When people think about upper blepharoplasty, they think about skin. Too much of it, folding over the lid, making the eyes look heavy, hooded, or tired. And removing redundant skin is a big part of the operation.
But there's another part of upper eyelid surgery that can matter just as much to how your eyes look afterward, and it rarely gets discussed: the position, depth, and shape of the upper eyelid crease. A change of only a few millimeters in where that crease sits can transform the appearance of the eyes. For some people, raising a low crease is the single most powerful thing we can do. For others, the same change would look too dramatic, too deep, or simply not like them.
So upper blepharoplasty isn't only a question of how much skin to remove. It's also a question of how your particular eyelid wants to fold — and whether changing that fold would actually make you look better. That's what this article is about. (If you haven't read my broader article on upper blepharoplasty and the "ingredients" of a droopy eyelid, it's a good companion to this one.)
Key takeaways
- The crease, not just the skin, shapes the result. Moving the crease a few millimeters can change the look of the eyes more than the amount of skin removed.
- Crease height, crease depth, and "pretarsal show" are three different things. Two people with the same crease height can look completely different, depending on the prominence of the eyes, the brow, skin thickness, and volume.
- I usually work with your natural crease — preserving it, raising it, or reinforcing it. Lowering a crease is uncommon and much less predictable.
- I simulate the crease in the office with a small stick to see how your eyelid naturally wants to fold before we decide anything.
- A higher crease isn't automatically better. It can look unnatural on fuller features, change your look more than you'd like, or conflict with a future brow lift.
- Crease work adds about one to two weeks to the more noticeable recovery, and the crease can look too high or deep early on before it settles.
What is the upper eyelid crease?
The upper eyelid crease is the fold you see above your lashes when your eyes are open. It looks like a simple line in the skin, but it's actually created by the machinery that opens the eyelid. The levator muscle lifts the lid through a broad, tendon-like sheet called the levator aponeurosis, and fine connections between that sheet and the overlying tissues are what make the skin fold at a particular level as the eye opens.
It's worth separating three things that people (and many websites) use interchangeably:
- The anatomical crease is where those attachments are — the line where the skin wants to fold.
- The visible fold is what you actually see when you look in the mirror with your eyes open. It may sit right at the anatomical crease, or the skin above it may hang down and cover part of it.
- A pseudofold is a secondary fold that forms somewhere other than the true crease — often higher — as the tissues around the eyelid change with age.
Much of what I'll describe below comes down to the relationship between these three.
Crease height, crease depth, and pretarsal show are not the same thing
When I evaluate an upper eyelid, I'm thinking about three related but different features:
- Crease height is how far above the lash line the crease sits.
- Crease depth is how deeply the skin folds inward — a soft, shallow fold versus a sharp, deeply set one.
- Pretarsal show is how much smooth eyelid skin you can see between the lashes and the overlying fold when your eyes are open. It's the "platform" people often mean when they say they want to see more of their eyelid.
These move together, but they aren't interchangeable. Someone with a relatively low crease can have just as much pretarsal show as someone with a higher one. Two people with exactly the same crease height can have very different depth. It all depends on the anatomy around the eye and how it has aged.
Why the prominence of your eyes matters
One of the biggest factors is how far forward your eyes sit relative to the bony rim of the orbit and the brow above them.
When the eyes are more prominent, the eyelid is supported farther forward. The crease tends to look shallower — and that same crease can also look a little higher, because of the way the lid drapes over the eye. When the eyes sit deeper, the eyelid folds farther back relative to the brow, and the crease tends to look deeper.
Skin thickness matters too. If the skin above the crease is thin, the fold looks softer and more delicate. If it's thick, the same crease can look puffy. And the brow — how high it sits and how lax it is — changes how much skin rests on the fold to begin with.
This is the honest limitation behind crease surgery: height and depth go together, and in general I can't set both independently. I can't change someone's anatomy 100%. Sometimes adjunctive procedures, like a brow lift or fat grafting to restore brow fullness, change the overall picture — but there isn't a dial for height and a separate dial for depth.
