Everything you need to know about Ptosis Correction by Plastic Surgeon Dr Samuel Ho

Blepharoptosis, or more commonly known by its short form “ptosis” or droopy eyelids, is a much more common problem than people would imagine.

Contrary to popular belief, it isn’t only the elderly age group that has to grapple with this condition - around 40% of my patients with ptosis are in their 20s - 40s. Of course, the underlying cause would be slightly different for this younger age group; it could be after small, unnoticed trauma (eg. constant eye rubbing), after eyelid infections (eg. styes), or due to the long term use of false eyelashes and eyelid glue/tape.

What is Ptosis?

Ptosis is defined as the abnormal, excessive covering of the iris by the upper eyelid. This gives you a ‘sleepy’ look but in greater severity, it can also cause significant symptoms. The severity thus determines if this is a “medical” or “cosmetic” ptosis. Sometimes, my patients appear to “see normally” or “they look ok”, but this may be due to forehead muscle compensation termed “Frontalis strain”.[1]

Types of Ptosis

Ptosis can be due to a whole variety of reasons. 

The most common form is aponeurotic or involutional ptosis. This forms the bulk of the ptosis patients that I treat. Typically, this happens when the aponeurosis or tendon of the eyelid opening muscle (levator palpebrae superioris) is damaged, lax, or even detached from the tarsus (cartilage plate) of the upper eyelid. This results in a very poor upper eyelid opening which causes visual obstruction in the upwards or outwards areas. This muscle aponeurosis thus has to be attached with permanent sutures, tightened, or in severe case, the scarred portion of the aponeurosis removed and shortened before being reattached. 
Other forms of ptosis would include congenital ptosis, neurogenic or myogenic or mechanical ptosis. These are far more uncommon and present far less in my practice.

Congenital ptosis is when the levator palpebrae superioris muscle fails to develop properly from birth. This type of ptosis are commonly treated very early in the patient’s life as chronically, it can lead to other visual disorders such as ‘lazy eye’ and severe astigmatism. 

Neurogenic ptosis results from various disorders affecting the 3rd cranial nerve. An example of this would be Horner’s syndrome, of which ptosis is simply one of a collection of symptoms and signs of the underlying disorder. Such patients can be treated with ptosis correction but I often would seek out the underlying cause and have that treated first. Similarly, myogenic ptosis such as ophthalmic myasthenia gravis is not treated initially with surgery but with medication to control the underlying condition. Only a small group would then need to go on to have surgical correction of the ptosis. Myogenic ptosis is more commonly caused these days by the improper application of botox to the periorbital area.

Mechanical ptosis occurs due to a weight of the excess upper eyelid skin pressing down, or sometimes due to the excessive use of fillers. Very rarely, tumours of the upper eyelid can cause this. 

Ptosis Symptoms & Signs

Ptosis can present with a whole host of varying symptoms and signs, some more subtle than others. Often, my patients come to after they or their friends and family notice the eyelid asymmetry and drooping in pictures. This makes them look sleepy when they are not.

There is also often upper and outer obstruction of vision. They also often feel heavy and fatigued, especially at the end of the day. Frontal headaches, forehead lines and eye irritation/tearing due to the eyelashes being pushed down are some of the other symptoms. As one can see, someone suffering from ptosis may have some or even all of these symptoms, which negatively impact their daily lives. What is worse, there is no exercise or special pill to take to help with this.

When patients come to me for a consultation, there are usually a few common questions that they always ask me. Let me list some of these here and try to answer them.

FAQs by Ptosis Patients

How is ptosis treated? Is there any non-surgical way to treat it?

