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The Cure-All to a Fatigued-Looking Face
by: Dr. Bunkis
For some, surgery is the only way to look
For some, surgery is the only way to look "awake."

Q: My upper lids droop over my eyelashes and I would like to have them fixed. I have seen two plastic surgeons, one who agreed that he could help me with my upper lids, another who told me I’d have to have a brow lift as well. My brows are fine with me and I do not understand why a brow lift would be necessary? Why would a surgeon recommend a procedure I did not ask for?

-C.C., Dove Canyon, CA

A: You really should go and have another talk with your plastic surgeons. If one recommended a brow lift, he should have explained why he did so. Rarely would we suggest a procedure about a body part not brought to our attention by a complaint originated by a patient. For example, we would never comment about very large or small breasts if a patient came in to discuss an abdominoplasty (i.e. “tummy tuck”).

The two exceptions I can think of relate to chin implants and brow lifts, but in such a situation, I sure would hope that the patient left the consultation with an understanding of why we are recommending the brow lift or chin implant procedures. Patients with weak chins who come in complaining of a large nose or a droopy neck cannot get a great profile without addressing the weak chin because the chin, nose and neck all contribute to the profile. Likewise, if a patient complains of heavy upper eye lids, we have to analyze the balance between the eyelid and brow position. Our duty is to lay out the options for a patient and each person has to choose the procedure(s) that will give them their desired results.

In a pure upper eye lid blepharoplasty, the thin skin excess of the lids is removed but the distance from the lashes to the brows is not changed. In patients with low brows, removing the thin, excess upper lid skin may not be appreciated unless the thicker tissues just below the brows are raised as well. This is not to say that every low brow must be raised when doing an upper lid procedure, but the patient has to understand that only the thin, upper lid skin excess will be removed, that the thicker brow hooding will be unchanged, and that the distance between the brows and lashes does not change with an isolated blepharoplasty. If a patient desires a more open-eyed look, this will only be accomplished if a brow lift is added to the eye lid procedure. Not only will the eye area look more open following a brow lift, but during a brow lift, the frown lines between the brows will be minimized because we can remove some of the muscles that cause these frown lines, called the corrugator and procerus muscles.

And finally, occasionally I’ll see a patient with hooding caused by low brows who thinks they would like an upper eyelid blepharoplasty, but when I gently elevate the brows, I can see that this patient does not have an excess of thin, upper lid skin, just low malpositioning of the brows and I will recommend to this patient that a brow lift be performed without a lid procedure per say.

A brow lift is a minimally invasive procedure. In the endoscopic brow lift, a few half inch incisions are made behind the hair line, allowing the instruments to be inserted. The tissues are freed from the bone, the muscles sculpted, and the brows raised a few millimeters. The brows are fixed in their new position with a variety of devices. The incisions are rarely perceptible after healing has taken place. Occasionally, a brow lift will be performed as an isolated procedure, but more commonly it will be combined with a minimally invasive midface or thread lift, an eyelid procedure or a standard face lift. If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Pease feel free to contact our office at 949.888.9700 to set up an appointment with Dr. Bunkis; you may also check out our web site at to see further examples of similar patients.

Pre & Post Upper Lid Blepharoplasty: 49-year-old male before and after an upper (and lower) lid blepharoplasty without a brow lift. Note that the distance between the lashes and brows is unchanged. The main benefit of the procedure was to remove the heavy eyelid skin from his lash lines.


 Pre & Post Brow Lift (and Facelift, no upper lid blepharoplasty): 47-year-old female before and after an endoscopic brow lift and facelift. In spite of her hooded upper lid appearance before surgery, raising her low brows showed that she did not have any excess eyelid skin.

949.888.970 | 30212 Tomas Ste. 275, Rancho Santa Margarita, CA 92688 |

As Medical Director of Orange County Plastic Surgery, Juris Bunkis, M.D., F. A.C.S. brings 30 years of surgical expertise to our communities. Dr. Bunkis is a Harvard trained, Board Certified Plastic Surgeon and Member of numerous prestigious organizations including the American Society of Aesthetic Plastic Surgeons, The International Society of Aesthetic Plastic Surgery, the American Society of Plastic Surgeons and the California Society of Plastic Surgeons. Dr. Bunkis, a former faculty member at the University of California, San Francisco, has published more than 40 scientific publications, abstracts and book reviews, and 17 book chapters in plastic surgery text books. For questions or advice, please contact Dr. Bunkis directly at

What do you think? Leave your comment here.

Comment by diana 3/10/2010 10:00:00 AM

What does an upper lid blepharoplasty entail (i.e. anethesia, recuperation, etc.). Also, what can you do for undereye crepiness and hollowing? Could you provide approximate costs for both procedures?

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