Patients with severe ptosis, which is a medical condition in which the upper eyelid droops or sags, resulting in the individual appearing perpetually tired and serious, often face difficulty in finding an effective treatment. To sufficiently lift the eyelid, vertical techniques are typically employed. In some cases, anchor techniques might also be necessary. In this article, we will explore the implications of severe ptosis, the various surgical strategies that are used to address it, and the underlying anatomy.
What is Severe Ptosis?
Severe Ptosis, often referred to as blepharoptosis, is a common eye condition caused by dysfunction of the upper eyelid muscle. The most obvious symptom of severs ptosis is a drooping or sagging of the eyelid, which sometimes results in the upper half of the eye being partially or completely obscured. This condition is most often caused by aging, but it can also be congenital or result from injury or neurological disease.
It is important to note that mild cases of ptosis are incredibly common, and are not cause for concern. Our eyes naturally undergo pronounced changes in structure as we age, and minor changes in eyelid appearance can be a normal part of the aging process. However, severe ptosis can have significant impacts on an individual’s vision and confidence.
Vertical Techniques for Treatment of Severe Ptosis
For patients with severe ptosis, surgery is frequently the most appropriate and effective treatment strategy. A range of so-called “vertical techniques” form the basis for ptosis surgery. The focus of surgery is typically on altering the length or tension of the muscles that hold the eyelid in place. A patient with severe ptosis may need to undergo one of several different surgical procedures, depending on the dynamics of the affected muscle and other variables. Common vertical techniques include:
- Frontalis Sling – This procedure is sometimes used to restore the upper eyelid to its previously lifted position. A silicon rod is attached above the eyebrow with sutures, and a muscle in the forehead is also manipulated and moved from the scalp to the eyelid in order to provide additional lifting power.
- Supramaximal Levator Advancement with Faden Suture – During this procedure, the muscle of the upper eyelid is resected, or cut, and moved upwards. Additionally, a Faden suture is inserted to maintain the muscle’s position in order to help ensure a lasting result. This procedure is particularly appropriate for individuals with severe asymmetry between the two eyes.
- Levator Retraction or Transposition – A muscle in the upper eyelid region is repositioned to lift the drooping eyelid. This procedure is typically used in cases where the levator muscle has become retracted, or lost some of its typical movement.
Variations of Anchor Techniques for Severe Ptosis
In some cases, one of several different so-called “anchor” techniques might be required in order to achieve a satisfactory result following ptosis surgery. These techniques all focus on resection or modification of the levator muscle or tendons in the eyelid in order to help ensure a lasting result. Common variations of anchor techniques include:
- Posterior Approach Levator Resection – This procedure is performed through an incision behind the eye. The levator muscle or tendons are then resected in order to shorten them and give the lid a lifted appearance.
- Posterior Aponeurosis Repair – When the attachment of the levator muscle or tendon to the eyelid is broken, a surgeon might elect to repair the connection from a posterior approach. A permanent suture is then used in order to secure the newly created connection.
- Levator Elongation with External Tu
Understanding the Anatomy of the Upper Eyelid
When formulating a treatment plan for individuals with severe ptosis, a surgeon must carefully consider the anatomy of the upper eyelid. This region is comprised of several structures that all play a roll in looking, moving, and functioning normally. The key structures include the:
- Levator Palpebrae Superioris – The primary muscle that lifts the upper eyelid
- Tarsal Plate – A piece of connective tissue that provides a framework for the upper and lower eyelids
- Mueller’s Muscle – Provides the upper eyelid with additional lifting power
- Riolan’s Muscle – Provides the upper eyelid with additional lifting power
During a ptosis surgical procedure, a surgeon will carefully consider each of these structures. The objective will typically be to either modify the length or tension of the levator palpebrae superioris or to repair/reposition the other essential structures.
Vertical techniques form the basis for an effective surgical treatment for severe ptosis. When necessary, anchor techniques can be employed to: shortened the levator muscle or tendons; repair the posterior aponeurosis tendon; and elongate the levator muscle. In each case, the anatomy of the upper eyelid must be carefully considered in order to achieve an optimal result.
