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Ptosis repair

Eyelid ptosis is a drooping of the upper eyelid. It is usually caused by detachment or weakness of the muscle which raises the eyelid (levator muscle). A droopy lid may block your vision and you may need to use your forehead muscles to try to lift your eyelids.

Ptosis may be due to aging, trauma, contact lens wear or eye surgery. It may also be congenital (present at birth). Some rare muscle diseases or autoimmune disease such as myasthenia gravis can cause a ptosis. 

ptosis

What is ptosis surgery and how is it carried out?

The aim of ptosis surgery is to raise your upper eyelid. This may improve your visual field and may improve the cosmetic appearance. There are a number of different surgical techniques to raise your lid depending on the cause of your ptosis. The operation is usually carried out under a local anaesthetic as your cooperation is needed to try and accurately set the height of your upper lid. After anaesthetic eye drops have been inserted, local anaesthetic is injected into the lid to numb the area and the operation is then carried out. You may go home the same day.

Occasionally it may also be carried out under local anaesthetic with sedation or a general anaesthetic.

  • Levator muscle advancementThis is the most common ptosis surgery used. An incision is made in your natural upper lid skin crease. The levator muscle that lifts your lid is identified. This is reattached or moved forward to strengthen it and secured with dissolving stitches. The lid crease skin incision is stitched with dissolving stitches, which will usually drop out over a few weeks by themselves. However, some people will need to have them removed.
  • Brow suspensionThis operation is used if you have an abnormal very weak levator muscle. Some people are born with this condition, others may develop an abnormal muscle later in life. Either a synthetic material such as a non-dissolving stitch is used, or tissue from the upper thigh (fascia lata) is taken and used as a sling to connect the upper eyelid to the forehead. The forehead muscles can then be used to lift the eyelid. This involves two cuts on the upper eyelid, two cuts just above the eyebrow, and one on the forehead.

Are there alternatives to surgery?

A ptosis prop is a simple thin plastic arm which attaches to a pair of glasses. When the glasses are put on it gently pushes the eyelid upwards. It can be quite effective but is usually reserved for people who can’t have, or don’t want, surgery.

 

What should I do prior to surgery?

If you are taking aspirin or any other blood thinners you will need to inform your doctor as you may need to stop these. This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. All herbal medicines should be stopped at least 14 days before surgery. If you are on Warfarin you should have an INR test within the 5 days before surgery and bring the result of this to surgery.

Smoking impairs healing and if possible you should try to stop 6-8 weeks before surgery. If you have high blood pressure ensure that this is well controlled as it will make you more likely to bleed and bruise.

Please bring with you a list of your current medications with details of any known allergies. You will not be able to drive yourself home after the procedure. Please arrange for someone to accompany you home.

What happens after ptosis surgery?

If you are in any discomfort take painkillers such as Paracetamol or Ibuprofen. If your wound begins to bleed, apply pressure to the area with a clean pad for 10 minutes. If the bleeding does not stop seek medical attention.

You should keep the incision clean using clean cotton wool and sterile saline solution or boiled cooled water. You will also need to use eye drops or ointment 4-6 times a day for at least 2 weeks to keep the eyes lubricated.

After surgery you should avoid makeup for 1 week and contact lenses for 2-4 weeks. Cool compresses or ice packs should commence as soon as the pad is removed, or immediately if there is no pad, for 5 minutes 4 times a day for the first 2 days to help the swelling and bruising. You may wrap a bag of frozen vegetables in a clean tea towel to do this or buy an eye cool pack from your pharmacist.

People vary in how quickly the swelling and bruising improves. Bruising will usually improve over 2-3 weeks. Swelling takes longer; most will go away over 3-4 weeks. Swelling and bruising may track into your upper cheeks causing swollen lower lid eye bags this will improve over time.

Many people return to normal activities after 2-3 days. Try to avoid strenuous activity for 2 weeks after surgery to help your wounds heal.

The lid scars fade to a white line over a number of months. Most of the scar will be hidden in your natural lid creases. Sunlight can impair the healing of your scar so it is useful to wear sunglasses in sunny conditions whilst you are healing.

What are the complications of ptosis surgery?

  • Bruising and swellingThis happens after the operation to everyone
  • Blurred visionThis is common and often due to the ointment or drops used
  • ChemosisSwelling of the clear covering of your eye (conjunctiva) can last a few weeks, this is common
  • WateringThis is common and occurs due to irritation of the eyes
  • Dry eyeYou may have a reduced blink for a few weeks after surgery and reduced eye closure. This can cause dry eyes and you will be advised to use artificial tears. This will resolve in most people. If you had dry eyes prior to the operation they may be worse and you may need to use artificial tears on a long term basis
  • Corneal abrasionA scratch to the front of the eye; this can be painful but it will normally heal very quickly
  • Lid asymmetryIt is difficult to achieve exactly the same height for each eyelid following surgery and some degree of difference is unavoidable. Occasionally further surgery may needed to lift an eyelid further or to lower a lid that is too high
  • Eyelid contour abnormalitiesThe curve of the eyelid may initially look abnormal. This is often due to swelling and will usually settle – occasionally further surgery is needed
  • Inability to close the eyelidsThis happens often for a short period after surgery and is treated with artificial tears. If the lid is lifted too high, it may be difficult to close the eyelids completely. In some cases this over-correction is intentional and is managed by regular eye ointment until the eyelid drops naturally. In other cases further surgery may be needed to lower the eyelid. The cornea is at risk of ulceration, thinning and infection if the eyelids are not able to close completely after surgery
  • ScarringWounds heal very well in the majority of people. However, abnormal scars may occur within both the eyelid and deeper tissues. In rare cases, abnormal scars may result. Scars may be unattractive and of a different colour to the surrounding skin. There is a small possibility of visible marks in the eyelid or small skin cysts from stitches. These may be temporary or permanent
  • AsymmetryThe human face and eyelid region is normally variable. There can be further variation from one side to the other following surgery
  • Further surgeryOccasionally it is necessary to have a further operation
  • Loss of sensationAny incision can cut through nerves; it is possible to have some numbness around the incision site. This usually goes away over a number of months; occasionally it may be permanent
  • InfectionThis is rare if you follow the instructions on looking after your wound
  • Ptosis of opposite eyeSometimes people notice that the non-operated eye has dropped a little following surgery. This is not a complication of surgery but the brain adjusting to the new position of the operated eye. For this reason, although you may initially appear to have ptosis on one side only, it is often on both sides and you may wish to proceed with surgery to the other side at a later date
  • Haematoma A sudden bleed around the eyeball; the eye is pushed forward, the vision often reduces and it is usually painful. This is very rare, but a bleed can crush the optic nerve and cause loss of vision long term. This needs urgent treatment
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