Differentiating Types of Eyelid Ptosis, and its Specialized Surgical Correction

By: Amiya Prasad, M.D.

Thank you for the question. You submitted a single photo and you are asking if this is ptosis. And you describe in your situation where your right eye continues to get lower over time and you are asking whether or not if it’s ptosis or is it extra skin. Well, I can certainly give you some guidance on how I evaluate patients like yourself in my practice. A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon practicing in Manhattan and Long Island for over 20 years and eyelid ptosis is a very common issue that I deal with in my practice. And so I can give you some guidance to how I evaluate a patient and what ptosis means in reference to how to address your cosmetic and visual concerns. So to begin with, the definition of ptosis has to do with the relative position of the eyelid margin to the center of the eye. So if somebody has an eyelid that’s lower than its normal position which is typically 2mm below the top of the colored part of the eye, the iris, then below that level technically is ptosis.

Now generally, if people have relative slightly low eyes but they can see perfectly well and that is always referred to as bedroom eyes and people get kind of accustomed to that natural look and often it runs in families. But in a situation that you are describing where there is some progression, that is a situation that is very common and referred to as acquired ptosis. An acquired ptosis means that the onset of the drooping of the eyelids was later in life and that is in contrast to congenital ptosis. Congenital ptosis means you are born with the ptosis. You may want to look at some more photos and see if your eyelids were significantly higher than it is currently or if it was slightly higher.

Very often people are born with ptosis but it is mild but as they get a little bit older, the eyelids droop down. Now, in terms of whether or not it is extra skin, I would say based on the photo you submitted that it is likely that the volume of skin over your eyelid is contributing to the degree of ptosis. When there is a lot of skin over the eyelids and puts a physical weight on the eyelid, we refer to that as mechanical ptosis. Of course, an acquired ptosis should be evaluated properly so that no neurologic or medical issue can be determined and associated with the ptosis. And the most common cause of acquired ptosis is called levator aponeurosis or aponeurotic ptosis.

Acquired aponeurotic ptosis sometimes referred to as age-related and basically the reason why it gets droopier has to deal with a muscle and this muscle is called the levator muscle. The levator muscle is the muscle that lifts the eyelid and from the word levator. Well, there is a tendon on this muscle called the levator aponeurosis.

Differentiating Types of Eyelid Ptosis, and its Specialized Surgical Correction

As people get older and including variety of reasons like genetics and as well as issues such as chronic eye rubbing or the wearing of different contact lenses, that tendon can get thin and so it becomes attenuated or it separates or becomes decreased. So the typical solution for acquired ptosis is levator muscle surgery or ptosis surgery. Now, this is all determined based on a very specific type of examination performed typically by an oculoplastic or oculofacial plastic surgeon.

The goal is to not just address the extra skin but to address the muscle. Thank you for the question. You submitted a single photo and you are asking if this is ptosis. And you describe in your situation where your right eye continues to get lower over time and you are asking whether or not if it’s ptosis or is it extra skin. Well, I can certainly give you some guidance on how I evaluate patients like yourself in my practice.

A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon practicing in Manhattan and Long Island for over 20 years and eyelid ptosis is a very common issue that I deal with in my practice. And so I can give you some guidance to how I evaluate a patient and what ptosis means in reference to how to address your cosmetic and visual concerns. So to begin with, the definition of ptosis has to do with the relative position of the eyelid margin to the center of the eye.

So if somebody has an eyelid that’s lower than its normal position which is typically 2mm below the top of the colored part of the eye, the iris, then below that level technically is ptosis. Now generally, if people have relative slightly low eyes but they can see perfectly well and that is always referred to as bedroom eyes and people get kind of accustomed to that natural look and often it runs in families. But in a situation that you are describing where there is some progression, that is a situation that is very common and referred to as acquired ptosis.

An acquired ptosis means that the onset of the drooping of the eyelids was later in life and that is in contrast to congenital ptosis. Congenital ptosis means you are born with the ptosis. You may want to look at some more photos and see if your eyelids were significantly higher than it is currently or if it was slightly higher. Very often people are born with ptosis but it is mild but as they get a little bit older, the eyelids droop down. Now, in terms of whether or not it is extra skin, I would say based on the photo you submitted that it is likely that the volume of skin over your eyelid is contributing to the degree of ptosis. When there is a lot of skin over the eyelids and puts a physical weight on the eyelid, we refer to that as mechanical ptosis. Of course, an acquired ptosis should be evaluated properly so that no neurologic or medical issue can be determined and associated with the ptosis.

And the most common cause of acquired ptosis is called levator aponeurosis or aponeurotic ptosis. Acquired aponeurotic ptosis sometimes referred to as age-related and basically the reason why it gets droopier has to deal with a muscle and this muscle is called the levator muscle. The levator muscle is the muscle that lifts the eyelid and from the word levator.

Well, there is a tendon on this muscle called the levator aponeurosis. As people get older and including variety of reasons like genetics and as well as issues such as chronic eye rubbing or the wearing of different contact lenses, that tendon can get thin and so it becomes attenuated or it separates or becomes decreased. So the typical solution for acquired ptosis is levator muscle surgery or ptosis surgery. Now, this is all determined based on a very specific type of examination performed typically by an oculoplastic or oculofacial plastic surgeon.

The goal is to not just address the extra skin but to address the muscle. In our practice, it is routine to perform this procedure in our office operating facilities under local anesthesia with very LITE™ sedation because we actually want your cooperation during the surgery. And there is no pain but we actually open your eyes and even sit you up during the surgery to see the eyelid level and make adjustments appropriately. So it is deceptively complex this type of work and procedure because you are dealing with very delicate muscles and very minimal numbers of millimeters which can go one way or the other. So it is very important to meet with a doctor who is highly experienced in this area and can guide you as to what is the appropriate plan to help you have your eyes open up and look better and having you feel like your eyes are not continually drooping and again.

You have to basically start with a proper diagnosis and then a plan that typically is a surgical plan such as ptosis surgery. So I hope that was helpful, I wish you the best of luck and thank you for your question!.

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