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Ptosis – Surgery for Better Vision

For more than 20 years, Cosmetic Oculofacial Plastic Surgeon Dr Amiya Prasad has helped patients from around the world affected by ptosis, commonly referred to as “droopy eyelid” see and look better by performing ptosis surgery.

There are many different types of ptosis which can affect your vision and appearance. Dr. Prasad will perform a ptosis evaluation and recommend a treatment plan. Contact us for a consultation and learn more about the ptosis procedure below.

What is ptosis?

PTOSIS (pronounced “TOE-sis”) or a droopy eyelid, refers to a drooping of the upper eyelid of one (unilateral ptosis) or both eyes (bilateral ptosis). The droop may be barely noticeable, or the eyelid can descend over the entire pupil. It can affect both children (congenital ptosis) and adults (acquired ptosis). The most common ptosis cause is related to aging (involutional ptosis).

It is often seen that people with a droopy eye raise their eyebrows unconsciously (resulting in horizontal forehead lines). If the skin is relatively tight, some eyelid elevation can happen with eyebrow raising. Ptosis repair is not performed by most cosmetic and plastic surgeons as ptosis surgery is a highly specialized and delicate procedure. Ptosis correction surgery is only performed by oculofacial/oculoplastic surgeons who have training in both facial cosmetic surgery and ophthalmology like Dr. Amiya Prasad.

Droopy eyelid-levator muscle illustration

What Causes Ptosis?

Ptosis which is present since birth is typically the result of a developmental defect in the levator muscle. Adult, or acquired ptosis, is usually associated with the thinning or detachment of the levator muscle tendon also called the “levator aponeurosis” .

A droopy eyelid can also be the result of trauma after significant eyelid swelling. It may also be caused can also by neurologic conditions such as myasthenia gravis, Horner’s Syndrome, and 3rd nerve or oculomotor nerve palsy.

Ptosis Symptoms

The most obvious sign of ptosis is the drooping upper eyelid. Depending on how severely the eyelid droops, people with ptosis are often concerned about the cosmetic appearance. Vision may also be affected depending on how low the eyelid is relative to the pupil. Sometimes people with ptosis tilt their heads back to try to see or raise their eyebrows constantly try to lift the eyelids.

  1. Increased heaviness of the eyelid
  2. Impaired vision
  3. Tilting of the head to see better
  4. Constant raising of the eyebrow in order to lift the eyelid
  5. Headache due to forehead muscle strain and eyestrain

The degree of droopiness is individual. If you think you may have ptosis, compare a recent photo of your face with one from the past to see if your eyelid position has changed. As you get older, there’s a little bit more stretch and that compensatory action doesn’t work as well.

It’s very common for people who have a long history of ptosis to say it’s worse at the end of the day (heavy eyelids). Some people with ptosis are particularly bothered if the eye that is being affected is the dominant eye.

hollywood actor with ptosis
ptosis before and after
before and after Ptosis surgery - female patient

Types of Upper Eyelid Ptosis

Congenital ptosis: a term which means the droopy eyelid is present since birth due to the muscle responsible for lifting the eyelid (levator muscle) not developing fully. The levator muscle doesn’t contract completely nor does it fully relax. Congenital ptosis can get worse as a person gets older because of the natural structural changes of the face which occurs with aging.

In cases of congentital ptosis where the levator muscle is so poorly developed that the muscle can’t function, then a highly specialized surgery called a frontalis sling is required. The frontalis sling involves the anchoring the upper eyelid to the frontalis muscle using a material such as “fascia lata” and silicone. The normal function of the frontalis muscle is to raise the eyebrow.

Frontalis sling diagram
before and after congenital ptosis surgery - male patient
ptosis frontalis sling before and after

Acquired Ptosis: Refers to ptosis which is not congenital and can have several different causes. In adults, the most common type of ptosis is called involutional ptosis, which typically occurs slowly with aging. This condition is due to a stretching or thinning of the tendon of the levator muscle that lifts the eyelids called the levator aponeurosis.

Many people with this condition are frustrated by the strain of keeping their eyes open particularly as the day progresses. This type of ptosis can also occur after cataract surgery, LASIK, laser vision correction and other eye procedures. Acquired ptosis can also be related to neurologic conditions including stroke, myasthenia gravis, Horner’s syndrome, and 3rd nerve palsy.