What I evaluate before deciding anything about the crease
Before we talk about crease height at all, we first have to establish that upper blepharoplasty is the right operation and that it can actually achieve your goals. Then, when it comes to the crease, I'm looking at:
- Eyelid skin thickness and quality
- Globe position — how prominent or deep-set the eyes are
- Brow position and how lax the brow is
- The bony orbit and how the eyelid relates to it
- Muscle strength of the eyelid — both the muscle that opens it (the levator) and the one that closes it (the orbicularis)
- Orbital fat volume — where there's fullness and where there's hollowing
- The lacrimal gland, which can slip forward and create fullness in the outer upper lid
- Dry eye, because how well the eye stays lubricated affects how much I'm willing to change the eyelid
Eyelid height itself — whether there's ptosis, a weak lid-lifting muscle — is assessed separately as part of every eyelid evaluation. That's its own topic, which I cover on my ptosis repair page; this article stays focused on the crease.
Your options: preserve, raise, reinforce — or, rarely, lower
Preserving your natural crease
If upper blepharoplasty is the right choice, I often use your natural crease. In many people it already has a good height and shape, and removing the redundant skin above it is all that's needed for a meaningful, natural improvement. When in doubt, the crease you were born with has a lot going for it.
Raising a low crease
Some people's natural crease sits relatively low. In those cases, raising it allows more pretarsal show and a more open, defined eyelid. The effect is powerful — raising the crease can improve the appearance with or without skin removal, although in practice I usually combine the two.
The tradeoff is that a higher crease can also become deeper, and that look isn't for everyone. If you have fuller lower lids or fuller facial features, a deep or high upper crease can look unnatural — out of harmony with everything else around it. More on that below.
Reinforcing the crease you have
Sometimes the crease is in the right place but has become looser, or less dominant, and the skin just above the lashes — the pretarsal skin — has become lax. In that case I may reinforce the existing crease, or recreate it at the same height and shape, rather than raising it.
There's a practical reason this matters. A skin-removal blepharoplasty alone doesn't always smooth out the pretarsal skin. And the crease can migrate: the eyelid can start to favor folding somewhere other than where the true crease is. That's why a surgeon can use a patient's natural crease, remove the right amount of skin, and still discover afterward that the visible fold sits lower than expected. Reinforcing the crease helps the eyelid fold where we intend it to.
Lowering a crease
Lowering a crease is much less common. It usually comes up when a crease is too high after prior surgery, or in the setting of other eyelid conditions. It's also considerably harder and less predictable than raising one. That's one of the reasons I'm conservative with crease changes — and with tissue removal in general — in the first place.
How I simulate the crease with a stick
The most useful part of my upper blepharoplasty consultation is simulating the crease. Using a small, thin stick, I press gently along the eyelid at a chosen height and have you open, close, and blink. The eyelid will usually fold a certain way based on the height I pick — and we simply watch what forms.
Sometimes the simulated crease looks exactly right. Other times the eyelid favors its own configuration: a crease that tapers toward the inner corner, or one that flares toward the outer corner, or a fold that's a little different from what I intended. Those patterns come from your anatomy and the mechanics of your eyelid.
I generally like to recreate what forms during the stick simulation, because the eyelid is likely to adopt it — the mechanics of the lid already favor it. If we try to force something different from what the simulation shows, there's more variability. Sometimes that can still be done well. Other times it's not a good idea, and it's important that you understand why, because this is exactly why the same operation produces different results in different people. Everyone's anatomy is different, and so is how it responds.
A few other things I'm watching for during simulation:
- Fine-tuning the height. If one position creates an undesirable shape at the inner or outer part of the crease, going slightly higher or lower often produces a better configuration.
- Stability. A good crease shouldn't vary much from blink to blink. If the simulated fold keeps changing, I treat that height with caution.
- Reinforcement. If I'm considering reinforcing your existing crease, I can use the stick to put a little more tension along it and see whether the skin above the lashes smooths out.
- Your reaction. Some people love the extra pretarsal show a higher crease gives them. Others look in the mirror and realize they prefer their natural crease, or something more conservative. Both are completely reasonable.
The point of the simulation isn't to talk anyone into a different crease. It's the closest thing we have to a preview — the most realistic picture of what's achievable for your eyes — so we can make the decision together. It isn't a guarantee of exactly how the crease will heal, but it gives us information that measuring and removing skin alone can't.
When I'd rather not raise the crease
Even when a higher crease looks attractive in isolation, there are times I'd advise against it:
- It changes your look more than you're comfortable with. If you've always had a fuller-appearing upper lid, I generally want to keep it somewhat close to that — with some exceptions.
- It doesn't fit your features. I like the upper lid to match the lower lid to some degree. A high, deep crease above full lower lids, or on a fuller face, can look incongruous.
- The fold isn't stable. If the simulated crease varies a lot with blinking, it's not a configuration I want to commit to.
