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Ptosis refers to a “droopy” upper eyelid. This droopiness can become so heavy that it blocks your vision. This happens because the pupil (black spot in the middle of the eye) can be covered by the drooping eyelid. Ptosis is typically caused by weakening or stretching of the muscle (levator palpebrae superioris) responsible for holding the eyelid open. Ptosis can be caused by congenital or acquired defects in the muscle (or its tendon), which lifts the upper eyelid. It is also associated with lesions, which weigh the eyelid down, or certain neurological diseases. The most common reason for ptosis increasing age which causes stretching of the tendon and weakening of the levator palpebrae superioris muscle. Other conditions that present like ptosis are excess skin or fat in the upper eyelid or eyebrow drooping. These are distinct conditions with different causes, although they may also impact your eye’s ability to see.
Surgery is only treatment that can be used to improve ptosis due to stretched out tendon or poor muscle function. Your surgical plan will depend on the severity of the ptosis as well as the cause. Surgery is designed to restore strength and tone to the levator muscle that supports the upper eyelid. Mild to moderate ptosis with good levator palpebrae superiorus (LSP) function can be approached from the inside of the eyelid in a minimally invasive way.
Significant or congenital ptosis generally requires an incision in a natural skin crease similar to blepharoplasty surgery. Some patients require transfer of their forehead muscle called frontalis or various sling procedures to improve eye opening and symmetry. Your doctor will guide you through the process if you are a surgical candidate for correction.
Some patients may notice one or both of your upper eyelid drooping. This will lead many patients to see their doctor. Patients may notice that they need to constantly lift their forehead to compensate for eyelid drooping, which may bring them to their doctor to get their forehead lines treated. Severe ptosis will lead to blocked upper field of vision leading to patients manually elevate their eyelids or tape them open. If you are bothered by puffy eyes or loose skin under the eyes, then this is a good time to bring this up with the surgeon as they can be addressed at the same time as the ptosis of the eyelid.
An eye exam will document the condition of the eyes before surgery. You will need a full vision check from your Ophthalmologist prior to any eyelid surgery. Our doctor will discuss the procedure with you including risks, benefits and alternative treatments. They will review your medications including herbal and over-the-counter drugs and supplements. Many herbal products and pain relievers make it harder for you blood to clot and should be discontinued before surgery. You will sign informed consents and get your instructions for before and after surgery.
You will see your own personal physician for a medical clearance to make sure they feel it is safe for you to have surgery. Your physician may order laboratory blood tests, an EKG or a chest X-ray. You need to stop smoking as this delays healing. You should have nothing to eat or drink after midnight before your procedure. You will be told when to arrive at the surgery center before your surgery. You are signed in, change into a gown, given an IV, and talk to the nurse and anesthesiologist. You will then talk to your surgeon before you get any medication at the hospital so you can ask questions.
You are taken in to the operating room, lie down on your back, and the anesthesiologist will put you to sleep with a breathing tube to make sure your airway is safe. The area to be operated on is sterilely prepared with a cleaning solution and drapes. A local anesthetic is injected to decrease bleeding and discomfort. Both eyes are usually protected with special lubricating ointment and a special contact lens during surgery. Protection of both eyes is necessary because we use the unaffected eye to create symmetry. Mild ptosis can be repaired without external scars and patients can be asleep for that procedure.
Minimally invasive treatment is called Mueller muscle-conjunctival resection or Putterman’s procedure, where a small segment of inner lining of the eye along with Mueller’s muscle is removed leading to tightening of the eyelid elevators.
However, if ptosis is moderate to severe or in revision surgery the external approach is used with a scar hidden in the eyelid crease. External approach also allows removal of excess scar tissue from prior surgery. If an external approach surgery is used, then you cannot be fully asleep for that procedure, so that we can custom match the amount of elevator tendon/muscle resection or advancement to your needs. Instead of having full general anesthetic, patients get “twilight” anesthesia with local anesthesia that is injected into the eyelid. Your surgeon will ask you to open your eyes during your surgery so that the lid can be custom tighter to according to your needs in real time. The scar is hidden in an upper eyelid crease.
Rarely, if the elevators of the eyelid are not functional, patients may need frontalis suspension procedure where tendons are borrowed from another site of the body (donor site) to attach eyelid elevation to brow muscles. Patients are typically completely asleep for this procedure. After this type surgery, you may need a few months to be able to close eyelids during sleep and will need to have a good lubrication regimen. Borrowing materials from donor sites does not affect their long-term function significantly, but it does add to the recovery time, because each donor site will have its own healing timeline. These tendons can be borrowed from outer lining of chewing muscle (temporalis fascia), outer thigh (tensor fascia lata) or rarely leg (plantaris longus) and transplanted to support the upper eyelid. Donor site care instructions will be given and usually involve wearing a special wrap around the head, thigh or leg for 7-10 days.
After eyelid repositioning, the skin is closed and special tapes may be placed around the incision to support the eyelids. These tapes have to stay dry for a minimum of 48 hours.
You are taken to the waiting room and watched to make sure you are recovering from anesthesia well. Because ptosis surgery is considered a minimally invasive procedure, you may go home the same day. You need someone to bring you home from the surgery center to make sure you get home safely.
The procedure is not very painful, but you may take oral pain medicine the doctor has given you or acetaminophen (Tylenol). If you need a narcotic pain medicine you should take them with food in your stomach and start on a mild stool softener like Senna. You will be often given antibiotic and moisturizing eyedrops for use during the day and an ointment to place between your eyelids at night. Frequently, your doctor will prescribe antibiotics especially if complex repair with borrowing tissues was undertaking. Keeping your head elevated will decrease pressure on the incision.
You should take it easy for at least one week and your doctor will let you know what level of activity you can resume. Call your doctor if you have increasing redness of the incision, sudden change in vision, fever, bleeding, pus, drainage, the incision opens or you have worsening pain. Also, let your doctor know if you have any other concerns. You will see your doctor the week after surgery and sutures will be removed. You usually can be performing normal activities within two weeks of surgery.
The risks of your ptosis surgery will vary depending on how severe your condition is and what other medical conditions you have. The general risks of any eyelid surgery include bleeding, infection, dry eyes, eye irritation, difficulty with eye closure, visible scarring or skin discoloration, eye muscle injury, the need for additional surgery, chronic pain, numbness, temporary blurry vision or rare vision loss and risks of general anesthesia. Preparing for surgery and following your doctor’s instructions are useful to help minimize risks.
The Surgeons of Norelle Health are highly trained and skilled in the diagnosis, management, and treatment of ptosis surgery. Dr. Araslanova can provide the optimal treatment for blepharoptosis. Moderate to severe ptosis causing symptoms may be covered by your insurance although most insurances consider milder ptosis that doesn’t block vision to be cosmetic. Photographs and visual field-testing showing eyelid position and visual obstruction are necessary for coverage. If the degree of ptosis is not severe enough to affect your vision, it could still be corrected as a cosmetic procedure to improve symmetry. As out-of-network physicians, we will check your benefits for you and let you know if there are costs are so there are no surprises. We use an individualized treatment plan for your concerns to provide a personalized holistic plan of care. If you would like assistance, please feel free to contact us.