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There are several common types of eyelid malpositions. This is a general medical term for eyelids that don’t sit and do what they are supposed to do. Normally the eyelids are firmly held against the eye. Tears lubricate the eyelid movements and the eyelids themselves function like the windshield wipers of the eyes. This is the result of a delicate balancing act between the eyelid position and tension of the eyelid ligaments. In the lower eyelid the muscle that helps close the eyelids functions like a muscular hammock to hold the lower eyelid against the globe.

In the upper eyelid the levator palpebra superioris muscle is responsible for opening the eyes by elevating the upper eyelids. The action of this muscle is transmitted to the upper eyelid by a broad fan like tissue called the levator aponeurosis. Individuals may be born with a droopy eyelid and the levator muscle may not work as effectively as a normal muscle. Under the microscope, the muscle may look incompletely developed with fat and connective tissue replacing the muscle that should be present. Crowell Beard, M.D, has referred to this as “developmental dystrophy”. As the levator muscle does not effectively lift the lid, there may also be insufficient traction on the skin by the same muscle to generate a crease in the affected upper eyelid. It is not uncommon to see a heavy eyelid and an absent eyelid crease. Occasionally the heavy eyelid is associated with other eyelid abnormalities such as the blepharophimosis syndrome. This syndrome has a heredity basis and can run in families. A less common form of congenital ptosis called Marcus-Gunn jaw-winking ptosis: movement of the jaw causes a fall in the position of one of the eyelids. Treatment of these conditions is based on the degree the levator muscle is able to lift the eyelid. This measure is called the levator function.

In adults, congenital ptosis is seen but the most common cause of upper eyelid ptosis in the adult is acquired ptosis. There are several causes of acquired ptosis. The most common cause appears to be attenuation of the levator aponeurosis, which becomes stretched out over time. This is also referred to as levator dehiscence ptosis but it is controversial if the levator actually “dehisces,” a medical term for separates, or if the attenuated tendon gets cut in the process of performing the surgical repair. Other causes of acquired ptosis include four broad categories: neurogenic, myogenic, traumatic, and mechanical. It is helpful to classify and properly diagnosis the basis of the droopy eyelid because this has a bearing on the choice for repairing the upper eyelid ptosis.

There are two principle approaches to repairing acquired upper eyelid ptosis. For small amounts of ptosis (1-2 mm) a simple test is performed during the preoperative assessment. An eye drop is instilled into the eyes and the response to the drops is measured. If the drop raises the eyelids to the desired height, the lid position is very likely to respond to a surgery referred to as a Conjunctival Muellerectomy. This surgery is performed from behind the upper eyelid using a special clamp called a Putterman ptosis clamp. If the eyelid does not respond to the eye drops or if the degree of ptosis is too large a second type of ptosis surgery is indicated. This type of surgery is called an anterior levator resection ptosis surgery. This surgery is performed through an incision at the eyelid crease on the outside of the eyelid. The levator aponeurosis is dissected and sutures are tied to effectively shorten the aponeurosis. Surgery is performed under local anesthesia. This facilitates repositioning of the eyelid. The patient is asked to open and close the eye. The sutures can be repositioned to adjust the eyelid position. Once this is satisfactory, the sutures are permanently tied and the eyelid is closed. Skin sutures are removed within a week. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for upper eyelid ptosis surgery.

Laxity of the lower eyelid can present as either a turning in or turning out of the lower eyelid. These malpositions usually occur in older individuals. The type of lower eyelid malposition is determined by the nature of which structure have become weak in the eyelid. When the lower eyelid retractors become attenuated, the forces on the eyelid tend to favor an inward rotation of the lower eyelid. This is called entropion. This causes the eyelashes to rub against the eye and cause severe irritation. There are various approaches to address these issues. Typically the lower eyelid retractors are reattached and the lower eyelid is shortened. When the lower eyelid is lax and there is contraction of the lower eyelid skin or weakening of the orbicularis oculi muscle as occurs with Bell’s palsy, the lower eyelid rotates away from the eye. This is called ectropion. In this situation, the lower eyelid does not rub against the eye. However, the lid does not protect the eye and this can also cause irritation. Surgery is directed at lengthening the lower eyelid and resuspending the lid back against the globe. In both cases, an assessment of the midface support is essential. With entropion and ectropion, failure to address midface ptosis can lead to an unsatisfactory result. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for repair of entropion or ectropion.

