Eyelid surgery: functional and aesthetic reasons

Eyelid surgery is often thought of as a purely cosmetic operation, but drooping eyelids can also get in the way of seeing clearly. Some people seek surgery because heavy upper lids have started to block part of their vision; others are bothered by hooded lids or bags under the eyes. Many have a mix of both concerns. This guide explains the difference between the functional and aesthetic reasons for eyelid surgery, which signs need a prompt medical check, what surgery can and cannot change, and what recovery and the risks involve.

Understanding drooping eyelids

MedlinePlus, the patient information service of the US National Library of Medicine, describes two main problems that can make the upper eyelid droop. In ptosis, the edge of the eyelid sits lower than normal, usually because the muscle that lifts the lid is weak or the nerves that control it are affected. In dermatochalasis, the lid position is normal but there is excess loose skin on the upper eyelid. The two can occur together.

The distinction affects the operation. Blepharoplasty removes excess skin and fat, while ptosis repair includes tightening the eyelid tendon; an eyelid lift may include one or both. The American Society of Plastic Surgeons notes that ptosis needs a different surgical treatment from a standard blepharoplasty, so an accurate diagnosis comes first.

Drooping may be present from birth, develop with ageing, or follow an injury or illness. MedlinePlus explains that most cases are due to ageing, but conditions such as diabetes, stroke, myasthenia gravis, Horner syndrome, tumours around the eye and eyelid swelling, for example from a stye, can also cause it. If an underlying condition is found, it is treated as well.

Functional reasons: when eyelids affect vision

When the upper eyelid hangs low, it can partly block the upper part of your field of vision, or block vision completely if it covers the pupil. MedlinePlus also lists tired or aching eyes and increased tearing among the possible symptoms. Children with a drooping lid may tilt their head back to see underneath it.

MedlinePlus states that an eyelid lift is needed when drooping eyelids reduce vision. It describes surgery as being done for vision problems in more severe cases and for appearance in milder cases. Before surgery for this reason, you may be asked to have your vision checked by an eye doctor. Tests can include a slit-lamp examination and visual field testing, which measures how much of your surrounding vision is blocked. The American Society of Plastic Surgeons also notes that sagging upper eyelid skin can sometimes impair vision and that surgery can help functional problems as well as cosmetic ones.

Drooping eyelids in children

In children, a drooping eyelid is assessed differently. MedlinePlus explains that severe drooping that blocks vision can lead to amblyopia, often called lazy eye, which can cause long-term vision problems. In these cases surgery may be needed promptly. Children with milder drooping need regular eye examinations to make sure amblyopia is not developing, and if vision is not affected, surgery can often wait until about age 3 to 4.

Signs that need a prompt check

Most drooping develops slowly. However, MedlinePlus advises contacting a doctor or eye doctor if:

• one eyelid suddenly droops or closes;
• drooping comes with double vision or pain;
• drooping is affecting your appearance or your vision.

It also recommends seeing an eye specialist (ophthalmologist) for any drooping eyelid in a child, and for drooping in adults that is new or changing quickly. These checks are about finding the cause first, before any thought of cosmetic surgery.

Aesthetic reasons and what surgery cannot change

The American Society of Plastic Surgeons lists several concerns that eyelid surgery can address:

• loose or sagging upper eyelid skin that forms folds;
• fatty deposits that make the eyelids look puffy;
• bags under the eyes;
• lower eyelids that droop and show white below the coloured part of the eye;
• excess skin and fine wrinkles on the lower eyelid.

It is just as important to know what eyelid surgery does not do. MedlinePlus explains that it will not remove wrinkles around the eyes, lift sagging eyebrows or get rid of dark circles under the eyes. The American Society of Plastic Surgeons notes that a drooping brow and excess upper eyelid skin can be related, and MedlinePlus explains that eyelid surgery can be done alone or together with a brow lift or facelift.

The NHS advises thinking carefully about your reasons for cosmetic eyelid surgery, the risks and the fact that results cannot be promised. In the UK, it suggests discussing your plans with a GP first, because a medical condition affecting the eyelids may make surgery unsuitable.

Health factors to discuss

The American Society of Plastic Surgeons describes good candidates as people in good general health without conditions that impair healing, non-smokers, people with a positive outlook and achievable goals, and those without serious eye conditions.

MedlinePlus lists health problems that can raise the risk of complications from an eyelid lift:

• diabetes;
• dry eye or reduced tear production;
• heart disease or blood vessel disorders;
• high blood pressure or other circulation problems;
• thyroid problems, including an underactive thyroid and Graves disease.

The NHS also advises telling your surgeon about any medicines you take that reduce blood clotting. Bring a full list of your medicines and any eye conditions to the consultation.

The operation and recovery

Eyelid surgery can be done under local or general anaesthetic. For the upper lids, the NHS describes a cut along the natural eyelid crease, through which excess skin, fat or muscle is removed, so the scar usually sits hidden in the fold. For the lower lids, the cut is made just below the lashes or on the inside of the lid, and fat is removed or repositioned, sometimes with a little skin. The NHS gives an operation time of about 45 minutes to 2.5 hours, and the majority of patients leave on the day of surgery.

Recovery differs between people, so treat the figures below as a guide and follow your surgeon's instructions. Sources describe the following general pattern:

• most people can see well after 2 to 3 days, though blurred vision, watering and sensitivity to light and wind may occur in the first weeks (MedlinePlus);
• stitches, if used, are removed after 5 to 7 days (MedlinePlus);
• activities are limited for 3 to 5 days, and strenuous activity, including lifting and bending, is avoided for about 3 weeks (MedlinePlus);
• contact lenses are avoided for at least 2 weeks (MedlinePlus);
• many people take about 2 weeks off work, and cannot drive for a number of days (NHS);
• bruising may last 2 to 4 weeks (MedlinePlus), and scars may stay pink for 6 months or longer before fading to a thin line in the eyelid fold (MedlinePlus).

The NHS lists common aftercare advice such as propping your head up with pillows when resting, using a cold pack, wearing sunglasses and not rubbing your eyes. Travelling patients should also note the NHS position on air travel: after an operation on the face, it recommends staying off planes for 7 to 10 days, because clots are more likely both after surgery and on flights.

Risks to understand

The NHS lists expected, temporary effects such as puffy, numb eyelids that are hard to close, irritated or watery eyes and bruising. Possible complications include:

• blurred or double vision;
• dry eyes, and difficulty closing the eyes during sleep, which is rarely permanent;
• eyelids that look uneven, or noticeable scarring;
• a pulling down of the lower lid, which is often temporary, or an outward turning of the lower lid (ectropion);
• bleeding into the eye socket or injury to the eye muscles, which are rare;
• changes in vision and, very rarely, loss of sight.

General surgical risks apply as well, including excess bleeding, clotting in a vein, infection and anaesthetic allergy, though each is small. A result that falls short of what was hoped for is also possible, and some people then consider another operation. If you had surgery in the UK, NHS advice for intense pain or symptoms that worry you is to phone the clinic straight away, or to use NHS 111.

Next steps

Because drooping eyelids can have more than one cause, an assessment that looks at both the eyelids and your vision is a sensible starting point. Learn about the plastic and aesthetic surgery service on our site, or work through the short questionnaire in Find my physician to narrow down whom to consult.