Surgical Considerations in the Upper Eyelid and Brow


The upper eyelids and brow should be considered together for rejuvenation of the upper third of the face. The upper eyelid is one of the first areas of the face to show signs of aging, with excess skin. If left long enough, the redundant skin can obstruct a patient’s peripheral vision. Patients often complain of heaviness of the upper eyelid with outside observers commenting that the patient looks tired. Along with redundant skin, the upper eyelid can have bulging of the fat pads that surround the eye. The excess fat should be removed during upper eyelid blepharoplasty (eyelid lift).

The brow descends with age due to laxity in the supporting structures. The lateral, or outer portion of the brow, descends at an accelerated rate when compared to the central portion of the brow because of differences in attachment to the underlying soft tissue and bone. This results in a more rapid accumulation of redundant skin on the outer portion of the upper eyelid, which is termed “lateral hooding.” When determining the correct brow lift procedure, the surgeon should determine if the effects of aging on the brow include primarily the lateral brow or the more central portions of the brow. If there is a significant discrepancy in aging of the central and lateral brow, with the lateral brow primarily affected, a lateral temporal brow lift may be indicated. With this procedure an incision is placed in the hair overlying the temple and the brow is elevated in an upward and outward direction to restore its natural arch and youthfulness.

Often times patients do not seek consultation until the effects of aging are more advanced with the central brow having dropped significantly, as well. In this instance a total brow rejuvenation procedure should be performed, with several options currently being used. The most state-of-the-art brow lift procedure is the endoscopic brow lift whereby the brow is lifted using tiny incisions in the scalp and telescopes to release the brow and reposition it in an elevated position. There is controversy as to the effectiveness of this procedure. Over time, it has become apparent that in experienced hands it is an equally effective, less invasive procedure.

The trichophytic brow lift, an open technique, camouflages the incision by placing it in the hairline mirroring the entire length and carrying the incision down into the hair tuft over the temples. This is an effective technique that is still commonly used today by many surgeons. The primary consideration is whether the patient is willing to tolerate a much longer incision and more invasive procedure. Other types of brow lifts still used today, although less commonly, include: the coronal, direct, and midbrow lift with specific indications for each technique. The direct and midbrow lift place incisions in the forehead skin and are typically indicated for facial paralysis and older, male brow lifts respectively. The coronal brow lift approach places a large incision in the central scalp from ear to ear and is almost never indicated for rejuvenation procedures, but rather as an approach to facial trauma and head and neck procedures. The coronal brow lift incision may be indicated to reverse a previously over pulled brow procedure that has resulted in a “surprised look.”

When considering the upper eyelid and brow as a unit, one must restore brow position prior to removing upper eyelid skin to prevent “lagopthalmos,” or eyelid retraction, and dry eye. If the brow is at an appropriate height with a youthful arch, the upper eyelids may be addressed without a simultaneous brow lift. When a low brow position and redundant eyelid skin occur together, a brow lift should accompany an upper eyelid blepharoplasty with the brow lift performed first to prevent negative outcomes.

When patients present with primary concerns about their upper eyelids, the brow must be assessed at the same time in order to get optimal results. When a low brow is not corrected at the same time as the upper eyelid blepharoplasty, a future brow lift procedure can have a much higher complication rate and may preclude the procedure all together. Finding a surgeon who is familiar with the many brow lift techniques and assesses the brow and eyelids together as a complex, is important to avoid complications and deliver optimal results.

Article by
Atlanta Facial Plastic Surgeon