Upper-Eyelid Heaviness: Looking Beyond the Eyelids to the Forehead and Temples

Upper-eyelid heaviness does not always arise from the eyelid skin alone. The position of the forehead, temples, and brows can also contribute. When planning natural-looking rejuvenation, it is important to evaluate the upper face as one continuous anatomical region.

The Main Approaches to Forehead and Temporal Lifting

The procedures currently performed can be broadly organized into the following approaches.

A hairline incision with direct removal of excess skin
A hairline incision combined with treatment of the muscles that contribute to wrinkles
Repositioning and fixation of forehead and temporal tissues through an endoscope or limited incisions
An endoscopic or limited-incision lift combined with selected muscle treatment when necessary

Each method has advantages and disadvantages. A smaller incision is not automatically better, and direct skin excision is not automatically the most powerful approach in every patient.

Open Forehead Lift vs Endoscopic or Limited-Incision Lift

Comparison of an open forehead lift with an endoscopic or limited-incision forehead lift. The appropriate procedure depends on forehead height, the degree of laxity, and the patient's acceptance of scars, among other factors.
Comparison	Open Forehead Lift	Endoscopic (Limited-Incision) Forehead Lift including limited-incision temporal lift
Overview	An incision is made along the forehead hairline to improve deep forehead wrinkles and laxity. When treatment of muscles such as the frontalis and corrugator supercilii is added, longer-term wrinkle prevention may also be expected.	Incisions of approximately 2–3 cm are made in both temples, with additional 1–2 cm incisions near the center of the forehead. The brows are elevated through approximately four small incisions in total. A long-lasting brow-elevation effect is one of its characteristics.
Indications	Pronounced forehead laxity Deep forehead wrinkles Strong contraction of the forehead or glabellar muscles Significant brow asymmetry A high forehead The forehead can also be lengthened when appropriate.	Forehead laxity Brow ptosis A low or short forehead
Risks and Limitations	A visible or conspicuous scar Future hair transplantation may become more difficult Reduced or altered sensation in the forehead or frontal scalp The brow-elevation effect may be more prone to relapse	Asymmetry can be more difficult to correct than with an open forehead lift Reduced or altered sensation in the forehead or frontal scalp Because the incisions are placed within hair-bearing scalp, alopecia may develop around a scar depending on scar formation and postoperative wound care Wrinkles may recur sooner The hairline moves backward, which may make the procedure unsuitable for someone who already has a high forehead For patients with a high forehead, hair transplantation may sometimes be an option, so posterior movement of the hairline is not necessarily a disadvantage in every case.

A hairline incision allows direct removal of excess skin and can make it easier to adjust forehead height and deep wrinkles at the same time. The scar, the effect on future hair transplantation, and sensory changes in the forehead or scalp must also be considered.

Endoscopic and limited-incision procedures reposition the forehead and temporal tissues through several small incisions. They can minimize the length of the scars, but another approach may be more suitable depending on the amount of laxity and the height of the forehead.

Approaches to a Temporal Lift

Comparison of an open temporal lift with a limited-incision temporal lift. The brow tail, lateral upper eyelid, and outer eye area should be evaluated together.
Comparison	Open Temporal Lift	Limited-Incision Temporal Lift
Overview	An incision is made along the temporal hairline to correct temporal laxity. Because tissue can be lifted directly from a position close to the outer eye and brow tail, the effect can be strong and is less prone to relapse.	Incisions of approximately 2–3 cm are made within the hair-bearing scalp on both sides of the temple. Laxity extending from the outer eye to the temple is lifted through these incisions. The scars are small and usually concealed within the hair, and the result tends to look natural.
Indications	Laxity around the outer eye A desire to correct laxity around the outer eye A desire to reduce crow's-feet when smiling	Laxity around the outer eye A desire to correct laxity around the outer eye Patients in whom lifting only the outer eye would create an overly upturned appearance A desire to enhance the effect of a facelift A desire to reduce crow's-feet when smiling
Risks and Limitations	A visible or conspicuous scar	More prone to relapse than a procedure using a hairline incision Because the incisions are placed within hair-bearing scalp, alopecia may develop around a scar depending on scar formation and postoperative wound care

An incision along the temporal hairline allows laxity to be adjusted directly from a position close to the outer eye and brow tail. A limited-incision approach makes it easier to conceal the scars within the hair, but fixation must account for the amount of tissue movement and the possibility of relapse.

How Should the Muscles of Facial Expression Be Addressed?

The position of the brows and wrinkles of the forehead, glabella, and outer eye are mainly influenced by the following muscles.

Frontalis: elevates the brows and contributes to horizontal forehead lines
Corrugator supercilii: draws the medial brows inward and contributes to vertical glabellar lines
Procerus: contributes to horizontal lines over the nasal root
Orbicularis oculi: closes the eyelids and also influences the position of the brow tail and outer eye

Muscle treatment is performed not only to reduce wrinkles but also to balance the muscles that elevate the brows against those that depress them.

Overly aggressive treatment, however, can affect facial expression, brow position, and sensation. It is important to combine muscle treatment with the planned amount of forehead movement and to treat only the necessary muscles within the necessary area.

How to Select the Appropriate Procedure

Forehead height and hairline position
The overall brow shape, brow tail, and asymmetry
Where upper-eyelid laxity is concentrated
Dynamic wrinkles of the forehead, glabella, and outer eye
Acceptance of scars, sensory changes, and recovery time

Summary

There are several approaches to forehead and temporal lifting, and each serves a somewhat different purpose. Rather than choosing a procedure by name first, it is important to determine where the upper-eyelid heaviness originates and then select an approach that addresses its cause.

This article provides general information about forehead and temporal lifting. The comparisons are broad summaries and do not cover every surgical technique or individual variation. Please discuss your own indications and risks with your surgeon during consultation.