Is There a Difference Between Having Ptosis and Having an Eyelid That is Just Set Lower?

I recently had a consultation with an oculoplastic surgeon; after he had examined both of my eyes, he told me that the problem was due to the fact that my left eyelid was just naturally set lower. He then applied some kind of an eyedrop that caused my eyes to open really wide, he said that he could fix the problem by performing something called a "Muellerectomy." My question is, do I actually have ptosis or do I just have an eyelid that is naturally set lower? I have attached a recent picture...

Doctor Answers 4

Mild Ptosis can be a normal anatomic variation.

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Oculoplastic [sometimes referred to as Oculofacial or Ophthalmic Plastic] Surgeons are highly specialized surgeons trained extensively in plastic surgery of the periocular region. This includes the  orbit [eye socket], eyelids, brows, midface, as well as the lower face/neck region [depending on the institution of training].

When it comes to the position of the eyelids, one of the most important measurement is the distance between the eyelid margin [where the lashes are positioned] to the center of the pupil. This is called the MRD, or Margin-to-Reflex Distance. "Reflex" refers to where a light reflex is observed when a light is directly shined in the eye and is the center of pupil. This measurement is used to determine whether a patient is considered to have eyelid ptosis [blepharoptosis], or in layman's terms, a droopy eyelid. It is generally accepted that a measurement of less than 3 mm is needed for an eyelid to technically be considered ptotic.

However, there are established racial/ethnic norms in the population, which our group reported in the Archives of Facial Plastic Surgery [Margin Reflex Distance in Different Ethnic Groups, Arch Facial Plast Surg. 2009;11(5):303-30]. In our study, the average MRD in caucasians, was 5 mm.

Having said that, normal variations in individuals are to be expected, as that is how an avergage is calculated. Each person should be evaluated individually to establish whether this is an "acquired" problem, that is, something that has developed slowly [or sometimes quickly depending upon the condition], or whether this is a longstanding issue.

The way to address this is by looking at your photographs from years ago. A good place to start would be your yearbook photos, especially if you have portrait size photos available. Some patients have the "bedroom" eye appearance that they are born with and often does not affect their visual field, and is "normal" for them.

That is why the "eyedrop test" that you mentioned is an especially  important pre-operative evaluation for patients with "subtle" ptosis that does not affect the visual field. It will give the patient an excellent idea of what he/she can expect from surgery [what they will look like postoperatively], and whether that is a "look" that they like.  I would estimate from your photo, that your MRD is about 3.5 to 4 mm. If the eyedrop test is efficacious, your eyelid would rise by 1-2 mm, taking your measurment to about 5 mm, the average in a caucasian. Only you can decide whether this is something that is pleasing to you. Some patient like the "bedroom" eye look and wouldn't want  wider, more awake looking eyes.

Bottom line:  your eyes are slightly lower than the average caucasian. Old photos will confirm if your eyes are naturally lower, or have become more ptotic over the years. In either case, a mullerectomy can raise your eyelids, and the "eyedrop" test is a good way for you to find out whether you like that look or not.

Best of luck.

Seattle Oculoplastic Surgeon
5.0 out of 5 stars 41 reviews

It looks like mild ptosis

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Oculoplastic surgeons are specialized in ptosis repair. A mullerectomy is probably a good way to correct your ptosis.

You have 1 mm of left upper eyelid ptosis.

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Dear Concerned

Your surgeon sounds like they know what they are doing.  Should you have this fixed?  Sure if it bothers you.  This degree of ptosis is considered cosmetic and not likely covered by health insurance.  The problem is that the heavy eyelid suggests to people that you are stoned or disinterested.  Only you will be able to judge how important these issues are for you.  Fixing this is not an emergency, or a medical necessity.  Recovery from this type of surgery is relatively.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

From the limited view the amount of ptosis is minimal

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The picture shows minimal ptosis and not enough for surgical correction. You have lower set eyebrows and in patients with ptosis the brow position is much higher to compensate for the ptosis and it is not the case in your picture. You may try a personal consultation with aboard certified plastic surgeon to evaluate the whole face and not just the eyes.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.