What the research shows
Heavy upper lids can block vision, and surgery helps. An American Academy of Ophthalmology review found that removing the excess skin improves vision, the upper field of sight and daily activities (Cahill 2011). In patients who met Danish criteria for functional surgery, the upper visual field widened substantially and every patient was satisfied (Jacobsen 2017). Patients also reported fewer headaches after surgery (Hollander 2019).
Dry eye symptoms usually ease. Pooled randomized trials found fewer dry eye symptoms after surgery (Todorov 2025), and a year after surgery tear tests were unchanged while irritation had eased, whichever technique was used (Hollander 2022b).
Removing a strip of muscle adds little. Some surgeons remove a strip of the orbicularis muscle, which closes the eye, along with the skin. Comparative studies found no lasting difference in appearance, while muscle removal caused more early swelling, bruising and pain (Samargandi 2021). A half-face trial showed the muscle side looked worse at one week and the same at one and three months (Damasceno 2011). Patients rated both methods the same at a year (Hollander 2022a), and pooled trials found more trouble closing the eye fully after muscle removal (Todorov 2025).
The brow can sit a little lower afterward. Pooled studies found the brow dropped about a millimeter and a half on average after upper lid surgery, less after simple blepharoplasty than after double eyelid surgery or ptosis repair (Liu 2023). In one large series, women's brows did not drop and men's dropped slightly (Huijing 2014).
The cornea changes slightly. The shape of the cornea shifted after surgery, more with muscle removal, which changed lens calculations at one month, a point for a patient planning cataract surgery (Doğan 2024).
Where surgeons disagree
- Muscle or skin only. The pooled evidence favors keeping the muscle in routine cases (Samargandi 2021, Hollander 2022a); the authors note that some lids may still need it removed.
- Aspirin before surgery. Continuing low-dose aspirin did not increase bruising, and the authors suggest patients keep taking it; the study was too small to rule out bleeding problems (Winkler 2020).
What is new
- Tranexamic acid, a drug that slows bleeding, reduced bruising and shortened recovery by most of a day in pooled trials (Abo Zeid 2025).
- Oral bromelain, a pineapple enzyme, reduced swelling in the first days after surgery in a randomized trial (Shamloo 2026).
- Arnica ointment did nothing in a randomized trial (van Exsel 2016), and ice packs eased next-day pain only slightly and did not reduce swelling or bruising (Pool 2015).
What is still unknown
- The effect on brow height in different patients: results vary by technique and by population (Liu 2023).
- Long-term results in diverse patients: the main trials enrolled White European patients and followed them for a year (Hollander 2022a).
Key papers
- Damasceno 2011: muscle removal makes the first week worse and the final result the same.
- Cahill 2011: when lid surgery improves vision.
- Huijing 2014: what happens to the brow after upper lid surgery.
- van Exsel 2016: arnica ointment does not help.
- Hollander 2019: the functional benefits of upper lid surgery.
- Samargandi 2021: review favoring muscle preservation.
- Hollander 2022a: patients rate skin-only and skin-muscle surgery the same.
- Todorov 2025: pooled randomized trials on dry eye, satisfaction and technique.
- Abo Zeid 2025: tranexamic acid shortens bruising and recovery.