Why did I write this article?
I am an eyelid specialist (oculoplastic surgeon) in Denver. I perform 1000s of eyelid surgeries a year including ptosis repairs. From my patients and second-opinion patients, I have found there is a lot of misunderstanding of ptosis surgery by patients. Most patients and even some doctors don't understand what eyelid ptosis is, how it is treated and what the surgery entails. Often patients view ptosis and ptosis repair as a “simple” or “easy” procedure. They often confuse the surgery with an eyelid lift or blepharoplasty which is an entirely different procedure. Because patients don't like the way the drooping eyelid looks, they view it as a cosmetic procedure even if insurance is covering it. This article was create to educate my patients and others patients so there is a better understand of what is happening with their eyelids and a realistic expectation of how it can be fixed or improved.
First off, what is ptosis of the eyelid?
Ptosis comes the Greek work “ptosis” meaning falling. Ptosis of the eyelid is a drooping of the eyelid itself. There are many different things that can mimic eyelid ptosis (masqueraders of ptosis) but ptosis of the eyelid exists when the eye opening is narrower on one side because the eyelid itself sits in a lower position. Ptosis of the eyelid involves the eyelid sitting at a lower position usually because the muscle of the eyelid is weak.
What are the masqueraders of ptosis?
Not every eyelid that appears narrow is ptosis of the eyelid. There are dfferent conditions that can appear like ptosis of the eyelid but are actually not caused by drooping of the eyelid muscle. When we look online at questions that patients who think they have ptosis (but actually don't) these are the top four causes:
Ptosis of the Eyebrow
This is when the eyebrow sits low resulting in skin above the eyelid to hang low. It can create the appearance of eyelid drooping when in fact the patient doesn’t have eyelid ptosis at all. In fact we call this "eyebrow ptosis". This is treated by either raising the eyebrow if severe or removing a pinch of skin.
Excess eyelid skin (dermatochalasis)
This is the most commonly confused condition with ptosis of the eyelid. Also called Dermatochalasis, this is excess skin on the upper eyelid which can create the appearance of a drooping eyelid. It can be on one side or both eyelids. Removing the skin reveals the open eyelid behind it. The surgery for this is called a blepharoplasty and is a completely separate procedure from a ptosis repair. Often patients choose to have this procedure done cosmetically (out of pocket) during a ptosis repair so the eyelid looks as nice as possible when repaired.
Enophthalmos (sunken eye)
When the eye is sunken from a trauma or disease, the eye can appear smaller which can mimic ptosis or drooping of the eyelid. The treatment is directed at pushing forward the sunken eye.
Exophthalmos (bulging eye)
In thyroid eye disease where an eye is bulging, the eye can appear more open relative to the opposite eye. As a result the patient may feel the other eye is drooping. In the photo above, the "drooping eye" is actually the normal eye. The other eye is too open or high. The treatment is directed at the more open eye most often or underlying cause of the bulging eye.
Why see an oculoplastic surgeon?
In short oculoplastic surgeons are plastic surgeon experts of the eyelid. They specialize in training in eyelid drooping and they also correct these problems surgically and medically. It is analogous to a cardiologist for your heart .
There are no better experts in the world for eyelid surgery than oculoplastic surgeons. It is analogous to a cardiologist for your heart . Oculoplastic surgeons like myself spend two years specializing in eyelid surgeries. Ptosis surgery is the most common. Some oculoplastic surgeons like myself perform up to 1000 eyelid ptosis repairs a year.
What causes ptosis?
This the most complicated question because there can be variation for each patient. It is first important to understand what causes the eyelid to droop. The eyelid height is determined by a muscle in the eyelid. This is called the levator aponeurosis. The muscle is controlled from a signal from the brain to nerve that then stimulates the muscle. Anywhere on that chain and the eyelid will be drooping. Sometimes one component has a problem. Other times a pair or all of the componenets (brain, nerve and muscle) have an issue.
Brain Causes
Third nerve nucleus
This is most often caused from a stroke or tumor which presses the central part of the brain that controls eyelid opening. Often both eyelids are drooping and often associated with a stroke. It is obvious that other things are wrong with the patient other than the drooping eyelids.
