Patients with upper eyelid ptosis often develop brow ptosis as they age. The reason for this phenomenon is that eyelid ptosis hinders upper visual field. Therefore, the brain sends a signal to use the forehead muscle to lift the brow to maximize eyelid elevation. This is call forehead compensation. However, forehead compensation or brow elevation can only be maintained for so long. So after a minute or so, one tends to relax the forehead muscle. It is this repetitive movement of forehead elevation and relaxation that stretches the retaining ligaments of the brow. Therefore, with age, the brow tends to drop.
Brow dropping or brow ptosis makes eyelid appear puffy. Many of these patients believe that their upper eyelid puffiness is due to excess upper eyelid fat. Therefore, they request that they get a double eyelid surgery and upper eyelid fat removal. If a plastic surgeon performs double eyelid surgery with fat removal, the consequence is worsening of eyelid ptosis without resolution of a puffy eyelid. This is because the creation of the double eyelid fold will burden the already weak eyelid muscle (levator aponeurosis muscle) by making a connection (skin to the eye elevating muscle) for the double eyelid fold. In addition, removal of the eyelid fat will remove the lubricating effect / gliding effect of the levator muscle from the more superficial orbicularis oculi muscle of the upper eyelid. Therefore, there will be more adhesion as the patient ages and this will worsen eyelid elevating effect (from adhesions).
If a patient receives double eyelid and ptosis surgery but not brow lift, then the eyelid will remain puffy or the puffiness will worsen. This reason for this is that as the eyelid opens well from the eyelid ptosis surgery, the brow/forehead will relax and therefore, the brow will remain at the low relaxed state. And because the patient will not use the forehead to lift the eyes, the patient will often be bothered by the puffy appearance of the upper eyelid skin.
Therefore, it is important to simultaneously lift the forehead at the time of the eyelid ptosis surgery in older patients or in patients with significant puffy upper eyelid. By performing these maneuvers, the eyes will appear awake and bright. And the upper eyelid will appear thin and youthful.