Key Points

•The eye and periocular structures are central to the perception of facial beauty.

•Symmetry, averageness, and feature size are core concepts in facial beauty.

•Features should be evaluated in the context of patient age, ethnicity, and gender.

•Preoperative asymmetries should be photo-documented and discussed.

•A knowledge of what is perceived as beautiful is essential for surgical success.

3.1Introduction

The eye and periocular area are not only central features of the face, but house the organ responsible for sight. As such, the eye and adjacent area are instinctively perceived as an essential feature of facial beauty. Characteristic changes in the periocular area with age signal the onset of puberty to senescence. For this reason, we all intuitively look to the eye to assess age, beauty, health, mood, level of consciousness, and intelligence. Fair or not, these judgments are wired into our psyche, and patients often wish to modify appearance to alter perception. A study of what is perceived as “beautiful” in the periocular area will help the surgeon to appropriately guide patients and assess whether their goals are realistic.

When addressing perception of the periocular region, there are several core concepts that form a foundation for beauty. These general characteristics span the borders of age, race, and ethnicity, and include facial symmetry, averageness, and feature size. While not overtly apparent to the unschooled observer, these characteristics are instinctively

J.B. Holds (*)

Clinical Professor, Departments of Ophthalmology

and Otolaryngology Head and Neck Surgery St. Louis University School of Medicine, Director, Ophthalmic Plastic and Cosmetic Surgery, Inc., Des Peres, MO, USA

e-mail: jholds@sbcglobal.net

perceived and provide an important background for one’s perception of individual features.

The presence of symmetry is one key to facial beauty. The periocular region often displays marked asymmetry, particularly in the areas of the brow, eyelid margin, eyelid skin fold, globe prominence, and cheek projection [1]. In a study of facial symmetry by Rhodes et al. [2], the photos of digitalized mirror-image faces were found to be more attractive than the unaltered asymmetric ones. The degree of asymmetry was found to inversely correlate with perceived attractiveness.

The importance of symmetry to the oculofacial surgeon cannot be overstated. All patients have a degree of facial asymmetry; however, many lack awareness of it. It is the surgeon’s responsibility to photo-document these asymmetries preoperatively, and to thoroughly discuss with the patient their impact on the surgical plan and projected outcome. It should be stressed that a certain degree of asymmetry will persist postoperatively. These issues must always be discussed preoperatively and the patient must acknowledge the surgeon’s concerns regarding asymmetry and the ability of surgery to address it. A failure to resolve these issues preoperatively is a common cause of postoperative patient unhappiness.

The concept of “averageness” holds that the average facial features of a particular population form the ideal [3]. This theory was evaluated by Langlois and Roggman [4], who compared the photos of individuals to the composite images of the group. Their results showed that the composites were rated as more attractive. Similarly, the Virtual Miss Germany project, performed at the University of Regensburg, morphed the faces of 22 Miss Germany finalists into one digital composite face. When compared to the face of the actual winner and all other contestants, the composite Virtual Miss Germany was selected as more attractive by all examiners.

Finally, feature size is another general characteristic that plays a role in the perception of what is beautiful. There are some anatomical features that in deviating from the mean, tend to enhance beauty [5]. The size of these “desirable” features deviates from the concept of averageness. Examples

of this concept in the periocular area include increased eye width, malar prominence, and orbit size, all of which are typically perceived as more attractive.

3.2Specific Anatomic Subunits

Skin is not only the largest organ in the body, but often the first indicator of health and beauty when observing a face. The presence of good skin tone and clarity can change the perception of an average face to an exceptional one. Skin should be uniform and smooth, without fine wrinkles or deeper rhytids. Ideally, it is free of blemishes, with no dyschromias or abrupt changes in quality, texture, or contour (Fig. 3.1).

The upper eyelids display a gently curved marginal contour, with a more acute angle medially, and a peak height displaced towards the lateral limbus. Along with the lower eyelid margin, this achieves a desirable almond shaped configuration of the palpebral fissure (Fig. 3.2). Centrally, the upper eyelid margin falls just below the limbus, with no superior scleral show [6]. The upper eyelid should have a healthy, full appearance with neither significant fat pad protrusion, nor superior sulcus hollowing (Fig. 3.3). The lashes should be long and thick, with a gentle outward curve

A well defined eyelid crease is located approximately 10 mm above the lash line, with notable variation based on sex and ethnicity. There should be a platform of visible, well fixated pretarsal skin inferior to the crease which on average measures 3–6 mm (Fig. 3.4). The eyelid crease tends to be slightly lower in males, and is often markedly lower or absent in many Asians. While beyond the scope of this chapter, a thorough discussion of patient expectations and desires pertaining to eyelid crease and skin fold configuration must be held preoperatively. This is especially true with the Asian blepharoplasty patient.