Treatment depends on the underlying cause of the ptosis.[2] If it is due to a neurological or auto-immune cause resulting in muscle weakness, such as ophthalmic myasthenia gravis, which is very rare, then the treatment is usually non-surgical and I would refer the patient to a Neurologist or Neuro-ophthalmologist for further treatment.[2]

Much more commonly, it is due to a laxity or a defect in the tendon/aponeurosis of the upper eyelid opening muscle, the levator palpebrae superioris. Unfortunately, there is no real non-surgical method to treat this effectively - most methods like the use of Botox or Thermage radiofrequency are very temporary measures that last for a few months at most. Minimally-invasive techniques such as suture-based non-incisional blepharoplasty or “stitching” only help with mild ptosis.
 
I divide the surgical treatment of ptosis into incisional and non-incisional.[3] For non-incisional suture ptosis correction, it is done via a small incision on the upper eyelid skin and the levator aponeurosis is tightened en-mass with without actually visualising it. An alternative to this is doing it from the underside in a scarless manner. Both techniques are only suited to correct mild ptosis and do not address the issues of excess upper eyelid skin or fat.

I typically perform the incisional method as the majority of my patients have moderate to severe ptosis, or need to address upper eyelid skin laxity or excess upper eyelid fat. There are a few variations of this incisional method, but the one I perform most commonly is the levator underthrough plication technique. Other more traditional techniques include levator aponeurosis resection and frontalis suspension or frontalis orbicularis oculi muscle flaps, which are reserved for a special group of patients with very severe ptosis and/or weak levator function on clinical assessment.

Is ptosis surgery the same as cutting eyelid surgery for creating double eyelid creases?

I usually describe it as such to my patients - ptosis surgery is double eyelid surgery plus, in the sense that the beginning and the end of the procedure is similar to a double eyelid surgery, with an additional component of muscle aponeurosis/tendon tightening.

What this implies is that the bonus of ptosis surgery in addition to correcting the drooping eyelid would be a double eyelid crease if you did not originally have one although it is possible not to have one as well (which is commonly requested for by my male patients). It also means that the surgery is a little longer than a regular double eyelid surgery, taking around 1.5 to 2 hours due to the need to tension the muscle tendon properly and the need to make delicate adjustments for each eyelid. Often, you would be asked to open and close your eyes multiple times towards the end of the procedure.

What exactly is done during the procedure and what do you mean by muscle tightening?

The incision is made along the natural double eyelid crease or a selected double eyelid crease if my patient does not have one. Any excess skin or fat is removed during this procedure. After reaching the muscle aponeurosis/tendon, I will then proceed to do a trial tightening via a levator underthrough plication, which is a proprietary technique of mine. This works very well for about three quarters of patients, and allows for complete reversibility and much lower bruising and downtime. In the remaining 25%, where this does not produce a good correction, I would then need to perform a aponeurosis shortening, which involves cutting and reattaching the muscle tendon.

After checking for symmetry, and for good eye closure, I then proceed to suture the wound close just like for a double eyelid creation.

Is it painful and am I wide awake throughout?

I sedate all my patients with a mild sedative. This makes it much more comfortable for them as well as allows for a much smoother operation. Local anaesthesia is administered around the eyelid prior to the procedure and after the sedation takes effect. The only discomfort some of my patients tell me is during the muscle tendon tightening where some of them might feel the tightening akin to a pinching effect. Most do not remember much about the procedure after.

My eyes are very small. Will I be able to fully close my eyes after enlargement?

In short, yes, eye closure is a pre-requisite. Over-enlargement is hence not encouraged to prevent this from happening. However, in the first few weeks, the eyes may have a small gap of about 1mm when sleeping due to the initial tightening and swelling. This will resolve gradually and should not result in significant eye symptoms other than mild dryness.

What is the price for Ptosis Surgery in Singapore? Can I claim Medisave and insurance for it? 

The professional or surgeon’s fee for ptosis correction can vary between clinics; my surgeon’s fees start from $4,500. An itemised breakdown of the various charges will be given to you by my clinic staff after the consultation. In addition to the surgeon’s fees, other costs include anaesthesia fees, facility fees, medical consumables and equipment fees, medications and GST.