Nerve Causes
Third Nerve Palsy
Often caused by injury to the nerve that controls the eyelid, this nerve injury can be temporary in some patients but also can be permanent if it is related to a stroke. The third nerve controls the eyelid muscle but also the movement of the eyes so the patient will usually have a sudden onset double vision with a very drooping eyelid.
Horners Syndrome
This is caused by an injury to the nerve that controls a portion of eyelid lifting (Muellers muscle). This can be from trauma, surgery, a tumor but most often is idiopathic (i.e we really don’t know the reason). The droop is usually a few milimeters. It is most easily fixed with a MMCR or Muellers Conjunctival Resection.
Autoimmune Nerve Disease (Myasthenia Gravis)
This is an autoimmune condition causing drooping of the eyelid that gets worse as the day progresses. As the patient rests, sleeps or even closes the eye for several minutes the drooping improves. In fact placing a pack of ice on the eye for a few minutes improves the drooping. Additionally, this can be associated with double vision. There is neurological testing of blood for this disease and the treatment is usually medication.
Muscle Causes
Aging
This is far and above the most common form of ptosis. The eyelid becomes droopy because the muscle stretches resulting in the eyelid sitting at a lower position. In other patients it can be combined with a degeneration of the muscle where the muscle turns into fat (similar to a congenital ptosis). In other patients it is a combination of a loose muscle with degeneration. Risk factors for this type of ptosis are of course advanced age but also contact lens use (particularly hard lenses) and eye surgery. During Eye surgery an instrument is placed to open the eye. It can cause the muscle of the eyelid to stretch or relax.
Congenital Muscle Maldevelopment
In this type of drooping of the eyelid, a person is born with a degenerated muscle where the muscle did not develop properly. Like a person born with a missing arm or malformed hand it is due to genetics most often. This can be inherited but also can be a spontaneous mutation. There are syndromes associated with congenital ptosis such as Kearns Sayre syndrome or blepharophimosis syndrome.
Genetic Muscle Degeneration
Some genetic diseases such as Chronic Progressive External Ophthalmoplegia or Oculopharyngeal dystrophy result in degeneration of the eyelid muscle over time. Though patients are born with a normal muscle, the muscle breaks down and turns to fat over time causing drooping eyelids. It can be associated with other symptoms such as trouble moving the eyes (CPEo) or trouble swallowing as well (oculopharyngela dystrophy). These diseases are inherited directely from parent to child and often many family members have the same problem.
How is Ptosis fixed or repaired?
Ptosis is repaired by lifting the eyelid. In certain cases this is done with medicine for those who have autoimmune conditions that cause ptosis. In most cases a surgery is needed to raise the eyelid. This is done in three primary ways. First the muellers muscle can be lifted, This is called an muellers muscle conjunctiva resection or MMCR. It is also known as a Putterman procedure after Allan Putterman in Chicago who made the procedure famous. A second technique is called a levator resection which is a tightening of the levator muscle. Finally there are techniques using a sling or material to connect the lift of the eyebrow to the eyelid. By elevating th eyebrow the eyelid raises.
What is the anesthesia for ptosis repair?
Some ptosis repairs can be completed with no anesthesia except numbing shots. Other times IV sedation is given which is anesthesia medicine in an IV in the arm. Finally most children have ptosis surgery with general anesthesia.
How long does ptosis surgery take?
Ptosis surgery takes anywhere between 10 minutes for one eye in a mueller procedure to 40 minutes for both eyelid sling procedure.
Does skin get removed during a ptosis repair surgery?
The short answer is no. That is considered cosmetic surgery and insurance covers just the muscle tightening. This creates a lot of confusion for patients because skin removal makes it look better but remember insurance companies don't care about how things look just how you see. The excess skin has to be at a level that blocks the vision of the patient. Usually removal at the same time during a ptosis repair is not covered. It is an extra out of pocket expense. The picture below is of a patient who had a ptosis repair and elected to not pay for out of pocket blepharoplasty or skin removal. As one can see the eyes are much more open and the patient can see however if one had removed the skin at the same time there wouldn't be the excess skin which may have "looked" nicer.
