Drooping upper eyelids (ptosis) in their various forms is the most common disorder seen by oculofacial plastic and reconstructive surgeons. When the upper eyelid droops, it may block your upper field of vision. Ptosis may range in severity from mild to severe - with excessive covering of your eye and corresponding diminution of your visual field.
This condition can be either unilateral or bilateral and reflects a change in the levator muscle (the principal upper eyelid elevator muscle) or much less frequently is the result of deficient nerve supply to this muscle. In adults, aging is the principal factor behind the stretching of the levataor muscle which can either become weakened or detached (levator aponeurosis dehiscence). However, ptosis may also follow trauma, neuromuscular disorders such as myesthenia gravis or Horner's syndrome, or cataract surgery.
Ptosis that is present at birth (congenital ptosis) is much less common. This is the result of improper development of the levator muscle.
Symptoms of ptosis include difficulty keeping your eyes open with resultant diminution of your upper field of vision. Less commonly, eyestrain, eyebrow aching from the increased effort needed to raise your eyelids, and fatigue may be present, especially when reading. In severe cases, it may be necessary to tilt your head back or lift the eyelid with a finger in order to see out from under the ptotic eyelid(s).
It is important for a patient to have a complete eyelid/oculofacial plastic surgical evaluation to identify the cause of drooping eyelids. Once this is done, Dr. Kohn will be able to determine whether the condition is appropriate for surgical correction. The cause of the ptosis and the extent of the disorder determine the choice of surgical procedures and the quantitative extent of correction. Other conditions may coexist with ptosis, most commonly dermatochalasis (see Upper Blepharoplasty).
Ptosis surgery usually involves tightening or repositioning of the levator muscle (levator aponeurosis dehiscence repair) in order to elevate the eyelid to the desired position. This involves placing an incisioin at the upper eyelid crease (the natural fold of the upper eyelid). Dr. Kohn then performs a quantified reattachment of the levator muscle to its normal position - adjusting the sutures intraoperatively to optimize eyelid height, fold (crease), contour, and symmetry. In adults this outpatient surgery is performed under local anesthesia with intravenous sedation. In children this procedure requires general anesthesia.
In severe ptosis the levator muscle is extremely weak and a frontalis suspension ("sling") operation may be indicated, thereby enabling the forehead muscles to elevate the eyelid(s). Frontalis suspension is an outpatient procedure performed under general anesthesia for all patients.
Discomfort is usually quite minimal following surgery with pain medication rarely required. The eyes are not covered after the surgery and no bandages are necessary. Antibiotic ointment is simply applied to the suture lines at bedtime and the sutures are removed approximately one week later.
RISKS AND COMPLICATIONS
As with any surgery, bleeding and infection are potential risks - but are extraordinarily uncommon with ptosis surgery. Minor bruising or swelling may be expected and will likely go away in one to two weeks.
The main goal of ptosis surgery is to elevate the upper eyelid to restore a normal and full field .of vision, and symmetry with the opposite upper eyelid. It is important to realize that when operating on an abnormal muscle, completely normal eyelid position and function after surgery may not be possible to achieve in all cases. Yet, Dr. Kohn has performed over 3000 ptosis repairs and has a 2% re-operation rate owing to his experience and use of intraoperative quantification and suture adjustment. At other centers, studies have placed the reoperation rate at 25% for ptosis surgery.
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