Drooping eyelids and eyelid lifts*

With this post, I want cover the different types of drooping eyelids. Drooping eyelids are the most common reason new patients visit our office. Drooping eyelids can result from several different problems. The two most common types of drooping eyelids are ptosis (pronounced ‘toe-sis’) and dermatochalasis (pronounced der-mato-ca-ley-sis); take a look at the photos below. The photo set on the left represents a before-and after image of a patient with ptosis. The photo set on the right is a patient with dermatochalasis, before and after a 'lid lift.' I think understanding the difference is important, because surgery to fix each problem is different. Ptosis is a droop of the eyelid itself, whereas dermatochalasis is excess eyelid skin cascading over the eyelashes. I regularly use the analogy of a garage to explain the difference.

In the garage analogy, the eyelid is similar to a garage door and excess eyelid skin is like an awning blocking the door. A garage door that is too low is like ptosis, a condition where the eyelid itself is too low (above left). Dermatochalasis is similar to an over-sized, heavy awning blocking our view into the garage (above right). With dermatochalasis, excess skin prevents us from seeing a patient’s whole eye.

In patients with excess eyelid skin, the eyelid itself is often in good position behind the extra skin. But this isn’t always the case: sometimes there is so much extra eyelid skin that the skin acts like a veil, hiding a drooping eyelid behind it. Put another way, some patients have both extra skin and a drooping eyelid, meaning they have both ptosis and dermatochalasis combined. In our analogy, this is the equivalent of having a large awning in front of a garage door that is too low. This is where knowing the difference between excess eyelid skin (dermatochalasis) and a low upper eyelid (ptosis) is important, because surgery to remove extra eyelid skin will not fix a drooping eyelid. In the case of our analogy, this would be like trimming back an awning in front of a garage, only to find out that the garage door behind the awning was too low.

I mentioned earlier that surgery to fix excess eyelid skin is very different than raising a drooping upper eyelid. Fixing excess eyelid skin is the more straightforward of the two surgeries. In this surgery, trimming back the excess skin generally reveals a wider field of view. This surgery is called blepharoplasty, or commonly a ‘lid lift.’ Fixing a drooping eyelid (ptosis) is more complicated. Let’s carry our garage analogy a little further. A garage has a motor to lift the door and a chain connecting the motor to the door. The eyelid is similar, with a muscle that lifts the lid and a tendon-like structure connecting the muscle to the eyelid. If a garage door is too low, you could image taking out chain links between the motor and the door would help raise the door. Surgery for drooping eyelids (ptosis surgery) is similar – tighten the connection between the eyelid and the lifting muscle to raise the garage door. There are a number of ways to tighten the connection between the eyelid and the lifting muscle, but the underlying strategy is the same: tighten the connection and raise the eyelid.

I think understanding the difference between excess eyelid skin and a drooping eyelid is especially important if you are trying to compare your eyelid surgery to a friend that also had eyelid surgery. It’s possible they had surgery simply to remove excess skin - a ‘lid lift.’ This is very different than surgery to tighten the connection between the eyelid and the lifting muscle (ptosis surgery). Because the surgeries have different risks and benefits, comparing ptosis surgery to a ‘lid lift’ is like comparing apples to oranges. My take home point is that not all eyelid surgeries are the same and it is important for your surgeon to match the eyelid surgery to your problem.

*Any information on this website is informational and does not replace the need to see an eye care professional