An understanding of what is considered beautiful can shape our approach to the evaluation and management of patients seeking rejuvenation in this critical area.

References

1.McCurdy JA. Beautiful eyes: characteristics and application to aesthetic surgery. Facial Plast Surg. 2006;22(3):204–14.

2.Rhodes G, Profitt F, Grady JM, et al. Facial symmetry and the perception of beauty. Psychon Bull Rev. 1998;5:659–69.

3.Volpe CR, Ramirez OM. The beautiful eye. Facial Plast Surg Clin North Am. 2005;13:493–504.

4.Langlois JH, Roggman LA. Attractive faces are only average. Psychol Sci. 1990;1:115–21.

5.Baudouin JY, Tiberghian G. Symmetry, averageness, and feature size in facial attractiveness of women. Acta Psychol (Amst). 2004;117(3):313–32.

6.Shorr N, Enzer YR. Considerations in aesthetic eyelid surgery. J Dermatol Surg Oncol. 1992;18(12):1081–9.

7.Wolfert FG, Gee J, Pan D, et al. Nuances of aesthetic blepharoplasty. Ann Plast Surg. 1997;38:257–62.

8.Wolfort FG, Baker T, Kanter WR. Aesthetic goals in blepharoplasty. In: Wolfort FG, Kanter WR, editors. Aesthetic blepharoplasty. Boston: Little Brown; 1995. p. 17–34.

9.Farkas LG. Anthropometry of the head and face. New York: Raven; 1994.

Key Points

•Underlying general medical, ophthalmic, dermatologic, and psychologic pathology may warrant prior attention in the periorbital aesthetic assessment.

•The periorbital face may subdivided into: (1) orbitoskeleton and globe, (2) the forehead and upper eyelid complex, and (3) the lower eyelid and midface complex.

•Orbito-skeletal changes such as midface hypoplasia can contribute to the aging or “tired” face.

•Enophthalmos may abet eyelid ptosis or pseudoptosis and also cause a superior sulcus “hollow” deformity.

•Exophthalmos may produce an undesirable “surprised” appearance and may exacerbate eyelid retraction and ocular surface disease.

•Dynamic rhytids and static rhytids should be identified and contrasted since the treatments vary.

•Brow ptosis independently causes dyscosmesis, but also increases the amount of apparent upper eyelid dermatochalasis.

•Levator function and the eyelid crease are critical in the assessment of the upper eyelid and ptosis. Race and sex variations in the crease should be recognized.

•Eyelid malposition, skin quality, laxity, orbital fat herniation, and cheek descent are important findings. Palpation and digital repositioning are helpful in surgical planning.

•The nasojugal and palpebro-malar grooves may create a midfacial double convexity that may be a key rejuvenation target.

J.P. Tao (*)

Assitant Professor, Director, Oculoplastic Surgery, Department of Ophthalmology, University of California, Irvine, CA, USA

e-mail: j.tao@uci.edu

4.1Introduction

Facial aesthetics and beauty standards vary across society, cultures, and over time. Additionally, physical beauty is highly subjective. Today, media presents a benchmark of beauty, however these are often unrealistic. Yet, the individual contemplating cosmetic surgery may have these ideals in mind. Working with these expectations may be challenging and requires an organized approach [1].

The oculofacial cosmetic patient commonly desires correction for an aging or fatigued appearance. Common complaints include “bags,” “puffiness,” “dark circles,” “wrinkles,” or looking “tired” (Fig. 4.1). Other requests include looking “natural” with particular avoidance of a “surprised” or “overdone” appearance. In general, patients seek to look like themselves, but “refreshed,” “rested,” or “younger.”

In addition to identifying the cosmetic goals, the evaluation includes a thorough medical assessment to establish surgical candidacy. Conditions directly affecting the eyes and periocular structures, in particular, thyroid ophthalmopathy or myasthenia gravis, mandate consideration and treatment prior to considering aesthetic interventions. Additionally, prior facial surgery – cosmetic or otherwise – should be recorded. Ophthalmic disease, such as dry eyes or blepharitis, should be addressed and dermatologic issues such as keloid formation or hyperpigmentation should be identified.

A psychological assessment is also critical. Identifying unrealistic, manipulative, unstable, or even hostile patients is imperative since their response to the results may be unpredictable.

The periorbital surgeon must understand common misconceptions. For example, perfect symmetry is often equated with beauty. However, even ideal, model faces exhibit subtle asymmetry and some of the natural variations may actually correlate with attractiveness. Ultimately, balanced proportions are desirable, but perfect symmetry is generally not possible or preferred [2, 3].