Ptosis Caused by a Prosthetic Eye: Prosthetic eyes (artificial eyes) can cause stretch and thinning on the levator muscle (the muscle that lifts the eyelid). The physical weight, shape and lack of natural lubrication can contribute to the progression of ptosis. The ocularist can change the shape of the prosthesis to push the eyelid upward.

Unfortunately, this can result in the prosthesis becoming heavy and uncomfortable. Ptosis correction can help the ocularist make the prosthesis smaller and more comfortable.

Ptosis cause by a prosthetic eye before and after correction
Ptosis cause by a prosthetic eye before and after correction

Ptosis in Children

When dealing with congenital ptosis, if the child has no significant ptosis where it is affecting visual information before the age of 6, then a correction can be done at a later time when it’s more of an aesthetic decision. If the ptosis is affecting vision before the age of 6, ptosis surgery can be performed to insure better visual development. Consultation with a pediatric ophthalmologist is recommended to confirm the visual condition and ongoing management.

Ptosis in children is often from a poorly developed levator muscle that can not lift the eyelid. In such cases of congenital ptosis, children would need a frontalis sling procedure at a young age so that proper, unobstructed vision can also develop. Children can also find it easier to adapt to raising their eyelids with the frontalis (eyebrow) muscle at a younger age than those who have a frontalis sling procedure in their teens or as adults.

ptosis surgery in children before and after correction surgery
ptosis surgery in children before and after correction surgery

Choosing a Surgeon for Ptosis Repair

Ptosis surgery is a highly specialized procedure that can’t be performed by most cosmetic surgeons who perform other types of eyelid surgery such as blepharoplasty. Since the procedure involves working with the delicate levator muscle which raises and lowers the upper eyelid, choosing the right surgeon is very important. Oculoplastic surgeons or oculofacial plastic surgeons are specially trained in delicate procedures for the eye including surgery (ophthalmology) and specialized training in plastic surgery of the eyes (ophthalmic plastic and reconstructive surgery).

Dr. Amiya Prasad is a cosmetic and reconstructive oculofacial plastic surgeon with over 20 years of experience performing highly specialized ptosis surgery.

See ptosis before and after photos

ptosis before and after old
ptosis before and after adult

Candidate for the Ptosis repair

Ptosis surgery may be necessary when the droopy eyelid has caused the upper eyelid to partially or completely block the vision. In children, aggressive management is often required in order to allow the vision to develop normally.

To examine the eyelid, Dr. Prasad does a ptosis evaluation. He looks at the center of the pupil and how it relates to the upper eyelid called the marginal reflex distance. When it’s above a certain level, there is no ptosis, but if it’s below a certain level, there is ptosis. Ptosis is also graded: mild, moderate or severe.

For the people concerned with asymmetry, it is important to note that it is not only limited to the soft tissue of the eyelids such as the skin and levator muscle, but sometimes related to the natural underlying bone structure. The human face is not perfectly asymmetric. If someone looks at their face long enough, they can notice the subtle asymmetry of the two sides.

Ptosis is a term which means “droop”.

When the eyelid droops, we call it “eyelid ptosis” Ptosis or eyelid droop is often referred to as a “lazy eye”. If you or someone you know has one or both eyes looking partially closed, you may be looking at ptosis.

In most situations, appearance and vision can be improved with ptosis surgery. I’ll help you understand what is responsible for the most common types of ptosis as well as how I work with my patients to formulate a strategy that will have the most likelihood for success.

I’m Dr Amiya Prasad. I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculoplastic Surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years. I routinely treat a wide range of ptosis patients in my practice.

Many of my patients are patients who’ve undergone previous ptosis surgery done elsewhere. When I meet a patient with ptosis, I start by reviewing the history to see if you were born with ptosis or if you developed ptosis later. When someone is born with ptosis, it’s referred to as “Congenital ptosis”.

If you develop ptosis later, its referred to as “Acquired ptosis”. In either situation, I first establish that there is no neurologic cause for ptosis before discussing surgical options.

Ptosis is essentially the result of a condition affecting the “levator muscle”. The “levator muscle” is the muscle that lifts the eyelid, like the word “elevator”

The type of surgery I recommend depends on the cause of the ptosis as well as the strength of the levator muscle. Surgical correction typically involves either some type of muscle advancement or shortening. If the muscle is too weak, then surgery is performed to connect the muscle that lifts the eyebrows to the eyelid.

When patients considering ptosis surgery come to our office, they express a desire to have their eyes look open and as symmetric as possible. Very often, patients come in requesting cosmetic upper eyelid surgery for sagging skin and don’t realize that they also have ptosis.

