What is eyelid ptosis and why it deserves special attention
If you have noticed that one or both of your upper eyelids are progressively drooping, covering part of the pupil and making it difficult for you to see, you are likely facing eyelid ptosis (ICD-10 code H02.4, acquired ptosis). This condition, commonly known as "droopy eyelid," goes far beyond an aesthetic issue — it is a functional problem that can significantly compromise your quality of life. As a plastic surgeon in Londrina, Brazil, I perform ptosis correction surgery in adult patients with good levator function.
Throughout more than twenty years of practice, I have treated hundreds of patients with eyelid ptosis. Many arrived at the office thinking they only needed a blepharoplasty to remove excess skin, when in fact the real problem was the weakness of the levator muscle. This distinction is crucial because the correct treatment depends on an accurate diagnosis.
Eyelid ptosis occurs when the levator muscle — responsible for keeping the eye open — loses its strength or detaches from its insertion in the tarsal cartilage. The result is an eyelid that descends beyond the normal position, potentially covering the pupil partially or completely. Unlike simple excess skin treated in blepharoplasty, ptosis involves a muscular or aponeurotic dysfunction that requires a targeted surgical correction.
In my practice, I find that many patients live with ptosis for years before seeking treatment. Some adapt by tilting their heads back or constantly raising their eyebrows to compensate for the drooping eyelid. These compensations, in addition to causing muscle fatigue and headaches, can mask the true severity of the problem. If this sounds like you, an in-person evaluation is the next step.
The causes of eyelid ptosis: understanding why your eyelid has drooped
Eyelid ptosis can have various origins, and identifying the correct cause is essential to define the best surgical approach. In my experience, I classify the causes into four main groups:
Involutional ptosis (due to aging)
This is by far the most common cause I encounter in my practice. As the years go by, the aponeurosis of the levator muscle — a tendinous structure that connects the muscle to the eyelid — stretches, thins, or partially detaches from the tarsal cartilage. The result is an eyelid that gradually droops over the years. This type of ptosis tends to be bilateral, although often one side is more affected than the other.
The prolonged use of rigid contact lenses can accelerate this process, as the repeated manipulation of the eyelid when putting in and taking out the lenses contributes to the stretching of the aponeurosis. Previous eye surgeries, such as cataract surgery, can also trigger involutional ptosis.
Congenital ptosis
Present from birth, congenital ptosis occurs when the levator muscle does not develop properly during gestation. The muscle has an abnormal amount of fibrous tissue instead of contractile muscle fibers, resulting in reduced lifting capacity. It can affect one or both eyes.
In children, congenital ptosis deserves special attention because it can cause amblyopia — the so-called "lazy eye" — if the drooping eyelid obstructs the visual axis during the critical period of vision development. In these cases, early surgical correction is essential.
Neurogenic ptosis
Caused by problems in the nerves that control the levator muscle. The most well-known is the paralysis of the third cranial nerve (oculomotor nerve), which in addition to ptosis can cause strabismus and pupil dilation. Myasthenia gravis, an autoimmune disease that affects the junction between the nerve and the muscle, can also initially manifest as eyelid ptosis, often with a fluctuating characteristic — worsening throughout the day and improving with rest.
Mechanical and traumatic ptosis
Palpebral tumors, scars, chronic inflammatory processes, and direct trauma to the eyelid or orbital region can cause ptosis due to excessive weight on the eyelid or direct injury to the levator muscle and its aponeurosis. Previous surgeries in the area also fall into this category.
During the consultation, I perform a detailed examination to identify not only the presence of ptosis but its specific cause, as this determines the most appropriate surgical technique for each patient.
Ptosis versus blepharoplasty: the difference that many do not know
One of the most frequent confusions I encounter is between ptosis and dermatochalasis (excess skin on the upper eyelid). Although they can coexist — and often do — they are distinct conditions that require different treatments.
What is dermatochalasis
Dermatochalasis is the excess skin and sometimes fat on the upper eyelid. The excess skin hangs over the eyelid crease and can cover the eyelashes, but the eyelid margin itself remains in a normal position. The treatment is upper blepharoplasty, which removes the excess skin and fat.
