Double eyelid surgery and getting older: what happens to the crease over the years, and what can be done later

A double eyelid crease made at 25 has to live on a face that keeps ageing. People reasonably wonder what it will look like at 55 and 75, and whether anything can be done then. This article sets out what the long-term studies actually measured, how the upper lid changes with age whatever was done earlier, and what can be done later. There is a gap to name at the start: none of the studies cited here follows double eyelid creases for 10, 20 or 30 years, so those questions cannot be answered with data. What follows is the evidence that does exist, with its limits.

Does a double eyelid crease last as I get older?

Some creases hold and some do not, and the studies cannot give a lifelong answer. The longest follow-up in the studies cited here runs to about four and a half years, and it measures how many people needed another operation, not how a crease looks at 50 or 70.

A 2025 study of 1,000 buried suture operations followed for four years found reoperation after 13.4% of the operations done with a continuous suture and 26.2% of those done with a two-point suture. Suture loosening was the reason in 81.87% of reoperations. A 2026 study of two-point buried suture operations, followed to mid-2025, found reoperation after 17.0% of the operations in which upper eyelid fat was removed at the same time and 33.5% of those in which it was not. A third study took 600 cases from a national database of 52,281 operations and found reoperation in 22.3% overall, highest in the under-20 group (41%) and lowest in the 30 to 39 group (12%). The 60-and-over group showed a trend towards more reoperation that was not statistically significant.

These numbers need careful reading. All three come from the same group of clinics in Japan, and all three are retrospective, which means the authors looked back at records rather than following people forward by design. The endpoint is reoperation, so someone who lives with a faded crease and never goes back is not counted. And the age in the third study is the age at the operation, not the effect of ageing afterwards. None of the three tells you what a crease does between 40 and 70. They do show that a buried suture crease can loosen, that technique and anatomy influence how often, and that a meaningful share of people return for another operation within a few years.

Does a buried suture crease age differently from an incision crease?

Possibly, but none of the studies cited here compares them over decades. A buried suture crease is held by stitches placed under the skin, and loosening is the commonest reason for redoing it in the studies above. An incision crease is made through a cut in the skin. How the two methods compare at the start is in my article on incision and buried suture methods.

For incision-type methods the long-term evidence is thin. One report on a mini-incision technique followed 110 patients for 3 to 12 months and then re-examined 24 of them (46 lids) after a further three years. The authors found no case in which the fold disappeared, and obvious shifting of the fold in four lids. That is a small number of people examined by the surgeons who designed the technique, and it says nothing about what happens after 60. The same paper describes the incisional approach as leaving a permanent crease. That is the authors' statement, not something they measured, and a crease that stays is not the same as a crease that looks unchanged.

Whichever method is used, the lid around the crease goes on ageing. The next sections explain what that ageing is.

How does the upper eyelid age whatever was done before?

Skin loosens, fat can bulge forward, the brow can matter more, and the tendon that lifts the lid can stretch. These changes happen in lids with and without a crease, and each has its own name and its own treatment.

Skin first. EyeWiki, a clinical reference written by ophthalmologists, says ageing weakens the connective tissue and reduces skin elasticity, and that weakening of the orbital septum, the thin membrane that holds the fat in the eye socket, allows fat to herniate and adds to the bulging look. The medical name for loose, excess upper lid skin is dermatochalasis. Moorfields Eye Hospital describes the same pattern: hereditary factors and changes with age can cause drooping of the skin and the tissues beneath it, with fat pushing forward.

Then the lifting muscle. The levator is the muscle that raises the upper lid, and it pulls through a flat tendon called the levator aponeurosis. The American Academy of Ophthalmology says that adult ptosis, the medical name for a droopy upper lid, can occur when the levator stretches or separates from the eyelid, and that this can be caused by ageing or by injury. A systematic review of repair techniques calls involutional ptosis, the age-related kind, the commonest form, commonly caused by the effect of progressive age on the aponeurosis.

The brow is the third factor. EyeWiki notes that brow position matters when judging how much skin a lid really has, to tell true from apparent excess, and that a brow lift is often done alongside blepharoplasty when the brow has dropped. None of the sources cited here measures how far the brow descends over the decades, so this article gives no figure. A heavy brow and a heavy lid can look alike, and the article on telling them apart explains how they are separated at an examination.

