[Ptosis, Duhan Plastic Surgery] - [Sleepy-Looking Eyes, Ptosis Eye Correction]

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Ptosis (Sleepy-Looking Eyes)

If the eyes do not open fully and always look sleepy, this is called ptosis.

It is broadly divided into congenital ptosis and acquired ptosis.

It is also divided into true ptosis, in which the function of the levator palpebrae superioris, the muscle that lifts the eyelid, is reduced, and false ptosis, which only looks like ptosis.

The purpose of ptosis correction is to restore a large, clear eye shape, and ptosis correction surgery requires an appropriate method and skilled technique depending on the severity of the condition.

Director Shin Duhan

■ Examples of ptosis

■ Types of ptosis

1. Congenital true ptosis

This occurs when the function of the levator palpebrae superioris, the muscle that lifts the eyelid, is congenitally reduced. It may occur in both eyes or in one eye.

In congenital ptosis, it is better to correct it early before the function of the levator palpebrae superioris deteriorates.

In cases of true ptosis, even after double eyelid surgery there is almost no effect of making the pupil look larger, and ptosis correction must be additionally performed to increase the vertical size of the pupil.

2. Congenital false ptosis

There are cases where the levator palpebrae superioris function is not reduced, yet the eyes still look sleepy.

This happens because, in eyes without double eyelids, the drooping of the eyelid covers the pupil.

This can be mistaken for ptosis, and even plastic surgeons sometimes mistakenly judge it as true ptosis, so caution is needed.

Congenital false ptosis can have the effect of making the eyes appear larger simply through double eyelid surgery alone, so separate ptosis correction is not necessary.

In the case above, the patient wanted ptosis correction (eye correction) because the eyes looked sleepy, but after temporarily creating a line with wire, the previously hidden pupil became clearly revealed, showing that there is no ptosis at all.

This is a typical case of false ptosis, where simple double eyelid surgery alone is sufficient.

Nevertheless, there are clinics that recommend ptosis correction (eye correction) unnecessarily, so be very careful.

3. Traumatic false ptosis

This occurs when the levator palpebrae superioris, the muscle that lifts the eyelid, is damaged due to improper surgery or trauma. If the damaged levator palpebrae superioris is only partially injured, recovery is not difficult, but in cases of complete injury, recovery can be difficult because the levator palpebrae superioris may retract if it is not restored quickly.

The damaged levator palpebrae superioris is located and restored to correct the condition.

4. Traumatic false ptosis

This refers to cases in which the levator palpebrae superioris, the muscle that lifts the eyelid, functions normally, but its function is hindered by external factors, so the muscle cannot exert its strength properly.

It commonly occurs due to scar adhesion when the double eyelid line has been made too thick.

Correction is performed by fully incising to release the scar tissue adhesion beneath the double eyelid line and lowering the line.

5. Senile true ptosis

This occurs when the levator palpebrae superioris, the muscle that lifts the eyelid, gradually loses function due to aging, weakening the power to open the eyes.

It usually occurs after the age of 50, and in senile cases, as with congenital ptosis, the prognosis after surgery is often poor.

Surgery combines upper eyelid blepharoplasty, which removes skin, with ptosis correction.

6. Senile false ptosis

As people age and the eyelids droop due to aging, the pupil becomes covered, making it look as if the eyes are not opening fully, like ptosis.

In such cases, you must temporarily lift the eyelid skin or create a temporary double eyelid to check the actual vertical width of the pupil.

You should not diagnose ptosis simply because the eyelid is covering the eye.

Upper eyelid blepharoplasty alone can make the eyes appear larger, so ptosis correction is not necessary.

■ Causes of acquired ptosis

| 01. In cases where the double eyelid line is made too high 02. In cases where rubbing the eyes habitually causes scar tissue inside the eyelid, interfering with the function of the levator palpebrae superioris 03. In cases where aging reduces the function of the levator palpebrae superioris 04. In cases where the levator palpebrae superioris is damaged due to trauma |

■ Differences between ptosis and a normal eye​

□ When the eyes are opened naturally and the person looks straight ahead, it is normal for the upper part of the black pupil to be slightly covered by about 1–2 mm. If more of the black pupil is covered than that, ptosis should be suspected.
□ When the eyes are opened naturally and the person looks straight ahead, the vertical eye opening should be 8 mm or more to be normal. If the vertical opening is narrower than that, it is ptosis.
□ When looking upward after first looking downward as much as possible, the range of movement of the eyelid should be about 14–16 mm. If it is less than that, it can be judged as true ptosis.

■ Ptosis examination method​

The examination method for ptosis is to check the vertical width of the pupil while facing forward.

