I have unilateral, congenital ptosis of the right lid. I had two surgeries on the levator muscle at 3 and 25. Each surgery was initially successful, but the lid dropped back down. I am 31, and my surgeon wishes to perform a frontalis suspension. I am undecided about the effectiveness of a third surgery. I am not optimistic about the results after having two "failed" surgeries and am worried about possible complications due to this being my third surgery. I can currently close my lid completely.
Should I Have a Third Ptosis Surgery? (photo)
Doctor Answers 7
Why people born with ptosis may need more than one surgery in a lifetime and the adjustment time needed for frontalis suspension
Congenital ptosis, meaning ptosis that you were born with, is due to the fact that a particular muscle called the levator muscle did not develop completely. The muscle neither contracts properly nor relaxes properly. I’m assuming that the procedure done when you were 3 was a levator resection and it was done for the purpose to allow you to develop proper vision. Between the ages of 0 and 6 years old, without proper visual input and clear images on your retina, you develop a condition of permanent vision loss called amblyopia. That procedure was done to prevent amblyopia and allow you to develop your vision properly.
When someone is born with ptosis and there is surgery needed at an early age for proper visual development, it is understandable that additional surgeries will be needed as the person gets older. When you’re dealing with a muscle that doesn’t function well, eventually most patients with congenital ptosis needs an average from 2 to 5 or even more operations in their lifetime. The idea is to try to do a procedure that is safe and allows you to look as symmetric as possible. Regardless of the type of surgery that’s done, it’s difficult to achieve symmetry at all fields of gaze. The eyes basically need to look good when the patient is in a normal social interactive position known as primary gaze. What surgeons aim for is that the eyelid is in the best position when the patient is looking straight ahead.
I’m seeing from your photos that you don’t have enough muscle to work with. Not knowing if you have residual levator function, it makes complete sense to do some kind of frontalis suspension. Frontalis suspension is a procedure where the eyelid is connected to a muscle called the frontalis muscle. This muscle is responsible for raising the eyebrows. This procedure creates a closer connection between the frontalis muscle and the eyelid.
What I have observed over the 20 years of doing this is that kids adapt a lot more quickly than adults with frontalis suspension. Once the eyelid is lifted, it takes an average of 6 months for the adult to coordinate their blinking and their eye movements to the point that it becomes natural. The key thing to remember is you have to lubricate your eyes properly with artificial tear drops, lacrilube or a gel at night as well as humidifier to make sure that the eye is protected because when you are sleeping, your eye would slightly be open.
I won’t refer to your previous surgeries as failed. Unfortunately, these are the types of procedures that do require for it to be repeated with the goal of getting the eyelid to open. You may need another frontalis suspension procedure at some point. Again, with any surgery, this particular surgery may not be perfect and may require some enhancements, which is the reality of ptosis surgery. I hope that was helpful, and thank you for your question.
Frontalis sling is the classic method, and if you haven't had that performed before then it would be a good option for you.
The other option of maximal levator resection or full thickness lid resection may give you a better result when you have your eyes open, but it will be more risky in terms of dry eye problems and eyelid closure.
Revisional congenital ptosis surgery
Congenital ptosis with poor levator muscle strength doesn't leave many options. The classic technique would be frontalis sling, however you might benefit from another technique called full thickness lid resection ptosis surgery which takes advantage of the existing scar. No matter which technique you do, you have to understand that you have a difficult problem and your eyelid will never be normal.
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everyone is right on....if you have loss of vision due to the lid covering your pupil, and are willing to risk difficulty closing your eye ( and dry eye) and a less than 100% success rate then the sling is your procedure.
I personally feel that a frontalis suspension for an adult is not a very good idea.
We do them on children because even though the kids have trouble closing their eyelids, they adapt. Adults do not adapt well to these situations. If I were an adult in your situation, I would get multiple opinions from recognized leaders in oculoplastics. Generally these will be university based surgeons who run their own fellowship. These will be the individuals with the greatest experience with the surgery that is being discussed. These are very difficult situations especially if you have less that 8 mm of levator function. Look on the ASOPRS website and use the geographic directory. Don't have surgery until you have had at least 3 consults with university based oculoplastic surgeons.
Congenital ptosis surgery
Unfortunately, there is no real "cure" for congenital ptosis. The main muscle that lifts the eyelid doesnt function normally and there is no way to make it function better. That being said, if you have already had multiple levator muscle surgeries, a frontalis sling procedure would probably give you best chance of a longer-term lift in the eyelid position. The procedure is far from ideal - the curvature of the eyelid is sometimes suboptimal after this procedure and the eye may not close completely. Only you can decide if it worth going through another surgery. Best wishes.
Third ptosis surgery?
Only you can answer whether you should have a third procedure. Does the drooping bother you sufficiently to warrant this? If you are bothered by the ptosis than the sling is a viable answer. However, if the lid is brought up, you may have more difficulty achieving full closure and greater dry eye symptoms.