The contour of the lower eyelid follows a gentle downward curve from lateral to medial, with the central margin at the level of the limbus and no inferior scleral show. Laterally, the insertion of the lower eyelid forms a lateral canthal angle that is slightly higher than the medial canthal angle (Fig. 3.5). The lateral canthal angle is fixated laterally, appropriately acute,

Fig. 3.2 Frontal view of the same woman as Fig. 3.1. The upper eyelid displays a regular curved marginal contour, with (A) an eyelid peak tending towards the lateral limbus and (B) a more acute angle nasally. (Photo courtesy Guy G. Massry, MD)

Fig. 3.1 Oblique view of the right brow and eyelids of a woman in her mid-30s. Note the smooth skin without obvious rhytids or dyschromia. There is uniform texture, quality, and contour of the skin from the brow to the lids to the midface. (Photo courtesy Guy G. Massry, MD)

Fig. 3.3 Frontal view of another woman. (A) Superior lid margin falls just below the upper limbus without sclera show. (B) There is neither fat protrusion or sulcus hollowing. (Photos courtesy Guy G. Massry, MD)

Fig. 3.5 (A) The lateral canthal angle is slightly higher than the medial canthal angle. (B) The central margin of the lower lid is at the level of the limbus with no inferior scleral show. (Photos courtesy Guy G. Massry, MD)

and sharply defined. The eyelid skin is tight with a smooth transition from thin eyelid skin to thicker cheek skin inferiorly. A subtle roll of plump pretarsal orbicularis muscle just inferior to the lashes provides a youthful look [7].

It is difficult to describe the lower eyelid without consideration of the midface. There should be a gradual

transition of contour from eyelid to cheek (Fig. 3.6) without the double convexity that may arise from bulging fat pads and tear trough deformity (Fig. 3.7). High, prominent cheeks with a youthful fullness are aesthetically desirable.

Like the cheek, the eyebrow helps frame the eye, and is integral to its beauty. The head of the eyebrow should be positioned at the superomedial orbital rim, in a vertical line with the medial canthus and nasal ala. Its head and tail should be aligned horizontally. In the female the brow arcs gently upwards over the orbital rim, with the maximal arch in line with an imaginary line between the nasal ala and the lateral limbus. The tail of the brow should terminate in a similar line drawn between the nasal ala and the lateral canthus [7] (Fig. 3.8). In the male, the brow is flatter, of thicker hair, lies at the superior orbital rim, with a lower positioned tail. An attractive eyebrow has a gradual transition from thicker subbrow skin to thinner upper eyelid skin, and lacks prominent glabellar furrows or “frown lines.”

The forehead is intimately associated with the eyebrow, and has a width approximately twice its height [8] (eyebrow to hairline – Fig. 3.8). There should be a normal hair line superiorly, with the forehead well fixated without contributing to glabellar or eyebrow ptosis. The skin of the forehead and brow is smooth without visible furrows in women. With men,

Fig. 3.7 Compare Fig. 3.6 to this woman. In this patient the lid/cheek junction demonstrates the typical double convexity formed by bulging lower lid fat, a nasojugal groove (tear trough) and descent of the midface. (Photo courtesy Guy G. Massry, MD)

some furrowing of the brow may confer a desirable rugged appearance.

While not visible or easily amenable to cosmetic surgical alteration, the bony orbit provides a foundation that affects the overall perception of beauty. Faces with a larger orbital width in the horizontal axis are perceived to be more attractive [9]. A slightly higher superior vertical height also decreases crowding of the upper eyelids, allowing increased visualization of the lid crease and pretarsal platform. In general, the intercanthal distance should approximate the width of the palpebral fissure (Fig. 3.9).

Fig. 3.8 The ideal female brow begins and ends on as horizontal plane. (A) Medially it is in line with the medial canthus and nasal ala. (B) It peaks in an imaginary line drawn from the nasal ala through the lateral limbus. (C) It end is a similar line from the nasal ala through the lateral canthus. The forehead is twice as wide (2×) as its vertical height (×). (Photos courtesy Guy G. Massry, MD)

3.3Conclusion

There are a number of general characteristics and specific anatomic relationships that affect our perception of attractiveness in the periocular region. While some of these factors are amenable to medical or surgical alteration, others are not.

Fig. 3.9 In the ideal situation, the (A) intercanthal distance is equal to the (B) horizontal palpebral fissure distance. (Photo courtesy Guy G. Massry, MD)