Eyelids and Brows: Questions and Answers
A plastic surgeon's guide to heavy upper eyelids, drooping lids, under-eye bags and low brows: what causes each, which operation treats it, and when non-surgical treatment can or cannot substitute. Dr. Kim does not perform eyelid surgery or forehead lifts at Violacell Plastic Surgery, where his practice is non-surgical; these answers are general guidance to help you understand your options.
Eyelid, Brow or Muscle?
Why do my upper eyelids look heavy?
Heavy upper eyelids rarely have a single cause. Loose eyelid skin can fold over the crease, fat can bulge, the eyebrow can drop and push skin down, or the muscle that opens the eyelid can weaken so the lid itself sits low. Several of these often occur together. Each needs a different treatment, and treating the wrong one can leave the heaviness unchanged or make it look worse, so the first step is finding out which is present.
How can I tell whether my brow or my eyelid is the problem?
Relax your forehead completely and look straight into a mirror. Then gently lift your eyebrow with a fingertip to where it naturally belongs. If most of the heaviness disappears, the brow is a large part of the problem. If loose skin still rests on the lashes, the eyelid skin is a factor. If the eyelid edge still covers part of the dark center of the eye, the lifting muscle may be weak. This is a rough check; an examination measures each of these properly.
What is ptosis of the eyelid?
Ptosis, or blepharoptosis, means the upper eyelid edge sits lower than normal because the muscle that lifts it is weak or its tendon-like attachment has stretched. It can be present from birth or develop later with age, long-term contact lens wear or eye rubbing. The eyes look sleepy, and many people raise their eyebrows to see, which deepens forehead lines. Ptosis is not caused by extra skin, so removing skin alone does not correct it.
Why do I raise my eyebrows all the time?
Constant brow raising is often the body's way of clearing the field of vision when the upper eyelids are heavy, whether from loose skin, a low brow or a weak eyelid-opening muscle. The forehead muscle, the only muscle that lifts the brows, works all day, which creates deep horizontal forehead lines and a tired feeling by evening. Relaxing the forehead muscle without treating the cause can make the eyelids feel heavier, so the cause is checked first.
Why does my brow droop more at the outer end?
The forehead muscle that lifts the brows does not reach far to the side, so the outer third of the brow has less lifting support. At the same time, the ring muscle around the eye pulls the brow tail down. As tissue loosens, the outer brow often drops first, producing hooding at the outer corner of the eye. In a column published under his name, Dr. Kim notes that when there are few forehead lines but the outer eye droops, the cause is often skin sagging below the brow.
Does sagging start at the forehead?
Often it travels downward. In a column published under his name at Violacell, Dr. Kim writes that when the forehead is opened in surgery, the skin is only loosely attached to the muscle and firmly anchored along the deep lines, and the clinic's writing describes sagging that moves from the forehead to the brow and then to the eyes. That is why brow position is examined together with the eyelids, and why removing eyelid skin is not always the right first step.
Can heavy eyelids affect my vision?
Yes. When loose skin or a low eyelid margin covers the upper part of the visual field, people often notice it when reading, driving or looking up, and they may lift their brows to see. A drooping eyelid that covers part of the pupil can block more of the field. If you notice a change in vision, especially on one side or suddenly, see an eye doctor first, because some eyelid and vision changes have medical causes that need assessment before any cosmetic treatment.
Should I worry if one eyelid is lower than the other?
Slight differences between the two sides are common and normal. A lid that sits clearly lower, especially if the difference has appeared recently, may reflect ptosis on that side, and a lid that droops suddenly, changes through the day or comes with double vision, a headache or a different pupil size needs prompt medical assessment, because these can have neurological or other medical causes. For gradual, long-standing differences, measurement of both lids comes before any cosmetic plan.
Are puffy eyelids always a surgical problem?
No. Thyroid eye disease, allergies, fluid retention, poor sleep and salt intake can all make eyelids look puffy, and these are not surgical problems. A bulge at the outer upper eyelid can be the tear gland rather than fat. True fat bulges and loose skin that persist all day, and do not change with sleep or season, are more likely to be structural. A careful history and examination help separate the two.
Upper Blepharoplasty
What does upper blepharoplasty do?
