When might a brow lift and subbrow blepharoplasty be combined? Why brow position and excess skin must be assessed together
A brow lift or subbrow blepharoplasty may be considered when skin above the eyes sags and creates a hooded appearance.
Both procedures address sagging around the brows and upper eyelids, but they differ in their direct treatment areas and roles.
A brow lift dissects and repositions tissues around the forehead and brows to adjust descended brows and upper facial tissues.
Subbrow blepharoplasty, in contrast, uses an incision beneath the brow to remove or reposition excess skin below the brow and toward the upper eyelid.
If brow descent and skin laxity beneath the brow coexist, one procedure alone may not adequately address both causes.
In this situation, a combined approach may be considered: a brow lift to adjust brow position and subbrow blepharoplasty to address skin expected to remain.
However, combining the procedures does not always produce a better result.
The decision to combine them and the extent of each correction should follow assessment of resting brow position, forehead muscle use, skin remaining when the brow is raised, lateral hooding, eye closure, and ocular condition.
How do a brow lift and subbrow blepharoplasty differ?
Brow lift
A brow lift involves dissecting sagging tissues around the forehead and brows and repositioning them appropriately.
With aging, descent of these tissues lowers the brows, and tissue beneath the brows may press on the upper eyelids, creating a heavy, hooded appearance.
Descent of the outer brow can particularly accentuate lateral hooding, where skin overlaps above the outer corner of the eye.
A brow lift aims to adjust the brow and upper facial tissue positions responsible for these changes.
Subbrow blepharoplasty
Subbrow blepharoplasty involves an incision immediately beneath the brow and removal or repositioning of loose skin to improve overlap beneath the brow and over the upper eyelid.
Medical literature uses terms such as subbrow blepharoplasty, infrabrow blepharoplasty, and sub-brow lift. In Korea, it is also described as an under-brow lift or an infrabrow incision procedure.
Its main purpose is generally to address skin laxity beneath the brow and skin overlap at the outer upper eyelid.
Depending on the technique, only skin may be excised, or the orbicularis oculi muscle or deeper tissues may also be adjusted or fixed.
Brow position may also change to some extent depending on the amount of skin removed and whether deeper tissues are fixed.
Thus, procedures with the same name may differ in surgical extent, fixation method, and expected changes between clinics and patients.
Its scope and mechanism differ from a brow lift, which involves broader dissection and repositioning around the forehead and brows.
A prospective study performing subbrow blepharoplasty in 101 selected patients with upper eyelid skin laxity and lateral hooding from a group of 804 Asian patients reported that the procedure could be used for upper eyelid rejuvenation in selected patients.
However, the study focused on patient satisfaction at 4 weeks after surgery. It did not evaluate long-term outcomes or directly compare other techniques, so it does not mean that identical results can be expected in every patient.
Feature | Brow lift | Subbrow blepharoplasty
Main surgical area | Tissues around the forehead and brows | Skin beneath the brows and surrounding tissues
Main purpose | Repositioning descended brows and upper facial tissues | Addressing excess skin beneath the brows and over the upper eyelids
Main issues assessed | Brow drooping, forehead muscle use, outer brow descent | Subbrow skin laxity, lateral hooding
Incision location | Within the hairline or on the forehead, depending on technique | Along the lower brow border
Limitations | Skin may remain beneath the brow if laxity is severe | Does not broadly lift the entire forehead and brows
Brow position and skin laxity can both contribute to upper-eye hooding
A hooded appearance should not simply be attributed to loose skin.
Descent of the brow and forehead tissues can push both the tissue beneath the brow and the upper eyelid skin downward over the eyelid.
If the skin beneath the brow has also lost elasticity, excess skin may remain near the upper eyelid even when the brow is raised appropriately.
Similar-looking hooding may have different causes, as follows.
When brow drooping is the main issue
Descended brow and forehead tissues press on the upper eyelid. If raising the brow appropriately substantially reduces skin overlap, brow position may be a major contributor.
When subbrow skin laxity is the main issue
Brow position is relatively appropriate, but loose skin beneath the brow and over the upper eyelid overlaps. Lateral hooding, with thick skin overlap at the outer eyelid, may be particularly noticeable.
When both issues coexist
The brow has descended, and considerable skin remains beneath the brow and at the outer eyelid even when the brow is raised appropriately. Brow position and remaining skin can then be assessed separately when considering combined surgery.
