Blepharoplasty with facelift and brow lift

Why they are combined

• Blepharoplasty and brow lift address related structures: forehead and brow position, upper eyelid skin, and lower eyelid or tear-trough contour are described and planned together in the same surgical overview (PMID 20595828). Brow lift technique itself is covered in browpexy-and-direct-brow-lift.md, temporal-and-lateral-brow-lift.md and endoscopic-brow-lift.md.
• Among 2,530 candidates for upper eyelid blepharoplasty, 13.7% had undiagnosed ptosis, most of it mild (85.5%); ptosis was far more common in patients with eyebrow asymmetry (75.3%) than without it (3.7%), so an asymmetric brow can be a sign of masked lid ptosis rather than, or in addition to, true brow ptosis (PMID 37694225). Ptosis repair itself is covered in blepharoptosis-repair.md.
• In a survey of 214 Aesthetic Society members, high-volume upper blepharoplasty surgeons (100 or more cases a year) more often added concomitant brow lift, fat grafting and ptosis repair than lower-volume surgeons (PMID 33346340).
• In a 278-patient, 533-eyelid series, a brow lift was added to upper blepharoplasty in 31.7% of eyelids, and ptosis correction in 20.5% (PMID 38315110).
• In a 13,346-patient rhytidectomy database, blepharoplasty was the most common procedure added to a facelift, with an average of 2.3 procedures performed in 3.8 hours per patient (PMID 32459769).

Sequencing

• A surgical overview presents endoscopic or lateral brow lift, upper lid blepharoplasty with supratarsal fixation, and lower lid blepharoplasty with tear-trough correction as parts of one combined plan for the upper face (PMID 20595828). Tear-trough and lid-cheek junction technique is covered in tear-trough-and-lid-cheek-junction.md.
• Elevating multiple facial planes in one setting (facelift, forehead contouring with brow lift, cheek implants, rhinoplasty, mandible contouring) in 25 patients caused no vascular complications; complications were limited to those already known for each individual procedure (PMID 31098694).
• A multicenter survey of facelifts under local anesthesia found that high-volume surgeons (more than 500 facelifts in 19 months) had shorter average operative times and a significantly lower venous thromboembolism (VTE) rate than lower-volume surgeons; limiting ancillary procedures was proposed as a way to shorten operative time (PMID 23708241).
• In 1,753 plastic surgery cases, each added hour of operative time raised the odds of a complication by 21%; risk rose significantly after 3.1 hours (odds ratio 1.6), 4.5 hours (odds ratio 3.1) and 6.8 hours (odds ratio 4.7) (PMID 24696297). A systematic review of facial plastic ambulatory surgery reached a similar conclusion linking longer procedure duration to complication risk (PMID 30476941).

Brow position after upper blepharoplasty

• Meta-analysis of 17 studies: brow height fell after upper eyelid surgery overall (mean difference 1.45 mm); simple blepharoplasty alone dropped the brow 0.67 mm, double-eyelid surgery 2.52 mm and ptosis correction 2.10 mm; skin excision itself did not change brow height (PMID 36890345).
• Landmark 1992 series: 15 patients (28 eyes) with measurable brow ptosis who declined browpexy underwent upper blepharoplasty alone; 22 of 28 eyes showed no significant brow change, 3 eyes had mild to moderate descent, and all patients were pleased with the result regardless (PMID 1390430).
• In 60 East Asian patients (120 eyes), the distance from the upper lid margin to the brow shortened after both upper blepharoplasty and levator advancement, with a larger change after levator advancement than after blepharoplasty (PMID 22421841).
• In 45 patients (90 brows), angular photographic analysis showed the brow moves downward after upper lid blepharoplasty, most in the lateral portion, occurring on both sides (PMID 22571187).
• A counterpoint in 19 patients found no statistically significant change in eyebrow height at the medial, central or lateral brow after upper blepharoplasty, once fat excision, ocular dominance and change in MRD1 were accounted for (PMID 26505314).
• Adding internal browpexy to upper blepharoplasty in 48 patients: blepharoplasty alone produced a 6.13% decrease in mid-pupil brow height, versus a 2.99% increase when internal browpexy was added (PMID 39150758).
• Combining a lateral pretrichial subcutaneous brow lift with upper blepharoplasty in 28 patients: the lateral brow line improved 50% (46 mm to 71 mm) and the brow apex line 45% (35 mm to 50.75 mm); 89% of patients were satisfied and 11% highly satisfied (PMID 40820029).

Results and evidence

• CosmetAssure, 6,126 aesthetic eye surgery patients from 2008-2013 (4,879 blepharoplasty alone, 441 brow lift alone, 806 combined): major complication rates did not differ between groups (0.4% combined versus 0.4% blepharoplasty versus 0.7% brow lift, p=0.65); hematoma was the most common complication in all three groups, 0.2%-0.5% (PMID 29369102).
• In 278 patients (533 upper eyelids), the revision rate was 3.8% after upper blepharoplasty alone versus 9.2% after upper blepharoplasty combined with ptosis correction and, in some cases, brow lift (p=0.008); reasons for revision after the combined procedure were overcorrection, residual skin and asymmetry (PMID 38315110).
• In the 13,346-patient rhytidectomy database, the overall adverse event rate was 5.1%, most often hematoma or infection; combined procedures, longer operative duration, general anesthesia and office-based surgery were each independently associated with higher odds of an adverse event (PMID 32459769).

