Droopy Eyelid (Ptosis) Surgery

Adult acquired blepharoptosis

What are the causes?

The most common type of acquired blepharoptosis, usually seen in adults, is caused by a stretching and thinning of the tendon of the muscle that raises the eyelid. (This muscle is the levator muscle – its tendon is referred to as the levator aponeurosis). This can occur as a result of ageing, after eye surgery e.g. glaucoma surgery, long term contact lens wear (particularly with hard or gas permeable contact lenses), or following an injury. It can also be caused by eye rubbing.This is referred to as an aponeurotic blepharoptosis. Other causes include Horner’s syndrome, eyelid or orbital lumps, or rare muscular conditions e.g. myotonic dystrophy, myasthenia or chronic progressive external ophthalmoplegia.

Before Surgery

A photograph of a patient with a left acquired blepharoptosis

After Surgery

A postoperative photograph of the same patient following a left Muller’s muscle resection performed via an incision on the inside of the upper eyelid

Click here to listen to this patient describing her experience of undergoing droopy upper lid surgery (a posterior approach Muller’s muscle resection) under “twilight Anaesthesia”. This is far preferable to general anaesthesia for the vast majority of adult patients.

Before Surgery

A photograph of a patient with a bilateral contact lens induced blepharoptosis

After Surgery

A photograph of the same patient seen following a bilateral posterior approach Muller’s muscle resection

Before Surgery

A patient with a bilateral brow ptosis and bilateral blepharoptosis and a right lower lid entropion

After Surgery

A photograph of the same patient 3 months following a bilateral temporal direct brow lift, a bilateral Muller’s muscle resection, a bilateral conservative upper lid blepharoplasty and a right lower lid entropion repair

Before Surgery

A photograph of a patient who suffered a severe injury to her left eye and upper eyelid resulting in a severe left upper lid ptosis

After Surgery

A photograph of the same patient following a levator aponeurosis advancement. She was also fitted with a cosmetic contact lens at Eye2C Optometry to camouflage the appearance of her blind eye and traumatic cataract caused by her injury.

What are the signs and symptoms of adult blepharoptosis?

A drooping eyelid is the primary sign of blepharoptosis. There may be some vision loss in the upper field of vision. There may be fatigue from attempting to elevate the lid or there may be a marked compensatory elevation of the eyebrows which act as a secondary elevator of the eyelids. Droopy eyelids can also have a profound effect on a person’s cosmetic appearance and self-esteem.

How is adult blepharoptosis treated?

The treatment is usually surgery although there are a few very rare disorders that may be treated medically (e.g. myasthenia). During surgery the levator tendon (the levator aponeurosis) may be tightened, usually under local anaesthesia with intravenous sedation provided by an anaesthetist (“twilight anaesthesia”), with an incision made in the upper lid skin crease. This is referred to as an anterior approach “levator aponeurosis advancement.” For most patients with a blepharoptosis however, an alternative “scarless” operation can often be performed via an incision on the inside of the eyelid. This is referred to as a posterior approach “Müller’s muscle resection.” This is a very commonly performed operation in our practice and allows a degree of postoperative adjustment of the height and contour of the eyelid. Below is an example of a patient seen before and a few weeks following a Müller’s muscle resection.

Very rarely the lids may be attached to the brow so that the forehead muscles do the lifting. This is required for patients who have very poor movement of the eyelid(s). This is referred to as a “brow or frontalis suspension procedure.” The eyelids may be suspended using synthetic material e.g. a nylon suture (polypropylene), a silicone band, or tissue taken from the outer aspect of the thigh (fascia lata) through a small incision just above the knee.

An ophthalmic consultation can provide a comprehensive assessment of your blepharoptosis, and a discussion of the best treatment option for you. Blepharoptosis surgery can be combined with an upper lid blepharoplasty (eyelid lift, eye lift, or cosmetic eyelid surgery), or this can be undertaken at a later date if necessary.

Blepharoptosis Surgery

You will visit the clinic to have a preoperative consultation with your surgeon. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire, providing information about:

• Your specific aims
• Your current and past general health
• Any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
• Any past dermatology history e.g. cold sores, eczema, rosacea, skin cancer
• Any history of a dry eye problem
• Any contact lens wear
• Any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments
• Any allergies
• Any medications you take (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements)
• Any history of smoking

It is very helpful if you have old photographs which you can bring along to the consultation.

