Congenital ptosis and cosmetic blepharoplasty

By Joseph Walrath, MD | Feb 10, 2019 | Blepharoplasty, Cosmetic, Ptosis, Reconstruction

A lovely young woman came to me a few years ago for a consultation with a complaint of congenital ptosis of the left upper lid.  “Congenital ptosis” is the medical term for an upper lid that is born droopy.  Usually, this means that the internal upper lid is not properly formed at birth: the levator muscle (the main muscle the lifts the eyelid open) is dystrophic.  It doesn’t work properly.  The level of function can be assessed clinically, but here is a rule of thumb: if there is a weak (or absent) upper eyelid crease, the function is reduced.  A careful assessment of the levator function is performed during office consultation.

A preoperative photo is depicted below:


In this young woman, the drooping lid was impacting her vision, and consequently, repair was a medically-covered procedure.  But it is hard to separate that from the cosmetic impact that the asymmetry creates as well.  Both of those issues were major problems.  It turns out that she came to me having already had prior corrective surgery, but it did not last.  She was even told at the time of that procedure that the surgical result probably wouldn’t last that long. 

Our first surgery was a levator resection.  That is a more advanced level of ptosis repair that requires complete release of prior scar tissue, the levator muscle itself, and the underlying Mullers muscle, a secondary elevator of the eyelid. Usually, as a reoperation, these structures are all fused together and released as a single unit.  The whole thing is then advanced and tightened with sutures in several positions.  This sort of repair is durable.  There is a reoperation rate, maybe 10-20%, to achieve optimum result.  The reoperation rate is likely a bit higher in people who have already undergone prior surgery, due to previous surgical disruption of normal anatomy. 

Our first surgery was only modestly successful in correcting the lid height.  We reoperated before getting the lid height and contour to the proper configuration.


Finally, we waited a suitable period of time for healing.  Sometimes it is important to wait, and to heal, before fine-tuning the eyelids.  In this case, we were left with a slightly asymmetric lid crease and skin fold, even though the contour of the lid on the eyeball, and the height, were very good.  We waited for the tissue to soften.  Then we performed our last procedure, this time on both upper lids.  Below is our three week postoperative photo.


This lovely lady was at the end of our journey, but I’m not sad, because I still get to see her for Botox every three months!