Droopy upper eyelids can be due to changes in the muscles that lift the eyelids, due to neurologic causes, or due to mechanical issues (too much skin). Babies can be born with droopy eyelids. Trauma and prior eye surgery can cause drooping of the lids.
Droopy upper eyelids give rise to ptosis (pronounced ‘toesis’). In some cases, droopy upper eyelids cause visual field obstruction and make it difficult to see, especially to drive or to read. Some studies show that ptosis makes people assume that you are asleep, or not too bright, if your eyes appear sleepy.
Droopy lower eyelids can either sag outwards (ectropion) or inwards (entropion). Usually, the lower eyelids are affected. In either case, patients are extremely uncomfortable, with burning and dryness of the eyes, as well as a foreign body sensation. Rarely, eye problems can be caused by these malpositions of the eyelid. In general, repair of these conditions is helpful and often curative. The tear ducts may also be blocked by longstanding drooping and can be corrected at the time of the eyelid surgery if necessary.
What is Ptosis (Droopy Eyelid)?
Droopy eyelids develop for many reasons, and a visit to an oculoplastic surgeon almost always begins with an investigation as to why your specific droop occurs.
Doctors conveniently divide droopy eyelids into those caused by:
- Mechanical issues: Drooping of the upper eyelids due to excess skin or the eyebrow’s weight on the skin. In these situations, redundant skin folds over the upper eyelid and occasionally makes its way onto the lashes.
- Myogenic (muscle) issues: Droopy lids caused by the weakening of the muscles or loosening of the attachments to the eyelid. Muscles have tendons that fix to the tissues they lift, and when the muscle or the tendon tears, they cannot do the job of lifting the eyelid as well, so the lid droops. We often see ptosis in patients after eyelid trauma, cataract surgery, glaucoma surgery, or any other eyeball surgery. Chronic trauma to the lids can also be caused by contact lenses. Both the insertion and removal of the lenses pull the lid in various directions, and the lenses themselves may induce chronic inflammation that makes the tendons weaker. Rare conditions of muscle weakness that only affect the eye muscles can also cause eyelid drooping. You can also be born with a weakness or the muscles or nonattachment of the tendons; this is called congenital ptosis.
- Neurologic issues: A disruption in the pathway between the nerves that signal lid lifting to the muscles that actually do the lifting. This can be seen in a condition known as ocular myasthenia. Establishing this diagnosis requires several tests. In this situation, the droop can be treated with pills rather than surgery. There can also be a malfunction of the nerves, such as with a stroke, or a tumor growing near the nerve, gradually affecting its function. A sudden eyelid droop can be an emergency and should be investigated.
Sometimes the cause of the droop is temporary, not serious, and easily remedied. For example, when a patient gets too much BOTOX® Cosmetic, the lid may not elevate because either the brows have become extremely heavy or because the BOTOX® Cosmetic has gone where it shouldn’t: to the muscle that lifts the lid. This condition can be remedied with drops and usually goes away within a month.
An Uplifting Experience
“Droopy lids aren’t just cosmetic issues associated with aging. Droopy lids impair vision by hiding what the world shows you in the superior field. They make you look tired, asleep, dull. Droopy eyelid surgery can be quite an uplifting experience.”
Preparing for Droopy Eyelid Repair
We always try to determine the cause of the droop.
If the condition is due to aging, called involutional ptosis, we will meet to discuss the risks and benefits of surgery and also discuss what techniques might accompany the droopy eyelid surgery. For example, patients with weak eyelid muscles also expect improvement in their appearance after the surgery.
To prepare for surgery, we have a preoperative regimen that involves the discontinuation of drugs, herbals, and nutraceuticals that thin the blood. We will inform you about foods to avoid (such as certain spices that thin the blood like turmeric, cumin, and some mushrooms). We suggest that you take supplements that have been proven to speed recovery and aid healing.
Droopy upper eyelid repair (ptosis surgery) is usually accomplished on an outpatient basis in an ambulatory surgery center or in our office suite. You are often awake for a portion of the procedure so that eyelid position can be set in an exact position; however, this procedure is completed while you are sedated using an IV or under general anesthesia. This choice will be based on your preference and your health.
It is not uncommon to need a revisional procedure shortly after the repair to adjust eyelid height to a satisfactory level. Postoperatively, there is minimal pain. Bruising is common and lasts for one to two weeks. Contact lenses cannot be worn for two weeks after surgery, but you can go back to work much sooner—usually within five days.
Droopy lower eyelid surgery, whether for ectropion or entropion, is also accomplished in an outpatient surgery center. Discomfort is minimal, though the eyelids can feel tight. Rarely, a dressing is applied, and only when a graft (extra tissue is placed) is applied to the eyelids. At your consultation with us, we will discuss details of your procedure along with what we expect will be your postoperative recuperation.
Recovery After Ptosis Repair
You can expect to be bruised for one to three weeks, regardless of the approach used. These bruises can extend to the lower lids or even the chin.
Sutures usually dissolve within one week; however, we keep some dissolving sutures to ensure that the eyelid crease stays in position for up to six weeks. We can remove these sutures earlier, but they are invisible, trimmed short, and not likely to cause any discomfort.
There is minimal pain associated with this procedure, and ice compresses are usually all that are necessary to lessen swelling, redness, and discomfort. TYLENOL® is generally the only additional medicine needed for pain control.
We see you back in the office one week after your ptosis repair. If any minor adjustments need to be made in the eyelid position, they can be performed in the office or the operating room.
