Floppy upper and lower lids, with a side of cosmetic mid-forehead brow lift and midface lift, please!

By Joseph Walrath, MD | Dec 20, 2022 | Cosmetic

This entry chronicles the clinical course of a patient, who (not uncommonly) had both medical and cosmetic considerations (midface lift and more).  We  start with the preoperative assessment, discuss the surgical planning, and review his postoperative recovery period out to 6 months.


This friendly 65 year old gentleman presented with complaints of left eye irritation and mucous accumulation.  He also had secondary cosmetic goals.

The examination was notable for a very lax, “floppy” left upper and lower lid.  The lids distracted from the eyeball to an abnormal degree, and the closure was impaired subtly as well.  Figure 1 shows the preoperative appearance of the patient.

midface lift on one of my patients at Woolfson Eye Institute

Figure 1

The upper and lower lid laxity can be seen: the left lower lid sags centrally, and the left upper lid lashes point downwards and inwards, a sign that the upper lid attachments to the bone have weakened and the lid has migrated toward the nose.  These are classic findings of “floppy eyelid syndrome.”  The abnormal laxity is demonstrated by distracting the lids away from the eye (Figure 2).

Blepharoplasty on one of my patients at Woolfson Eye Institute

Figure 2

The aesthetic examination is notable for a few findings as well:  a high forehead with sparse hairline; significant forehead wrinkles; faint brow hairs;  low brow position; puffy lower lids; and the lower lids riding low on the eyeball, showing the lower whites of the eyes (lower lid retraction).

Surgical planning – Midface lift and more

The surgical considerations were both medical and cosmetic.  To correct the symptoms on the left side, a canthoplasty would be required:  both the upper and lower lids would need to be treated individually, by separating them from the bone, shortening them horizontally, and securing them to the bone laterally with suture.  This would improve lid position and closure, and eliminate or reduce the irritation and mucous accumulation.  This procedure also leads to significant postoperative swelling and an extended period of healing (when both the upper and lower lid are treated in this manner).

Cosmetic considerations of the lower lid included elevation and tightening of both lower lid / midface complexes.  This would bring would obscure some of the lower lid surface contours and also eliminate the sagging lower lid appearance with the visible rim of white beneath the eye.  It would restore what we refer to as the “almond shape” of the eyes.  Additionally, the midface lift would support the lower lids after upper and lower canthoplasty, making the result of the midface lift more durable.

Midface lift in this case would involve some tissue accumulation at the “crows feet” area, which is where the deep sutures are located for the lift.  Since this area is already crowed by the drooping brow, I advised him that a brow lift really would be mandatory in this case.  One possibility would be a “temporal” brow lift, just lifting the outer corner.  But this would have led to an unnatural brow shape.

Therefore, we talked about full brow lift options.  I did offer to refer this gentleman for an endoscopic brow lift, but given his high hairline, I had misgivings about that.  Endobrow can push the hairline back, since the procedure frees up the entire forehead and scalp and redistributes everything posteriorly.  Additionally, the least powerful part of the endobrow procedure is the lift at the lateral aspect of the brows, and this was actually the most important part for this patient.

We then discussed two other procedures:  direct brow lift and direct mid-forehead brow lift.  Direct brow lift places an incision directly atop the brow hairs.  However, his brow hairs were relatively sparse, and I felt that direct brow would potentially lead to an unfavorable long term scar.  Finally, we discussed utilizing the deep paired wrinkles in the forehead to directly excise forehead tissue (a direct mid-forehead lift), which would elevate the brows and obscure the incision in new forehead wrinkle.  The obvious drawback of this approach is a very prominent incision initially (think “Frankenstein”), which over many months would fade and lead to the most favorable outcome, in my estimation.

In the end, we opted for canthoplasty (which turned out to be bilateral, in this case), midface elevation, lower lid retractor release, and direct mid-forehead lift.  This procedure was done under general anesthesia and took about 2 hours 45 minutes to perform.  There were no complications.

Postoperative course

Postoperatively, there was pain for a day, moderate at best, and well treated.  He then began the long(ish) healing process after this procedure.

Figure 3 (postoperative month 1) reveals improved lower lid position, improved brow position, and some swelling at the outer corners of the lower lids.  The central forehead scar is prominent.  All is as expected.

Mid-forehead lift & eyelid lift on one of my patients at Woolfson Eye Institute

Figure 3

After two more months of healing, now at month #3, he is healing appropriately (Figure 4).  The forehead incision is pink.  There is bunching at the outer corner of the eyes.  The lower lid position is excellent.  We decided to bring the tails of the brows up a bit more with direct temporal excision, a minor office surgery which was performed a few weeks later.

Canthoplasty on one of my patients at Woolfson Eye Institute

Figure 4

At 6 months (Figure 5), he is healing well.  He is still not a finished product, with several months of subtle healing still to come.  However, he is very happy with his appearance and has continued to have complete resolution of irritation and mucous accumulation in the left eye.

Blepharoplasty on one of my patients at Woolfson Eye Institute

Figure 5