What’s causing eyelids to look droopy and what treatments are available to fix them?
By Dr Amiya Prasad, a Board Certified Cosmetic Surgeon
Eyes that look droopy can create the impression that you’re tired or lacking energy or always sleepy. Drooping eyelids can also affect your vision.
I’ll discuss how I evaluate and help people who come in concerned about droopy eyelids everyday in my practice.
I perform a range of cosmetic eyelid procedures as well as complex reconstructive and revision eyelid surgery.
I routinely perform eyelid procedures that are not usually performed by general plastic or cosmetic surgeons, such as eyelid ptosis correction, as well as surgery for complications after eyelid surgery, such as eyelid retraction and ectropion.
Table of Contents
Why Does One of My Eyelids Droop?
A very common cause of a droopy appearance is the presence of heavily hooded eyelids.
Hooded eyelids are seen when the upper eyelid skin becoming redundant with age and sun exposure.
The medical term for redundant eyelid skin is dermatochalasis.
In some situations where the eyelid hooding is mild, I use botulinum toxin to relax the brow depressor muscles, this is often referred to as a Botox Brow Lift.
When someone has relative skin redundancy resulting in hooded upper eyelids, I perform cosmetic upper eyelid surgery, also called upper eyelid blepharoplasty.
This procedure is customized to address redundant skin, soft tissue and fat.
Although upper eyelid surgery is performed by a wide range of doctors, I cannot emphasize enough how deceptively complex this procedure is.
I often laugh when a colleague uses a phrase like “it’s just a simple bleph”.
It may be simple in their mind when you only perform this procedure in a limited way on a limited category of people.
In my practice, I have a wide range of patients who I perform blepharoplasty for, ranging from young Asians who want double eyelid surgery to older people who need ptosis surgery and brow lifting surgery to fully address their droopy appearance.
Before & After
As a specialist in revision surgery, I can also attest to how much millimeters matter.
A skin shortage after blepharoplasty can cause eye exposure and require skin graft surgery.
When a patient comes in concerned about drooping eyelids, I look for the presence of a condition called eyelid ptosis.
Ptosis is a descriptive term in medicine to describe something that is drooping.
Eyelid ptosis means that the upper eyelid margin is in a lower position than it should be.
Ptosis is frequently seen in the presence of excess skin over the eyelids, or “dermatochalasis”.
It’s particularly important to distinguish if the ptosis is caused by the physical weight of the upper eyelid skin or by the muscle, which lifts the eyelid called the levator muscle or a combination of the two.
I’ve observed that the presence of ptosis is frequently disregarded by general plastic surgeons.
These patients often feel that they went through the trouble of having cosmetic eyelid surgery but they still look very tired.
The most common cause for ptosis in adults is the atrophy, thinning or stretching of the tendon or aoponeurosis of the muscle, which lifts the eyelid called the levator muscle.
The word “levator” is spelled like the word elevator, without the letter “e”.
If I suspect a neurologic cause for eyelid ptosis, I refer my patient to a neuro-ophthalmologist for evaluation.
You can also be born with ptosis, a condition called congenital ptosis.
Again, most commonly, ptosis in adults due to thinning or stretching of the levator muscle and is referred to as involutional ptosis.
The levator muscle can also be affected by trauma directly as well as from swelling after trauma.
As stated earlier, physical weight on the eyelid from upper eyelid skin and skin below the eyebrow can physically weigh the eyelid down causing what is categorized as “mechanical ptosis”.
I perform a ptosis evaluation to determine the eyelid height and strength of the levator muscle.
In addition I perform other ophthalmologic measurements and examination to insure you have proper eye function after surgery.
There are different surgical procedures to address ptosis.
In order to address eyelid ptosis, one of the more frequent procedures I perform is to shorten a muscle from behind the eyelid called Mueller’s muscle.
This procedure, called conjunctivamuellerectomy, is done for mild eyelid ptosis and I often perform this procedure at the same time when I perform cosmetic blepharoplasty.
In other situations, I perform surgery directly on the levator muscle.
These procedures include levator advancement and levator resection.
Typically this is done when the levator muscle function is good.
For more severe ptosis cases where there is little to no function of the levator muscle I create a connection to the muscle that lifts the brow called the frontalis muscle, in a procedure called a Frontalis Sling.
It is challenging to achieve the optimal height, contour and symmetry in ptosis surgery.
I often have the patient sit up during surgery so I can see how they look with gravity.
I routinely perform eyelid surgery under local anesthesia with LITE IV sedation.
My patients recover much faster than they would under general anesthesia and they typically go back to work in about 1 week
A condition that may appear like the eyelids are drooping often seen with eyelid ptosis, is hollowing above the upper eyelids.
This appearance can be seen after fat removal when someone has had previous cosmetic upper eyelid surgery.
This appearance can also be due to fat and bone volume loss due to aging.
I find that enhancing the volume above the upper eyelid can restore the character of the eyes and improve a drooping appearance.
I prefer to use a hyaluronic acid filler placed precisely with a cannula for this area.
I have performed fat grafting for this area before the hyaluronic acid fillers were an option.
Fat grafting is less predictable and prone to complications, which are difficult to manage.
I like the predictability, precision, safety and reversibility of hyaluronic acid fillers, which can be done in my exam room as opposed to in the operating room where fat grafting is performed.
The appearance of drooping eyes is a common issue caused by different conditions.
The art is first understanding what outcome will result in a naturally aesthetic outcome.
A proper evaluation by a specialist to identify the specific anatomic factors, which can be skillfully addressed is critical for a successful result.
I hope you found this information helpful.
See also How to Fix Drooping Mouth Corners