The Different Surgical Techniques for Treating Ptosis / Droopy Eyelid Correction

Droopy eyelids or ptosis is a rather common condition that affects different age groups, although the cause of ptosis (medically known as blepharoptosis) may differ between individuals of different age groups. Regardless of the cause or the age group, the symptomatic or functional deficits of the ptotic or droopy eye remains the same:

•    Superior or lateral visual field obstruction
•    Upper eyelid and forehead heaviness and fatigue
•    Upper eyelid irritation 
•    Eye dryness
•    Headaches

This occurs as the upper eyelid is now covering more of the iris, resulting in a smaller visual field at rest. The forehead muscle compensates for this by involuntarily contracting very frequently to raise the eyebrows and hence the upper eyelids, improving the visual field and reducing eyelash irritation, which gives rise to the rest of the symptoms.

This article will deal mainly with the various surgical methods to treat the involutional or idiopathic form of blepharoptosis, which is essentially accumulated damage to the levator superioris palpebrae muscle (eyelid opening muscle) aponeurosis (tendon), resulting in a lax tendon that manifests as a droopy eyelid.

The doctor does not deal with the non-surgical methods as these are often temporary or worse, and do little to correct the actual droop of the upper eyelid. It is also important to note that no upper eyelid exercises will help in reversing this slow progressive condition.

The Surgical Techniques

There are a wide variety of surgical methods to correct blepharoptosis. Each varies in the technical complexity, the severity of ptosis that each can be used for (as each procedure produces a different degree of lift), the incision and hence scar position as well as the overall downtime post-procedure. 

They will be listed below in accordance to the severity of ptosis each is used for:

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•    The Fasanella-Servat operation[1] is a procedure that is minimally invasive as it is performed from the inner aspect of the upper eyelid, so there is no scar on the outer surface. It involves the removal of a portion of the cartilage plate (tarsus) of the upper eyelid as well as a portion of the Muller muscle, which is a tiny muscle that is responsible for a small degree of eyelid opening. 

Unfortunately, it is effective only for mild forms of ptosis from a variety of causes, and for a majority of the doctor’s patients, it would not correct the ptosis sufficiently or reliably. 

Furthermore, it does not allow for the removal of upper eyelid skin excess or fat, hence their older patients would not benefit from this.

Image from: Springer

•    Procedures that manipulate the levator aponeurosis.[2] All these procedures utilise an incision on the double eyelid crease to access the repair site. Essentially, it appears like an incisional double eyelid procedure, except much more work is performed internally. They typically use the under-through technique to tighten the levator palpebrae superioris muscle aponeurosis, as this allows for greater flexibility in adjustment as well as a shorter recovery time in terms of bruising and swelling. 

This works very well for most ptosis patients except for the congenital ones or those of a very severe degree. About 70% of their patients will do well with this method of correction. In the remainder, the under-through technique produces a suboptimal result during the surgery and I will usually proceed to perform a levator aponeurosis shortening-advancement technique to obtain the required result. 

This method results in a longer recovery time in terms of bruising and swelling than the previous technique, which is why the doctor does not use it for every patient if possible. Both these techniques allow for removal of excess eyelid skin and fat.

Image from: Researchgate

•    Frontalis procedures[3] such as frontal sling or the frontal obicularis oculi muscle (FOOM) flap. These are much rarer procedures that are performed for very severe ptosis, usually congenital ones. This is because the muscle belly strength itself is very weak in these patients and often we require a secondary muscle to augment it, whether it is the forehead (frontalis) muscle or the eye closing muscle (orbicularis oculi). 

These procedures are often much more cosmetically damaging, as it does not allow for natural-looking eyelid opening and usually results in a large gap when the eyelid is closed. Hence, it is reserved for a minority of cases in the practice.

•    Browlifts. Occasionally, it is the eyebrow or eyebrow area skin that is droopy and in excess. As such, the procedure performed may be an endoscopic browlift or more commonly, a direct infrabrow lift. The choice depends on various factors such as the patient’s eyebrow position, eyebrow thickness and length as well as the forehead height and curvature.

How do I know which procedure is suitable for me?

The choice is not left to the patient in this case. Rather, the surgeon is the one that makes the choice of the technique based on the severity of the blepharoptosis as well as accompanying factors such as eyelid skin excess and fat excess.

How do I shorten the downtime as much as possible?

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

Avoidance of smoking and alcohol as well as certain supplements (gingkobiloba, ginseng, omega fish oils etc) and medications 1 week prior to surgery will help with the reduction of bruising. Also, it is important to avoid strenuous activity particularly in the first 2 weeks, such as high-intensity interval training, contact sports, swimming and weight lifting. 

The use of a cold compress for the first 5 days followed by a warm compress after that is particularly helpful, and patients who are more compliant and do it more frequently tend to have a much shorter recovery period.

The doctor also uses certain medications to reduce bruising and swelling in their patients, including herbal supplements such as Arnica Montana.

In summary, ptosis correction is a simple, day surgical procedure in the right hands. I hope the above has been helpful.

References:
1.Noelene K Pang, Roger W Newsom, James H Oestreicher, Hans T Chung, John T Harvey Fasanella-Servat procedure: indications, efficacy, and complications Can J Ophthalmol. 2008 Feb;43(1):84-8. 
2.Saonanon P, Sithanon S. External Levator Advancement versus Müller Muscle-Conjunctival Resection for Aponeurotic Blepharoptosis: A Randomized Clinical Trial. Plast Reconstr Surg. 2018 Feb;141(2):213e-219e.
3.Riccardo Gazzola, Elena Piozzi, Luca Vaienti, Franz Wilhelm Baruffaldi Preis Therapeutic Algorithm for Congenital Ptosis Repair with Levator Resection and Frontalis Suspension: Results and Literature Review Semin Ophthalmol. 2018;33(4):454-460.
 

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