Why can my crease look lower, narrower or hidden as I get older?

Because loosened skin above the crease can hang over it, so the fold is covered rather than gone, or because the lid itself has dropped. These are different problems, and a reader who brings the wrong one to a consultation may be offered the wrong operation.

Skin hanging over a crease is dermatochalasis, and the lid margin may sit exactly where it always did. A lid that has dropped is ptosis, where the margin sits lower over the eye and the levator is the cause. Both can be present at once, and EyeWiki notes that they often coexist. A surgeon separates them by measuring where the lid margin sits, how well the levator moves, and how much skin lies above the crease, which is why a mirror alone cannot settle it.

It is a common worry that a crease set high at the first operation looks more out of place with age. A crease that is too high is a recognised complication, covered in my article on revision double eyelid surgery. None of the studies cited here says whether it looks worse in later decades, so this article does not state it as fact. It is a reasonable question to put to a surgeon, who can look at the individual lid.

What can be done later, and why is it judged then, not promised now?

The options are upper blepharoplasty to remove excess skin, ptosis repair to lift the lid itself, and revision to correct a crease problem. Which of them suits a lid, if any, can only be judged on the lid as it is at that time, so none of them can be promised now.

For skin, the operation is upper blepharoplasty, described in my guide to upper blepharoplasty. A 2012 series from one private practice in 99 Asian patients aged 42 to 78, mean age 55.7, with a mean follow-up of 24 months, reported asymmetry in 9.1%, scarring in 3.0% and an unfavourable cosmetic result in 2.0%. The authors recreated the crease in every patient, even those who already had one. They also reported that less skin needs to be removed in an Asian lid than in a Caucasian lid, because taking the maximum gives an unfavourable appearance. It is a single practice, retrospective, with no comparison group, so it describes one approach rather than proving it.

For a dropped lid, the operation is ptosis repair. The AAO says that for more severe ptosis the levator may need to be shortened and reattached to the lid. The same systematic review found no randomised, prospective trials comparing repair techniques for involutional ptosis, and notes that over 100 techniques have been described. The choice between them therefore rests on surgical judgement, not on trial evidence. My article on ptosis surgery in adults explains what it fixes.

For a crease that has become a problem, revision is possible but demanding. A 2025 series of 90 patients with high folds used a three-plane dissection with fat repositioning or grafting. At least six months after the operation, the mean crease height had fallen from 11.1 mm to 7.1 mm, 87.8% of patients were satisfied and 12.2% were not. Earlier blepharoplasty and coexisting ptosis were among the factors linked to satisfaction. The authors say further studies are needed. If a later problem raises the question of age, my article on whether there is an age limit for eyelid surgery answers it, and a second opinion before any operation is reasonable.

What should I think about at the first operation to make the later years easier?

Ask for a plan that leaves room for the lid to age: a crease at a natural height for that lid, conservative skin removal, and a surgeon who explains the anatomy. A crease set too high is the harder problem to put right later: the authors of the 2025 revision series above call its correction a significant challenge.

Anatomy is the reason a plan cannot be copied from a photograph. A cadaver and MRI study published in 1999 compared the upper eyelids of 9 Korean and 5 Caucasian cadavers. It found more fat in Asian lids, with a pretarsal fat component, and found that where the orbital septum joins the levator tendon differs, which helps explain why a crease is absent or low in many Asian eyelids. It is a small, old study, cited here for the principle rather than the numbers: lids differ, and a technique should fit the lid. My article on what changes underneath goes through this.

Three practical points follow from the studies in this article. Fat removal in suitable lids was linked with fewer reoperations in buried suture surgery, but that is a retrospective finding and not every lid is suitable. Skin removal is one place where being conservative matters, since taking the maximum in an Asian lid risks an unfavourable result. And double eyelid surgery has been linked with an average drop in brow height of about 2.5 mm in a 2023 review of 17 studies, which is one more reason the brow belongs in the first assessment.

Choosing who operates matters as much as the technique, and my guide to choosing an eyelid surgeon sets out what to check. If your lids already feel heavier or the crease has changed, have them examined by an eye doctor who can tell skin, lid and brow apart. For more on the area, see the aesthetics section and my hub article on why eyes look tired.