Upper blepharoplasty removes loose skin that hangs over the crease, may trim a thin strip of the eyelid muscle, and trims or repositions bulging fat when needed, then sets a clean crease. The incision is placed in or near the natural crease so the scar sits in a fold when the eyes are open. It does not lift a low eyebrow or strengthen a weak eyelid-opening muscle, so those causes are checked before the operation is chosen.
Who is a good candidate for upper blepharoplasty?
It suits adults whose main problem is loose upper eyelid skin, with or without bulging fat, and whose eyebrows sit in a reasonable position. Signs include skin resting on the lashes, a crease that has become hidden, and eye makeup that smudges onto the fold. If the brow is low, removing eyelid skin can bring it lower still, and if the eyelid edge sits low, ptosis correction is needed. Dry eyes and earlier eye surgery are discussed beforehand.
Can upper eyelid surgery bring my eyebrows down?
It can, when eyelid skin is removed while the real cause is a low brow. Taking away the skin that sits between brow and lashes shortens that distance, which can pull the brow down further and leave a heavier, sterner look. This is why brow position is checked first. When the brow is low, a forehead lift alone or together with eyelid surgery is often more appropriate, and the amount of eyelid skin removed is planned with the brow in mind.
What is a sub-brow excision?
A sub-brow excision removes skin just below the eyebrow instead of at the eyelid crease. It can suit thick upper eyelid skin with heavy outer hooding, or people who want to keep the crease shape they already have. The scar sits along the lower edge of the brow and usually fades well, though it can be visible without makeup in some people. It does not treat fat or create a new crease, and it does not lift the brow itself.
How long is recovery after upper blepharoplasty?
Stitches are commonly removed about five to seven days after surgery. Bruising and swelling are most noticeable in the first one to two weeks, and many people return to work and social activities within that time, sometimes with glasses or light makeup once the incision has healed. The crease often looks higher and more pronounced at first and keeps softening and settling over several months. Strenuous exercise is usually avoided for a couple of weeks.
Is upper blepharoplasty done under local anesthesia?
Usually, yes. Upper blepharoplasty is commonly performed under local anesthesia, often with light sedation, and typically takes around one to two hours for the upper eyelids alone. Being awake allows the surgeon to check eyelid closure and symmetry during the operation in some cases. General anesthesia may be used when other procedures are combined or for medical reasons. You will need someone to accompany you home if sedation is used.
Will upper eyelid surgery change the shape of my eyes?
It should refresh the eyes rather than change their character. Removing loose skin reveals more of the eyelid and crease, so the eyes look more open, but the crease height and shape are planned to suit the face. In Asian eyelids in particular, a crease set too high or a strongly changed eye shape can look unlike the person, so changes are planned conservatively. Discussing how much of the crease you want to show helps set the plan.
Is upper blepharoplasty different for men?
The principles are the same, but men usually have a lower, flatter crease and brows that sit lower and straighter, and a result that sets a high, curved crease can look feminine. Removal of skin and fat is therefore usually more conservative, and the crease is kept low. Men are also less likely to use makeup to hide early bruising or a healing scar, which is worth considering when planning time off work.
Can taking too much fat from the upper eyelid be a problem?
Yes. With age the upper eyelid often loses volume rather than gaining it, especially toward the outer part and under the brow. Removing too much fat can leave a hollow, sunken eyelid with a deep groove under the brow, which tends to look older and is difficult to correct. Modern upper blepharoplasty therefore removes fat conservatively, usually from the inner pocket near the nose where bulges are most common, and preserves volume elsewhere.
What are the risks of upper eyelid surgery?
Common, usually temporary effects include swelling, bruising, dry or watery eyes and a tight feeling. Less common problems include asymmetry, a crease that is too high or uneven, scar thickening, removal of too much skin making it hard to close the eyes fully, and hollowing from excess fat removal. Bleeding behind the eye is rare but serious and needs urgent care. Choosing the right amount of correction is what reduces most of these risks.
Double Eyelid Surgery and Ptosis Correction
What is double eyelid surgery?
Double eyelid surgery creates or refines the upper eyelid crease, the fold that appears when the eye opens. A crease forms where the skin is linked to the structures that lift the eyelid, and many Asian eyelids have no such link, or a weak one, which is a normal variation rather than a defect. The surgery creates that link with stitches or through an incision. The height and shape of the crease are chosen to suit the face, not to match a fixed ideal.
