Mild Ptosis More Complicated to Fix?

Question

I have mild ptosis and I was wondering if mild ptosis is more difficult to correct considering that the chances for overcorrection is higher and since overcorrection would make the eye so much worse than it was before. I'm so tired of living with ptosis but I'm not sure if surgery would be the right thing especially after hearing that perfect symmetry is difficult to achieve. Can any doctor pls advice me?Thank you so so much

Kenneth D. Steinsapir, MD · Answer

Nelly

	While it is absolutely true that ptosis surgery is a bread and butter procedure for board certified ophthalmologists who are fellowship trained in oculoplastic surgery and admitted to the American Society for Ophthalmic Plastic and Reconstructive surgery, mild ptosis repair is not easy particularly in an Asian eyelid.  

	It is important to understand that there can be a degree of inaccuracy with any ptosis surgery even when performed by the most experienced surgeons.  When performing surgery on larger amounts of ptosis, small differences in the eyelids are much more likely to be tolerated.  This can include mild under and overcorrects, mild asymmetries in the eyelid folds, differences in crease height placement.  DIfferences in how much skin is left on the eyelid platform and asymmetry in crease formation with fixation to the levator affects the degree to which the two eyelid platforms skin will hold makeup and the degree to which the upper eyelid lashes are supported are less of an issue in functional ptosis surgery cases compared to cosmetic ptosis cases.  Finally, ptosis surgery can affect the upper eyelid contour.  

	When we perform surgery for a small amount of ptosis, all of these factors must be considered because they all influence the perceived success of surgery.  You will notice all of these things.  Additionally, repairing ptosis surgery in an Asian eyelid will affect the amount of eyelid platform exposed after surgery.  It is generally necessary to also remove just the right amount of skin in order to have a symmetric amount of upper eyelid platform exposed after surgery.  An experienced eyelid surgeon will consider and discuss with you all of these factors and others such as the fact that it appears that your two eyes sit a different heights in your face.  This will have a direct bearing on your perception of your eyelids and if it is not discussed before surgery, you might even think that the surgery caused this difference.  So I agree with your caution.  I would recommend that you get a number of opinions and don't rush into surgery.

Charles K. Lee, MD, FACS · Answer

Mild ptosis is not uncommon in Asians. It is important first to recognize the condition prior to performing eyelid surgery so that it can be corrected. Levator advancement during the procedure is an effective manuever performed symmetrically to best address the ptosis. A conservative amount of skin excision may also be necessary depending upon the amount of levator advancement to avoid the "fat lid" look. Make sure your surgeon performs Asian eyelid surgery on a consistent basis and understands Asian aesthetics. Good luck!

A.J. Amadi, MD · Answer

There have been some very insightful comments made. I think we are all in agreement that Asian Eyelids can be challenging cases, especially when the ptosis is subtle. Oculoplastics Surgeons [synonymous with Ophthalmic Plastic or Oculofacial Plastic Surgeons] have the most amount of experience in this type of surgery. But make sure you find a surgeon that is experienced in both external and internal approaches to ptosis repair, as the different techniques can offer different benefits.

	Internal techniques do not require a skin excision and will not affect the position of the crease. However any change in eyelid position will change the degree of fold over the crease.

	Good luck

Mehryar (Ray) Taban, MD, FACS · Answer

Mild ptosis is at times more challenging but not always. Asian eyelids are challenging as well.  Having the proper exam to understand the problem in your particular eyelid and discuss solutions is critical.  Managing expectations is also important.  You should consult with an oculoplastic surgeon.

	Dr Taban

Chase Lay, MD · Answer

This is very common in the Asian eyelid practice but it can be difficult to achieve perfect results.  However, you do have options.  I take a couple of approaches.

	1.  It can be staged in two minor local procedures.  If the ptosis is minimal it can be addressed with a repair that is performed on the mucosal side (underside touching the eye).  This technique can reliably move the lid edge 1 to 3 mm.  After that, if there is a slight change in the position of your eyelid crease you can adjust that will a minor suture technique procedure (this may not be needed).