During my evaluation, I explain how excess skin over the eyelids which is referred to as “dermatochalasis” is different from drooping of the eyelid caused by the levator muscle which is of course “ptosis”.

There are often times when people have had cosmetic eyelid surgery or upper eyelid blepharoplasty elsewhere and they come in concerned that they still look tired. The reason for this is that they had upper eyelid skin removed but nothing was done to address the underlying muscle responsible for they eyelid droop.

Most ptosis surgery is for acquired ptosis due to a progressive stretching or thinning of the levator muscle. There are some patients who come in saying they’ve always had low upper eyelids which were referred to as “bedroom eyes” and that as time went on, the eyelids became lower and made them look tired. The objective in surgery is position the eyelid lifting muscles which include the levator muscle as well as another muscle called “Mueller’s muscle” in an advantageous manner to improve the position of the eyelids. I explain to my patients that these muscles are very sensitive and achieving the ideal result can be challenging.

The surgery is performed under local anesthesia with light intravenous sedation. In most cases, I have the patient open their eyes so I can monitor the height and shape of the eyelid. In fact, I routinely will sit the patient up during surgery and evaluate the appearance of the eyes in a way which more accurately reflects being vertical in real life.

This particular aspect of the surgery allows me to anticipate more accurately the outcome we’re aiming for. I do qualify the predictability of the procedure with my patients by explaining that 95% of the time, the eyes look right and there’s a satisfactory outcome.

Approximately 5% of the time, enhancements are necessary and are performed when swelling is significantly diminished which is usually after 3 months. Eyelid swelling is a normal part of the healing process.

The extent of the swelling is dependent on the extent of the surgery and the individual patient’s physiology. In the first 2 days after the surgery, cold compresses help decrease the initial swelling after surgery.

After the first 2 days, the clearing of swelling depends on the amount of swelling and circulation. I encourage my patients to be up and about walking, talking and smiling and if they’re planning to be more sedentary, warm compresses can help. Most people go back to work after 1 week.

I see our patients routinely more frequently in the first 2 months after surgery and then in approximately 3 month intervals for a year after surgery. Generally, I expect appearance to by close to the final appearance around 6 months. If a patient has a history of allergies, sinus problems, smoking or other circulation issues, swelling can persist longer than is typical.

Ptosis surgery can have a significant impact in your appearance and confidence. Functionally, eyelid ptosis can also affect your vision, and visual development in children who have it between birth and the age of 6.

If you’re questioning whether or not you have ptosis and if you should have surgery, meet with Fellowship trained Oculofacial Plastic Surgeon and learn about your situation and options.

I hope you found this information helpful…thank you for your question.

How is ptosis surgery performed?

In adult patient with ptosis, Dr. Prasad would perform levator advancement surgery where the muscle is moved forward without sacrificing any of it (in contrast to “levator muscle resection”). The procedure is performed with the goal of positioning the eyelid to the appropropriate level.

During surgery, in order to achieve the desired height, symmetry and cosmetic appearance, Dr. Prasad has his patients open and close their eyes. Typically, he will sit the patient up during the surgery and have them open and close their eyes so that the muscle and the position of the eyelid is observed with gravity and may be adjusted. The patient is comfortable while the muscle is being adjusted.

The procedure is typically performed under local anesthesia with intravenous (IV) sedation. The surgery can take anywhere from one to two hours.

 

How to Prepare for Ptosis Surgery

In order to prepare for ptosis surgery, it’s important to minimize the risks for complications during surgery such as bleeding and infection. Avoiding blood thinners such as aspirin, NSAIDS (such as ibuprofen), Vitamin E, and Ginkoba. Make sure you review all your medications including vitamins and supplements with Dr. Prasad before your procedure.

If you have any chronic eye problems such as dry eye or allergic conjunctivitis, its very important you manage these conditions with eye drops and other medications as necessary prior to surgery. Discuss any eye conditions you have with Dr. Prasad prior to surgery. As with any surgery, a full review of your medical history, current medications and risks associated with any systemic disease will be discussed with Dr. Prasad.

frontalis sling in child before and after surgery by Dr Amiya Prasad
frontalis sling in child before and after surgery by Dr Amiya Prasad

Ptosis Surgery Side Effects

Side effects are limited generally to swelling and bruising around the eye and cheek area. Dry eye can also occur temporarily after any eyelid procedure, but since ptosis surgery results in more exposure of the eye, its recommended to have artificial tears to keep the eyes lubricated after surgery.

