Brow Lift, Mid-Face Lift and Lower Blepharoplasty: Why I Almost Always Combine Them

Patients who come to see me about their eyes, their brows, or the general fatigue of their upper face often arrive with a specific concern in mind. They may have noticed heaviness in the outer brow. They may be bothered by the shadow under the lower eyelid that seems to have deepened over time. Or they may simply feel that “they constantly look tired, sad or bored” in a way that is difficult to explain. What I consistently find when I sit with them is that ageing of the lower lid and the cheek does not exist in isolation from each other; it is shaped by the position of the soft tissue above and the support of the mid-face below. When I plan surgery in this region, I am always thinking about how each structure relates to the others. That is why, for many of my patients, the conversation about a single procedure becomes a conversation about a single anatomical unit: the peri-orbital area.

This includes very independent anatomical compartments:

1. Forehead
2. Eyebrow
3. Upper eyelids
4. Temporal area
5. Lower eyelid
6. Zygomatic arch
7. Malar fat pad – the fatty tissue of the cheek, located on each side of the nose.

Why These Three Procedures Work Together

The brow lift I perform most frequently is a lateral temporal approach. The incision sits 2cm behind the hairline, and the aim is to lift the central and lateral third of the brow, the parts that tend to descend first with age, while preserving the natural arc of the inner brow. While the brow lift improves laxity over the temporal area (the side of each eye), it also reduces skin laxity over the upper eyelid and helps open the eye. This technique does not address the mid-face. The two anatomical regions are separate. But they are not independent.

When I lift the brow and begin to plan the lower eyelid at the same time, I am immediately thinking about the tear trough. Hyaluronic acid and Platelet-Rich-Plasma (PRP) are both valid options for correcting the tear trough. Surgically, we have considerably more options available, and I believe they produce results that are both natural and certainly more durable when successful.

One approach is to transpose the preorbital fat. This fat sits closer to the eyelid margin and contributes to the appearance of eye bags; moving it downward acts as a natural, permanent filler for the tear trough. When this is combined with lifting the mid-face, the correction is softer, more voluminous, and longer-lasting than anything that can be achieved with filler alone. This is not a theoretical advantage but is supported by a solid body of evidence-based scientific publications and is coherent with my own surgical experience over the last 20 years in plastic surgery.

The Case for Combining: A Clinical Perspective

I want to be clear about why I recommend this combination. It is not because it saves the patient a second operation, though it does. It is not because it reduces the number of times they need to go through anaesthesia, though that is a genuine benefit. The reason I recommend combining these procedures, when the anatomy supports it, is that operating on the lower eyelid without at least partially lifting the malar fat pad, the soft tissue of the mid-face, produces an inferior result.

There are two reasons for this. The first is structural: lifting the mid-face provides better support to the lower eyelid after surgery, which matters for both the cosmetic outcome and for longer-term stability. The second is about the tear trough specifically. If the mid-face is not addressed when operating on the lower eyelid, the correction of the tear trough is incomplete. The hollowing that patients find so ageing, and so difficult to treat with non-surgical options, requires the combined approach to be properly corrected.

The brow lift fits into this picture because the upper and lower eyelids are connected through the “Temporal Area”. Heaviness in the lateral brow pushes down on the upper eyelid, which in turn changes the overall perception of the eye.

The whole skin laterally to the eye (the Temporal Fossa: between the temporal hairline and the outer corner of the eye) moves down as well,l and this causes the descent of the lateral corner of the eye: this is called “ptosis of the lateral canthus”.

The final effect also includes the forehead becoming longer, particularly at its lateral aspect, where the eyebrow descends the most.

It has been demonstrated and widely approved that “the descent of the outer corner of the eye represents a major sign of ageing and also causes symptoms (such as dry eyes in particular) which can not be improved without an appropriate repositioning of the outer canthus through a blepharoplasty. A midfacelift will provide solid support to the blepharoplasty and suspension of the other canthus (also known as “canthopexy).