Risks and complications

• CosmetAssure VTE analysis, 129,007 cosmetic surgery patients: overall VTE rate 0.09%; combined procedures carried roughly 2.4 times the relative risk of VTE compared with a single procedure (0.20% versus 0.04%, p<.01); face-only procedures had one of the lowest VTE rates, 0.01% (PMID 28207041).
• In the local-anesthesia facelift survey of 74 surgeons, the overall VTE incidence was 1 event in 5,844 surgeries (PMID 23708241).
• National review of the American Association for Accreditation of Ambulatory Surgery Facilities database, 2012-2017: 42 deaths after outpatient cosmetic surgery, 38.1% thromboembolic in origin; VTE risk factor assessment was incorrect or absent in 59.5% of the cases reviewed (PMID 29649062).
• TOPS registry, 286,826 outpatient plastic surgery procedures: overall adverse event rate 5.7%, most often antibiotic requirement (1.4%), dehiscence (1.3%) or seroma needing drainage (1.1%); adverse event rates did not differ significantly between ambulatory surgery centers and office-based facilities (PMID 36877624).
• TOPS complication tracking, 214,504 patients across five aesthetic procedures including 29,797 blepharoplasties: hematoma 0.7%, deep surgical-site infection 0.2%, deep vein thrombosis or pulmonary embolism 0.1%; pursuit of combined aesthetic procedures was one factor associated with increased unplanned healthcare use (PMID 36728533).
• Analog CosmetAssure data from aesthetic breast surgery, 73,608 patients: overall major complications 1.46%; combining abdominoplasty with any breast procedure raised complication risk above either procedure alone (PMID 28333172), a general database pattern of added risk from combination that the eyelid-and-brow CosmetAssure data did not reproduce (PMID 29369102).
• Lower blepharoplasty and midface lifting share a complex, overlapping anatomy, and their complications are reviewed together; careful preoperative evaluation is advised to select the right combination of techniques (PMID 25440742). Midface and lid-cheek junction technique is covered in tear-trough-and-lid-cheek-junction.md.
• A California statewide database study of 477,741 outpatient procedures, including 16,893 combined-procedure cases, found the 12-month VTE rate for face procedures was 0.28%, and some procedure combinations (not including blepharoplasty pairings specifically) showed more than additive VTE risk (PMID 25415104).

Recovery

No study identified for this review separately reports recovery time for blepharoplasty combined with a brow lift or facelift against blepharoplasty performed alone. The available recovery-relevant data concern VTE timing: local anesthesia and shorter operative time are associated with a lower facelift VTE rate (PMID 23708241), and combined-procedure surgery carries a higher relative VTE risk than an isolated procedure in the same registry (PMID 28207041).

Current questions

• Whether combining brow lift with blepharoplasty adds risk: the largest eyelid-specific CosmetAssure series found no added major-complication risk (PMID 29369102), while broader CosmetAssure and TOPS data show combined procedures generally carry higher VTE and unplanned-care rates than isolated ones (PMID 28207041), (PMID 36728533).
• Whether upper blepharoplasty alone changes brow position: a 2023 meta-analysis found a small but significant drop (PMID 36890345), while individual paired-photograph studies disagree, some finding a measurable descent (PMID 22421841), (PMID 22571187) and others finding none once confounders are controlled (PMID 26505314).
• Whether to add internal browpexy routinely at blepharoplasty: a 2024 series reports it limits post-blepharoplasty brow descent (PMID 39150758), an approach detailed in browpexy-and-direct-brow-lift.md.
• What operative-time threshold should limit how many procedures are combined in one setting: a 2014 series found rising complication odds after 3.1 hours (PMID 24696297), and a 2019 systematic review of facial plastic ambulatory surgery reached a similar duration-complication link without naming a single universal cutoff (PMID 30476941).
• Registry research on this topic depends on the TOPS database, launched in 2002 and now holding more than 1 million procedure records contributed by American Society of Plastic Surgeons members (PMID 34529595).

Terms

• Brow ptosis: a lowered eyebrow position, which can be mistaken for or coexist with upper eyelid dermatochalasis (PMID 37694225).
• Dermatochalasis: excess, lax eyelid skin, covered in upper-blepharoplasty.md.
• Internal browpexy: a suture technique that fixes brow position through an upper blepharoplasty incision, detailed in browpexy-and-direct-brow-lift.md.
• MRD1: distance from the corneal light reflex to the upper lid margin, used to measure lid and indirectly brow position (PMID 22421841).
• Rhytidectomy: the surgical term for a facelift (PMID 32459769).
• CosmetAssure: a cosmetic surgery complication insurance program whose claims data are used to study major complication rates across practices (PMID 29369102).
• TOPS: Tracking Operations and Outcomes for Plastic Surgeons, an American Society of Plastic Surgeons outcomes registry (PMID 34529595).
• Venous thromboembolism (VTE): a blood clot, typically in the leg (deep vein thrombosis) or lung (pulmonary embolism), tracked as a major complication of combined aesthetic surgery (PMID 28207041).
• American Society of Anesthesiologists (ASA) class: a preoperative health classification used in these registries to compare patient risk across studies (PMID 32459769).

Papers