What is ptosis
In ptosis, the problem lies at the eyelid margin: it descends below the normal position (which would be about one to two millimeters below the upper limbus of the cornea). Even if you remove all the excess skin with a blepharoplasty, the eyelid will remain droopy if the levator muscle is not repaired.
The importance of correct diagnosis
I have received patients who had undergone blepharoplasty at another facility and left dissatisfied because "the eyelid was still droopy." The reason was simple: they had undiagnosed ptosis. The blepharoplasty removed the excess skin, but did not correct the weakness of the levator muscle.
On the other hand, it is very common for me to perform ptosis correction and blepharoplasty in the same surgical session. In fact, in patients over fifty years old, the combination of involutional ptosis with dermatochalasis is the rule, not the exception. In this case, I first correct the ptosis — reinforcing or shortening the levator aponeurosis — and then remove the excess skin. The result is a completely renewed look.
If you are unsure whether your problem is excess skin, ptosis, or both, an in-person consultation is the best next step. I take precise measurements of the palpebral fissure, the function of the levator muscle, and the margin-reflex distance to determine exactly what needs to be done.
Clinical evaluation: how I diagnose and classify ptosis
The success of ptosis surgery begins with a meticulous evaluation. During the consultation, I perform a series of measurements and tests that determine not only the severity of the ptosis but also the most appropriate technique to correct it.
Measurements I perform
- Margin-reflex distance (MRD1): the most important measurement. It is the distance between the upper eyelid margin and the light reflex in the center of the pupil. The normal range is four to five millimeters. In mild ptosis, it is between three and four millimeters; moderate, between two and three; and severe, below two millimeters.
- Palpebral fissure: the vertical distance between the upper and lower eyelid margins. The normal range is nine to twelve millimeters.
- Levator muscle function: I block the action of the frontalis muscle with my thumb over the eyebrow and ask the patient to look down and then up. The excursion of the eyelid indicates muscle function. Good function: above twelve millimeters; fair: eight to twelve; poor: below eight millimeters.
- Height of the eyelid crease: in involutional ptosis, the crease is often higher than normal, indicating disinsertion of the aponeurosis.
- Standardized photographic records: photographs in multiple gaze positions (frontal, up-gaze, down-gaze, lateral) are my primary method of documentation and surgical planning. I do not use an intraoperative phenylephrine test.
What else I evaluate
I also examine the position of the eyebrows, as many patients with ptosis develop a compensatory elevation of the eyebrow that needs to be considered in the surgical planning. I assess the presence of associated dermatochalasis, facial symmetry, orbicular muscle function, corneal sensitivity, and the tear film. I request ophthalmological evaluation when necessary, especially to rule out neurological causes.
When there is suspicion of myasthenia gravis, I order anti-acetylcholine receptor antibody testing and, if needed, electromyography. It is essential to rule out neurological causes before recommending surgery, as treatment in these cases may be non-surgical.
The technique I perform: levator muscle plication of the upper eyelid
In my practice, I perform a single technique for eyelid ptosis correction: levator muscle plication of the upper eyelid. This indication is restricted to patients with good levator muscle function — excursion greater than 10 mm on pre-operative evaluation.
How levator plication works
Through an incision in the natural crease of the upper eyelid (the same incision used in blepharoplasty), I identify the levator muscle of the upper eyelid. I then perform a plication of the muscle — folding it on itself with internal PDS (polydioxanone) sutures — to shorten the effective length of the muscle and elevate the eyelid margin to the desired height. The internal PDS sutures are absorbed over 6 months after surgery; the skin sutures are removed between the fifth and seventh postoperative day.
The incision is hidden in the eyelid crease and becomes practically invisible after healing. When indicated, I combine upper blepharoplasty in the same surgical session to remove excess skin. A brow lift may also be recommended when there is concurrent eyebrow droop.