Why consider a brow lift together with subbrow blepharoplasty?
1. Brow position and excess skin can be addressed separately
Although the procedures appear to treat similar areas, their main targets differ.
A brow lift adjusts descended tissues around the forehead and brows. Subbrow blepharoplasty removes or repositions excess skin beneath the brow and over the upper eyelid.
When brow drooping and subbrow skin laxity coexist, planning can allocate correction to each procedure's target area rather than concentrating all correction in one operation.
The purpose of combined surgery is not to raise the brows higher or remove more skin. The key is to distinguish brow repositioning from treatment of excess skin and address each cause appropriately.
2. Skin expected to remain after a brow lift can also be addressed
Adjusting brow position with a brow lift may reduce skin overlap above the eyes. However, substantial loss of elasticity or excess skin beneath the brows may leave some skin even after brow repositioning.
If laxity is particularly pronounced from the outer brow to above the outer eye corner, a brow lift alone may not sufficiently address lateral hooding.
Before surgery, the brow is raised to an anticipated position, or a target position is defined in the surgical plan, and the amount of subbrow skin expected to remain is assessed.
Even when both procedures are performed together, the planned brow lift position must be considered first when determining subbrow skin excision. Using the apparent skin excess at the current drooped brow position as the excision guide may cause excessive tightness once the brow is raised.
3. Outer brow drooping and lateral hooding can be addressed together
When the outer brow descends, skin above the outer eye corner may be pushed downward into triangular or folded overlaps.
Lateral hooding may reflect both descent of the outer brow and forehead tissues and laxity of the skin beneath the brow and at the outer upper eyelid.
If brow descent is a major contributor, a brow lift is needed to reposition the brow and surrounding tissues. If lateral skin remains after raising the brow to its anticipated position, subbrow blepharoplasty can further address that skin.
Upper eyelid skin laxity and lateral hooding have also been important selection criteria in subbrow blepharoplasty studies. However, lateral hooding alone does not mean every patient needs this procedure.
4. It may offer an option that reduces direct excision around the existing eyelid crease
Unlike conventional upper blepharoplasty, subbrow blepharoplasty adjusts skin through the lower brow border. It may therefore be an option for treating subbrow skin laxity without directly incising near the existing eyelid crease.
Adjusting skin beneath the brow may be considered particularly when there is substantial outer eyelid skin overlap but the patient wishes to preserve the existing crease itself.
However, subbrow blepharoplasty cannot guarantee that the existing eye shape or eyelid crease will remain completely unchanged. Changes in skin tension direction and excision amount can indirectly alter crease visibility and eye shape.
An incision scar may also remain beneath the brow, so brow density and shape, eyebrow tattoos, skin thickness, and scarring tendency should be assessed.
5. It may reduce excessive correction concentrated in one procedure
If brow drooping and skin laxity coexist, attempting to resolve all skin overlap with a brow lift alone may raise the brows higher than necessary.
Conversely, removing excessive subbrow skin without adjusting brow position may cause tightness, difficulty closing the eyes, changes in brow shape, or an unnatural eye appearance.
In patients who need both procedures, planning the target brow position and skin excision separately may reduce excessive correction concentrated in one area.
However, combining the procedures does not automatically prevent overcorrection. Their effects may overlap, so each correction may need to be planned more conservatively.
When might combined surgery be considered?
A combined brow lift and subbrow blepharoplasty may be considered when the following findings coexist.
- Descent of brow and forehead tissues
- Outer brow drooping together with lateral hooding above the outer eye corner
- Considerable skin remaining beneath the brow after it is raised appropriately
- Residual skin laxity that a brow lift alone is unlikely to address sufficiently
- Pronounced laxity beneath the brow and at the outer upper eyelid
- A wish to reduce direct skin excision near the existing eyelid crease
- Anticipated excessive brow elevation or skin removal if correction is concentrated in one area
Having some of these features does not necessarily mean both procedures are required. Resting brow position, skin amount, eyelid ptosis, eye closure, and dry eye should be assessed together.
When a brow lift alone may be sufficient
If brow drooping is the main cause of upper-eye hooding and raising the brow appropriately sufficiently reduces skin overlap, improvement may be expected with a brow lift alone.
Subbrow blepharoplasty may be unnecessary particularly when elasticity beneath the brow is relatively maintained and descent of forehead and brow tissues is more prominent than skin laxity.