- You might have a brow lift in the future. Lifting the brow later changes how much eyelid shows and how the crease looks. Raising the crease now and the brow later can change things too much, so if a brow lift is on the horizon, I'm more conservative with the crease — or we plan the two together.
Why the shape of the crease matters
The crease isn't always a smooth curve parallel to the lashes. Some people's crease tapers toward the inner corner; others flare upward toward the outer corner.
I usually try to keep your existing crease shape, because it's probably the most favorable and the most likely to hold. When I reinforce a crease, I keep it about the same. When I raise one, I follow the simulation, which often produces a configuration similar to your natural crease anyway.
A common question is whether a crease that flares outward can be made parallel. I don't usually try, for two reasons: most patients don't actually want it, and it would require lowering the outer part of the crease — which, as I mentioned, is much less predictable. It's also tempting to think that removing a little more or less skin can reshape the crease. It can't, not reliably. Adjusting the skin removal is for small refinements; a lateral flare is the dynamic of that particular crease, and trimming skin differently doesn't predictably change it.
At the inner corner, I'm more willing to act. I'll more often raise a low inner portion of the crease, as long as it doesn't create problems with the epicanthal fold — the small fold of skin at the inner corner of the eye. If it does, an epicanthoplasty of some kind is sometimes added, selectively. (Asian double-eyelid surgery has its own principles and techniques; I cover it separately on my Asian eyelid surgery page.)
Why the skin above the lashes gets loose
Patients often notice crinkled or loose skin just above the lashes, below their crease, and wonder why it doesn't simply go away with skin removal. In my experience there are a few reasons.
The most common association is a weakened lid-lifting mechanism. After that comes a migrating crease: as the fat behind the upper lid (the preaponeurotic fat) loses volume, it becomes easier for the lid to pivot and fold at a higher level, so a higher pseudofold starts to dominate. And the skin itself does get a bit thinner and lose a little volume over time, so there can be some true redundancy in that area.
Here's how I think about the mechanics — this is my clinical interpretation rather than something that's been precisely measured. Where the crease dominates is where most of the pull on the skin happens, and I don't think that force transmits very well to the skin below the crease. When the eyelid is younger, with robust tissues and a solid crease, the pull of the aponeurosis helps keep the skin below it smooth. When the crease weakens or migrates, that smoothing effect is lost.
That said, a skin-only blepharoplasty can sometimes help the pretarsal skin too. Skin glides freely, so laxity from above can sag down into that area, and the orbicularis can become slightly lax and fall a little with gravity. Remove the excess above, and the area below can improve. Isolated laxity of just the pretarsal skin — with nothing else going on — is actually rare.
Aging, volume, and what blepharoplasty can't restore
Upper eyelid aging is more complicated than skin stretching out. Skin quality changes, and the orbicularis muscle changes somewhat — but in my view those changes are relatively modest, and not the main reason the upper lid looks hooded. More often, the redundant skin is a consequence of what's happening underneath it.
The brow may descend. The fat around the upper lid and brow deflates or shifts. The bony orbit itself remodels and becomes a bit more squared off with age, so the eye no longer fits the eyelid quite the way it used to. Each of those changes affects where the skin folds and how much of the eyelid you see. When fullness behind the upper lid is lost, the skin can start favoring a higher fold, the original crease becomes less dominant, and the lid can look more hollow.
This is why I think of skin removal in blepharoplasty as removing redundancy — most commonly redundancy caused by volume changes. It improves the appearance, but it doesn't rebuild the fuller, younger anatomy that originally supported the skin.
And there are real limits. We can address brow position and brow deflation. But we don't have a good way to add true volume back inside the orbit, and doing so isn't common or always a good idea, for a number of reasons; in my practice, fat grafting is mainly about restoring fullness to the brow. Likewise, we can't do much to reverse changes in skin quality or in the orbicularis muscle itself.
How your eyebrow affects the result
The brow is part of this picture whether we operate on it or not, and there are two different effects worth understanding before surgery.
The contrast effect. Any upper blepharoplasty — skin removal, raising the crease, or both — can make a low outer brow look more noticeable. The central eyelid becomes more tucked in and defined, but the brow hasn't moved, so the remaining hooding at the outer corner stands out by contrast. The brow didn't fall; it's simply more visible next to a crisper eyelid.
The compensation effect. Many people unconsciously raise their brows to help lift heavy eyelids. After surgery, that extra effort is no longer needed, and the brows can settle to their true, lower resting position. Different mechanism, similar-looking result.
