Brow lift vs. Blepharoplasty - which is best for sagging eyelids?

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.

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I think this is a great question because the answer really depends on your individual anatomy.  Most of my patients who see me for eyelid or brow rejuvenation do so because they feel they have a very "tired" appearance.  When I evaluate a patient for eyelid rejuvenation, I'm first looking at the position and shape of the eyebrow, then the quality and amount of eyelid skin, and finally the presence or absence of fat around the eyes.  This will dictate what operation will give the patient the most natural result. 

In general, I like the brows on women to arc as they move from the center of the face to the side of the face, and this is widely considered the aesthetic ideal (in men, it's a bit different-- we want the brow to be a bit flatter).  Also, the position of the brow should be slightly higher in women than in men, sitting above the bony rim of the orbit.  If your brow already is at the proper height and  shape, then I'll evaluate the eyelids themselves. 

This evaluation will allow me to recommend either a browlift (and there are several different types of browlifts which can be performed based on what will give you the best result), a blepharoplasty, or both.  But the key is to give each patient the right operation or operations in order to best attain a natural, refreshed look. 

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.

If indeed it is only the eyelids that are sagging, then an upper blepharoplasty is the appropriate procedure for correction. The surgeon will determine the distance between the eyebrows to the eyelashes, and if that distance is adequate, just an upper blepharoplasty is performed.

If the distance is short and the brows are quite low, consideration should be given to a forehead lift or a browlift. A brow-lift is an operation that is used for someone who has very low set eyebrows. The procedure softens frown lines and horizontal lines of the forehead and can be done through an endoscopic approach or through the coronal approach.

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.

This will:

• 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. 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.

In regard to the upper eyelids, sometimes the primary cause of a sagging eyelid is a lower eyebrow. In that situation we want to make sure that we perform an endoscopic brow lift. In addition, if the upper eyelid skin is heavy, we want to do an upper lid lift where we make an incision on the crease of the skin and remove the upper eyelid skin.

In regard to the lower eyelids, you have to be very careful because if you remove too much skin you can have lower lid retraction, where the lower eyelid pulls down. If there is excess eyelid skin, you can do conservative therapies such as using a laser to tighten up the skin, or a direct excision.