3 Types of Eyelid Lift to rejuvenate hooded eyes

중년 눈성형 종류

Hooded eyes in the upper eyelids is a common concern for middle-aged adults, and eyelid lift surgery is a popular solution. This article will discuss the three eyelid surgery for periorbital rejuvenation: upper blepharoplasty, infra-brow lift, and brow lift. We will also present the pros and cons of each method to help you choose the best option.


Q. How can middle-aged eyelid surgery result in a sad and tired appearance?

brow change after upper blepharoplasty

A : When a large amount of skin is removed during upper blepharoplasty to address severe skin excess, the thick skin may fold, causing an unnatural double crease. Furthermore, the habit of using the forehead to elevate the sagging skin may disappear after surgery, resulting in a narrower distance between the eyes and eyebrows.
These two factors may lead to a harsh look. However, each individual’s habits and conditions vary; some may be satisfied with eyelid surgery alone.

Q. What distinguishes Upper blepharoplasty, Infra-brow lift, and Forehead lift?

A : Upper blepharoplasty involves removing lax skin while creating double eyelid folds. Infra-brow lift addresses sagging skin under the eyebrows and is recommended for patients with significant skin sagging. Endoscopic forehead lift improves skin sagging and forehead wrinkles simultaneously.

Q : Who is an ideal candidate for Upper lid blepharoplasty?

A : Patients with moderate eye-eyebrow distance and mild upper eyelid sagging are suitable candidates for upper lid blepharoplasty.

Q : Who is an ideal candidate for Infra-brow lift?

A : Patients with severe eyelid sagging and a long eye-eyebrow distance are ideal candidates for Infra-brow lift.

Q : Who is an ideal candidate for Forehead lift?

A : Forehead lift is recommended for patients with a narrow gap between the eye-eyebrow, less skin sagging, and concerns about forehead wrinkles. It can also be considered for patients with harsh impressions after previous upper lid blepharoplasty.

1. What is Upper Blepharoplasty?

1) Upper lid blepharoplasty: strengths and weaknesses

Blepharochalasis refers to the upper eyelid skin excess with aging. Upper Blepharoplasty (commonly called Eyelid Lift in the US) is a surgery that treats excess skin in the upper eyelids, creating a double eyelid crease.

a) The advantages of upper blepharoplasty include:

  • Easy removal of lax skin or bulging fat
  • Ability to make eyes bigger (by performing a ptosis surgery using the same incision)

b) However, there are also some disadvantages, including:

  • Possibility of an “operated look” if too much skin is removed
  • Risk of droopy eyebrows can lead to closer lid-brow distance and worsening glabellar wrinkles.

We will explain in more detail Why Operated Looks are Common in Asian Middle-Aged Blepharoplasty sections below.

2) Ideal conditions for Upper lid Blepharoplasty 

  • Eyes Thin-skinned eyes
  • A noticeable gap between the eyelids and eyebrows

If you meet these criteria, upper lid blepharoplasty may be your right choice. This procedure can help make your eyes appear larger, reduce puffiness, and correct droopy eyes with a sunken A-deformity.

3) Unsuitable conditions for upper blepharoplasty 

As we age, our facial features change in many ways, and one procedure alone may not always be enough to satisfy the needs of people over 50. If your eyelid skin is too thick, consider alternative procedures like an infrabrow lift or endoscopic forehead lift. The best choice for eyelid rejuvenation surgery can be complex and depends on factors such as the degree of eyeball protrusion, the prominence of the orbital bone, and your personal goals and concerns. It’s important to avoid self-diagnosis and biases when choosing a procedure and to have a good understanding of the age-related facial dynamics.

upper lid skin thickness
The figure of skin thickness(left) and area of skin excised in upper eyelid lift(middle) and infrabrow lift(right)

2. Sub-brow (Infra-brow) lift

1) What is a Sub-brow Lift?

As shown in the upper image, the skin depth near the eyelash is very thin and gets thicker as it reaches the cephalad. The subbrow lift removes skin just below the eyebrows, giving a more natural appearance than the eyelid lift because it can preserve thin skin above the eyelash.
However, the surgeon may not be able to alter the shape or height of the double eyelid crease to the patient’s desired appearance. One drawback of the procedure is that the incision scars may be visible during the early stages of recovery, but they will fade over 3-4 months.