Ptosis Surgery Aftercare

Post-surgical instructions are provided for the specific type of ptosis surgery you undergo. General instructions include: the application of antibiotic ointment, cold compresses and other details.

Follow up

Follow up appointment after surgery will be scheduled with you. Typically patients are seen after 1 week for suture removal for procedures such as levator advancement. In other types of ptosis surgery, you may need to be seen earlier.

Ptosis Surgery Recovery

After the surgery, it’s routine to remove sutures after 1 week. For most people who undergo ptosis surgery, the recovery period to return to work is about 1 week. Some bruising may be present for about 2 weeks.

Swelling of the eyelid can be present for up to a year, but the majority of patients find that within a few weeks of surgery, they’re appearance is acceptable and does not draw any attention. If you want to correct your ptosis before an important event like a wedding, the more time you allow for healing, the happier you will be with the final result.

Risk & Revision Surgery

Risks related to the ptosis surgery include under correction (eyelid too low), over correction (eyelid too high), eye exposure, scarring, infection, bleeding, excessive scarring and undesirable cosmetic result. Ptosis surgery is performed in ways to minimize these risks. If the eyelid shape, height or symmetry requires enhancement, additional surgery is indicated. Dr. Prasad is committed to helping his patients achieve the results which are most satisfactory and has a well established record of successful surgical outcomes.

Can I fix ptosis without surgery?

While some people recommend alternatives solution to fix a droopy eye, by getting enough sleep, using injectable such as Botox or Restylane, and eye exercises with a patch to strengthen the levator muscle; none of those options will help correct the ptosis as well as surgery.

Blepharoptosis vs Blepharoplasty?

Blepharoptosis is another term for ptosis surgery, whereas blepharoplasty is a term to describe eye lift surgery – the cosmetic procedure for the upper or lower eyelid to improve the appearance around the eye for excess upper eyelid skin or puffy eye bags.

What is the difference between upper blepharoplasty and ptosis correction? 

Hooding or drooping of the upper eyelids that  gives you a tired look is often seen with normal  facial aging if you are considering cosmetic  enhancement of your upper eyelids to help  you look more refreshed then you should know the  difference between excess skin over the eyes and  eye muscle related drooping eyelids why because  these are two distinct issues and are managed  very differently I often see patients who had  cosmetic upper eyelid surgery performed elsewhere  who still feel that they looked tired because  of their drooping eyelids this often means  that the operating surgeon didn’t address a  condition called ptosis a medical term to describe  a drooping upper eyelid I’ll discuss the  difference between hooded upper eyelids and ptosis  as well as how i address these conditions in  my practice.

I’m Dr Amiya Prasad, I’m a diplomate  of the American Board of Cosmetic Surgery and  a Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in practice in  New York City and Long Island for over 25 years, I perform a range of cosmetic eyelid surgeries  to treat issues like hooded upper eyelids puffy under eye bags and  Asian double eyelid surgery  as an oculoplastic surgeon. I trained first in  ophthalmology so I perform specific types of  eyelid surgery that’s usually not done by general  plastic surgeons such as treating eyelid ptosis  upper and lower eyelid retraction and treating  eyelids affected by conditions like thyroid eye disease.

So how do we differentiate eyelid  hooding from drooping upper eyelids or ptosis  upper eyelid hooding is typically due to the  eyelid skin stretching or sagging due to collagen  loss and changes in skin elasticity as your upper  eyelid skin changes it folds upon itself so there   appears to be excess hooded skin over the eyes  this condition is referred to as dermatochalasis when you have drooping eyelids or eyelid  ptosis the position of the eyelid margin.

Where the edge of your eyelashes emerge  is lower than it normally would be   people with eyelid ptosis are often aware that  one eyelid is actually lower than the other some people aren’t even aware that their  eyelids have descended significantly and are delighted to experience how much better  they feel when their eyes are actually more open other people have told me that they struggle to  keep their eyes open and they feel fatigue from straining to keep their eyes open eyelid  ptosis associated with aging is typically due to a stretching or detachment of the muscle  that lifts the eyelid called the levator muscle   levator is the word like the word elevator  without the letter e interestingly ptosis can be present with dermatochalasis making the  diagnosis of ptosis at times kind of challenging.

