Ptosis Surgery “Failed”? Here’s What Happened

What are the different ways Ptosis Repair “Fails”?

Ptosis repair is surgery to lift a droopy upper eyelid by tightening the muscle(s) responsible for lid elevation. When repair works well, the eyelid opens wider.  The eyes look more balanced, and peripheral vision from lid obstruction improves. Like any surgery, the result is not 100% predictable and optimal to our expectation. When this happens, it is disappointing and frustrating to the patient and the surgeon alike. It may also be anxiety-provoking as well as scary to the patient.

The important thing to know is that ptosis repair is a highly precise eyelid operation. Several factors can affect the final eyelid height, contour, and symmetry.

When a patient says ptosis repair did not work, it can mean different things:

• The eyelid is still too low.
• The eyelids are uneven.
• One eye looks more open than the other.
• The eyelid looks better initially and droops again.
• The eyelid opening improves, but extra skin still persists.
• The eyelid feels tight, dry, or uncomfortable.
• The result just does not match the patient’s cosmetic expectation.

Each of these situations has a different explanation and a different solution. That is why a careful preoperative and postoperative examination and reasonable expectation are so important.

1. It May Be Too Early to Judge the Final Result

The first crucial point to judging surgical results is have we given enough time for the eyelid to heal. We typically expect 80% internal healing at six weeks, 90% internal healing at three months and 100% internal healing after six months. During the initial recovery period, we expect inflammation, scar and tissue remodeling to take place and fluctuate day to day. Until the tissues remodel and mature after three or more months, the eyelid may look and feel tight and uneven.

For many patients, the eyelid position becomes easier to judge once healing has stabilized. I usually give 3-4 months for this to occur before making any final judgement, especially if we at all entertain revision.

2. The Eyelid May Have Been Under-corrected

Undercorrection means the eyelid was lifted, but not enough. This is one of the more common reasons a patient may feel that ptosis repair did not work.

Undercorrection can happen for several reasons. The eyelid muscle may be too weak to lift higher. In some cases, the surgeon may intentionally avoid tightening the muscle more during surgery because there is sign of lagophthalmos, or inability to close the eye completely, during surgery and want to avoid causing or exacerbating dry eye syndrome.

On the other hand, the surgeon may tighten the eyelid aggressively to get the ideal elevation and intentionally cause lagophthalmos if the surgeon and patient discuss and agree upon doing so at the risk of dry eye syndrome and the associated symptoms (i.e., dryness, burning, foreign body sensation, sharp pain, intermittent blurry vision and tearing.)

In other words, ptosis repair is a balance between what the muscle is capable and the risk of aggressive tightening of the muscle. The goal is not simply to lift the eyelid as high as possible. The goal is to create a functional, comfortable, and natural eyelid position.

3. The Eyelid May Have Recurrent Ptosis

Sometimes the eyelid looks good after surgery and begins to droop again soon after surgery.

This recurrent ptosis can occur unexpectedly if the repaired tendon and/or muscle stretch an/or the sutures loosen during recovery. This occurs more often if excessive inflammation is not controlled expediently or if we manipulate the eyelid prematurely after surgery. Such recurrence is rare if we adhere strictly to the post-operative instructions.

Inflammation responds well to strict icing for the first 72 hours, followed by heat thereafter until inflammation subsides. I might start patient on oral steroid in addition to the antibiotic ointment with steroid if I suspect or appreciate significant inflammation. I also ask patients to absolutely refrain from rubbing, pulling or tugging on the eyelid for six weeks after surgery. This also means not sleeping on the sides.

On the other hand, we expect ptosis to recur in most if not nearly all patients after ten years from surgery, as the muscles age, stretch, loose mass, and get replaced by fatty tissues. The recurrence can be sooner or more severe in patients with ptosis associated to muscle dystrophies, neurologic conditions, traumatized or injured muscle, or congenital ptosis. These conditions compromise the muscle from fully function with or without surgery. Other factors that can also contribute to the muscle weakening prematurely or more severely include frequent eye rubbing or inflammation; eyelid stretching, especially in long-term contact lens wear; eyelid trauma, or intraocular surgeries.

4. The Original Problem May Not Have Been Only Ptosis

This is one of the most important points.

Not all “heavy, tired, or sleepy eyelids” are ptosis. A patient may have true ptosis, but they may also have other issues in addition that makes patients feel they are still droopy, heavy, puffy or asymmetric, including:

• Dermatochalasis, or excess upper eyelid skin
• Brow ptosis, or a low/heavy eyebrow
• Thick eyelid skin
• Orbital fat herniation
• Asymmetric eye sockets or facial bones
• Asymmetric positioning of the eyeballs
• Eyelid retraction on the opposite side

If patients have any of the above problems, they may feel ptosis surgery fail to repair their problem. They are absolutely right—ptosis repair will not address these other problems. Therefore, in addition to ptosis repair, we should consider other combinations of treatments. Unfortunately, not all problems may be repair. For example, there is no procedure to thin out thick skin or to reposition the bones and eyeballs for balanced positioning.

