Why Upper Blepharoplasty Is Not Always the Answer for Lateral Hooding, Especially in Asians

A 70-year-old Asian patient presented with lateral hooding of the upper eyelids. She had already undergone two upper blepharoplasties for Asian eyelid crease creation. The first was performed abroad and the second locally; both were done more than 20 years ago.

The textbook answer for lateral hooding is an extended upper blepharoplasty. In this case, that would likely have been the wrong operation.

Why the Standard Approach Was Risky in This Patient

On examination, her eyes were already deep-set. This is a recognised consequence of orbital ageing. As we get older, the bony orbit enlarges and the periorbital fat atrophies, causing the eyes to appear sunken. In a patient with this appearance, any procedure that further reduces upper eyelid volume risks making the hollowness worse, not better.

The upper lid skin itself was noticeably thin; in fact it was thinner than expected even accounting for age and two previous procedures. This raised a specific concern - the old-school approach to upper blepharoplasty, particularly in earlier decades, often involved aggressive removal of orbicularis muscle and orbital fat alongside skin. If that had been done here, the lid had already lost structural volume it could not afford to lose again. An extended upper blepharoplasty, which would have removed more skin and potentially disrupted the remaining lid architecture, carried a real risk of producing a more hollow, cadaveric appearance rather than the refreshed result she was looking for.

The eyelid crease itself had long since disappeared, as is common over time in Asian patients after crease creation surgery. More importantly, there are ethnic differences to take into consideration:

• Asians tend to have higher eyebrows than Caucasians

• Asians also tend to have sparse but coarser eyebrow hairs, or their natural eyebrow shape is less than satisfactory, so this is often filled in or reshaped with tattoos

• Asian eyelids have a higher fat content that can project inferiorly to make the upper eyelid look puffy

Assessment

Standard assessments were performed and brow ptosis and eyelid ptosis were ruled out. The main concern was confirmed as excess skin causing lateral hooding. This was a skin problem, not of muscle, fat or the levator. The question here was how do we address the lateral hooding without compounding the existing hollowness.

Alternative Approaches to Lateral Hooding

Lateral hooding can be addressed in several ways depending on the underlying cause and the patient's goals. A temporal brow lift elevates the outer brow, reducing the skin that folds over the lateral upper lid. It is a good option when the brow position is low and the patient is amenable to changing it. In this case, she did not want her brow position altered, which made a brow lift inappropriate regardless of its technical merits. A sub-brow lift addresses the hooding directly by removing skin and fat from beneath the brow without changing brow position, making it the most appropriate option here.

The Plan: Sub-brow Lift First, Assess Intra-operatively

Rather than committing to an upper blepharoplasty revision pre-operatively, the plan was to perform a sub-brow lift first and assess intraoperatively whether further upper lid work was needed (see figure below). The sub-brow approach addresses lateral hooding by removing skin and fat from directly beneath the brow, placing the scar along the lower brow border where it is concealed. In this patient, the excision was taken full thickness to address both the skin and fat components of the hooding.

Intra-operatively, after the sub-brow lift was completed, the upper lid was reassessed. There was residual excess skin on the lid itself that warranted addressing, but the key decision was to remove skin only, without touching the remaining fat or muscle (if any existed at all within the scar tissues following her two prior procedures). This preserved what little structural volume remained in the lid and avoided the risk of further hollowing.

Two-step approach with sub-brow lift first, followed by upper blepharoplasty (from Ahn & Kim, The American Journal of Cosmetic Surgery, 2023)

The reason for this two-step approach is down to anatomy. In standard upper blepharoplasty, after skin is removed, thicker upper eyelid skin is used to create the crease, which is why it can look puffy still, especially given the Asian anatomy of having more fat in this area. In contrast, the sub-brow excision will remove the thicker portion of upper eyelid skin and the upper blepharoplasty that follows removes less skin. In effect, the final result is a thinner and less puffy eyelid (see Figure below).

Cross-sectional anatomy of the upper eyelid in Asian patients. Studies have shown that at the level of the sub-brow, skin thickness was 6.3 mm, compared to 2.5 mm at the eyelid. (from Ahn & Kim, The American Journal of Cosmetic Surgery, 2023)

Outcome

Sutures were removed at one week. She was delighted with the early results, especially given the context of this being a revision case. At 6 weeks, there was still residual swelling. Interestingly, this was located above the suture line (which is the area of involvement in the procedure), which suggests that the scarring below is quite thick and firm because usually, in eyelid procedures, such bruising and swelling tracks downwards.

Why This Case Matters

Revision eyelid surgery is not a repeat of the original procedure. The tissue you are working with has already been altered, and often in ways that are not documented or even knowable from the patient's history. The choice of sub-brow lift over standard blepharoplasty was informed by anatomy that is well-documented in Asian patients. The decision to be conservative within that approach, skin-only, no fat or muscle disturbed, was informed by findings unique to this patient's surgical history. Both mattered. Neither would have been sufficient alone.

For patients considering eyelid surgery in Singapore, you can read more about eyelid surgery at ZNG.

Written by Dr Ng Zhi Yang, UK & Singapore accredited Plastic Surgeon.

References

1. Chen T, Matarasso A. Lateral Temporal Brow Lift: A 20-Year Experience and Surgical Outcomes. J Craniofac Surg. 2026 Jun 1. doi: 10.1097/SCS.0000000000012992. Epub ahead of print. PMID: 42224034.

2. Turin SY, Vaca EE, Cheesborough JE, Sinno S, Mustoe TA. Simplified Lateral Brow Lift under Local Anesthesia for Correction of Lateral Hooding. Plast Reconstr Surg Glob Open. 2019 Jun 12;7(6):e2098. doi: 10.1097/GOX.0000000000002098. PMID: 31624658; PMCID: PMC6635213.

3. Cha J, et al. Subbrow blepharoplasty for upper eyelid rejuvenation in Asians. Aesthet Surg J. 2009 Jul-Aug;29(4):284-8. doi: 10.1016/j.asj.2009.02.008. PMID: 19717059.

4. Ahn JT, Kim PS. Combined Sub-Brow Lift and Upper Blepharoplasty to Minimize the Supratarsal Fold Thickness and Lateral Hooding: A Concept and Review of Cases. Am J Cosmet Surg. 2023;40(2):83-88. doi: 10.1177/07488068221100086.

5. Ichinose A, et al. Extended infrabrow excision blepharoplasty for dermatochalasis in Asians. Arch Facial Plast Surg. 2011 Sep-Oct;13(5):319-23. doi: 10.1001/archfacial.2011.53. PMID: 21931087.