Drooping eyelids: when it is cosmetic and when it is taking your sight

Blepharoplasty is one of the operations with the best ratio between how little it intervenes and how much it changes the expression: the gaze stops looking tired without the face changing its features. But before getting there, two things are worth separating, and they decide whether the surgery is cosmetic or functional.

The upper and the lower are two problems

In the upper eyelid what is left over is usually skin, weighing down on the lashes. In advanced cases it narrows the field of vision from above, and then it stops being a matter of appearance.

In the lower, what shows are the bags. They are not fat accumulated through neglect or from sleeping badly: it is the fat of the orbit, always there, pushing forward because the septum containing it has weakened. That is why creams, sleep and less salt do not shift them.

When it is no longer cosmetic

There are fairly clear signs that excess skin is affecting vision and not just expression:

• You raise your eyebrows without noticing in order to see better, and end the day with a headache or tension in the forehead.
• Driving or reading, you notice the field "missing" at the top.
• You see worse at the end of the day than in the morning, and the eyelid feels heavy.
• You lift the eyelid skin with a finger and see noticeably better.

That last gesture says the most. If lifting the skin opens up the field of vision, what you have is not a question of beauty.

The question that orders everything: eyelid or brow?

This is the part that explains most poor results. With the years the brow also descends, and a dropped brow pushes skin onto the eyelid and produces exactly the same appearance.

They are different things and are corrected differently. Removing eyelid skin when what has descended is the brow pulls the area downwards, lowers the brow further and leaves a worse gaze than you started with: harder, more closed and difficult to put right afterwards.

Before removing a millimetre of skin you have to know where the excess comes from. If it comes from the brow, what is needed is to lift the brow.

What the recovery is like

• First 48 hours. Swelling and bruising that increase, a gritty feeling and slightly blurred vision from the ointment. Cold locally and head elevated. It bothers little: it is an operation that frightens more than it hurts.
• Days 3 to 7. The bruising reaches its worst and then turns yellow. Stitches out towards the end of this period. You can read and use a screen normally.
• Weeks 2 to 3. Back to social life; make-up from when the stitches come out. Some swelling persists, more obvious on waking.
• Around 6 months. Result settled. In the upper eyelid the scar is usually practically hidden within the crease.

What it does not do

It does not remove crow's feet, which are expression lines and belong to another treatment. It does not change the colour of dark circles when that is pigmentation or a bony hollow. It does not lift the brow. And it does not stop ageing: the skin carries on and the result lasts years, not always.

If you wear contact lenses, have dry eye or have had refractive surgery, say so in the consultation before anything else: dry eye is the commonest post-operative complaint and that history changes the plan.