Doctor's Column

Sagging around the eyes after one's 50s is not a simple double eyelid issue, but a complex aging phenomenon in which the forehead, eyebrows, eyelids, and under-eye structures sag together. This case involves a 51-year-old female patient with a history of non-incisional (buried suture) double eyelid surgery 15 years ago, who exhibited a typical upper facial sagging structure characterized by a very narrow distance between the eyes and eyebrows, combined with wrinkles extending across the forehead, glabella, and bridge of the nose. Instead of incisional double eyelid surgery, the root causes of the drooping eyes were addressed by combining an Endotine forehead lift with a sub-brow lift, upper canthoplasty (epicanthoplasty), and lower blepharoplasty with a midface lift. This article provides a detailed analysis of how the eye shape and impression changed through preoperative, post-op day 1, and post-op 1-month follow-up stages.

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

"Whenever I try to open my eyes, I keep straining my forehead."

"I used to have double eyelids, but now my eyes seem to look smaller."

These were the very first words spoken in the consultation room by a 51-year-old female patient who had undergone non-incisional double eyelid surgery 15 years ago.

The surgery she had received hoping for clearer eyes ended up covering the eyes over time,

and each time she opened her eyes, tension in the forehead and glabella caused wrinkles to deepen as well.

This case was not merely a double eyelid problem,

but a case that required redesigning the entire "drooping eye structure" interconnected from the forehead to the eyebrows, eyelids, and under-eye area.

Patient Information

Age: 51

History of non-incisional double eyelid surgery in her mid-30s (around age 35)

Chief Concerns

Hooding of the double eyelid line

Dull and tired impression due to sagging eyelids

Coexisting bulging and hollowed under-eye fat

Connected wrinkles extending across the forehead, glabella, and nasal bridge

Desired Goals

Natural and clear eyes rather than "large double eyelids"

Incisional double eyelid surgery that looks thick and heavy is not recommended

Preoperative Photo Analysis – What were the problems?

① Insufficient distance between the eyes and eyebrows

As the eyebrows descended, pressing down on the upper eyelids,

the existing buried double eyelid line was completely covered by skin.

Consequently, the patient naturally used her forehead muscles to open her eyes, leading to fixed, permanent forehead wrinkles.

② Loss of upper facial margin (clearance)

Because the space between the eyes and eyebrows was narrow, performing incisional double eyelid surgery

carried a high risk of creating a heavy, thick, and unnatural appearance.

③ Accompanying structural issues in the lower eye area

Beyond simple fat protrusion, both under-eye bulging and hollowing linked with midface sagging were observed concurrently.

Final Surgical Plan – Why were these procedures necessary?

1. Endotine Forehead Lift + Sub-brow Lift

Addressing the root cause of brows and upper eyelids weighed down by forehead sagging

Structural repositioning so that the forehead muscles are no longer needed to open the eyes

Securing clearance in the upper face → Restoring a natural eye shape

2. Upper Epicanthoplasty (Diagonal Epicanthoplasty)

Gently opening the upper part of the epicanthal fold to enhance an open, refreshed look

Serving as an alternative to epicanthoplasty to create a refreshed look without overcorrection

3. Lower Blepharoplasty + Midface Lift

Overcoming the limitations of simple lower eyelid fat repositioning

Smoothing under-eye bulging + Lifting sagging cheeks

Lower face improvement that naturally blends down to the nasolabial folds

1 Day Post-Op – What surgeries were performed and how did they go?

Eyebrows are stably shifted upward through Endotine fixation

The compressive structure between the forehead, eyebrows, and eyelids is relieved, making the eyes feel much more comfortable

Although bruising and swelling are present, the contour and open look of the eyes are already visible

1 Month Post-Op – What has changed?

Clear and defined eyes without having to open them wide

The heaviness above the eyebrows is gone, creating a natural forehead line

The existing non-incisional double eyelid line is revealed naturally and has settled in

Both the under-eye area and the midface are smoothed out, making the overall impression brighter and more comfortable

Forehead–Eyebrow Line Changes (The Key to Improving Upper Face Structure)

Before surgery

The lower forehead and eyebrows are heavily weighed down overall

The distance between the eyebrows and eyes (eyebrow–upper eyelid space) appears narrow

The weight of the forehead muscles is directly transferred onto the eyelids

→ Resulting in a heavy, frustrated look even when the eyes are open

After surgery

As the lower forehead is repositioned upward

The eyebrow line gently lifts

Space between the eyebrows and eyes is naturally secured

→ A structure where the field of vision opens up without forcing the eyes open

Key Point: Rather than "the eyes got bigger"

It is a state where the weight pressing down on the eyes has been lifted

Space between the eyes and eyebrows is naturally secured

Less effort required when opening eyes, resulting in a more comfortable impression

Softening of forehead, glabella, and nasal bridge wrinkles

Noticeable change in eye openness (Upper canthoplasty + Upper face lifting effect)

Before surgery

Overlapping of Mongolian folds and upper eye skin

An impression of the upper inner corner of the eye being blocked

A structure where epicanthoplasty alone would have limited effects

After surgery

Selectively widening only the upper inner space through upper canthoplasty

Even without excessive canthoplasty

→ Increased pupil exposure

Eyes become clearer and more refreshed

📌 Point:

“No over-slit or torn look ✕”

“A structure where the eyes open easily ◯”

Considerations by Director Kim Sung-hoon

Sagging eyes in one's 50s and beyond is not just an issue of the double eyelids.

It is a structural issue caused simultaneously by a descending forehead, altered eyebrow position, and sagging eyelid skin.

If resolved with incisional double eyelid surgery, this case

was a prime example of where the impression could have ended up looking rather thick and unnatural.

The key was to first secure upper face space through an Endotine forehead lift and sub-brow lift,

and balance the entire eye area by combining lower blepharoplasty with a midface lift below the eyes.

This is a case requiring not just a 'surgery that only looks at the eyes,'

but a 'surgery that redesigns the eye structure.'

FAQ Frequently Asked Questions

Q1. Why is incisional double eyelid surgery not recommended for eye sagging in one's 50s?

A. If there is insufficient space in the upper eye area, it can result in a thick and unnatural appearance.

Q2. In what cases is an Endotine forehead lift suitable?

A. It is effective when the distance between the eyes and eyebrows is narrow and accompanied by forehead wrinkles.

Q3. Must a revision non-incisional (buried) double eyelid surgery be done with an incision?

A. No. Depending on the structure, a sub-brow lift or forehead lift may be more suitable.

Q4. Can lower blepharoplasty alone resolve under-eye issues?

A. If accompanied by midface sagging, there are limitations, so combined surgery is necessary.

Q5. Will my appearance change too drastically after surgery?

A. The goal is a "comfortable and natural look," not simply "looking younger."

Q6. How long is the recovery period?

A. Major swelling takes about 2 to 3 weeks to subside, and natural settling takes about 1 to 3 months.