3. Upper blepharoplasty vs. Sub-brow lift

1) Advantages of Upper lid blepharoplasty compare to infra-brow lift include

  • The same incision can be used to fix droopy eyes.
  • Can make double eyelid crease at the same time.
  • Less noticeable scar.

2) Subbrow lift has some advantages over upper lid blepharoplasty, including:

  • Improved treatment of excess skin.
  • Natural appearance with lower risk of an “operated look.”
  • Results are less dependent on the surgeon’s skills.

3) Common disadvantage of both surgeries

  • Eyebrows may descend (varies individually)

The possible drawbacks of undergoing lid surgery or infrabrow lift are that the brow may sag after the procedure, causing the eyelid and brow to appear close together. This drooping is referred to as the “disappearance of frontal muscle compensation.” It can be more severe if the individual has a habit of using their forehead muscle when opening their eyes. This issue is not typically a problem for Westerners, but for Asian eyes with heavy upper lids, a shorter distance between the lid and brow can result in a more stubborn appearance.

<The difference between eye-opening habit and ‘lid-brow distance’ changes; before and after surgery>
upper blepharoplasty before
Case who do not use forehead muscle in pre-op.
upper blepharoplasty after
3 months after eyelid lift.
Lid-brow distance had been nearly unchanged.
eyelid lift before
Case who use forehead muscle moderately in pre-op.
eyelid lift after
6 weeks after eyelid lift.
Lid-brow distance had been shortened in proportion to pre-operative brow elevation habit.
eyelid surgery before
Case who use forehead muscle a lot in pre-op.
eyelid surgery after
2 months after subbrow lift.
Lid-brow distance had been shortened a lot when compared to eye-opening photo in pre-op.

4) Effect of brow descent

The short lid-brow distance results some negative changes such as:

  • Excess skin on the upper lid may remain even after surgery.
  • The ‘lid-brow distance’ is narrowed, making an angry look.
  • If the transverse nasal creases are present, they get worse after surgery.

And if these changes are expected, the recommended treatment choice is a Brow lift.

4. Why Operated Looks are seen in Asian Middle-Aged Blepharoplasty

1) Difference in Skin Thickness

Patients who have undergone upper lid surgery often report that their appearance looks unnatural. To understand why this happens, it’s important to understand the thickness of the upper eyelid skin.

lid skin thickness invivo specimen
Lid skin thickness in vivo specimen
Three Skin Zones in the Asian Upper Eyelid Pertaining to the Asian Blepharoplasty.

As shown in the upper figure, a typical Asian upper eyelid has three zones of varying skin thickness. Near the eyelashes, the skin is thin, while the infra-brow area has a thick layer of skin and fat. It’s important to keep in mind that skin thickness increases from the eyelashes to the brow.
Young patients under 30 years old who need a relatively small amount of skin removed during the surgery are unlikely to experience the “operated look.” However, older patients requiring more extensive skin removal can end up sad or angry-look, regardless of the surgeon’s technical expertise.

upper blepharoplasty dissatisfaction
Heavy and thin fold in Asian double eyelid. If too much skin is excised, it will result in a heavy double eyelid fold with an operated look(left). The inborn double eyelid shows a light fold with a natural look(right). The white arrow indicates the edge of the fold.
Three Skin Zones in the Asian Upper Eyelid Pertaining to the Asian Blepharoplasty.

The above picture shows the results after lots of skin excess has been removed during the blepharoplasty. On the left, the thick skin above the lid crease makes a tired and sad look. On the other hand, the photo on the right is a natural double eyelid without surgery, featuring fine lid crease by thin skin.

2) Brow Descent after lid surgery

The second reason for the “operated look” is that the brow can descend after the surgery, particularly in middle-aged patients.
When the skin sags and blocks vision, people unconsciously lift their brows using their forehead muscles. After the saggy skin is removed, their field of vision improves, and they no longer need to lift their brows. This change leads to the forehead muscle relaxing, causing the eyebrow to descend.

brow change after upper blepharoplasty
Case examples of dissatisfied surgical results after eye lid surgery from brow descent and thick folding skin(pre- and 6-months post-op).
Subbrow Lift Using Frontalis Sling to Correct Lateral Orbital Laxity.

