Perception of Age, Attractiveness, and Tiredness After Isolated and Combined Facial Subunit Aging

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.

LEVEL OF EVIDENCE: 3

Understanding the Impact of Aging on Attractiveness Using a Machine Learning Model of Facial Age Progression

Background: Advances in machine learning age progression technology offer the unique opportunity to better understand the public's perception on the aging face. Objective: To compare how observers perceive attractiveness and traditional gender traits in faces created with a machine learning model. Methods: Eight surveys were developed, each with 10 sets of photographs that were progressively aged with a machine learning model. Respondents rated attractiveness and masculinity or femininity of each photograph using a sliding scale (range: 0-100). Mean attractiveness scores were calculated and compared between men and women as well as between age groups. Results: A total of 315 respondents (51% men, 49% women) completed the survey. Accuracy of the facial age progression model was 85%. Females were considered significantly less attractive (-10.43, p < 0.01) and less feminine (-7.59, p < 0.01) per decade with the greatest drop over age 40 years. Male attractiveness and masculinity were relatively preserved until age 50 years where attractiveness scores were significantly lower (-5.45, p = 0.39). Conclusions: In this study, observers were found to perceive attractiveness at older ages differently between men and women.

Perceived Age as a Mortality and Comorbidity Predictor: A Systematic Review

INTRODUCTION

Perceived age is defined as how old a person looks to external evaluators. It reflects the underlying biological age, which is a measure based on physical and physiological parameters reflecting a person's aging process more accurately than chronological age. People with a higher biological age have shorter lives compared to those with a lower biological age with the same chronological age. Our review aims to find whether increased perceived age is a risk factor for overall mortality risk or comorbidities.

METHODS

A literature search of three databases was conducted following the PRISMA guidelines for studies analyzing perceived age or isolated facial characteristics of old age and their relationship to mortality risk or comorbidity outcomes. Data on the number of patients, type and characteristics of evaluation methods, evaluator characteristics, mean chronologic age, facial characteristics studied, measured outcomes, and study results were collected.

RESULTS

Out of 977 studies, 15 fulfilled the inclusion criteria. These studies found an increase in mortality risk of 6-51% in older-looking people compared to controls (HR 1.06-1.51, p < 0.05). In addition, perceived age and some facial characteristics of old age were also associated with cardiovascular risk and myocardial infarction, cognitive function, bone mineral density, and chronic obstructive pulmonary disease (COPD).

CONCLUSION

Perceived age promises to be a clinically useful predictor of overall mortality and cardiovascular, pulmonary, cognitive, and osseous comorbidities.

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 .

Smiling makes you look older, even when you wear a mask: the effect of face masks on age perception

The widespread use of face masks in the era of the Covid-19 pandemic has promoted research on their effect on the perception and recognition of faces. There is growing evidence that masks hinder the recognition of identity and expression, as well as the interpretation of speech from facial cues. It is less clear whether and in what manner masks affect the perception of age from facial cues. Recent research has emphasized the role of the upper region of the face, a part not covered by a mask, in the evaluation of age. For example, smile-related wrinkles in the region of the eyes make smiling faces appear older than neutral faces of the same individuals (the aging effect of smiling, AES). In two experiments, we tested the effect of face masks on age evaluations of neutral and smiling faces in a range of different age groups from 20 to 80 years. The results showed that smiling faces were perceived as older than neutral faces even when individuals were wearing a face mask—and there was no effect of masks on bias in age evaluations. Additional analyses showed reduced accuracy in age evaluations for smiling compared to neutral faces and for masked compared to unmasked faces. The results converge on previous studies emphasizing the importance of the upper region of the face in evaluations of age.

Lip Lifting Efficacy of Hyaluronic Acid Filler Injections: A Quantitative Assessment Using 3-Dimensional Photography

The study aimed to compare the volume enhancement and the lifting capacity of two different hyaluronic acid gels for lip injection. Thirty-six Korean female patients were randomized into two groups according to the cross-linking degree of the hyaluronic acid filler injected. Using a fixed injection protocol, patients were injected with 1 mL of hyaluronic acid filler in the lips and followed up at four and 12 weeks after injection. Lip volume, lip projection, and columella–labial angle were measured using a 3-dimensional imaging system at each time point. Follow-up values were compared with baseline. Compared with pre-treatment values, there was a statistically significant increase in mean lip volume and lip projection at four and 12 weeks after injection, with no significant differences between the two groups. Lips injected with hyaluronic acid filler of intermediate cross-link density resulted in more acute angles than lips injected with lightly cross-linked hyaluronic acid. The difference was statistically significant at each follow-up time point. No serious complications were observed throughout the study period. Our results imply that in patients who want a prominent upper lip lift, lip injections using hyaluronic acid fillers with intermediate cross-linking density can be a good option due to their lift capacity. The degree of cross-linking may not be a significant determinant of simple lip volume augmentation when other variables are constant.