What is the difference between the suture and incision methods?
In the suture or non-incisional method, fine stitches are passed through small punctures to link the skin to the deeper eyelid structures, with lighter swelling and no long scar; it suits thin eyelids with little fat or excess skin, but the crease can loosen over time. In the incisional method, an incision along the planned crease allows skin, muscle and fat to be adjusted and the crease fixed internally, giving a more lasting crease at the cost of longer swelling and a fine scar.
How is ptosis corrected?
Ptosis correction strengthens the eyelid's lifting mechanism, usually by tightening or reattaching the tendon-like part of the lifting muscle (the levator aponeurosis) to the eyelid, through an incision in the crease or from the inner side of the lid. Mild cases may be treated with techniques that shorten a smaller muscle beneath it. The amount is set by measuring how low the lid sits and how strongly the muscle works. In Korea, correction of mild ptosis is often called eye-opening correction.
Can ptosis correction be combined with double eyelid surgery?
Yes, and this is common. When the eye opens weakly, creating a crease alone can leave the eye still looking sleepy, or the crease can look too high above a low lid. Correcting the lid height at the same time lets the crease sit in balance with the opening of the eye. Combining them needs careful measurement of both sides, because small differences in lid height are noticeable, and some asymmetry can remain and need adjustment.
How long does swelling last after double eyelid surgery?
After the suture method, swelling is usually lighter and the eyes often look presentable within about one to two weeks. After the incisional method, visible swelling and bruising commonly last one to two weeks, but the crease can look high and full for several weeks and usually takes three to six months to settle into its final shape. Stitches from an incision are commonly removed after about five to seven days. Swelling varies with eyelid thickness and the amount of tissue adjusted.
What is epicanthoplasty?
Epicanthoplasty changes the fold of skin at the inner corner of the eye, called the epicanthal fold, which is common in East Asian eyes. Reducing the fold can make the eye look longer and let a crease run more clearly toward the inner corner. It leaves a small scar near the inner corner that can stay red or visible for some months, and an overcorrected fold is hard to restore. It is considered when it suits the face, not as a routine addition to double eyelid surgery.
Can a crease that was set too high be lowered?
Sometimes, but it is difficult. A high crease is often the result of too much tissue removal, scarring at a high level or an eyelid that also opens weakly. Revision may involve releasing the old scar, restoring tissue or fat between the layers, setting a new lower crease and correcting the eyelid height, and it cannot always fully restore tissue that has already been removed. This is a key reason why crease height is planned conservatively the first time.
Lower Eyelids and Under-Eye Bags
What causes bags under the eyes?
Under-eye bags usually form when fat behind the lower eyelid pushes forward as the supporting tissue in front of it weakens. At the same time, the cheek below may lose volume, creating a groove between the eyelid and cheek that makes the bag look larger. Loose lower eyelid skin and fluid also contribute. Dark circles caused by pigment, or by thin skin over visible vessels, are a different problem that surgery does not correct.
What does lower blepharoplasty involve?
Lower blepharoplasty smooths the under-eye bag and the groove below it. Fat may be trimmed or, often, repositioned into the groove so the transition from eyelid to cheek is smoother. The approach can be through the inner surface of the eyelid, leaving no visible skin scar, which suits people without much loose skin, or through an incision just below the lashes when loose skin also needs to be removed. The lower eyelid's support is protected so its shape does not change.
What is fat repositioning under the eyes?
Fat repositioning moves the fat that forms the under-eye bag down into the groove below it, rather than simply removing it. This smooths the hollow and the bulge at the same time and avoids the sunken look that excessive fat removal can cause with age. In Korea this approach is widely used for under-eye bags. Whether repositioning, removal or a combination suits you depends on how much fat there is, how deep the groove is and the skin's condition.
What are the risks of lower eyelid surgery?
Swelling, bruising and temporary dryness or watering of the eyes are common. Specific risks include a change in the shape of the lower eyelid, such as pulling down of the lid or rounding of the outer corner, especially when skin is removed or the lid is lax; irregularities or remaining bulges; hollowing from too much fat removal; and, rarely, bleeding behind the eye, which needs urgent care. Checking lower eyelid laxity before surgery helps prevent shape changes.
