Dermatochalasis (drooping eyelids): causes, symptoms & treatment

Definition and aim of dermatochalasis

Dermatochalasis (ICD-10 H02.3) refers to excess skin on the upper and/or lower eyelids, resulting from a loss of elasticity in the connective tissue and skin over the course of a person’s life. It involves loose, often wrinkled and stretched eyelid skin. In the case of the lower eyelids, a prolapse of orbital fat tissue („eye bags“) may also occur.

It is important to distinguish this from:

• Blepharochalasis: A rare condition characterised by recurrent, painless swelling of the eyelids, leading to extreme thinning and atrophy of the eyelid skin.
• Ptosis (blepharoptosis): A drooping of the upper eyelid caused by weakness or dysfunction of the levator muscle, with the eyelid margin itself sitting lower.

Aim of the treatment The aim of treatment for dermatochalasis is to remove the excess skin and, where necessary, the prolapsed fatty tissue, in order to achieve a fresher, more alert appearance and to rectify any functional impairments (e.g. restricted visual fields).

Causes of dermatochalasis

The main cause of dermatochalasis is the natural ageing process:

• Loss of skin elasticity: As we get older, the production of collagen and elastin decreases, leading to sagging skin.
• Weakening of the connective tissue: The connective tissue that supports the eyelids also loses its firmness.
• Laxity of the orbicularis oculi muscle: The orbicularis oculi muscle can also lose its tone.
• Protrusion of orbital fat: The orbital septum, a connective tissue membrane that holds the fatty tissue of the eye socket in place, can become lax, thereby contributing to the protrusion of fatty deposits (eye bags).

Other factors that may contribute to dermatochalasis include:

• Genetic predisposition.
• Long-term exposure to sunlight (photoageing).
• Lifestyle factors like smoking.
• Less common: certain systemic diseases.

Symptoms: What are the signs of dermatochalasis?

The symptoms of dermatochalasis can vary depending on the severity and the part of the eyelid affected:

• Upper eyelids (drooping eyelids):
  • Excess skin that hangs over the edge of the eyelid and may rest on the eyelashes.
  • A tired, sad or strained expression.
  • A feeling of heaviness in the eyelids.
  • Difficulties when applying eye make-up.
• Lower eyelids (eye bags):
  • Bulges or „bags“ under the eyes.
  • Wrinkling and sagging of the lower eyelid skin.
  • Dark circles under the eyes are accentuated by the casting of shadows.

Consequences: More than just an aesthetic problem

As well as causing aesthetic concerns, severe dermatochalasis can also lead to functional problems:

• Restricted field of vision: Particularly in cases of severe drooping eyelids, the upper outer field of vision may be restricted, which can impair orientation and, for example, driving.
• Asthenopic symptoms: Constantly tensing the forehead muscles to lift the eyelids can lead to headaches and signs of fatigue.
• Skin irritation: Irritation, redness or eczema may occur in the folded skin.
• Mental stress: Many people affected feel that their appearance makes them look older or that they are constantly tired, which can affect their self-esteem.

Indications: When is treatment advisable?

Treatment for dermatochalasis is indicated if:

• One aesthetic impairment where there is subjective psychological distress.
• One functional limitation, in particular a confirmed field of vision defect.
• Recurring Skin irritation or inflammation occur in the area of the eyelid creases.
• There is a desire to rejuvenate the eye area and achieve a more alert appearance.

The decision on treatment is made in consultation with an experienced specialist following a thorough examination and consultation.

Surgery: Treatment of dermatochalasis (blepharoplasty)

1. Consultancy and Planning A detailed consultation, examination, photographic documentation, information about the risks and the precise surgical plan.
2. Anaesthesia Upper eyelid lifts can often be performed in Local anaesthesia, possibly under twilight anaesthesia. Lower eyelid or combined procedures are more commonly carried out under twilight anaesthesia or general anaesthesia.
3. Operation Marking out the incision lines. Precise removal of excess skin and fatty tissue. Muscle tightening where necessary.
4. Wound closure Fine skin sutures, often using self-dissolving sutures or thin non-absorbable sutures, which are removed after a few days.

Depending on the extent of the procedure, it takes around 1–2 hours and can usually be carried out on an outpatient basis.

Scarring following an eyelid lift

• Upper eyelid: The incision is made within the natural crease of the eyelid, so that the scar is barely visible, if at all, when the eyes are open.
• Lower eyelid: The incision is made either just below the lash line (subciliary) or on the inside of the eyelid (transconjunctival, if no excess skin needs to be removed).
  Scars are often slightly red at first, but they fade over time and usually become barely noticeable. Good scar care and consistent use of sun protection help this process along.

Dermatochalasis aftercare: Important steps for a successful recovery

• Cooling: Cool the area around the eyes regularly during the first few days.
• Elevating the upper body: Also whilst sleeping, to reduce swelling.
• Taking care of your body: Avoid exertion, bending over and heavy lifting for 1–2 weeks.
• Medicines: If necessary, use decongestant or antibiotic eye drops or ointments as directed.
• Thread pull: Usually after 5–7 days.

Recovery time following the procedure

Swelling and bruising: These are normal and often peak on the 2nd or 3rd day, but then largely subside within 1–2 weeks.

• Social skills: Usually after about 1–2 weeks, once the worst of the swelling has subsided and any stitches have been removed. Any slight residual bruising can often be concealed with make-up.
• Sport: Light physical activity can often be resumed after 2 weeks, whilst more strenuous exercise can be resumed after 4–6 weeks.
• Final result: Although a noticeable improvement is visible quite early on, the final aesthetic result is usually achieved after a few weeks to 3–6 months, once all the slight swelling has subsided and the skin has adapted to the new contours.

Coverage by the health insurance scheme

The cost of blepharoplasty to treat dermatochalasis varies depending on the extent of the procedure and typically ranges in Germany between approximately 2,000 and 5,000 euros per pair of eyelids or for a combined upper and lower eyelid lift.

• Cosmetic indication: If the motivation is purely aesthetic, the cost of the operation will be not covered by statutory or private health insurance schemes.
• Medical indication: Only if a clear medical necessity If it is demonstrated that there is, in particular, a significant restriction of the visual field caused by dermatochalasis of the upper eyelid (which can be objectively confirmed by a visual field test/perimetry), an application for reimbursement may be submitted to the health insurance fund. The criteria for this are strict, and the decision is made following an individual assessment, often by the Health Insurance Medical Service (MDK).

Important

Even if there is a medical reason for the procedure and the costs may be covered, it is advisable to find out about a Consequential Costs Insurance to inform you. This may cover the costs of medically necessary treatment that could arise as a result of unexpected complications following a cosmetic or medically indicated procedure.