The upper eyelid levator muscle complex is the muscle responsible for the eyelid’s position and dynamic excursions. Ptosis is defined as abnormal lengthening of the levator muscle causing lowering of the upper eyelid margin. Ptosis not only affects the aesthetic appearance of an expressive part of the face but can also compromise a patient’s field of vision.
Ptosis can also lead to secondary compensatory effects like overaction of the frontalis muscle in the forehead with eyebrow arching and asymmetry. In congenital cases, children with ptosis may develop amblyopia (lazy eye) or even developmental delay from limitation of their vision.
Surgical correction of ptosis enables reacquisition of the levator muscle tone and appropriate repositioning of the eyelid margin. This intricate surgical process involves balancing delicate relationships with the position of the contralateral eyelid and the eyebrow compensatory arching. Anatomic considerations of bony structure and individual soft tissue distribution are equally important to optimize surgical outcomes.
In the majority of cases the procedure is performed through the undersurface of the eyelid and without any incision made on the eyelid skin. This approach named Mullerectomy involves strengthening the levator muscle complex through shortening an underlying accessory muscle (Muller muscle) and conjunctiva. This scarless technique, which can be performed under local anesthesia alone, has the advantage of predictability and can raise the eyelid margin up to 3 mm. By balancing the amount of Muller muscle resection, and hence the degree of levator muscle reinforcement, subtle refinement and tuning of eyelid position can be achieved.
For patients with significant stretch of the levator muscle, an anterior surgical approach through a hidden skin crease incision might be necessary. This process involves a more complex manipulation of the eyelid soft tissues and requires patient cooperation as the muscle and eyelid area cannot be entirely anesthetized during surgery.
In congenital cases where the levator muscle is inherently abnormal and weak, a suspension sling is inserted to link the eyelid and eyebrow soft tissues. This ingenious procedure recruits the frontalis muscle to achieve the lifting effect. The frontalis is the main muscle of the forehead and its main function is eyebrow elevation. This minimally invasive procedure, which involves access through well- hidden entry points, has to be performed before the vision obstruction impacts the visual development of the child.
As an oculofacial surgeon Dr Papageorgiou can customize ptosis surgery based on individual ethnic, anatomic, functional and aesthetic characteristics. The majority of his surgeries are performed under monitored anesthesia and involve the Mullerectomy approach for refined, predictable outcomes and fast recovery.