Hooded eyes, honestly.

Four structures decide how open an eye looks. The eyelid skin, the thinnest on the body, lies over the orbicularis muscle that closes the eye; behind them the orbital septum holds two fat pads in the socket; beneath them the levator muscle, through a tendon called the aponeurosis, attaches to the tarsal plate and lifts the lid; and above them the brow, cushioned by its own fat pad, sits on the bone of the forehead. Eyelid surgeons measure the result of all four with one number: the margin reflex distance, MRD1, from the corneal light reflex in a flash photograph up to the lid margin, normally 4 to 5 mm, and measured with a finger holding the brow still so the forehead cannot cheat (StatPearls on ptosis). The four failures look alike from across a room and differ under the finger: surplus skin folding over the lashes with a normal margin underneath (dermatochalasis), a brow that has descended and pushed its skin onto the lid with a forehead straining to hold it up (brow ptosis — StatPearls on brow ptosis), a tendon that has stretched so the margin itself sits low (aponeurotic blepharoptosis, the commonest acquired form), and a hollow where the fat has gone that lets the skin fold into it. The specialist review of ptosis lists the masquerades that must be excluded before any cosmetic plan — a lid retracted on the other side, an eye set back, a third-nerve palsy, Horner's syndrome, myasthenia gravis (ptosis evaluation review) — and the rest of this page sorts the four by two tests you can do at home.

The three problems have different prevalences and the same complaint. In the Tehran Geriatric Eye Study, 3,267 people aged 60–97 had a complete eyelid examination: dermatochalasis was present in 55.15%, in 60% of women against 50% of men, brow ptosis in 5.01%, and true blepharoptosis by the examiners' definition in under 1% (Tehran Geriatric Eye Study). A British community survey that examined 400 randomly selected people over 50 at home found ptosis in 11.5%, rising from 2.4% in the fifties to 8.9% in the sixties and 20.8% over 70, bilateral in 39%, and due to a stretched or slipped tendon in most of the cases with a cause (British ptosis survey); a Chinese community study of people over 50 found 27% (Chinese ptosis study); and when 94 American eye-clinic patients over 50 compared their own lids to four photographs, 73% chose one with some ptosis, 41.5% mild, and a quarter had one lid lower than the other (clinic self-assessment study); the specialist review puts the prevalence above 20% over 70 (acquired ptosis review). The market has noticed: eyelid surgery overtook liposuction to become the most common surgical aesthetic procedure in the world in 2024, at about 2.1 million (ISAPS 2024), and American plastic surgeons alone reported 120,755 blepharoplasties (ASPS 2024).

The hooded eye punishes the wrong diagnosis. Remove eyelid skin from someone whose real problem is a fallen brow and the brow, no longer held up by the tension the surgeon just released, descends further — which is why the browpexy trials measure what a blepharoplasty alone does to brow height and find it falls (browpexy comparison). Remove skin from a lid whose margin has slipped and the eye still looks half-shut, because the margin is the problem and the skin was not (StatPearls on ptosis). Inject the forehead of a person whose frontalis was straining to hold up a low brow and both come down — the label rates eyelid ptosis and brow ptosis at 2% each, and the risk concentrates in exactly this face (prescribing information). And the non-surgical menu is measured in a unit the brochures avoid: ultrasound lifted the brow a mean 1.7 mm in the first blinded study (ultrasound brow study), radiofrequency about 1.2–1.5 mm (radiofrequency eyelid study), and a plasma pen burns the skin it claims to remove. The order on this page: sort the type with a finger and a photograph, treat the margin with drops or the tendon operation, the brow with the rung that matches the millimetres you need, and the skin with the operation that has the trials.

Sit at a mirror, look straight ahead and rest a finger on the brow bone to stop the forehead helping. If a fold of skin still hangs over the lashes, and lifting that fold with the other hand shows a lid margin sitting a normal 4–5 mm above the pupil's reflection, the problem is the skin: stretched, thinned and draped, sometimes with a soft bulge of prolapsed fat at the inner corner and a heavy, tired look that make-up disappears into by noon. It is the type the population studies count most — 55% of the Tehran cohort over 60 (Tehran Geriatric Eye Study) — and the type the operation was built for: the functional review lists an enlarged upper visual field, fewer headaches and better vision-related quality of life after skin removal (functional outcomes review). The devices below tighten this skin by a fraction of what the scalpel removes, and no cream reaches it. If the finger on the brow makes the fold disappear, read the next type instead.

