How To Tell If You Need A Brow Lift, An Eyelid Lift, Or Both

As the saying goes, the eyes are the windows to the soul. And, sometimes, these windows can be overrun by heavy upper lids, baggy lower eyelids, or even low-hanging brows that impede the appearance of an awake, youthful-looking eye. With so many potential changes affecting the eye area, how is one to know if they need a blepharoplasty (a.k.a. eyelid lift), a brow lift, or both? We tapped into four plastic surgeons for their insight on choosing the right surgery.

Age-Related Eye Changes

The aging eye can be difficult to navigate since there are various changes the area experiences. Like no two bodies are the same, neither are any two sets of eyes. But, for the most part, the relative transformation that most of us tend to notice to the eyes and the surrounding area include:

• Saggy Skin: The eyes boast perhaps the thinnest skin on the entire face, which is why they are often one of the first areas — if not the first — to show their age. Both the upper and lower eyelid skin can transform from firm and elastic to crepey, stretched out, and sagging.
• Under-Eye Bags: Not everyone experiences bulging bags, but, if they surface, it's usually from a weakening of the muscles and tendons coupled with displaced, protruding fat.
• Fat: In some, there are signs of fat loss and a hollowing of the under-eye area; in others, fat becomes displaced and begins to protrude from the lower eyelids causing bags to form.
• Fine Lines & Wrinkles: With changes to the quality of the skin come finely etched in lines and wrinkles around the eyes (i.e. crow’s feet), underneath them, and on the upper eyelids. Sun exposure, lifestyle choices, and inherently thin skin are all to blame.

Plastic surgeons don't follow a one-size-fits-all method to correct the eyes. Since the cause of aging in the region is multifactorial, your surgeon must tailor the solutions to address the issues at hand. For instance, if someone has excess skin, the skin has to be dealt with, says Steven Williams, MD, a board certified plastic and reconstructive surgeon in Dublin, CA, and the vice president of the American Society of Plastic Surgeons (ASPS). On the other hand, if there is fat atrophy, it should not be glossed over. “Without addressing each of these issues specifically, you will get incomplete results or unsatisfactory results,” he shares.

Although a brow lift and blepharoplasty both tackle age-related concerns on the upper third of the face, they address different facial features. As Dr. Williams explains, blepharoplasty helps correct loose lid skin on the upper and/or lower lid and periorbital fat. A brow lift, meanwhile, repositions the eyebrow and the skin of the forehead. “The brow is influenced by the frontalis muscle, a very thick, strong muscle, while much weaker muscles influence eyelids,” he notes.

Blepharoplasty, Brow Lift, or Both?

Now that you know how age and gravity affect the eye area, it’s time to talk about how to rejuvenate the region. As we’ve discussed, blepharoplasty can address skin and fat concerns on the upper and lower eyelids, while a brow lift can reposition the brow (which may have an effect on the upper lid) and target forehead skin laxity. These surgeries can be performed alone or in tandem depending on the patient and their aesthetic goals. Here’s what you need to know:

CHOOSE A BROW LIFT FOR EYEBROWS THAT APPEAR HEAVY

Dr. Williams says people often see him for a blepharoplasty consultation only to find out they need a brow lift. “Patients that feel they need an eye lift may have heavy brows as well,” he explains. “Many times, Botox® can contribute to masking brow ptosis issues, which can contribute to the overall undesired look.”

A brow lift is likely redundant skin on the upper eyelids is an issue (unless the brows have fallen considerably). In comparison, a brow lift focuses on raising the brow area strictly when the drooping stems from changes to the brows themselves and the area right above them. A brow lift also corrects any feeling of heaviness, says Robert Schwarcz, MD, a board certified reconstructive and oculoplastic surgeon in New York City.

Like so many other facial features, the brows can also ‘fall’ with time. Whenever a surgeon assesses a patient and checks their brow position, Dr. Schwarcz says the brows should ideally sit at the brow bone – not below it or encroaching on the eyelid space. When the brows sit lower on the face and closer to the upper eyelid than they should, they can block off a decent amount of real estate.

Excess skin is just one of many reasons why it is crucial to evaluate the brow and upper eyelid together. “If the lateral brow is sagging, it contributes to sagging skin and fullness in the upper eyelid,” explains Bob Basu, MD, a board certified plastic and reconstructive surgeon in Houston, TX. “A brow lift helps correct brow sagging and hooding to open up the entire eye.” If there is little space between the eyelid and the brow, a brow lift can open the eye area back up – likely without the need to remove as much upper eyelid skin.

A brow lift can be personalized for the patient. There are four different types of brow lifts that involve varying degrees of invasiveness (and scarring), and each one corrects a unique situation.

1. Coronal Brow Lift: This requires an incision from ear to ear (within the hairline) over the crown to remove excess skin and create more rejuvenated and lifted brows.
2. Endoscopic Brow Lift: Perhaps the most favored technique, this version is the least invasive surgical option and requires only a few small incisions.
3. Pretrichial Brow Lift: The hairline or trichophytic incision removes a small amount of skin as a way of elevating the eyebrows and is best suited for those with extremely high hairlines.
4. Direct Brow Lift: Making an incision directly over the eyebrows can lower a high hairline, however, this technique does not always address the entire brow but rather only a portion of it.