For many patients, neither is a problem — they're happy with the improvement in their eyelids and don't want brow surgery. For others, a brow lift is the right complement. What I don't recommend is trying to solve a brow-position problem by removing more and more eyelid skin; that doesn't fix the brow, and it can create problems of its own.
Your younger photos — and someone else's eyes
I like to review photos of patients from ten or twenty years ago, along with crease simulation. They show how the brow, crease, and surrounding tissues used to relate to each other.
But a younger photo isn't just a picture of less skin. Everything was in a better position: the brow, the volume, the orbit, the soft tissues. All of the "ingredients" that create how you look now are involved, so to fully recreate that photo, we'd have to address all of them — and some of them we can't fully address.
The same is true when someone brings in a photo of another person's eyes. Those photos are genuinely helpful for understanding what you find attractive — a bigger platform, a softer crease, a particular shape. But we aren't carbon copies of one another, and another person's eyelids usually aren't attainable on a different face. The most realistic outcome is what we can simulate in the office, plus whatever we can add back of the ingredients lost with time.
What recovery looks like when the crease is changed
When upper blepharoplasty involves raising, creating, or reinforcing the crease, the recovery is a bit different from skin removal alone. In my experience it can add another one to two weeks to the more noticeable phase of recovery, because crease work generates more swelling and takes longer to calm down.
Your eyes will usually feel harder to open at first. Part of that is the usual post-operative swelling, but part of it is that creating or reinforcing a crease places a new load on the tissues that open the eyelid (the levator aponeurosis and the tissue around it). So early on, the crease and the pretarsal show will look exaggerated — higher, deeper, more platform than expected — and even more so because your brows will try to elevate to help open the eyes.
This typically settles over three to six weeks. The crease and surrounding tissues keep softening and maturing for much longer, and I'd consider the final result to be somewhere around six to eighteen months out, depending on the person and the procedure. That doesn't mean you'll wait a year to look good — most people look quite natural well before then — but it's why I ask patients not to judge their final crease height or depth in the first few weeks.
One important caveat: "harder to open" and "looks high early on" describe normal healing. Significant or worsening pain, any change in vision, rapidly increasing swelling, or difficulty closing your eyes to protect them are different — those warrant a prompt call to your surgeon.
What makes a natural-looking crease?
To me, a natural crease isn't a particular number of millimeters. It's a crease that fits your eyes, your brows, your lower lids, and your face; that forms consistently from blink to blink; that doesn't erase the identity of your eyes; and that gives you an improvement you actually appreciate.
For some people, that means keeping the crease they have and removing the redundant skin. For others, raising or reinforcing the crease makes a substantial difference. And sometimes the best decision is to leave the crease alone entirely.
In upper blepharoplasty, a few millimeters can change the appearance of the eyes dramatically. Knowing when not to change those millimeters can be just as important.
Frequently asked questions
Can the eyelid crease be raised during upper blepharoplasty? Yes. When the natural crease sits low, it can be raised to increase pretarsal show and create a more defined lid, usually along with skin removal. Whether it should be raised depends on your anatomy, your features, and how the crease behaves when we simulate it.
Can a crease that's too high be lowered? Sometimes, but lowering a crease is much harder and less predictable than raising one. It usually comes up after prior surgery. This is one reason conservative crease decisions matter the first time.
Will I lose my natural crease shape? Not usually. I generally preserve your existing crease shape, because it's the configuration your eyelid favors and the most likely to hold.
Why does my crease look too high right after surgery? When the crease has been raised or reinforced, early swelling, temporary strain on the eyelid-opening tissues, and brows lifting to compensate all exaggerate the crease. It usually settles over three to six weeks and keeps refining for months.
Can removing more skin change a flared crease into a parallel one? Not reliably. The shape of a crease reflects how that eyelid folds; adjusting skin removal makes small refinements, but it doesn't predictably change the fold pattern.
Can I get the eyelids from a photo of someone else? Usually not exactly, because everyone's anatomy is different. Those photos are still useful for showing what you like, and simulation shows what's realistic for your eyes.
Eric S. Ahn, MD is a board-certified ophthalmologist and fellowship-trained oculofacial plastic, cosmetic, and reconstructive surgeon in Torrance, California. He specializes in eyelid surgery, ptosis repair, Asian eyelid surgery, and facial rejuvenation. To schedule a consultation, call the office at (310) 791-2233.
This article is for educational purposes and does not replace an individualized medical evaluation. All surgical procedures carry risks, and results vary with individual anatomy and healing.