Is a brow lift (forehead lift) better to raise sagging eyelids than a blepharoplasty?
Browlift Vs Blepharoplasty - Which is Best for Sagging Eyelids?
Doctor Answers 112
Brow Lift Vs. Blepharopasty
Aesthetic plastic surgery of the eyelids can produce a dramatic rejuvenating effect, literally taking years off of a person's appearance. Interestingly, many patients find that following eyelid surgery friends will say 'You look great!', but they usually cannot pinpoint exactly why.
If there is a facial rejuvenation surgery that is over-recommended and often overdone these days, it is without question the browlift. Look no further than the celebrity photo magazines for pictures of stars who look like they have just sat down on a plate of tacks. The goal of aesthetic plastic surgery should be to make a person look better and more youthful, not merely different, and certainly not as though one is perpetually surprised. My goal is to provide my patients with results which appear natural, and an unnatural-appearing brow is a dead giveaway that a person has had facial plastic surgery.
I rarely see a patient that has such significant brow descent that I recommend elevation of the entire brow. However, I frequently see browlift patients for whom conservative elevation of the lateral brow produces a more rested, bright, and even elegant appearance. This is very easily simulated with gentle upward traction on the skin of the lateral forehead - if you feel that this may apply to you then try it in the mirror and the improvement will be quite obvious
A youthful, feminine brow rests above the level of the orbital rim, which is the upper margin of the bony socket in which the eye resides. An aesthetically pleasing brow is somewhat arched laterally, and the lateral end or "tail" of the brow is higher than the medial end. It is quite common for the female brow to assume an essentially flat or horizontal orientation as a person ages.
If the skin and soft tissues lose enough elasticity with age and sun exposure, the lateral brow may even descend to a level below the orbital rim, producing a tired or even 'surly' appearance. The medial brow is relatively fixed in position and in most cases does not descend much, if any. In years past, a browlift surgery required an incision across the top of the head, from ear to ear. This was replaced in the 1990's, for most surgeons, by the endoscopic browlift, which allowed the same procedure to be performed through small incisions just behind the hairline.
Excessive or 'redundant' upper eyelid skin is a very typical aging change that leads people to seek eyelid surgery. In many patients, this surgery can be performed under light sedation with local anesthesia as an outpatient office procedure. In a few cases, protruding fat behind the eyelids is also removed. As with most facial aging changes, no two people present with exactly the same eyelid concerns. Surgical treatment is therefore individualized to the needs of each individual patient.
My approach to upper eyelid surgery is to be conservative with skin excision, and to reserve excision of fat for patients with significant fat excess. In my opinion, aggressive removal of upper eyelid skin and fat is a 'skeletonizing' procedure which risks making eyes appear more deep-set and aged, rather than younger. In fact, in many patients I perform structural fat grafting (using the patient's own fat, from the abdomen or hips) to help restore soft tissue volume around the eyes.
The next time you flip through Vogue or Allure (guys, just grab one at the checkout stand) take a close look at the eyes of the models. In most of them, women in their teens and twenties, you will see only a sliver of the upper eyelid, if it is visible at all. In many, the upper lid is completely obscured by soft tissue fullness between the brow and eyelashes, which I sometimes refer to as the 'brow roll'. Perusing the fashion magazines provides quick confirmation that the youthful upper lid is not a skeletonized upper lid.
A consultation with a board certified plastic surgeon with excpetional training and significant experience in performing conservative eyelid surgery and lateral browlifts can help you determine the appropriate surgery for you.
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Throughout one's lifetime, the four muscles that...
Throughout one’s lifetime, the four muscles that contribute to eyelid closure tighten and relax millions of times due to actions as slight as blinking to as strong as squinting in the sun. These four muscles are opposed by only one muscle that raises the eyebrows.
In time, this constant “tug of war” between the opposing forces that pull the eyebrows up and down leads to drooping of the brows and wrinkles across the forehead. The first damaging effects of this “tug of war” become apparent as early as the 3rd decade of life, and gradually worsen over time.
As the eyebrows droop, the skin between the eyelashes and the eyebrow that was once stretched smoothly across the eye begins to overlap. For women, this is first noticed as difficulty in applying eyeshadow because the “platform” on the upper lid begins to disappear beneath overhanging skin.
This phenomenon of the skin folding over the eyelid crease (known as hooding) gives the appearance of having too much fullness of the upper eyelids. Countless patients have expressed concern with this apparent excess of eyelid skin.
Classically, they pinch their upper eyelid and say “Doctor, my eyelids make me look tired. I want you to cut this skin out.” In reality, few patients would benefit by having the skin excised (cut out) since many do not truly have excess skin. On careful examination when the eyebrows are raised to their more youthful position, there is actually little to no extra skin on the eyelid.
In fact, removal of upper eyelid skin may pull the eyebrow down even further, exaggerating a tired appearance. In this case, a brow lift is fundamental to achieving an aesthetically pleasing result.
