Val Lambros and Steven Fagien
Introduction
Although there is abundant variation in the aging patterns of the billions of human periorbita (eyes) on the planet, there are also commonalities that influence the way the eye region is perceived. An old Asian is as easily recognized as is an old Caucasian and for similar reasons.We have found it more useful to examine the aging face and periorbital region in a linear fashion rather than to look at populations for several reasons. Firstly, population studies are valuable for looking at particular eye regions at a particular point in time, but comparisons are necessarily on different eyes and statistical differences are the usual method of analysis. Tables and charts of measurements are customary in anthropologic studies, but not so in surgery which relics on more direct visual comparisons. Secondly and more importantly, seen at a single point in time, the aging face and periorbital region are frequently deceptive. Because finger elevation may make a part look better, the perfectly reasonable but not necessarily true assumption may be that the part has fallen.
It is also easy to underestimate tissue thinning and deflation because their contribution to an aged appearance are not always immediately obvious, and altering these variables is not in the common surgical repertoire.
For several years we have conducted linear comparisons in individuals by means of highly matched old and recent photographs, which are sized and aligned on stable points. The image pairs are then studied by overlaying the images on the computer and transitioning from one to the other. The eye is very sensitive to motion presented this way, and differences in position and shape are easy to see and compare.
Briefly the technique is as follows: As has become customary during consultations, patients are asked to bring in old photographs of themselves. Friends and relatives are also easy targets because of the availability of old pictures. New pictures are then taken and every effort is made to match the orientation of these old photos. This is the most tedious part of the process as it takes many exposures to get within the several degrees necessary to make the technique valid and it takes some time to sort through them on the computer. Straight anterior-posterior (with the head level in primary position) [APs] are the easiest to match; obliques are more difficult and laterals are the most difficult to match because of the lack of reference points.
If not taken on a digital camera, the old and recent prints are digitized and compared in an imaging program, in this study, Adobe Photoshop. The layers function of Photoshop digitally stacks one image on top of the other and is indispensable in accurately matching multiple images. By toggling the upper image on and off, any offset relative to the lower image is quickly visible. In the antero-posterior view, the alignment and sizing points are the medial canthal tendon's insertion into the nasal side-wall, the interpupillary distance, the base of the columella and other confirmatory points. The two saved images, the old and the recent are then converted into a gif animation using Adobe Image Ready, or other gif animation programs. GIF Construction Set Professional was extensively used in this series. The gif animation automates the process of fading from one aligned and sized image to the other for careful inspection.
As the images are never perfectly aligned, some practice is needed to look at them. If the relative motion is small, within a degree or so, and in an easily understood direction, for example side to side or up and down, the eye compensates for the motion and the images make sense. If there is a combination of motions, then the progression is not as intuitive and there is less gained by studying position changes, though shape comparisons may be-made. Low-contrast tissue borders on the face are more easily appreciated from a distance rather than close-up and hence these images are best studied from a modest distance.
This method of analysis was not intended to be quantitative, though measurements can be taken. Rather it is a method to visually compare changes in size position and shape of structures. A rule of thumb is that the diameter of the iris is approximately lO'A-ll/, mm.
More recently we have used a 3-D camera (Canfield scientific) to acquire the entire surface of the face. These images can then be used to match to other 3-D images or to match against 2-D images. Measurements may be taken in any axis with this kind of system and comparing old and recent 3-D images is the logical future of this kind of research. None of these images are used in this article.
At current count the number of patients in the series is 135. The overwhelming majority of the patients studied were Caucasian and most were of normal (range) weight. Typically a patient in her 50s or 60s brings a photo from her teens or 20s, though intervals of ten to 60 years were obtained. In this series the average time between photos was 24.85 years. Behavioral issues can modify the pictures and the conclusions that may be drawn from them. Smiling pictures are not included in this study as a smile distorts the cheeks and may compress the lower lid. It is very common for people to elevate the brows slightly when being photographed. By and large this does not, in most, significantly affect the position of the upper lids and lower face, though it does affect conclusions that may be drawn about brow position.
We observed in these images several commonly known phenomena and several that were new to us.
