Drooping eyelids: excess skin, a lowered brow or ptosis

Is there excess skin on the eyelid?

EyeWiki, the American Academy of Ophthalmology’s (AAO) medical encyclopaedia, calls loose, redundant eyelid skin dermatochalasis and identifies ageing as a common cause. It is often accompanied by protruding fat. When this tissue hangs over the eye, it can reduce peripheral vision.

Has the eyebrow descended?

Two different situations bring people to the clinic with the same phrase: “my eyelids feel heavy”. One is excess upper eyelid skin. The other is an eyebrow that has descended and pulls the eyelid down with it. A drooping eyebrow also changes facial expression and may make someone look angry or tired. EyeWiki emphasises the need to look at the eyebrow’s position and shape to distinguish the two.

Is it ptosis?

In ptosis, the upper eyelid droops over the eye. The AAO explains that in adults this usually happens because the levator muscle, which lifts the eyelid, stretches or separates from the eyelid, due to age or an injury to the eye. It sometimes occurs after certain eye operations and, rarely, because of diseases or tumours affecting that muscle. Cleveland Clinic adds that in other cases the cause is damage to the nerves controlling the eyelid. Ptosis may restrict or block vision.

They look similar, so examination is needed. Eyelid assessment is not limited to the skin: it distinguishes excess skin from a descended eyebrow, because the solution differs, and checks whether the eyelid itself is drooping.

The consultation also reviews vision and tear production, ophthalmic history, medication, allergies and smoking. Attention is paid to risk factors such as thyroid disorders, ocular dryness, hypertension, diabetes or glaucoma, and a history of dry eye or retinal detachment.

If excess skin interferes with vision, EyeWiki describes how this is documented: with a visual field test, with the eyelid in its usual position and lifted.

If there is excess skin, upper blepharoplasty removes it and, when examination indicates it, also fat and muscle. The incision is placed in the natural eyelid crease, concealing the scar. When excess skin interferes with vision, the procedure can improve the visual field. It does not remove facial wrinkles or correct a drooping eyebrow, as SECPRE also notes.

If the eyebrow has descended, a brow lift raises it and reshapes its position and form. It does not change the shape of the eye or treat eyelid bags. It is often considered alongside upper blepharoplasty.

If it is ptosis, the approach changes. Upper blepharoplasty alone does not correct every cause of drooping eyelids, and ptosis is one of them. The AAO and Cleveland Clinic describe surgery that acts on the levator muscle: it is tightened and, in more pronounced ptosis, may be shortened and reattached to the eyelid. It needs its own assessment.

When it appears suddenly. Cleveland Clinic advises seeing an eye specialist if an eyelid suddenly starts to droop or close, and seeking advice for any double vision or pain.

There is a combination worth knowing: a drooping eyelid on one side, a smaller pupil in that eye and reduced sweating on that half of the face. These are the signs of Horner syndrome, and Cleveland Clinic recommends seeing a doctor as soon as possible. In these cases, do not wait for a facial surgery appointment: see your doctor or attend an emergency department.

Swelling and bruising gradually ease during recovery. Temporary blurred vision and dry eye are also assessed. Possible complications include infection, bleeding, prolonged oedema, difficulty closing the eyelids completely, asymmetric healing and, exceptionally, changes in or loss of vision. The result may not be as expected and may require another procedure.

These complications are exceptional. At the consultation, following medical assessment, risks are explained individually according to each patient’s characteristics. A brow lift has its own risks, detailed on its page.