- Return the eyebrows and eyelid skin to a more youthful appearance
- Reduce forehead wrinkles
- Create a rested expression
- Anchor the brow to minimize further descent of the eyebrows
If there truly is excess eyelid skin after restoring the eyebrows to their normal position, then a pinch of skin can be removed to minimize eyelid fullness.
It should be noted that a percentage of the population would, in fact, benefit solely from removal of upper eyelid skin without a brow lift. These people do not have significant sagging of the brow and forehead and tend to fall into two categories:
- They inherited upper eyelid fullness with excess skin, usually apparent by the 20s or 30s
- They are in the 60s, 70s, or older and the skin has lost elasticity or has been stretched from rubbing the eyelids.
Significant excessive upper eyelid skin can interfere with vision. With appropriate documentation and approval, insurance may cover the costs of a functional blepharoplasty to restore vision. Eyelid surgery performed purely for aesthetics or for a condition not severe enough to warrant insurance coverage is considered cosmetic blepharoplasty.
The truth is that we have been doing too many brow lifts...
The truth is that we have been doing too many brow lifts. If you look at beautiful young models, most of them have low brows! Raising the brows in many women just makes them look different, not younger.
So, you have to make the right diagnosis. If the eyebrow is at the level of the bone above the eye, the patient does not need a brow lift. I just do an upper blepharoplasty which mostly consists of removing redundant skin. The inside of the eyebrow almost never needs to be raised.
So, if a patient's brows are below the level of the bone, then I perform a lateral or outer brow lift to gently raise and arch the brow. This is done with minimal scarring and a blepharoplasty is done at the same time.
It must also be said that it is a big mistake to do a blepharoplasty alone in a patient who really needs a brow lift because then, you will be dragging the brows further down.
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Brow lift or Eye lift - which one do I need?
This is a key decision and one that you should consider carefully before proceeding ahead. The fact is that most people with heavy eyelids have a combination of droopy brows and excess eyelid skin. The important thing is to decide whether it is a brow lift or an upper eye lift that gives you the best cosmetic outcome. In some individuals, both procedures may be necessary to get the best possible outcome.
First, let's take a look at the ideal brow position in a woman. The inside corner of the brow begins at the root of the nose, and gently climbs to higher level, reaching its peak typically somewhere half way between the pupil of the eye and the outside corner of the eye, and then dropping down at the temple. While in a woman the brow is ideally above the level of the bone and curves upward on the side, in a man, the brow is typically at the level of the bone and tends to be more horizontal.
Now that we have an idea of the ideal brow position, a rather simple test can be performed to see whether you are a good candidate for a brow lift:
- Stand in front of a mirror and look straight ahead.
- Make sure that you are not intentionally lifting up your brow.
- Place the index and middle fingers of both hands, half way between the brow and the hairline, one aligned with the center of the brow and the other at the outer corner of the brow.
- Gently lift and glide the forehead skin up toward your scalp. Go back and forth a few times, seeing the effect of the simulated brow lift on the shape of your eyes.
- Try turning your head away from the brow, toward your nose, and again glide the forehead skin up toward your scalp, seeing the effect of the lift on the side of your brow.
- If you like the look of your eyes with this maneuver and if the crease of your eye becomes more visible and the eye appears more alert and youthful, then you may be a good candidate for a brow lift.
If your brow is resting in a good position but there seems to be excess fullness and folded skin obscuring the crease of your eye, then you may be a better candidate for an upper eye lift. Results of an upper eye lift are more difficult to simulate than a brow lift. An eyelift can typically improve the excess droopy skin that covers the cease of the upper eyelids and in some people can even rest on the upper eyelashes. Eye lifts do not elevate the brow position, and, in fact, can sometimes slightly lower brow position. Lower blepharoplasty or lower eye lift can improve bagginess of the lower eyelids and the excessive wrinkling that some of us get on the skin of the lower eyelids.
When you are being evaluated for upper eyelid...
When you are being evaluated for upper eyelid improvement, it is imperative that your surgeon make the correct diagnosis.
Excess upper lid skin either comes from the eyelid, too low of a brow, or both. If your eyebrows are too low, manual repositioning is performed. If you lose all the excess skin, then you only need a browlift. If you still have extra eyelid skin after pushing your eyebrows back into a youthful position, then you need both a browlift and a blepharoplasty.
Normal position for a female brow is roughly one centimeter above the upper bony margin of the orbit, with the peak at the margin between the middle and outer third of the eyebrow. A male eyebrow is ideally situated at the upper bony margin of the orbit. If the brow is already in this position during the physical exam and there is still excess skin on the upper lid, then a blepharoplasty is all that is needed.
Blepharoplasty is for sagging eyelids, Brow Lift is for sagging brow
If your eyebrow is about 1 centimeter (about 1/2 inch) higher than the bone above your eyelid at the high point of the arch of the eyebrow, then your brow is in a normal position and any upper eyelid excess is best treated with a blepharoplasty.
If the eyebrow is at or below the bone then you have brow ptosis and may need a brow lift.
Most commonly, if you have brow ptosis, you will also have excess eyelid skin and both a brow lift and blepharoplasty may be required-often in stages-usually the blepahroplasty first and the brow lift later.
