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What is the difference between cosmetic and functional upper eyelid surgery?

Excess skin in the upper eyelids can often run in families and cause lateral hooding and interfere with vision. Hooded upper eyelids can cause impaired vision at a younger age than would normally be expected from just ageing changes. The excess skin will hang over the lashes or touch the eyelashes, and when pinched there can be about 10 to 12 mm of excess skin easily identified. Sometimes there is a prominent fat pad, but most often when excess upper eyelid skin runs in the family, it is just the excess skin. The person can see the lashes and has to lift their eyebrows all the time to try and lift the skin off the lashes and see out better, as there is a kind of curtain down over the vision and even an upper black line crossing the view. The skin lying on the eyelashes can stunt their growth.
This upper eyelid excess skin is called dermatochalasis. You will require a referral to an oculoplastic surgeon to assess the functional aspects of the dermatochalasis. If you are just worried about the cosmetic appearance, it is most likely not a practical problem.
To determine whether the problem requires cosmetic or functional upper eyelid surgery, the oculoplastic surgeon will ask you about symptoms. If you have a functional upper eyelid problem, you can benefit from a functional upper eyelid blepharoplasty performed to help restore the top field of vision that is impaired by the redundant excess upper eyelid tissues, mainly skin. Functional blepharoplasty is done if there is heaviness, ache above the eyebrows, elevated eyebrows, head tilt to see well, very watering eyes from the lateral corners of the eyes and visual field defect, plus loss of full contrast sensitivity as less light is reaching the eyes.
Functional upper eyelid surgery is done to remove the excess skin with any underlying excess fat and also to correct any ptosis at the same time. I will talk more about what ptosis is in a future blog on functional eyelid surgery.
Blepharoplasty is usually done on an outpatient basis or day care basis. To decide whether blepharoplasty is right for you and what you may realistically expect, you have to explore the benefits and risks of blepharoplasty surgery. Occasionally, insurance coverage may be applied depending on your private medical insurance company.
You will undoubtedly require a referral letter from your General Practitioner, a clear history of functional problems from the excess upper eyelid skin and droopy eyelids. Once there is a technical indication for eyelid surgery, the insurance companies often request photographic evidence and visual fields that demonstrate an impairment of visual function and may consider supporting your surgery. Your oculoplastic surgeon can arrange for you to have these tests done and will write an objective report on the findings. There are strict criteria set by the insurance companies, and they only sometimes pay for functional eyelid surgery and never pay for cosmetic eyelid surgery.
Jane Olver is an Oculoplastic Surgeon at Clinica London who is very experienced in functional upper eyelid surgery, both for dermatochalasis and for ptosis. She operates on many patients weekly and has been doing this type of surgery since she first became a consultant in 1994. Although she is now fully in private practice, functional eyelid surgery remains a major part of her oculoplastic practice.

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