Surgery was supposed to cure it,ptosisbut it has come back. Have you ever experienced that?
What you'll learn in this article
- Accurate definition of "recurrence" of ptosis and how to distinguish it
- Differences in recurrence rates between congenital and acquired causes, and the surprising age group most prone to recurrence
- Mechanisms that trigger recurrence (loosening of sutures, material degradation, residual fat)
- Reality of revision surgery (difficulty, success rates, risks of overcorrection and complications)
- What to be careful about after surgery to prevent recurrence
Every time you look in the mirror, thinking "maybe my eyelids are drooping again" is truly distressing. After summoning the courage to have surgery, when your field of vision narrows again and you suffer from forehead wrinkles and shoulder stiffness, many people become discouraged, thinking "Is there an unfixable cause in my eyes?" However, recurrence of ptosis and asymmetry between the eyes are not problems unique to you alone—they can occur at a certain probability depending on anatomical factors, aging, and surgical methods. This article provides a detailed explanation based on the latest international medical literature data of the true reasons for recurrence and the real state of revision (re)surgery. Why does ptosis, which was treated at great expense, recur? The answer was hidden in an unexpected "persistence of certain tissue" and "age-related factors."
What does it mean for ptosis to "recur"? (Definition and how to identify recurrence)
The phenomenon of the eyelid drooping again after ptosis surgery is called "recurrence," and in medical research, clear criteria have been established. According to a study investigating long-term postoperative outcomes of congenital ptosis (DOI: 10.1016/j.ajo.2016.12.013), recurrence is defined as "a decrease in the postoperative eyelid height (MRD: distance from the center corneal reflex to the upper eyelid margin) to less than 50% of the initial postoperative MRD (Ho et al. 2017)."
In other words, if the eyes were wide open immediately after surgery but the eyelid droops over time and the field of vision becomes obstructed again, it is considered a recurrence. Remarkably, when certain conditions are met after surgery, the risk of recurrence increases by "11-fold" (the reason for this striking figure will be explained later). As a means of identification, if you begin to look at things with your chin raised (chin-up posture) as before surgery, or if you unconsciously pull your eyebrows up using the forehead muscles (frontalis), this may be a clear sign of recurrence.
Congenital vs. acquired — How do recurrence rates differ? (Comparison based on paper data)
The recurrence rate of ptosis varies greatly depending on whether the cause is "congenital (from birth)" or "acquired (due to aging or prolonged contact lens wear, etc.)," as well as the patient's age and the surgical technique chosen.
Recurrence data in congenital ptosis
A large-scale study conducted in Taiwan over 10 years involving 319 cases (390 eyes) reported that the overall recurrence rate was 14.1% (55 eyes) (Ho et al. 2017). When analyzed by surgical technique, patients who underwent frontalis suspension (FS) had a recurrence rate of 37.2% (Ho et al. 2017), whereas patients who underwent levator muscle shortening (LMR) had only 6.8%, indicating that suspension technique carries significantly higher recurrence risk. Furthermore, the recurrence-free survival rates at 1 year, 5 years, and 10 years post-op were 97.3%, 80.5%, and 76.7% in the LMR group, respectively, whereas they were 90.9%, 42.9%, and 20.8% in the FS group, demonstrating that the effect is lost rapidly over time.
Age-specific recurrence rates in acquired ptosis
Did you know that the highest recurrence rate is not in "elderly people with weakened tissues," but in "people under 20 years old"?
According to a study of 600 cases of acquired ptosis treated with the non-incision technique (double-point fixation) extracted from 52,281 cases of data from within Japan, the overall re-operation rate due to suture loosening was 22.3% (Okumura et al. 2025). However, when stratified by age, the following significant differences were observed.
In this way, a U-shaped trend emerged, with the youngest age group (under 20 years old) showing a significantly elevated re-operation rate, followed by a renewed increase in risk among the elderly (60 years and older).
Why does it droop again after surgery? Mechanisms of recurrence (muscle-tendon loosening, adhesion, aging)
The mechanism of recurrence varies depending on the surgical technique used and the condition of the patient's tissues. Three main factors are considered:
1. Suture loosening and age-related factors (tissue elasticity)
In non-incision methods such as the burial technique, loosening of the sutures placed on the levator aponeurosis or tarsal plate is the primary cause of recurrence. The reason the recurrence rate exceeds 40% in the young age group (under 20 years old) is that young people have high skin elasticity and soft orbicularis oculi muscles, making it difficult to form strong adhesions, and the sutures tend to slip due to mechanical forces from repeated blinking. Conversely, in elderly people 60 years and older, aging causes the skin to thin and collagen and elastin to decrease significantly, lowering the structural integrity of the tissue and making the sutures more prone to loosening.
2. Physical changes and degradation of silicone rods (artificial materials)
In the case of "frontalis suspension using silicone rods" performed for severe congenital ptosis, degradation of the material embedded in the body directly leads to recurrence. In a study analyzing silicone rods removed from patients with recurrence under electron microscopy, the breaking strength decreased by approximately 50% within 3 years post-op (Kim et al. 2017), and numerous cracks and fragments were found on the surface and cross-section, with the structure itself found to be collapsing.
