What Causes Saggy Eyelids?


Valerie DeBenedette, Senior Medical Editor

Valerie DeBenedette is a science writer who specializes in keeping people informed about medicine and their health. She has more than 20 years of experience writing for newspapers, magazines, and websites and has written about most areas of medicine. For many years, she was a contributing writer to Cosmetic Dermatology and to Drug Topics, the leading pharmacy trade magazine. She also was a contributing editor to The Physician and Sportsmedicine for many years. She has written about most fields of medicine, including dermatology, sportsmedicine, ophthalmology, general surgery, orthopedics, and women's health; as well as public health policy and the pharmaceutical industry. In addition, she is the author of Caffeine, a book for young people. She is a member of the National Association of Science Writers.

November 07 2008

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Eyelids are not something anyone thinks about too often, until they start to make us look tired or old before our time, or worse, start to interfere with vision. That is when having drooping or sagging upper eyelids becomes a reason many people start to think about having an eye lift or blepharoplasty.

Eyelids are not just a flap of skin. They are a complex structure that includes the conjunctival membrane, a thin but strong layer of connective tissue called the tarsal plate that gives the lid some of its shape, subcutaneous tissue including some fat, and skin. A muscle called the levator palpabrae superioris connects to the tarsal plate and acts to pull the eyelid up to open the eye. The orbicularis oculi is the muscle that closes the eye.

An eyelid can look droopy for one of two reasons: either the entire eyelid is not being pulled up as far as it should be or excess skin on the eyelids has started to sag and hangs down over the lower margin of the lid. Loose skin on the eyelids (especially if it is loose enough to sag over the margin of the eyelid) is called dermatochalasis, while a drooping eyelid is called blepharoptosis or just ptosis, which is the word used when any body part is drooping out of its normal position. In either case, if the loose skin or drooping eyelid blocks part of the pupil, it can interfere with sight.

Let's deal with the more serious kind of drooping eyelid first. A ptotic eyelid (either one or both) may be hanging low because of a problem with either the muscles that pull the eyelid up or the nerves that control those muscles. The muscles can become lax or loose due to age, due to damage to the eyelid, or from a muscle or nerve condition. The droopiness caused by age usually comes on gradually as the muscles slowly weaken, but the problem may be more noticeable when a person is tired.

However, ptosis of the upper eyelid can be a symptom of several health conditions, including diabetes, diseases of the nervous system such as myasthenia gravis, or damage to the third cranial nerve that controls the eyelids. Myasthenia gravis is a serious autoimmune neuromuscular disease that results in nerve weakness. One or both eyelids may droop to the point of blocking sight, and in serious cases, the ability to open the eyes may be completely lost. In general, if the ptosis is caused by a systemic muscle weakness, other muscles in the face, head, or body may be affected.

A drooping eyelid can also be a symptom of a brain tumor or stroke, especially if it comes on within a few days or a few hours or if just one eye is involved. If you suddenly experience a badly drooping eyelid, contact your physician.

An eyelid that is drooping can usually be fixed surgically. This surgery would be covered by health insurance if it can be shown that the drooping lid impairs vision. There are several procedures that can be used, most of which shorten the levator muscle or its attachment to the tarsal plate, and some of which create a sling to support the muscle. In cases of severe ptosis that cannot be fixed surgically, such as in severe myasthenia gravis, a person can use a special pair of eyeglasses that have a wire support that presses into the upper lid along the crease of the lid. This support holds the lid up. The person periodically moves the glasses forward (to let the eyes blink) and then back into place.

The type of sagging eyelid caused by excess skin on the upper lid—dermatochalasis—is also sometimes called pseudoptosis. The skin of the eyelids is thinner than almost anywhere else in the body and is easily stretched. As we grow older, we lose subcutaneous fat around the eye, which can cause a hollow look or the appearance of gauntness. The skin that had been filled out by that fat is now hanging loosely and can start to look like crepe paper. This sagging skin can be exacerbated by smoking and sun damage, both of which interfere with the skin's ability to renew itself. Fatigue can make this sagginess look worse.

For most people, this loose skin can make them look older or more tired than they really are, but it is strictly a cosmetic problem. However, for some people, the skin on the upper eyelid has grown so loose that a fold of it is either resting on the eyelashes of the upper lid or even hanging down in front of the margin of the eyelid. This cuts off peripheral vision or even some central vision.

This extra skin can be corrected easily with a surgery called Blepharoplasty. This surgery removes the excess skin and redrapes the remaining skin on the eyelid. The eyes look more wide open, giving a more alert and youthful appearance. Blepharoplasty can be performed by either an ophthalmologist (a medical doctor who specializes in treating eye problems) or a plastic surgeon.