Ptosis Correction Surgery - Before and After, Recovery Photos

Ptosis Correction surgery is a surgical procedure done to correct the ptosis condition (dropping of the upper eyelid). Ptosis is caused by weakness in the muscle that controls the raising of the eyelid. It might be difficult to raise the eyelid and fully open the eye, which gives a tired appearance and may obstruct vision.

Anatomy and Physiology of the Eyelid

Eyelids are movable tissues primarily of skin and muscles that shield and protect the eyeball from mechanical damage and help to provide moisture essential for the normal functioning of the conjunctiva (a mucous membrane that lines the eyelid and covers the visible portion)  and cornea (the transparent part of the eyeball that covers the iris and the pupil). 

Each eyelid contains:

1. A fibrous plate called a tarsus, which gives it the structure and the shape
2. Muscles which move the eyelid
3. Meibomian (or tarsal) glands secrete lubricating fluids. 

The lids are covered with skin, lined with mucous membrane, and bordered with a fringe of hairs, the eyelashes. The movement of the lids occurs through the action of a circular lid-closing muscle the orbicularis oculi, and of the lid-raising muscle, the levator of the upper lid. Impulses for closing and opening of the eyelids come from the facial nerves and oculomotor nerve, respectively. The lid borders are always lubricated with an oily secretion called sebum. 

Ptosis can occur in all age groups and result from various factors. Ptosis correction surgery is conducted to tighten the muscles that lift the upper eyelid. This surgery can help get rid of various types of ptosis conditions including:

1. Aponeurotic ptosis
2. Neurogenic ptosis
3. Myogenic ptosis
4. Mechanical ptosis
5. Traumatic ptosis

Individuals suffering from the following issues need ptosis correction surgery:

1. Obstruction in vision and loss of peripheral field of vision due to ptosis.
2. Heaviness in the eyelids.
3. Cosmetic issues such as ptosis give a tired-looking appearance

Ptosis correction surgery is generally performed for medical or cosmetic reasons. The procedure usually takes about 45 to 90 minutes to complete depending upon the patient’s age, comorbidities of the patient and the type of the ptosis condition. The procedure is performed by an ophthalmologist and professional medical team. The procedure is conducted under local anaesthesia to keep the patient comfortable. 

There are three ways of correcting ptosis:

1. External approach: It is also called levator advancement and is performed on individuals with strong functioning of the levator muscle. The surgeon will cut the eyelid skin and reposition it by attaching the levator muscle to the tarsus (connective tissue in the eyelid). This elevates the eyelid and helps the patient to see appropriately.
2. Internal approach: This surgery is advised for individuals with strong functioning of the levator muscle. The surgeon will turn the eyelid inside out and correct the eyelid's muscles from the inside. The surgeon may either remove the Mueller’s muscle or the levator's muscle. Both the muscles are responsible for lifting the eyelid. The shortened muscles help the patient to see better due to the lifted eyelid.
3. Frontalis sling surgery: This surgery is performed when the patient has ptosis and poor functioning of the eye muscle. The surgeon will attach the upper eyelid to the muscle above the eyebrow (frontalis muscle) with the help of a small silicone rod, which helps elevate the eyelid.

The steps involved in the ptosis correction procedure are mentioned below:

1. Skin marking: Skin markings will be done on the upper eyelid in sitting posture and eyes in primary gaze to maintain symmetry in both eyes.
2. Position during surgery: For ptosis correction surgery, the patient will be kept in a supine position (lying horizontally facing up).
3. Cleaning and draping:
   1. Draping and regular cleaning of the face will be done. 
   2. Both eyes will be kept exposed to check the eyelid position during the procedure.
4. Anaesthesia: The surgeon will inject local anaesthesia so that the patient does not feel any pain and he/she is awake during the surgery.
5. Monitoring:
   1. The anesthesiologist will monitor the oxygen, blood pressure, heart function, and ventilation of the patient throughout the procedure.
   2. The nurse will check the safe positioning while placing and moving the patient on the operating room table.
   3. The eye surgeon/ophthalmologist will monitor the eye’s intraocular pressure and changes in operating condition during the progression of the surgery.
6. The eye surgeon/ophthalmologist will then:
   1. Make a small incision (cut) into the eyelid’s natural folds/creases to find tiny muscles that raise the eyelids.
   2. Remove the extra fat tissue and loose skin.
   3. Tighten the eyelid muscles by stitching them and lifting the eyelids.
   4. Further, close the cut in the skin of the eyelid with more stitches.