5. The Other Eyelid May Have Drooped After Surgery

The two upper eyelids are neurologically connected. When one eyelid is significantly droopy, the brain sends extra stimulation to both eyelids to compensate for the droopy side. After the worse eyelid is corrected, the brain reduces that extra stimulation. As a result, the muscle on the opposite eyelid that has not been operated on may start to relax, causing this “normal” eyelid to appear droopy after surgery. This is known as Hering’s law.

To the patient, it may look like the surgery made the other eye worse. In reality, the second eyelid may have had mild ptosis all along, and that ptosis is now being unveiled without all that extra stimulation from the brain.

This is why preoperative testing, eyelid measurements, and considering bilateral ptosis at the are necessary.

6. The Eyelid Height Improves, but the Contour Is Not Ideal

Ptosis repair is not only about eyelid height. The shape of the eyelid matters too.

A patient may have an eyelid that is technically higher after surgery, but the contour may look peaked, flat, irregular, or asymmetric. This can happen because of scar tissue, uneven tension of the sutures used to tighten the muscle, or differences in eyelid anatomy or muscle response.

In some cases, patient’s expectation of certain contour shape is just not consistent with ptosis repair. For example, if patient is accustomed to a flat contour associated with severe ptosis and now has a rounder contour after ptosis repair, the patient may not acclimate or accept this change. While this rounder contour is expected of ptosis repair and, therefore, is considered normal, it is not normal to the patient.

In some cases, small contour issue improves with healing or lid pulls. In other cases, surgical revision may be needed to refine the eyelid shape.

7. The Type of Ptosis Matters

Ptosis can have different causes, and the cause affects the surgical plan.

Common types include:

Aponeurotic ptosis
Age-related ptosis is the most common and usually responds to surgery well. Times when it does not is when the muscles loose too much muscle mass and/or becomes infiltrated with fat.

Congenital ptosis
This is present from birth and often involves an eyelid muscle that has not develop normally. This one of the most difficult ptosis to repair. The repair is often sub-optimal and repeated many times.

Mechanical ptosis
This occurs when something physically weighs the eyelid down, such as excess tissue, swelling, scarring, or a mass. The repair should address the underlying mass effect.

Neurogenic ptosis
This occurs when the nerve signal to the eyelid muscle is abnormal. This is challenging to fully address, as muscle tightening does not change the function of the nerve. In most cases, nothing does.

Myogenic ptosis
This occurs when the muscle itself is weak, as in certain muscle disorders. This is another difficult one to repair. While tightening the muscle helps it contract more, the muscle still cannot contract effectively if there are no normal or enough normal muscle fibers.

A procedure that works well for one type of ptosis may not be the best choice for another. For example, a patient with good levator muscle function may do well with levator advancement or resection, while a patient with poor levator function may need a frontalis sling.

8. Medical Conditions Can Affect the Result

Certain medical conditions can make ptosis more difficult to correct or more likely to fail or recur. These include:

• Myasthenia gravis
• Thyroid eye disease
• Chronic progressive external ophthalmoplegia or other muscular dystrophy
• Prior nerve palsy
• Prior eyelid trauma or surgery
• Autoimmune or connective tissue disease
• Abnormal scarring or wound healing

9. Expectations May Not Match What Ptosis Repair Is Designed to Do

Ptosis repair lifts the eyelid margin (or lash line) to a higher position on the eyeball. It does not remove eyelid skin, lift the brow, or smooth wrinkles. As the matter of fact, ptosis can create worsened appearance of brow ptosis and dermatochalasis. When the lash line moves up, it pushes into the eyelid fold and causes it to bunch up and even fold over the lash line. The skin fold now appears heavier or more hooded.

If the lash line goes up and the brain no longer recognizes a ptosis and relaxes the forehead muscle from lifting the brow as a compensatory mechanism, the brow will also rest and go back down to its natural position. If there is brow ptosis, the natural position will be at the orbital rim or even lower. This brow descent will cause the eyelid fold to appear fuller or more hooded.

These distinctions are important to understanding the result that we see after ptosis repair.

Achieving the ideal result really depends on doing the right surgery for the problem and doing combination of procedures necessary to address the different problems.

Lastly, we should have a realistic expectation of surgery. I think if surgery can get us 85-90% improvement—that is reasonable.

10. Most pre-operative asymmetries will persist

Most patients naturally have some degree of asymmetries of their face, including the eyes. While we aim for symmetry in the aesthetic world, the normal expectation is to improve the asymmetry and not necessarily achieve identical symmetry after surgery. Such expectation is not reasonable or achievable in most cases and sets us up for disappointment.

11. Prior Surgery Can Make Revision More Complex

Revision ptosis surgery is different from primary ptosis surgery. The anatomy has been moved, and scar tissue may replace the normal tissues, distort their appearance making them harder to identify and even affect muscle function.

This does not mean revision is impossible. Surgical plan must be individualized, and expectation should be guarded accordingly.

What Should You Do If You Think Your Ptosis Repair Did Not Work?

If you are unhappy with your result, the first step is a careful examination after the appropriate recovery. Your surgeon will assess:

• Eyelid height
• Eyelid contour
• Eyelid symmetry
• Levator muscle function
• Brow position
• Amount of excess skin
• Bone and eye alignment
• Eye surface health and dryness
• Eyelid closure
• Old photos, if available
• Whether the issue is undercorrection, recurrence, asymmetry, contour, or a separate cosmetic concern