Droopy Eyelid (Ptosis)
When the eyelid itself sits low — how it is measured, why it happens, and when it needs investigating rather than operating on
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Droopy Eyelid (Ptosis)
Blepharoptosis — Assessment and Repair in Manchester
Ptosis — properly blepharoptosis — is a drooping of the upper eyelid itself. The lid margin sits lower over the pupil than it should, because the levator muscle that lifts it is weak, stretched, or has detached from where it attaches.
It is different from hooded eyes, and the difference matters more than almost anything else on this page. Hooding is surplus skin over a normally positioned lid; ptosis is the lid itself sitting low. They look similar in a mirror and they need completely different operations. Removing skin from an eye with unrecognised ptosis produces a tidier eyelid that is still half shut, and that is the single commonest reason people seek revision after eyelid surgery.
There is also a category of ptosis that is not a cosmetic matter at all. Drooping that comes on suddenly, varies through the day, affects both sides unevenly, or comes with double vision needs investigating before anyone discusses surgery, because in a small number of cases it is the first sign of something neurological. That is covered further down and it is the most important part of this page.
How Ptosis Is Measured
MRD1, levator function, and why both matter
Understanding Your Assessment
Two measurements decide everything, and both take seconds.
MRD1 — margin reflex distance. The distance from the centre of the pupil to the upper lid margin when you look straight ahead. Normal is around 4 to 4.5mm. This is the number that tells you whether ptosis exists and how marked it is:
• Mild: MRD1 around 3mm — roughly 2mm of droop.
• Moderate: around 2mm — roughly 3mm of droop.
• Severe: 1mm or less — 4mm or more of droop, with the lid encroaching on the pupil.
Levator function. How far the lid travels between full downgaze and full upgaze, with the brow held still so you cannot cheat with your forehead. Normal is 13mm or more. Good function (over 8mm) means the muscle is working and can simply be tightened. Poor function (under 4mm) means the muscle is not doing the work, and the lid has to be lifted by a different mechanism — a sling connecting it to the forehead muscle.
MRD1 tells you how much the lid needs lifting. Levator function tells you which operation can lift it. Neither alone is enough, which is why an assessment that only looks at the amount of skin is not an assessment at all.
Why ptosis gets missed
Because people compensate without realising. When a lid sits low, the brain recruits the frontalis — the forehead muscle — to lift the brow and open the eye. Patients arrive with permanently raised brows, deep forehead lines and tension headaches, having had no idea they were doing it.
That compensation also masks the ptosis on examination unless the examiner holds the brow down. Which is why your surgeon will press firmly on your brow and ask you to look straight ahead — it stops you cheating, and the lid drops to its true position.
It is also why some patients are surprised after surgery to find their forehead relaxes and their frown lines soften. They were not frowning; they were holding their eyes open.
When Ptosis Needs Investigating, Not Operating On
The presentations that change the appointment
Most ptosis in adults is aponeurotic — the tendon of the levator muscle has stretched or detached with age, contact lens wear, previous eye surgery or repeated eye rubbing. It comes on slowly over years, affects one or both sides, and is a mechanical problem with a mechanical solution.
Some ptosis is not that, and these features are the ones that change what happens next:
• Sudden onset — over hours or days rather than years.
• Variability — better in the morning, worse by evening, or fluctuating through the day.
• Double vision, or the eye not moving normally in all directions.
• A different pupil size on the drooping side.
• Pain, headache, or any other neurological symptom.
Any of those means a medical assessment before a surgical one. Sudden ptosis with a dilated pupil, in particular, is a same-day matter rather than a clinic appointment. We would rather say this plainly on a web page than have someone book a cosmetic consultation for something that needs a different doctor. If any of the above describes you, contact your GP or NHS 111 today, or attend an emergency department if it came on suddenly with pain, double vision or a change in your pupil.
How Ptosis Is Repaired
The operation follows the measurement
There is no reliable non-surgical treatment for a mechanically drooping lid. Ptosis crutches on spectacles exist for people unfit for surgery. What follows is what the measurements point to.
