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External approach, or levator advancement, is the most commonly performed surgery to treat ptosis. It is recommended for people with ptosis who have strong levator muscle function.

In an external approach, the oculoplastic surgeon makes an incision in the skin of the eyelid. The surgeon then repositions the attachment of the levator muscle by stitching it to the tarsus, which is connective tissue in the eyelid. This usually results in an elevated eyelid that allows you to see better and is more cosmetically appealing. 

This procedure is performed using sedation to help you relax, although you can still respond to your doctor. The surgeon may ask you to perform certain eye movements, for instance, during the procedure. This can help the doctor to determine how wide your eyelid should open. 

Because the incision involved in this surgery is made in the eyelid crease, the scar is usually hidden.

Your doctor may choose to perform ptosis surgery using an internal approach. This is also recommended for people with strong levator muscle function.

In this procedure, the surgeon turns the eyelid inside out and shortens the eyelid muscles from the inside of the eyelid. Either the levator muscle or Mueller’s muscle—which also plays a role in lifting the lid—is shortened.

When you need less of the eyelid to be elevated, the surgeon typically shortens the Mueller’s muscle. The levator muscle is often shortened when you need more of the eyelid lifted. 

This procedure requires either general anesthesia or sedation. Your doctor can help determine which is best for you.

If you have ptosis and poor muscle function, your eye surgeon may choose to perform frontalis sling fixation. Poor muscle function is most often caused by congenital ptosis and, occasionally, neurogenic ptosis or myogenic ptosis.

In this procedure, a surgeon attaches the upper eyelid to the frontalis muscle—the muscle just above the eyebrows—typically with the use of a small silicone rod that is passed through the eyelid, underneath the skin. Connecting the eyelid to the frontalis muscle with this rod allows the forehead muscles to elevate the eyelid.

Frontalis sling fixation is usually performed using general anesthesia.

For both children and adults, a common side effect of this procedure is an inability to completely close the eye after surgery. Most of the time, this is a temporary side effect that resolves two to three months later. 

Because the eye cannot close during this time, your doctor gives you eye drops and ointment to keep the eye properly lubricated. This helps to guard against infection, irritation, and vision changes, as well as conditions like dry eye syndrome, which is chronic dryness in your eyes.

After any type of surgery for ptosis, your doctor may suggest limiting your activities for up to a week while the eye heals. Doctors also recommend avoiding rubbing your eye or doing anything else that could potentially irritate the eye. Bandages are not necessary. 

Because ptosis surgery lifts the eyelid, a larger surface area of the eye is exposed, leaving it prone to dryness. This is especially true after frontalis sling fixation. In addition, the eyelid can become inflamed after surgery and may not be able to close completely, also contributing dryness.

For these reasons, in the few weeks after ptosis surgery, you may develop new or worsening symptoms of dry eye syndrome. Your eye surgeon may recommend medications or other treatments to keep the eye properly lubricated.