Ptosis (droopy upper eyelid)

Ptosis means “abnormal lowering of a tissue or organ”.

Blepharoptosis  or upper eyelid ptosis refers to a droopy upper eyelid.

Ptosis of the upper eyelid is a common problem. It can be a congenital problem (children can be born with a droopy upper eyelid) but ptosis is far more often acquired (onset is often in middle-age or later).

Drooping of the upper eyelid occurs if the muscle that pulls upper eyelid upwards (the levator muscle) becomes stretched or it’s attachment to the upper eyelid is weakened. This can happen with ageing but can also occur after eye surgery, contact lens wear and injury to the eyelid.

A mild ptosis can be a cosmetic concern because it can result in asymmetry of the appearance of the eyes. A droopy upper eyelid can convey a tired appearance.

More often ptosis is severe enough to also interfere with vision. The upper eyelid may droop over the pupil and obstruct light entering the eye. This may be particularly noticeable when looking down to read or at the end of the day when tired.

Procedure 

Surgery to correct ptosis can: 

• Improve the cosmetic appearance of the eyes by raising the upper eyelids resulting in a fresher more alert look to the eyes.
• Improve vision by allowing more light to enter the eye

Ptosis surgery steps

• Adult ptosis surgery is performed under local anaesthesia with or without intravenous sedation (“Twilight anaesthesia”). Children have surgery under general anaesthesia
• The surgery can be performed via an incision on the inside of the upper eyelid (a posterior approach ptosis correction). This avoids a skin incision and is suitable for mild / moderate ptosis and in cosmetic cases where a skin incision is undesirable
• Ptosis surgery can also be performed via an upper eyelid skin incision (an anterior approach ptosis correction). This is a suitable approach for more severe ptosis or when removal of upper eyelid skin is necessary at the same time (combined ptosis and blepharoplasty surgery)​
• The levator muscle or the Muller’s muscle (a sheet of muscle that acts with the levator muscle to lift the upper eyelid) is identified. The pulling effect of the levator muscle is enhanced by tightening Muller’s muscle (a Muller’s muscle resection) or advancing the tendon of the levator muscle (levator advancement) and reattaching it to the upper eyelid
• After checking that the height and contour of the upper eyelid is good the skin incision closed with fine stitches. These are usually removed in clinic after one week. No stitches are usually needed to close the incision on the inside of the upper eyelid if a posterior approach ptosis correction is performed

Ptosis surgery risks and complications

I will explain potential eyelid surgery complications in detail to you. You will be asked to sign a consent form to ensure that you fully understand the procedure you will undergo and any risks or potential complications which can include: 

• Blurred or impaired vision, including loss of eyesight (extremely rare)
• Corneal abrasion - this is a scratch to the surface of the eyeball that causes persistent pain. This is rare but can occur with any surgery on or near the eye and is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used
• Dry eyes - eyelid closure can be impaired following surgery and usually improves over 2-3 weeks. You will be asked to use lubricants during the day and a lubricant ointment at night to prevent a dry eye
• Bleeding (haematoma) - This can very rarely lead to a loss of vision, including blindness. A haematoma usually needs to be drained in the operating theatre
• Infection- this is rare but it is important to follow post-operative wound care instructions to help to prevent such a problem
• Numbness and other changes in skin sensation
• Undercorrection (residual droopy upper eyelid)
• Overcorrection (retracted upper eyelid that is too high)
• Contour abnormalities - occasionally the upper eyelid contour can be altered by ptosis surgery so that an unnatural peak or droop in one part of the upper eyelid is noticeable. This can sometimes be improved in the post-operative period by applying eyelid traction (pulling down on the eyelashes and the edge of the eyelid in the area of peaking) but other cases may require further surgery to improve this
• Drooping of the fellow upper eyelid. Raising the upper eyelid on one side can result in some drooping of the other side. This cannot always be predicted prior to surgery and it is important to be aware of this possibility and of the possible need to undergo ptosis surgery on the other side subsequently if this were to occur and not settle in the next few weeks after surgery
• Scarring. Most eyelid wounds heal very well with scars that are barely perceptible after a few months. However occasionally wounds can become thickened and may require attention with additional treatment such as steroid injections or, rarely, surgical revision to improve the scar
• Skin discolouration and swelling
• Sutures may spontaneously surface through the skin, become visible or produce irritation that require removal
• Acute glaucoma - this is sudden raised pressure and pain within the eye,  haloes around lights with blurring of vision, headache and vomiting. This can occur very rarely following eyelid surgery. Any such symptoms following surgery should be reported to your surgeon who can diagnose and treat this, should this occur
• Possibility of revision surgery if the outcome is not as expected 

Be sure to ask questions:

It’s very important to ask any question you have about your proposed eyelid procedure. I’ll do my best to address any concern you may have.

When you go home

If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require admission to hospital and additional treatment.

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

• Why you want the surgery, your expectations and desired outcome
• Medical conditions, drug allergies and previous medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol & tobacco
• Previous surgeries

The following will also take place at your consultation

• Evaluation of your general health and any pre-existing health conditions or risk factors
• An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
• Photographs for your medical record
• A discussion about treatment options
• Recommendations for treatment most appropriate for you
• Discussion about likely outcomes of eyelid surgery and risks or potential complications
• The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation