Written by Eric Hink, MD, Assistant Professor, Ophthalmology

Oculofacial Plastic Surgery

Age, sun associated skin damage, and heredity all play a role in the changing appearance of our eyelids. The eyelids may become heavy, droopy and hollow leading to an appearance of fatigue, sadness, and disinterest.

Heavy, fallen or droopy upper eyelids can occur in three ways: droopiness of the eyelid itself (ptosis, pronounced “toe-sis”), extra skin on the upper eyelid that hangs over the eyelid margin (dermatochalasis), or eyebrow and forehead descent that pushes the eyelid and eyelid skin down (brow ptosis).

Often patients develop heavy and droopy upper eyelids through a combination of these problems. Surgery to correct heavy upper eyelids may involve upper eyelid ptosis repair (to correct the fallen eyelid), blepharoplasty (to address the extra eyelid skin and fat), or brow lift (to elevate the brow). If these factors affect the upper eyelids and significantly block vision then surgical repair may be covered by insurance.

Upper Eyelid Ptosis Repair

What is ptosis? Ptosis is a medical term that describes a droopy or fallen upper eyelid. This may happen to one eye or both eyes. In most patients the upper eyelid typically rests where it’s lower edge just begins to cover the top of the colored part of the eye (1 mm below the superior limbus). Eyelids that rest below this location when open are fallen or ptotic.

What causes ptosis? The position of the upper eyelid depends on the function of the muscles that lift the eyelid (the frontalis, Mueller’s muscle, and the levator palpebrae superioris or levator). The most common cause of ptosis is a weakening of the attachment primary muscle that lifts the eyelid, the levator. This may result from aging, trauma, or previous eye surgery. Other more rare causes of ptosis include congenital (at birth) weakness of the muscle, and neurologic or muscular disease.

What are the symptoms? Ptotic eyelids may block part of the vision and patients may have difficulty seeing objects above them. It may be difficult to keep the eyes open and patients may develop brow ache or headaches from constant use of the brow muscle (the frontalis) in an effort to lift the eyelids.

What is the treatment? Surgery is directed at tightening the attachment of the levator to the eyelid through an incision that lies in the natural crease of the upper eyelid. Alternatively, surgery may tighten the muscle in the back part of the upper eyelid, Mueller’s muscle, through an incision on the inside of the eyelid. Patients with weakness of the levator muscle may require a “sling” operation to elevate the eyelid.

Upper Eyelid Blepharoplasty

What is Dermatochalasis? The upper eyelid blinks about 18,000 per day. The dynamic movement of the upper eyelid depends on the skin above the eyelid being extremely thin (the thinnest of the body) and loose. With time this skin can stretch and hang over the edge of the upper eyelid. Additionally fat underneath the skin can protrude (especially fat pads in the inner upper eyelid) causing an abnormal puffiness to the upper eyelid. This extra skin and fat of the upper eyelid is termed “dermatochalasis.”

What is an Upper Eyelid Blepharoplasty? The upper eyelid blepharoplasty is a surgery that removes the extra skin and fat in the upper eyelid. The incision is hidden in the upper eyelid crease and becomes virtually undetectable after healing is complete. Each patient’s eyebrows, eye sockets, and eyelid shape (and position of the eyelid crease) are unique and influenced by age, sex, and ethnicity. Surgery is individually tailored to give a natural, nonsurgical appearance.

Surgery is typically performed as an outpatient with local anesthetic or under light, intravenous sedation. Minor bruising and swelling typically resolve within the first two weeks.

Each patient’s concerns and rejuvenation goals are the starting point for a discussion regarding possible surgical and non-surgical interventions. Many techniques may be used together to address each component of the aging face in an effort to produce a natural harmonious result while minimizing cost, risk, and recovery time.

Brow Lift

The eyebrows are one of the most expressive parts of our face. They convey our emotions and expressions as much as a smile or a frown; the high-brow of someone who is awake, alert, relaxed and calm, the furrowed brow can display anger, worry or intensity, the fallen brows of someone who is tired. Women’s brows are typically higher, thinner and arched to peak above the outside corner of the eye.

The skin below the eyebrow typically lies above the top of the bony eye socket where an underlying fat pad softens and hides the eye socket. The eyebrow aesthetically frames the eye, with the skin below the brow serving as a large mat which gives the eyes the correct size and attention. Men have lower, flatter brows with much less skin visible beneath the eyebrow.

What is brow ptosis? Age, heredity, and sun exposure contribute to droopy, or ptotic, brows. This is typically most noticeable near the tail of the brow (where the brow tapers to the temple) in an area where the forehead muscle that lifts the brow is weakest. This causes more exaggerated hooding at the outside corner of our eyelids and worsens wrinkles known as crow’s feet.

What is the treatment? There are numerous surgical techniques designed to elevate the brows and each of these has its own benefits and limitations and should be tailored to each individual’s appearance and anatomy.

Techniques may involve a brow lift from the lid crease (blepharoplasty) incision, an endoscopic brow lift (using a small camera and instruments placed through tiny incisions in the hair line), a pretrichial (an incision just in front of the hairline) brow lift, or a direct brow lift (with an incision just above the eyebrow).