Why I do not perform other techniques
Other techniques described in the literature (conjunctivomullerectomy / Müller muscle resection, frontalis sling with fascia lata, Fasanella-Servat) have valid indications in specific scenarios. I do not perform any of these in my practice. Cases where levator plication is not indicated — mainly patients with low levator function (< 10 mm), severe congenital ptosis and neurogenic ptosis — are referred to Dr. Giovanni André Pires Viana, former professor of periorbital plastic surgery at Escola Paulista de Medicina for many years and a Brazilian reference in complex ptosis. Being honest about what I do and what I do not is part of ethical practice.
Local anesthesia with sedation: why the patient must be awake
Eyelid ptosis surgery is performed under local anesthesia with sedation, not general anesthesia. The reason is technical: during the procedure, I need to ask the patient to open and close the eyes, look up and look down, so that I can measure the eyelid height in real time and confirm the planned 2 mm over-correction.
Sedation ensures comfort and keeps anxiety at bay without suppressing the patient's ability to follow commands during surgery. This intraoperative adjustment is the differential that allows reliable symmetry — something that would be impossible under general anesthesia, where the patient cannot move the eyes.
Planned 2 mm over-correction: not a mistake, it is design
At the end of the surgery, the operated eyelid is left 2 millimeters higher than the normal position — the planned over-correction (hypercorrection). This can look excessive in the immediate post-operative period and raises questions in the first few days. It is not a technical error: it is a calculation.
Over the first month after surgery, the muscle accommodates and the eyelid progressively descends, leveling with the contralateral eye in approximately 30 days. If I were to leave the eyelid already at the final desired height, over the month it would drop further and the final result would be under-corrected. The over-correction exists to compensate for this predictable settling.
This information is essential so that patients understand that the initial "too high" look is expected and resolves on its own. Unnecessary postoperative anxiety is avoided with this prior explanation during the consultation.
The levator is diseased: no "definitive cure" for ptosis surgery
Patients should understand a technical fact: the levator muscle of an eyelid with ptosis is, in general, diseased — and this disease continues to exist after surgery. Plication effectively shortens the muscle and corrects the droop in the present, but it does not treat the underlying cause (aponeurotic disinsertion, dystrophy, tissue aging).
As a result, a revision surgery may be needed over time, typically between 5 and 15 years after the first correction, depending on the degree of underlying muscle disease. For this reason, one cannot speak of a "definitive cure" for eyelid ptosis with surgery. What is offered is an effective and long-lasting correction — but not a lifelong one.
This technical honesty is part of the consultation. Realistic expectations produce satisfied patients in the long term.
The surgery step by step: how I perform ptosis correction
I describe here the most common procedure in my practice: the advancement of the levator aponeurosis, often combined with upper blepharoplasty.
Anesthesia and marking
The surgery is performed under local anesthesia with sedation. Before starting, with the patient seated, I make precise markings on the eyelid, outlining the eyelid crease, the amount of skin to be removed, and the reference points for symmetry.
Incision and access
The incision is made in the natural crease of the upper eyelid, following the previously made marking. After removing the strip of skin and orbicularis when there is coexisting dermatochalasis, I access the orbital septum and identify the levator muscle aponeurosis.
Identification and repair of the aponeurosis
I identify the aponeurosis — which in involutional ptosis is often thinned, disinserted, or elongated — and carefully release it. I perform the advancement or reinsertion of the aponeurosis on the anterior face of the tarsal cartilage with nylon or polyester sutures. The key point is to position the suture in the exact location that will provide the appropriate elevation of the eyelid.
Intraoperative adjustment
Here lies the differential of the technique under local anesthesia: I ask the patient to open their eyes and compare the height and contour of both eyelids. I make fine adjustments to the sutures until I achieve the desired symmetry. This possibility of real-time adjustment is impossible under general anesthesia and greatly contributes to superior results.
Closure
I close the incision with fine sutures that are removed between the fifth and seventh day. The scar is hidden in the natural eyelid crease and becomes practically imperceptible in a few weeks.
The procedure lasts between forty-five minutes and one and a half hours, depending on whether it is unilateral or bilateral and if combined with blepharoplasty. The patient goes home the same day.
