Ptosis Treatment & Surgery

Treatment of Ptosis

The choice of operation depends on three factors: the degree of ptosis, the remaining levator function, and the phenylephrine test result. Your surgeon reviews all options with you at consultation and tailors the approach to your anatomy and goals.

Müller Muscle–Conjunctival Resection (MMCR — Internal Approach)

• Incision made through the inner conjunctival surface of the lid — no external scar
• Best candidates: good levator function (≥ 10 mm) and a positive phenylephrine test
• The amount of Müller muscle and conjunctiva resected is determined by a formula based on the phenylephrine response
• Patient is under general or IV sedation (no intraoperative adjustment needed)
• Can be combined with cosmetic upper blepharoplasty

Levator Advancement (External Approach)

• Incision placed within the upper lid crease — scar is hidden in the natural skin fold
• The aponeurosis is reattached or tightened to the tarsus under direct vision
• Patient is awake during the key adjustment step so lid height and contour can be refined in real time
• Preferred for aponeurotic ptosis with moderate-to-good levator function
• Can be combined with cosmetic upper blepharoplasty through the same incision

Frontalis Sling

• The eyelid is suspended directly from the frontalis (forehead) muscle using a sling material
• Required for severe ptosis with poor levator function (≤ 4 mm) — the typical situation in congenital ptosis and Marcus Gunn jaw wink
• Sling materials include autogenous fascia lata (harvested from the thigh), silicone rod, or Gore-Tex
• The patient opens their eye by raising their brow, not by contracting the levator
• Lagophthalmos (incomplete lid closure on downgaze and during sleep) is expected; lubricating eye drops are needed long-term
• Performed under general anesthesia; lid height is determined by a surgical formula

Fasanella-Servat Procedure

For mild ptosis with good levator function, the Fasanella-Servat procedure removes a small strip of the upper tarsus, Müller’s muscle, and conjunctiva from the back of the lid. It is quick and predictable for small (1–2 mm) corrections and leaves no external incision.

Frontalis Sling Materials

When levator function is poor (often in congenital ptosis), a frontalis sling links the lid to the brow. Materials include autologous fascia lata (harvested from the thigh — the most durable, preferred in older children and adults) and synthetic options such as silicone, Gore-Tex (ePTFE), Supramid, or Mersilene mesh, which allow earlier surgery in young children.

Upneeq®

Upneeq® (oxymetazoline hydrochloride ophthalmic solution 0.1%) is the first and only FDA-approved prescription eye drop for acquired low-lying eyelids in adults. It is a non-surgical option for patients with mild ptosis.

How It Works

Oxymetazoline is an α-adrenergic agonist that selectively stimulates Müller’s muscle, lifting the upper eyelid by approximately 1 mm within 5 minutes of instillation. The effect lasts up to 8 hours.

Key Facts

• Once-daily drop applied to each ptotic eye
• Single-use, preservative-free container; discard after each dose
• Contact lenses must be removed before instillation; may be reinserted 15 minutes later
• Average eyelid lift is ≈ 1 mm — meaningful for mild ptosis; not sufficient for moderate or severe ptosis
• Clinical trials showed statistically significant improvement in superior visual field at 2 and 6 hours post-dose

Who Is a Candidate

• Adults with mild acquired aponeurotic ptosis who prefer a non-surgical option
• Patients who show lid elevation on the phenylephrine test
• Patients who are not yet surgical candidates due to other health conditions

Precautions

• Use with caution in patients with cardiovascular disease, uncontrolled hypertension or hypotension, or orthostatic hypotension — alpha-agonists affect vascular tone
• May increase the risk of angle closure glaucoma in patients with untreated narrow-angle glaucoma
• New ptosis with a variable or fatigable pattern (suggesting Myasthenia Gravis), or with a dilated unreactive pupil, requires specialist evaluation before Upneeq is prescribed