What are the risks and complications of ptosis surgery? Overcorrection, a lid that will not close, dry eye and asymmetry

Ptosis, the medical name for a droopy upper lid, is repaired by working on the levator, the muscle that lifts the lid. That is a millimetre operation on a lid that has to blink, close and stay wet for decades, so its complications are different from those of a skin operation. This page covers the ones that belong to ptosis surgery: a lid set too low or too high, unevenness between the two sides, a lid that will not close fully and the dry eye that follows, and how often a second operation is needed. Emergencies after any eyelid surgery are in what can go wrong after eyelid surgery, and I will not repeat them.

What are the risks and complications of ptosis surgery?

The recognised list is short and specific. EyeWiki, the American Academy of Ophthalmology's clinical wiki, says correction of blepharoptosis may be complicated by bleeding, infection, swelling, undercorrection or overcorrection, eyelid asymmetry, granuloma formation, a foreign-body sensation on the cornea and exposure keratopathy, which is damage to the front of the eye from being left uncovered. The American Academy of Ophthalmology tells patients that, as with any operation, ptosis repair has possible risks and complications that the ophthalmologist should discuss beforehand.

Most of that list is about one thing: the final lid height and whether the lid still protects the eye. Bleeding and infection are possible after any operation. What is particular to ptosis surgery is that the result is judged in millimetres, so a small error is visible, and a lid lifted too far can leave the eye exposed. The rest of this page follows those two threads.

What is normal in the first weeks, and when should I call?

Swelling, bruising, tightness and a lid that sits a little uneven are expected early and usually ease over a few weeks, and the range between hospitals is wide. I have set out the typical timeline in what ptosis surgery recovery actually involves, so I will only draw the line here.

Expected: puffy, bruised, tight lids; a lid that looks higher or lower than its partner while the swelling is uneven; a gritty feeling that closes properly and eases with lubricating drops. Worth a call to the operating team the same day: an eye that will not close, a red or painful eye, vision that changes, bleeding from the wound, or swelling that is building instead of easing. A lid that is still clearly wrong after the swelling has settled is not an emergency, but it is a reason to say so at your review, not to wait and hope.

What if the lid ends up too low, too high or uneven?

It can happen, and the published numbers are small but not zero. Undercorrection means the lid is still lower than planned, overcorrection means it sits too high, and asymmetry means the two sides do not match. A 2005 case series from Ben Simon and colleagues in the American Journal of Ophthalmology followed 159 adults, 272 operations, for involutional ptosis, the droop that comes with age. It reported overcorrection in four cases (1.4 per cent), lagophthalmos, an eye that does not quite close, of 1 mm in 10 (3.6 per cent) and pyogenic granuloma, a small red overgrowth of healing tissue, in two (under 1 per cent). That describes one group of patients reported in 2005. It is not a rate for any particular surgeon.

Early unevenness is common because swelling differs between the two lids, as the recovery page describes. A 2026 report from Istanbul, in BMC Ophthalmology, counted asymmetry as more than 1 mm between the two lids when deciding who needed a second operation, which shows how fine the measurement is. The practical point is that a difference the mirror shows may be only a millimetre or two.

What I could not find in the sources I read is a reliable rate for lid crease or contour problems after ptosis surgery, so I give none. If the crease sits at a different height from the other side, or the lid edge has an uneven curve, say so at review. A skin crease is a separate question from the muscle, and it deserves its own answer. What happens next, including the idea that a second operation is a normal part of this field and not a failure, is in does ptosis surgery last? Recurrence, undercorrection and revision.

Why does the eye sometimes not close fully after ptosis surgery?

Because a lid lifted higher has further to travel to close, and swelling and a stiff lid make it slower. The medical name is lagophthalmos, an eye that does not shut completely. Often it is mild and temporary. In the Istanbul report, lagophthalmos occurred in six instances across the primary and repeat operations of 28 patients' records. All settled in about two weeks with ice, massage and lubricant drops, and none developed a corneal ulcer. That is a small sample, so it shows what a good course looks like, not how often it happens.

