Male Brow Lift and Blepharoplasty.

After reading this article, one should better understand the anatomy of the forehead, brow, and eyelid complexes in the male patient. A thorough history and physical examination allows the facial plastic surgeon to properly select male patients in whom blepharoplasty and brow lift may be indicated. Specific surgical approaches to upper and lower blepharoplasty are discussed in detail. Surgical techniques and indications for each approach to brow lift in men, including direct, midforehead, coronal, pretrichial, endoscopic, temporal, and transblepharoplasty are explicitly outlined.

Horizontal Gaze Assessment: An Extensive Narrative Review.

OBJECTIVE: Bipedalism was a significant milestone in the evolutionary development of Homo sapiens sapiens, influencing neocortical evolution and subsequent behavioral changes. Coordinated visual and sensory inputs are crucial for posture, environmental interaction, and surgical planning, with horizontal gaze being a pivotal parameter. This narrative review aims to explore various geometric measures used to assess horizontal gaze in patients, highlighting their applications in surgical planning. METHODS: A literature review was conducted in indexed databases using Mesh terms like "Cervical Vertebrae" and "Visual Fields" along with keywords such as "horizontal gaze" and "sagittal spine parameters." Among 477 initially identified articles, 41 were selected for inclusion after rigorous filtering. RESULTS: The most recognized method for assessing horizontal gaze is the Chin Brow Vertical Angle (CBVA), initially described in patients with ankylosing spondylitis. Clinical photography is employed as a tool for CBVA calculation, while other measures like McGregor slope and Slope of the Line of Sight have been considered as alternatives to CBVA. Each method presents its unique advantages and limitations. CONCLUSIONS: This review highlights the need for further research into horizontal gaze measurement methods. Developing novel approaches to determine horizontal gaze can significantly enhance surgical planning and, consequently, improve patient outcomes. The ongoing exploration of these geometric measures offers promising prospects for advancing the field and optimizing patient care.

A Biological Approach to Periorbital Aesthetics in Caucasian Females: A Review of the Literature.

The face plays an important role in human interactions, and the periorbital region is particularly important for recognition and attractiveness. There are several studies on the beauty of the periorbital region with a variety of methodologies, but few articles consider the attractiveness factors derived from evolutionary psychology such as symmetry, dimorphism, age and average, neoteny, and facial expression. The aim of this study was to identify periorbital attractiveness criteria in Caucasian females based on experimental studies and to interpret them in the light of studies on biological attractiveness factors. A review of literature was conducted with PubMed, the Cochrane Library Database, and EMBASE. Studies published after March 20, 2022, were analyzed, and no date limit was applied to reference papers. The search strategy was focused on 3 main concepts: attractiveness AND evaluation AND facial feature of periorbital region. A total of 780 articles were identified with this search strategy; 534 were excluded based on title and abstract and another 110 after full text assessment. Eighteen articles were finally included in the analysis. The main factors identified were an ascending intercanthal axis and eyebrow axis, a regular pretarsal plate and a well-defined upper lid crease, no scleral show, and an open eye fissure exposing the upper half of the iris. In our review we were able to identify objective anthropometric characteristics linked to biological attractiveness criteria that may be helpful in preoperative planning and assessment of the periorbital region of patients.

Skin-Only Versus Skin-Plus-Orbicularis Resection Blepharoplasty: An Elaborated Analysis of Early- and Long-Term Effects on Corneal Nerves, Meibomian Glands, Dry Eye Parameters, and Eyebrow Position.