How long is recovery after lower blepharoplasty?
Bruising and swelling are usually most noticeable for about one to two weeks, and many people return to social activities in that time. When the inner-eyelid approach is used there are no skin stitches; with an incision below the lashes, stitches are commonly removed after about five to seven days. Mild swelling and firmness where fat was repositioned can take several weeks to months to settle. Eyes may feel dry or water for a short period afterwards.
Can under-eye bags be treated without surgery?
Partly. When a mild bag sits above a groove, filler placed carefully in the groove can soften the transition, though it does not remove the fat and needs experience to avoid lumps and swelling. Thermage with the eye tip or skin boosters can improve thin, crepey skin under the eye. True fat bags that bulge forward are not removed by devices or injections. In one of his answers, Dr. Kim notes that a fat bulge remaining after lower eyelid surgery is improved by threads to a limited extent.
Forehead and Brow Lift
What does a forehead lift do?
A forehead lift, also called a brow lift, raises eyebrows that have dropped and softens the muscles that pull the brows down and together. It can open a heavy, tired look around the eyes, reduce hooding at the outer upper eyelid and soften frown lines between the brows. Many people also raise their brows less afterwards, so horizontal forehead lines may soften. It does not remove excess eyelid skin, which may still need upper blepharoplasty.
What is an endoscopic brow lift?
In an endoscopic brow lift the surgeon works through several short incisions behind the hairline, using a thin camera to see under the forehead. The tissue is released from the bone along the brow and temple, the muscles that pull the brows down are partly weakened, and the forehead is lifted and fixed higher while it heals. Scars are small and hidden in the hair, but the method tends to raise the hairline slightly, which matters for a high forehead.
What is a hairline incision forehead lift?
In this method, one incision is made along the front hairline, and the forehead tissue is lifted and a strip of skin removed so that the brows are raised without moving the hairline back. It suits people with a high forehead, for whom an endoscopic lift would make the forehead look longer, and it allows more direct control of brow position. The scar sits along the hairline and is usually concealed by the hair as it grows through, though it can be visible with the hair pulled back.
Who should not have a brow lift?
A brow lift is usually reconsidered when the brows already sit high, because raising them further can create a surprised look, or when the heaviness comes mainly from a weak eyelid muscle that needs to be assessed first. A very high forehead may call for a hairline incision rather than an endoscopic lift. Dry eyes or difficulty closing the eyes need assessment, especially before combined eyelid surgery, and bleeding disorders, uncontrolled blood pressure and smoking need to be addressed first.
How long is recovery after a forehead lift?
Swelling and bruising around the forehead and eyes are most noticeable for about one to two weeks, and many people return to daily activities within that time. Swelling often moves down around the eyes in the first days. Numbness, tingling and itching of the scalp are common and can last for months as the sensory nerves recover. The brows may sit slightly high at first and settle over the following weeks as swelling fades.
When is a forehead lift combined with eyelid surgery?
When both the brow and the eyelid skin contribute to heaviness. Raising the brow first corrects the distance between brow and lashes, and the amount of eyelid skin removed is then planned from the new brow position, which usually means removing less. In a column published under his name, Dr. Kim describes a wide, active forehead with brows close to the eyes as a sign of much excess skin, for which a forehead lift with skin excision below the brow may be considered.
How long does a forehead lift last?
Usually many years, though the brows may settle somewhat over time. How long the result holds depends on how firmly the tissue was fixed while it healed, the weight of the forehead skin, and habits such as frowning. Aging continues, so the forehead and eyelids keep changing slowly. Keeping the muscles that pull the brows down less active, for example with small doses of botulinum toxin, is sometimes used to help maintain the position.
What are the risks of a forehead lift?
Numbness and itching of the scalp are common and usually improve over months. Other possible problems include asymmetry of the brows, a brow raised too high or too little, hair thinning near incisions, a visible or widened scar with the hairline method, a change in hairline position, and some return of brow descent over time. Injury to the nerve branch that raises the brow is uncommon and usually temporary; it is avoided by working in the correct layer near the temple.
Non-Surgical Options Around the Eyes and Brows
Can Ulthera lift my eyebrows instead of surgery?
