Acquired Blepharoptosis for the Dermatologic Surgeon: Recognition, Assessment, and Nonsurgical Management

Blepharoptosis, or drooping of the upper eyelid, is commonly encountered by dermatologic surgeons due to aging, medical conditions, periocular procedures, and/or inadvertent neurotoxin administration. Proper recognition and management are critical for both functional and cosmetic outcomes.

To review clinically relevant anatomy, diagnostic evaluation, and nonsurgical treatments for acquired ptosis, emphasizing considerations specific to dermatologic practice.

A literature review of PubMed and Embase identified English-language studies and clinical trials addressing the diagnosis and management of blepharoptosis, with emphasis on nonsurgical and dermatologic applications.

Key diagnostic tools include the marginal reflex distance 1, levator function testing, and standardized preprocedure and postprocedure photography. Oxymetazoline 0.1% demonstrates modest but statistically significant improvement in marginal reflex distance 1 and superior visual field improvement in randomized trials. Off-label adrenergic agents and targeted pretarsal botulinum toxin injections may offer adjunctive benefits, although supporting evidence is limited.

Dermatologic surgeons are positioned to identify and manage mild acquired ptosis using validated metrics and nonsurgical options. Selective botulinum toxin placement can be considered in selected cases; supporting evidence remains limited. Appropriately identifying cases that need referral for surgical repair will also benefit patient care by improving vision, daily function, and cosmesis.