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Topic 15 - 1
Repair of
Eyelid Ptosis 
upper blepharoplasty photos Upper Eyelids ptosis aponeurosis dehiscence

ptosis of the upper eyelid

Other names: Droopy eyelid repair, "cosmetic ptosis repair"

Primary goal: Elevation of a drooping (not baggy) upper eyelid that may be interfering with peripheral vision

Secondary goals: (May be performed in conjunction with blepharoplasty, as in the example that follows)

Female with Ptosis
Before and After Photos

Special anatomy: Review: The levator muscle begins in back of the eye and turns into an aponeurosis (similar to a tendon) as it enters the eyelid. Most cases of adult-onset ptosis are the result of thinning or tearing of the levator aponeurosis. Less commonly, neuromuscular diseases such as myasthenia gravis, muscular dystrophy, Horner's syndrome, or multiple sclerosis may cause the muscle itself to become partially paralyzed (requiring far different operations from those discussed here.)

Anesthesia: Local anesthesia with minimal sedation is mandatory to allow for active patient cooperation during surgery

Operative technique: Through an upper eyelid crease skin incision, the blepharoplasty is carried out as described above to the point through and including the removal of fat. Now on good display, the levator aponeurosis ("tendon") can be inspected by the surgeon (surgery photo). The aponeurosis is "tucked" using non-dissolving sutures. The surgeon must be careful to not only create a smooth lift for the droopy lid, but also match the one upper eyelid to the other upper eyelid and to restore the normal curve to the lid margin (which becomes flattened with ptosis).

Variations: Ptosis, especially when mild, may also be repaired by several different operations performed from the back side of the eyelid ("Müller's muscle-conjunctival resection" and "Fasanella-Servat procedure") in conjunction with blepharoplasty from the normal skin approach. While such less invasive "posterior approaches" work well in mild ptosis surgery performed as an isolated procedure, the advantage of using such less adjustable operations in lieu of identification and direct repair of a torn or thinning levator tendon once the eyelid is fully open during upper blepharoplasty is harder to appreciate.

Advantages: If a patient suffers from a combination of both baggy eyelids and drooping eyelids (ptosis) yet only the bagginess is addressed, the final result will be disappointing.

Limitations: Ptosis repair does not interfere with blepharoplasty surgery but may prolong recovery. Because the tissue being operated upon is defective, the reoperation rate is higher than with cosmetic blepharoplasty and is about 1 in 6 per eyelid.

Special care and recovery: The upper eyelid may not fully "express" the lift until all of the internal inflammation has disappeared. In most cases, it takes about three to six weeks for the effect of a ptosis repair to become fully apparent, but longer recovery periods (3-6 months) may be experienced. For this reason, the decision to reoperate should not be made prematurely.

Risks and complications: See Chapter 28: Blepharoplasty Risks - Complications. In addition, ptosis repair may be complicated by overcorrection and undercorrection, irregularities of lid shape, and asymmetry between the two sides.

Comments: Ptosis repair is a delicate and very precise operation, and any surgical shortcomings will be readily visible For this reason, many patients with ptosis choose to have their combined blepharoplasty-ptosis repairs performed by surgeons specializing in both cosmetic and corrective eyelid surgery.

Next: The Root Cause of
Most Adult Ptosis

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