If you are happy to email us digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.

• You may have your blood pressure checked by the nurses.
• The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
• Please answer all questions completely and honestly as they are asked only for your own well-being, so that your surgery can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.
• You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants (e.g. Warfarin or Rivaroxaban) they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
• If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).
• Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) are examined as well as the eyelids themselves.
• The rest of your face is then examined. Photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific permission.
• All our patients are provided with a detailed report following a consultation. This summarises the consultation, the recommendations and also the preoperative and postoperative requirements.
• We much prefer that our patients return to see us in clinic before proceeding with their surgery so that we can have the opportunity to answer any queries and so that a consent form for surgery is completed in advance and not on the day of surgery. If a patient is traveling a long distance however, this second consultation can be omitted and instead queries can be addressed by email and a copy of the consent form sent in advance so that this can be checked by you.

For patients who are insured, a formal visual field record and photographs are often required by the insurance company. These can be arranged with Becky, the optometrist of Eye2C Optometry at the Face & Eye clinic in Manchester. Alternatively the visual fields can be organized by your own optometrist.

What are the possible complications of ptosis surgery?

Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.

Most complications of eyelid surgery are amenable to successful treatment.

Complications from cosmetic eyelid surgery include:

• Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anesthetic used in the operation, swelling of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva (this may mimic a severe hay fever reaction) is referred to as “chemosis” and in some patients can take a few weeks to resolve.
• Watery eyes – this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.
• Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Xailin gel) and an ointment at night (Xailin Night ointment). These should be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.
• Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a bandage contact lens needs to be used.
• Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem.
 A haematoma usually needs to be drained in the operating theatre.
• Damage to the muscles that move the eyeball (e.g. the superior rectus muscle from the use of cautery to seal a bleeding blood vessel adjacent to the muscle) causing double vision is an extremely rare problem and this usually resolves by itself with time. In the very unlikely event that double vision were to persist, a referral to another ophthalmic surgeon with expertise in the management of eye movement disorders and possible further surgical intervention would be required.
• Exposure of the cornea, the clear sensitive surface of the eye. When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops.
• Acute glaucoma – this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
• Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
• Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. A cosmetically unacceptable asymmetry further surgery may be required to address this.
• Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically. Most blepharoptosis surgery in our practice is performed via an incision on the inside surface of the upper eyelid (a posterior approach) and the wound is therefore invisible to others (‘scarless blepharoptosis surgery’).
• Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required.
• Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. an unusual degree of postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.

What happens after blepharoptosis surgery?

After blepharoptosis surgery, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding. For some patients, a stitch is passed through the lower eyelid which is used then pulled up to protect the eye under a dressing. The stitch is taped to the forehead and is usually removed the next day. This is referred to as a ‘Frost’ stitch.

You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used for a levator aponeurosis advancement are dissolvable but are usually removed in clinic after 2 weeks. The sutures used for a Muller’s muscle resection are removed in clinic after approximately 3-7 days depending on the height of the lid in the early postoperative period.

The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The aesthetics nurses at the clinic Face & Eye can demonstrate this to you). It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.

A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.

The scars gradually fade to fine white marks within a few months. (When the surgery has been performed via a conjunctival incision on the inside of the upper eyelid there are no visible scars). Those in the upper eyelid are hidden within the skin crease unless an additional skin incision is required to remove a “dog-ear” of excess skin just below the tail of the eyebrow.

You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Xailin gel and Xailin Night ointment at bedtime.

It is often recommended that you use Xailin Night ointment to the eyes 2 hourly for the first 48 hours after surgery following any upper lid surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). These medications can be purchased from my clinic Face & Eye . You are advised to sleep with the head raised approximately 20-30 degrees. It may be preferable to raise the head of the bed if possible.

Contact lenses should not usually be worn for a few weeks following this type of surgery but this will depend on the type of lenses you wear and your postoperative progress.

Twilight Anaesthesia

Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of my surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.

Click here to watch a video of Dr Paul Lancaster, consultant anaesthetist, talking about what is involved in twilight anaesthesia.

Click here to watch a video of a patient describing her experience of “twilight anaesthesia”. She underwent a bilateral upper lid blepharoplasty and endobrow lift at the clinic.

Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drug is given through that. This is Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 20 years.