As I mentioned earlier the treatment strategy  for hooded upper eyelids or dermatochalasis is different from eyelid ptosis so an accurate  diagnosis is very important surgery for upper   eyelid dermatochalasis is more than just skin  deep the eyes are three-dimensional so addressing   the deeper soft tissue is very important  to achieve a natural and aesthetic result   many patients express to me their concerns about  being able to close their eyes after surgery they   ask these types of questions because they’re aware  of individuals who had eye-related problems due to   the inability to properly close their eyes  after aggressive upper eyelid skin removal.

I help people from around the world who have had this type of problem with advanced reconstructive   procedures such as skin grafting to the upper eyelids to replace lost skin as an oculoplastic   surgeon I’m familiar with dry eyes and other ophthalmologic issues which need to be factored   in when planning cosmetic eyelid surgery.

I always  say that eyes that look good function well my   surgical aesthetic focuses on natural looking  results which are more youthful and vibrant   not plastic although redundant eyelid skin can  be present at the same time as eyelid ptosis   many people learn the hard way that removing  eyelid skin alone will not treat eyelid ptosis.

As I stated earlier I see a lot of people who  had upper eyelid surgery and then come to me   to address their eyelid ptosis which wasn’t  taken care of initially eyelid ptosis requires   specialized surgery to shorten or reattach  the levator muscle or another muscle called   Mueller’s muscle I routinely perform cosmetic  upper eyelid surgery or blepharoplasty with ptosis   surgery I perform a lot of my ptosis procedures  from the underside of the upper eyelid there are   times when I only perform the ptosis surgery  without making any incisions on the outside.

I perform upper eyelid blepharoplasty as well as  ptosis correction surgery using local anesthesia   with LITE IV sedation my patients avoid the side  effects often seen with general anesthesia such as   nausea and vomiting in addition  to prolonged recovery from surgery   so in closing I want to encourage anyone  considering upper eyelid cosmetic surgery   to understand the difference between  upper eyelid hooding and upper eyelid   ptosis if you suspect that you have  ptosis as well as hooded upper eyelids   a proper evaluation will help you have the  procedures that are best suited for your situation.

 I hope you found this information helpful thank you for your question 

Will My Eyesight Change after Ptosis Surgery?

For most people, the eyesight has some improvement since the droopy eyelid can block part of or all of the pupil. Ptosis can cause a mild astigmatism, so after surgery, the cornea shape can change slightly requiring a change in eyeglass or contact lens prescription.

Cost of Ptosis Surgery

The cost of the droopy eyelid surgery is dependent on the type of procedure as well as the anesthesia and facility costs. Dr. Prasad’s offices have state-of-the-art surgical facilities in Manhattan, New York City and Garden City, Long Island. Fees are determined after Dr. Prasad performs your examination. Dr. Prasad’s practice does not participate in any insurance plans.

Will ptosis surgery fix a lazy eye?

In order to correct a lazy eyelid, or eyelid ptosis, eyelid ptosis correction surgery is needed. Ptosis surgery involves going into the eyelid skin to work on the levator muscle. There are various techniques in ptosis eyelid surgery, but the basic principle is working on the levator muscle by shortening, or reattaching it so that the eyelid opens more effectively.

Dr. Prasad performs ptosis surgery frequently in his practice under local anesthesia with LITE IV sedation. The patient will be requested to open their eyes and look up to make sure the height, shape and contour are balanced. Ptosis surgery improves the appearance of a lazy eye when it is done with the best symmetry possible.

Ptosis FAQ videos

Patient Reviews on Eyelid Ptosis Surgery

Dr. Prasad performed revisional ptosis surgery on my daughter who was born with congenital ptosis We are 6 months out after surgery and her eyes are perfectly aligned! Reviewer: name withheld
I used to have a slightly drooping eyelid, a progressive condition. After consulting different surgeons, I went with Dr. Prasad and I am truly glad I did. The drooping was corrected in both eyes and I healed up very nicely. Reviewer: Jester
I have eyelid Ptosis and wanted the get in touch with the best surgeon in this field to fix it. Now 3 months later, I am really happy with the result, the all process went well. Dr. Prasad and his team are true professionals. Reviewer: name withheld
I went on to have a Ptosis eye surgery and I am really happy with the result, the aftercare was thorough. I will come again. Reviewer: Name withheld

Oculoplastic surgeon Dr. Amiya Prasad is an expert in cosmetic and reconstructive eyelid surgery. Schedule your consultation with Dr. Prasad for your eyelid ptosis surgery today! Contact Dr. Prasad at his New York office at (212) 265-8877 or in his Garden City office at (516) 742-4636, or fill out the contact form below.

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