Background
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, [1] 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.
Pathophysiology
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. [2] 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. [3] When associated with dermatitis, a nonspecific chronic infiltrate is seen.
Epidemiology
Frequency
United States
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.
Mortality/Morbidity
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. [4]
Race
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.
Sex
Dermatochalasis occurs with equal frequency in males and females.
Age
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.
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Preoperative image prior to upper blepharoplasty.
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Postoperative image after upper blepharoplasty.
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Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.
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Postoperative image after 4-lid blepharoplasty and canthopexy.
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Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.
