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The Symptom: Drooping Eyelids

Esther was getting fitted for a new pair of glasses when, for the first time, someone mentioned her drooping eyelids. “You know,” the sales lady told her, “your eyelids are pushing your lashes down.” And it was true. Esther had been noticing her eyelids were feeling heavy and were beginning to droop, but until that moment she hadn’t considered it much more than an annoyance.

Esther: before and three months after brow-lift surgery.

“My eyelids had begun to fall down over my eyes and were really obstructing my vision,” Esther says. “I was also getting headaches from the tension of trying to hold my eyelids up by raising my eyebrows. That was when I decided it was time to seek some help.”

Fortunately, Esther brought herself to a pair of the most gifted surgical hands in the Triangle area. Dr. Cynthia Gregg, a facial plastic surgeon, is not only a highly skilled physician, she is also adept at providing thoughtful and careful patient-centered care.

“Esther came to me with the symptom of drooping eyelids,” Dr. Gregg recalls. “Actually, this is one of the most common issues that brings people to see me—and while it is a common complaint, the condition can have several potential causes. What someone sees as the problem is not always, in fact, the real issue.”

The Symptoms and the Problem

 “Esther came to us last spring with the complaint of tired eyes,” says Dr. Gregg, “believing she might be a good candidate for eyelid surgery. But I pointed out to her in our first meeting that the major cause of the excess skin weighing down her eyelids was actually brow ptosis—or droopy brows—not excess eyelid skin.

“Lifting the brows to their correct anatomical position would eliminate most of the problematic excess skin on the upper lids,” explains Dr. Gregg. “She would still have a small amount of excess skin on the upper right lid that could also be addressed with an upper lid blepharoplasty procedure at the same time as a brow lift, but Esther opted not to have this done.
“The photographs shown here are of Esther three months after her procedures; she tells me she is very pleased with the outcome of our work together.”

The Process

“In determining how to proceed with a patient, I first, of course, need to listen to their description of their issue—why they have come to see me—and then we move to a physical exam. Then, I have to work backwards and figure out what’s actually causing that symptom. Drooping eyelids, for example, may be the result of excess skin over the eye, a fallen brow, a neurological disease like myasthenia gravis or Horner syndrome, undiagnosed thyroid disease, trauma, or a number of other anatomical or systemic issues. Not all of these possible causes will be appropriately treated with surgery—and, of course, treating the wrong thing surgically will not take care of the problem.

“When Esther came to see me, her symptom was drooping eyelids, but her issue wasn’t excess skin in the eyelid as she thought, it was that her brow had fallen—which is very often the case.”

Dr. Gregg fully understands the consequences of only treating the symptom from a patient encounter some years ago. Ashley, a patient in her 50s, had come to her—after having had two surgical procedures to remove excess eyelid skin—to address the same issue of heavy eyelids with excess skin weighing down her eyelids. Despite previous surgeries, her heavy eyelid issue persisted.

“She had been completely misdiagnosed,” Dr. Gregg observes. “What she needed was a brow lift, and someone had just kept removing skin from above her eyes. As a result, it was recommended she have skin grafts placed on her upper back on her upper eyelids and then proceed with a brow lift—which was what she needed in the first place.

“Another good example,” Dr. Gregg continues, “is aging around the mouth. Patients come in frequently saying, ‘I hate the way my mouth looks.’ So that’s the symptom; but what, in fact, is the problem? Is it volume loss? Laxity? Deformity? Muscle-weakness or over-activity? Is it disease-oriented? In facial plastics we don’t just treat what the patient sees in the mirror. We have to consider the patient’s underlying anatomy and assess each individual patient as a unique case.”

Dr. Gregg

Esther says she did indeed come to Dr. Gregg with the belief that skin removal over her eyes was the treatment she needed. Then, Dr. Gregg lifted her forehead up with her hand. “It was instant relief,” Esther remembers. “My eyebrows lifted up and the excess skin over my eyes wasn’t there anymore. It was like weight being instantly taken off and I completely understood what Dr. Gregg had been explaining to me.”

A Menu of Possibilities

Relying on her extensive training, the latest technology, and years of experience, Dr. Gregg performs the full range of facial plastic surgery procedures, including forehead and brow-lift surgery, facial scar treatment, otoplasty (to correct protruding ears), rhinoplasty nasal surgery, blepharoplasty eyelid surgery, rhytidectomy facelift surgery, and mid-face lift.

She and her staff—which includes a surgical nurse, nurse injectors, and an aesthetician—also offer a comprehensive range of skin care procedures and products, including treatment of sun damage and photo-aging, Botox cosmetic injections, laser hair removal, and use of natural cosmetic dermal fillers such as Restylane, Juvéderm, and Sculptra.

Form Follows Function

Drooping, heavy eyelids may be aesthetically unpleasing, but they can also cause a function issue. “If the condition is sufficiently severe, it can obstruct the visual field—which had begun happening to Esther,” Dr. Gregg says. “The condition can also cause headaches from tension related to the strain of trying to keep the eyes open and vision unobstructed. And the condition can cause neck pain—a result of holding the head in odd ways in order to see clearly from under drooping lids. These important functional issues need to be addressed along with the cosmetic considerations.

“Functionality is an important part of facial plastics often overlooked, yet vitally important,” notes Dr. Gregg. “‘I don’t like my nose’ is a common complaint from those seeking a rhinoplasty. But is an aesthetically unpleasing nose a symptom of a larger systemic issue? Patients will come in having had some trauma in childhood or a congenital bump in the nose, and it’s only after I ask them detailed questions that I’ll discover they also have sleep apnea or other functional breathing issues. Then my priority is both to correct the ‘symptom’ they don’t like—the look of the nose—and also to fix the functional breathing problems.”

Functional issues are also a form of plastic surgery that insurance will cover with appropriate diagnosis. “Referral to the appropriate provider to have functional problems assessed when I believe they are present is something I’m always happy to help patients with,” says Dr. Gregg. “Whether it’s for insurance purposes or because a problem is perhaps neurologic or disease-related, I have a strong network of colleagues with whom I work closely to ensure my patients get the appropriate treatments, whatever they may be.”

As for Esther, she proceeded with the brow lift, and couldn’t be happier with the results. “I hadn’t really noticed it before, but my irises had become obscured by my eyelids,” she says. “Now you can see my whole iris. My eyes don’t look so heavy and tired anymore, and even better they don’t feel so heavy. My visual field has increased, and my headaches have lessened too. Having this procedure was the best decision I could have made. I’m truly grateful to Dr. Gregg.”