Rarely, only a brow lift is needed if brow ptosis is severe and the eyelid skin is not excessive.
The blepharoplasty is a simpler operation with a well hidden scar and most plastic surgeons do the blepharoplasty first and find that that is all that is needed.
Males normally have a lower brow-oten the brow is positioned right at the level of the bone obove the eye-thus blepahroplasty is usually done first in males as the scarring caused by a brow lift is more difficult to conceal in males.
Browlift vs. Blepharoplasty: not always "versus"
Browlift and blepharoplasty (upper) are not mutually exclusive procedures--they can be done in conjunction. In some cases, neither procedure will address your particular problem. It all depends on proper evaluation of the eyelid/brow complex, as well as a detailed discussion of your concerns and your surgeon's aesthetic sense.
In my experience, I think browlifts tend to be overutilized, and can give a surprised/startled look. On the other hand, upper blepharoplasty when performed too aggressively can make you look skeletonized, "operated", and/or unnatural (eg, kenny rogers!).
Make sure you seek a surgeon (facial plastic, plastic, oculoplastic) who is not just experienced doing eyelid/brow procedures, but also has aesthetic ideals that matches yours.
Hope this helps!
Brow lift or blepharoplsty to treat the saging upper lid
If you compare the upper eyelid to a curtain, the brow is the rod from which it hangs. Therefore the brow position will affect the eyelid and vice-versa.
When people have too much skin on their upper lids they will keep their brows up to be able to see better or even to look better. Hand someone a mirror. When they bring it in fron of their face the eyebrows move up automatically. If one operates on the eyelids to correct the upper lid excess, the brow will assume a lower position which could be unattractive.
Therefore when I see a patient for Blepharoplasty who is likely to have that problem after surgery, I will suggest a brow lift at the same time. There are time when I have refused to do a Blepharoplasty in a patient whom I thought needed a brow lift at the same time and they didn't want or couldn't do it. A brow lift alone can improve the condition of the upper lids but it would only work in mild cases of upper lid excess.
How to rejuvenate heaviness in the upper eyelids
In order to answer this question, one has to know if the patients eye brows are
- brows currently droopy?
- patient male or female?
- where the brows always heavy or is this change new?
- In youth, did the patient like their eye brow position?
- Does the patient have a problem with dry eyes
In order to answer many of these questions, my patients are instructed to bring in photos of themselves from their 20's and each decade up until the age at which they present. This helps me understand the evolution of their aging eye area.
Yes, heaviness in the eye brows contributes to heaviness in the upper eyelids as it tends to push down excess brow skin over the eye lids.
In male patients who always had heaviness in their eye brows, the most natural approach is simply an upper eye lift. This avoids an unnatural feminized appearance which can result from lifting the brows in men especially if overdone.
In female patients, if their eye brows are heavy but have not changed in position, I tend to not lift the brows if they liked where their brows were positioned in youth. An upper eye lift alone is sufficient to rejuvenate the eyes. If there is a significant change in their brows, then I will recommend an upper eye lift and brow lift.
Caution: I will try to avoid performing a brow lift and eye lift in someone who has a problem with dry eyes as this can accentuate the problem. Patients are certainly warned.
Browlifts and upper eyelid blepharoplasties do different things. It is a mistake to try to do a really big browlift to make the upper eyelids look good, or a really big upper eyelid surgery when the brows have become heavier.
It is usually better to have each procedure performed conservatively, and avoid an exaggerated look or an upper eyelid that appears still heavy once the brows come down again, which they almost always do due to the powerful closing muscles of the eye acting over time. When the upper eyelids are performed with a fat conserving technique, the upper eyelids can look natural, youthful and unoperated.
You can try this yourself in the mirror and raise up the brows until the upper eyelids look good. Usually you will see a very exaggerated appearing brow contour before the upper eyelids look good. Therefore, the browlift is not the answer for both the upper eyelids and the brow, since they are really two different areas.
The main focus for browlifts in our practice is the lateral brow, the outer portion of the brow, affecting skin that lies outside of where an upper lid blepharoplasty reaches. We do not routinely raise the central brow much because this can give a startled appearance.
The types of browlift- endo vs. coronal vs. pretrichial vs. minimally invasive lateral vs. Endotine will have profoundly different effects on the appearance and the hairline. Basically, any brow procedure that originates above the hairline will raise the hairline. It is best to have a candid discussion with a number of board certified surgeons before choosing your procedure.
The effects on creating areas of baldness or loss of sensation also need to be considered. For most of our patients conderned with not having a raised high forehead when their procedure is done, we perform lateral browlifts, minimally invasive. This technique actually restores an aging hairline by lowering it slightly. It also preserves the all important deep branch of the supraorbital nerve, the branch that is cut during a coronal lift that gives sensation to the top of the head. Endotine techniques are promising but many patients complain of pain or sensitivity with the hooks underneath the brows.
For a complete discussion of browlift techniques, you may want to preview my chapter in the "Mathes" Plastic Surgery textbook on my website "drbrent.com" under Articles.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.