Heavy Eyelids May Be More Than Meets the Eye

The aging upper eyelid is a common concern, and blepharoplasty surgery is often the answer to correct the heavy or overhanging excess eyelid skin.  An upper blepharoplasty removes the excess skin and the discreet scar hides nicely within the natural upper eyelid fold.  Sounds simple, right?

The upper blepharoplasty usually is that simple in a younger patient who only has a premature or genetic excess of eyelid skin.  But in older patients, there are other considerations.  The main issue is the brow and how the muscles of the forehead are interacting with the upper eyelid.  Oftentimes I am suggesting a browlift with an upper blepharoplasty, or even a browlift, without a upper blepharoplasty!  This often surprises a patient who thinks just a simple blepharoplasty will do.  The browlift is needed less to lift the brow (no one wants a deer in the headlights look), but more to open the eye, take some heaviness off the eyelid, and allow the forehead muscle (frontalis) to relax.  

Some foreheads strain to hold up a heavy eyelid, and failing to recognize this can lead to the forehead relaxing and the eyebrow dropping after doing an upper blepharoplasty by itself.  This obviously creates a new problem.  The better plan in this situation is to do both the blepahroplasty and the browlift at the same time.  The eyebrows then get set a bit higher, the orbit (eye socket) is more open, the excess eyelid skin is removed, and the forehead has less lines because now the forehead muscle doesn't have to work so hard to keep the eyebrows and eyelids up.

There are different browlifts depending on the amount of brow drop (ptosis) or forehead strain, and mild cases can get a "Botox Browlift" with strategically injected neuromodulators like Botox. However, injecting neuromodulators to improve horizontal forehead lines in a forehead straining to keep up droopy eyelids can cause them to drop even more.  That's one way to know that what you really need is a browlift!



Douglas J. Mackenzie, MD

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