[In] October 13, 2000, Dr. Wulc corrected the ptosis in my right eye. He repaired it perfectly and my vision was restored. Sixteen years later, and my eyelids still match! I’m so grateful that I had Dr. Wulc perform that delicate surgery.
Frequently Asked Questions
Are there different types of ptosis repair?
There are multiple types of procedures that are useful to correct eyelid drooping. The one that has the most chance of success with the least side effects and postoperative issues will be recommended for you at the time of your consultation.
Procedures that have been described include:
- Removal of excess skin and fat (blepharoplasty)
- Aponeurotic surgery (tightening the tendon that holds the eyelid in place)
- Mullerectomy (tightening a different muscle in the eyelid, Muller’s muscle)
- A sling (using other tissue to substitute for very poor upper eyelid elevator function)
My friend had eyelid surgery, and she was better in a few days and had to go in only once. Why might I need more than one procedure?
This is a very common situation—you have a droop related to muscle weakness, but your friend, in all probability, just had excess skin and fat in her upper eyelids that required removal. There is a much greater likelihood of a secondary procedure when eyelid muscles are tightened than when the skin and fat are trimmed when in excess. In the latter situation, you are dealing with a tailor job. In the former situation, you are trying to correct muscle weakness, eyelid contour, and eyelid crease issues. The level of complexity increases.
Will insurance cover my ptosis surgery?
Three things are required—other than health insurance—to determine whether your surgery will be covered.
- We need visual fields that demonstrate a droop. This can be measured with a computerized visual field test and obtained by your eye care provider.
- We need specific photographs which we obtain in our office on the day of your visit.
- Finally, we need to make in-office determinations and measurements which we share with your insurance company. Once you have given us the go-ahead, we will send this information to your provider to determine whether insurance will pay for the procedure.
How long will the ptosis repair procedure take to perform?
The procedure lasts less than an hour.
Do you use bandages or an eye patch after ptosis surgery?
You will not require patches or bandages after your ptosis repair. Our studies have shown no benefit to either of these for procedures around the eyes, such as droopy lid repair, blepharoplasty, or brow lift.
Will my eyes close after the surgery?
This is a common question and a common fear because almost everyone knows someone whose eyes wouldn’t close after surgery like this.
Initially, due to the local anesthetic we use to numb you, your eyes won’t close well since it can affect the muscles that close the eyes. Once the anesthesia effects are gone, the eyes begin to close.
Generally, eyes that don’t close well result from too much skin resection after upper blepharoplasty (cosmetic operation) or extensive scarring. Complete eye closure is expected after most ptosis repairs, and any problems can be remedied. We have seen many patients facing this problem who have undergone surgery elsewhere (or in very rare cases, patients on whom we’ve performed an inadvertent ptosis overcorrection), and we can treat them so that their eyes do close.
When can I exercise after ptosis repair?
We ask you to wait at least 10 days before doing anything too vigorous, such as activities where your head is below your heart. This may cause a rush of blood to the operated area and cause discomfort. We would also like you to wait about three weeks before doing something like yoga.
When can I wear makeup after ptosis repair?
Makeup can be worn safely on the eyelid crease area where the healing incisions are two weeks after surgery. We ask you to wait this long because we don’t want your makeup to get embedded in the incision area, causing something like a tattoo. You can wear makeup everywhere else, however, to conceal the bruising.
When can I resume my blood thinners or arthritis meds that might cause bleeding after ptosis surgery?
We will discuss this with you and your primary during your consultation, as the answer is different for everyone. If you are on blood thinners for cardiac reasons or a previous stroke, we recommend that you resume your medication sooner; however, in general, we would like you to wait a week before resuming blood-thinning medications.
How long will the results of the ptosis surgery last?
Ptosis surgery provides long-lasting relief of eyelid drooping. In more than 25 years of practice, only a handful of patients have returned for additional treatment. These causes were generally due to an underlying chronic condition or an additional surgery on the eye itself that caused the droop to return.
What are the risks of ptosis repair?
The risks of ptosis repair can be serious, including blindness from bleeding, infection, and scarring. Fortunately, these are very rare. We need to keep in close contact after the surgery because these serious complications are preventable and correctable once a postoperative problem is diagnosed.
The most common risks after this surgery include:
- Overcorrection (rare in our practice)
- Undercorrection (reported in about 18 to 25 percent of patients in most published studies by oculoplastic surgeons)
- Dry eye that requires additional therapies (due to increased surface evaporation of tears off of the cornea)
Undercorrections are correctable, and overcorrections are reversible. Dry eye is treatable; in extreme cases, a dry eye can be corrected by reversing the ptosis repair, which is always possible, but very rare.
Am I a good candidate for ptosis repair?
To determine if you are a candidate for ptosis repair, a consultation with your ophthalmologist or optometrist is necessary. You can consult with us directly, either via a telehealth consult or in person.
What other cosmetic surgeries might be necessary to make me look my best?
Generally speaking, ptosis surgery will improve your vision and may improve your appearance. Occasionally, widely open eyes accentuate other issues, such as drooping eyebrows or excess skin in the upper lids. This can be remedied by combining brow lift surgery or upper eyelid sculpture (blepharoplasty). We will always discuss your options during your consultation.
Why should I choose you for ptosis surgery?
Ptosis repair is best performed by someone with qualifications and experience. It is performed by ophthalmologists, oculoplastic surgeons, and plastic surgeons. We have over 25 years of experience and have performed thousands of these surgeries safely. A consultation with us might be worthwhile in determining if our practice is right for you.