The risk is the cornea, the clear window at the front of the eye, which depends on the blink to stay wet. EyeWiki says that for patients expected to have lagophthalmos after surgery, generous lubrication is needed. It also says great care is needed for patients with dry eyes, reduced corneal sensation, an absent Bell phenomenon (the upward roll of the eye when the lids close, which protects it), double elevator palsy or progressive external ophthalmoplegia, so that exposure keratopathy is avoided. A 2025 cohort from Naples makes the same point: lagophthalmos after ptosis repair is well recognised, especially in vulnerable patients, and poor Bell phenomenon can lead to dryness and ulceration.

The practical message is to tell the surgeon about dry eye, previous eye surgery and anything that numbs the cornea before the operation, not after. I explain the closure problem on its own in lagophthalmos: when the eyelids do not close fully, the dryness in dry eye after eyelid surgery, and a lid that sits too high in eyelid retraction after eyelid or brow surgery. An eye that will not close, or that hurts or turns red, is a same-day call.

How often is a second operation needed, and does the type of ptosis matter?

It varies with the technique and with the cause, and the cause matters more than people expect. The same Ben Simon series reported reoperation for residual ptosis in 15 of 272 operations overall (5.5 per cent), but by group it ranged from 3 per cent after Müller muscle conjunctival resection to 18 per cent after external levator advancement. Müller muscle conjunctival resection shortens a small lifting muscle from inside the lid, and external levator advancement tightens the main lifting tendon from the skin side. A 2025 study in Orbit of 240 adults and 404 eyelids found success in 90 per cent of eyelids after Müller muscle conjunctival resection and 79 per cent after levator surgery, and a 2026 report in BMC Ophthalmology found that 108 of 780 patients (15 per cent) at one hospital needed revision. These are different hospitals, definitions and eras, so I would not average them. Read together, they show that a second operation is a recognised part of this surgery, and how often depends on the technique and the cause.

The cause of the droop changes the odds. The Naples cohort followed 122 patients (152 eyes) for a median of about three years and found the droop returned in 35 eyes (23.0 per cent). Return was significantly less frequent in aponeurotic ptosis, where the levator tendon has stretched or come away, than in other forms such as congenital and myogenic ptosis, where the muscle itself is weak. In the authors' analysis, non-aponeurotic ptosis was the only independent predictor of recurrence, with a hazard ratio of 2.44. A hazard ratio of 2.44 means a bit more than twice the risk at any point in follow-up. Weak muscle function is also why a frontalis sling, which links the lid to the brow so the brow lifts it, is used in some cases. A 2025 meta-analysis of congenital ptosis with poor levator function found levator-based and frontalis-based operations comparable for lagophthalmos, with levator-based surgery showing lower recurrence and fewer implant or suture problems. That was in children, so do not carry the numbers over to adults.

What should I ask about complications before ptosis surgery?

Ask what is causing the droop, which operation is planned and why that one, and what the surgeon would do if the lid ended up too low, too high or unable to close. Those three answers carry most of the risk conversation. Add what your eye drops, contact lens use and any dry eye mean for the plan, because prostaglandin analogue drops, a class used for glaucoma, were the strongest predictor of failure in the Orbit study.

Also ask who you ring if the eye will not close at night, and when the lid height will be checked. Ptosis surgery is usually day surgery under local anaesthetic, according to the American Academy of Ophthalmology and you go home the same day. If the answers leave you unsettled, a second opinion before eyelid or orbital surgery is ordinary and sensible. Whether the operation suits your lid at all is covered in ptosis surgery for adults in Malaysia, and my eyelid conditions page sets out how I assess a droopy lid; the wider picture is in what actually makes eyes look tired.

A lid height measured in millimetres deserves a plan measured in the same way: what is expected, what is normal, and when to call.