Dermatochalasis is redundancy and laxity of the eyelid skin and muscle, sometimes referred to as “baggy eyes.” It is common in elderly persons and is occasionally seen in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the eyelid connective tissues contribute to dermatochalasis, which more frequently involves the upper lids, but is also common in the lower lids.
Systemic diseases such as thyroid-related orbitopathy, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis,  hereditary angioneurotic edema, and xanthelasma may predispose to dermatochalasis. Genetic factors may play a role in some patients.
Dermatochalasis can be a functional or cosmetic problem for the patients. When functional, dermatochalasis frequently obstructs the superior visual field. In addition, patients may note ocular irritation, entropion of the upper eyelid, ectropion of the lower eyelid, blepharitis, and dermatitis. When cosmetic, patients note a fullness or heaviness of the upper eyelids, “bags” in the lower eyelids, and wrinkles in the lower eyelids and the lateral canthus.
Steatoblepharon describes the herniation of the orbital fat in the upper or lower eyelids. It is associated frequently with dermatochalasis. However, some patients may present with isolated steatoblepharon. Herniation of the orbital fat in the eyelids is because of a weakening of the orbital septum, usually because of age. Most commonly, it is noted in the medial upper eyelid but can give the appearance of “bags under the eyes.”
Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that typically affects the upper eyelids in younger patients.
The pathophysiology of dermatochalasis is consistent with the normal aging changes seen in the skin. This includes loss of elastic fibers, thinning of the epidermis, redundancy of the skin, and lymphatic dilation.  Histopathologic studies have shown that the orbicularis oculi remains morphologically intact as patients age and that the predominant findings were located in the epidermis and dermis.  When associated with dermatitis, a nonspecific chronic infiltrate is seen.
Dermatochalasis most frequently occurs in elderly persons and is very common; the severity is quite variable. The age of onset most frequently is noted in the 40s and progresses with age. Some patients have a familial tendency and develop dermatochalasis in their 20s.
Visual-field loss is the most frequent sequelae of dermatochalasis. In severe cases of dermatochalasis, patients can lose more than 50% of their superior visual field. Patients with a purely aesthetic deformity may not have any visual field defects.
Blepharitis frequently is seen in patients with moderate-to-severe dermatochalasis. It is characterized by eyelid skin edema and erythema; scurf; meibomian gland inflammation and plugging; and, occasionally, hordeolum.
Eyelid deformities, such as upper eyelid entropion and lower eyelid ectropion or retraction, can be seen with redundant upper or lower eyelid skin. The redundant upper eyelid skin overhangs the lashes, causing lash ptosis and entropion with resultant keratitis. In patients with severe lower eyelid dermatochalasis, laxity of the lower eyelid develops with resultant eyelid retraction or ectropion.
Blepharoplasty surgery for dermatochalasis has been found to provide significant improvement in vision, peripheral vision, and quality-of-life activities. Predictors of improvement in quality of life include superior visual-field loss of at least 12°, a chin-up posture, symptoms of eye fatigue due to droopy lids, a marginal reflex distance 1 (MRD-1) of 2 mm of less, and down-gaze ptosis impairing reading. 
Race does not seem to play a role in dermatochalasis; however, patients of Asian origin frequently note fullness in the upper eyelid. This is due to the difference in eyelid anatomy. The Asian patient’s orbital septum fuses with the levator aponeurosis low above the eyelid margin or not at all. This allows the preaponeurotic fat to prolapse anteriorly in the eyelids.
Dermatochalasis occurs with equal frequency in males and females.
Dermatochalasis most commonly occurs in elderly persons, and its presence and severity increase with age.
Blepharochalasis is a disease of young persons, especially seen at puberty.
Gonnering RS, Sonneland PR. Ptosis and dermatochalasis as presenting signs in a case of occult primary systemic amyloidosis (AL). Ophthalmic Surg. 1987 Jul. 18(7):495-7. [Medline].
