Eyebrow ptosis or hooded eyelids, can you tell the difference?

Dr Tim Pearce

January 11, 2024

There has recently been a noticeable trend, particularly amongst celebrities, with individuals seeking a ‘fix’ for hooded eyelids and turning to procedures like Botox®, botulinum toxin or cosmetic surgery. Aesthetic clinicians may experience more and more requests for this indication, but addressing hooded eyelids with Botox injections presents a complex process for practitioners with patient selection playing a pivotal role in achieving optimal results. Adding to this challenge, many aesthetic clinicians find it difficult to distinguish between a hooded eyelid or eyelid ptosis, and an eyebrow ptosis. Can you tell the difference?

In this blog, Dr Tim Pearce delves into the essential considerations for effectively diagnosing and treating hooded eyelids, shedding light on the intricacies of the process.

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What are hooded eyelids?

When it comes to treating hooded eyelids, there are two different reasons why your patients might attend your clinic – more on that later – and you must understand how to diagnose the indication before you treat them. If you do not accurately identify these patients, warns Dr Tim, you will do the wrong treatment and make them look worse but also miss a potential opportunity to make them look better. You will see patients who have this problem and have come specifically to see you about this concern, but also patients who do not mention it, even though you spot it; but if you treat them in the wrong way, you are going to make them very sad, tired-looking, and unhappy.

In explaining the manifestation of a hooded eyelid, Dr Tim notes that if the skin from the forehead of the patient has almost one continuous plane, without any folds interrupting it, all the way down to the eyelashes, then you have a potential hooded eyelid. This is most evident if you push down on the eyebrow, and you can see the energy making its way through to the eyelid. The difference in structure should be quite apparent. In most people, if you push down on the eyebrow, there is a divide between the eyelid and the forehead skin which prevents the forehead skin from transmitting energy into the eyelid.

There is also a partial hooded eyelid type where the connections around the eyelid skin are not a complete single surface as previously described, but there is enough energy transmitted from the skin above the eye for it to rest on the eyelashes themselves.

These structures must be correctly identified in the patient, especially before performing a botulinum toxin treatment in the forehead to address lines and wrinkles, but similarly, in patients who are asking you to help lift their eyebrows.

The difference between eyelid ptosis and eyebrow

One of the primary reasons why understanding how to diagnose hooded eyelids is so important is because it can very easily confuse aesthetic clinicians. Dr Tim often sees practitioners who think they have a patient with eyelid ptosis when in fact they have an eyebrow ptosis. This is a crucial learning point because the cause and treatment for eyelid and eyebrow ptosis are completely different.

How the energy from the forehead makes its way into the skin near the eyelashes is down to the structure of the eye in this area.

If a droopy eyelid or eyelid ptosis is manifesting where there is no connection in that energy, it is likely caused by the levator palpebrae muscle being relaxed. However, if the patient has the same symptoms, but it is related to loose skin above the eye, from the forehead muscle shrinking down, you must do something to lift the eyebrow, rather than attempting to treat the levator palpebrae muscle, which is usually achieved by relaxing the orbicularis oculi muscle to give a little lift.

A brow ptosis is not a hooded eyelid, an eyebrow ptosis is a heavy brow. Learn more about what causes brow ptosis and the different types of brow drop.

However, if the patient has ‘the wrong type of skin’, some of that energy can rest on the eye making it look a lot like an eyelid ptosis. This is usually more of an illusion than reality, explains Dr Tim. If you look very closely at the shape and the position of the eyelashes relative to the iris, instead of relative to the forehead, you will see that they are relatively the same, within half a millimetre. It is the bunching of skin above the eyelashes that makes it look like the eyelid is drooping.

Treating patients who complain about hooded eyelids

Let’s consider some different patient scenarios that you may encounter.

Scenario One

A patient attends your clinic asking to look ‘less tired’ and you notice that they have hooded eyelids.

This is quite a common complaint, and sometimes the patient will be more specific and state that they have hooded eyelids and ask what you can do to resolve it. You must assess how much of that hooding is down to the contractility of the orbicularis oculi muscle, the muscle that pulls the eyebrow down which is partially contributing to the position of the hood. If you relax that muscle, using botulinum toxin, you can lift it a little bit; using the eyebrow itself and by relaxing orbicular oculi and perhaps even treating the frontalis, you may be able to create a little lift which can open the eyes slightly.

This type of patient is not particularly risky because they have specifically requested treatment to make them look less tired.

Scenario Two

The very tricky patients are those who have forehead lines and only want those addressed, but who have hooded eyelids. As an aesthetic clinician, you will probably do it at least once, maybe twice, until you never forget and never do it again when you realise that getting rid of forehead lines with a standard dose pattern for botulinum toxin on a patient with hooded eyelids causes them to look even worse.

Typically, you must be very careful using botulinum toxins in any patient with hooded eyelids unless you are specifically trying to lift their eyebrows. Dr Tim warns that he would not be treating such a patient if they only want to rid themselves of forehead lines because so many of them will end up looking tired, and you will have an unhappy patient to console.

How do you manage a patient who attends your clinic specifically to treat forehead lines but who has significantly hooded eyelids?

Dr Tim advises that firstly you get to the bottom of what they are hoping to achieve and why they have come for a consultation, often patients are seeking to feel a specific way, look younger or feel more confident, for example, and home in on a particular area for treatment to achieve that goal. At this point, if you know that treatment would produce a negative result, they will be grateful for your expert advice, and more so if you can offer alternative ideas for improvement.

If the patient maintains that they only want their forehead lines treated and they are not interested in other options, unfortunately, you must think of either another way to treat their forehead lines in isolation or not treat the patient at all. You may consider offering combination treatments, including a very low dose of botulinum toxin to avoid causing a brow drop, alongside solutions to improve skin quality. Such patients require a more complex solution with little tweaks to avoid causing a negative outcome.

Get more insight from Dr Tim:

• Eye anatomy to prevent eyelid ptosis from BOTOX®
• How to identify and fix eyelid ptosis caused by Botox injections

Dr Tim loves to receive questions, comments, and data on clinical practice experiences from his followers. You can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

How to fix hooded eyelids with Botox. Brow ptosis vs hooded eyelid.

Dr Tim says:

“In recent years, a noticeable trend among celebrities involves the pursuit of a ‘hooded eyelid’ fix, achieved through procedures like Botox or surgery. Addressing hooded eyelids with Botox presents a complex process where patient selection plays a pivotal role in achieving optimal results. Adding to the challenge, clinicians often find it difficult to distinguish between a hooded eyelid, eyelid ptosis, and brow ptosis. In this episode, I delve into the essential considerations for effectively diagnosing and treating hooded eyelids, shedding light on the intricacies of the process.”

Watch the full Aesthetics Mastery Show here.

The show has had thousands of views already and has also generated some interesting feedback and queries.

Read the comments and join in the debate on our YouTube channel.

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In the next few weeks, Dr Tim Pearce is going to be launching something amazing that involves an incredible 3D learning experience for injectors, a community of clinicians on the same mission as you to help you achieve your goals, and exclusive online access to him and his team. Be the first to join the movement by joining the priority waiting list.

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