To artfully perform a good brow lift, incisions are made so that the surgeon can go in either endoscopically or more traditionally to lift the muscles and raise the outer third of the brows. As a result, the eyebrows appear better positioned and regain a more natural shape, plus the forehead will appear smoother. By improving the positioning, the brows look less heavy and the eyes look more awake.

But there is still a balancing act at play to achieve a natural result. “I always look at old photos to see if a patient always had low brows or did it change with aging,” Dr. Schwarcz says. “Not to complicate things, but in a small subset of the population – usually seen in very thin face patients – the brows can go up with age.” Furthermore, it's imperative not to overcorrect the brows when lifting them because that can make a person appear surprised. “Also, it’s important to be aware if someone has a hollow upper eyelid region, as this can be more exposed with a brow lift,” Dr. Schwarcz adds.

Preventatively, neuromodulators (i.e. the so-called Botox brow lift) can help maintain the arches. “Recent data proves that the frontalis muscle has a bi-directional pull on the skin of the face – both up and down,” Dr. Williams shares. “Botox may delay the need for a brow lift when used to treat that downward pull.” Even post-brow lift surgery, surgeons still may recommend neurotoxin injections to correct any wrinkles that crop up around the eyebrows, like between them (known as the glabellar lines or elevens) or right above them.

OPT FOR AN UPPER BLEPHAROPLASTY IF THE LIDS ARE HOODED

A tired-looking eye can result from upper eyelid hooding and loose skin (independent of the brow). In some cases, a low-hanging lid can impede the eyes' ability to function correctly. The excess skin makes it hard to apply makeup and eye products and can even affect one's vision. In the case of the latter, insurance may cover the cost of treatment.

Regardless of the cause, most plastic surgeons perform an upper eyelid blepharoplasty in one of two ways: either as a skin pinch or as a fat and skin removal procedure. Dr. Williams says that the techniques used for blepharoplasty depend on what needs to be corrected. “For example, if excess fat is contributing to the tired or heavy look, then ignoring the fat will lead to an incomplete result,” he says. Most patients need to address a combination of thick muscle, skin excess, and fat.

A small incision is made in the crease of the upper eyelid or in the lash line (we promise it sounds scarier than it is), which provides access to excise the skin and remove or reposition fat. Depending on the patient, the fat can be adjusted instead of removed to allow it to lay better without losing volume.

GO WITH A LOWER BLEPHAROPLASTY WHEN STUBBORN BAGS PERSIST

Is concealer not enough to send those under-eye bags packing? Puffy and protruding bags, which usually come with crepey skin, often require surgical intervention in the form of a lower eyelid blepharoplasty. “In the earlier days of the blepharoplasty operation, over obsession with the excess fat was a concern,” Dr. Williams recalls. “Modern-day techniques include a combination of fat removal and also fat repositioning to avoid the hollow look that most patients want to avoid.” Although plastic surgeons can remove fat in several ways, most practice is through an incision in the eyelid to avoid an external scar.

Dr. Basu explains that a lower blepharoplasty can remove loose skin and fat bags and improve the overall appearance of the lower eyelids. “Often, fat repositioning or fat micrografting also improves a tear-trough deformity – the hollowing in the lower eye area that contributes to an aged or tired look,” he says. “I frequently complement my surgical results with fat micrografting to achieve a more refreshed, natural-looking, rejuvenated result.” This way, there's a smooth transition between the lower eyelids and where they meet the upper cheeks.

It should be noted that a lower eye lift cannot fully eradicate every minor imperfection. When skin texture concerns, such as lines and wrinkles, are a patient's priority to get rid of, a resurfacing laser is often used instead.

DO A COMBINATION FOR HOLISTIC REJUVENATION

For some, both the upper and lower lids and the eyebrows require a refresh to create a holistic and harmonious result. “In moderate to severe cases, we can achieve the best results with both a brow lift and an upper eyelid lift,” Dr. Basu shares. It's essential to visit a board certified plastic surgeon to learn about your options and determine your needs.

Of course, when pairing procedures, your surgeon can do any combination. Still, the most popular combos are usually a brow lift and upper blepharoplasty and, perhaps, correcting the lower lids as necessary. The reason is that loose skin often accompanies upper lid hooding and a saggy brow, so addressing all the changes yields the most positive results.

When faced with more than one eye-related issue, most patients opt to go in for everything at once because it means a reduced cost (compared to two separate appointments), one recovery period, and maximized results. When done individually, Dr. Schwarcz says it’s usually because the patient doesn't want too much surgery at once or because “they want more accurate results to see how much skin is left after the brow lift heals.” In this staggered approach, the brow surgery comes first with the blepharoplasty performed later. “This is less common because there are two healing times and extra operating room expenses,” he notes.

The Takeaway

As Dr. Basu explains, the best ways to maintain the results of an eyelid lift, brow lift, or both include following a healthy lifestyle (think: hydration, good nutrition, and getting proper sleep), adopting a medically supervised skincare regimen, and introducing modalities to minimize collagen loss. If aging and tired eyes are the bane of your existence, consider a consultation with a board certified plastic surgeon, facial plastic surgeon, or oculoplastic surgeon for a full assessment of what changes you are experiencing in the upper third of the face and the best ways to address them.