When I can lift the lateral brow at the same time as addressing the lower eyelid and the mid-face, the result reads as coherent. Every part of the eye area looks as though it belongs to the same person at the same moment in time. That coherence is much harder to achieve if the procedures are staged.

What Patients Experience: A Real Case

A patient of mine recently came to me for a second procedure. She had her first breast augmentation with me following a pregnancy. At that time, she had done extensive research, seen several surgeons, and eventually chose to proceed under my care based on both the sense of ease and satisfaction during the consultation process (always in two stages in my practice) and, of course, my reputation. I am proud to say that she was satisfied with the result. When the time came to address a combination of facial and breast procedures, the choice of surgeon was, in her words, obvious.

In the same session, she had a lateral temporal brow lift, a mid-face lift, a lower blepharoplasty, and an exchange of breast implants. The facial component addressed everything I have described above. The breast exchange involved moving to a larger implant with the same footprint but greater projection, and correcting an asymmetry where the left implant sat slightly higher and more medially than the right. These are separate anatomical regions with entirely compatible recovery positions (patients can rest in bed on their back throughout the whole recovery period), which makes the combination safe and practical. It is worth being clear about why this combination was possible and safe in her case. First, she was a healthy patient, confirmed by a thorough pre-operative assessment. Second, the resting position for every part of the surgery was coherent: she could recover on her back throughout, which is essential when facial and breast procedures are combined. Third, the whole procedure was completed within six hours and under deep sedation, allowing a fast recovery from anaesthesia. Those three factors, a healthy patient, a coherent recovery position, and a controlled operating time under deep sedation, are what make a combination of this scope both safe and practical.

You can see this case below and I am simply enormously grateful to this amazing young lady for allowing me to publish her results along with an interview to share more details about her experience under my care.

At six weeks post-operatively, she described her recovery as fast and smooth, with swelling resolving within the first couple of weeks. She returned to normal physical activity quickly and described feeling progressively happier with the results as the weeks passed. That trajectory, gradual improvement over several months as swelling continues to settle, is exactly what patients should expect after this kind of combined procedure.

Recovery: What to Expect After a Combined Facial Procedure

Surgery is more invasive than injectable treatment, and it carries a longer recovery period. That is a straightforward clinical fact, and I think it is important to state it plainly rather than minimise it. But the recovery period for a combined facial procedure is not simply the sum of the individual recoveries. Patients are going through a single recovery once, not three separate ones.

Swelling is the dominant feature of the early recovery period. It is significant in the first two weeks and continues to reduce over the following months. The final result after this kind of procedure is not fully visible until approximately three months post-operatively, and I make sure to tell this to every patient at consultation. What they see at six weeks is encouraging but not complete.

Incisions from the lateral temporal brow lift sit just behind the hairline and, provided there is no tension on the closure, are designed to become difficult to detect over time. One of the principles I return to consistently in facial surgery is that a well-healed scar is one where the skin edges are brought together without any tension at all. If I have removed the right amount of skin, the closure is tension-free, and that is the foundation of an incision that fades.

Safety and Pre-Operative Assessment

The decision to combine procedures is always governed by what can be done safely. The pre-operative assessment must reflect that. Before any combined procedure of this scope, I want to confirm that a full blood count is satisfactory, that liver and kidney function are within normal range, and that coagulation parameters are correct. These are not optional checks. If any values fall outside an acceptable range, we address that before proceeding, or we stage the surgery.

The strategy for recovery needs to be comprehensive but also adequate to what each person can realistically achieve.

The advantages of combining procedures are genuine. But they are never a justification for accepting elevated risk. The patient’s safety governs every decision.

In cases where patients have had several injections of hyaluronic acid (HA) over the years, before dissolving them, I refer them to our Department of Radiology for an HA-tracking MRI. This new application in modern radiology gives us a complete 3D view of the distribution and thickness of HA in our patients. The next step is to proceed with dissolving injections of Hylase, ideally three to six weeks before surgery.