What’s Aponeurotic Blepharoptosis?

Hello, I’m Dr. Kanazawa, a Japanese plastic surgeon.

If this is your first encounter with the word “ptosis”, you may be wondering what it is all about.

I personally launched this website on May 24, 2012, in order to bring information about ptosis to the general public. And I’ve been slowly building it up.

Please try this article as a first step 🤗

I’ll tell you the 3 causes of blepharoptosis, 6 ways to prevent it, how to self-diagnose it, and 4 ways to deal with droopy eyelids.

At the end, I will show you 14 model cases. You may find someone whose experience matches your own.

What is “Blepharoptosis”?

The part of the word “blepharo-” means “eyelid”. “Ptosis” is “drooping”.

The Achilles tendon is in your ankle. When your Achilles tendon is ruptured, you cannot point your toes. This is because the power of the calf muscles cannot reach your foot. This kind of tendon is also found in the eyelids. This tendon in your eyelid is called “aponeurosis”.

The aponeurosis that lifts the eyelids

The aponeurosis is a muscle-tendon of the levator palpebrae superior. The levator muscle comes from behind and along the top of the eyeball, and its tendon membrane connects to the edge of the eyelid. When the levator muscle contracts, it lifts the eyelid. In other words, it is the muscle that opens your eye. With age or injury, the aponeurosis stops functioning, causing the eyelid to droop.

levator palpebrae superioris muscle
muscle elevates eyelid
levator motion
muscle contraction

Definition of Ptosis

Criteria for Ptosis Requiring Surgical Treatment (Grade B) from the Japanese Society of Plastic Surgeons Guidelines

Quantitative evaluation criteria

  • Margin reflex distance 1 (MRD(1)) of 2 mm or less measured in primary gaze
  • Superior visual field loss of at least 12 degrees or 24%
  • Down-gaze ptosis impairing reading documented by MRD1 of 2 mm measured in downgaze

Qualitative evaluation criteria

  • Self-reported functional impairment from upper eyelid droop
  • Chin-up backward head tilt induced by visual field impairment caused by lids
  • Interference with occupational duties and safety resulting from visual impairment caused by the upper lids
  • Symptoms of discomfort, eye strain, or visual interference due to the upper eyelid position

I bet you have no idea what this technical gibberish is talking about. The point is that your eyelids droop and your field of vision narrows. When the field of vision narrows, it becomes difficult to see things.

What does it mean when the aponeurosis breaks down, making it difficult for the power of the eyelid muscle to be transmitted to the eyelid?

The analogy is that of a torn Achilles tendon.

poping achilles
tendon ruptured


When the power of the eyelid muscle is not transmitted to the edge of the eyelid, the eyelid falls.

The nerves that move the eyelid muscles and the eyelid muscles themselves are healthy but simply fail to transmit power. This lowering of the eyelid is called “aponeurotic blepharoptosis.”

The power source is strong, but there is an error in the mechanism that transmits the power.

For examle,

  • Bicycle with a broken chain
  • A car on a snowy road with worn tires.

No matter how hard the power source tries, it can’t transmit the power…

What causes the aponeurosis to break?

Here are the three main causes of breakage.


You can see this. As we age, the aponeurosis deteriorates. It’s like the elastic in your old underpants.

(2) Mechanical irritation: rubbing the eyes, long-term contact lens wear

When you rub your eyes or wear contact lenses, you put physical strain on your eyelids. It is the same as if you pull or shrink an elastic tube, it will eventually break.

(3)Eyelid Injuries

The strong impact on the eyelid tears the aponeurosis all at once. This is the same as an Achilles tendon rupture.

In short, it is a structural failure phenomenon. Why does the structure fail? The aponeurosis is made up of soft collagen fibers. It is the same as the skin loosening and drooping with age. Sometimes the collagen fibers tear, like stretch marks. As a surgeon, I am keenly aware of the looseness of the aponeurosis connection. It’s like cellophane tape that has lost its adhesive and has deteriorated…

The eyelid hangs on the levator muscle

If you look at it another way, your eyelids are hanging on to your eyelid muscles. They are desperately clinging to them.

If you blink 20,000 times a day, that means that your eyelids are battling against the power of your eyelid muscles. It is hanging on the eyelid muscle like a rodeo cowboy.

