Ptosis means downward displacement of an organ or tissue. Ptosis in the field of ophthalmology usually refers to a drooping upper eyelid (a blepharoptosis) but it can also refer to a drooping of the eyebrow (brow ptosis) or the midface (midface ptosis). Ptosis may affect one or both eyelids and can be very asymmetrical depending on the underlying cause. The most common cause of ptosis is a loosening of the tendon (aponeurosis) of the muscle (the levator) that lifts the eyelid, often following years of hard contact lens wear. Blepharoptosis is often age-related. Ptosis can also affect children. It is important to see a specialist oculoplastic surgeon to determine the underlying cause of the blepharoptosis before proceeding with any surgery.
The treatment is usually surgery although there are a few very rare disorders that may be treated medically (e.g. myasthenia). During surgery for adults the levator tendon (the levator aponeurosis) is tightened, usually under local anaesthesia with intravenous sedation provided by an anaesthetist (“twilight anaesthesia”). This is referred to as a “levator aponeurosis advancement”. An alternative operation can very often be performed via an incision on the inside of the eyelid. This is referred to as a “Müller’s muscle resection” and this leaves no visible scar (scarless ptosis surgery).
A patient with a left ptosis
The patient following a scarless Müller’s muscle resection
A patient with a bilateral ptosis
The patient following a scarless Müller’s muscle resection on both sides
A patient with a left ptosis
The patient following a scarless Müller’s muscle resection and an upper lid blepharoplasty
A patient with a left ptosis
The patient following a scarless Müller’s muscle resection and an upper lid blepharoplasty
Very rarely, for patients who have poor movement of the eyelids (poor levator function) e.g. due to a congenital developmental abnormality the lids may be attached to the brow so that the forehead muscles do the lifting. This is referred to as a “brow or frontalis suspension procedure”. The eyelids may be suspended using synthetic material e.g. a nylon suture (polypropylene), a silicone band, or using tissue taken from the outer aspect of the thigh (fascia lata) through a small incision just above the knee.
Ptosis surgery is sometimes combined with an upper eyelid blepharoplasty if there is an overhang of loose skin in the upper eyelid. The procedure can be performed under local anaesthesia on a day case basis. Most patients, however, prefer “twilight anaesthesia”.
You will visit the clinic to have a preoperative consultation. This usually lasts for 40 minutes. You will be asked to complete a healthcare questionnaire, providing information about:
- your current and past health
- any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
- any previous non-surgical aesthetic treatments e.g. Botox injections (these can cause a ptosis) or, dermal fillers injections
- any eye problems e.g. dry eyes, or if you use contact lenses
- any previous major surgery or significant illnesses
- any allergies
- medications (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements),
- any skin problems
- whether or not you smoke
You may have your blood pressure checked by the nurses at the clinic.
It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.
The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
If you are unsure of the names of any medications, bring them with you.
You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. It is important that your blood pressure should also be under good control if you take medications for hypertension. This is very important.
If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).
- Your vision in each eye will be measured.
- Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope as seen in the photographs above)
- Your tear film status is determined to ensure that you do not have a predisposition to a dry eye problem
- The back of the eyes (called the fundus or retina) is examined as well as the eyelids themselves
Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
Some insurance companies request copies of preoperative photographs and some also require a visual field examination, to confirm that the eyelid problem is restricting your peripheral vision.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of ptosis surgery?
Most complications of eyelid surgery are amenable to successful treatment.
Complications from upper eyelid blepharoplasty surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Watery eyes – this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.
- Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Hyabak drops, Hylotears, Viscotears, Systane drops) and an ointment at night (Lacrilube). These should be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball is called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem.
A haematoma usually needs to be drained in the operating theatre
- Exposure of the cornea, the clear sensitive surface of the eye. When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops. If too much skin is removed from the upper eyelids, the eyelid closure can be compromised long term. This may require further surgery to correct it. For this reason, great care is taken to mark the skin to be removed before surgery is commenced. Such a problem is very unusual in the hands of an oculoplastic surgeon.
- Acute glaucoma – this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- Numbness. Any skin incision can cause minor areas of numbness as the very fine delicate sensory nerves can be cut. This is usually mild and improves over a few weeks or months after surgery.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. A cosmetically unacceptable asymmetry e.g. of the upper lid skin crease, is always possible and further surgery may be required to address this.
- Undercorrection or Overcorrection. In some cases the upper eyelid can be too low or too high and may need further surgery to improve this.
- Contour abnormalities. Occasionally the upper eyelid contour can be altered by ptosis surgery so that an unnatural peak or droop in one part of the upper eyelid is noticeable. This can sometimes be improved in the post-operative period by applying eyelid traction (pulling down on the eyelashes and the edge of the eyelid in the area of peaking) but other cases may require further surgery to improve this.
- Drooping of the fellow upper eyelid. Raising the upper eyelid on one side can result in some drooping of the other side. This cannot always be predicted prior to surgery and it is important to be aware of this possibility and of the possible need to undergo ptosis surgery on the other side subsequently if this were to occur and not settle in the next few weeks after surgery.
- Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds or due to some thickening of fat that may have been placed as a graft. These usually resolve with time but occasionally steroid injections are required.
- Numbness. Any skin incision can cause minor areas of numbness as the very fine delicate sensory nerves can be cut. This is occasionally noticeable after upper eyelid blepharoplasty. It is usually mild and improves over a period of a few weeks or months after surgery.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
After surgery, the eyes are treated with cool packs. Activity is restricted for 2 weeks to prevent bleeding. For some patients a postoperative eyepad is required and a stitch (Frost suture) is placed in the lower eyelid and taped to the forehead to ensure that the eye is closed and protected. This is usually removed the following day at the clinic.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks (unless you have had a scarless ptosis operation). The sutures used are dissolvable but are usually removed in clinic after 2 weeks. The sutures used in a scarless operation are removed after 4-7 days depending on postoperative progress. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The nurses at the clinic can demonstrate this to you). It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
The upper lid scars gradually fade to fine white marks within a few months. The scars are hidden within the skin crease unless an additional skin incision is required to remove a “dog-ear” of excess skin just below the tail of the eyebrow.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops if you have any allergies. These will be prescribed for you e.g. Xailin gel and Xailin Night ointment at bedtime. Alternative drops are Theoloz Duo, Hylo Forte drops, Hylo Tear drops, or Hyabak drops.
It is often recommended that you use ointment to the eyes 2 hourly for the first 48 hours after surgery following any upper lid surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). Click here to watch a short video showing you how to insert your ointment.
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Contact lenses should not be worn for 2-3 weeks following this type of surgery.
Please note that although ptosis surgery can be performed under local anaesthesia alone, local anaesthesia with safe, conscious intravenous sedation given by a very experienced and skilled consultant anaesthetist (commonly referred to as “twilight anaesthesia”) is also available where requested. This form of anaesthesia is extremely popular with our patients and the effects are reversed very quickly. It enables local anaesthetic injections to be given painlessly with little recollection of the surgery, and helps to keep patients calm, relaxed and comfortable. It also helps to prevent rises in blood pressure thereby minimizing bleeding and postoperative bruising.
Any patients requiring general anaesthesia or who are unsuitable for surgery at our day case facility, the Face & Eye Clinic, will be treated by our surgeons in a local private hospital e.g. Spire Manchester Hospital.