3. Adhesion failure due to residual fat tissue (ROOF, etc.)
During surgery, if fat in the upper eyelid (fat posterior to orbicularis oculi: ROOF, or orbital fat) remains, it acts as a physical barrier and can impede the intended stable adhesion between tissues. One study found that the re-operation rate in the group where fat was removed was 17.0%, whereas in the group where fat was not removed, it reached 34.1% (Okumura et al. 2025).
Success rates and risks of revision surgery — Reality as shown by papers (difficulty of re-operation, complication rates)
Difficulty and success rates of revision surgery
Revision surgery becomes more difficult than the initial surgery because scar tissue forms from the first operation and the original anatomical structure is disrupted. However, data analyzing 59 cases of under-correction revision surgery showed that 25.4% achieved sufficient correction and 61.0% achieved normal correction (Park et al. 2023), with over 86% of patients in total achieving favorable results.
Complications dramatically increase recurrence rates
Specific postoperative complications dramatically increase the risk of recurrence. According to multivariate analysis data of congenital ptosis:
Risk of overcorrection (excessive elevation)
In revision surgery, overcorrection was observed in 17 of 59 cases (28.8%). The reason is that during re-operation, the levator muscle has lost its elasticity, so if it is adjusted too high during surgery, it will not descend to a natural height postoperatively.
Management of left-right asymmetry
Patients with a preoperative difference of 1 mm or more in eyelid height between left and right had a reoperation rate of 42.7%, which was significantly higher compared to patients without asymmetry (28.1%) (odds ratio 1.90).
One reason why correction of left-right differences is difficult is "Hering's law." When one eyelid is raised, the other eyelid drops due to balance in neural transmission in the brain. According to one report, in approximately 4% of patients after unilateral ptosis surgery, the contralateral eyelid dropped 1–2.5 mm.
A "two-stage approach" has been shown to be effective as a management strategy. The method involves first operating on the more severely affected eye, then waiting approximately 6 months postoperatively before precisely matching and operating on the other eye.
What you can do postoperatively to prevent recurrence
1. Choosing the appropriate surgical timing (especially in children)
In congenital blepharoptosis, the recurrence rate reaches 73.3% when surgery is performed before age 1 (11.7% for age 1 and older). Unless there is severe vision impairment, waiting until around age 5–6 is an important strategy for preventing long-term recurrence.
2. Thorough postoperative inflammation and infection prevention
"Surgical site infection" increases the risk of recurrence 9.45-fold. After surgery, it is necessary to use prescribed medications correctly, sleep with the head elevated, and manage swelling with cold packs. Strenuous exercise should be avoided for 7 days postoperatively.
3. Eliminating risk factors at the surgical planning stage (fat removal)
For patients with thick eyelids, appropriate removal of ROOF or orbital fat during surgery is expected to reduce the reoperation rate by approximately half.
"What about my case?"
Book a free consultation
We do not engage in high-pressure sales. Please feel free to reach out.
Summary of this article
- Recurrence rates vary by age: Recurrence risk is particularly high in young people under 20 years old (41.0%) and in elderly people over 60 years old, which is related to skin elasticity and tissue strength.
- Degradation of artificial materials can also be a cause: In suspension surgery using silicone rods, the strength is halved approximately 3 years after surgery, and material rupture or displacement of the rod causes recurrence.
- Complications dramatically increase the risk of recurrence: Inflammation-related complications such as postoperative entropion (11.25-fold) or surgical site infection (9.45-fold) are powerful risk factors for recurrence.
- Correction of left-right differences requires care: Because of Hering's law, preoperative left-right difference is a major factor in reoperation. A two-stage surgery with intervals may be effective in some cases.
- Fat removal contributes to recurrence prevention: If eyelid fat is left in place, the thread tends to slip; data show that proper removal can reduce the recurrence rate by half.
Recurrence and left-right asymmetry in blepharoptosis always have underlying medical causes and mechanisms. Even if the first surgery did not go as planned, there is no need to give up. By accurately assessing your current condition and tissue characteristics, appropriate revision surgery is entirely possible. If you have any concerns, please feel free to consult with us.
References
- Ho et al. 2017. Factors Associated with Surgical Outcomes in Congenital Ptosis: A 10-Year Study of 319 Cases. Am J Ophthalmol. 2017 DOI
- Suga et al. 2017. Preoperative asymmetry is a risk factor for reoperation in involutional blepharoptosis. JPRAS. 2017 DOI
- Kim et al. 2017. Analysis of the causes of recurrence after frontalis suspension using silicone rods for congenital ptosis. PLoS ONE. 2017 DOI
- Unknown et al. 2023. Surgical success rate and factors affecting outcomes of conjunctivo-mullerectomy for ptosis. Sci Rep. 2023 DOI
About the author of this article
Hiromitsu NakamuraPhysician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
With a track record of research presentations at domestic and international academic conferences, he is also involved in technical guidance and education for Zetith Beauty Clinic as a whole. He specializes in precision aesthetic medicine based on anatomical principles and pursues natural results tailored to each individual's skeletal structure and tissue.