PURPOSE: To evaluate the early- and long-term effects of 2 different blepharoplasty techniques on corneal nerves, meibomian gland morphology, clinical parameters of dry eye disease (DED), and eyebrow position. METHODS: This prospective, interventional study included age-sex-matched blepharoplasty patients who had a skin-only resection (24 eyes of 12 patients; Group-S) or a skin-plus-orbicularis muscle resection (24 eyes of 12 patients; Group-M) procedure. Preoperative and postoperative parameters of in vivo corneal confocal microscopy (IVCCM; corneal nerve fiber density [CNFD], nerve branch density [CNBD], and nerve fiber length), meibomian gland area loss (MGAL), DED (Schirmer I test and noninvasive tear breakup time), and eyebrow heights (lateral [LBH] and central [CBH]) were evaluated and compared between the intervention groups ( ClinicalTrials.gov , NCT05528016). RESULTS: Compared with baseline, the CNBD of Group-S (19.91 ± 7.66 vs. 16.05 ± 7.28 branches/mm 2 , p = 0.049) and CNFD of Group-M (19.52 ± 7.45 vs. 16.80 ± 6.95 fibers/mm 2 , p = 0.028) was significantly decreased at postoperative first week. However, in both groups, IVCCM parameters returned to baseline values at postoperative first month and first year ( p > 0.05). A significant MGAL increase was observed in Group-S (18.47 ± 5.43 vs. 19.94 ± 5.31, p = 0.030) and Group-M (18.86 ± 7.06 vs. 20.12 ± 7.01, p = 0.023) at the postoperative first year, demonstrating meibomian gland atrophy. Only significant changes were observed in Group-M in LBH (16.17 ± 2.45 vs. 16.67 ± 2.28 mm, p = 0.044) and CBH (17.33 ± 2.35 vs. 17.96 ± 2.31 mm, p = 0.004) at postoperative first year. CONCLUSIONS: Blepharoplasty with or without orbicularis resection seems to have similar effects on IVCCM, DED, and MGAL parameters. However, incorporating an orbicularis muscle resection in a blepharoplasty operation could slightly elevate the eyebrow position.

Predicting the eyebrow from the orbit using three-dimensional CT imaging in the application of forensic facial reconstruction and identification.

Eyebrows are the most important facial feature in facial recognition with its shape rated to be more helpful than color or density for facial reconstruction or approximation. However, little extant research has estimated the position and morphological territory of the eyebrow from the orbit. Three-dimensional craniofacial models, produced from CT scans of 180 Koreans autopsied at the National Forensic Service Seoul Institute, were used to conduct metric analyses of subjects (125 males and 55 females) between 19 and 49 (mean 35.1) years. We employed 18 craniofacial landmarks to examine the morphometry of the eyebrow and orbit with 35 pairs of distances per subject measured between landmark and reference planes. Additionally, we used linear regression analyses to predict eyebrow shape from the orbit for every possible combination of variables. The morphology of the orbit has more influence on the position of the superior margin of the eyebrow. In addition, the middle part of the eyebrow was more predictable. The highest point of the eyebrow in female was located more medially than the male. Based on our findings, the equations for estimating the position of the eyebrow from the shape of the orbit is useful information for face reconstruction or approximation.

Brow Position Change and its Potential Risk Factors Following Upper Blepharoplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Eyebrow position affects human facial expression and aesthetic appearance. However, upper-eyelid surgeries may cause brow position changes and affect the function and aesthetics of the eyebrow. The purpose of this review was to assess the influence of upper-eyelid surgeries on brow position and morphology. METHODS: PubMed, Web of Science, Cochrane Library, and EMBASE were searched for clinical trials and observational studies published between 1992 and 2022. The brow height from the center of the pupil is analyzed to show the brow height change. The change in brow morphology is measured by the change in brow height from the lateral palpebral and the medial palpebral. Studies are further divided into subgroups according to different surgical techniques, author locations, and whether to conduct skin excision. RESULTS: Seventeen studies met the inclusion criteria. Nine studies and 13 groups were included in the meta-analysis, indicating that brow height decreased significantly after upper-eyelid surgeries (MD = 1.45, 95% CI [0.87, 2.07], P < 0.0001), and simple blepharoplasty, double-eyelid surgery, and ptosis correction can cause the brow position to drop by 0.67, 2.52, and 2.10 mm, respectively. East Asian authors group had a significant decrease in brow height compared with the non-East Asian authors group (28 groups, p = 0.001). Skin excision during blepharoplasty does not affect brow height. CONCLUSIONS: Brow position changes significantly following upper blepharoplasty according to the decrease in brow-pupil distance. The morphology of the brow showed no significant postoperative change. Different techniques and authors locations may result in different levels of postoperative brow descent. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Male Eyebrow and Eyelid: An Anthropometric Analysis of White Professional Models.