Karnaz A, Katircioglu YA, Ozdemir ES, Celebli P, Hucumenoglu S, Ornek F. The Histopathological Findings of Patients Who Underwent Blepharoplasty Due to Dermatochalasis. Semin Ophthalmol. 2017 Feb 6. 1-5. [Medline].
Lee H, Park M, Lee J, Lee ES, Baek S. Histopathologic findings of the orbicularis oculi in upper eyelid aging: total or minimal excision of orbicularis oculi in upper blepharoplasty. Arch Facial Plast Surg. 2012 Jul-Aug. 14(4):253-7. [Medline].
Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011 Dec. 118(12):2510-7. [Medline].
McKinney P, Zukowski ML. The value of tear film breakup and Schirmer’s tests in preoperative blepharoplasty evaluation. Plast Reconstr Surg. 1989 Oct. 84(4):572-6; discussion 577. [Medline].
Espinoza GM, Israel H, Holds JB. Survey of oculoplastic surgeons regarding clinical use of tear production tests. Ophthal Plast Reconstr Surg. 2009 May-Jun. 25(3):197-200. [Medline].
Finn JC, Cox S. Fillers in the periorbital complex. Facial Plast Surg Clin North Am. 2007 Feb. 15(1):123-32, viii. [Medline].
Montes JR. Volumetric considerations for lower eyelid and midface rejuvenation. Curr Opin Ophthalmol. 2012 Sep. 23(5):443-9. [Medline].
Hoorntje LE, Lei BV, Stollenwerck GA, Kon M. Resecting orbicularis oculi muscle in upper eyelid blepharoplasty – A review of the literature. J Plast Reconstr Aesthet Surg. 2009 Apr 10. [Medline].
Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning. Otolaryngol Clin North Am. 2007 Apr. 40(2):381-90. [Medline].
Prado A, Andrades P, Danilla S, Castillo P, Benitez S. Nonresective shrinkage of the septum and fat compartments of the upper and lower eyelids: a comparative study with carbon dioxide laser and Colorado needle. Plast Reconstr Surg. 2006 May. 117(6):1725-35; discussion 1736-7. [Medline].
Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases. Plast Reconstr Surg. 2010 Jan. 125(1):315-23. [Medline].
Tonnard PL, Verpaele AM, Zeltzer AA. Augmentation blepharoplasty: a review of 500 consecutive patients. Aesthet Surg J. 2013 Mar. 33(3):341-52. [Medline].
Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting: long-term evidence of its efficacy in midfacial rejuvenation. Arch Facial Plast Surg. 2009 Jan-Feb. 11(1):24-8. [Medline].
Brown MS, Siegel IM, Lisman RD. Prospective analysis of changes in corneal topography after upper eyelid surgery. Ophthal Plast Reconstr Surg. 1999 Nov. 15(6):378-83. [Medline].
Zinkernagel MS, Ebneter A, Ammann-Rauch D. Effect of upper eyelid surgery on corneal topography. Arch Ophthalmol. 2007 Dec. 125(12):1610-2. [Medline].
Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg. 1998 Sep. 102(4):1219-25. [Medline].
Cheng JH, Lu DW. Perilimbal needle manipulation of conjunctival chemosis after cosmetic lower eyelid blepharoplasty. Ophthal Plast Reconstr Surg. 2007 Mar-Apr. 23(2):167-9. [Medline].
Weinfeld AB, Burke R, Codner MA. The Comprehensive Management of Chemosis following Cosmetic Lower Blepharoplasty. Plast Reconstr Surg. 2008 Aug. 122(2):579-86. [Medline].
Moesen I, Mombaerts I. Subconjunctival injection of tetracycline 2% for chronic bulbar chemosis after transcutaneous four-eyelid blepharoplasty. Ophthal Plast Reconstr Surg. 2008 May-Jun. 24(3):219-20. [Medline].
Prischmann J, Sufyan A, Ting JY, Ruffin C, Perkins SW. Dry eye symptoms and chemosis following blepharoplasty: a 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg. 2013 Jan. 15(1):39-46. [Medline].