Why does ptosis surgery sometimes not work?
Ptosis surgery is extremely difficult and unpredictable. Any surgeon, oculoplastic or otherwise who portrays eyelid ptosis repair as “simple” or “easy” is either being misleading, doesn’t really understand the omplexities of the procedure or has not performed the procedure enough. The procedure can be performed completely flawlessly and end up with an overcorrection, undercorrection or eyelid contour abnormality. Overcorrection means the eyelid ends up too high. Undercorrection means that the eyelid doesn’t raise up enough. Eyelid contous abnormality implies the shape of the lifted eye is not the shape of the other eye.
What makes ptosis repair complex or unpredictable?
Each eyelid ptosis procedure or technique carries with it risks of unpredictability. For example a sling technique using either silicone, fascia lata or frontalis muscle is performed when the patient is asleep. It then depends on the elevation of the eyebrow to lift the eyelid to a good position how high the eyelid will raise. This is based on a judgement call by the surgeon during the surgery. There is no way to check on the table how the patient raises the eyebrow because the patient is asleep during surgery. Also the eyebrow is numbed which paralizes the eyebrow function. It is a guess that is made based on how high previous patients raise the eyelid and how open the eyelid is during the procedure once the sling material or frontalis muscle is attached. The complicated thing is that after tightening the eyelid with a sling sometimes the patient does not raise the eyebrow as much after the surgery. So one can see there are a lot of unpredictable variables at play in sling surgery for example.
In a Levator muscle advancement, the levator muscle is advanced and tied with a suture to lift the eyelid. The patient is sat up to test the eyelid height and then the suture is made permanent. This procedure can have unpredictavbility as the eyelid height when the patient is sat up does not necessarily with how the eyelid will be at one week. This is due to several causes. First the weight of the numbing medicine can make the eyelid look low during the surgery. As the eyelid is tightened, the eyelid can raise higher and then be too hight. Second the eyelid tends to drop after the set position in the operating room. As a result, surgeons over “overcorrect” the height of the eyelid and allow the eyelid to drop over the week after surgery. Sometimes it doesn’t drop and the eyelid is too high. Other times the eyelid relaxes too low after the surgery. Additionally a levator advancement can have contour abnormalities as the numbing medicine which swells the eyelid can mask an irregularity of the shape of the eyelid compared to when the numbing medicine is absorbed. This can all occur if the surgery is performed flawlessly.
In a MMCR or putterman procedure, the lift of the eyelid is based on a math formula of roughly 4 mm of tightening for 1 mm of lift. That is an average that predicts the eyelid lift 90-95% of the time. The rest of the time it is too high or too low. There is no way to adjust or compensate to get a higher success rate.
What is the recovery for ptosis repair?
Often there is initial bruising and swelling which resolves over two weeks. During that time, the eye can feel dry and irritated. The vision can be blurry. The eyelid can have trouble closing initially. Sometimes the final eyelid height is not truly apparent for 3 to 4 months especially when there is extensive swelling. Patience is essential during the healing process which can be challenging for patients.
What else makes eyelid ptosis repair unpredictable? What is a Herrings phenomenon?
There is a phenomenon called the Herrings phenomenon. This occurs when one eyelid is lower than the other eyelid. Sometimes when one eyelid is lifted, the other eyelid which was previously the normal eyelid drops. It is based on brain function and this can happen 20% of the time. There is no way to know if that is going to happen ahead of time so one can compensate. If one lifts the now low eyelid that was lifted, the other eyelid that was just lifted can also drop as well. One can imagine through this see saw pattern how difficult it can be to get the eyelids “just right”.
Why do patients get frustrated with ptosis surgery?
There are several things that frustrate patients with ptosis surgery. In short, patients expect the eyelids to look symmetrical or even after surgery and may not fully understand the complexities of the surgery.