BACKGROUND: Surgical lift of eyebrows is one of the most efficient facial rejuvenation methods. Although the popularity of those procedures seems to be increasing among men, little is known about aesthetically pleasant male eyebrow shape and position. METHODS: Semiautomatic photogrammetric analysis of 300 professional White male models of assumed age (18 to 39 years old) was performed. The assessment was conducted in two sessions, using A.I.D. software. A set of linear, angular, and surface area morphometric parameters of the periorbital region was measured. RESULTS: A total of 600 periorbital regions were quantitatively evaluated. Statistical analysis showed high interrater reliability for all three types of measurements. The mean width of the eyebrow was found to be 47.28 ± 4.55 mm. The male eyebrow was flat and low-located, overlying the orbital rim. The apex was located at the lateral two-thirds of the brow's width. The vertical distance between the eyebrow's peak and the hairline was 51.3 ± 7.15 mm. In addition, averaged body contours were generated using the A.I.D. software, enabling graphic summarization of facial outline and periorbital contours of all analyzed subjects in the form of a single figure. CONCLUSIONS: Based on the aesthetic preferences of several leading modeling agencies, a concept of the ideal eyebrow for White men was created. The collected morphometric data on the periorbital region may guide the surgical rejuvenation attempts of achieving youthful and natural brow contours. It may also aid its reconstruction using hair transplant techniques.

Brow Anatomy and Aesthetics of the Upper Face.

The surgical approach to the brow has changed perhaps more than any other facial esthetic procedure in the past 20 years. Understanding the functional anatomy of the upper face is the best means of maximizing results and minimizing untoward events in this region. The surgical and clinical correlation is addressed in detail in this article. Cadaver and intraoperative photographs are used to illustrate critical points. Armed with the details of this anatomy, the reader will best be able to best individualize surgical treatment.

The Arched Rainbow Brow in Thyroid Eye Disease.

PURPOSE: To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED). METHODS: A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial ( y = ax4 + bx3 + cx2 + dx + e ) was fitted to each eyebrow. RESULTS: Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c , and d . Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b . Age >50 years ( p = 0.009) and the presence of brow fat expansion ( p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow ( p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor ( p = 0.009). CONCLUSIONS: The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

Synchronous facial action binds dynamic facial features.

We asked how dynamic facial features are perceptually grouped. To address this question, we varied the timing of mouth movements relative to eyebrow movements, while measuring the detectability of a small temporal misalignment between a pair of oscillating eyebrows-an eyebrow wave. We found eyebrow wave detection performance was worse for synchronous movements of the eyebrows and mouth. Subsequently, we found this effect was specific to stimuli presented to the right visual field, implicating the involvement of left lateralised visual speech areas. Adaptation has been used as a tool in low-level vision to establish the presence of separable visual channels. Adaptation to moving eyebrows and mouths with various relative timings reduced eyebrow wave detection but only when the adapting mouth and eyebrows moved asynchronously. Inverting the face led to a greater reduction in detection after adaptation particularly for asynchronous facial motion at test. We conclude that synchronous motion binds dynamic facial features whereas asynchronous motion releases them, allowing adaptation to impair eyebrow wave detection.

Aesthetic ONE21 Technique for Injecting IncobotulinumtoxinA into the Forehead: Initial Experience With 86 Patients.

BACKGROUND: Treatment of upper facial lines is a common aesthetic practice; however, there is limited information on systematic tailored approaches for the treatment of forehead wrinkles using botulinum toxin A. OBJECTIVE: To describe the safety and efficacy of the ONE21 technique using incobotulinumtoxinA (INCO) for the treatment of forehead wrinkles. METHODS: Single-center, retrospective study with 86 females presenting a baseline Merz Aesthetic Scale (MAS) score ≥2 for dynamic forehead lines who had been treated with INCO using the ONE21 technique. Assessment was performed by two independent blinded raters using MAS for forehead lines (dynamic and at rest), and eyebrow positioning, based on standardized pictures taken before (baseline) and 4 (±2) weeks after treatment injection. The primary outcome was the percentage of subjects with a MAS improvement ≥2 points for dynamic forehead lines at week 4 (±2). Secondary outcomes were MAS scores for resting forehead lines and for eyebrow positioning. RESULTS: The mean age was 46.2 years, and mean total dose of INCO, 20.3 U. Most (97.7%) subjects had a MAS improvement of ≥2 points for dynamic forehead lines at week 4 (±2); 100% improved ≥1 point. MAS scores for resting and dynamic lines, and eyebrow positioning were significantly improved (P<0.001). Eyebrow positioning MAS improved ≥1 point in 56.9% of subjects, and 39.5% maintained the original shape. CONCLUSION: INCO injection using the ONE21 technique is effective and safe in treating forehead wrinkles, providing a natural result, with a customized treatment and a predictable eyebrow shape. J Drugs Dermatol. 2021;20(1):31-37. doi:10.36849/JDD.5617.