You can see that the act of shaking it loose (mechanical stimulation) can cause the aponeurosis to break.

muscle and eyelid
eyelid hanging onto muscle

Can the deteriorated aponeurosis be healed?

Unfortunately, there is no way to restore the original elasticity. A torn aponeurosis also do not heal spontaneously.

Stretch marks are also caused by the tearing of collagen fibers. Once they form, they don’t heal, do they?

What’s the problem with eyelids falling off?

It narrows your vision, obviously. However, before the field of vision narrows, the body tries to raise the eyelids to compensate, which creates unnecessary muscle tension and sympathetic nervous system excitement, resulting in the following symptoms.

  • Stiff shoulders: Tension in the muscles from the back of the neck to the shoulders.
  • Headache: Tension in the muscles at the temples and back of the neck.
  • Eye strain: You get tired from around your eyes to the back of your eyes. You press your fingers between your eyebrows. Related article: “Eyelid Fatigue”.
  • Fatigue: Tiredness due to continued sympathetic nervous system excitement.
  • Anxiety disorders: Imbalance of hormones that control autonomic nervous system balance.
  • Autonomic Dysreflexia: Related Articles “Eyelids were involved in brainstem arousal and sympathetic control”

There were many reports of improvement in these symptoms after treatment of droopy eyelids. This is where the history of eyelid physiology began to be studied in depth.

How to prevent the progression of aponeurotic blepharoptosis

Here are six prevention tips. The conclusion is to treat your eyelids in a delicate manner. The aponeurosis is a soft tissue made up of collagen fibers. It’s a bit of a cliche, but you have to treat these fragile, soft tissues with love.

(1) Don’t pull or rub your eyelids wildly

If you pull, the soft tissue will stretch. When you use eye tape to make double eyelids fold, you pull on the skin when you remove it. You may also scrub off your makeup. Let’s be careful. (Related article: “Are you using the wrong make-up remover?” Use a special cleanser or remover.

(2) Quit wearing contact lenses

Wearing contact lenses for long periods of time not only stretches the aponeurosis, but also causes the Muller’s muscle to lose its function. (Related article: “Why contact lenses cause droopy eyelids to progress”)

(3) Don’t gain weight on your face recklessly

Obesity is an aggravating factor for ptosis (Related article: “Sad news! Obesity is a risk factor for droopy eyelids! ” ) Thick, heavy eyelids can lead to drooping. Try to lose weight in your face. Personally, I recommend reducing your carbohydrate intake (no limit on protein and fat).

(4) Don’t let your eyelids swell

When the eyelids swell, the aponeurosis is stretched. If you are prone to swelling, be careful not to drink heavily or take in too much salt. You may want to avoid crying late at night watching sad movies late at night. Your eyelids will be swollen the next morning.

(5) Encourage circulation of eyelids

Use warm or cooling eye packs to stimulate circulation. Lymphatic massage of the face is also effective. (I have spoken with a woman who said that lymphatic massage temporarily cured her drooping.) The lymph around the eyes gathers in front of the ears on each side and goes down to the neck. Lymphatic massage of the neck and in front of the ears is recommended. The order of massage is neck to face. If the massage is too strong, it will accelerate the sagging of the skin. The massage should be gentle.

(6) Rehabilitation to improve eye power

This is also called “levator muscle training”. Pull your chin back and turn your eyes upward (keep your eyebrows and forehead relaxed) If you do this, the “levator switch” is turned on and the eyelid muscles are easily activated. In the case of aponeurotic ptosis, the power of the levator muscle gradually weakens. As a result, the forehead muscle becomes stronger and the eyebrows start to lift up, changing the appearance of the face. (Related article: “If you want to prevent or overcome drooping eyelids, turn on the levator muscle switch”) Practice four times a day when you stand in the bathroom or on the train.


So, I’ve been training my levator muscles too, stimulating the muscles.

Do I have droopy eyelids? How to Self-Diagnose


Try a method called the brow block test.

Use a wall-mounted mirror or one that stands vertically, such as in a bathroom. This test is to raise your eyelids without using your forehead.

  1. Face the mirror keeping your head level and gently close your eyes.
  2. Look down in your closed eyelids.
  3. Relax your forehead.
  4. Place your own index finger on the eyebrow and hold it in place so that the eyebrow does not move.
  5. Then gently open your eyelids.

If the field of vision is narrowed in this condition (the pupil is covered by the edge of the eyelid), ptosis is highly suspected.

