Doctor's Column

Tearing, lower eyelid bulging, and eyelid sagging commonly seen in men in their 60s often stem not simply from lower eyelid fat issues, but from a continuous aging process connecting the forehead, upper eyelids, lower eyelids, and midface. Through the actual case of a 65-year-old male patient, this article explains from an anatomical and functional perspective why an Endotine endoscopic forehead lift, sub-brow lift, thin non-incisional double eyelid surgery, and lower blepharoplasty with a midface lift were planned together. Covering the cascade of effects—including tearing caused by weakened lateral canthal support, the habit of overusing the forehead, and midface descent—supported by literature, we present the principles of combined surgery aimed at looking "masculine and natural, without looking tired."

Face Designer, Dr. Sung-Hoon Kim, Director of SH Plastic Surgery

Hello. I am Sung-hoon Kim, Face Designer and Director at SH Plastic Surgery.

A biting wind started blowing yesterday, and the cold is fierce, as if signaling the full onset of winter.

In weather like this, tears often stream down without you even realizing it.

However, the problem isn't that tears flow because the eyes are irritated by the cold wind,

but that tears keep running

constantly, even in daily life.

It is truly unfortunate that many people do not know whether they should visit a hospital for such concerns.

CASE

"Under my eyes are puffy, and people keep telling me I look tired.

And tears keep running only from my left eye."

These were the first words from a 65-year-old male patient born in 1960.

Looking closely, he presented with under-eye bulging, eyelid sagging, and compensatory brow movement—using the forehead to open the eyes.

This is not an isolated issue in one area of the eye, but a typical aging pattern in middle-aged and older adults where the entire periocular region is interconnected.

Patient Basic Information

Age 65

* Primary Symptoms

Persistent tearing in the left eye

Coexistence of under-eye bulging and hollowing

Overall sagging around the eyes

Habit of using the forehead to open the eyes (compensatory eyebrow movement)

Cause Analysis ①

Cause of Tearing: Lateral Sagging + Weakened Lateral Canthal Support

The main reason tears flowed particularly from the left eye

was the weakening of the lateral canthus support and the sagging of the lower eyelid.

When the lower eyelid sags downward, the position of the lacrimal punctum shifts slightly,

which can lead to a functional issue where tears cannot be drained properly and spill out of the eye.

Cause Analysis ②

Reason for Overusing the Forehead = Excessive Upper Eyelid Skin Laxity

This patient was the type to engage the forehead muscles first when opening his eyes.

This is a sign of significant sagging due to severe skin laxity in the upper eyelids, along with a lowered eyebrow position.

In this state, performing only an upper blepharoplasty (SB) or double eyelid surgery can lead to the following problems:

Eyebrows dropping suddenly, resulting in eyebrow ptosis

Deepening of wrinkles between the eyebrows and on the bridge of the nose

Bulging of the upper eyelids

Worsening of left-right asymmetry

In other words, simply excising the sagging skin without addressing the compensatory movement of the eyebrows that has persisted for decades

is very likely to create a fierce impression and an unnatural, operated-on look.

It is big.

The Core of This Case

The "eye-opening force" must be distributed from above.

A common aging pattern in 65-year-old men

is a structure where one opens the eyes using the forehead instead of the eyes.

Therefore, the solution required

correcting the position of the forehead and eyebrows,

and structurally organizing the sagging around the eyes.

Both of these were needed simultaneously.

Final Surgical Plan and Rationale

1. Endotine Endoscopic Forehead Lift

Relief of compensatory eyebrow movement -> Correction of eye-opening habits

Anatomically stabilizing the eyebrow position

Reducing the risk of upper eyelid bulging, as well as glabella and nasal bridge wrinkles

2. Sub-Brow Lift (Replacing/Complementing SB)

Accurately excising only the sagging skin -> Most natural results

A method particularly well-suited for men

Designed to minimize visible scarring

When combined with a forehead lift, enables sophisticated refinement of the upper face

3. Thin Non-Incisional (Buried) Double Eyelid Design

Prominent double eyelids appear unnatural on men

Selecting a thin, stable line that still looks good after a forehead lift

4. Lower Blepharoplasty + Midface Lift

Simple fat repositioning has limitations

Lifting the sagging midface together

Improving the tear troughs

Strengthening lower eyelid support

Helping to relieve tearing in the left eye

Conclusion

A typical 65-year-old case where the forehead, eyes, and midface are interconnected

Left eye tearing

Under-eye puffiness

Drooping eyelids

Overuse of the forehead muscles

Wrinkles between the eyebrows and on the bridge of the nose

Because all these causes were connected as a single progression of aging,

Forehead lift + sub-brow lift + lower blepharoplasty + midface lift + thin double eyelids

was the most harmonious approach.

Reflections by Facial Designer Dr. Kim Seong-hoon

“The goal of eye surgery for men in their 60s is not to look ‘young.’

The key is to look less tired, masculine, and natural.

As in this case, the answer often cannot be found by looking at just one area.

Only when the forehead, eyes, and midface are viewed as a single structure

and both function and appearance are designed together will the results last long.”

FAQ

Q1. Do men also need a forehead lift?

Yes. If there is forehead overuse and eyelid sagging, it is rather effective.

Q2. Can watery eyes also improve with surgery?

If the cause is structural (lower eyelid sagging), it helps improve the condition.

Q3. Is double eyelid surgery mandatory for men?

It is not mandatory, and even when necessary, it is designed to be very thin.

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SH Plastic Surgery Clinic