Photogrammetric Analysis of Eyebrow and Eyelid Dimensions in Indian American Adults.

In cosmetic surgery, knowledge of the average dimensions of periorbital features based on gender and ethnicity is essential to improve the patient appearance and maintain the ethnicity. The aim the study was to establish gender-specific periorbital anthropometric and anthroposcopic data for Indian Americans (IA) and to assess the statistically ethnic differences by comparing with published data of Malaysian Indians (MI). Evaluation of periorbital features was done on the standardized frontal photographs of 400 IA, aged 18 to 26 years. The measured values were evaluated by an independent t-test. Sexual dimorphism was found in all 15 measurements. The eyebrow height, combined height of the orbit and eyebrow, eyebrow apex inclination, apex to lateral canthus distance, medial end of brow to medial canthus distance, lateral end of brow to lateral canthus distance; pretarsal skin height, palpebral fissure height, palpebral fissure inclination (PFI), and medial canthus tilt were significantly greater in female than the males. In males, eyebrow apex hairline distance, apex to lateral limbus distance, eyebrow apex angle (EAA), lower eyelid height, and interpupillary distance was significantly greater than the females. Significant ethnic difference was found between IA and MI for eyebrow height, apex to lateral limbus distance, EAA, palpebral fissure height, and PFI in male group. In female group, EAA, medial canthus tilt, and PFI were significantly greater in MI. Four types of epicanthus were observed and the brow apex between lateral limbus and lateral canthus was the most common position. The generated normative data may be useful during diagnosis and treatment planning.

Three-Dimensional Territory and Depth of the Corrugator Supercilii: Application to Botulinum Neurotoxin Injection.

This study aimed to determine the three-dimensional (3D) territory and depth of the corrugator supercilii muscle (CSM) using a 3D structured-light scanner. Thirty-two hemifaces from Korean and Thai embalmed cadavers were used in this study, and 35 healthy young Korean subjects also participated. A 3D analysis of the CSM territory and depth was performed using a structured-light 3D scanner. The most frequently observed locations of the CSM identified in the cadaver were confirmed in healthy young subjects using a real-time two-dimensional B-mode ultrasonography system. The CSM was present in all of the cadavers and healthy young subjects at the intersection point between the vertical line passing through the medial canthus and the horizontal line passing through the glabella (Point #6). The CSM was located on the medial side of the lateral limbus in most cases. The most-medial and most-lateral origin points were at depths of 5.7 ± 1.4 mm (mean ± SD) and 6.6 ± 1.4 mm, respectively; the corresponding depths of the insertion points were 5.4 ± 1.4 mm and 5.6 ± 2.1 mm, respectively. The origin and insertion points of the CSM were at similar depths. The injection depth should be around 4 mm for botulinum neurotoxin (BoNT) injections into the CSM. Point #6 could be regarded as an effective target point for managing the glabellar frown line and preventing palpebral ptosis when injecting BoNT into the CSM. Clin. Anat., 33:795-803, 2020. © 2019 Wiley Periodicals, Inc.

Anthropometry Analysis of Beautiful Upper Eyelids in Oriental: New Eyelid Crease Ratio and Clinical Application.

