The Differences Between Double Eyelid Surgery and Ptosis Surgery (Ptosis)

What is the difference between double eyelid surgery and ptosis surgery?

In double eyelid surgery, the patient presents with monolids or an absence of upper eyelid creases. The intent of surgery is to create upper eyelid creases that allow the eyelid margin and lashes to be seen more clearly and for the lashes to turn upwards and outwards instead of downwards. This creates a more wide-eyed appearance that is aesthetically pleasing. All double eyelid surgeries are considered cosmetic in nature.


Ptosis surgery is more appropriate for patients who have an observable upper eyelid droop. This means that the upper eyelid margin is sitting at a lower position than is normally seen in those without ptosis. The degree of droop may be mild or it could be very obvious. Risk factors for this droop include contact lens wear, previous eye surgeries or simply frequent eye rubbing. If the droop is mild, ptosis surgery can be performed for cosmetic reasons. If the droop is severe and meet criteria set by Ministry of Health, ptosis surgery can be performed as a medical procedure to eliminate the obstruction to superior visual field caused by the droopy upper eyelid.


Are the surgical techniques different?


The surgeries are very different indeed. 


Double eyelid surgery


With double eyelid surgery, every surgeon will have a preferred technique developed over years of training and experience. The techniques are broadly categorised into suture techniques and incisional techniques. 


With suture surgery, the surgeon passes a fine non-absorbable suture through the tissues of the eyelid in a certain way that allows a crease to form when the eye is opened. Advantages of this type of surgery are largely a shorter down time and less visible wounds. Disadvantages include higher rate of disappearance or fading of the crease, particularly in those with thicker tissues in the eyelid.


With incisional surgery, the exact technique used depends on the amount of excess skin and orbicularis (eye closing muscle) the surgeon has to manage. In some, a small amount of tissue has to be removed whilst in others, hardly any is required. The surgeon also has to dissect, identify and isolate structures within the eyelid to which the skin edge can be anchored. This internal step essentially allows the skin crease to form when the eye is opened. 


With the incisional technique, one could also take the opportunity to give the eyelid an additional small lift and/or open up the inner corner of the eye by performing a medial epicanthoplasty. The latter involves additional surgery at the inner corner of the eye. As this area is more prone to more prominent scarring, it may not always be recommended if there is no need for it.


Advantages of the incisional technique include the ability to reduce bulky tissue on the upper eyelid and generally, greater longevity. There is, as mentioned above, the ability to add on more enhancements where needed or desired.


Ptosis surgery


Anterior approach


Ptosis repair requires the surgical dissection to go deeper in order to identify and isolate the muscle that lifts up the lid. This muscle is known as the levator palpebrae superioris muscle. It is important that the surgeon is very familiar with the anatomy in this area as changes due to wear and tear may result in injury to the muscle or its sheath during the dissection. The surgeon may find that the levator muscle has become detached from the firm portion of the eyelid known as the tarsal plate. Alternatively, the muscle may still be attached but has become so thinned and stretched that it loses some of its lifting ability. The crucial step would be to reattach or shorten the levator muscle so that its lifting ability is enhanced.


Posterior approach


Sometimes, ptosis repair is performed from the back of the eyelid. This is known as the posterior approach. The essential step involves shortening the muscles that lift the upper eyelid. These muscles include the levator muscle as well as the more posterior and weaker Muller’s muscle. This technique works best for milder degrees of ptosis. It is not suitable for those with heavier eyelid tissues who require some removal of skin and surface muscle.


What are the problems I may face with double eyelid surgery?


The vast majority of patients will do well and be happy with the double eyelids created. Occasionally, one might have problems with too high or too low a crease, asymmetrical creases or more prominent scarring. An experienced surgeon will help address these problems if they arise. However, it is possible that revision surgery may be needed to achieve the desired results. If this is indeed the case, it would be best to wait for a few more months before heading for the revision surgery as surgeries performed too close together risk even greater scarring.


What are the problems I may face with ptosis surgery?


Similar issues are occasionally encountered with ptosis surgery. An additional problem that may be more frequently seen in ptosis repair patients is that of some asymmetry in eyelid height. A small degree of asymmetry is not visible and the result is often still pleasing. However, if there is a significant difference noted, the surgeon could perform an adjustment procedure a few days after the surgery if an anterior approach ptosis repair had been performed. This adjustment procedure helps to improve the symmetry in the vast majority but may not yield the most optimal results in a few. In these few cases, it would be best to wait for a few more months before considering additional surgery.


To avoid under/over-correction and asymmetry and the need for post-op adjustment, it is important to have intra-operative checks to ensure a good end-point. For this reason, ptosis surgery is done under light sedation only with the patient fairly alert during most parts of the surgery. 


For more clarification, do make an appointment with Dr Looi at Ava Eye Clinic