Oculofacial Plastic Surgeon
Laura Phan, M.D.
Laura Phan, M.D.
  • 15055 Los Gatos Blvd Suite 320, Los Gatos, CA 95032. (408) 502-5000 0

Laura Phan, M.D.

Ptosis surgery is a procedure to raise droopy eyelids, when the eyelid margin lays low and may cross the patient’s line of sight. Ptosis is caused by aging, muscle or nerve abnormality, trauma, or tumor. In majority of the time, ptosis is due to aging, wherein the tendon of one of two muscles that is responsible for elevating the eyelid, called the levator aponeurosis, is attenuated and dehisced. In other words, the levator aponeurosis thins and stretches from the eyelid; the contractile force of the levator muscles does not transmit to the eyelid. The levator muscle is also often replaced by adipose tissue, or fat, which further affects the contractile force of the muscle. 

Ptosis is repaired surgically. This repair improves peripheral vision as well as the sleepy appearance. An incision may be made externally on the eyelid crease or internally on the back side of the eyelid. Whether the approach is external or internal depends on several factors, including the severity of ptosis and the inherent muscle function. The number and strength of muscle fibers cannot change. Instead, during surgery, the aponeurosis and muscles are shortened, which in turn tightens the muscle. Shorter, tighter muscles contract with greater tension to pull up on the eyelid. 

Ptosis surgery can be done in the office with local anesthesia or in the operating room under intravenous sedation, depending on the patient's comfort level with surgery. During the surgery, the surgeon will have the patient sit up towards the end of the procedure to evaluate the lid height, contour and symmetry and adjust the muscle tightness accordingly. For accuracy of this evaluation and adjustment, local anesthesia is preferable when possible. 

What to expect after surgery
The skin of the eyelid is the thinnest of the body, which means the incision through the skin is unlikely to leave visible scarring. Furthermore, the incision is placed in the eyelid crease and hidden by the eyelid fold.

It is generally recommended that patients plan on staying home for three days after the procedure and apply ice to the eyelids to reduce bruising and swelling. It typically takes about two weeks for the bruising and swelling to subside, although the bruising can be effectively covered with makeup or sunglasses after the second week. Minimal restrictions are placed regarding exercise, bending and heavy lifting for one week to prevent more bleeding or swelling than necessary. Sutures are removed 7-10 days after the surgery, once the skin heals. Although the skin heals within a week, muscles take at least one month to recover majority of the fibers and 2-3 more months to regain all of their strength. Final results are evident when the last of the internal swelling resolves and scarring settles down.

Ptosis repair is one of the more challenging eyelid surgeries. The difficulty is in the unpredictability of the results. While the indications of the surgery are to elevate the eyelid, increase the opening of the eye, and improve peripheral vision, the results can be spot on, or one or both eyelids do not elevate, elevate partially or elevate too much. There is, therefore, the risk of asymmetry. This unpredictability is a result of the interplay between science, art, and unknown factor in how the muscle and skin respond to the surgery and ultimately heal, irrespective of an uneventful surgery. Fortunately, the success rate is still 90-95%. 

When one of the unexpected outcomes occurs after surgery, it is disappointing and frustrating to the patient and the surgeon. But, it usually can be addressed. This often involves repeat surgery and the associated additional time, resource, and inconvenience. This risk, as well as all other risks associated with surgery, should be considered thoroughly beforehand. 

Aside from a perfect surgery, if that is even possible with every surgery, reasonable and achievable goals guarantee success.