• Triple eyelid refers to an extra eyelid fold.
  • There are many potential causes, but age is the primary factor.
  • Most triple eyelids do not resolve on their own.
  • Blepharoplasty or brow lift surgery can correct this issue.

Triple eyelid occurs when the upper eyelid has two folds instead of one. Several factors may be involved, but in most cases it is caused by redundant skin, fat atrophy, or an improper functioning of the eyelid’s fibrous muscle tissue.

We spoke with a panel of expert surgeons to find out more about this common aesthetic concern.

triple eyelid crease
Triple eyelid crease. Credits: Dr. Siew Tuck Wah.

What causes triple eyelid?

“It requires a good physical exam and medical history to determine the exact cause,” says Benjamin P. Caughlin MD, a facial plastic surgeon in Oak Park, IL. “Sometimes the fat has fallen, and sometimes the muscle attachment is weakened. Other times the skin is torn away from the ligament.”

Any number of the following potential factors may be at play.

  • Aging and loss of skin elasticity

By far the most important factor is age. Triple eyelid is much more common in older patients than among people in their 20s.

  • Ethnicity

“Triple eyelids can affect anyone, but they more commonly affect Asians,” says New York City board-certified plastic surgeon Stephen Warren, MD. “Asians tend to have low upper-eyelid creases and more upper-eyelid fat closer to the eyelid margin. As the skin loses its elasticity and the fat atrophies, the person is set up to have multiple eyelid creases.”

  • Skin tone

People with paler and thinner eyelid skin are more prone to develop a triple eyelid, even at a younger age, according to William H. Truswell, a board-certified facial plastic surgeon based in Easthampton, MA who currently serves as president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

  • Body type

While triple eyelid is more common among older patients, young people who are thin and athletic sometimes develop multiple upper eyelid creases.

  • Long-term contact lens use

“Prolonged use of contact lenses over the years causes the muscles to be pulled away,” says Caughlin. This is especially common in older patients.

  • Ptosis

Ptosis, or sagging of the upper eyelid, is usually a factor. Ptosis can be congenital (present at birth) or caused by trauma, but is typically a result of aging.

  • Lack of fat

Insufficient fat supply is a factor in the development of triple eyelid, regardless of other factors. A lack of fat can be caused by aging, trauma, or surgery. It can also be caused by a protruding eyeball.

  • Edema

Edema is a collection of excess fluid in the body’s tissues or cavities. Some inflammatory conditions can cause water retention that leads to the formation of a triple eyelid.

Will it go away on its own?

In most cases a triple eyelid will not resolve on its own and requires surgery to correct, though there are some exceptions.

Truswell says that allergies, a cold, or a lack of sleep can cause inflammation and swelling in the lids, which can eventually result in the formation of a triple eyelid. In these cases, the problem may resolve on its own without surgery.

Caughlin concurs. “If it’s simply edema from inflammatory conditions, we can sometimes get away with topical anti-inflammatories. If it’s the skin, muscle or fat, then it requires surgery to correct.”

Warren says that triple eyelids do not resolve spontaneously but cites one additional scenario in which a patient might choose to forego surgery.

“For persons mildly affected, the triple eyelid can appear to improve or get worse depending on the time of the day and the person’s level of hydration,” Warren explains. “Some persons who are mildly affected can see improvement when they apply moisturizers.”

Triple eyelid surgery

All of the experts we interviewed agree that surgery is the best solution to correct triple eyelid. Some doctors rely solely on surgery, while others while others may attempt to enhance the effects of the surgery through fat or filler injections.

Truswell believes that surgery alone is the solution to a triple eyelid, and that turning to minimally-invasive treatments may backfire.

“Adding volume through the use of fillers may enhance the fold and change the way the eyes look,” he explains. He also warns that exercises, Botox, and lasers — all of which are sometimes touted as solutions to a triple eyelid — will unfortunately not be effective.

Other surgeons, however, find that minimally-invasive treatments can be helpful in correcting a triple eyelid.

“If the triple creases are shallow, fillers or fat injection alone may be enough to expand the skin and eliminate them,” says Warren. “However, most patients will benefit from a modest skin excision, release of the levator adhesions, and the addition of a small amount of fat.”

In most cases, correcting a triple eyelid will require eyelid surgery (with or without fat or filler injections), a brow lift, or a combination of these procedures.

Blepharoplasty

If your surgeon determines that you need upper eyelid blepharoplasty to correct your triple eyelid, he or she will take several steps to determine your candidacy and the approach that should be taken during surgery. A physical examination and vision examination will be required. Photos will also be taken to help plan the surgery.

In preparation for the procedure, the surgeon will ask that you stop taking certain medications that thin the blood or exacerbate bleeding:

  • Ibuprofen (Advil, Motrin)
  • Aspirin
  • Naproxen (Naprosyn)
  • Naproxen sodium (Aleve)
  • Warfarin (Coumadin, Jantoven)
  • Other medications and supplements that can increase bleeding

The surgeon will also ask that you stop smoking a few weeks before surgery, as smoking can interfere with the healing process.

You will be instructed to arrange for a friend or family member to drive you home once you are cleared following surgery, and to have someone available to monitor you the first night after your surgery.

Eyelid surgery is typically performed on an outpatient basis. The surgeon will use local anesthesia and administer intravenous medication to make sure you’re relaxed. Incisions are then made along the eyelid fold to remove excess skin, muscle and fat.

Bruising and most of the swelling should subside within a couple of weeks. Scars can take several months or longer to fade. During this time, you should take steps to protect your eyelids from sun exposure.

There are no statistics that track the cost of blepharoplasty specifically for correction of triple eyelids. However, according to the latest statistics from the American Society of Plastic Surgeons (ASPS), the average cost of blepharoplasty surgery is $3,022.

Brow lift surgery

If your eyebrow is drooping and pushing on the upper eyelid, this too may need to be addressed. According to Caughlin, Botox injections may be beneficial in certain cases. For other patients, a brow lift — or a procedure that includes both a brow lift and eyelid surgery — may be the only effective option.

Depending on the type of brow lift, the procedure may be performed under conscious sedation (IV sedation) or general anesthesia.

Some surgeons prefer to make small incisions near the hairline and use an endoscope (a small, thin tube with a camera attached). Others will perform a “coronal incision,” which is an incision from ear to ear along the top of the head. The forehead skin is then lifted and adjustments are made to the muscles. Brow lift incisions are closed with skin adhesives, clips or sutures.

These wounds generally take 10-14 days to heal, during which time you will need to keep your head elevated and avoid applying heat or ice. The recovery process will continue for several more weeks and may last up to several months.

According to statistics from the American Society of Plastic Surgeons (ASPS), the average cost of brow lift is $3,403.

» For more information on treatments for triple eyelid, use Zwivel’s directory to locate and contact a board-certified plastic surgeon in your area.

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