There is also a self-diagnostic check sheet.

What to do if you have eyelid ptosis?

(1) Eye tape or double (lid) adhesive

Eye tapes or adhesives which make double eyelids can temporarily relieve the heaviness of the eyelids. However, in the long term, they can worsen droopy eyelids. They should only be used temporarily.

(2) Suspending your eyebrows with a tape

When you are at home, fix your eyebrows with adhesive tape to suspend them. This will relieve some of the heaviness of your eyelids. (Recommended for severe cases. Be careful not to accidentally go out with it.)

(3) Botulinum toxin injection

Botulinum toxin injections are used to relax the muscles that close the eyes (orbicularis oculi, etc.) The effect lasts for 3 to 6 months and the eyelids will feel lighter.




(4) Surgery

If you have the enthusiasm to fix your ptosis, you can repair the levator muscle aponeurosis. See a plastic surgeon or an ophthalmologist. Before going to see the surgeon, inquire whether he or she treats blepharoptosis.


  • blepharoptosis repair
  • eyelid ptosis repair
  • blepharoplasty

Is ptosis treatment a cosmetic procedure?

The treatment of ptosis is to repair the broken aponeurosis. Although it is a treatment for a phenomenon associated with aging, it is a treatment for functional improvement, just like cataract surgery, dental implant treatment, or treatment for osteoarthritis of the knee. Although there are cosmetic and aesthetic elements, the main purpose is to restore function. It is not just cosmetic surgery.

See before-and-after treatment of actual ptosis patients

Model 1

Over a long period of time, contact lens use may have caused aponeurotic blepharoptosis. The upturned eyelashes are another characteristic of contact lens ptosis.

The patient underwent surgery. The floppy aponeurosis of levator muscle was observed.

Restoring the broken aponeurosis. The muscle itself was healthy.

Repairing the connection of the levator muscle. No resection of the skin is done.

The eyelid muscles are healthy itself. It was made to wait on the bench. Isn’t it a pity? But now the eyelid muscles are ready to play again.


There is a risk of complications from eyelid surgery.

*We are grateful for her consent to use these photos for the purpose of increasing eyelid ptosis awareness. Thank you for your cooperation😊.


Here is a list of celebrities with blepharoptosis that I can think of. A drooping eyelid in itself is also a gentle impression. It does not necessarily mean that all cases should be cured.

Forest Whitaker): Left eyelid ptosis. You can see the pronounced left eyebrow elevation.

Paris Hilton): Left eyelid ptosis


◎The causes and etiology of aponeurotic eyelid ptosis.

Fujiwara, T., Matsuo, K., Kondoh, S., & Yuzuriha, S. (2001). Etiology and pathogenesis of aponeurotic blepharoptosis. Annals of plastic surgery46(1), 29-35.

◎Treatment of aponeurotic blepharoptosis and Horner’s syndrome can restore contraction of the levator muscles.

Matsuo, K. (2003). Restoration of involuntary tonic contraction of the levator muscle in patients with aponeurotic blepharoptosis or Horner syndrome by aponeurotic advancement using the orbital septum. Scandinavian journal of plastic and reconstructive surgery and hand surgery37(2), 81-89.

◎In Japanese women, there was a strong correlation between long-term hard contact lens wear and eyelid ptosis.

Eplasty. 2013 Jun 19;13:e30.Hard contact lens wear and the risk of acquired blepharoptosis: a case-control study. Kitazawa T.

◎ “Could it be that the eyelid opener stretches the eyelid horizontally?”

Orbit. 2012 Aug;31(4):274-8. Blepharoptosis following anterior segment surgery: a new theory for an old problem.
Mehat MS, Sood V, Madge S.

◎BEARD’S PTOSIS.Michael Callahan and Crowell Beard

◎Guidelines of the Japanese Society of Plastic Surgeons (Head and Neck and Facial Diseases)


Above, I presented:

  • What is blepharoptosis?
  • How to prevent ptosis
  • How to deal with
  • self-diagnosis
  • Actual models


  • Did you see that ptosis is a phenomenon that can happen to anyone?
  • Do you have habits that make you prone to ptosis?
  • Did you understand that prevention is the key?

Taking care of your eyelids is taking care of your body and brain.

For other model patients, please go to the next page.

To see the video and photos, please go to the next page. Do any of these resemble someone close to you?






what is aponeurotic ptosis