Post-operative recovery: what to expect
The recovery from eyelid ptosis surgery is generally smoother than patients imagine. Here I describe what you can expect at each phase:
First 48 hours
There will be swelling and bruising in the eyelid area, which is completely normal. I recommend cold compresses (ice wrapped in a clean cloth) for twenty minutes every hour during the first 48 hours. Keep your head elevated, even while sleeping. Over-the-counter pain medication such as acetaminophen, along with any prescribed medications, effectively controls discomfort, which is usually mild. Lubricating eye drops are used to keep the cornea protected.
First week
Swelling peaks between the second and third day and begins to regress. Bruising may extend to the cheek area and gradually disappear within ten to fourteen days. Sutures are removed between the fifth and seventh day at the office, quickly and with brief discomfort controlled by routine care.
Second to third week
Most of the swelling has subsided, and you will be presentable for social activities. The eyelid may show slight temporary asymmetry due to residual edema — this is expected and resolves spontaneously. Light makeup can be used after suture removal.
One to three months
The result progressively refines. The scar in the eyelid crease matures and becomes increasingly discreet. The sensitivity of the eyelid, which may be altered in the first few days, normalizes completely.
Final result
Between three and six months, the final result is fully apparent. The eyelid assumes its final position, the eyelid contour looks natural and balanced, and patients report a significant improvement not only in appearance but also in visual field.
Important care
- Avoid intense physical exertion for two to three weeks
- Do not wear contact lenses for at least two weeks
- Protect your eyes from the sun with sunglasses
- Do not scratch or rub your eyes during recovery
- Apply eye drops and ointment as prescribed
- Attend all follow-up appointments
Eyelid ptosis in children and infants: I do not operate — I refer to Dr. Giovanni Viana
Congenital ptosis in children and infants is a condition that requires a specific approach and subspecialist expertise. I do not perform eyelid ptosis surgery on children in my practice. All pediatric patients who arrive for evaluation are referred to Dr. Giovanni André Pires Viana, who was for many years professor of periorbital plastic surgery at Escola Paulista de Medicina and is a national reference in complex ptosis, including pediatric cases and patients with low levator muscle function.
Why referral is the correct conduct
Severe congenital ptosis can cause amblyopia (the "lazy eye") if the eyelid covers the visual axis during the first years of life, when the brain is developing vision. Such cases require very early surgery — often before age two — and involve techniques such as frontalis sling with autologous fascia lata or synthetic materials, procedures that fall outside my routine practice of levator plication in adults with good function.
In addition to the specific technique, pediatric surgery requires experience with pediatric general anesthesia, intraoperative calculation without patient cooperation, and long-term follow-up (it is common to require further interventions throughout childhood and adolescence). All of this justifies referral to a dedicated specialist.
What I do at the child's consultation
When parents bring a child with ptosis, I clinically evaluate the situation, guide the family about the degree of urgency (whether there is a risk of amblyopia), and make the formal referral to Dr. Giovanni Viana with a report of my observations.
Risks and complications: transparency above all
As with any surgical procedure, the correction of eyelid ptosis has risks that I discuss openly with all my patients. I believe that transparency is fundamental for a trusting relationship.
Under-correction and over-correction
The adjustment of eyelid height is millimetric. Differences of just one millimeter are noticeable. Under-correction (eyelid that remains lower than desired) and over-correction (eyelid that is higher, making it difficult to fully close the eye) are the most common complications. Intraoperative adjustment under local anesthesia greatly minimizes this risk, but surgical revisions may be necessary in a small percentage of cases.
Asymmetry
Achieving perfect symmetry between the two eyes is the greatest technical challenge of ptosis surgery. It is important to understand that no human face is perfectly symmetrical, and small asymmetries are acceptable and natural. In more noticeable cases, a revision may be recommended.
Lagophthalmos
Difficulty in fully closing the eyes may occur in the first few days after surgery, especially during sleep. Therefore, I prescribe eye lubricants and nighttime ophthalmic ointment. This condition usually improves as the edema regresses and the tissues settle.
