In short. A dry eye, a lid that only just closes, thyroid eye disease, and a low crease that is a family feature rather than a sign of age. The reasons to be declined.

Key points

  • A low fold with a short distance between the lash line and the brow is a normal shape in many faces and not a sign of ageing.
  • Someone whose lid has looked like this for thirty years, and whose family members share it, is not a candidate for skin removal: there is no excess, and taking skin leaves a hollow edge where a fold used to be.

There are people for whom this operation is a poor idea, and the reasons are specific rather than general. Some concern the surface of the eye, some the position of the lid, and some what the patient is asking the operation to do.

The eye that is already dry

The skin removed from the lid is part of what spreads moisture across the eye when you blink. An eye that is already symptomatic — gritty on waking, or needing drops through the day — is working with less margin, and the operation takes some of that margin away. Where dryness is mild and treatable, it is treated first. Where the surface is already compromised, the honest answer is that another procedure on the lid is not the way to spend what is left.

The lid that only just closes

Some lids meet completely but with very little to spare, which is common with age and with a long-standing weakness of the raising muscle. Removing skin from a lid in that position is what produces an eye that stays open at night. It is measured before the operation rather than discovered after it, and where the measurement is borderline the amount that can be taken is smaller than the patient expected.

Active thyroid eye disease

Thyroid eye disease changes the position of the lid and the amount of tissue behind the eye while it is active. An operation planned then is planned against a moving target. It is a reason to wait rather than to give up, and the timing is decided with the team managing the thyroid condition.

The lid that was always shaped this way

A low fold with a short distance between the lash line and the brow is a normal shape in many faces and not a sign of ageing. Someone whose lid has looked like this for thirty years, and whose family members share it, is not a candidate for skin removal: there is no excess, and taking skin leaves a hollow edge where a fold used to be. A change is a finding. A shape is not.

When the request is the wrong one

A request for a wider eye, a more open look or an almond shape is not answered by removing skin, nor is a request to remove skin that sits on the brow. A request that the eyes look like a particular photograph is answered by measurement rather than agreement, because crease height follows the lid.

Reasons this operation is declined

  • A tear film that is already compromised, or drops used through the day.
  • A lid that closes completely but with very little to spare, or a margin that sits low.
  • Active thyroid eye disease, or a fold that has been the shape of this lid all along.

What to do instead, and which alternative matches which reason, is set out in Alternatives to Upper Eyelid Surgery, Including Doing Nothing. Whether to operate on the upper face at all belongs to the brow lift pages.

Related reading

Frequently asked questions

How dry is too dry for eyelid surgery?

There is no single figure, and the honest version is that it is a judgement made on the examination. What matters is how much of the surface is already compromised and how tightly the lid closes now. An eye that is symptomatic on waking, or that needs drops through the day, has little margin, and the operation takes some of it away.

Does thyroid eye disease rule out eyelid surgery for good?

Not for good, but it rules it out while the disease is active, because the lid position and the amount of tissue behind the eye keep changing and the amount of skin to remove cannot be decided in advance. Where the disease has been quiet for a long period an operation can be planned, and that decision belongs with the team managing the thyroid condition.

Is a low crease that runs in my family a reason not to operate?

Not a reason by itself, and a reason to be careful. A low fold on a lid with a short distance between the lash line and the brow is a normal shape rather than a sign of age, and setting a higher crease on it produces a lid that looks hollow and unlike the rest of the face.

Risks & Limitations

  • The amount of skin removed decides how completely the lid closes. Too much and the eye is exposed at night and the surface becomes dry and gritty, and skin that has been taken cannot be stretched back.
  • The dry eye question decides candidacy here more than any question about appearance. The skin being removed is part of what spreads moisture over the eye, so an eye that is already gritty on waking or needs drops through the day has less margin to spend.
  • A brow lift and a repair of the muscle that raises the lid are different operations, not variations of this one. Removing skin does not lift a brow or widen the eye opening, and it can make either finding worse.
  • The crease is set from the anatomy of your own lid. A crease placed higher than the lid can hold reads as hollow and staring, and over-resection produces a sunken upper lid that cannot simply be filled back with skin.
  • The two sides settle at different speeds and the difference narrows over three to six months, so the crease sits higher than its final position in the early weeks. The lid is judged across a year, and the scar matures and fades towards the crease over six to twelve months without disappearing.

When to Seek Care

  • Any change in vision, including blurring or a patch of lost sight — seek emergency care immediately.
  • An eye that is painful and gritty with a discharge, or a lid that does not close at all.
  • Increasing swelling or pain after the first few days rather than settling, spreading redness, warmth or fever.
  • Bleeding from the incision that does not stop with gentle pressure, or a wound that opens.

References & Further Reading

  • American Society of Plastic Surgeons (ASPS) — procedure and safety guidance
  • International Society of Aesthetic Plastic Surgery (ISAPS) — global procedure and safety guidance
  • National Institute for Health and Care Excellence (NICE, UK) — relevant guidance
  • Cochrane Library — systematic reviews
  • Chinese Medical Association Plastic Surgery Branch — clinical guidance

Medically reviewed by Tongchun Mao, MD (毛彤春), Deputy Director & Head of Aesthetic Surgery. Last reviewed: 19 September 2026.

This page is patient education, not medical advice, and it does not cite individual studies. Discuss your own case with a qualified clinician. To arrange an assessment at Chongqing West District Hospital, see Contact & Consultation.