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

BACKGROUND

There is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one's perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age.

OBJECTIVES

The authors hypothesized that covering the lower third of the face with a mask will make a person appear younger.

METHODS

One hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients' age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis.

RESULTS

Masked patients on average appeared 6.17% younger (mean difference = 3.16 years, P < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, P = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age (P = 0.0617) and patients BMI > 35 (P = 0.5084).

CONCLUSIONS

The mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.

Three-dimensional measurement and analysis of botulinum toxin A injection for improving the aesthetic appearance of upper lip

This study evaluated the efficacy of botulinum toxin A (BTX A) in improving the aesthetic appearance of lips. Twenty-four outpatients with clinical evidence indicating decreased fullness of lips or gummy smile were selected and received BTX A injection on the orbicularis oris. We observed a significant decrease in wrinkles and improvement in gummy smile in all patients 4 weeks after the injection. Aesthetic lines also changed significantly. Local injection of BTX A on the orbicularis oris could simultaneously achieve mild lip enhancement, improvement in fine wrinkles around lips, and mild gummy smile.

Skin Recovery After Discontinuation of Long-Term Moisturizer Application: A Split-Face Comparison Pilot Study

Introduction

Facial moisturizers are commonly used by healthy women and increasingly men of all age groups. This study aimed to investigate the effects of moisturizer discontinuation and the subsequent evolution of symptoms.

Methods

Two prospective observational split-face comparison pilot studies were performed in Switzerland and enrolled (I) 20 healthy women aged 17–25 years in winter and (II) 36 female subjects 15–20 and 40–55 years of age in summer. Moisturizers were stopped on the investigational half of the face. On the control side, the usual skin care regimen was continued. Daily subjective (I/II) and objective (I) skin assessments for the occurrence of typical symptoms of dry skin (dryness, itching, scales, redness, wrinkles) were collected.

Results

In the winter study (cohort I) in both the subjective and objective assessment, all skin changes increased significantly within 1 day after discontinuation. On day 7, dryness (p < 0.001), itching (p < 0.025), redness (p < 0.001) and scales (p < 0.049) were significantly different in the subjective assessment and redness (p < 0.004) and scales (p < 0.001) in the objective assessment. Skin dryness reverted to baseline levels after 6 days in the objective assessment and 10 days in the subjective assessment. The control side’s condition was reached after 6 days. In the summer study (II), only among the 15–20-year-olds was dryness significantly higher on the intervention side from day 1 (p < 0.028) to day 14 (p < 0.009). Their recovery time was 11 days until dryness intensity scores comparable to baseline were reached, and 21 days until the control side’s values were matched. Over a 7-day period, the overall mean dryness score was significantly different between the interventional and control sides for both young and old participants.

Conclusions

Both healthy young and aging female subjects react with typical symptoms of temporary dryness to a sudden stop of a previous long-term moisturizer treatment but regain normal levels quickly without continuation of moisturizers. The skin recovery time for skin dehydration is 1–3 weeks in young female subjects with varying intensities depending on the season.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00453-0) contains supplementary material, which is available to authorized users.

Improvement in Jowl Fat following ATX-101 Treatment: Results from a Single-Site Study

BACKGROUND

Jowl fat overhang can reduce jawline definition. The most common treatment to reduce jowl fat is liposuction. ATX-101 (deoxycholic acid injection), a minimally invasive treatment approved for submental fat reduction, may also be an effective treatment for jowl fat. The current study evaluated the efficacy and safety of ATX-101 treatment for reducing jowl fat.

