What you actually need may be a brow lift.
Daniel J. Givens, MD · Double board-certified facial plastic surgeon
Patients frequently come to see me because they are bothered by heavy upper eyelids. They see extra skin, particularly toward the outside of the eyes, and assume that an upper blepharoplasty is the solution.
For most patients, an upper blepharoplasty is the right treatment. In the remaining patients, however, the brow may be contributing significantly to what they perceive as excess eyelid skin. Sometimes that is apparent to me as soon as I walk into the room.
If we don't recognize that, we can perform a technically good upper blepharoplasty and still leave the patient with some of the heaviness that bothered them in the first place.
About 4 out of 5
Patients Dr. Givens sees for heavy upper eyelids have enough excess skin and good enough brow position that an upper blepharoplasty alone makes sense.
ANATOMY
The brow ages by rotating downward
The central brow tends to remain more stable while the tail of the brow descends. As it moves downward and inward, it pushes additional tissue into the lateral upper eyelid. If there is significantly more hooding laterally, I start thinking about the brow.
BROW POSITION
Men
A natural brow generally sits around, or sometimes slightly below, the orbital rim and has a relatively flat shape.
Women
The brow generally sits around the orbital rim medially, arches slightly, and rises above the orbital rim laterally.
These are guidelines rather than measurements that we try to impose on everyone. The goal is to work with someone's existing anatomy.
A CLUE
Your forehead may already be trying to lift your brows
Many patients with heavy brows or excess upper-eyelid skin are constantly contracting the frontalis muscle, which is the large muscle of the forehead that elevates the eyebrows. They usually don't realize they're doing it. Essentially, they're giving themselves a small, continuous brow lift.
IN THE EXAM ROOM
The mirror test
I hand the patient a mirror and gently reposition the tail of the brow upward and outward. It only takes a few millimeters. Then we look at the upper eyelid. Some of what appeared to be excess eyelid skin disappears.
I let the brow fall back into its resting position, and the lateral hooding returns. This helps us decide whether the patient needs an upper blepharoplasty, a brow lift, or both.
COMMON CONCERN
Why people are afraid of brow lifts
Brow lifts have a reputation that comes partly from results people remember from previous decades. Older coronal and endoscopic techniques sometimes emphasized more vertical or central elevation, which could create the surprised appearance patients are understandably worried about.
"A youthful brow isn't simply a higher brow."
Shape and position matter. The movement I usually want is subtle and more oblique, particularly laterally.
YOUR OPTIONS
When is an upper blepharoplasty enough?
Blepharoplasty alone
Excess upper-eyelid skin but relatively good brow position. An upper blepharoplasty alone may be exactly the right operation.
Brow lift
Patients who would benefit somewhat from a brow lift but simply aren't ready for it. That's reasonable too.
Both
They can be performed together, or the brow lift first and the upper blepharoplasty a couple of months later.
For younger patients with early brow descent, surgery may not be necessary. We can sometimes create a small chemical brow lift with neurotoxin. A Botox brow lift is modest. It cannot reproduce what we can accomplish surgically.
TECHNIQUE
How I perform a brow lift
Endoscopic-style
Small incisions within the hair and temporal scalp, working underneath the periosteum (the tissue covering the skull) and releasing the attachments around the orbital rim.
Hairline or pretrichial
A zigzag incision along the hairline, for more advanced brow aging, particularly significant central or glabellar (between-the-brows) descent.
Gliding
Used for a period of time, but generally no longer used.
WHAT TO EXPECT
Recovery and tradeoffs
Sensation and healing
Temporary forehead or scalp numbness is common after a brow lift, and sensation usually returns. Numbness can be more extensive with a hairline brow lift. Hair loss around the incisions is possible with either technique, but I have found it to be extremely uncommon with my endoscopic approach.
What we watch for
Risks include asymmetry, settling or recurrent descent, infection, problems with skin blood supply, scarring, and injury to the frontal branch of the facial nerve that moves the brow. Some degree of asymmetry is normal because our underlying muscle tone is not perfectly symmetric.
When insurance may apply
When brow or eyelid position interferes with peripheral vision or creates significant forehead strain, brow lifting and upper blepharoplasty can sometimes be considered functional rather than cosmetic. Visual field testing is generally used to determine whether insurance criteria are met.
THE BOTTOM LINE
Sometimes the eyelid isn't the whole problem
Sometimes it is.
Sometimes the brow is the primary problem.
And frequently, both are contributing.
The goal isn't to make someone look surprised or obviously operated on. It's to gently reposition the brow so the upper face looks less heavy, less tired, and more alert while still looking like the same person.
NEXT STEP
Not sure if it's your eyelids or your brow?
The mirror test takes a minute. Or let's talk through what's right for you.