1. Levator Advancement — good function
The workhorse repair, for the great majority of adult aponeurotic ptosis where levator function is preserved. Through an incision in the natural eyelid crease, the stretched or detached aponeurosis is found and reattached or advanced onto the tarsal plate, raising the lid. Frequently done under local anaesthetic so that lid height can be checked with you sitting up and looking ahead during the operation — which is the main reason for doing it awake.
2. Müller’s Muscle Resection — mild ptosis
For mild ptosis with good function, approached from the underside of the lid so there is no skin incision at all. Suitability is usually tested beforehand with a drop that temporarily stimulates Müller’s muscle; if the lid lifts to where you want it, the operation will do the same. Elegant, but only for small amounts of lift.
3. Frontalis Sling — poor function
Where levator function is poor (under about 4mm), tightening a muscle that is not working achieves nothing. Instead the lid is connected to the forehead muscle with a sling, so the frontalis lifts it — formalising the compensation the patient has been making unconsciously. Used in congenital ptosis and in some neurological cases.
4. Ptosis Repair With Blepharoplasty — both findings
Commonly both are present, particularly over sixty: the lid is low and there is surplus skin above it. Both are addressed in one operation through the same crease incision. Correcting only one leaves the patient half-treated and dissatisfied.
To have MRD1 and levator function measured and find out which of these applies to you, book an assessment in Manchester on 0161 470 9280 or enquire online. If your ptosis has features that need medical investigation first, we will tell you and help you get to the right place.
Ptosis in children
Congenital ptosis is a different problem
Ptosis present from birth or early infancy is not the adult condition with a younger patient. It is usually a developmental problem with the levator muscle itself, so function is often poor and a sling is more likely to be needed than a simple advancement.
The reason it matters urgently is amblyopia. If the lid covers the visual axis during the critical period of visual development, the brain can fail to develop normal vision in that eye — and that is not recoverable later. Congenital ptosis therefore needs assessment by a paediatric ophthalmologist, not a cosmetic surgeon, and timing is driven by the vision rather than the appearance.
If you are reading this about a child, the right first step is your GP and a referral into paediatric ophthalmology on the NHS. We will say the same if you contact us, and we would rather direct you there than book an appointment.
Children Go to Paediatric Ophthalmology
Congenital ptosis risks amblyopia if the lid covers the visual axis during visual development. That is an NHS paediatric ophthalmology pathway via your GP, not a private cosmetic consultation.
Expect a Second Procedure Sometimes
Lid height is the hardest thing in eyelid surgery to get exactly right, and a proportion of repairs need a small adjustment afterwards. That is normal for this operation rather than a sign something went wrong.
Ptosis and Your Vision
The functional case, and NHS funding
A lid that encroaches on the pupil obstructs the upper visual field. People adapt by tilting the chin up and holding the brows raised, and often do not recognise how much they are compensating until it is corrected.
Where ptosis is severe enough to affect vision, repair may be funded on the NHS. It generally requires formal visual field testing demonstrating obstruction, and thresholds vary between commissioning areas. Unlike hooded-eye surgery, where funding is uncommon, genuine ptosis with documented field loss has a more established case.
If you are lifting your brows to see, or tilting your head back to read, it is worth asking your GP before going private. We arrange visual field testing as part of assessment where the picture suggests it, and we will tell you if you look likely to meet local criteria.
What Repair Costs
Quoted at Consultation
Ptosis repair is quoted individually after assessment, because the operation depends on your levator function — a levator advancement, a Müller’s muscle resection and a frontalis sling are three different procedures with different operating times.
For reference, related eyelid surgery at Deansgate Hospital starts from: upper blepharoplasty £2,500 under local anaesthetic or £5,000 under general, upper and lower blepharoplasty £6,500, lower lid surgery £5,500, and brow lift £8,000. Where ptosis repair is combined with a blepharoplasty, the combination is quoted together.
The fee covers your surgeon, the procedure, the hospital, dressings and all routine follow-up. Assessment is a free consultation with a £25 booking deposit, redeemable against treatment.
Where your ptosis is severe enough to affect your visual field, ask your GP about NHS funding before booking privately.
Assessment and Repair, Step by Step
From first appointment to twelve-month review
A ptosis assessment is a measurement exercise first and a surgical discussion second. Here is what each stage involves.
You are examined sitting upright looking straight ahead. MRD1 is measured on each side, then levator function with your brow held firmly still so the forehead cannot compensate. The height and symmetry of the lid creases are noted, the amount of surplus skin assessed separately, and brow position checked.