Unnecessary skin excision may only add scarring, tightness, and changes in brow shape, so the amount of skin remaining with the brow raised must be assessed.
When subbrow blepharoplasty alone may be sufficient
If brow position is stable and the main issues are subbrow skin laxity and lateral hooding rather than descent of the entire forehead and brows, subbrow blepharoplasty alone may be considered.
Even then, it is necessary to check whether the patient habitually engages the forehead to raise the brows.
If compensatory forehead muscle activity masks true brow drooping, hooding related to brow descent may persist after skin removal by subbrow blepharoplasty alone.
Brow drooping must also be distinguished from eyelid ptosis
Descended brow and forehead tissues pressing on upper eyelid skin can make the eyelid itself appear droopy. However, this must be distinguished from true eyelid ptosis, in which insufficient levator function causes the eyelid margin to descend.
If supporting the brow appropriately reduces hooding but the eyelid margin remains low, eyelid ptosis should be assessed separately.
A brow lift and subbrow blepharoplasty address brow position and skin laxity. They do not directly correct true eyelid ptosis caused by inadequate function of the structures that elevate the eyelid.
If eyelid ptosis is present, correcting only the brow and skin may reduce excess skin without sufficiently improving eyelid opening.
Preoperative assessment should therefore include the following.
- Position of the upper eyelid margin
- Levator muscle function
- Differences in eyelid height between the eyes
- Eye closure
- Dry eye and foreign-body sensation
- Previous eye surgery or vision correction surgery
How is the surgical extent determined?
1. Assess brow position with the forehead relaxed
Opening the eyes widely or tensing the forehead raises the brows and may mask true brow drooping. Resting brow position and asymmetry should be assessed with the forehead muscle relaxed.
2. Raise the brow to the anticipated position and assess skin changes
The expected position after the brow lift is established, and the amount of subbrow and upper eyelid skin remaining there is assessed. If most overlap decreases with brow elevation, subbrow blepharoplasty may be unnecessary or require less excision.
3. Assess lateral hooding and skin thickness
The clinician checks whether the outer eyelid skin is thicker and overlaps more than the inner skin, and whether skin above the outer eye corner obstructs vision or obscures the eye shape.
4. Assess eye closure and ocular condition
Raising the brows and removing subbrow skin changes tension around the eyes. The amount of skin removed should account for complete eye closure, dry eye, and any corneal disease.
5. Assess brow shape and scarring factors
Because subbrow blepharoplasty requires an incision along the lower brow border, the following factors should be assessed.
- Brow hair density and thickness
- Position and shape of eyebrow tattoos
- Skin color and thickness
- A tendency toward hypertrophic scars or keloids
- Brow height and asymmetry
- The likelihood that the subbrow incision will be visible
Considerations when combining the procedures
Although the procedures correct different areas, some effects overlap. Combined surgery requires closer consideration of how the two corrections interact than when either is performed alone.
Excessive brow elevation
Raising the brows too high may create a surprised expression, an unnatural brow curve, or asymmetry.
Excessive skin excision
Removing too much skin in subbrow blepharoplasty can cause eyelid tightness, difficulty closing the eyes, or new or worsened dry eye.
Changes in brow shape and position
Excision direction, closure tension, and deep-tissue fixation can change brow height, curvature, and the direction of the outer brow.
Subbrow scarring
The incision may initially be red and firm. It may fade over time, but complete scar invisibility cannot be guaranteed for every patient.
Altered sensation and hair loss around incisions
Reduced sensation, tightness, or abnormal sensations in the forehead or scalp may occur after a brow lift. Depending on the incision technique, reduced hair density or hair loss around the incision is also possible.
Bleeding, hematoma, and infection
Both procedures carry risks of bleeding, hematoma, and infection. Sudden severe swelling and pain or rapidly increasing swelling on one side requires assessment by the clinical team.
Rare nerve injury
Depending on the surgical extent and dissection plane, a brow lift carries the possibility of temporary or, rarely, persistent dysfunction of facial nerve branches.
Asymmetry and possible revision surgery
Preexisting differences in brow or eyelid height or forehead muscle use may leave some asymmetry after surgery. Healing and tissue adhesions may also make additional correction necessary.
Does combining the procedures speed recovery?
Performing both procedures at the same time allows treatment of two areas within one surgical plan and recovery period.
However, the wider surgical extent may cause swelling, bruising, tightness, and sensory changes in the forehead, scalp, and subbrow area together.