For a mild drop, it may help a little. Ulthera is cleared in the United States for lifting the eyebrow, and energy placed over the forehead and temple can raise the brow by a small amount as collagen forms over the following months. The change is modest and varies between people. It does not release the tissue holding a low brow down, so when the brow sits well below the bony rim, a forehead lift is the effective option. Nerve paths at the temple guide where energy is placed.
Can Thermage help hooded eyelids?
When hooding comes mainly from thin, crepey eyelid skin and the brow sits in a reasonable position, Thermage with the eye tip can firm the eyelid skin without an incision. The eye tip is designed for the delicate skin around the eyes, including the upper and lower eyelids, with protective eye shields in place. It does not remove a true fold of excess skin, lift a low brow or correct ptosis. See Thermage around the eyes for details.
Can botulinum toxin lift the brows?
Small doses placed in the muscles that pull the brows down, between the brows and at the outer brow tail, can let the brow sit slightly higher for a few months. Dr. Kim has written that weakening the muscles that pull downward can create a lifting effect. The change is small and temporary, and placing toxin in the forehead muscle that raises the brows can make the brows and eyelids feel heavier, especially when the eyelids are already heavy. Dosing is planned with that risk in mind.
Can a thread lift raise a low brow?
Threads placed in the forehead and temple can lift the brow a little, and the clinic's writing notes that forehead skin is thin, which suits threads. The lift is modest and lasts months rather than years, and swelling and bruising usually settle in about a week. Threads do not remove excess eyelid skin or correct ptosis. When the brow is clearly low or there is a lot of excess skin, a forehead lift, with or without eyelid surgery, gives a larger and more lasting change.
Can fillers help a hollow upper eyelid?
A hollow or sunken upper eyelid, often from age-related volume loss or earlier fat removal, can sometimes be improved with small amounts of filler or with fat grafting. The area is delicate: product can show as lumps or swelling under thin eyelid skin, and injection near the eye carries a rare but serious risk of vascular complications. Dr. Kim has written that blindness from injections occurs when product enters a vessel and that safety rules must be followed. Experience and a conservative amount matter.
Can Ulthera be used close to the eyes?
Ulthera is used over the forehead and brow to lift the eyebrow, and over the temple, but not on the eyelids themselves, and the transducer is kept away from the eye. Energy near the temple is placed with the path of the nerve that raises the brow in mind. For the thin skin of the eyelids, Thermage with the eye tip is the device designed for that area. Which device suits depends on whether the problem is brow position or eyelid skin.
Can skin boosters improve the skin around the eyes?
Skin boosters can improve thin, dry or finely lined skin around the eyes by supporting the dermis. Re2O, a skin booster made from human acellular dermal matrix, is the booster Dr. Kim pairs with Thermage, typically over a series of sessions; it is regulated in Korea as a human tissue product and is not FDA-approved. Boosters do not remove loose skin, bags or a low brow. They are most useful when the main change is skin quality, or alongside other treatment.
When is surgery clearly the better choice for the eyes?
Surgery is usually the effective answer when loose upper eyelid skin rests on the lashes, when the eyelid edge covers part of the pupil, when the brows sit well below the bony rim, or when fat bags under the eyes bulge forward. Devices and injections cannot remove skin, strengthen the lifting muscle or move fat behind the eyelid. Dr. Kim's role at Violacell is to tell you which of these you have; he does not perform eyelid surgery or forehead lifts there.
Can non-surgical treatment help after eyelid surgery?
Yes, once healing is complete. Surgery changes the structure but not the quality of the skin, so Thermage with the eye tip, skin boosters or careful energy treatment of the forehead may help with fine lines and firmness later. Timing is agreed with the operating surgeon, usually after several months, when swelling and sensitivity have settled and the scar has matured. Earlier surgery is always mentioned, because it changes the layers near the eye.
How does Dr. Kim assess the eyes and brows at a consultation?
He examines brow position with the forehead relaxed, whether you raise your brows to see, the height of the eyelid edge, how strongly the eyelid opens, the amount of loose skin and fat, and the lower eyelid and cheek. Because his practice at Violacell is non-surgical, he then explains whether Thermage, Ulthera for the brow or skin treatment could reasonably help, or whether upper blepharoplasty, ptosis correction or a forehead lift is the realistic answer, which would be done with a surgeon who performs it.