Your surgeon will also check the strength of eyelid closure, corneal sensation and tear film, because a lid that is lifted must still close properly and protect the eye. You will be asked about contact lens wear, previous eye surgery, and how long this has been going on.
Photographs are taken, and where the lid encroaches on the pupil, formal visual field testing is arranged. You leave with your measurements, an explanation of which operation they point to, and a written quotation.
Before any surgical plan, the pattern of your ptosis is assessed for features that suggest something other than a stretched tendon: sudden onset, variability through the day, double vision, restricted eye movement, unequal pupils, or associated neurological symptoms.
Where any of those are present, you are referred for medical assessment before surgery is discussed — which may mean bloods, imaging, or an ophthalmology or neurology opinion. Operating on ptosis that has an underlying medical cause without establishing it first is poor practice, and it can also mean operating on a lid whose position is going to change anyway.
For the large majority this step confirms straightforward aponeurotic ptosis and the plan proceeds. For a small number it is the most useful thing the appointment does.
Levator function decides it. Good function with mild ptosis may suit a Müller’s muscle resection from the underside of the lid, with no skin incision — tested beforehand with a drop that temporarily stimulates the muscle, so you can see the likely result in advance.
Good function with moderate or severe ptosis points to a levator advancement through the eyelid crease. Poor function points to a frontalis sling, because tightening a muscle that is not working achieves nothing.
Where surplus skin is present as well, a blepharoplasty is combined through the same incision. Where the brow has descended and is doing compensatory work, that is discussed too — lifting the lid can let the brow drop back down, which occasionally changes the appearance more than expected.
Most levator advancements are performed under local anaesthetic, and deliberately so. Lid height is set intraoperatively with you sitting up and looking straight ahead, which cannot be done under general anaesthetic — the single biggest factor in getting the height right.
Through an incision in the natural eyelid crease, the levator aponeurosis is identified and advanced or reattached to the tarsal plate, with height and contour adjusted and checked before closing. Where a sling is used, the lid is connected to the frontalis with suture or fascia through small incisions above the brow.
Forty-five minutes to an hour for most repairs. Deansgate Hospital is a day-case facility, so you go home the same day once your surgeon and the recovery team are happy with you.
First 48 hours. Swelling and bruising, worst around day two to three. Sleep propped up, cold compresses, no bending or straining. Lubricating drops or ointment, because the lid may not close completely at first.
Week 1. Sutures out at five to seven days. The lid height at this stage is not the result — swelling holds it high or low unpredictably, and judging it now is the commonest cause of unnecessary worry.
Weeks 2 to 3. Bruising fades and becomes concealable. Back to a desk job typically at seven to ten days. Dryness settles as closure returns to normal.
Weeks 3 to 6. Light walking only — nothing strenuous, nothing that raises your heart rate or blood pressure, because raised pressure around fresh eyelid wounds risks bleeding.
Six weeks to three months. Exercise resumes. Final lid height is judged at around three months, and any adjustment is considered only after that.
The defining risk of ptosis surgery is that the height is not exactly right. Under-correction leaves the lid still low; over-correction leaves it too high, which looks worse and can stop the eye closing. A proportion of repairs need a further adjustment, and you should go in expecting that possibility rather than being surprised by it. Doing the operation awake, with you sitting up, is what minimises it.
Also recognised: asymmetry between the two sides, and the phenomenon where lifting one lid allows the other to drop — a known effect of the way the brain drives both lids together, which is why your surgeon assesses both sides even when only one looks affected.
Beyond that: bruising, swelling, dry eye and difficulty fully closing the lid, usually temporary; altered lid crease height or contour; visible scarring, usually minimal in the crease; and infection. The rare but serious complication is bleeding behind the eye, which can threaten vision and is why straining is restricted and blood thinners need a plan agreed in advance.
Droopy Eyelid (Ptosis)
Frequently Asked Questions
What is ptosis?
Drooping of the upper eyelid itself, because the levator muscle that lifts it is weak, stretched or has detached from its attachment. The lid margin sits lower over the pupil than it should. It is different from hooded eyes, which is surplus skin over a normally positioned lid — and the two need completely different operations.
