What’s causing my eyelids to look droopy?

Eyes that look droopy can create the impression that you’re tired or lacking energy or always
sleepy.
Droopy 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’m Dr Amiya Prasad.
I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial Plastic Surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years.
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.
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.
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.
Closing: 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…thank you for your question