Sagging & Hooded Eyelids

What is the anatomy of the periorbital area and eyelids?

The eye socket is composed of four bones. The frontal bone of the skull (forehead) defines the upper portion, and contains the brow ridge (superciliary arch). The lower portion is formed by the zygomatic bone and the maxilla (upper jaw). Two small lacrimal bones sit next to the nose to complete the circular orbital area.

The Anatomy of the Eye

The eyeball sits within the eye socket suspended by small ocular muscles, which control eyeball movement, ligaments, and the large optic nerve. The eyeball consists of the clear cornea, white sclera, and pigmented iris. The iris is adjusted by the sphincter muscle which circularly constricts or dilates to change pupil size and the amount of incoming light.

The skin, fat, and muscle tissue surrounding the eye is comparatively very thin. Facial muscles provide an extensive and continuous range of motion for expression. The lacrimal gland sits under the skin on the upper outer eye and produces tears which run down and towards the nose into the collecting duct. The lacrimal caruncle is the red mound on the medial (towards the nose) portion of the eye which produces secretions for eyeball lubrication.

The upper eyelid and lower eyelid are lined on the inside with conjunctival tissue, contain the hair follicles for eyelashes on their margins, and meet at the medial (nose side) and lateral (ear side) canthi. They are controlled by small eyelid muscles. The palpebral fissure is the natural separation of the eyelids when open.

What are the causes of sagging and hooded eyelids?

Sagging and hooded eyelids can be caused by genetics, certain medical conditions, and natural aging. As we age, the already thin skin around the eye continues to degrade due to progressively decreasing collagen and elastin production (two important substances for skin elasticity and appearance), while we simultaneously accumulate years of daily wear and tear leading to accompanying muscle weakness. These factors cause eyelids and the skin around the eye to lose its structure and begin to droop or sag.

Genetics also plays a major role in eyelid appearance. People of all ethnic groups may experience naturally hooded or sagging eyelids, however, individuals of Asian descent are especially predisposed to hooded eyelids or a so-called monolid. It is believed that thousands of years of fine tuning by Mother Nature has naturally led to Asian people lacking a distinct upper eyelid crease or supra palpebral fold due to underlying bone structure and accommodations for the environment many Asian ethnicities originated in.

What are the main concerns related to sagging and hooded eyelids?

There are numerous distinct and unique concerns related to the appearance of both the upper eyelid and lower eyelid. The umbrella term “eyelid malpositioning” captures abnormalities of the normally six to seven millimeter space from the eyelid crease to the eyelid margin. Medical terms like entropion (inward turning of the eyelid), and ectropion (outward turning of the eyelid) may be contributing factors to overall malpositioning. The subcategories of hooded and sagging eyelids are detailed below:

• Eyelid Ptosis: Refers specifically to upper eyelid drooping or sagging. Ptosis can be caused by improper function of the levator muscle which controls movement of the upper eyelid, and can also result from loss of skin structure and integrity secondary to aging. Eyelid ptosis can affect men, women, and children. In children, the condition is treated quickly to prevent development of lazy eye or cross eye. Trauma can also cause eyelid ptosis.
• Sagging Lower Eyelid and Sagging Upper Eyelid: Refers to a drooping or inappropriately oriented eyelid. Eyelids may appear this way from natural aging leading to loss of skin tone and integrity, medical conditions (like thyroid and neurological disorders), genetics, or acquired through trauma. An entropion or ectropion condition may be a component of a sagging eyelid.
• Upper Eyelid Fold: Also known as a hooded eyelid, this refers to upper eyelids that lack a definitive crease. This is very common in Asian cultures and causes the “monolid” appearance or a lack of a distinctive curving upper eyelid.

Who may wish to correct their sagging and hooded eyelids?

Whether caused by genetics or acquired through aging, trauma, or medical illness, individuals with sagging or hooded eyelids that interfere with appearance, or possibly vision, may consider an eyelid procedure.

Individuals of Asian descent can benefit from unique and highly specialized procedures for addressing hooded eyelids. Any candidate with eyelid malpositioning or other abnormalities who has ruled out underlying medical illness can consult with a plastic surgeon to determine their best treatment option.

How can someone change the effects of sagging and hooded eyelids?

Blepharoplasty is the umbrella term for surgeries performed on the upper eyelid or lower eyelid. Depending on your unique concern, numerous procedures with varying levels of invasiveness exist to alter eyelid anatomy restoring both appearance and function.

For Eyelid Ptosis:

These procedures are generally aimed at correcting the position and function of the upper eyelid by altering the connection of the eyelid to the musculature surrounding the upper portion of the orbit. Eyelid Ptosis Surgery External Approach, Eyelid Ptosis Surgery Internal Approach, and Eyelid Ptosis Frontalis Sling Fixation are different techniques for accomplishing this.

For Eyelid Malposition:

There are various classifications of eyelid malpositioning that can be corrected with different procedures depending on the specific concern.

• Generally misaligned/malpositioned eyelids: This can be due to genetics, aging, trauma, or a previous blepharoplasty. Eyelid Malposition: Scar Excision and Spacer, Lateral Canthal Suspension Canthopexy for Lower Eyelid Malposition, Lateral Tarsal Strip Canthoplasty for Lower Eyelid Malposition, and Lower Eyelid Malposition: Massage and Steroid Injection can be utilized to restore eyelid appearance and function.
• Entropion: Is specifically corrected through a Corner Sutures for Entropion procedure. Entropion (inward turning of the eyelid) can affect both the upper and lower eyelids.
• Sagging Lower Eyelids: Are corrected through a Lower Eyelid Blepharoplasty Transconjunctival Approach or Lower Eyelid Blepharoplasty Transcutaneous Approach. These utilize slightly different surgical techniques to alter excess skin, fat, and muscle tissue.
• Sagging Upper Eyelids: Caused by tissue degradation from aging or trauma, this can be addressed with an Upper Eyelid Blepharoplasty. This surgical procedure removes or alters excess skin, fat, and muscle tissue to restore appearance.

For Upper Eyelid Fold:

These surgeries are mostly aimed towards individuals of Asisan ancestry to correct the lack of a definitive upper eyelid crease. Asian Blepharoplasty, Asian Blepharoplasty Open Incisional Approach, and Asian Blepharoplasty Partial Incisional Suture Technique utilize slightly different surgical techniques to reconstruct the supra palpebral fold.

For a comprehensive look at all the treatment options outlined above, check out our guide to Eyelid Correction Solutions.