Heavy upper eyelids: upper blepharoplasty or forehead lift?
It depends on where the heaviness comes from. If the main cause is extra skin (and sometimes fat) on the upper eyelid while the eyebrow sits at a normal height, an upper blepharoplasty is usually the better fit. If the eyebrow itself has dropped and is pushing skin down onto the eyelid, a forehead lift (brow lift) is usually the better fit, because removing eyelid skin alone will not raise the brow. Many people have some of both, and some have a third cause, a drooping eyelid muscle, which needs a different correction. Finding the main cause comes first.
Heavy upper eyelids can make the eyes look tired and, in more advanced cases, block part of the upper field of vision. The choice of operation should follow the cause.
Three common causes of heavy upper eyelids
1. Extra upper eyelid skin. With age, eyelid skin stretches and loses elasticity. The extra skin folds over the eyelid crease and may rest on the lashes, especially at the outer corner. Fat behind the eyelid may also bulge forward, adding fullness. This is often called dermatochalasis.
2. A low eyebrow (brow ptosis). The eyebrow and forehead tissue can descend with age. The outer part of the brow often drops first. When the brow drops, it pushes the skin below it down onto the upper eyelid. The eyelid looks heavy even though the eyelid itself may not have much extra skin.
3. A drooping eyelid (eyelid ptosis). In this case the edge of the upper eyelid sits too low over the eye, usually because the muscle that opens the eyelid, or its tendon, has stretched or weakened. The problem is the position of the eyelid margin, not extra skin or a low brow.
These causes often occur together, and the plan depends on which one is the main contributor.
A simple mirror check
This gives only a rough idea:
- Look straight ahead into a mirror with your face relaxed. Try not to raise your eyebrows.
- Notice where your eyebrows sit. In many people, the brow sits around the upper edge of the bony eye socket. A brow that sits clearly below that edge may be low.
- With your fingertips, gently lift the eyebrow to the height you think looks natural. Do not pull it high.
- Look at your eyelids now. If most of the heaviness disappears, the brow is likely a large part of the problem. If a fold of skin still hangs over the crease with the brow lifted, extra eyelid skin is likely part of it.
- Look at the edge of the upper eyelid. If it covers a clear portion of the colored part of the eye even with the brow lifted and the skin out of the way, an eyelid droop may be involved.
Another clue is the forehead. Many people with low brows raise their eyebrows all day without noticing, which leads to deep horizontal forehead lines.
What an upper blepharoplasty does
An upper blepharoplasty removes extra skin from the upper eyelid. Depending on the eyelid, a small strip of muscle or some fat may also be removed or adjusted. The incision is usually placed in or near the eyelid crease, so the scar lies within a natural fold when the eyes are open. It can also define or refine the eyelid crease.
It usually suits people who have:
- extra eyelid skin with the brow at a normal height
- fullness from fat in the upper eyelid
- skin resting on the lashes at the outer corner
Its limits matter. An upper blepharoplasty does not raise a low brow. If a low brow is the main cause and only eyelid skin is removed, the distance between the brow and the lashes becomes shorter. The brow can sit closer to the eye, which may look heavy or tense, and sometimes the brow drops further after surgery because the forehead no longer needs to hold it up. Removing too much eyelid skin to make up for a low brow can also make the eyes hard to close fully for a while, and can cause dryness.
What a forehead lift does
A forehead lift, or brow lift, raises the eyebrows and forehead tissue to a more natural position. As the brow rises, the skin it was pushing down onto the eyelid lifts with it. There are several approaches, including small incisions within the hair with a camera (endoscopic), an incision at or near the hairline, and incisions near the temple for the outer brow. The choice depends on brow shape, forehead height, hairline and the lift needed.
A forehead lift usually suits people who have:
- eyebrows that sit low, especially at the outer side
- heaviness that clearly improves when the brow is lifted with the fingers
- deep forehead lines from constantly raising the brows
Its limits matter too. A forehead lift does not remove extra skin that belongs to the eyelid itself, and it does not correct an eyelid muscle droop. Lifting the brow too high can create a surprised look, so the goal is a natural height.