It is widely accepted that, under normal conditions, the globe itself does not shrink with time. However one of the common signs of aging is that the eyes appear to become smaller. Although, historically, there has been speculation on why this occurs, we found this visual finding to be related to the actual size of the eyelid aperture, both horizontal and vertical, though we believe that horizontal shortening is perceptually more powerful. In this we are in agreement with other authors. Medialization of the lateral canthal tendon, an extremely common finding, is combined with a frequent, albeit mild degree, of lid ptosis (1—2 mm) to create the illusion of the smaller eye (Figs 2-1 and 2-2). The presence of age-related enophthalmos may also be contributory and would explain by itself many of the findings but cannot be directly observed in this study.
The brow position is difficult to assess, as mentioned, because of the tendency of people to hold their brows up. Because we are unaware of any non-muscular phenomenon that will elevate the brows with time (except possibly a compensatory response for those individuals that develop blepharoptosis), we made the assumption that brow elevation was behavioral in these individuals and these patients were excluded from our brow position analysis. In most patients whose brows remained in the same position, the forehead did not look as if it was contracting, making it difficult to know if brow position was unaltered because of minor frontalis function or because the brow truly did not descend. We suspect the latter, though we cannot prove it to date.
Twenty patients had brow descent. As a clinical aside we would note that the brows do not descend as much as they are elevated with a brow lift (Fig. 2-2).
The area of the superior orbital rim and upper lid commonly lose soft tissue volume. This occurs typically at the medial third of the upper lid and the entire brow extending onto the temple. This finding may be related to the population studied, and is by no means universal but was con¬sistent enough to be remarkable. In many of these patients the changes in subcutaneous volume were accompanied by dermal changes which were sometimes profound (Fig. 2-1). In many patients dermal changes of periorbital skin overwhelm deeper shape changes.
Of great interest is the change in shape of the upper lid arc and consequently the shape of the lid aperture. Again this finding is not universal but is widespread. In the young person, the upper lid arc can have a distinct medial peak, giving the eyelid aperture a characteristic almond shape (with the apex laterally) (Fig. 2-1 A). This is not to be confused with the so-called almond shape of the eyelid seen in Asians (Fig. 2-3). With time the peak of the upper lid moves laterally (Fig. 2-1B), giving the upper lid arc a more elliptical shape and reducing its medial (peak) elevation. Although this phenomenon is most obvious in the age span from childhood to adolescence, one can also trace it over longer periods of time. The upper lid arc shift may be partially responsible for the smaller eye seen in older patients, as it makes the medial scleral triangle smaller. The causes of this finding are probably multifactorial and complex. The levator aponeurosis is known to stretch medially more than laterally with time.8 In addition retrusion of the globe into the orbit (from volume loss and shifts) may also play a part. Certainly the area needs more study.
Figure 2-1 A, 36 years old. B, 54 years old. Careful inspection of these two images reveals that there is minimal ptosis of the brows. The medial upper lid has deflated somewhat. There is an oblique line of moles near the left lower lid-cheek junction which has not changed position. The lid-cheek junction is unchanged. In passing, we note that upper lid surgery would not restore the look of the younger picture.
Figure 2-3 The epicanthal fold imparts an 'almond' shape to the eye. However, the upper lid arc is not almond-shaped but fusiform. The arc of the upper lid margin can change with age.
We somewhat arbitrarily define the lid-cheek junction (LCJ) as the pigmented border of the thin lid skin with the thicker, less pigmented cheek skin at the mid-pupillary line. The most significant finding of this longitudinal study is the positional stability of the lid-cheek junction. In 93 of the 135 patients, the lid-cheek junction could be well seen in both the old and recent photographs. In five of the 93 (5.3%) the lid-cheek junction was seen to descend. This finding was unanticipated, as another of the common visual conceptions of aging is that the lid-cheek junction and the dark circles appear to enlarge with time (Fig. 2-4). What appears to happen is also likely complex whereas the border of the lid-cheek junction remains stable, but the thinning skin allows the underlying musculature to show through and at the same time the enlarging lower lid shadow delineates the border even more. The attenuation of the retaining ligaments combined with subtle loss of regional suborbicularis oculi fat (SOOF) may also add to the deflationary effects. In other words, the lid-cheek junction and the dark circles seem to grow by increasing contrast not by descent. From about the midpupillary line in different subjects
Figure 2-4 A, Taken at the age of 52.
