A Complete Guide to Ptosis Surgery: Treating Droopy Eyelids

안검하수 눈매교정

Ptosis surgery is a procedure that is often recommended in conjunction with double eyelid surgery. Are you curious about how to improve the appearance of droopy eyelids? This article provides information on the effects of the surgery, the surgical procedure, the criteria for deciding whether to undergo the procedure, and the potential side effects.

1. Understanding Ptosis or Droopy Eyelid

1) Blepharoptosis

Ptosis or blepharoptosis is the medical term for droopy eyelids, often referred to as “sleepy or tired eyes”. This condition occurs when the muscle responsible for opening the eye is weak. There are both congenital (present at birth) and acquired causes, such as injury, disease, or aging. Ptosis is classified into mild, moderate, and severe categories. Approximately half of the Korean patients who seek double eyelid surgery at plastic surgery clinics have mild ptosis.

2) Ptosis surgery

Ptosis correction refers to the surgical treatment of droopy eyes.

2. Surgical Method for Correcting sleepy eye

To create a more attractive appearance, the surgery aims to ensure that the upper eyelid covers the pupil and iris by 5-10% of their size. The surgical procedure involves treating the levator (the exact medical term is levator palpebral superioris and levator aponeurosis, but for short, I termed levator in this article), which lifts the eyelid during eye movement.

eyelid anatomy section
The figure below shows that the levator (green in the figure) inserts into the tarsus (small cartilage-like tissue that supports the edge of the eyelids, white in the figure).

Some individuals are born with a weak levator, while others may experience a separation of the levator from the tarsus due to aging or injury. Ptosis correction involves overlapping or shortening the levator, increasing its strength and improving eye-opening function. It is the same principle as folding the rubber band to create more powerful strength. 

mechanism of ptosis surgery
The principle of making traction power more efficient when the eyes are opened by advancing/folding the levator.
Upper Eyelid Ptosis Correction with Levator Advancement in Asian Patients using the Musculoaponeurotic Junction of the Levator as the Key Reference Point.
ptosis surgery video

3. When is Ptosis correction Needed with Double Eyelid Surgery?

attractive eyes

The ideal exposure of the iris and pupil is subjective, and there is no clear answer as to what constitutes “beautiful eyes.” However, there are certain circumstances where ptosis correction can be beneficial, including:

  • Those who desire more prominent and vivid eyes.
  • Those who expect to decrease the vertical height of the palpebral fissure after double eyelid surgery.
  • Those with unequal size of eyes.
  • Those with apparent ptosis or a hollow upper eyelid.
droopy eyelid treatment
Before and after ptosis correction in conjunction with double eyelid surgery.
Double eyelid surgery is to make a neat crease on the eyelids, while ptosis correction is to make bigger and more vivid eyes. 
correction of asymmetric eyes
Ptosis correction for a size difference between the eyes.
sunken eyes treatment
Ptosis correction can also benefit eyes with sunken, high fold, and sleepy looks in the elderly.

4. Possible Side Effects of Ptosis Surgery

Ptosis correction can result in complications for some patients. A survey of 10 senior American surgeons specializing in ptosis correction found a re-operation rate of 12-18%, demonstrating the unpredictability of the procedure. It’s important to remember that all surgeries carry potential side effects and to carefully consider one’s age, eye condition, and goals before undergoing the procedure.

1) Under-correction

Sometimes, a patient’s eyes may still appear smaller than desired after the surgery. This disappointment is due to a deficient levator correction length or improper suture fixation. Swelling during the procedure can make it difficult for the surgeon to assess the results accurately. It is advisable to wait at least six months for the final outcome. However, if the surgeon is confident that under-correction is likely, early revision within 2-3 weeks of the initial procedure may be helpful.

2) Over-correction

ptosis surgery side effect
Upper: pre-op
Middle: 13 days after the initial surgery. Just before the revision operation on the left side.
Bottom: 2 months after revision on the left side. Six days after simple excision of the skin excess on the right.

Retraction, or overcorrection, is another potential side effect of ptosis correction. Signs of overcorrection include visible upper sclera and discomfort that persists long after the procedure. Common symptoms of overcorrection include headache, eye strain, palpitation, tinnitus, and dizziness, which are caused by Muller’s muscles. These symptoms are rare but can be corrected surgically if necessary. However, doctors have no consensus about the best course of action, so close follow-up is recommended.

3) Asymmetry

Achieving symmetrical eye dimensions during ptosis surgery can be challenging due to differences in levator power, the effects of anesthesia on eye-opening muscles, and difficulty in assessing the exact size due to swelling or Hering’s law of equal innervation.

ptosis Herring's law
Herring’s law Photo: Ptosis on the left eye(upper figures). The right eye became smaller when the left eyelid was raised(bottom figures), showing Herring’s law positive.
The art of blepharoplasty

Both surgeons and patients need to keep in mind that secondary adjustments may be necessary. 

4) lagophthalmos

lagophthalmos after eyelid surgery
Mild lagophthalmos on the right eye. 1 month after surgery.

Lagophthalmos refers to a gap between the upper and lower eyelids during eye closure and can be caused by over-correction of ptosis or excessive skin removal. As shown in the above photo, mild cases often improve on their own without symptoms. However, severe cases can worsen dry eye syndrome, so the surgeon should carefully consider the patient’s dry eye symptoms before surgery.

5) Dry eye syndrome

Dry eye syndrome is a potential side effect of ptosis correction and can be exacerbated by lagophthalmos. Fortunately, they may improve over time if symptoms are mild.

5. Conclusion

Ptosis surgery requires expertise and can significantly change one’s appearance. Patients can achieve safe and pleasing results by understanding one’s orbital condition and setting realistic goals. I hope this article has helped provide information about the procedure and its potential side effects.

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