Eyelid surgery is among the most frequently requested procedures at Ninth People's Hospital's International Department — and also one of the most misunderstood. This guide clarifies the four most common concerns and what each actually requires.
Patients often arrive describing a concern — "my eyes look tired," "one eyelid is lower than the other," "I have bags I can't get rid of" — without knowing which anatomical issue underlies it. The distinction matters enormously, because the wrong diagnosis leads to the wrong procedure, and the wrong procedure is the most common reason patients end up seeking revision surgery.
True ptosis means the upper eyelid margin sits lower than it should — typically covering more than 2mm of the iris. This is a functional issue before it is an aesthetic one. In many cases, patients with untreated ptosis unconsciously raise their brows to compensate, causing forehead tension and fatigue.
Ptosis has several subtypes. Aponeurotic ptosis — where the levator muscle's tendon stretches or detaches, usually with age or contact lens use — is the most common. Congenital ptosis involves underdevelopment of the levator muscle itself and requires a different surgical approach. Myogenic and neurogenic causes must be ruled out before surgery.
Correction involves either advancing the levator aponeurosis, resecting the levator muscle directly, or using a frontalis sling for severe cases where the levator has minimal function. The approach is determined by how much levator function remains. Getting this wrong — applying a cosmetic blepharoplasty to a lid that has underlying ptosis — is one of the most frequent causes of poor outcomes seen at revision centres.
Roughly half the world's population of East Asian descent lacks a defined supratarsal crease — the fold that creates the appearance of a "double eyelid." This is anatomically normal; no eyelid is deficient. Double eyelid surgery creates a crease where one does not exist, or reinforces an inconsistent one.
There are two primary approaches: the suture (non-incisional) method, which attaches the skin to deeper structures through small punctures, and the incisional method, which removes a defined strip of skin and fat to create a permanent, more defined crease. The suture method is less permanent and better suited to patients with thinner lids and minimal excess tissue. The incisional method offers more reliable long-term results, especially in patients with fuller lids or significant hooding.
A critical planning decision is crease height. A crease set too high looks unnatural on an Asian face and is a common complaint in revision cases. The goal is to create a crease that looks intentional and harmonious — not to produce a Westernised appearance unless that is explicitly the patient's goal.
Prominent fat pockets in the lower lid — the bulges that appear beneath the eye, distinct from dark circles — are caused by orbital fat that has prolapsed forward as the septum weakens with age. They are structural, not related to fluid retention, and do not respond to creams or lifestyle changes.
The traditional approach was simple fat excision: remove the excess fat and close. This works but can leave patients looking hollowed beneath the eye if too much is removed, trading one problem for another. The more nuanced modern approach is fat transposition — mobilising the fat and repositioning it into the tear trough depression below, simultaneously reducing the bulge and filling the hollow. The result is more natural and ages better.
Which approach is appropriate depends on the anatomy. Patients with deep tear troughs benefit most from transposition. Those with minimal hollowing and primarily excess fat may do well with conservative excision. A surgeon who only offers one approach is not tailoring treatment to your anatomy.
The tear trough is the crescent-shaped depression that runs from the inner corner of the eye toward the cheek. It creates a shadow that reads as fatigue or ageing. Tear troughs are distinct from fat bags — in fact, some patients have both — and require a different solution.
Filler injection is frequently used for mild-to-moderate tear troughs with good outcomes in the right patient. Fat grafting offers a more permanent solution. Surgical fat transposition from the lower lid addresses both the fat bag and the trough simultaneously. The choice depends on the degree of hollowing, skin quality, and whether lower lid surgery is being planned for other reasons.
Each of the above conditions looks superficially similar in a photograph. A surgeon assessing from photos alone — without examining lid function, levator strength, skin excess, and fat distribution in person or through detailed clinical history — cannot give a reliable recommendation. Many of the revision cases seen at Ninth People's Hospital's International Department trace back to a misidentified primary problem.
When submitting your case, include photographs in neutral lighting showing both eyes fully open, looking straight ahead, and both eyes gently closed. Note whether you have had any prior eyelid procedures, injections, or laser treatments. The more information provided upfront, the more specific the assessment can be.
Our surgeons review eyelid cases from patients worldwide. Share your photos and history to receive a personalised opinion on which procedure — if any — applies to your situation.
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