The ability to claim from Medisave or from your insurance company depends on the graded severity of the ptosis. This is first assessed by myself clinically, after which if I feel that it is warranted, a detailed and complete Visual Field assessment and MRD1 grading is done by my ophthalmologist, who will furnish a report with a charting of these values and measurements. This, in addition to certain pre-operative photos taken by my clinic staff form the basis of a smooth and successful claim.

Now what is MRD1? This refers to the Marginal Reflex Distance 1 and relates to the upper eyelid, measuring the distance from the central corneal reflex (pupil centre) to the upper eyelid; as opposed to MRD 2 which refers to the lower eyelid, measuring the distance from the pupil centre to the lower eyelid. Using the MRD1 measurement, ptosis is then sub-divided into mild, moderate and severe. For it to be medisave or insurance claimable, the MRD1 +2mm or less, indicating either moderate or severe ptosis. In mild cases, a ptosis correction will enhance their appearance but may not be medically indicated. This will be reflected in the ophthalmologist examination.

What can I expect after surgery?

Bruising and swelling is to be expected after any eyelid surgery. Bruising typically takes about a week to 10 days to completely resolve. Swelling can take a while longer to completely resolve, ranging from 2-3 weeks to 2-3 months in the elderly patients. Most of my patients take about a week of medical leave and are able to return to work after.

Pain is extremely tolerable and low, even in those with very low thresholds of pain! Most of my patients experience an aching feeling due to the swelling for a few days, without the need to take the oral painkillers at all. They are able to shower and wash their faces the next day. 

The skin stitches are removed typically on day 5 and I usually need to see my patients twice after the surgery - day 5 and 1 month after. Most are fine after 2 follow-ups although a small group may require a third visit around the 2 to 3 month mark as they may be slower to recover (usually the elderly group of patients).

There is usually an immediate improvement in symptoms and function. The obstruction of vision should be corrected although swelling can mean the final result can take a few months before the final size is reached. Many of my patients tell me that they feel lighter and that things are “brighter”, which some will report as an improvement in visual clarity which isn’t actually so - there is simply less obstruction and a greater visual field.

Those of my patients who had headaches before also have resolution of some of these, due to a reduction in frontal strain. Their forehead lines improve and their eyebrows return to a more rested, natural position.

In the aesthetic sense, a less sleepy appearance with larger and more attractive looking eyes is the final result of ptosis surgery, in addition to a more defined double eyelid crease.

Although ptosis correction is relatively straightforward and done very commonly in my clinic, some complications can occur even with the best of care and you should be made aware of it.

These include:

Bleeding (typically in the first 24hrs) - This results in a lot of swelling and a purplish appearance. It typically occurs when a tiny capillary or vessel starts to bleed due to exertion. If severe, the bleeding vessel may need to be stopped surgically.

Under/overcorrection - This can result in the inability to close the eyes completely. Adjustments can be made and are usually simple 15-20 min procedures done under local anaesthesia. Typically, only 1 eyelid needs to be adjusted.

Chemosis - which is the swelling of the conjunctiva, the mucous membrane lining the inside your eye eyelid. This typically resolves with cold compress and eye drops.

In summary, ptosis correction is a simple, day surgical procedure in the right hands. The pre-operative clinic assessment is the key step to ensuring a good outcome, as is the pre-surgical marking and simulation that I do on the day of surgery. I hope the above has been helpful.

References:
1. Martin JJ Jr. Ptosis repair in aesthetic blepharoplasty. Clin Plast Surg. 2013 Jan;40(1):201-12. doi: 10.1016/j.cps.2012.06.007. Epub 2012 Aug 26.
2. Bradley EA, Bartley GB, Chapman KL, Waller RR. Surgical correction of blepharoptosis in patients with myasthenia gravis. Ophthalmic Plast Reconstr Surg. 2001 Mar;17(2):103-10.
3. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003 May-Jun;27(3):193-204. doi: 10.1007/s00266-003-0127-5. Epub 2003 Aug 21.
 

 


 

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