Palpebral ptosis: causes and treatments

11/03/2025

When people in general talk about a droopy eyelid they actually mean that the skin of their upper eyelids is hanging over, or resting on, their eyelashes and they complain of a heavy feeling, less visual field or simply find it aesthetically unpleasing. Often times, what they actually have, or also have, is an upper eyelid ptosis. This means that the eyelid has actually dropped. To understand it better, it means that the border of the upper eyelid is positioned too low. This can cause a sleepy or inattentive look and in some cases also significantly impact the visual field. The cause of having a ptotic eyelid is often involutional, because of aging. Another frequent cause is the use of contact lenses. Then there are also rarer causes like eyelid lesion, such as tumours, scarring or even neurological or muscular diseases. 

Treatments for palpebral ptosis

Since the vast majority is caused by aging, contact lens wear or is innate, the solution is the majority of cases is surgical. In some cases of micro ptosis, one could consider treatment with botuline toxines, but this effect is temporarily. The surgical approach can differ from patient to patient. I will discuss the most frequent techniques used in my practice today: 

• Internal approach for micro or mini ptosis

If someone presented with a micro or mini ptosis, so one or both eyelids are positioned only slightly lower, often times this can be corrected though an internal approach. What does that mean? It means that the procedure can be performed through the inside of the eyelid, without making a skin incision. Under local anaesthesia some tissues from the inside of the eyelid are removed and when a suture is placed it will be removed after a week in the consultation room. Nowadays, especially when the ptosis correction is done in combination with a blepharoplasty to remove excess skin in the upper eyelids, I perform this surgery without the placement of a suture whatsoever. This means the surgical time is shorter, the effect of the surgery can be a bit slower, but in doing so we prevent possible irritation of the cornea by the suture placed.  

• Levator muscle repair

When the eyelid ptosis is more pronounced we have to operate on the muscle of the upper eyelid, called the levator muscle. This muscle and it’s tendon are then plicated and reinserted at their original position and thus the ptosis is corrected. This procedure can also be done from a posterior approach called White Line Advancement or Posterior Levator Reinsertion. This is convenient in younger patients, with otherwise good muscular function and where no skin needs to be removed and thus skin incision are prevented. 

• Treatment for congenital ptosis

In congenital ptosis, the first choice is to do a levator resection. So again, you operate the levator muscle of the upper eyelid, but instead of just reinserting it, you need to resect it first. You have to shorten it. 
In other cases where the muscle function is insufficient and the child cannot use the eye well because it is covered by the eyelid, a new connection has to be made by means of brow suspension surgery, as to prevent a lazy eye. This is another interesting topic for another time.  

An important takeaway message from this is, that it is pivotal that a patient looking to have aesthetic eyelid surgery done, looks for professional advice to discard an underlying ptosis. As it is logical, that when not recognised, it will also not be corrected. And it is important to do so in the initial surgery, to prevent disappointment of the end result. 

Dr. Rob van der Veen, oftalmólogo del Centro de Oftalmología Barraquer