Doctor's Column

Eye surgery for individuals in their 50s cannot be resolved simply by making the double eyelid line bigger. This is because, as time passes after non-incisional double eyelid surgery, eyelid sagging, hooded double eyelid lines, lower eye fat imbalances, and midface sagging often occur simultaneously. Through the actual case of a 51-year-old female patient, Dr. Sung-hoon Kim of SH Plastic Surgery explains a combined surgical strategy that corrected the upper eye area with a sub-brow lift and upper epicanthoplasty instead of an incisional double eyelid surgery, and naturally improved the under-eye area and nasolabial folds by combining lower blepharoplasty and a midface lift. He details the anatomical rationale, covering sub-brow lift vs. upper blepharoplasty, the limitations of under-eye fat repositioning, and the necessity of lower blepharoplasty plus midface lifting.

Face Designer Dr. Sung-hoon Kim, SH Plastic Surgery

"Doctor, my double eyelids used to be defined,

but now the line is completely covered and my eyes look so stuffy."

Hello.

I am Dr. Sung-hoon Kim, Face Designer and board-certified plastic surgeon.

Spending my days in the consultation room,

I hear stories like this quite often.

"Doctor, my eyes used to look fine,

but lately, whenever I take photos, my eyes look completely obscured."

"I have double eyelids, but it feels like they are disappearing."

Women around their 50s in particular

often bring this up hesitantly.

It is because the non-incisional double eyelid surgery they had when they were young,

rather than making the eyes look defined,

has at some point shifted to looking covered by the eyelids instead.

Actually, rather than being a specific problem, this change

is simply closer to the natural result of time passing.

The skin gradually sags,

the strength to open the eyes is not what it used to be,

and the under-eye and cheek areas begin to sag as well.

In times like this, many people ask:

"Then should I just make the double eyelid bigger again?"

"Do I need to redo it using the incisional method?"

However, to that question, I always

begin the conversation in a slightly different direction.

What I am going to talk about today is

not about 'surgery to remake double eyelids',

but about 'how to understand and organize the structures around the eyes'.

Today's topic is

Drooping eyes in one's 50s, instead of incisional double eyelid surgery,

This is an actual case of choosing a sub-brow lift, upper canthoplasty, lower blepharoplasty, and midface lift.

Why incisional double eyelid surgery was not recommended,

On what basis the sub-brow lift and lower blepharoplasty were planned together,

And how this choice transformed the overall impression—

I would like to explain. ^^

If you look in the mirror right now and feel that

your eyes "look a bit different from before,"

I hope today's story

helps you understand the reason behind that change.

The patient was a female born in 1975, 51 years old.

In her mid-30s, about 15 years ago, she had non-incisional double eyelid surgery and said she was very satisfied at the time.

However, as time passed, the eyelid skin sagged, and the existing non-incisional line was covered from above and became almost invisible.

In addition, under the eyes, one side bulged while the other looked sunken,

and her biggest concern was that her overall impression looked dull and tired.

CASE

The core issue for this patient was not the "double eyelids."

When I first saw this case, this was my assessment:

"This is not a matter of simply recreating double eyelids.

The structures both above and below the eyes have collapsed at the same time."

Summary of Main Issues

Covered double eyelid line → Sagging eyelid skin

Thick upper eyelids → Risk of looking even heavier with incisional double eyelid surgery

Bulging under the eyes + sunken areas → Midface sagging, not just a fat issue

An aging appearance extending down to the nasolabial folds

<Pre-surgery>

Therefore, for this patient,

incisional double eyelid surgery was actually strongly discouraged.

Final Surgical Plan

"Sub-brow Lift" + "Upper Canthoplasty" + "Lower Blepharoplasty & Midface Lift"

Reasons for Choice

1. Sub-brow Lift

(Sub-brow lift · Sagging eyelids · Correction of hooded double eyelids)

The root cause of the buried crease line appearing hooded is eyelid sagging

An upper blepharoplasty incision carries the risk of accentuating a heavy, thick impression

Directly removing only the sagging skin beneath the eyebrows → Natural restoration of the upper face

If scarring is a concern, an endoscopic forehead lift could also be considered in this case, but

Taking into account both the eyebrow position and skin laxity, a sub-brow lift was determined to be more suitable.

2. Upper Epicanthoplasty (Diagonal Epicanthoplasty)

(Improvement of epicanthal folds · Alternative to front epicanthoplasty · Expansion of the upper eye area)

In cases with heavy upper eyelids, the effect of traditional front epicanthoplasty is limited

Securing only the inner-upper space of the eyes through upper epicanthoplasty

Achieving a refreshed, open look without overcorrection

An approach focused on removing the stuffy, hooded look rather than just "enlarging" the eyes

3. Lower Blepharoplasty + Midface Lift

(A choice to overcome the limitations of lower eyelid fat repositioning)

This surgery was the key element of this case.

Simple lower eyelid fat repositioning:

✔ Resolves the bulging, but

✔ Leaves midface sagging completely unaddressed.

Potential adverse effect of appearing even more hollow over time

By combining lower blepharoplasty + midface lift:

Cleans up under-eye bulging

Lifts sagging midface cheeks

Delivers a lifting effect that naturally extends down to the nasolabial fold area

Postoperative

1. Sub-brow Lift

(Sub-brow lift · Sagging eyelids · Correction of hooded double eyelids)

2. Upper Epicanthoplasty (Diagonal Epicanthoplasty)

(Improvement of epicanthal folds · Alternative to front epicanthoplasty · Expansion of the upper eye area)

3. Lower Blepharoplasty + Midface Lift

(A choice to overcome the limitations of lower eyelid fat repositioning)

International research on facial aging consistently points to one core takeaway:

"Eye aging past one's 50s is

not just an issue of the eyelids, but a problem of midfacial descent."

The midface fat pad (malar fat pad) is

a single continuous structure extending from under the eyes to the cheekbones and nasolabial folds

If the midface is not lifted together during lower blepharoplasty,

the step difference between the under-eye area and the cheek becomes more pronounced.

Therefore, for this patient,

Lower blepharoplasty alone was rather an incomplete solution.

<1 Month Later>

Reflections by Facial Designer Dr. Kim Seong-hoon

“The goal of eye surgery in one's 50s

is not to ‘look young,’

but to achieve a **‘naturally neat and tidy look.’**

The ‘thick double eyelid line’ that this patient wanted

could actually have ended up being the most dangerous choice.

I always assess it this way:

Is the double eyelid the problem,

or have the structures above and below it collapsed?

This surgery

was not about making the eyes bigger,

but about reorganizing the structures around the eyes.

That is why, even as time passes,

it remains neither excessive nor prone to collapsing.”

FAQ

Q1. Are there many cases where incisional double eyelid surgery is avoided even in one's 50s?

Yes. Depending on skin thickness and the degree of sagging, it is often not recommended.

Q2. What is the biggest difference between a sub-brow lift and upper blepharoplasty?

Upper blepharoplasty is a surgery that creates a double eyelid line,

while a sub-brow lift is a surgery that trims sagging skin.

Q3. Can't I just get under-eye fat repositioning?

When accompanied by midface sagging, the limitations are clear.

Q4. Isn't lower blepharoplasty + midface lift too major of a surgery?

The more structural the cause of aging is, the more fundamental this choice becomes.

Q5. How long is the recovery period?

Return to daily life takes 2 to 3 weeks, and natural settling takes around 3 months.

Q6. Is this kind of combination surgery necessary for everyone?

No. The decision must be made only after an anatomical diagnosis.

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