Eyelids: Saggy Upper Eyelids and Baggy Lower

Cosmetic surgery of the eye areais a large and complex field. Many aspects need to be considered, including the eyelids, the eyebrows, the corners of the eyes, the skin around the eyes, and the upper cheeks. Each of these areas features to be assessed both in isolation, and in terms of its effect upon other features. (You may notice I have not mentioned the eyeballs themselves, but these wondrously complex organs are surprisingly robust and usually remain relatively unchanged in appearance throughout our lives.)Let’s consider each of these parts of the eye in turn, and consider how their appearance may be improved through surgery.




As we age, our eyebrows tend to fall, due to the effects of gravity and gradual weakening of the suspensory muscles of the forehead. This in turn can cause the skin of the upper eyelid to gather into an unattractive festoon over the lash line. Many people subconsciously compensate for this by using their forehead muscles to raise the brow, which can lead to prominent, deeply-etched horizontal forehead wrinkles. Treating these wrinkles with Botox can sometimes have the adverse effect of unmasking the eyebrow droop and causing increased heaviness of the upper eyelids.


Browlift is an operation which raises the resting position of the eyebrow. Often, this procedure will restore a youthful, alert appearance to the eyes without any other surgery being needed. The trend these days is towards minimally invasive surgery involving the placement of suspensory threads, which can lift the eyebrows up to a more youthful position. Dr Mahony uses a variation of technique known as the “Fernandes browlift” which requires minimal anaesthesia and involves tiny incisions at the hairline, through which the suspensory sutures are threaded and anchored.  Dr Mahony has developed a method that raises a loop rather than a point, for a more even result. Bruising and downtime are minimal, and results are often equivalent to the more invasive and expensive “endoscopic” browlift.


Upper eyelids


These structures consist of skin, muscle, fat, and a deep layer of connective tissue. Any or all of these structures may require surgical correction. A fine incision is made in the natural crease, and trimming of the appropriate layers is then performed (blepharoplasty). The crease itself is sometimes repositioned with internal sutures. Great finesse and judgement are required – too little taken, and the difference will be minimal; too much, and the lids will look unnaturally tight. If far too much is removed, the eyelids may even fail to fully close! Careful pre-operative assessment and planning are crucial – in good hands, such adverse outcomes are very rare.


Lower eyelids


An incision is usually made either just below the lashes, or in a natural crease of the lid. Skin and/or fat are then carefully trimmed. If the lower lid is floppy, it may need to be re-suspended with a carefully placed internal suture. Full, baggy lower lids will require removal of fat. Creased and floppy lids may only need trimming of skin. Usually, both skin and fat require some trimming.


If the skin is in good shape but the lower lids appear full and convex, a fat-only removal can be performed with a small incision through the back of the lid (the surface normally adjacent to the actual eyeball), which avoids an external scar. However, eyelid skin tends to heal extremely well with minimal scarring, so the advantages of this internal or “transconjunctival” approach are modest.




A saggy outside corner is usually due to dropping of the brow, and is best addressed with a browlift. The inside corner will usually be improved by surgery to the upper eyelid.




A hollow appearance, or a prominent oblique furrow under the eyes, are tell-tale signs of mid-face sagging. The least invasive method of correcting this problem involves (again) the use of internally placed suspensory threads, which will lift and/or bunch the cheek fat back into its more youthful position. Often, that is all that’s needed. Alternatively, a small amount of fat can be taken from another area such as the tummy or inner thighs, and injected into this area to correct the contour.




Poorly performed surgery may result in various adverse outcomes – a stretched look, difficulty in closing the eyes, or poor adherence of the lower lid to the eyeball, resulting in a “sad dog” appearance. All of these can be avoided by careful pre-operative assessment and planning. Internal bleeding after surgery is a very rare but serious complication. Deterioration in vision may be an early sign, and must be reported immediately. The surgeon may need too reopen the incision and stop the bleeding – this must be done without delay, even if it is four o’clock in the morning!


People with certain eye diseases such as glaucoma, Graves’ disease, Sjogren’s disease or diabetes may be at higher risk. Make sure you disclose your complete medical history (including all medications and allergies) to your surgeon at the first consultation.




Careful pre-operative asessment, correct identification of the cosmetic problems, and judicious planning of the corrective procedure, will generally result in a very satisfactory rejuvenation of tired, ageing eyes, and may transform the appearance of the entire face. In good hands, these procedures carry low risks and produce high degrees of client satisfaction.