Callahan MA. Prevention of blindness after blepharoplasty. Ophthalmology. 1983 Sep. 90(9):1047-51. [Medline].
Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness following blepharoplasty: two case reports, and a discussion of management. Ophthalmic Surg. 1990 Feb. 21(2):85-9. [Medline].
Korn BS, Kikkawa DO, Schanzlin DJ. Blepharoplasty in the post-laser in situ keratomileusis patient: preoperative considerations to avoid dry eye syndrome. Plast Reconstr Surg. 2007 Jun. 119(7):2232-9. [Medline].
Griffin RY, Sarici A, Ayyildizbayraktar A, Ozkan S. Upper lid blepharoplasty in patients with LASIK. Orbit. 2006 Jun. 25(2):103-6. [Medline].
Abell KM, Cowen DE, Baker RS, Porter JD. Eyelid kinematics following blepharoplasty. Ophthal Plast Reconstr Surg. 1999 Jul. 15(4):236-42. [Medline].
Alfonso E, Levada AJ, Flynn JT. Inferior rectus paresis after secondary blepharoplasty. Br J Ophthalmol. 1984 Aug. 68(8):535-7. [Medline].
American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. American Academy of Ophthalmology. Ophthalmology. 1995 Apr. 102(4):693-5. [Medline].
Bernardino CR. Re: improvement of dermatochalasis and periorbital rhytids with a high-energy pulsed CO laser: a retrospective study. Dermatol Surg. 2004 Dec. 30(12 Pt 1):1500; author reply 1500. [Medline].
Collin JR. Blepharochalasis. A review of 30 cases. Ophthal Plast Reconstr Surg. 1991. 7(3):153-7. [Medline].
Custer PL, Tenzel RR, Kowalczyk AP. Blepharochalasis syndrome. Am J Ophthalmol. 1985 Apr 15. 99(4):424-8. [Medline].
Frankel AS, Kamer FM. The effect of blepharoplasty on eyebrow position. Arch Otolaryngol Head Neck Surg. 1997 Apr. 123(4):393-6. [Medline].
Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg. 2004 Jun. 113(7):2124-41; discussion 2142-4. [Medline].
Kamer FM, Mikaelian AJ. Preexcision blepharoplasty. Arch Otolaryngol Head Neck Surg. 1991 Sep. 117(9):995-9; discussion 1000. [Medline].
Kosmin AS, Wishart PK, Birch MK. Apparent glaucomatous visual field defects caused by dermatochalasis. Eye (Lond). 1997. 11 (Pt 5):682-6. [Medline].
Morax S, Touitou V. Complications of blepharoplasty. Orbit. 2006 Dec. 25(4):303-18. [Medline].
Putterman AM, Urist MJ. Reconstruction of the upper eyelid crease and fold. Arch Ophthalmol. 1976 Nov. 94(11):1941-54. [Medline].
Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morphology in predicting dry-eye syndrome after blepharoplasty. Plast Reconstr Surg. 1988 Oct. 82(4):619-25. [Medline].
Vold SD, Carroll RP, Nelson JD. Dermatochalasis and dry eye. Am J Ophthalmol. 1993 Feb 15. 115(2):216-20. [Medline].
Zimbler MS, Prendiville S, Thomas JR. The “pinch and slide” blepharoplasty: safe and predictable aesthetic results. Arch Facial Plast Surg. 2004 Sep-Oct. 6(5):348-50. [Medline].
Grant D Gilliland, MD Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates
Grant D Gilliland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, Texas Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery
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Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society
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Edsel Ing, MD, MPH, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Active Staff, Michael Garron Hospital (Toronto East Health Network); Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital, Canada
Edsel Ing, MD, MPH, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Canadian Ophthalmological Society, Canadian Society of Oculoplastic Surgery, Chinese Canadian Medical Society, European Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Statistical Society of Canada
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Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society
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