Dry eye
Patients who already have a tendency to dry eye may experience temporary worsening after surgery. Pre-operative assessment of the tear film is essential.
Hematoma and infection
Rare with proper technique and rigorous post-operative care. Discontinuing anticoagulants and anti-inflammatory medications before surgery reduces the risk of bleeding.
The revision rate in ptosis surgery is around ten to fifteen percent in the global medical literature, which is higher than in most aesthetic procedures. I inform all patients of this because I believe that realistic expectations are the foundation of satisfactory results. In my practice, with intraoperative adjustment under local anesthesia, my revision rate is below this average.
Results: what ptosis correction can do for you
The results of eyelid ptosis surgery are often described by my patients as transformative. And it is not an exaggeration. The eyelid that previously covered part of the pupil returns to its natural position, revealing a gaze that had been hidden for years.
Functional benefits
- Wider visual field: patients report seeing "more" — not because visual acuity has changed, but because the upper visual field has been unblocked.
- Elimination of compensatory fatigue: no longer needing to constantly raise the eyebrows to keep the eyes open, the frontal muscles relax and tension headaches disappear.
- Improved cervical posture: patients who tilted their heads back to compensate for ptosis return to a natural position.
- Greater comfort in reading and using a computer: activities that require a wide visual field become more comfortable.
Aesthetic benefits
- More open and youthful gaze: the eyelid in the proper position gives a rested and alert expression.
- Improved facial symmetry: especially in unilateral ptosis, correction restores balance between the two sides of the face.
- Periorbital rejuvenation: when combined with blepharoplasty, the transformation of the eye area is complete.
- Renewed self-esteem: many patients report a significant improvement in self-confidence after surgery.
Durability
The correction of eyelid ptosis is long-lasting. In involutional ptosis corrected by advancement of the aponeurosis, the results last for many years. In some patients, there may be a degree of recurrence over decades, which is natural considering that the aging process continues. But even in these cases, any future revision is a simpler procedure than the original surgery.
My experience and approach in ptosis correction
I graduated from the State University of Londrina (UEL) School of Medicine and had the privilege of training under Professor Ivo Pitanguy, the greatest name in Brazilian plastic surgery. Over more than twenty years of practice, I have performed over eight thousand plastic surgeries, including hundreds of eyelid ptosis corrections. I am a full member of the Brazilian Society of Plastic Surgery (SBCP) and the American Society of Plastic Surgeons (ASPS), and a former resident at the Ivo Pitanguy Institute in Rio de Janeiro.
Ptosis surgery requires a rare combination of deep anatomical knowledge, millimetric technical precision, and refined aesthetic judgment. The levator muscle and its aponeurosis are delicate structures that require careful manipulation. The success of the procedure depends on very fine adjustments — literally one or two millimeters — that make all the difference in the final result.
My treatment philosophy
Each ptosis is different, and there is no one-size-fits-all approach. In my practice, I customize the surgical technique for each patient based on the cause of the ptosis, the function of the levator muscle, age, expectations, and associated conditions. This individualization is what allows for consistently good results.
I also believe in the importance of treating the periorbital region as a whole. A ptosis corrected together with a upper blepharoplasty, when recommended, provides a much more natural result than treating each problem in isolation. Similarly, if there is concurrent eyebrow droop, a brow lift can be combined for a complete result.
For patients seeking an integrated approach to facial rejuvenation, ptosis correction can be combined with procedures such as facelift, fat grafting, facial filler, or botulinum toxin, always respecting the anatomical particularities of each region.
Post-botox eyelid ptosis: not surgical, reverses on its own or with eye drops
One of the most searched situations online is "eyelid ptosis after botox" — when botulinum toxin injected in the glabellar or forehead region diffuses into the levator muscle and causes a temporary droop. I do not perform surgery for post-botox ptosis, because it is not a surgical case.
