Aponeurotic Ptosis Surgery

Left Eye Ptosis (Drooping Eyelid) Left Eye (Post Ptosis Surgery)

Levator palpebrae superioris Aponeurotic Ptosis Surgery

General Overview:

Aponeurotic Ptosis is referred to as age-related ptosis (adult or senile onset ptosis). This may happen as a result of dehiscence, senescence, or disinsertion of the levator palpebrae superioris (LPS muscle – The muscle which elevates the eyelid) aponeurosis. Most of the times, post-operative causes are considered to be one of the major causes. Intraocular surgery or chronic inflammation may produce  the same effect. Wearing contact lenses for a long amount of time is said to produce a strong effect on this condition.

There are a few eyelid surgeries that are performed in order to treat aponeurotic Ptosis.

•  Muller’s Muscle Resection:

T  Muller’s Muscle Resection is perfor,ed only in cases with mild ptosis, with very good leavtor muscle action. This operation is carried out by giving/making an incision on the inside of the eyelid (conjunctival side) from within. 3 stitches are made use of for tightening the Muller’s muscle. These stitches are removed within 3 weeks post surgery. This operation is usually performed on only those patients who have shown a favourable reaction to an eye drop test (phenylephrine test) carried out  in the clinic – In this test, a drop of phenylephrine drug is put into the eye and the eyelid evaluated for a correction of the ptosis.

Levator Aponeurosis Advancement:

The operation is carried out by making an incision in the natural skin crease of the eyelid (eyelid crease). Stitches are given to tighten the levator aponeurosis tendon (Levator plication) and then the wound is closed. The results of surgery are better when performed under local anaesthesia, since when you are awake during the operation you can open your eyes when asked, to let the oculoplastic surgeon judge the best position for your eyelids. Generally all the stitches are absorbable and will drop out on their own after a few weeks.

Aims of aponeurotic ptosis surgery:

The surgery points to elevate the eyelid enough to terminate the ptosis causing problems with vision.

The perfect result is obtained when:

1. The eyelid is at a normal level.
2. The level of one eyelid corresponds with and is similar to that of the other lid.
3. The eye closes fully and is comfortable.
4. The lid has a natural curve, contour and a well defined symmetrical lid crease, which corresponds to the other lid.

Procedure of surgery:

For advancement of aponeurosis an incision is made in the skin crease of the lid and the levator tendon is located. The tendon is tightened with stitches. The tightening of the tendon is performed, depending on the levator muscle function as well as the amount of ptosis to be corrected. Then the lights are dimmed and patient is asked to open their eyes to know whether the stitches are in the appropriate position and if needed they are adjusted. Once the stitches are appropriately positioned, the skin is closed using dissolving stitches. The wound ends up in the natural skin crease of the lid, which forms when the eye opens, so that the incision for the surgery does not show once it has healed. A pad is then put on the operated eye.

For Muller’s muscle resection an incision is made on the inside of the upper lid and the levator palpebrae superioris muscle is shortened using non dissolving stitches which rest on the natural skin crease of the lid.

The surgery takes about an hour for each eye. If both the eyes have drooping, it is usually best to operate on both sides at the same time in order to obtain most accurate results.

Advantages of surgery:

• Refinement in the quality of vision, where a part of the eye was initially encrusted by the drooping upper lid
• An enhancement in the upper part of your field of vision
• Improving symmetry with the other eyelid
• Restoring the eyelid and the eye appearance back to normal

Complications of surgery:

• Wound infection – There is a small risk of infection after surgery, which necessitates treatment with antibiotic tablets.
• Bruised and swollen eyelids – The lid may feel sore and look bruised and remain swollen for up to a few weeks.
• Overcorrection – The eyelid is raised too much after the operation and the eye may then become dry and sore. Drops and ointment can help to provide relief and comfort. Massage and traction on the lid may treat a little amount of overcorrection. Rarely, a further surgery to lower the eyelid is needed soon after the initial one.
• Under correction – The eyelid is still low even after the surgery.
•  Poor contour – The shape/curve of the upper lid is not proper.
• Incomplete lid closure- The lids may not close completely with the eye somewhat open at night. The danger involved is that the front surface of the eye may become uncomfortable and dry. Drops and ointment may help to treat this but rarely further surgery is necessitated.
• Reoperation – Further surgery is needed in about 4% of cases.

Ptosis eyelid surgery is amongst the toughest of all plastic surgeries. As you look at the world, the world looks at your eyes and hence, even a mm’s difference in the two eyelid heights will be noticed by all. Therefore, ptosis surgery should be performed only by the most well trained, best oculoplastic surgeons.

To watch a video of a lady treated for senile, aponeurotic ptosis, by Dr. Debraj Shome:

To read more on Ptosis surgery, click on the link below from Dr. Debraj Shome’s blog:

http://debrajshome.wordpress.com/2013/07/29/best-blepharoptosis-surgeon-in-india/