Cosmetic Benefits of Repair of Small Degrees of Ptosis
Oculoplastic surgeons routinely treat ptosis, which strictly speaking is a malposition of the upper eyelid. The upper eyelid margin rests at a position that is too low on the eye, sometimes to the point where it blocks vision. Ptosis that can be reasonably determined to affect vision is often repaired and covered by insurance.
The following discussion focuses on the cosmetic impact of ptosis repair.
Figure A represents ptosis on the patient’s left side. The orange line labeled “M” (lid Margin) is closer the pupil on the patient’s left. There are several aesthetic consequences to the left sided ptosis:
1. The left eyebrow has subconsciously elevated, in an effort to left the lid up more.
2 The skin fold (labeled “F”, and shaded yellow) is less pronouced, since the skin is stretched upward by the brow that is elevated on the left side.
3. The upper eyelid platform (“P”), which is the area between the lid crease (“C”) and the lid margin (“M)”, has increased.
It is the lid platform (“P”) that is perhaps the most important determinant of eyelid symmetry than almost anything else, when we are dealing with small variations between right and left. For example, most patients would report that the symmetry is improved simply by removing some of the fold (“F”) from the right side. This would make the platforms (“P”) more equal, even though it would not address the ptosis on the left or the brow asymmetry either. Another approach might by to lift the left upper lid with a ptosis repair, thus shortening the platform (“P”) on the left. Often times, when ptosis is repaired, the elevated brow will relax down a little bit as well, which also has the effect of making the platform (“P”) smaller by bring some of the skin down and lowering the fold.
Goals of Upper Blepharoplasty.
There are many subtle goals of upper blepharoplasty, but one unifying thread is nearly all patients want to increase the size of the lid platform, by removing some combination of skin, muscle, and fat. This is typically done as a subtractive procedure — some of the skin fold (“F)” is removed, and it unmasks the lid platform (“P”). A common complaint from women is that they want to wear eye shadow but cannot, because the skin fold blocks the lid platform and the eye shadow smears. Displaying more of the lid platform allows a patient with this complaint to wear eye shadow again.
Ptosis, or abnormally low lid margin (“M”), makes patients look tired. Opening the eyes more leads to a brighter, more alert appearance. However, in the wrong proportions, ptosis repair is antagonistic to the goals of upper blepharoplasty. When the surgeon raises the lid margin (“M”), it decreases the lid platform (“P”). But as we discussed early, most patients want to increase the lid platform (“P”) when undergoing cosmetic eyelid surgery, because that is the makeup space. Thus, it is important to balance the brightening effect of ptosis repair with the need to platform maximization.
A small amount of ptosis correction during upper blepharoplasty can lead to an enhanced, brightened appearance.
The patient reviewed here desired a more refreshed look. She did not want to seek any brow procedure as she was concerned to avoid dramatic changes in appearance. Her preoperative photo is shown in Figure B.
Figure B. Preoperative photo.
There are several features worth noting. The left skin fold is lower than the right skin fold — this is due to subtle brow droop on the patient’s left side, which has the effect of bringing the skin fold down. Additionally, the patient has very mild ptosis of the upper lids — the lid sits about 1mm above the visible pupil.
Correcting the ptosis without removing tissue with an upper blepharoplasty would be unsatisfactory because bringing the lid up higher would place the lid margin up underneath the skin fold. Removing tissue alone with an upper blepharoplasty, without correcting the ptosis, would still give the appearance of fatigue.
The surgical plan involved a small degree of ptosis repair (1-2 mm), combined with biased upper blepharoplasty. The upper blepharoplasty with slightly biased to remove a little more excess tissue from the left side than the right side — this would compensate for trace brow droop on the patient’s left side.
Figure C. Postoperative photo
The lid height has been lifted a small degree, while maintaining a normal contour. The lid platforms are similar, despite a slight brow droop that persists on the left side. Overall, the patient projects a symmetric and refreshed image. Colleagues were focused on her hair as the positive change that they were seeing, and not the subtleties of the eyelid surgery.
As a rule of thumb, these sort of assessments are very fine grained and are truly only appreciated by oculoplastic surgeons, as opposed to other types of doctors who operate on eyelids.