Before the patient undergoes the ptosis correction procedure, the doctor/ surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Ptosis Correction Surgery

Before the surgery, your eye surgeon will:

1. Determine the cause, type and severity of the ptosis.
2. Do a comprehensive examination of the eyes, such as a visual acuity test (how well the patient can read the smallest letters on a standardised chart), perform a close physical examination of the eyelid, and ask about the patient’s family health history.
3. Will measure the marginal reflex distance-1, which is the distance between the corneal light reflex of the pupillary centre and the upper eyelid’s margin, to know the level of visual obstruction and amount of droop/sag.
4. Ask the patient about the goals for the surgery and will explain the complications of the surgery as well.
5. Will take the patient’s pre-operative photographs for comparison.

A few days before the surgery, the patient will meet the anesthesiologist for the following:

1. The medical history of the patient (including anaesthesia history) will be checked, and the results of the investigations recommended by the doctor will be reviewed.
2. For ptosis correction surgery, local anaesthesia will be preferred.
3. Medical history and physical examination will determine if the patient is fit for anaesthesia.
4. The patient will be instructed whether he/she can take any oral medicine.
5. The patient will be advised not to eat and drink before the surgery.

On the day of Ptosis Correction Surgery

On the day of the surgery, the healthcare staff will take the patient to the pre-operative room, where he/she can expect the following:

1. Consent formalities
2. The healthcare staff will note the following information:
   1. The time of the patient’s last meal and fluids
   2. Medical history, current symptoms and allergies
   3. Vital signs like body temperature, blood pressure and heart rate
3. The healthcare staff will trim the hair on the surgical site if needed.
4. They will place a soft, thin tube called an intravenous line into a vein in the hand or arm so that medicines can be given directly into the blood vessel.

A patient who has undergone tympanostomy can expect the following after the surgery:

The recovery process at the hospital

After the surgery, the patient will be moved from the operating room to the recovery room (also called the post-operative room), where:

1. The healthcare staff will closely monitor the patient’s condition for a few hours.
2. The patient will receive painkillers and antibiotics for post-surgical pain and prevent any infection.
3. If the patient has had outpatient surgery, he/she will be sent home on the same day after you are stable on monitoring.
4. The surgeon will cover the eyelids and eyes with ointment and a bandage.
5. The care team will guide the patient to take over-the-counter pain medication.
6. The surgeon will recommend lubrication eye drops or antibiotics to lower the itching and burning.
7. If the patient has had outpatient surgery, he/she will be sent home on the same day after you are stable on monitoring.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must be followed at home.
2. The patient can place a cold pack wrapped in a towel over the area to lower bruising and swelling.
3. As much as possible, keep the head lifted for several days.
4. The patient should avoid
   1. Wearing contact lenses for at least two weeks.
   2. Strenuous activities for almost three weeks.
   3. Getting the eyelid wet.
   4. Swimming for four weeks.
   5. Drinking alcohol and wearing eye makeup for a few weeks.
   6. Going in the sun.

First follow-up appointment

1. The first follow-up will be around 7 to 10 days after the surgery. 
2. The doctor will evaluate the recovery of the eyelid and also change the dressing done post the surgery.
3. The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
4. The doctor will also advise the patient for further timely follow-ups as well.

Ptosis correction surgery is a safe procedure with several benefits that improve the quality of life of an individual. Some of the benefits of ptosis correction include:

1. Improves vision
2. Improves the function of the eyelid
3. An individual look younger
4. Boosts the confidence
5. Minimal scarring

Like any other surgery, risks and complications are also associated with ptosis correction surgery. These include:

1. Bleeding
2. Pain
3. Allergic reaction to the material, medicine, or equipment
4. Cornea tear/abrasion
5. Cosmetic issue
6. Over-correction (eyelid raised too high)
7. Under-correction (eyelid not raised enough)
8. Bleeding in the eye socket
9. Contour defects in the eyelid
10. Conjunctival prolapse (extreme cut between the levator and conjunctiva that damages the suspensory ligament that holds the lens in its place).
11. Suture granuloma (small cluster of inflammatory cells formed at the site of surgery)
12. Infection of the surgical site

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she notices the following symptoms:

1. Bleeding
2. Pain
3. Vision impairment
4. Redness and swelling in the eyelid
5. Infection in the eye

Generally, ptosis does not have severe consequences if not treated. However, if the ptosis is affecting  vision (mostly in the case of children), then it may cause:

1. A chin-up position: If the ptosis is severe, the patient may develop a chin-up position to see things correctly. A chin-up position can further affect skills development and may cause neck problems. It also causes contraction of the forehead muscle to lift the upper eyelid.
2. Astigmatism: It is a misshaping of the cornea. The pressure on the front of the eye causes refractive error and distortion of vision.
3. Amblyopia: It is an abnormal development of vision which results from astigmatism or other refractive errors. 
4. Deprivation Amblyopia: If the eye is completely covered due to ptosis, light does not enter the eye, so no image will be created. This is known as deprivation amblyopia.

The cost of ptosis correction surgery ranges from ₹15,000 to ₹30,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.