ARTE FACIAL
by Abraham Gómez, M.D.
Definition | Droopy Eyelid Surgery (ptosis repair)
Ptosis repair is the correction of a droopy eyelid. This operation is utilized to correct an acquired ptosis or a droopy eyelid that has been present since birth (congenital ptosis). It is one of the most common functional eyelid surgeries performed by oculoplastic surgeons. Droopy eyelid surgery employs one of two methods: an inside approach (leaving no visible scar) or a skin incision placed in the eyelid crease. In both cases, it is an outpatient operation. Ptosis surgery must not be confused with upper blepharoplasty, which removes excess upper eyelid skin.
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Indications for surgery
Patients seek ptosis repair surgery for functional or cosmetic reasons, and the former applies to droopy eyelids that cause significant visual impairment, specifically in the patient’s visual field. Most insurance companies will only reimburse ptosis repair operations when the visual field is significantly compromised, and for this reason, require preoperative photographs as well as a visual field test. This point is noteworthy for patients intending to preauthorize their surgery or file for reimbursement.
Mild eyelid ptosis may cause a cosmetic concern for some patients, even if their vision is not affected. Their droopy eyelid becomes noticeable when they are tired or when seeing themselves in a photograph. Although ptosis repair is also indicated in these cases, insurance companies will not cover the operation.
Risks of the operation
Ptosis repair is a very safe operation when performed by an experienced oculoplastic surgeon. Although patients are usually knowledgeable of the benefits of the surgery, they are not always aware of the risks and potential complications. The risks are similar to most eyelid plastic surgery procedures and include bleeding (manifested by postoperative bruising), swelling, scarring, and wound infection, which is very rare.
Surgical outcomes that result in under or overcorrection are not infrequent and must be contemplated by the patient in all cases. Undercorrection refers to an outcome where the eyelid margin was not elevated to the desired height. This result may occur in up to 10% of cases. Undercorrection will require additional intervention in some cases, but not all. It is wise to wait at least three months before considering further intervention.
Alternatively, overcorrection produces the opposite effect where the eyelid is elevated higher than desired. The result is a retracted upper eyelid which gives the patient a surprised look. When performed early in the postoperative period, eyelid massages may be employed to treat overcorrection of ptosis by lowering the eyelid height. In some cases, however, patients may require an additional operation to lower the eyelid if massage therapy proves ineffective.
Duration of the operation
Ptosis repair is a relatively short surgery, and its duration depends on various factors such as the surgical technique used, the anatomy of the patient, and whether it is the first operation or a reintervention. In cases where both upper eyelids must be raised, surgical time is prolonged (unilateral vs. bilateral ptosis repair); however, most procedures are completed within 30 to 45 minutes.
Type of anesthesia
Conscious sedation is the preferred type of anesthesia for ptosis repair surgery. Local anesthesia is suitable on some occasions, for example, when the patient is very cooperative and has a high pain threshold. The choice of anesthesia also depends on the surgical approach. The posterior approach (müllerectomy or CMMR) can be quite uncomfortable for the patient and is preferably done under sedation, while levator advancement (skin approach) is often performed under local anesthesia. The skin approach also requires more patient cooperation, so it is preferable that they be awake during the operation.
Pre-surgery instructions
Preoperative instructions for ptosis repair surgery are similar to most eyelid surgery procedures. Before proceeding with the surgery, patients must understand the risks of the operation and sign an informed consent.
A surgical portfolio with pre and postoperative instructions is sent via email to all patients before the operation. It is imperative that patients carefully read these instructions since following them will help guarantee the best possible surgical result.
Post-surgery care
As indicated above, instructions for postoperative care are sent to the patient before the operation in a pdf format. Dr. Gómez will review these instructions with the patient on the day of surgery after the operation’s completion. If the procedure is done with sedation, the instructions will be reviewed with the person accompanying the patient.
Application of cold compresses or ice packs on the operated eyelid is advised for the first 24 hours after surgery, but massaging the area is strongly prohibited as it may break the deep sutures.
Mild swelling and slight bruising are completely normal after droopy eyelid surgery. However, severe swelling is not expected and should prompt the patient to immediately contact his surgeon. Otherwise, the excessive swelling may cause the internal sutures to break, affecting the success of the operation. Bloody oozing through the surgical wound is often experienced in the early postoperative period and up to 3 days after surgery. Patients should gently dab their eyelids with clean gauze to remove the drainage, but it is crucial that they not rub the eyelids.
Regarding restriction of activities after droopy eyelid surgery:
All eyelid plastic surgery operations require a certain amount of postoperative rest. This is even more important after ptosis repair because excessive swelling of the eyelid tissues from these activities may disrupt the internal sutures. If one of the sutures breaks, the surgery will fail. Therefore, patients must avoid unnecessary efforts until the tissues have had time to heal. Patients should consider that the more they rest during the postoperative period, the higher the likelihood of a successful outcome.
