Thank you for your question.
You submitted a single photo and with a history where you describe having undergone ptosis
surgery for congenital ptosis approximately 11 months ago. And you stated in your question
that you have a concern about the absence of a defined crease on the left eye and some
residual ptosis. In addition, you comment that you feel that you are more asymmetric
than you were prior to surgery and you are looking for some guidance.
Well, I can certainly share with you how I evaluate a patient like yourself in my practice.
A little bit of background, I’m a Board-certified cosmetic surgeon and fellowship-trained oculofacial
plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island
for over 20 years and ptosis surgery is one of the most common procedures we do in our
practice. And so, certainly for your situation, I can give you some ideas. However, there
is probably some benefit related to additional information that could be helpful but to just
basically remind you with the issue of congenital ptosis.
First of all, congenital ptosis, congenital meaning you were born with this ptosis and
what the issue is, with congenital ptosis is that the muscle that lifts the eyelid called
the levator muscle, levator like the word elevator, didn’t develop quite properly.
And there is a spectrum of how much impact the congenital issue is that’s based on
level of the eyelid relative to the pupil (mild, moderate to severe) and then the amount
of muscle function, how well the levator muscle contracts. So you can have anywhere from minimal
function or zero function or zero millimeters of movement to excellent muscle function.
Based on that combination, a ptosis surgeon will then determine how to do your operation.
Now in our practice, for adults, depending on their type of ptosis, the majority of our
patients will actually do the procedure under local anesthesia with LITE™ sedation. One
of the biggest challenges of ptosis surgery is trying to achieve the optimal height and
contour to maximize symmetry. So we’ll actually, during surgery, sit someone up during surgery
to see their eyelid levels and do a comparison and make sure that we achieve that optimal
goal.
Now to address first the issue about the crease, the eyelid crease is a function of the amount
of skin that there is available to fold over. So when you look at your right eye where you
have a little bit of hooding or a little bit of extra skin and on the left eye, the operated
eye, you notice that there is very little additional skin. So the question that first
comes into mind, since you didn’t have a blepharoplasty, there was probably a discussion
about the extra skin. So that means that likely, you had skin removed with the intention to
try to improve the hooding on that eye. Now when that occurs, it is clear that there is
a difference between the amount of skin over your eyes and that I think may be the core
issue of the asymmetry.
In so many ways, when we are trying to do an operation like this, if the person doesn’t
want to have a blepharoplasty in the other eye where there is extra skin, then very limited
blepharoplasty is typically undertaken. And at times, I will try to avoid removing any
skin at all. I just use the eyelid crease to enter this space in order to address the
levator muscle. In some ways, this is analogous to what we do for Asian eyelid surgery. With
Asian eyelid surgery, the intention is to create a crease but it is critical to maintain
a certain amount of extra skin so that there is a fold and that the fold is able to overlap
and create a natural crease.
Now in terms of the eyelid level achieved, looking at your photo, it seems that the symmetry
is pretty much there and the way that I determine that is looking at the eyelid margin relative
to the pupil, to the center of the pupil. And what I typically explain to every patient
who’s going to have unilateral ptosis surgery or one side, I explain that the goal is to
maximize symmetry. We want to get you as close to the other eye as possible. However, it’s
important to understand that within a range of normal which is the general population,
people without clinical diagnosis of ptosis, the majority, it is the norm to have both
eyes to have up to a 2 millimeter difference between them and it still looks natural and
symmetric. You know, the human body is beautifully imperfect. When we talk to patients about
doing fillers or volume or facelifts, I always make a point to point out how different one
side of the face is with the other.
So in terms of the height of your eyelid margin relative to the pupil, you are probably as
close as could be expected and there is probably no additional value in doing more surgery.
However, a solution which is worth considering in terms of maximizing symmetry would be to
consider doing a contralateral or a blepharoplasty in the right eye because that way, you at
least have more balance between the two eyes. I’m sure that this was probably discussed
with your doctor prior to surgery. And in terms of trying to create a crease, the limitation
in this situation is how much skin is available to fold over. And based on the photo you submitted,
it doesn’t look like there is enough skin so that even if a crease was to be “anchored”
in that’s a technique to try to define the crease, the anatomy of the shape of the eye
socket and the amount of skin that’s available is likely to limit any meaningful change with
any surgery for crease formation.
So I think that my impression is that the overall issue with the asymmetry is more about
the asymmetry between the hooding on one eye compared to the absence of hooding on the
other eye. So, if the goal is to have better symmetry, then I would suggest considering
having a right upper eyelid blepharoplasty.
I think it’s very important that you have this discussion with the operating surgeon.
I think your overall result, if the goal of the ptosis surgery was to lift the eyelid,
based on this photo, your objective has been achieved. Now to maximize cosmetic symmetry,
consider the right upper eyelid blepharoplasty.
So I hope that was helpful, I wish you the best of luck and thank you for your question.