Droopy Eyelid (Ptosis)
3 December 2019 onur
Since this is a subject that I have difficulty in explaining during examination, I thought it appropriate to make a preliminary explanation here.
My patients are surprised when they hear it for the first time, and they are often caught off guard.
Sagging of the excess skin on the eyelid (blepharochalasis) and droopy eyelid (blepharoptosis) are completely different things.
The eyelid consists of layers.
In the outermost layer, there is the skin and just below this skin is a superficial muscle like a curtain that is tightly adhered to the skin. This outermost layer loosens and sags over time. This sagging covers the upper eyelid fold, the skin may contact the eyelashes, and in advanced cases, it may even block the visual field of the eye. The treatment we apply to eliminate sagging, excess skin is the surgical removal of the excess part of the skin and sometimes a part of the superficial muscle that is attached to it. The medical name for this procedure is blepharoplasty. It is popularly known as eyelid aesthetic surgery or eyelid job.
Blepharoplasty does not correct droopy eyelids!!!
In the deep compartment of the upper eyelid, there is a muscle that serves to open the eyelid, that is, to raise the eyelash border.
Let’s call this muscle the Levator for short. Levator means “lifter” in Latin. The Levator muscle begins on the inside of a bone located at the back of the eyeball. The body of the muscle travels forward above the eyeball. Where the eyelid begins, the muscle body turns into a curtain made of connective tissue. The curtain of the muscle runs down the deep compartment of the upper eyelid and attaches to the hard cartilage plate just below the eyelashes.
These details are not very important to you, but it is enough to know that there is a “mechanism” here.
When there is a problem in any part of this mechanism, the eyelid cannot be opened sufficiently and remains low.
This is the case with the eyelid of Forest Whitaker or Paris Hilton.
In a normal eyelid, the eyelash border tangentially crosses the colored halo of your eyes. It certainly does not cover the black circle in the center of the eye. In patients with droopy eyelids, the eyelash border gradually slides down, first blocking the colored halo of the eye and then the black circle in the center that provides vision.
There are various causes of droopy eyelids. These causes vary from brain tumors to bone fractures around the eyes, from eyeball placement disorders to hormonal disorders, and from neurological diseases to the normal aging process.
So it’s not just an aesthetic problem.
However, it is a problem we frequently encounter in plastic surgery.
The most common cause of droopy eyelids in society is the wear and tear of the curtain mechanism of the Levator muscle due to aging. The fact that the eyelids of an individual who has reached the age of 50 are 1-2 mm below their level at 20s is already considered a part of the normal aging process. We can observe clinically significant drooping of the eyelids in approximately one third of the patients who come for eyelid rejuvenation procedures.
From the perspective of facial rejuvenation, the key point is that the droopy eyelids of the patients are noticed before the aesthetic surgery of the eyelids.
If it is noticed, we can go down to the deep layer during eyelid surgery and repair the Levator curtain after we are done with the superficial layer, and both the sagging of the eyelid skin and droopy eyelids will be corrected in the same session.
If it is not noticed early on, the drooping of the eyelid begins to attract greater attention after the sagging of the skin on the upper eyelid is corrected. The eye appears squinted, as if it were small. A faint, languid look comes up. A secondary surgery is required to correct this condition. The patient becomes unhappy. Very rightfully, of course.
I say this because, from the patient’s perspective, it is a perfectly reasonable reproach to say, “I was expecting the lid to be lifted when that sagging skin was removed”.
But you should also know that droopy eyelids are sometimes hidden/masked. Before the operation, both the Levator muscle and the Frontalis muscle on our forehead receive an intense “lift” signal from the brain in order to lift the weight on the eyelid. Prior to surgery, the eyelid may appear to be at its normal level thanks to this heavy signal traffic. When the excess skin on the eyelid is removed or the eyebrow is raised, the weight becomes lighter, the signal decreases, and the drooping of the eyelid becomes obvious.
If you have had eyelid surgery and the drooping of the eyelid has become obvious later, do not dump on my colleagues, because the diagnosis of this condition may be missed even by physicians who specialize in this field.
If you are doing research about aging around the eyes, a question mark should pop up in your mind about whether you have a droopy eyelid. This is the purpose of this blog post.
There are 3 basic symptoms of droopy eyelids. Observe yourself for these symptoms.
- The eyelash border has covered the colored halo of the eye from above and approaches the black circle in the center of the eye.
- The upper eyelid skin fold is higher than normal.
- The eyebrow is higher on the affected side.
You can review the images by typing “eyelid ptosis” into Google.
There are 2 basic approaches in the treatment of aging-related eyelid drooping in aesthetic surgery:
The first is the skin approach.
The second is the approach from the inside of the eyelid.
In addition to these approaches, the skin excess of the upper eyelid, the upper lid fold and the eyebrow position should also be corrected through additional surgical interventions.
Discussing the approaches or surgical combinations suitable for each patient is not the subject of this post, and the decision processes are extremely complex. What you need to know is that this is not so “simple”.
In a young patient, we can easily handle droopy eyelids from the inside of the eyelid. We may not need to do anything to excess skin, the upper eyelid fold or eyebrows.
However, the situation is very different in aging patients. In this group, the eyelids are droopy, the eyebrows look misleadingly higher than they originally are, and the upper eyelid skin appears taut. If you only correct the “drooping” by entering from the inner surface of the eyelid in this group, first the upper eyelid fold and then the eyebrows will go down to their normal (lower) position following the normalization of the eyelid mechanism.
But all of a sudden you end up with excess upper eyelid skin and drooping eyebrows, which was not the case before the operation!
Therefore, I explain to patients in the aging process that forehead lift, upper eyelid aesthetic surgery and droopy eyelid surgeries are a whole and if one is missing, we cannot achieve the ideal aesthetic result.
I don’t just explain it, I demonstrate it with case examples in the clinic.
If my patient says, “Doc, you do the eyelid but I don’t want anything else”, then they should declare in writing that they understand and accept that their eyebrow will fall and excess skin will form on the eyelid following the surgery.
Another issue is asymmetries.
The eyes are asymmetrical in each individual.
Eyelid drooping is almost always asymmetrical. This asymmetry causes asymmetry between the eyebrows as well. As a conventional rule, it is often not possible to obtain a symmetrical eyelid in a single session in droopy eyelid surgeries. The surgery will reduce the existing asymmetry, but it will not create two identical eyes. There may be a 1-2 mm difference between the eyelid levels after surgery. I repeat: Do not take these surgeries lightly. The mechanism is quite complex. Even if your surgeon levels the eyelids exactly during surgery, level differences may occur due to wound healing, edema and surgical adhesions during the follow-up process. For instance, when one side is done, the hidden drooping on the other side may become obvious during follow-up. Therefore, revisions are quite frequent.
Think of this surgery as a 2-session procedure.
Don’t be upset when revision is needed. If it’s over in one session, you’ll celebrate.
Finally, one of the most common causes of droopy eyelids in plastic surgery is botulinum toxin applications. In 2 or 3 out of every 100 patients, the toxin finds a way to reach the Levator muscle and weakens that muscle, resulting in the development of droopy eyelids. Botox-related drooping is always temporary and usually resolves completely within 6-12 weeks. In the meantime, we can camouflage the drooping of the eyelid by using an eye drop so that our patients do not experience difficulties in social life.
Now this was a long text. I am tired of typing. But I don’t want to give you further tiredness as you read.
This is a deep, comprehensive matter.
If you want to learn more about droopy eyelids, please do not hesitate and come see me for an examination.
Take good care… of yourself and your beauty.