When both are needed
When both a low brow and extra eyelid skin are present, both procedures may be planned. The brow position is usually set first and the eyelid skin is then measured from that new position, so that the right amount is removed. This order helps avoid removing too much eyelid skin. They can be done in one session or in stages, depending on the person.
When the problem is eyelid ptosis
If the edge of the eyelid itself sits low, neither removing skin nor lifting the brow will fully correct it. The eyelid muscle or its tendon may need to be tightened or repositioned. This is a different operation, and it may be combined with skin removal if both problems are present. More on this is on the eyelid surgery page.
Some causes of drooping need medical attention before any cosmetic surgery is considered. A droop that appears suddenly, that changes a lot during the day, that affects only one side and is getting worse, or that comes with double vision, headache or eye pain should be checked by a physician first.
Recovery and risks compared
As a general guide:
- Upper blepharoplasty: swelling and bruising are usually most visible for one to two weeks. Stitches are usually removed within about a week. The scar is often pink at first and fades over several months.
- Forehead lift: swelling may spread down to the eyelids and cheeks in the first days. Numbness or a tight feeling of the forehead and scalp is common and usually improves gradually over weeks to months.
Possible risks of an upper blepharoplasty include asymmetry, dry or irritated eyes, temporary difficulty closing the eyes fully, visible scarring, infection and bleeding. Very rarely, bleeding behind the eye can threaten vision and needs urgent treatment. Possible risks of a forehead lift include numbness or itching of the scalp, hair thinning near incisions, a change in hairline position with some approaches, asymmetry of the brows, and, rarely, weakness of the forehead muscle from nerve injury, which is usually temporary.
Tell the surgeon about dry eye, eye disease, previous procedures and any blood-thinning medicines or supplements.
What about non-surgical options?
Non-surgical treatments can make small changes but do not replace surgery when the heaviness is clear. Ulthera (microfocused ultrasound with real-time imaging) is cleared by the US FDA to lift the eyebrow and may give a modest brow lift over a few months in suitable people.
How Dr. Kim assesses heavy eyelids
At an in-person consultation, Dr. Kim examines the eyelids and brows at rest, with the forehead relaxed, and with the brow gently supported. The examination usually looks at:
- the height and shape of the brow, especially the outer brow
- how much skin and fat the upper eyelid has
- the position of the eyelid margin and the strength of the eyelid-opening muscle
- forehead lines
- eye dryness, eye health and previous procedures
The decision between an upper blepharoplasty, a forehead lift, both, or a ptosis correction is made from this examination.
Why it matters who makes the call
Heavy eyelids, a low brow and a weak eye-opening muscle look alike in the mirror. Dr. Kim trained in facial surgery and checks the brow and eyelid together, so he can tell whether Ulthera over the brow or Thermage with the eye tip may help, or whether surgery is the honest answer. Why Dr. Kim
Common questions
How can I tell whether my brow or my eyelid is causing the heaviness?
Look straight ahead in a mirror with your forehead relaxed and gently lift your eyebrow to a natural height with your fingertips. If most of the heaviness disappears, the brow is likely a large part of the cause. If a fold of skin still hangs over the crease, extra eyelid skin is likely involved. An examination is needed to confirm this.
Can an upper blepharoplasty make a low brow look worse?
It can. Removing eyelid skin does not raise the brow. When a low brow is the main cause, removing only eyelid skin shortens the distance between the brow and the lashes, and the brow can sit closer to the eye after surgery.
What if my eyelid itself droops?
If the edge of the upper eyelid sits too low, the eyelid muscle or its tendon may need correction. Removing skin or lifting the brow alone will not fully fix it. A droop that appears suddenly or comes with double vision should be checked by a physician first.
Dr. Kim currently provides non-surgical treatment at Violacell Plastic Surgery and does not perform these operations there. This article is meant to help you judge which problem you have and what to ask the surgeon you choose.
Related pages: Upper blepharoplasty · Forehead lift · Eyelid surgery · Ulthera · Planning a visit