Will ptosis surgery make my eyes more almond shaped, or should I focus on the lower lid?

The upper lids are more noticeable and I would recommend that as the priority for correction. This would be ptosis repair. For the lower lids, your orbits are a bit shallow, so my preference would be fat grafting to build up the cheekbone area and possibly elevating the position of the lower lids.

Eye shape is determined by multiple factors including separately upper eyelids and lower eyelids, in addition to eyeball position, bony structure, etc. The exact procedures would depend on individual anatomy and desired goal. Best to have more detailed evaluation and discussion in consultation.

It is possible that the lower eyelids could be helped at the same time of the ptosis surgery with a lateral canthal procedure. A detailed personal consultation should assess basis for your issues to determine precisely what you need. In particular, while scarless ptosis surgery is very popular, it is often ineffective. The appropriateness of this surgery is not assessed on the basis of the neosynephrine drop test but rather the actual physical examination of your eyelids. I highly recommend seeing more than one surgeon before committing yourself to a particular approach.

No one ever "needs" a lower lid blepharoplasty. It is an elective procedure and only you can determine if your features concern you enough to do something about improving the cosmetic appearance of your eyes and whether it would be worthwhile.  Following the advice of anyone who would presume to tell you what to do based on  limited photo and more importantly without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS 

La Jolla, California