Ptosis means descent and blepharoptosis is the medical term for drooping of the eyelid. It may occur as an isolated issue or be present along with excess skin of the upper eyelid and brow ptosis (drooping of the eyebrows). Anatomically, ptosis is usually caused by a weakness of the muscle (“levator”) that lifts the eyelid, a partial detachment of this muscle, or a nerve problem to the muscle. There are many causes of eyelid ptosis: medical conditions (e.g., stroke); prior eye trauma or eye surgery; congenital birth defect; chronic rubbing of the lids (e.g., allergies); hard contact lens use; a tumor (rarely); and age-related. Sudden onset ptosis can even be an emergency which should prompt an urgent ophthalmic evaluation, particularly if there is also new double vision. Most cases of ptosis do not improve with time, but they can nearly always be improved with corrective surgery. Most commonly, the levator muscle is effectively strengthened by advancing and/or shortening the tendon of the muscle, either through a posterior approach on the inside of the eyelid or through an anterior approach through a small incision that is well hidden in the upper eyelid crease. In rare cases, the muscle is too weak, which necessitates a surgical linkage to be performed between the eyelid and the forehead lifting muscles. Dr. Burroughs has performed thousands of ptosis corrections for either cosmetic or medical reasons, has published on ptosis correction techniques, and is commonly referred patients with ptosis by other plastic and ophthalmic surgeons. If ptosis repair is performed as an isolated procedure, then it is performed quite comfortably in about 15 minutes per side under just local anesthesia in the office or with sedation at a surgical facility. Repair of droopy upper eyelids may be done to: improve cosmetic appearance (reduce the “tired” look), improve peripheral vision, increase the light entering the eye which can help visual acuity, reduce end-of-day frontal area headaches and neck pain in people who have adapted by chronically raising their eyebrows or by adopting a backwards head-tilt (“chin-lift”) position to see better, and can rarely improve dry eye symptoms.
Frequently asked questions about ptosis surgery:
1. How does Dr. Burroughs perform ptosis surgery?
Ptosis surgery of the eyelids can be performed by either an internal approach through the inside of the eyelid or through an external upper eyelid crease incision. Dr. Burroughs has found many patients prefer the internal approach as it can be done without patient cooperation during the surgery and has a “hidden” incision. Whereas the external approach most commonly requires a patient to cooperate during the procedure by looking up and down to obtain the ideal eyelid height elevation, contour, and symmetry.
2. Which approach (internal) or external works the best?
Many factors go into determining which approach may be best for a given patient. Patients with the most severe forms of ptosis will generally be best served by an external approach (through the skin) that will require some cooperation during surgery to achieve the needed result. Some patients may be very nervous about having to be awake during surgery and prefer the internal approach, when appropriate, so that they can be totally asleep or heavily sedated during the procedure. The internal approach won’t work for all patients, but Dr. Burroughs can do a quick test with some eye drops in the office that gives a good approximation of the expected result. Unfortunately, the internal approach doesn’t work as well for congenital forms of ptosis, but for teenagers and older patients, it generally works well if the eye drop test is positive.
3. How successful is ptosis surgery?
Ptosis surgery has a very high success rate when performed by an experienced surgeon, but up to 10% of patients may require later adjustments to address any over or under-corrections. It is one of the most difficult eyelid surgeries to perform well, and Dr. Burroughs is recognized as an accomplished expert and has taught other surgeons and published on ptosis repair techniques. Some overcorrections can be adjusted by a downward eyelid massage afterwards to loosen the corrective tightening.
4. Will insurance cover ptosis surgery?
Yes, if it is affecting vision (e.g., reading, driving problems), but strict visual field criteria have to be met. Most insurances will not cover ptosis surgery at the same time as an upper eyelid lift (blepharoplasty), so patients need to choose which component bothers them most, repair them at different surgeries, or pay a cosmetic fee so that it may be repaired at the same time.
5. How does ptosis differ from excess upper eyelid skin?
Ptosis is drooping of the entire eyelid margin, whereas excess skin of the upper eyelid is called dermatochalasis or blepharochalasis when associated with frequent bouts of eyelid swelling. A ptosis repair alone in the presence of excess upper eyelid skin will worsen the sagging of the upper eyelid skin do to a draping effect. Similarly, a skin-removal upper blepharoplasty alone will not correct co-existent ptosis of the eyelid margin. Dr. Burroughs can explain these differences during a consultation. It is safe, but considerably different surgical procedures are needed to perform a combined blepharoplasty and ptosis surgery at the same time. However, Dr. Burroughs has published a textbook chapter on combining these surgeries. Unfortunately, some insurance companies will not cover repair of excess skin and ptosis repair simultaneously, but Dr. Burroughs attempts to get both of these issues covered by insurance when both are medically necessary.
6. What is recovery like from ptosis surgery?
If only ptosis surgery is performed, bruising and swelling can be quite minimal. When additional procedures such as a forehead lift, blepharoplasty, or facelift are performed, then recovery can be longer. Otherwise, recovery is very similar to upper eyelid lift surgery.
7. Will having ptosis surgery change how I look?
Yes, your eyes will look more open, giving a less “sleepy” look. Some patients with ptosis not only have a droopy eyelid but abnormal contour issues of the eyelid margin that may be improved at the same time as lifting the eyelid.
8. Will ptosis surgery help my vision?
Peripheral vision can be substantially improved, and central vision and night vision can be improved on a rare basis by allowing more light to enter the eyes. Peripheral vision is very important for critical visual activities such as driving, walking in crowds of people, and to avoid accidentally striking your head against objects (e.g., cabinets).