What to know about droopy eyelids (ptosis)

I am so proud to have my recent manuscript, Surgical outcomes of aesthetic upper blepharoplasty with anterior plication ptosis repair performed under general anesthesia in Facial Plastic Surgery private practice, accepted for publication in the American Journal of Cosmetic Surgery!  Thank you to my mentor and co-author Dr. Stephen Perkins!

Please enjoy the excerpt below! (some minor changes of medical lingo) 

A refreshed, youthful periorbital appearance includes a crisp, smooth supratarsal crease, flat and smooth eyelids, well seated brow position, and volume deep to the brow.  In facial aging, the periorbital region is one of the first areas to change.  The brow position deflates and sits flat against the orbital rim.  As the brow and upper lid deflate and descend, a fold of skin develops where there was fullness and a crisp supratarsal crease.  The orbital septum weakens resulting in bags/puffiness of upper and lower orbital fat.  Weakening of the upper eyelid retractors can cause eyelid drooping (ptosis).    

During a consultation for periorbital rejuvenation, I collect a detailed history including history of corrective eye surgery, corrective lenses, history of dry eye symptoms and trauma, with particular attention to conditions that may affect or have eye manifestation such as thyroid disorders.  On examination, I evaluate the degree of excess upper and lower eyelid skin, puffiness of orbital fat, brow position, lipoatrophy, tear trough deformity, the presence of upper eyelid ptosis or pseudoptosis, and levator (muscle) function. 

When ptosis is noted, I perform a neurological head and neck examination.  A droopy (ptotic) upper eyelid may be associated with compensatory hyperactivity of the forehead muscle (frontalis) and a chronically raised brow.  Often, the cosmetic aging face patient will be aware of excess upper eyelid skin without noticing upper eyelid ptosis or malposition of the brows. 

Upper eyelid ptosis is defined by the margin-to-reflex distance 1 (MRD-1) – the distance between the upper lid margin and the pupillary light reflex in primary gaze.  The normal MRD-1 value is greater than 2.5mm; however, the majority of the population will have a MRD-1 value of 4-5mm.1  An upper eyelid MRD-1 less than 2.5mm is considered ptotic.1 

Evaluation of upper eyelid muscle (levator) function is also critical in a patient with ptosis.  The levator function is measured by asking the patient to look down and up while stabilizing the brow position.2  Levator function may be excellent (>10mm), good (8-10mm), fair (5-7mm), or poor (1-4mm).3  Mild ptosis is usually associated with good levator function, moderate ptosis with fair levator function, and severe ptosis with poor levator function.3  Levator function has critical implications on the correct procedure for ptosis repair.

Upper eyelid ptosis may be unilateral, symmetrical bilateral, or asymmetrical bilateral.  In asymmetric bilateral ptosis, according to Hering’s law, if only the more ptotic eye is corrected, the contralateral lid will worsen post-operatively.4,5  In these patients, both ptotic lids should be corrected. 

There are two main categories of upper eyelid ptosis: congenital and acquired.  Causes of acquired upper eyelid ptosis include traumatic, myogenic, neurogenic, mechanical, and involutional.1  The most common form is involutional ptosis with downward and lateral shift of the tarsal plate, caused by attenuation of the levator aponeurosis.1  A low lid margin, high upper eyelid crease, normal levator function, and thinned upper eyelid are signs of acquired involutional ptosis.

During standard upper blepharoplasty, variable amounts of skin, muscle, and fat are excised.2  These techniques do not typically alter the internal dynamic function of the eyelid.2  In contrast, ptosis surgery involves dissection and realignment of muscles involved in eyelid movement.Ptosis repair can lead to changes in upper eyelid shape and contour which are not normally seen with traditional upper blepharoplasty.2 

In our Facial Plastic Surgery private practice, when cosmetic upper blepharoplasty patients are noted to have ptosis, Dr. Archer's preferred technique is upper blepharoplasty with anterior levator plication repair.  This is a safe and effective technique for repair of droopy eyelids in facial rejuvenation. 

Thank you for reading our blog post! Please reach out to Dr. Archer on social with questions, comments and any recommendations on topics! Twitter @ArcherMD, Instagram @archerfacialplastics, Facebook @archerfacialplastics.  More plastic surgery Q&A information by Dr. Archer on RealSelf.com: http://bit.ly/realselfdrarcher

Pic from http://www.eyelidsurgerycentre.com/conditions/ptosis/

  1. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid surgery. Plast Reconstr Surg. 2014 Dec;134(6):1154-1170.
  2. Massry GG. Ptosis repair for the cosmetic surgeon. Facial Plast Surg Clin N Am. 2005;(4):533-539.
  3. Iliff JW, Pacheco EM: Ptosis surgery. In: Tasman W, Jaeger EA Eds. Duane’s clinic ophthalmology. Lippincott Williams and Wilkins, Philadelphia, pp 1-18, 2001.
  4. Cetinkaya A, Kersten RC. Surgical outcomes in patients with bilateral ptosis and Hering’s dependence. Ophthalmology 2012;119:376-381.
  5. Erb MH, Kersten RC, Yip CC, Hudak D, Kulwin DR, McCulley TJ. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg. 2004;20:418-422.


Kaete Archer, MD Facial Plastic Surgeon

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