Ptosis Correction — Levator Muscle Repair

What Is Ptosis and How Does It Differ from Hooded Eyelids?

Normally, the upper eyelid margin covers about 1–2 mm of the top of the pupil. When the eyelid margin itself (not just excess skin) droops and covers more of the pupil, this condition is called ptosis. Patients often raise their eyebrows or tilt their heads back to see, and the eyes may appear tired and smaller. This is distinct from excess eyelid skin hooding over the crease (which is treated with blepharoplasty) — excising skin alone will not elevate the eyelid margin.

Common Causes

Age-related aponeurotic ptosis (most common in adults): The levator aponeurosis stretches or disinserts from the tarsal plate, while muscle function remains good. Congenital: Poor development of the levator muscle from birth, resulting in weak muscle function. Long-term contact lens wear or prior eye surgery: Causes stretching of the aponeurosis. Underlying medical conditions (such as myasthenia gravis, third nerve palsy, etc.): These must be ruled out by an ophthalmologist or neurologist prior to cosmetic surgery. Therefore, sudden-onset ptosis, ptosis that fluctuates throughout the day, or ptosis accompanied by double vision or other muscle weakness requires a thorough medical evaluation first.

Technique Selection Based on Levator Muscle Function

The surgeon measures levator muscle function (the excursion of the eyelid margin from downgaze to upgaze). Good muscle function: Levator aponeurosis plication or advancement via the eyelid crease approach — the most commonly used technique, which can be combined with double eyelid creation and skin excision. Moderate muscle function: Greater muscle resection or shortening. Poor muscle function: Frontalis suspension (sling procedure) using autologous fascia or synthetic materials — an advanced procedure requiring careful consideration. Outcomes depend heavily on baseline muscle function; weak muscle function carries a higher risk of recurrence or the need for revision.

Risks to Consider

Under-correction or over-correction (incomplete eyelid closure during sleep, dry eyes), asymmetry — occasionally, the unoperated side may appear ptotic once the surgical side is elevated (Hering's law), irregular eyelid contour, scarring within the crease, swelling and bruising, recurrence in cases with poor muscle function, hematoma, and infection (rare). For these reasons, secondary touch-ups or adjustments may be required.

At BonBoz

Our plastic surgeons carefully measure levator muscle function, margin reflex distance (MRD) on both sides, evaluate for Hering's law, and rule out medical conditions that require specialized evaluation. The surgical technique is customized based on muscle function and is often combined with eyelid crease design for optimal symmetry. The consulting surgeon personally performs the surgery; the possibility of revision, the risk of recurrence, and the limitations associated with poor muscle function are clearly explained beforehand — with no unrealistic promises made.