First week after droopy eyelid surgery.
Avoid any activity that requires significant exertion, including exercise, heavy lifting, and bending for prolonged periods. Total bed rest is not necessary. You may take short walks a couple of times a day to keep active. Also, working on the computer is acceptable, but your eyes will get tired more quickly. Apply artificial tear drops before you use electronic devices.
Second week after droopy eyelid surgery
You will be seen for your first follow-up appointment around day seven after the operation. Your surgeon will examine the eyelid height, contour, and amount of swelling. If overcorrection is identified at this point, he will recommend eyelid massage therapy. He will remove sutures as well, if necessary.
Exercise may not be resumed yet, especially after suture removal, as even mild force may cause breaking of the wound.
Third week after droopy eyelid surgery
You may ask the doctor about resuming your daily exercise routine and other activities during the third-week postop. appointment. The amount of force that you may exert at this moment will depend on your clinical course, as determined by the surgeon.
Avoid sun exposure until your doctor’s approval (this is important from postop. day one). UV light will affect the healing of your incision and may cause the scar to pigment or become red.
Description of the procedure
There are two main surgical techniques to raise a droopy eyelid: Levator advancement (skin incision approach) and Müller’s muscle resection (CMMR). We will describe them separately.
Ptosis Repair: Levator Advancement
Eyelid ptosis is frequently caused by the weakening of the muscle that elevates the upper eyelid. Stated more precisely, by the weakening of the tendon (aponeurosis) that attaches this muscle to the firm structure on the lower part of the eyelid, called the tarsus. Levator advancement repair identifies the muscle aponeurosis and attaches it to the tarsus using sutures to restore the muscle’s function. Once reinforced, the muscle and its aponeurosis will raise the eyelid, correcting the ptosis.
With the patient lying down on the operating table, the surgeon marks the area to make the skin incision. If it was determined during the physical examination that the patient would benefit from an upper blepharoplasty in addition to the ptosis repair, the marking will include excess skin to be removed. Local anesthesia is administered to the operative sites. The skin is then prepped with an iodine solution or alcohol to sterilize the area before beginning the operation.
A skin incision is made along the marking. At this point, excess skin is removed using microsurgical scissors or an electrocautery device. Next, the surgeon dissects the tissues inferiorly, over the surface of the tarsus – where the levator muscle attaches – to expose the area where the sutures will be placed. The dissection is carried out superiorly to identify the aponeurosis of the levator muscle, which is generally loose or weak in patients with eyelid ptosis. The aponeurosis is then sutured to the anterior surface of the tarsus. Doing this will allow the levator muscle to pull up on the eyelid margin and correct the ptosis. The patient is asked to open their eyes to evaluate the degree of correction, and the suture is adjusted until adequate contour and height is achieved. The skin over the eyelid wound is closed with a running suture, and ophthalmic ointment is placed over the incisions. It is not necessary to patch the eyes.
The patient is taken to the recovery room until the sedation wears off and is ready for discharge.
Ptosis Repair: Conjunctiva and Müller Muscle Resection (CMMR)
Müller’s muscle is responsible for approximately 2 mm of eyelid elevation in normal conditions. In patients with ptosis who respond well to the phenylephrine test, which stimulates this muscle, CMMR is an excellent option to raise the eyelid. This operation is predictable, safe, and requires minimal downtime after surgery. Nevertheless, it should only be performed in mild to moderate cases of ptosis.
No markings are necessary for this operation. The anesthesiologist will start intravenous sedation in the operating suite, and the surgical site is sterilized with an iodine solution or alcohol. Anesthetic drops are applied in the respective eye and over the conjunctiva on the backside of the droopy eyelid. A traction suture is placed to evert the eyelid. The conjunctiva and Müller’s muscle are grasped with forceps and pulled gently to separate them from the deeper tissues of the eyelid. A predetermined amount of Müller muscle and conjunctiva is measured and marked with a cautery device, and a special instrument is utilized to hold the tissues. An absorbable suture is then passed underneath the bottom of the instrument and woven in through the held tissues in a serpentine manner. A steel blade is used to cut the predetermined amount of Müller muscle and conjunctiva. The suture is passed through the inside of the lid to exit on the skin side above the tarsus. Both ends of the suture are then secured to the eyelid skin. The traction suture is removed, and a contact lens is placed on the cornea. This lens will prevent a corneal abrasion if the suture rubs against the eye surface.
The patient is taken to the recovery room until the sedation wears off and is ready for discharge.
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