Drooping Upper Eyelids
The two most commonly performed upper eyelid surgeries are blepharoplasty and ptosis repair. While the two surgeries can be performed together, they correct different problems. The distinction between the two is a source of confusion for many patients.
Dermatochalasis: excess skin and tissue hanging over eyelashes
After blepharoplasty (same patient)
Upper eyelid blepharoplasty may also be referred to as 'eyelid lift', 'lid lift', and 'cosmetic lid surgery'. This procedure removes excess skin and fat from the upper eyelids, a condition called dermatochalasis. Patients with mild dermatochalasis complain that their eyelid skin folds make their eyes look tired or smaller, or interfere with eyelid makeup. In severe cases, dermatochalasis will hang over the eyelashes and cause a “hood” over the patient’s vision. By eliminating heavy folds of skin and fat, blepharoplasty makes eyelids lighter and more visible, and opens up vision. Blepharoplasty is performed under local anesthesia (numbing injections in the eyelid) with or without sedation. An incision is made in the upper eyelid skin crease, and excess skin above the incision is trimmed away. Any bulging fat is also removed. The skin is closed with stitches along the original eyelid skin crease. Dr. Lee uses dissolving stitches which melt away on their own over 7-10 days. After blepharoplasty, patients report lighter eyelids, more visible eyelids, more open vision, and a more youthful appearance (see photos). The incision remains hidden in the eyelid skin crease and after healing, the eyelids have a very natural appearance--it is usually very difficult, if not impossible, to detect that the patient underwent surgery. After blepharoplasty, patients frequently report acquaintances complimenting them on an improved appearance without being able to identify what has changed. Blepharoplasty may be covered by insurance if the skin folds are causing direct obstruction of central vision.
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Ptosis repair is a surgery which addresses drooping of the eyelid itself (ptosis), as opposed to a drooping skin fold. Patients with ptosis complain of obstructed vision, hooded vision, or fatigue in their eyelids. Ptosis repair raises the eyelid by shortening the connection between the eyelid and the muscle that lifts it (levator palpebrae superioris, or levator for short). Contrary to popular belief, the eyelid is not raised by removing skin, as this would make the eye difficult to close. Ptosis repair is almost always performed under local anesthesia with sedation. An incision is made either in the eyelid skin crease or on the undersurface of the eyelid, depending on the type and degree of ptosis. Through this incision, the connection between the eyelid and levator muscle is shortened so that the eyelid is hanging higher from the muscle. In most patients, the surgery simply recreates the same connection that used to exist before gravity and age stretched it. Depending on the type of ptosis repair, stitches may need to be removed after surgery. After ptosis repair, patients report more open vision and a more alert appearance. As with blepharoplasty, it is virtually impossible to detect the ptosis repair incision. Ptosis repair is usually covered by insurance because the eyelids are directly obstructing vision.
Some patients have both ptosis and dermatochalasis and require both ptosis repair and blepharoplasty simultaneously.
See Gallery for additional photos
Ptosis: drooping eyelids directly obstruct vision
After ptosis repair (same patient)
Note that eyelid skin has not been removed
Frequently asked questions and answers about upper eyelid surgery
Will insurance cover my eyelid surgery?
Insurance covers ptosis repair in most cases because the eyelids are obstructing vision. Insurance may cover blepharoplasty if the skin folds are hanging over the eyelashes and directly obstructing central vision, but certain specific requirements must be met.
What are the risks of surgery?
As with any other surgery, eyelid surgery carries a small risk of infection and bleeding. Some patients notice their eyes feel more dry after eyelid surgery. This can be controlled with lubricating eyedrops and other treatments. Because surgery is not an exact science and healing is not completely predictable, revision may be necessary, though it is unlikely. Blindness has also been reported after blepharoplasty or ptosis repair, but is extremely rare. The incidence of this complication has been calculated at 0.005% (5 thousandths of 1 percent; Ophthal Plast Reconstr Surg. 2004 Nov; 20(6):426-32). Note that a patient in Georgia is three times more likely to die from a car accident during a given year than lose sight in one eye from eyelid surgery (Georgia motor vehicle death rate 0.015% in 2016).
How long will it take to recover?
Expect to be very bruised and swollen after surgery. Different people heal at different rates, but about 70% of the swelling and bruising is gone after one week. About 90% of the swelling and bruising is gone after two weeks. After two weeks, it is often difficult to tell that a patient has had eyelid surgery.
When will I be able to return to work?
People undergoing only upper eyelid surgery generally feel comfortable returning to work after 1 to 1½ weeks. People undergoing lower lid surgery alone or four lid surgery often take 1½ to 2 weeks to return to work, although many return sooner.
When will I be able to resume normal activities?
You will need to avoid strenuous activity for at least one week after surgery, but normal household activities such as reading, watching TV, and computer work are all acceptable. Patients are recommended to not drive for one week. Gentle exercise may resume one week after surgery and full exercise two weeks after.
Will I be asleep for the surgery?
No. Sedatives will be given to help you relax, and anesthetic will be injected in your eyelids to eliminate pain, but you will not be unconscious. In an ambulatory surgery center, sedation will be given by vein and will be so powerful that you will neither feel the numbing injections nor remember the surgery. If surgery is performed in our office, only mild oral sedation will be given.
Will the surgery be painful?
The numbing injections are moderately painful, but will eliminate pain afterwards. Some additional injections may be necessary during the procedure to maintain numbness, but these are even less painful than the first injections. If surgery is performed in an ambulatory surgery center, heavy sedation will block the pain of the injections.
How much pain will I have after surgery?
Surprisingly little. The vast majority of patients need no more than acetaminophen (Tylenol), and most do not even need that.
Will I have visible scars?
No. The incisions for upper eyelid surgery are hidden in the eyelid crease and are essentially invisible after healing.
When will I need to be seen again?
You will be seen seven or eight days after surgery, then three to four months later.
Will the stitches need to be removed?
Most likely not. In most cases, dissolving stitches are used and need not be removed. In certain people who have a history of reaction to sutures, nylon sutures will be used and will require removal about 1 week after surgery.