids skin creating the double eyelid fold (palpebral fold).
• In many Oriental patients, the levator aponeurosis expansions (penetration) into the pre-tarsal crease are absent. This results in single eyelid appearance.

INTRODUCTION

• Upper eyelid surgery (blepharoplasty) can create or improve the configuration of double eyelid or remove excessive droopy skin. It can be done by incisional method or by suture technique.
• There are 2 methods of upper eyelid surgery:
  • Incisional blepharoplasty – result in a faint scar
  • Suture blepharoplasty – scarless
• Purpose of incisional blepharoplasty :
  • Creation of double fold :
    • During incisional blepharoplasty, excess skin is removed and very fine sutures secured the wound edge (which is the location of the double fold) to the deeper eyelid structures to create a permanent fold.
  • Removal of excessive upper eyelid skin (which causes the eye to appear “aged” and may obstruct vision)
  • Removal of excessive upper eyelid fat pad (which gives the eyelid a puffy appearance), eyebag surgery is often done concurrently.
  • Correction of ptosis (Droopy eyelid)

COMPARISON OF SUTURE AND INCISIONAL BLEPHAROPLASTY

	Suture Double Eyelid Surgery(scarless)	Incisional Double Eyelid Surgery
Photo	Suture Blepharoplasty Suture blepharoplasty – Cross section	Incisional Blepharoplasty
Purpose	Creation of double eyelid fold in young patient who have no upper eyelid skin excess or fat excess.	Creation of double eyelid fold (for all age groups) Removal of excessive upper eyelid skin Removal of excessive upper eyelid fat pad. Ptosis correction
Scar	Scarless	Faint scar in the upper eyelid crease
Longevity of Result	Less permanent upper eyelid fold (unpredictable loss of fold)	Permanent
Post-surgery downtime	Generally limited swelling and bruising (however some patients has downtime similar to incisional blepharoplasty)	Swelling much improved after 1-2 weeks
Suture Removal	Usually none	1 week post operative

STYLE OF UPPER LID DOUBLE FOLD (PALPEBRAL FOLD)

TAPERED FOLD (IN FOLD)	PARALLEL FOLD (OUT FOLD)
Upper Eyelid – High Tapered fold – Blepharoplasty	Upper eyelid – Parallel fold – Blepharoplasty
More common among Orientals. Inner corner of the double fold starts of nearer the eyelash margin and gradually tapers outwards.	More common among Caucasians. Entire length of double fold is almost parallel to the eyelash margin.

LOW FOLD	HIGH FOLD
Upper eyelid – Low in-fold – Blepharoplasty	Eyelid – Tapered fold (high)
Narrow separation of double fold. Appears more natural. Double fold tends to disappear earlier with ageing.	Wide separation of double fold. Appears less natural. Results last longer and becomes more natural with ageing

• The style of double eyelid fold is summarized in the table above.
• Some patients have strong tendency towards forming parallel fold. It may not be easy to create a tapered fold in this group of patients.
• During consultation Dr. Ng will advise you regarding the most suitable style and height of double eyelid fold to be created.
• In some instance the original height of the double eyelid crease can be maintained.

SUITABLE CANDIDATES

• Patient of any age group who wishes to create double upper eyelid fold.
• Patient with excessive upper eyelid causing aged appearance and/or obstructing vision
• Patient with puffy eyelids due to fat pad excess
• Patient who has weakness in the opening mechanism of the eye (Ptosis)

DESCRIPTION OF PROCEDURE

• Marking and taping simulation of the intended fold height before surgery in agreement with patient
• Incision over intended eyelid fold
• Removal of excessive upper eyelid skin, muscle and fat pads if present
• Upper eyelid crease is secured by tagging the intended fold to the deeper structures including tarsal plate.
• Meticulous wound closure with very fine non-absorbable sutures.
• Topical antibiotic ointment
• Surgical duration : about 1.5 hours
• Home on the same day

ANAESTHESIA

• Combination of local anaesthesia with IV sedation administration – for greatest comfort

POST OPERATIVE CARE

• Mild discomfort to be expected includes:
  • Swelling usually resolves by 1 week.
    • In rare instances swelling may take several weeks to resolve.
    • Avoid exertion and rest 30 degree head up to hasten resolution of swelling.
  • Bruising usually resolves by 2 weeks.
  • Tearing
• Post-operative medications:
  • Antibiotic ointment to be applied regularly 3-5 times a day
  • Antibiotic eyedrop 3 times day
  • Oral antibiotics
  • Analgesics (pain relief) and anti-swelling medications
• Removal of suture at 1 week.
• Resumption of light exercise for 3-4 weeks.
• Refrain from wearing contact lens up to 4 weeks post-surgery.

RISK AND COMPLICATION

• Bleeding/ Haematoma (blood clot accumulation)
  • Avoid exertion post-operative.
• Infection
  • Very rare
  • Avoided by clean (sterile) technique during the surgery.

FREQUENTLY ASKED QUESTION

Can we ensure symmetrical result after blepharoplasty ?

• Perfectly symmetrical eyes are uncommon.
• Many patients have pre-existing asymmetrical height of the globe of eye, size of eye-opening, the amount of extra skin and fat in the eyelids, and the distance between the brow and upper eyelid.
• Because of all these factors, asymmetry can still result despite best efforts to plan the fold symmetrically.
• Incisional blepharoplasty is more suitable to improve symmetry if you have obviously asymmetrical upper eyelids.

Can double eyelid surgery give me brighter and more alert looking eyes ?

• This depends on whether the patient has pre-existing droopy upper eyelids (blepharoptosis)
• The “bright, alert and non-sleepy” appearance of the eyes is determined by how wide the upper eyelid can open (imagine this as the “window opening”). This opening is controlled by the lifting mechanism of the upper eyelid which is in the deepest layer of the upper lids. In the usual double eyelid surgery, we operate on the superficial layers and not the deeper layer (imagine this as “trimming the curtain” only). Therefore, if the patient has pre-existing droopy upper eyelids (blepharoptosis), simple double eyelid surgery cannot restore the bright and alert appearance.
• If the patient has no pre-exiting blepharoptosis but only significant skin excess, creation or restoration of double eye fold together with removal of skin excess can potentially brighten up the eyes.
• This is the reason occasionally double eyelid consultation become prolonged due to additional explanation needed in some cases.

A consultation would guide you regarding which is the most common and best procedure used by top Singapore plastic surgeon for double eyelid surgery.