In normal eyes, the vertical width is between 8 and 9 mm, and generally those with 8 mm or less are considered to have ptosis.

However, because everyone’s eye shape and size differ, ptosis is not diagnosed solely based on exact measurements.

The diagnosis is made by judging objectively whether the expression looks sleepy, and comparing this with the measurements.

The function of the levator palpebrae superioris is also measured and evaluated.

1. Vertical palpebral fissure height (measurement of the eye’s vertical opening)

2. Check whether the expression looks sleepy

3. Measure the function of the levator palpebrae superioris (normal 14–16 mm)

■ Ptosis surgery methods

1. Levator palpebrae superioris shortening procedure​

This is a method of overlapping and suturing the eyelid-lifting muscle (levator palpebrae superioris) by about 4–8 mm to shorten its length, and it is mainly applied in cases of mild ptosis.

Ptosis correction must be performed through an incision, so a double eyelid line will additionally be created during the process. Therefore, people without double eyelids will end up with at least a hidden double eyelid whether they like it or not.

■ Levator palpebrae superioris shortening procedure: surgical process

1. Design is marked and local anesthesia is administered.

2. An incision is made along the design line.

3. After the incision, the orbital septum is opened to expose the levator palpebrae superioris.

4. After exposing the levator palpebrae superioris and marking the amount to shorten, the marked area and the upper tarsal border are tied together with sutures.

5. To create the double eyelid line, sutures are buried at three points.

6. The outer skin is sutured.

2. Levator palpebrae superioris resection

This is a method of shortening the length of the eyelid-lifting muscle (levator palpebrae superioris) by resecting about 5–10 mm and suturing the end of the resected levator palpebrae superioris to the tarsus.

It is mainly applied in cases of moderate ptosis.

3. Frontalis suspension

This method is performed in cases of severe ptosis with levator palpebrae superioris function of 5 mm or less, where recovery of function is difficult to expect with shortening or resection alone.

The frontalis muscle of the forehead is advanced and tied to the tarsus of the eyelid so that the frontalis muscle takes over the function of the levator palpebrae superioris.

It must be done under general anesthesia, and serious complications such as lagophthalmos can occur.

4. Mueller’s muscle shortening

Instead of levator palpebrae superioris shortening, shortening using the Mueller’s muscle beneath the levator palpebrae superioris is sometimes performed.

Mueller’s muscle shortening has the advantage of minimizing lagophthalmos, but it is difficult to predict surgical prognosis and recurrence is common. Also, because surgery must be performed while damaging the levator palpebrae superioris in order to access Mueller’s muscle, it has no particular advantages.

In addition, anatomically many people have Mueller’s muscle that is nearly absent or very thin, so this method cannot be applied in such cases.

■ Before and after ptosis surgery

■ Postoperative care guidelines​

1. Apply cold compresses using the cooling pack provided by the hospital.

Do this for 2 hours a day for 3 days.

The cold compress can be done continuously for 2 hours, or divided into 20–30 minute sessions.

It is usually convenient to do it before going to sleep.

2. Use the prescribed artificial tears and eye drops to prevent dry eyes.

3. Follow-up visits after surgery are usually twice: the day after surgery and the day the stitches are removed.

The stitches are removed on day 3 or 4.

4. Makeup and face washing are allowed after the stitches are removed.

Until the stitches are removed, wash the face with a wet towel.

5. Since no bandage is applied to the surgical area, daily life is possible.

6. Swelling after surgery varies by individual. Usually, most swelling subsides in about 7 days, but the time until it fully settles is about 1 to 3 months.

7. Lagophthalmos, in which the eyes do not close completely, varies depending on the degree of ptosis and how much the levator palpebrae superioris was shortened, but usually it takes 15 days and in some cases longer than 6 months.

On average, it progresses for about 2 to 3 months and then the eyes naturally begin to close properly.​

Asymmetry in the line is usually caused by having different designs, removing too much skin on one side, one side being partially loosened, adhesion of scar tissue on one side, or the occurrence of ptosis on one side.

Ptosis can be corrected with revision surgery, and uneven eyes can also be improved.

At our clinic, based on more than 20 years of rich clinical experience and know-how, surgery is performed only after various examinations and tests during consultation to predict the postoperative outcome, and only when there is a sufficient possibility of improvement after surgery.

The most important factor in revision surgery is the amount of excess skin and the location and intensity of the scar line.

The purpose of revision surgery is broadly twofold.

Restoring a large, clear eye shape and restoring a natural double eyelid line.

After revision surgery, the double eyelid line is made thinner and more natural.

During surgery, the existing scar line must be removed and a new line must be created below it.

In revision surgery, the eyes are also opened wider to correct the sleepy-looking eye shape.

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