Section: Other Challenges
Ptosis in the Asian Upper Eyelid
"Ptosis" designates the presence of a droopy upper eyelid caused by a deficiency in the internal elevating mechanism of the lid rather than by overhanging excess skin and fat. the droop may be severe but is often quite subtle as shown below.
While ptosis occurs infrequently in patients of Asian and Occidental lineage, it is our experience that the condition tends to be present at a noticeably higher incidence and at a younger age in the Asian population. If more than very mild ptosis is untreated in the patient undergoing Asian double eyelid surgery, the final result may be compromised.
Whether performed in conjunction with cosmetic eye surgery or as an isolated surgical procedure, ptosis correction in Asian eyes poses an added challenge because of the impact of surgery on the presence, position, and shape of the eyelid crease.
Special Considerations in the Asian Upper Eyelid
In a patient with preexisting well-defined upper eyelid creases, most standard operative techniques for ptosis repair may be employed with little or no modification.
In a patient with creaseless "single" eyelids or with weakly-defined but creased "double" eyelids, some standard operative techniques may inadvertently introduce unacceptable asymmetry. This is especially true when ptosis is present on only one eye. While an in-depth discussion of surgery options is overly complex, the following basic guidelines may be helpful:
• If ptosis is bilateral (present on both eyes) and a patient also desires creation or enhancement of the upper eyelid crease, both operations (blepharoplasty and ptosis repair) may be performed simultaneously through the standard Asian double eyelid surgery skin incision.
• If ptosis is unilateral (present on only one of the two eyes) and there is also noticeable crease asymmetry, the standard double eyelid surgery skin incision may also be employed.
Young patient with ptosis
The upper eyelid is drooping low even though the brow has been pulled high by the patient trying to see better.
During surgery through a skin approach, a well-defined tear in the tendon of the eyelid opening muscle was identified and repaired. To view a photo of the actual tear in this patient, click here.
• If ptosis is present in an uncreased (or minimally creased) eyelid and a patient desires only correction of the droopiness (but no alteration of the crease), several options are available:
• Ptosis surgery from an incision placed on the inside (conjunctival surface) of the eyelid - Several well-proven and reliable operations exist for the correction of mild ptosis from the back surface of the eyelid. Since the skin, orbicularis muscle, orbital septum, and orbital fat are not disturbed during such an approach, the chance for alteration of the crease is lessened.
• Ptosis surgery from an incision placed of the front (skin surface) of the eyelid - For more advanced ptosis, a variation on the standard skin incision has been described for use on Asian eyes. The incision is made at a lower level and the dissection into the eyelid is distinctly different than in the Occidental patient. While the intent is to avoid disturbing tissue planes involved in eyelid crease formation, the dissection may prove challenging.
Some patients seeking Asian double eyelid blepharoplasty may be unaware of the simultaneous presence of ptosis and surprised by the need for additional and more specialized treatment. However, cosmetic Asian eye surgery performed alone will not correct ptosis, and so it is important to recognize and discuss this disorder prior to undergoing surgery. Since the margin of error in ptosis surgery is about 1.0 mm, tiny amounts of preexisting ptosis are often best left untreated.
In patients who undergo simultaneous double eyelid surgery and ptosis repair, a delay in overall healing is normal and should be anticipated. Generally, the lift from the ptosis repair may not be expressed fully for 3-6 weeks and sometimes not for as long as three months. If only one eyelid undergoes ptosis repair, there may be a very noticeable difference in the comparative rates of healing between the two eyes.
As ptosis is caused by a preexisting anatomic deficiency in the levator muscle complex, the outcome of ptosis repair is not nearly as predictable as with pure double eyelid surgery; a realistic goal is improvement rather than near-perfection. The need for reoperation per eyelid is about one in six.
In cases of advanced ptosis in which the eyelid's levator muscle complex is poorly formed, improvement may be only slight even after several operations.
Next: Ptosis Repair - Advanced
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