BACKGROUND: Beautiful upper eyelids can make one feel more attractive and confident. However, the definition of a beautiful upper eyelid in Orientals is still not defined. The aim of this study was to define the most beautiful upper eyelids in Orientals. METHODS: Participants, who met the inclusion criteria such as Asian ethnic, ages between 18 and 25 years, and double eyelid fold, were conducted. Double upper eyelids were classified into three groups, group A: most beautiful; group B: average; and group C: less beautiful upper eyelid, by plastic surgeons and beauty contestant winners. Eleven linear measurements and type of epicanthal fold were analyzed. RESULTS: A total of 153 participants were included, 66 were male and 87 were female. The mean ages were 21.45 years in males and 21.41 years in the female group. The vertical distances of the palpebral fissure, height of the double fold, height of the lid crease and height of the closed upper eyelid were found to be significantly different between the most, average and less beautiful upper eyelids in both males and females. The type 1 epicanthal fold was the most common in the most beautiful upper eyelid group. CONCLUSION: The most beautiful double upper eyelids in Orientals demonstrated a higher vertical palpebral fissure, double eyelid fold, and height of eyelid crease than the average and the less beautiful double upper eyelids. The ratio of height of lower margin of eyebrow to eyelid crease: Height of eyelid crease is 1.2:1 to create the beautiful double upper eyelids. However, preoperative consultation with realistic expectations is important. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reliability of periocular anthropometry using three-dimensional digital stereophotogrammetry.

PURPOSE: Non-invasive three-dimensional (3D) stereophotogrammetry is becoming increasingly popular in many fields. However, few studies have focused on its periocular application. We aimed to provide evidence for the periocular application of a novel anthropometric procedure using 3D stereophotogrammetry by evaluating its reliability. METHODS: Fifty-one Caucasians were recruited (102 eyes; mean age, 31.9 ± 13.6 years). Two sets of 3D images were acquired for each subject, and two measurement sessions were performed on each image by two raters. Fifty-two periocular landmarks were identified, and then 49 corresponding linear, curvilinear, and angular measurements were evaluated for intrarater, interrater, and intramethod reliability. RESULTS: Our findings showed highly reliable results for mean absolute difference (0.59 and 0.68 unit), relative error measurement (2.66% and 3.08%), technical error of measurement (0.59 and 0.66 unit), relative technical error of measurement (2.71% and 2.96%), and intraclass correlation coefficient (0.98) for intrarater 1 and intrarater 2 reliability; respectively 0.94 unit, 4.06%, 0.89 unit, and 3.94%, as well as 0.97 for interrater reliability; and respectively 0.98 unit, 4.66%, 0.96 unit, and 4.64%, as well as 0.96 for intramethod reliability. CONCLUSIONS: This imaging system and the landmark identification protocol are highly reliable. The collected measurements and their errors can be applied for the comparison of reliability among various 3D imaging systems and populations. It could be utilized for planning surgeries and evaluating treatment outcomes for physicians in ophthalmology, plastic and esthetic surgery, and in the maxillofacial field where periocular morphology alterations are made.

Exploring Brow Position Changes with Age in Koreans.

PURPOSE: Several studies have described age-associated brow drooping in Westerners. However, there are few studies that address brow drooping in the Asian population, and especially in the Korean population. Therefore, we studied brow position changes with age in Korean individuals. METHODS: A total of 300 adults older than 18 years were enrolled. The ImageJ program was used to analyze digital photos of the patients by measuring the following parameters: marginal reflex distance-1, brow-to-pupil distance, nasal ala-lateral brow distance, lateral brow plumb line, and the angle formed by the line from the mid pupil to the midline of the brow and a line from the midline of the brow to the lateral brow. We divided the patients into three groups (18 to 40, 41 to 60, older than 61) and compared them using the ANOVA test. RESULTS: Group A included 100 patients between 18 and 40 years of age. Group B included 100 patients between 41 and 60 years of age. Group C included 100 patients older than 61 years. There were significant differences between groups A and C and between groups B and C with regard to marginal reflex distance-1, brow-to-pupil distance and the angle. Lateral brow plumb line showed significant difference only between groups A and B. Nasal ala-lateral brow distance was not significantly different across the three groups. CONCLUSIONS: We sought to describe the physiologic facial changes that occur in Korean individuals. We also hoped to establish guidelines for ptosis corrective surgery. We used various parameters to characterize the aging process in Asians. Our data demonstrated that, like Westerners, Koreans experience lateral brow drooping with age; however, this change was only significant in the group aged >61 years.