	2.  Performing an open levator advancement while performing a blepharoplasty works well but can be challenging for the occasional eyelid surgeon.  The measured movement of the eyelid can be very reliable, however.

	3.  The surgeon should be testing you pre-op for a drop in the opposing eyelid.  After a ptosis repair the other lid tends to drop a bit.  Your surgeon should test for this pre-op.  If he/she doesn't consider another consult.

	Good luck to you. 

	Dr. Chase Lay

Kenneth K. Kim, MD · Answer

It depends on how mild the ptosis is. Some ptosis is considered a mild/border line ptosis. You should also ask, is there an asymmetry or is it a bilaterally symmetric ptosis? What is more difficult to correct is asymmetric ptosis. Overall, the answer to the question is that mild ptosis is actually easier to correct. The reason is because of the fact that mild ptosis has a relatively good levator apponeurosis and Mueller’s muscle functions compared to those of severe ptosis. Therefore, how easy to correct a ptosis purely depends on a surgical/technical performance rather than your inherent tissue function. A severe ptosis is much more difficult to correct because intrinsically the muscle is weaker, and it has lost its natural elasticity. However, people often think that severe ptosis is easier to correct because any change or any improvement is considered a surgical success. In comparison, correcting a mild ptosis has very little room for error since you’re already starting out with relatively small amount of room to collect. To make it more simple to understand, in a mild ptosis you would be correcting 1mm to 2mm whereas in a severe ptosis, you would be correcting about 3mm to as high as 4mm. Therefore, starting from 4mm to 2mm versus 3mm is either way, an improvement. However, you would feel that correcting a mild ptosis of just 1mm would be more difficult to correct since the surgeon needs to be very meticulous and avoid overcorrecting which would lead to a surprised look. As long as the surgeon can technically manipulate the muscle function and can confidently elevate the eyelid position at the appropriate size, then it is a much easier situation. Also, ptosis surgery should be done under local anesthesia so that the patient remains awake for a complete cooperation of opening and closing the eyes during the procedure. In addition, you are also expected to sit up periodically during the procedure, in order for the surgeon to examine the eyelid position with a gentle gaze versus a forceful eye-elevating gaze. With this kind of feedback, the surgeon should be able to correct your eyelid accordingly to the aesthetic standards.

Larry Fan, MD · Answer

Dear nelly89,

	Ptosis repair, particularly in Asian eyelids, can be challenging, but an experienced eyelid surgeon should be able to help. Your photos are difficult to see.

	Warmest wishes,

	Larry Fan, MD

Sam Goldberger, MD · Answer

Hi Nelly.  You ask many good questions.  The answers are not simple.  A lot will depend on your particular findings and what your expectations are.  Oculoplastic surgeons commonly perform surgery for mild ptosis with good results so you may indeed be a good candidate.

	I believe you need an evaluation with a physician who performs  a lot of ptosis repairs.  You will either be comfortable with his approach or decide that it is not right for you.  You may want to see photos as well.

Christopher I. Zoumalan, MD, FACS · Answer

Hi Nelly, I also agree with the other doctors that although ptosis surgery is one of our "bread and butter" surgeries as Oculoplastic surgeons, mild ptosis in Asian eyelids is very challenging due to several reasons.  Of particular note, there is always the possibilty of overcorrection or undercorrection, but this can be largely avoided by selecting the right surgeon who has experience in mild ptosis surgery.  More specific to you though, the surgeon needs to pay close attention to the shape of your eyelids as well and to respect your wishes on how you want them to look after the surgery. This includes close attention to the position of your lid crease and the fold of skin that exists between your brow and your eyelashes. When doing any type of ptosis surgery, these are crucial factors Oculoplastic surgeons take into account in order to get the optimal result to satisfy us and the patient.

	Hope this helps and good luck.

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