Doing the Upper eyelids versus Forehead lift

Today I got a very nice letter from a patient who had consulted with me about Eyelid surgery. I had recommended a Brow lift with a mid Facelift. She thanked me for a very thorough and knowledgeable consult, but decided to go ahead and get just her eyelids done by an ophthalmologist who does Plastic surgery.

This is an issue I encounter often, and I thought I would write my thoughts down in case anybody can benefit from this. First of all, whenever somebody comes to me complaining of excess skin in the upper eyelid, they expect a simple procedure under local anesthesia to remove that extra skin from the upper eyelid. The answer to the problem; however, is not that easy in most cases. The reason is that there really is very little, if any, extra skin in the upper eyelid.

You can see for yourself by getting in front of the mirror and pulling up your eyebrow until it is slightly above the bony ridge above your eye socket. When you position the eyebrow there, there is very little extra skin on your eyelid. If your brow were there all the time, you wouldn’t think of getting the “extra skin” cut out because there would be very little, if any, extra skin. So you have to ask yourself, is the answer to cut out skin or to put the brow where it used to be when you were younger?

Some people feel like the patient who wrote me that nice note. They may agree with me that putting the brow where it belongs is the more logical choice, but they don’t want the longer and more expensive procedure.

The danger with this approach is the following: After cutting the “extra skin”, the brain sends a signal to the brow elevator muscles. It says “guys, you don’t have to lift the brow so hard, because that extra skin is gone, so relax a little and let the brow come down some.” So the brow comes down a little, then the patient thinks the surgeon didn’t take enough skin and asks for a little touch up. The surgeon may not do it because he feels that if he takes out too much skin, the patient may not be able to close her eyelids properly, causing an irritating and sometimes painful condition named “dry eye syndrome”.

On the other hand, he may feel confident of taking just enough skin, and get a good result. The problem with this approach is that even if he is successful, he now has created a smooth upper eyelid but a very low brow position that makes the eye appear crowded in.

If the patient then wants to raise her brow some to get a fresher, more open look, the surgeon is boxed in. If he raises the patients brow now, he will for sure create problems with the upper eyelid.

I recently had a patient who had the same concerns, and I let her talk me into doing just the upper eyelids. I explained to her all the brow position issues and she reassured me she understood, but she wanted just something “conservative” done and she wouldn’t mind if the upper eyelid didn’t come out smooth. To make a long story short, she minded very much and wanted a “touch up”. I thought this would only make matters worse and even showed her preoperative pictures compared to the postoperative pictures, including how the brow had descended.

At this point patients feel like they are entitled to what they paid for and may not listen to my reasoning. For this reason, now, when somebody who has a brow position problem with “excess skin” in the upper eyelids asks for my opinion, I recommend a brow lift. If they want eyelid surgery only, I refer them elsewhere.

Perhaps some people are afraid of a Brow lift because it seems like such a big procedure. It is not necessarily so. Some surgeons do Brow lifts using an ear to ear incision through the scalp, called a coronal incision. They pull the skin back and cut the “excess skin”. If not done properly, you can raise the hairline too much and get a “surprised look”. I would be scared, too.

I prefer doing the Brow lift with an endoscope. You make 1-inch incisions hidden in the hair and put a scope under the skin until you reach the muscles that make the brow come down. Then you divide those muscles with very delicate instruments to preserve all the nerves and blood vessels. The whole thing takes about as long as it takes to do the upper eyelids, but you need intravenous sedation. I have never heard of anyone getting a high hairline, and you would have to be trying really hard to get a “surprised look” using the endoscope.

Browlift first, then eyes if needed

So in summary, if you feel like you have too much skin in the upper eyelids, raise your brow to a level just above the bony ridge over the eye. If there is still excess skin, it would be great to have just upper eyelid surgery. If the excess skin is mostly gone, think seriously about repositioning the brow to its more youthful position.

After all, what makes more sense, cutting away skin or putting things where they belong?