Ptosis repair, the process of lifting the upper lids, is somewhat of an artform. All of the most respected surgeons in the oculoplastic field will tell you that the surgery can still be frustrating, even when one is at the top of their game. Why is that? It turns out that the main lifting muscle of the eyelid can undergo degeneration… or patients can be born with dystrophy in that muscle… or the tendon from that muscle can slip. Neuromuscular or myogenic problems can lead to the drooping lid. And to top it off, the lid heights can change during the operation due to anesthetic effects.
The preoperative exam needs to be incredibly precise in order to get a predictable result. For example, if the main eyelid muscle contracts only a few millimeters less than average, the standard surgery will be a complete failure. If the eyelid muscle contracts only a few millimeters less than that, eyelid surgery alone will no longer fix the problem. It breaks down like this:
- Eyelid lift > 12 mm – standard external ptosis repair should work
- Eyelid lift 11-12 mm – standard external ptosis repair may not work
- Eyelid lift 7-10 mm – advanced ptosis repair techniques required
- Eyelid lift < 5-6 mm – eyelid muscle be connected to forehead (using deep, deep sutures under the brow) in order to achieve any lift
In addition, there are some patients who can have the internal lift as well, without an external skin excision. We do tests in the office to see if patients are candidates for that.
At any rate, in the past two weeks, I’ve basically performed the whole palette of eyelid surgeries, from standard lifts to internal lifts to using silicone rubber bands to connect the eyelid to the forehead. Each of those 10 patients required a slightly different surgery, in terms of where to form the eyelid crease, how aggressive to advance the main eyelid muscle, how to fixate the eyelid crease, etc etc.
So far, there have been happy returns!
Sample patients from the past month:
Patient 1: This little girl was born with a droopy eyelid on the right, so droopy in fact that it was thought to be interfering with normal visual development on that side. The picture below also demonstrates on the common features of the examination of a child with congenital ptosis: loss of eyelid crease and fold. The upper eyelid is featureless.
Postoperatively, in most positions of gaze, the eyelid on the right looks very similar to the one of the left. The right upper eyelid also has a lid crease and a fold now, which matches the left side quite well. The photo below as one week postoperative.
Patient 2: She had a congenital droop on the left, but since this child was older, I had the option to use a more durable suture in the repair. The silicone sutures occasionally wear out after a few years; a more lasting suture can be fashioned from a strip of lateral leg tendon. This strip can be obtained in though a 3 cm incision on the lateral aspect of the leg, several cm above the knee. Preoperative, she has the common findings of congenital ptosis, with a featureless upper eyelid on the left.
Patient 3: Finally, your typical “involutional” ptosis… the one that comes from having a long life filled with smiling, or perhaps, eye surgeries. Preoperatively, she has multiple eyelid creases and appears tired.