How do I know if I have ptosis or just hooded eyes?
Lift the skin fold with a finger and look at where the lid margin sits. If the eye underneath looks normal, it is hooding. If the lid itself is still low over the pupil, that is ptosis. Properly it is measured as MRD1 — pupil centre to lid margin, normally 4 to 4.5mm. Below that indicates ptosis. It takes seconds to measure and it is the whole basis of the assessment.
What causes a droopy eyelid in adults?
Most commonly the levator tendon stretching or detaching with age — called aponeurotic ptosis. Contact lens wear, previous eye surgery and repeated eye rubbing all contribute. It comes on gradually over years. Ptosis that appears suddenly, varies through the day, or comes with double vision has different causes and needs medical assessment first.
When should I worry about a droopy eyelid?
See a doctor urgently if it came on suddenly, if your pupil is a different size on that side, if you have double vision, if the eye does not move normally, or if there is pain or headache. Also if it varies through the day — better in the morning, worse by evening. Sudden ptosis with a dilated pupil is a same-day matter, not a clinic appointment. Contact your GP or NHS 111, or attend an emergency department if it came on suddenly with pain or double vision.
Can ptosis be fixed without surgery?
Not reliably. It is a mechanical problem — a muscle or tendon not holding the lid where it should — and there is no injection, cream or exercise that corrects that. Ptosis crutches attached to spectacle frames exist for people who are not fit for surgery. Where ptosis has a medical cause, treating that cause may improve the lid.
What is levator function and why does it matter?
How far your lid travels between looking fully down and fully up, with the brow held still. Normal is 13mm or more. It determines which operation can work: good function (over 8mm) means the muscle can simply be tightened; poor function (under 4mm) means tightening it achieves nothing and the lid has to be lifted by a sling connected to the forehead muscle instead.
Why is the operation done awake?
So lid height can be set with you sitting up and looking straight ahead. Lid position under general anaesthetic bears little relation to where it sits when you are upright and alert, and getting the height right is the hardest part of this operation. Most levator advancements are therefore done under local anaesthetic, and that is a feature rather than an inconvenience.
Will the height be exactly right?
Usually, but not always — this is the defining risk of ptosis surgery. Under-correction leaves the lid low; over-correction leaves it too high and can stop the eye closing properly. A proportion of repairs need a small further adjustment, and you should expect that possibility rather than be surprised by it. Final height is judged at around three months, not before.
Can fixing one eyelid affect the other?
Yes, and it is a recognised effect. The brain drives both lids together, so lifting a droopy lid can allow the other one to drop — sometimes revealing ptosis on that side that was being masked. It is one reason your surgeon assesses and measures both sides even when only one looks affected.
My child has a droopy eyelid — what should I do?
See your GP for referral to paediatric ophthalmology. Congenital ptosis is a different condition from the adult form, usually with poor levator function, and the urgency is about vision rather than appearance: if the lid covers the visual axis during visual development, the brain can fail to develop normal vision in that eye, and that is not recoverable later. This is an NHS pathway, not a private cosmetic consultation.
Can I get ptosis repair on the NHS?
Where the droop is severe enough to obstruct your visual field, often yes — genuine ptosis with documented field loss has a more established funding case than hooded-eye surgery. It generally requires formal visual field testing, and thresholds vary by commissioning area. If you are lifting your brows or tilting your head back to see, ask your GP before going private.
How much does ptosis repair cost?
It is quoted individually after assessment, because levator advancement, Müller’s muscle resection and a frontalis sling are three different operations with different operating times. For reference, upper blepharoplasty at Deansgate Hospital starts from £2,500 under local anaesthetic or £5,000 under general; where ptosis repair and blepharoplasty are combined, the combination is quoted together.
Is your eyelid drooping, or is it the skin above it?
Ptosis Assessment, Manchester
Two measurements — MRD1 and levator function — take seconds and decide everything: whether you have ptosis at all, and which of three quite different operations can correct it. An assessment that only counts the skin is not an assessment.
Book an assessment with one of our consultant plastic surgeons in Manchester. Both eyes are measured, both sides assessed, and if your ptosis has features that need medical investigation first, we will tell you and help you get to the right place. Call 0161 470 9280 or enquire online.