3) Periorbital change relate to Botox injection

The same phenomenon occurs after Botox injections, as seen below; the before-and-after photo of a patient who received Botox to reduce wrinkles on the forehead and glabella.

forehead botox
The botox injection in the forehead and glabella: before(left) and after(right). The ‘lid-brow distance’ became short.

While the patient was happy with the reduced wrinkles, the periorbital changes were less favorable, resulting from the weakened action of the forehead muscle.
To avoid this issue, planning the surgery carefully and discussing the expected changes with the patient is important. Some surgeons advise against upper lid surgery for all patients, while others believe that the key is the surgeon’s experience and discretion in selecting the right candidates for Upper blepharoplasty.

5. What is an Endoscopic forehead lift?

1) Introduction

An endoscopic forehead lift is a cosmetic procedure that aims to smooth out wrinkles and reduce muscle activity on the forehead and glabella, creating a similar effect to Botox injections.

It is best suited for;

  • individuals with a narrow brow-lid distance,
  • significant eyebrow movement when opening and closing their eyes,
  • moderate wrinkles on the forehead and glabella.
brow lift
Before and after of the endoscopic forehead lift.

One common mistake plastic surgeons have made in treating middle-aged patients is removing excess skin through lid surgery or sub-brow lift when a forehead lift is required. The brow descends as people age, leading to an illusion of eyelid skin redundancy, known as “pseudo-blepharochalasis.” Treating this condition with blepharoplasty alone can result in a sad, tired appearance and a long scar that extends from the eyelid to the lateral periorbital skin.
More likely, however, isolated blepharoplasty performed when significant forehead ptosis is present usually results in a loss of the stimulus for brow elevation. It will produce further descent of the eyebrow as the forehead muscle relaxes and the reappearance of pseudo skin excess in the superolateral orbit and across the upper eyelid. This result will exacerbate the existing ‘pseudosad,’ ‘pseudo-tired,’ or disinterested appearance rather than improving it. This sequence of events explains why many patients over their 50s are often disappointed with the patient’s overall appearance after upper lid blepharoplasty, despite technical proficiency in the excision of upper eyelid tissue.

In contrast, a endoscopic forehead lift can effectively address forehead ptosis and prevent the further descent of the eyebrow, providing a more youthful appearance. A thorough consultation with a skilled plastic surgeon is essential to determine the best surgical plan based on individual needs and facial features. If you want to know more about a good candidate for foreheadplasty, please refer to this article.

6. Three orbital rejuvenation surgery comparison

Excess Skin RemovalEyelid Crease Shape ChangeMaking Bigger EyesChanges in Lid-Brow DistanceFrowning linesScar
Upper BlepharoplastyExcess Skin Removal+Eyelid Crease Shape ChangepredictableMaking Bigger Eyespossible (by ptosis correction in the same incision)Changes in Lid-Brow Distance(depending on age and habbit) may shorten, sometimes sad lookFrowning lines(depending on age and habbit) may worsenScarinvisible when eyes open
Sub-brow LiftExcess Skin Removal+++Eyelid Crease Shape ChangeunpredictableMaking Bigger EyesimpossibleChanges in Lid-Brow Distance(depending on age and habbit) may shorten, sometimes sad lookFrowning lines(depending on age and habbit) may worsenScarvisible within 3 months. scar management might be needed
Endoscopic Forehead LiftExcess Skin Removal++Eyelid Crease Shape ChangeunpredictableMaking Bigger EyesimpossibleChanges in Lid-Brow DistancelengthenFrowning linesimprovesScarhardly visible (within the hair)

7. Conclusion

Periorbital surgery requires a comprehensive aesthetic plan and high technical proficiency as it is an “unforgiving” area. Patients should consult with a skilled plastic surgeon to determine the best surgical plan for their needs rather than making a decision based on acquaintances or solely on the desire for double eyelids or bigger eyes.
Deciding surgical plan by the patient alone is not a good idea. Instead, it is better to prioritize their needs and ask the expert for possible options. And if the doctor is skilled with every procedure, they will recommend the most beneficial choice without any bias.

If the primary purpose of having surgery is to make double eyelids or to make eyes bigger, a doctor should consider lid surgery first. However, consider a sub-brow lift if skin excess is your biggest concern. If the distance between your brows and eyelids is too close, it might be better to have a forehead lift. I hope this article will provide the strengths and weaknesses of each procedure.

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