How I treat drooping eyelids (Ptosis) in older people
Drooping eyelids is called ptosis or blepharoptosis. Older people often gradually develop this over the years, and a typical appearance is someone who is lifting their eyelids indirectly with their eyebrows to lift the skin out of the way of their vision and be able to open their eyes maximally.
When the eyebrows are relaxed the eyelids droop down and start to encroach on the visual axis and get in the way of how well they are seeing. This group of patients are usually aged 65-85 and can be men or women. It is related to thinning of the tissues with age, and the medical term is Involutional Ptosis.
We tend to see Involutional ptosis more often in women, but then there are more women alive than men in the older age group. Very often I detect the drooping eyelid or ptosis when a patient comes to see me saying their eyelids are dropping, and that they cannot see and they want eyelid surgery.
There are two causes of eyelid drooping, one of which is excess skin folds which require blepharoplasty and the other is a drooping eyelid called ptosis where the thin muscle which lifts the eyelid has thinned further and no longer holds the eyelid up in its normal position and they appear droopy.
In this group of patients aged with ptosis, the appearance is such that there is a lot of skin showing on your upper eyelids and the contour of the upper lid is rather flat, and the area between the lid and the brow is a bit sunken and hollowed. In this group of patients aged 65 to 80, I have to assess them and decide whether they require brow surgery or eyelid surgery or a combination of both.
Increasingly I am finding that patients only require eyelid surgery as the aim is to help them to look more natural and more like themselves, but without the drooping eyelids. Once I have lifted the eyelids, their hyper eyebrow elevation will reduce, and they will feel less tired because they no longer have to have all the effort of lifting the eyelids during the day.
In patients aged 65 to 85 with ptosis, I can carry out the surgery under local anaesthetic as a day case at Clinica London. They can have a normal breakfast on the day of surgery. We admit them about an hour before to see the nurse and I go through the consent process with them.
We take them through to the treatment operating room and prepare them for the surgery with the prepping and draping and marking. I mark the eyelids in a sitting position so I can get the best possible natural skin crease height, restoring the height that they previously had.
I then proceed to try and restore the eyelid height and contour through ptosis eyelid surgery. There are two ways of doing ptosis eyelids surgery, one from the front of the eyelid through the skin and the other through the undersurface of the eyelid called the posterior approach.
In this blog post, I am going to talk more about the front of the eyelid approach, which is a small fine incision hidden within the skin crease of the upper eyelid. Through that little skin incision – and the skin is indeed very thin in the older person – I then encounter the underlying thin muscle called the orbicularis.
I go through that muscle to prepare the upper eyelid fibrous plate called the tarsus plate to receive some stitches and advance the levator muscle. I do the surgery with infiltrative and topical local anaesthetic, and it takes up to an hour. If I need to do two sides, this may be an hour and a half. Very often I have to combine ptosis surgery with an upper eyelid blepharoplasty in the same operation so that I can remove some excess skin which is causing hooding.
After the surgery, I do not repair eyes, but just put Cartella shields on as then the patients feel less claustrophobic. I will have used a combination stitches and TISSEEL fibrin adhesive, so the wounds are quite secure. However, I keep them at Clinica London for an hour after the surgery in the recovery room. We give them a hot cup of tea and a sandwich. Once I know that they are well settled, and their eyelids are comfortable, then they can go home either with the eye shields on or behind some dark glasses.
It is imperative that all patients having ptosis eyelid surgery in the age group of 65-85 go home accompanied with a friend, neighbour or member of the family and that they are not alone at home that night. Otherwise, we have to arrange a local hospital stay.
We are always in contact after the surgery to know how they get on. The patient has to sleep the first night propped up and then after that they can wear dark glasses during the day, and the plastic shields at night to protect the eyes against the pillow or another person’s elbow, and then they return in one week to have the stitches out.
As you can see, drooping eyelids are different in the younger group compared to the much older group. There is also a group in the middle-aged 45 to 65 who get ptosis, and I will be writing about them in my next blog post.