The extra skin of the upper eyelids can be removed using an incision that follows the natural lid crease and is quite subtle. A common finding in patients with excess skin in the upper lids is sagging of the brow; the brow normally rests on or slightly above the boney rim of the orbit. Women sometimes conceal this sagging by plucking the lower part of the eyebrows, sometimes entirely removing the hair and replacing it with a pencilled-on eyebrow. A more subtle and subconscious way that patients conceal the droop is by actively raising the brow, often creating deep creases in the forehead; the plastic surgeon will encourage the patient to relax the forehead and close the eyes which reveals the defect. We have patients who are shocked how hard they were working the forehead when it’s pointed out to them. It is an error to ignore the sagging brow and remove the lid skin as it can worsen the apparent sagging and drag the eyebrow even further down. Insurance may pay for upper lid surgery if the lid is impairing vision.

The lower lid fat can be removed through an incision just under the lashes or inside the lid, depending upon how much skin tightening is needed. For patients with smaller bags, it’s sometimes appropriate to remove the fat from within the lid and use the laser to tighten the skin.