B, Taken at 62. He tilts upward very slightly in the older picture. Within the lower lid some compression of lid landmarks can be seen, common in sun-damaged skin, but the lid-cheek junction remains stable. Visible on both the right and left malar area are crosses made by orbicularis wrinkles. These landmarks stay stable over the time that the face has clinically acquired a great deal of laxity. The skin quality can be seen to deteriorate.
one can see different patterns of soft-tissue borders comprised of pigmentation and thinner skin and malar mounds. These arc not well characterized though often put into the category of 'nasojugal folds.' In fact the findings of positional stability seem to pertain to all pigmented borders around the lower lid and upper midface as well as to the LCJ. In addition moles, wrinkles and other markers on the upper midface and malar region are similarly stable over time, leading one to the conclusion that gravitational soft tissue descent is not a major aging consequence in aging of these areas.
As mentioned, this lower lid and upper midface area is also known to overlie a major distribution of retaining ligaments and the support offered by these ligaments may be more likely to allow for deflationary effects and less for overall geographic tissue motion (descent). The regional dynamic motion, and the limitations due to retaining ligaments, is likely a primary culprit of many of the visual changes of the face including, but not limited to, focal fat loss and shifting, dermal lines and depressions, etc. Attenuation of mobility (i.e. with botulinum toxin) in selected regions, although still speculative at this point, may also in some way influence facial/periorbital aging.
An additional finding which is difficult to see but consistent, is the appearance of the caruncle and its relation to the globe. In many aging patients the caruncle seems to extend onto the medial globe and the medial upper lid seems to go from being tented smoothly over the globe to a 'break point' as the lid indents very slightly inferiorly before contacting the globe. This sign, though subtle, is frequent and is consistent with a number of mechanisms. We tentatively ascribe it to progressive enophthalmos. In addition the superior lacrimal papilla seems to enlarge with age.
Traditional surgery is excellent for removing and redraping skin muscle and fat in the upper lid and brow and establishing definition of soft tissue against bone. A defined upper eyelid and brow has little fat, considerable lid show and provides ample area for make-up. These effects are surgically easy to achieve and results can be dramatic. While many patients and surgeons believe that an extremely defined eye is the most desirable result, definition is not necessarily a desirable change in the aging patient, as young periorbita tend to exhibit fullness and hollow ones are associated with age. In other words, though not immediately visible with surgical swelling, the newness of the look creating more definition sometimes further ages the appearance of the periorbita. Though beyond the scope of this article it appears that there is a paradigm change in what looks acceptable. The same amount of fat in an older eye typically looks worse than the same amount in the young. Many older lids are operated on for what is essentially minimally changed anatomy from youth. And finally why would one 'hollow out' the upper lid of a young person who has a normal amount of fat?
A greater understanding of the true anatomic changes that cause these involutional occurrences of the orbital region has shed light on methods that arc both safer and more aesthetically effective. The best surgical results seem to be those that impart rejuvenation yet are largely undetectable. Un-fortunately many methods impart dramatic changes in facial appearance. A careful observation of the true visual changes of several aspects of facial/periorbital aging has also challenged traditional and current concepts of aging and the varied surgical approaches, and also offers a greater perspective on what direction we should be heading for to achieve the most aesthetic and natural results. However, it is true that many patients have fixed ideas about how they should look after periorbital surgery, and their thoughts should be taken into account in the final treatment plan.
These collective observations are a contradistinction of traditional concepts of periorbital and facial aging; however in many ways they will enhance our understanding of the changes we see and the solutions for reversal. We have said that these are as yet just several notations of an extremely complicated process for which some components are difficult to measure on a short-term photographic basis. Finally, as surgeons we like to think that our methods rejuvenate patients, although the reality is that most (at best) create the illusion of youth. Finally, to this end, we believe that the word 'rejuvenation' is more of a marketing term than truth. It is rare that the cosmetic surgery replaces the true youthful composition and, in many cases, it is best that it doesn't. When people look better than they did, they are commonly perceived as being younger than they arc. We think that the highest goal of cosmetic surgery is to weave a complex illusion that improves the face, without relying on doctrines or fixed principles to do so.
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