Iatrogenic ptosis from botulinum toxin is a spontaneously reversible phenomenon. Improvement typically occurs between 4 and 12 weeks after onset, as the effect of the toxin wears off. During this period, an ophthalmologist may prescribe alpha-adrenergic eye drops (apraclonidine, low-concentration phenylephrine) that stimulate the Müller muscle and temporarily elevate the eyelid by 1-2 mm, attenuating the aesthetic discomfort during the waiting period.
If you are looking for correction of real, structural (non-iatrogenic) ptosis, refer to the earlier sections of this page. If your ptosis started after a botulinum toxin injection, the appropriate conduct is to wait for spontaneous reversal, with or without eye drops under ophthalmological guidance, and not to pursue surgery.
Do eyelid exercises work for ptosis?
There is plenty of content online about "eyelid strengthening exercises" as a solution for ptosis. In my practice, exercises do not work to correct structural eyelid ptosis when there is real levator muscle disease or aponeurotic disinsertion. The levator is a small, involuntary muscle and does not respond to strength training the way larger skeletal muscles do.
Exercises may have value in specific neurological contexts (rehabilitation of facial palsy, for example), but that is a neurology or physical-therapy prescription, not a solution for ptosis from levator laxity. When a patient arrives reporting months of exercise attempts without result, the honest conversation is that surgery is the only intervention with proven efficacy when indicated.
Relative contraindications: glaucoma, contact lenses, thyroid disease
Beyond the general contraindications of any surgery (coagulopathies, uncontrolled hypertension, active smoking), there are three specific relative contraindications for eyelid ptosis surgery that require careful evaluation and, frequently, lead to the decision not to operate:
- Glaucoma: increased intraocular pressure associated with glaucoma and chronic use of anti-glaucoma eye drops can affect the cornea and the tear film, increasing the risk of post-operative complications (severe dry eye, corneal ulcer). Patients with glaucoma are generally not operated on by me.
- Active contact lens users: prolonged use of rigid lenses is a known cause of involutional ptosis but it is also a risk factor for post-operative complications (lens intolerance after surgery, sensitized cornea). I generally avoid operating on patients in active contact-lens use.
- Thyroid disease, especially Graves orbitopathy: thyroid disease can cause eyelid retraction (the opposite of ptosis) and orbital changes that destabilize any eyelid surgical planning. I operate only after stable endocrinological control and favorable ophthalmological evaluation — or refer.
Other situations in which I do not operate and refer: neurogenic ptosis (III cranial nerve palsy, myasthenia gravis, stroke sequelae), ptosis with low levator function, and pediatric cases — all sent to Dr. Giovanni André Pires Viana.
Pricing and insurance: private pay only
The fee for eyelid ptosis surgery is defined individually during the in-person consultation, after evaluating levator muscle function, ptosis severity, laterality (unilateral or bilateral) and associated procedures (such as upper blepharoplasty). Only the initial consultation fee (R$ 800 / approx. US$ 140) and the follow-up fee (R$ 400 / approx. US$ 70) are published on the site. USD values are approximate and subject to the daily exchange rate (BRL is the billed currency).
Context for US patients
Comparable eyelid ptosis surgery in the United States is typically quoted between US$ 4,500 and US$ 9,000 in private practice, before anesthesia and facility fees. Surgery in Londrina is offered to international patients on a self-pay basis; most travelers combine the procedure with a short stay in Brazil.
Health insurance and Medicare
In my practice, surgery is offered on a private-pay basis only. US Medicare and private US health insurance typically do not cover cosmetic eyelid ptosis procedures performed abroad; functional ptosis with documented superior visual field obstruction (by Humphrey perimetry) may justify review by your carrier on a case-by-case basis, but that is the patient's responsibility to pursue. I do not bill international insurance directly.
About the codes (ICD-10 and CPT)
Eyelid ptosis carries the code ICD-10 H02.4 (acquired ptosis). The corresponding surgical code in the US is CPT 67904 (repair of blepharoptosis, external approach). In my private practice, these codes are recorded in the medical chart for clinical documentation and for possible post-payment reimbursement requests by the patient with their own carrier.
