Brow lift or upper blepharoplasty: how do the indications differ?
As the skin above the eyes sags with age and gradually covers the eyelid crease,
many people first think of upper blepharoplasty.
They expect removing the visibly loose skin to improve the hooded appearance as well.
However, similar-looking drooping around the eyes may originate in different locations.
In some cases, the upper eyelid skin itself loses elasticity and becomes loose.
In others, descent of the forehead and brows pushes the skin and soft tissue beneath the brows
down toward the upper eyelids, making the skin overlap more prominently.
Because these two conditions can look similar, it may be difficult to distinguish them simply by
the amount of skin covering the eyelids.
Similar-looking drooping can have different causes
The forehead, brows, and upper eyelids may seem separate, but they are interrelated structures of the upper face.
Aging not only reduces skin elasticity; it may also gradually shift the soft tissues of the forehead and brows downward.
As the forehead and brows descend, the skin beneath the brows also moves downward, creating more overlapping skin on the upper eyelids.
Conversely, the forehead and brows may remain in position while the upper eyelid skin itself loses elasticity, loosens, and folds over the crease or lashes.
Despite a similar appearance, the first step is to distinguish descent of forehead and brow tissue from excess upper eyelid skin itself.
1. When a brow lift may be considered
A brow lift involves dissecting sagging tissues around the forehead and brows, moving them in an appropriate direction, and securing them in a new position.
It may therefore be considered when forehead and brow descent, rather than the eyelid itself, is the main cause of upper-eye hooding.
Typical features may include the following.
✔ A reduced distance between the eyes and brows
✔ Drooping of the inner brow, creating a stern-looking brow angle
✔ Pronounced skin hooding over the outer upper eyelid
✔ A less visible eyelid crease and a more hooded appearance than before
✔ Brows that rise when opening the eyes
✔ A habit of engaging the forehead to open the eyes
✔ Horizontal forehead lines deeper than those of others of the same age
Compensatory use of the frontalis, or forehead muscle, is particularly important.
People with descended brows may unconsciously use this muscle to raise their brows when opening their eyes.
Even if the brows do not appear particularly low, descent when the forehead fully relaxes may reveal previously masked brow drooping.
Preoperative assessment should include brow position with the forehead relaxed, the distance between the eyes and brows, and the degree of forehead muscle use, rather than only the usual eyes-open appearance.
2. When upper blepharoplasty may be considered
Upper blepharoplasty addresses excess skin in the upper eyelid itself to improve skin overlap.
It may be considered when the distance between the eyes and brows is not narrow, but the upper eyelid skin has lost elasticity and become loose.
Skin folding over the eyelid crease or descending toward the lashes may make the eyes appear heavy and hooded.
The following features are assessed when considering upper blepharoplasty.
✔ Brow position has not descended substantially
✔ Loose skin covers the lashes or eyelid crease
✔ Considerable eyelid skin remains even when the forehead and brows are raised
✔ Eyelid skin folds even without substantial forehead muscle use
In upper blepharoplasty, the incision is generally designed with the existing eyelid crease and eye shape in mind, and the necessary amount of skin is removed.
As eyelid tissue thickness and fat distribution vary between patients, the surgical extent may be planned by assessing the surrounding soft tissues as well as the skin.
An important point is that enough upper eyelid skin must remain for natural eye closure.
Removing more skin than necessary without considering eyelid movement and the existing eye shape may cause unwanted changes, such as tightness during eye closure or a hollow appearance above the eyes.
The aim of upper blepharoplasty is therefore not to remove as much visible skin as possible, but to identify how much of the excess originates in the eyelid itself and determine an appropriate excision.
How are a brow lift and upper blepharoplasty distinguished?
The choice is not based on a single test or specific measurement.
The brow and eyelid shape are assessed comprehensively from several angles.
Feature | When a brow lift may be considered | When upper blepharoplasty may be considered
Main change | Descent of forehead and brow tissue | Laxity of the upper eyelid skin itself
Brow position | Often lowered | Often relatively maintained
Distance between eyes and brows | Often reduced | May be relatively maintained
Forehead muscle use | Often pronounced when opening the eyes | May be less prominent
When the brow is raised | Eyelid skin overlap may decrease substantially | True skin excess may remain even with the brow raised
Main surgical area | Skin and tissues around the forehead and brows | Upper eyelid
Three factors are particularly important.
Brow position with the forehead relaxed
For people who habitually engage the forehead muscle, observing it as fully relaxed as possible helps establish the true brow position.
If brows that usually appear appropriately positioned descend considerably when relaxed, brow drooping may be contributing.
Distance between the eyes and brows
The distance between the eyes and brows may narrow as the brows descend.
However, natural brow position and facial skeletal structure vary, so the decision to perform a brow lift should not depend on a single distance measurement.
It is helpful to consider the previous appearance, current brow position, and heights of the inner and outer brow together.
The amount of skin remaining when the brow is supported
During examination, supporting the brow at an appropriate position shows how the eyelid skin changes.
If raising the brow substantially reduces the skin covering the eyelid crease, brow descent may be contributing significantly to the apparent eyelid drooping.
Conversely, if considerable upper eyelid skin remains after adjusting brow position, coexisting upper eyelid skin laxity should be assessed.
However, manually lifting the brow is only a reference maneuver during clinical assessment.
The direction and force of a manual lift do not reproduce tissue movement after surgery, so choosing a procedure based on a single self-test is inappropriate.
Frequently asked questions
Q. If a lot of skin covers my eyelids, do I need upper blepharoplasty?
A. The visible amount of skin alone is insufficient to determine the appropriate operation.
There may be true excess upper eyelid skin, but descent of the forehead and brows can also push skin and soft tissue toward the eyelid, increasing apparent overlap.
Brow position, forehead muscle use, and the amount of skin remaining when the brow is appropriately supported should therefore be assessed together.
Q. If lifting my brows by hand makes my eyes look more open, do I need a brow lift?
A. This can provide one clue about the contribution of brow drooping.
However, the force and direction of a manual brow lift differ from tissue movement during surgery.
Rather than relying on this test alone, the usual brow position, forehead muscle use, eye-to-brow distance, and actual amount of upper eyelid skin should be assessed together.
Q. Does a short distance between the eyes and brows always require a brow lift?
A. No. This distance also varies with natural facial skeletal structure and brow shape.
Instead of deciding solely because the distance is short, assessment should include whether the brows have descended compared with the past
and where they sit when the forehead is relaxed.
Q. Will a brow lift eliminate the need for upper blepharoplasty?
A. This depends on the individual's brows and eyelids.
A brow lift alone may be considered if moving the brows to an appropriate position is expected to reduce upper eyelid skin overlap sufficiently.
If considerable true upper eyelid skin laxity would remain after adjusting brow position, upper blepharoplasty may also be considered.
Q. Can a younger person need a brow lift?
A. Age alone cannot determine whether surgery is needed.
Depending on brow position, facial skeletal structure, eye-to-brow distance, and habitual forehead muscle use, brow drooping may create a hooded appearance even at a relatively young age.
Conversely, an older person whose brow position is maintained and whose main issue is excess upper eyelid skin may be considered primarily for upper blepharoplasty.
If you would like to know whether a brow lift or upper blepharoplasty is appropriate, contact us at 02-545-3700 or through “UVOM Plastic Surgery” on KakaoTalk to arrange assessment of your forehead, brows, and upper eyelids.
For more articles on brow lifts, select a title below ▼
Why do eyelids look more droopy when the brows descend?
Double-eyelid surgery or a brow lift for drooping eyes? It depends on the cause.
Why can the eyes look surprised after a brow lift?