Objective To investigate the rational classification method and treatment of upper lid skin laxity in middle-aged and elderly people in order to guide clinical practice for optimal results. Methods A retrospective analysis was performed on 105 cases of various kinds of blepharoplasty with upper eyelid skin laxity in middle-aged and elderly patients performed between May 2000 and May 2005, classified according to eyebrow position, upper eyelid bloating or not, and upper eyelid skin width, and evaluated the surgical results. Results Surgical satisfaction rate was 87% [77 cases], basic satisfaction rate was 11% (10 cases), and dissatisfaction rate was 2% (3 cases) in 105 patients. Conclusion In middle-aged and elderly patients with upper lid skin laxity, different treatment methods should be used according to the characteristics of upper lid laxity and according to different typologies. Upper lid skin laxity is related to age and genetics, and the results of a single procedure are often not significant. Therefore, some scholars have used blepharoplasty along with browlift for different clinical features with satisfactory results. 1. In middle and old age, due to various reasons, such as genetics, age, and sleep disorders, facial skin gradually appears to relax and age, most obviously around the eyes, especially the outer skin of the upper lid. Because the middle and inner 2/3 upper eyelid muscles are stronger and act as a counterweight to the gravity of the upper lid itself, most middle-aged and older adults have a sagging or flabby upper lid in the lateral 1/3, creating what is commonly known as a triangular eye shape that affects aesthetics and life. It is also a typical feature of aging in the face of the middle-aged and elderly, and is characterized by a predominantly lateral sagging of the eyebrow, accompanied by loss of the orbital sulcus and the accumulation of sagging tissue on the upper eyelid, making the upper lid bloated and swollen, which not only aggravates the “triangle eye” deformity and severely obscures vision, but also leads to deepening of the interbrow and temporal wrinkles. The anatomical basis for this: (1) the skin is less elastic, saggy and redundant, with relative atrophy of the subcutaneous fat; (2) the orbicularis oculi muscle is also weak, with reduced tone; (3) the orbital septum is atrophied, with a depression of the upper lid or a relative increase in orbital fat that prolapses in front of the lid plate or presses down on the lid margin; (4) the septal fascia is loose and weak, adding to the sagging orbital fat; (5) the levator muscle is stretched and stretched over time, causing the tendon membrane to become more and more stressed. The burden gradually increases, transforming the tendon membrane into a relaxed, elongated state; (6) the lid plate is loosened, aged, and piled up in front of the joint fascia. Due to its anatomic features and different causes, different individuals have different manifestations and therefore the treatment methods and strategies should be different. 2. Previously, there were no individualized surgical options for the treatment of upper lid laxity in middle and older age. Upper blepharoplasty accounts for almost all cosmetic eye surgery in the middle-aged and elderly. However, for most middle-aged and elderly people, the procedure may indirectly aggravate the crow’s feet and make the overall appearance of the eyelid less coordinated, which is not ideal and takes a long time to recover. It is also believed that the treatment of upper eyelid skin laxity through a brow margin incision is simple, the incision is concealed, there are no visible marks on the eyelid area, and the postoperative recovery is quick and natural, and the more serious complications of eyelid surgery can be avoided. Some of the above methods of blepharoplasty are very effective, however, they are too general to be clinically useful for each individual. In the past, there has not been a classification of the specific characteristics of middle-aged and older ptosis and a targeted treatment plan based on that classification, and although there are numerous procedures for ptosis, there is little guidance for a plastic surgeon, especially a young one who is new to the specialty of plastic surgery. By retrospectively analyzing the cases undergoing surgery over the past 5 years, we have been able to typify and implement different procedures according to the different clinical characteristics of different recipients, and have proposed the concept of individualized treatment plans, with a postoperative satisfaction rate of 98% in this group. 3. Upon entering middle and old age, the appearance of aging such as sagging eyebrows and loose or bloated upper lid skin is demonstrated. In this group of cases, they were first classified into two types based on the presence or absence of brow ptosis: i.e., non-pendulous brow – type I and brow ptosis – type II; and secondly, they were further classified into 4 subtypes each based on the presence or absence of upper lid bloating, change in eyebrow-eye spacing and heavy lid line width. Based on the above classification and subtypes, different surgical approaches are developed and individualized, resulting in a much higher satisfaction rate after surgery. Surgical options for Type I patients: In this type of patient, although the eyebrows are not drooping, the upper margin incision will cause the eyebrows to appear elevated and deformed, so the lower margin incision is an ideal option for those with upper eyelid skin laxity that manifests as a widening of the eyebrow-eye distance and narrowing of the blepharoplasty line width. The traditional blepharoplasty incision is a better option at this time. The blepharoplasty incision not only allows for the widening of the eyelid line directly through the patient’s technique, but also has the advantage of being able to remove fat and eliminate upper lid bloating. The surgical option for type II patients: middle-aged and elderly people have an aging upper eyelid and brow ptosis due to skin and muscle laxity, especially on the lateral side of the eyebrow. Therefore, ptosis is more common in patients with ptosis than in those without ptosis, which is consistent with the statistical results of this group of cases. For patients with ptosis, an upper brow margin incision is more necessary. The upper margin incision is used to fix the brow fat pad, remove excess skin from the upper eyelid and brow area, lift the eyelid, and indirectly widen the eyelid line, while improving eyelid laxity and correcting sagging eyebrows, crow’s feet and forehead lines, resulting in a more harmonious overall view of the patient’s face. For patients with widened eyebrow-eye spacing or upper lid bloating, a blepharoplasty incision is made to shorten the eyebrow-eye spacing or eliminate upper lid bloating while completing the upper eyebrow margin incision, resulting in a more perfect postoperative appearance.