Combined surgery therefore cannot be assumed to provide faster or easier recovery.
The actual recovery course may vary with the following factors.
- Brow lift incision location and extent of dissection
- Amount of skin removed during subbrow blepharoplasty
- Whether the orbicularis oculi muscle and deeper tissues are adjusted
- The patient's skin thickness and degree of swelling
- Smoking and underlying conditions
- Previous forehead, brow, or eyelid surgery
- Use of medications that may affect blood clotting
Expected swelling, sensory changes, and scar healing should be discussed based on the specific techniques to be performed.
Is there sufficient research directly comparing combined surgery?
Studies have reported that subbrow blepharoplasty can address upper eyelid skin laxity and lateral hooding in selected patients.
A study of a particular direct brow lift technique involving skin excision both above and below the brow also reported correction of outer brow drooping and upper eyelid hooding together.
However, this was a case series analyzing one specific direct brow lift technique with skin excision above and below the brow.
It did not study combining a conventional brow lift performed through the scalp or hairline with subbrow blepharoplasty.
It therefore cannot directly establish the effectiveness or safety of the combined approach described in this article.
The study also provided level IV evidence without a control group, so its findings should not be generalized to all patients or other techniques.
The currently available literature does not support a general conclusion about superiority based on direct comparison of a conventional brow lift alone with combined brow lift and subbrow blepharoplasty.
The need for combined surgery should therefore be based on brow position, skin laxity, lateral hooding, eye closure, and ocular condition rather than a particular satisfaction figure.
Frequently asked questions
Q. Does a brow lift eliminate the need for subbrow blepharoplasty?
A. Not necessarily. Adjusting brow position with a brow lift may substantially reduce skin overlap above the eyes.
However, if considerable skin remains beneath the brow and at the outer eyelid after raising the brow to the anticipated position, subbrow blepharoplasty may also be considered.
Q. Does subbrow blepharoplasty alone raise the brow itself?
A. Its main purpose is generally to address excess skin beneath the brow.
However, brow position may change somewhat depending on skin excision and fixation of the orbicularis oculi muscle or deeper tissues. It should not be expected to have the same extent of effect as a brow lift that broadly repositions tissues around the forehead and brows.
Q. Will combining the procedures raise my brows too much?
A. Combining the procedures does not necessarily cause excessive brow elevation.
However, brow lift elevation and the skin excision and fixation effects of subbrow blepharoplasty act together. Excessive correction in either can cause a surprised expression, tightness, or changes in brow shape.
Q. Will the scar beneath my brow be very visible?
A. The incision is generally placed along the lower brow border, but redness, firmness, and pigment changes may occur initially.
It may fade over time, but this varies with brow density, skin characteristics, closure tension, and individual scarring tendency. Complete invisibility cannot be assumed.
Q. Will my existing eyelid crease remain unchanged?
A. Subbrow blepharoplasty approaches from a different location than conventional upper blepharoplasty, which incises the eyelid crease itself.
It can therefore offer an option without directly incising near the existing crease. However, changes in tension beneath the brow and the amount of exposed skin may indirectly change the apparent crease or eye shape.
The original appearance cannot be guaranteed to remain completely unchanged.
Q. Can combining the procedures shorten the recovery period?
A. There is a practical advantage in treating two areas during one operation and recovery process.
However, the larger surgical extent may cause swelling, bruising, and sensory changes in the forehead and subbrow areas together, so recovery cannot be assumed to be faster or more comfortable.
The purpose of combining the procedures is to divide their roles, not to produce a stronger lift
A brow lift and subbrow blepharoplasty improve similar upper-eye hooding but differ in their direct targets and roles.
A brow lift adjusts descended tissues around the forehead and brows. Subbrow blepharoplasty addresses skin expected to remain beneath the brow and over the upper eyelid, taking into account the brow position that the lift will create.
When brow drooping and subbrow skin laxity coexist, combined surgery can address each problem separately.
However, there is no need to add subbrow blepharoplasty when raising the brow sufficiently reduces skin overlap, or to add a brow lift when brow position is stable.
The decision to combine procedures and the extent of each correction should follow assessment of relaxed brow position, skin remaining after brow elevation, lateral hooding, eyelid ptosis, eye closure, and dry eye.
For questions about combining a brow lift with subbrow blepharoplasty, contact us at 02-545-3700 or through “UVOM Plastic Surgery” on KakaoTalk.
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