The brow test is the one that changes the plan. Relax the forehead completely — most people have to be told twice — and note where the brows sit: at or below the bony rim, with the outer third lowest, is a descended brow. Now lift the outer brow about half a centimetre with a fingertip: if the hood over the outer eye disappears, the eyelid skin was never surplus, it was displaced downward by the brow above it (StatPearls on brow ptosis). The forehead is the second witness: horizontal lines and brows that ride up whenever you look at someone are the frontalis working all day to do what the finger just did, and the forehead-lines guide explains why toxin there makes this face heavier. Only 5% of the Tehran cohort were counted as brow ptosis (Tehran Geriatric Eye Study), but it hides inside a large share of the 55% with "hooding", and it is the type the ladder below is built for: a few millimetres from toxin in the depressors, about two from ultrasound, two to three from a browpexy stitched through the eyelid incision, three to four from an endoscopic lift. Blepharoplasty alone on this face removes the skin and lets the brow fall into the gap.

Take a flash photograph straight on, eyes relaxed, brow held by a finger, and measure from the white reflection on the pupil up to the edge of the lid. Four to five millimetres is normal; under about 2.5 is ptosis, and a difference between the two eyes is the commonest way people first notice it (StatPearls on ptosis). The other signs are a lid crease that has migrated upward, a lid that looks thin and long above the lashes, a forehead that lifts when you try to open the eye wide, and a look of tiredness that sleep does not remove. The commonest cause after fifty is a stretched or slipped levator aponeurosis — the tendon of the lifting muscle — from age, years of contact lenses, rubbing, or previous eye surgery, and it accounted for most of the cases with a cause in the British survey, where prevalence reached 20.8% over 70 (British ptosis survey; acquired ptosis review). This is the type with a prescription drop and a specific operation, and the type a blepharoplasty leaves half-shut. A ptosis that arrived over days, that varies through the day, or that comes with double vision or a small pupil is the safety section, today.

Look at the lid from the side in overhead light: a deep shadow under the brow bone, a visible groove above the crease and a thin, folded, multi-creased lid with a bony look is the sunken lid. It comes from loss of the orbital fat with age or weight loss, from the fat removed in an earlier blepharoplasty, and in some faces from a deep-set anatomy that was always there, and it makes the skin above it fold into the hollow so the eye reads as hooded and older at once. It is the one hooded type that adding treats: a 357-patient series of hyaluronic gel placed in three planes under the brow improved every grade of hollowing by at least one level (357-patient filler series), and a 35-woman study of fat repositioning with fat grafting filled a mean 5.9 mm hollow with 1.1 mL and held it on ultrasound at six months (fat-grafting study). A surgeon who removes skin and fat from this lid deepens the hollow; a surgeon who repositions the fat and takes little skin treats it.

The face most likely to be injected for forehead lines is the face least able to afford it: a person whose brows sit low and whose frontalis has been lifting them for years has lines because the muscle works, and relaxing it drops the brows and the lids they were carrying. The label rates brow ptosis at 2% and eyelid ptosis at 2% against 0% on placebo (prescribing information), a true lid ptosis follows toxin that has diffused to the levator from glabellar or crow's-foot injections, and the 2026 review of toxin complications ranks upper-lid ptosis as the most frequent clinically significant one, managed with alpha-adrenergic drops (toxin complications review). Apraclonidine 0.5% raises the lid 1–3 mm by contracting Müller's muscle while the toxin wears off (apraclonidine report), and oxymetazoline 0.1% does the same with trials behind it. The forehead-lines guide has the eyelid test that predicts which foreheads should not be injected; the drop below is the rescue.

Sort the type before anyone with a syringe or a scalpel does. First the forehead: relax it fully, twice, and note whether the brows sit at or below the bone rim and whether the forehead is lined from holding them up. Second the finger: lift the outer brow half a centimetre — hooding that disappears is a brow problem, hooding that stays is skin. Third the photograph: a flash picture straight on with a finger on the brow, and a ruler from the pupil's white reflection to the lid edge, 4–5 mm being normal and under about 2.5 the ptosis type, with any difference between the eyes noted (StatPearls on ptosis). Fourth the side view under a ceiling light for the hollow. Fifth the history: contact lenses for decades, previous eye surgery, previous toxin and when, and above all anything sudden, variable, or accompanied by double vision, a droopy face, a small pupil or weakness — the masquerades that need a doctor today rather than a clinic (ptosis evaluation review). Most faces over 55 have two of the four types at once, which is why the surgeons combine an eyelid operation with a browpexy or a tendon repair, and why the photograph is what you judge everything on this page against.