Unilateral vs bilateral ptosis: how I manage each case
Most of the cases I see are unilateral ptosis (one eye only). In a unilateral case, I perform levator muscle shortening only on the affected side — I do not manipulate the levator of the unaffected eye.
To improve the visible symmetry between the two sides, I may remove a small amount of skin from both upper eyelids (a small associated bilateral upper blepharoplasty), adjusting the crease height and overall appearance. This approach preserves the function of the healthy eye and only adjusts excess eyelid skin, if present.
In truly bilateral cases — where both eyes show ptosis measured by MRD1 — plication is performed on both sides, with individualized intraoperative adjustment for each eye. The 2 mm over-correction is applied on both sides.
Frequently Asked Questions about eyelid ptosis
What is the difference between eyelid ptosis and excess skin on the eyelid?
They are different conditions. Eyelid ptosis is the drooping of the upper eyelid margin due to weakness of the levator muscle or disinsertion of its aponeurosis. Excess skin (dermatochalasis) is a fold of skin that hangs over the eyelid crease, but the eyelid margin itself remains in a normal position. Treatment for ptosis requires repairing the levator muscle; excess skin is treated with blepharoplasty. Often, both conditions coexist and are corrected in the same procedure.
Is eyelid ptosis surgery performed under local or general anesthesia?
Exclusively under local anesthesia with sedation. This choice is technical, not preferential: during surgery, I ask the patient to open, close and move the eyes up and down, which is essential to confirm the planned 2 mm over-correction. Sedation keeps the patient comfortable without suppressing the ability to follow commands. I do not perform ptosis surgery on children (referred to Dr. Giovanni A. P. Viana).
Which surgical technique do you use?
I perform levator muscle plication of the upper eyelid, indicated when levator function is good (excursion greater than 10 mm). Through an incision in the eyelid crease, I fold the muscle on itself with internal PDS sutures to effectively shorten it. I do not perform conjunctivomullerectomy, frontalis sling, Fasanella-Servat or Müller resection — cases that require those techniques (low levator function, severe congenital ptosis, neurogenic ptosis) are referred to Dr. Giovanni A. P. Viana.
Why is my eyelid "too high" in the first days?
It is expected and planned. At the end of surgery, I leave the eyelid 2 millimeters higher than normal — the planned over-correction. Over the first month, the muscle accommodates and the eyelid progressively descends until it levels with the contralateral eye in about 30 days. Without the over-correction, the final result would be under-corrected.
How long does eyelid ptosis surgery take?
Unilateral correction takes 45 to 60 minutes. Bilateral, about 90 minutes. Combined with blepharoplasty, total time is between 90 and 120 minutes. It is an outpatient procedure — the patient goes home the same day.
Does ptosis correction leave a visible scar?
The incision is placed in the natural crease of the upper eyelid, hidden in the fold. Skin sutures are removed between day 5 and day 7; internal PDS sutures are absorbed over 6 months. After complete healing, the line becomes practically invisible.
Can eyelid ptosis come back after surgery? Is there a definitive cure?
There is no "definitive cure" for eyelid ptosis with surgery. The reason is technical: the levator muscle is typically diseased (the underlying cause — aponeurotic disinsertion, dystrophy, aging — is not eliminated by plication). For this reason, a revision surgery may be needed 5 to 15 years later, depending on the degree of muscle disease. The result is effective and long-lasting, but not lifelong.
Does US health insurance or Medicare cover my ptosis surgery in Brazil?
In my practice, surgery is offered on a private-pay basis only. US Medicare and most private US insurance do not cover cosmetic eyelid ptosis surgery abroad. If your ptosis has a documented functional component (superior visual field obstruction on Humphrey perimetry), you may submit for review by your carrier — that is your responsibility. The ICD-10 code (H02.4) and CPT 67904 are recorded in the chart for possible post-payment reimbursement claims.
Do eyelid exercises work for ptosis?
Eyelid exercises do not correct structural eyelid ptosis when there is real levator muscle disease or aponeurotic disinsertion. The levator is a small, involuntary muscle and does not respond to strength training the way larger skeletal muscles do. When a patient reports months of exercise attempts without result, the honest conversation is that surgery is the only intervention with proven efficacy when indicated.
