Droopy Eyelid Surgery (Ptosis Correction)

INTRODUCTION

Eye Cross Section - Droopy Eyelid - Blepharoplasty - Ptosis Correction 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 droopy appearance rather than 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.
Photo of ptosis and dermatochalasis
BlepharoptosisDermatochalasis
Diagram
Blepharoptosis - Droopy Eyelid - Ptosis Correction Blepharoptosis
Dermatochalasis - Droopy Eyelid - Differentiate from Ptosis Correction Dermatochalasis
MechanismDroopy 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 groupAll ageOlder age
Associated disorderBoth conditions can co-exist
Medical claimsConsidered medical conditionConsidered 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 – 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

  • Amount of upper lid droop or descent (over the limbus)
Blepharoptosis Assessment - MRD measurement for droopy eyelid Blepharoptosis Assessment – MRD
  • 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 LimbusMRD1
Degree of Blepharoptosis
Ptosis Assessment by Coverage of Limbus - Droopy eyelid Ptosis Assessment by Coverage of Limbus
Blepharoptosis Assessment by MRD for droopy eyelid Blepharoptosis Assessment by MRD
Mild1-2 mm3-4 mm
Moderate3 mm2 mm
Severe> 4 mm1 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 determines the type of corrective surgery to be done.

 

Table of Levator Function Assessment

Levator ExcursionLevator Function
Levator Function Test for Droopy Eyelid - Lid Closed Levator Function Test – Lid Closed
Levator Function Test for Droopy Eyelid - Lid Open Levator Function Test – Lid Open
Good : >10 mm
Fair : 5-10 mm
Poor : 0-5 mm

SUITABLE CANDIDATES

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

 

DESCRIPTION OF PROCEDURE

Table of Status of Levator Function and Corresponding Ptosis Correction Procedures

Levator Function
Excellent (> 10 mm)Moderate (5-10 mm)Poor (0-5 mm)
Type of Procedure
  • Aponeurotic surgery (Fasanella-Servat procedure, Putterman’s procedure, Mutarde’s Split Level Approach)
  • Mullerectomy
  • Levator advancement or plication
  • External levator resection
  • Frontalis suspension
  • Frontalis Orbicularis Oculi Muscle (FOOM) flap
  • Many surgical procedures have been described for the correction of blepharoptosis tailored according to levator function.
  • The most common procedures done by our plastic surgeon are 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 is 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 :
  • 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 special request of the patient.
    • Result might be affected because of inability to check for symmetrical eye-opening.

 

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
    • 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 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.
  • 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 eye, 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 in only one eye?

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

FINANCIAL COUNSELLING

  • Blepharoptosis correction is considered a medical condition.

 

After a consultation our plastic surgeon would explain the most common causes of ptosis, sagging or droopy lid and recommend the best droopy eyelid correction surgery method that is used by top plastic surgeon in Singapore.