Excess skin
Ptosis surgery addresses the openness of the eyelids. It does not address the skin above the eyelids. When patients get a ptosis surgery, the skin removal usually is not covered by insurance. That is a “cosmetic” procedure. Insurance usually cover ptosis surgery to help patients see better. Perfect symmetry of the eyelids is not the endpoint of an insurance paid ptosis repair only seeing better. Patients often get frustrated if there is skin asymmetry after ptosis surgery. The eyelids will still “look different”.
Healing Time
The healing from ptosis surgery though initially can take two to three weeks to heal often takes 3-4 months before final height is achieved. This takes patience. It can be difficult for a patient to wait during that period even if an eyelid seems low.
Success rate
Ptosis surgery does not have a 100% success rate. Often patients refer to all eyelid surgeries as “eyelift” or “eyejob” lumping the most simple blepharoplasties with more complex procedures such as “ptosis repair” and others. They may have a neighbor who had an “eyelift” and recovered in 2 weeks. It creates confusion around expectations for ptosis surgery. Patients may believe it is an easy surgery since their friend, facebook acquaintance or neighbor had an “eyelift” and everything turned out so well so fast.
Every patient is different
Every patient is different so every muscle is different. Even if the same procedure is done on two people who's eyelids look very similar, there can be two very different outcomes. As a result asking on Facebook or Next-door "How did your surgery turn out" or "how was your recovery" or "What is the process" is extremely self misleading.
Why do plastic surgeons shy away from ptosis surgery?
First off ptosis surgery is extremely difficult to perform. One has to have expert knowledge in eyelid lifting techniques, anatomy and the eye surface. Also, it is largely a thankless surgery. There is a myth that patients have that “if the surgeon was good enough” the eyelid would be perfect. Often in this unpredictable surgery, if things are not perfect even if the surgery was performed flawlesslypatients will say “My eyes were botched”. Nothing is further from the truth but based on this false assumption of the surgeon being able to compensate for any muscle, eyelid height, Herrings or situation. Even the best oculoplastic surgeons have to reoperate on ptosis patients. In comparison if someone has a heart attack because of aging clogged arteries it is easy to wrap one’s head around the fact that heart surgery may or may not fix the problem permanently. The problem with the heart could recur. No one would reasonably expect a heart surgeon to make their heart the way it was when they were 30. However, with ptosis repair the expectations are different. No one can imagine a patient or family blaiming a heart surgeon trying desperately to save the life of a patient with a bad heart and the heart giving out or patient dying . In ptosis surgery a similary patient with a bad eyelid muscle commonly blame the surgeon for an outcome where the eyelid is too high, too low, eyelid closure issue, contour abnormality even if the surgery was performed flawlessly and the surgeon gave it their all. Similar surgeries but different expectations. It is fascinating psychologically for sure.
Even some oculoplastic surgeons shy away from these procedures and focus on blepharoplasty where skin is removed. This procedure is where skin is removed on the eyelid and has a 99% success rate. In the world of google reviews, surgeons are disincentivized to perform procedures that don’t have perfect results consistently. Some don’t want to deal with unhappy patients if it doesn’t work. At the end of the day, many patients don’t generally care how hard the surgeon tried to get it right if the eyelids aren’t great after. Finally, for a difficult surgery, ptosis surgery is not compensated well. A Medicaid one sided ptosis surgery pays the surgeon as much as a woman’s haircut for example. This combination of factors makes some surgeons shy away from the procedure.
Wow this sounds scary. How do most of your patients do?
The truth is that the vast majority of my patients do exceedingly well. I have been performing the surgeries for over a decade so I am lucky to have the knowledge skin and experience to set someone up for the best chances for success. The truth however is that not everyone's surgery works on the first shot and its important as a patient to know that. There are some patients who need a second or third procedure. For example below is a patient who came to see me for a second opinion after 4 surgeries from another national expert. Many surgeons online portray that every surgery is perfect and easy. That is not only misleading but creates unhappiness. If one was going for heart surgery, it would be misleading for a surgeon to claim "every patient I have does great!" especially if it wasn't true. The same goes for ptosis.