Trauma and disease can necessitate the removal of an eye. Often this is recommended when the eye has lost all useful vision and has become a blind, painful eye. This may follow soon after a sudden trauma, the discovery of an intraocular tumor, or after a long fight to preserve a diseased eye. The removal of an eye is the option of last resort. A second opinion is advisable if there are any questions about the best course of action. Generally, it is not recommended to remove a blind eye that is otherwise comfortable. In this circumstance, if there are cosmetic issues, a custom contact lens or scleral shell can be fabricated by an ocularist with good cosmetic results. When a blind eye becomes painful, removal by enucleation or evisceration is generally recommended. Enucleation means the removal of the entire eye. The extraocular muscles may be reattached to the intraconal implant that is placed in the orbit to make up the volume lost when the damaged eye is removed. Once the socket has healed, an ocularist then fabricates an acrylic prosthetic piece to fit behind the eyelids, referred to as a “glass eye.” An evisceration involves the removal of the cornea and the contents of the eye, but leaves most of the eye wall or sclera intact. The advantage of this procedure is that it is less disruptive to the orbital tissues and leads to more natural movement of the acrylic prosthetic. Generally, an evisceration is preferred if there are no reasons that might favor an enucleation in a particular circumstance. There has been a push toward integrated intraconal implants made of hydroxyapatite. Unfortunately, these implants are often not well tolerated resulting in exposure of the implant and the need for revisional surgery. The anophthalmic socket (socket without an eye) often requires revisional surgery due to a number of factors. One of the common issues is related to inadequate replacement of orbital volume because too small of an implant was chosen at the time the eye was removed. The ocularist attempts to compensate for this by making a larger prosthesis. However, over many years, the weight of the oversized prosthesis can stretch the eyelids leading to secondary issues, including chronic discharge and difficulty retaining the prosthesis. A consultation with Dr. Steinsapir is needed to determine the best options for rehabilitation of the anophthalmic socket.

It is the goal of the primary surgeon to make the best closure of the area after the removal of the skin cancer. However, for a number of reasons, the initial closure often represents the best compromise at the time. It is quite common that more than one stage of reconstruction will be necessary to obtain the best aesthetic and functional results. Dr. Steinsapir has found that for a variety of reasons, people do not always get the best advice regarding the value or need of having further reconstruction. The message can sometimes be that the patient is being vain, or ungrateful in asking for a better reconstructive result. In some cases, the reconstructive surgeon has made their best effort and really doesn’t have any idea how to make the compromised area functionally or aesthetically better. Dr. Steinsapir prides himself on providing innovative approaches to improve eyelids compromised by prior reconstruction. A personal consultation with Dr. Steinsapir will determine what options are available to improve your appearance and the function of your eyelids.

The initial repair of a facial laceration is often performed under less than ideal conditions. Tissue swelling can compromise the alignment of the tissues even when the repair was performed by a plastic surgeon, facial plastic surgeon or eye plastic surgeon. It is often possible to achieve a much more acceptable result after the initial repair. In many cases, the body can heal remarkably. For this reason, Dr. Steinsapir advises waiting 6 to 12 months before considering having an unacceptable scar revised. An exception to this rule is sometimes made if it is clear that for whatever reasons the reapproximation of the wound edges is clearly inaccurate. Scar revision involves excising the old scar tissue using a W-plasty tissue rearrangement. The fresh wound edges are carefully reapproximated using magnification. These procedures are generally performed under local anesthesia in the office procedure suite. The revised scar is always more visible while it is healing. The sutures are all removed within one week after the procedure. As the wound heals, the redness quiets and over the course of several months the wound matures. The technique is very effective for highly visible scars. A personal consultation with Dr. Steinsapir will determine if the scar you are concerned with will benefit from scar revision.