Photo-documentation (preand postoperative) is important. Furthermore, reviewing photographs of the patient at a

younger age may be useful to identify intervention targets (Fig. 4.2). A portable facial mirror is useful to enhance the doctor–patient aesthetic facial dialogue [4].

With patient objectives in mind, the face must be analyzed both as a single unit as well as in components. The periorbital region is particularly important since the eyes are key defining facial features, and eye contact naturally draws attention to this zone. Additionally, the periorbital anatomy and musculature are central in facial expressions, mood, and offer “tell-tale” signs of age or fatigue [5].

Ultimately, the surgeon must connect the exam findings to an array of interventions and surgical procedures. Successful

outcomes can be achieved when the correct approach is combined with good technique. The periorbital face may be considered in the following units: (1) orbitoskeleton and globe, (2) the forehead and upper eyelid complex, and (3) the lower eyelid and midface complex.

4.2Orbito-skeletal and Globe Assessment

The facial bones form the framework and base of attachments for ligaments and muscles that define the face. These deep structures contribute significantly to the external appearance.

Fig. 4.3 Prominent malar eminences and cheekbones are considered youthful and beautiful

The midfacial or “cheek” bones, including the zygoma laterally and the maxilla medially, are of particular importance. A prominent malar eminence is generally considered a sign of beauty and youth, and is seen more commonly in those of Asian and African descent (Fig. 4.3). Increasing age may subtract from this feature.

Morphologic studies have demonstrated that the orbital skeletal subunit remodels over time. With increasing age, the orbit may become progressively longer vertically and the infraorbital rim may resorb [6].

While radiographic imaging is usually not necessary, visual inspection and palpation can help identify a hypoplastic or flat malar zone that can contribute to a tired or aged appearance. Individuals with midface hypoplasia, whether congenital, age-related, traumatic, or post-surgical, may benefit from facial skeletal augmentation, such as onlay implants.

The relationship of the globe to the orbitofacial skeleton is important. Enophthalmos, or a sunken eye, may produce eyelid ptosis or pseudoptosis and also cause a superior sulcus “hollow” deformity – all, which contribute to a tired or aged appearance (Fig. 4.4). Exophthalmos, or a prominent eye, may exacerbate eyelid retraction and produce a “surprised” or a “deer-in-headlights” look (Fig. 4.5). Proptosis also increases the risk of postoperative eyelid malposition [7].

Anterior globe prominence is commonly measured with the Hertel exophthalmometer, which provides the distance in millimeters to the corneal apex, from an imaginary line between the left and right lateral orbital rim, drawn in the coronal plane (Fig. 4.6). Normal readings are 15–17 mm for adults with a range from 12 to 22 mm. This distance tends to vary with race, with African-American having higher readings, due to a shallower orbit when compared with Caucasians or Asians, in general. A difference between the two eyes of greater than 2 mm is considered abnormal and further workup may be necessary.

The results of exophthalmometry can influence surgical planning. For instance, the position of lateral canthal fixation, as in lower eyelid blepharoplasty or midface lifting, must be tailored according to the degree of eye prominence. Also, higher degrees of exophthalmos may require modifications to standard blepharoplasty, such as orbicularis muscle suspension or spacer grafts [8]. Very high proptosis may in fact be an indication for further workup and potentially other procedures, such as orbital decompression (especially if the patient has thyroid-associated ophthalmopathy – see Chap. 26).

An ophthalmic examination and globe assessment are essential. The principal components include visual acuity, extraocular muscle motility, eyelid/external exam, pupil exam, visual field testing, and anterior segment exam.

The eyelids should be assessed for malposition, closure, tumors, and skin disease. Ectropion, entropion, retraction, trichiasis, blepharitis, and meibomian gland dysfunction should be identified and addressed. Lash loss or margin notching may signify malignancy. Eyelid closure and the spontaneous blink dynamics should be documented. Incomplete closure, or lagophthalmos, can cause significant corneal, conjunctival, and ocular surface pathology.

Conjunctival findings may include injection, inflammation, or neoplasms such as pinguecula or squamous neoplasia. Prior glaucoma surgery, especially the presence of a trabeculectomy conjunctival bleb, is important to note since eyelid surgery may compromise the delicate aqueous filtering conduit.

The cornea should be inspected for clarity, the overlying tear film break up time, exposure, keratitis, and sensation. Fluorescein or rose Bengal dye may be helpful in detecting superficial cornea disease or dry eye syndrome, which may be exacerbated with eyelid surgery.

Reflexive eye protective mechanisms should be checked. Some surgeons assess tear production with Schirmer’s testing. The Bell’s phenomenon should be evaluated by digitally elevating the upper eyelid while asking the patient to forcefully close his/her eyes. The normal finding should be an upward eye movement shifting the cornea under the upper eyelid.