Reconstructive Services

Functional Upper Eyelid Ptosis Repair

Ptosis is a condition in which the upper eyelid margin (where the eyelashes come out) is low. Ptosis can be present by in isolation or in combination with dermatochalasis (excess eyelid skin). Ptosis can be caused by several factors, most commonly due to stretching of the muscle tendon that lifts the upper eyelid (involutional ptosis), but also due to muscular diseases (myogenic ptosis), nerve injuries (neurogenic ptosis), tumors (mechanical ptosis), or it can be present at birth (congenital ptosis). Ptosis repair is considered “functional” or “medically necessary” when the eyelid blocks the upper field of vision. A visual field test can determine if upper eyelid ptosis is considered medically necessary and therefore may be covered by insurance.

Functional ptosis repair is usually performed as an outpatient procedure. There are several different surgical techniques used to repair upper eyelid ptosis. The amount of eyelid muscle (levator) function and cause of ptosis helps determine which operation to choose. Depending on the type of operation, ptosis repair may be performed in the office or at an outpatient surgery center.

The 2 most common surgical procedures used to repair ptosis are the “external” or “internal” ptosis repair. These procedures are usually used when the eyelid muscle has normal strength. External ptosis repair involves making a small incision in the upper eyelid fold, and reattaching or tightening the slipped upper eyelid muscle (levator) tendon. The incision is closed with sutures, which are usually removed in about a week. Internal ptosis repair involves making a small incision on the inside of the eyelid and tightening the tissue without any skin incisions. Dissolvable sutures are used for internal ptosis repair. Both external and internal ptosis repair take about 30-60 minutes, and cause relatively little postoperative pain. Swelling and bruising usually improve within a week or two.

For types of ptosis in which the eyelid muscle (levator) does not function properly, other surgical techniques can be used. For moderately decreased eyelid muscle (levator) strength, an eyelid surgery called a tarsal resection can be performed. This involves shortening of the thick plate of the eyelid (called the tarsus). For ptosis with more severely decreased eyelid muscle (levator) strength, an eyelid surgery called a frontalis suspension (sometimes called a frontalis sling) can be performed. Frontalis suspension is an eyelid surgery that involves “suspending” the upper eyelid to the eyebrow using a piece of the body’s own tissue, processed tissue, or synthetic tissue. The eyebrow acts as a “sling” to lift the poorly functioning eyelid.

Types of Ptosis

Involutional Ptosis (“age related” ptosis)
Involutional ptosis is the most common type of ptosis. It is caused by a stretched or slipped upper eyelid muscle tendon (the levator aponeurosis). Involutional ptosis is usually due to age related stretching of the eyelid muscle tendon. Although the tendon is stretched, the actual muscle strength is normal. Other causes of involutional ptosis include contact lens use, prior eye or eyelid surgery, trauma, and certain degenerative eye diseases. Involutional ptosis may block the visual field to the point that it considered medically necessary (insurance may cover ptosis surgery). Involutional ptosis is usually repaired by either the internal or external ptosis surgery.

Congenital Ptosis (Ptosis present at birth)
Congenital eyelid ptosis is by definition present at birth. Congenital ptosis is usually caused by a poorly developed eyelid muscle (the levator muscle). It is may be replaced by fatty tissue. Congenital ptosis can range from mild to severe. If congenital ptosis blocks the field of vision, then eyelid surgery should be performed to prevent a condition called amblyopia. Amblyopia is when the brain’s visual system does not develop properly due to inadequate sensory input from the eye (something prevents vision getting from the eye to the brain).

The type of surgery used to correct congenital ptosis is determined by how much strength the upper eyelid muscle (levator) has. If the strength is good, then an external ptosis repair can be performed. If the strength is moderate, then a tarsal resection procedure may be indicated. If the strength is poor, then a frontalis suspension may be the only viable option.

Myogenic Ptosis (ptosis due to a weak upper eyelid muscle)
Myogenic ptosis occurs when the upper eyelid muscle (the levator muscle) does not function appropriately. Myasthenia gravis and certain types of muscular dystrophy are examples of diseases that cause myogenic ptosis.

Treatment of myogenic ptosis involves properly diagnosing the underlying disease, and then treating the disease with medicine if possible. If necessary, ptosis surgery can be performed if medical treatment is not sufficient.

Neurogenic Ptosis (Ptosis due to nerve injury)
A nerve called cranial nerve 3 (or the 3rd nerve) controls the upper eyelid muscle (levator muscle). When this nerve is damaged, then neurogenic ptosis occurs. Neurogenic ptosis can be the result of a stroke, trauma, or a condition called Horner’s syndrome.

Treatment of neurogenic ptosis depends on how much residual levator strength is present. Nerves may recover slowly after an injury. Due to this, ptosis surgery is usually delayed for many months until it is clear that nerve will not recover any further.

Mechanical Ptosis (Ptosis caused by extra weight)
Mechanical ptosis is a low eyelid due to excess weight. Frequently this is caused by a growth or tumor, such as skin cancer, weighing down the eyelid

Addressing whatever is weighing down the eyelid treats mechanical ptosis. Usually this involves surgical removal of a tumor and reconstruction of the resultant defect (MOHS reconstruction). Ptosis surgery can be performed if the lid does not come up after the tumor is removed.

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