I have glaucoma, use contact lenses or have thyroid disease. Can I have the surgery?
These three conditions are relative contraindications in my practice, and I generally do not operate on patients with glaucoma, in active contact-lens use or with thyroid disease (especially Graves orbitopathy). The risk of post-operative complications (severe dry eye, eyelid instability, retraction) increases significantly. The decision is made case-by-case at the in-person consultation.
My ptosis is unilateral. Do you operate only on the affected side?
When ptosis is unilateral, I shorten the levator muscle only on the affected side. To improve visible symmetry, I may remove a small amount of skin from both upper eyelids (a small associated bilateral upper blepharoplasty), adjusting the crease. I do not manipulate the levator of the unaffected eye.
My child has ptosis. Do you operate on children?
I do not perform ptosis surgery on children or infants, because pediatric ptosis requires subspecialty care in pediatric periorbital plastic surgery. I refer all pediatric patients to Dr. Giovanni André Pires Viana, former professor of periorbital plastic surgery at Escola Paulista de Medicina and a Brazilian reference in complex ptosis. At consultation, I evaluate, counsel on urgency (amblyopia risk) and make the formal referral with a report.
Is there any treatment for eyelid ptosis without surgery?
There is no definitive non-surgical treatment for structural ptosis. There are temporary devices ("eyelid crutches" attached to glasses) that can help in cases where surgery is not possible. Alpha-adrenergic eye drops (oxymetazoline, apraclonidine) temporarily elevate the eyelid by 1-2 mm — useful as a palliative or in the setting of post-botox ptosis, but they do not replace surgery for structural ptosis. In ptosis from myasthenia gravis, clinical treatment of the underlying disease (neurology) may improve the condition.
Can I correct eyelid ptosis and have blepharoplasty at the same time?
Yes, and this is the most common situation in my practice. Most adult patients with involutional ptosis also have excess skin on the upper eyelid. Both conditions are corrected during the same procedure, through the same incision. The result is a complete rejuvenation of the gaze.
How long does it take to see the final result?
A provisional result is visible in the first week, after suture removal. Residual edema resolves in 4 to 6 weeks. The final result (with a mature scar and eyelid contour leveled with the contralateral side) stabilizes between 3 and 6 months after surgery. Typical time off work is 1-2 weeks.
Can botulinum toxin cause eyelid ptosis? Do you operate on post-botox ptosis?
Yes, it is a known complication of botulinum toxin (Botox) application in the forehead and glabellar region, when the product migrates to the levator muscle. I do not operate on post-botox ptosis — it is spontaneously reversible in 4 to 12 weeks, as the effect of the toxin wears off. During that period, an ophthalmologist may prescribe alpha-adrenergic eye drops (apraclonidine, phenylephrine) that temporarily elevate the eyelid. Surgery is indicated only for structural (non-iatrogenic) ptosis.
What preparation is required before ptosis surgery?
Laboratory workup (CBC, coagulation panel, fasting glucose), cardiac clearance with EKG, standardized photographic records and, when appropriate, an ophthalmological evaluation. Anti-inflammatory medications, aspirin, vitamin E and herbal supplements are discontinued 15 days prior. Smoking is stopped for the same period. Eight-hour fast before surgery.
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If you have noticed that your eyelid is drooping, compromising your gaze or vision, the next step is an in-person evaluation. During the consultation, I take all necessary measurements to diagnose the cause and degree of ptosis, and I explain exactly which technique will be most suitable for your case. My team is ready to assist you.
Learn more about the first consultation, the pricing, and the guidelines for pre-operative preparation and post-operative recovery.
Recover your gaze! Schedule your consultation now.
Dr. Walter Zamarian Jr.
Plastic Surgeon in Brazil
Rua Engenheiro Omar Rupp, 186
Londrina, PR 86015-360
Brazil
YouTube Channel: Dr. Walter Zamarian Jr.
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