METHODS

In this prospective single-site study, 66 adults were treated for excess jowl fat with ATX-101 (area-adjusted dose: 2 mg/cm). Eligible patients had pinchable fat on the jawline and relatively minimal skin laxity in the jowl. Depending on the size of the treatment area, ATX-101 injections of 0.2 ml spaced 1.0 cm apart or 0.1 ml spaced 0.50 to 0.75 cm apart were administered. Improvement in jowl appearance was assessed 6 months or more after the last treatment in person by the clinician. Improvement was also assessed by the patient and two independent plastic surgeons using blinded before/after treatment photographs. Safety was evaluated via adverse events.

RESULTS

The mean number of ATX-101 treatments received was 1.8, with a mean injection volume of 0.8 ml per treatment per jowl. The majority of patients (98 percent) experienced an improvement in jowl appearance. Common adverse events were injection-site edema, numbness, tenderness, and bruising. Injection-site marginal mandibular nerve paresis and alopecia were experienced by three patients each; all events resolved without sequelae.

CONCLUSIONS

ATX-101 effectively reduced jowl fat and was well tolerated in this small cohort. Care should be taken when injecting ATX-101 into jowl fat to avoid underlying anatomic structures such as the marginal mandibular nerve.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Efficacy of dermal redensification in chronoaged face: Quantitative volumetric assessment

BACKGROUND

Mesotherapy for chronoaged skin shows heterogeneous results.

OBJECTIVES

The aim of the study was to assess the efficacy of dermal redensification on the face and neck.

METHODS

Patients with mild-moderate-severe chronoaging of face and neck were included and, every 14 days, treated with four sessions of dermal redensification, consisting of 1 mL of hyaluronic acid (15 mg/mL) plus a dermo-restructuring complex. Skin improvements were analyzed at 8 weeks for amelioration by Wrinkle Severity Rating Scale and quantification of superficial wrinkles and texture by high-resolution 3D camera. All patients underwent a self-assessment questionnaire and Global Aesthetic Improvement Scale.

RESULTS

Thirty-six patients were enrolled (median age 55 [42-67] years). Eight weeks after treatment all patients reported a significant improvement, being Global Aesthetic Improvement Scale ≥2 in 69% of the subjects. Patients' perception of improvement of their skin quality was highly satisfactory in all items explored on the self-assessment questionnaire relating to radiance, elasticity, texture, and smoothness. Subjects with fine and moderate/deep wrinkles had an improvement >25% and 50%, respectively. Quantification of wrinkles with filters for superficial plane (1 mm) showed a statistically significant median decrease, both in width (1.53 [1.41-1.72] mm vs 1.27 [1.12-1.34] P < 0.001) and depth (0.46 [0.27-0.61] vs 0.12 [0.6-0.18] P < 0.001). Indentation decreased by a median of 20%.

CONCLUSIONS

The synergic effects of hyaluronic acid and dermo-restructuring complex show an objective amelioration of skin texture, wrinkles, and self-evaluation of skin appearance.

Assessing Improvement of Patient Satisfaction Following Facelift Surgery Using the FACE-Q Scales: A Prospective and Multicenter Study

INTRODUCTION

Assessment of patient satisfaction following an aesthetic surgery has shown an increasing trend over the past years. To date, there is no prospective and comprehensive study evaluating this aspect after surgical facial and neck rejuvenation. The aim of the current work was to address patient satisfaction after face and neck lift surgery using a validated questionnaire.

PATIENTS AND METHODS

We present a prospective and multicenter study (five regional centers) involving all patients undergoing face and neck lift surgery between April 2015 and April 2017 in several French centers for aesthetic surgery. All subjects assessed the FACE-Q scales before the procedure, and furtherly at 3-month, 6-month and 12-month follow-ups.

RESULTS

Thirty-six patients were included with a median age of 58.5 years old [IQR 54.0-66.0]. The FACE-Q outcomes were significantly higher at 3-month follow-up (p < 0.001). Seventy-five percent of the patients underwent an additional surgical procedure associated with face and neck lift. Particularly, a combined blepharoplasty led to a significant increase in the score of global facial appearance. The patients considered themselves a mean of 6 years younger in the third month after surgery. These results remained constant at six and twelve postoperative months.

CONCLUSION

A statistically significant improvement of the FACE-Q scores could be highlighted on every scale, with permanent results at 6 and 12 months postsurgery. We hereby present the first study with evidence that appearance and quality of life outcomes can be reliably assessed after rhytidectomy.

LEVEL OF EVIDENCE IV

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 .

Types of hairline recession in androgenetic alopecia and perceptions of aging in Asian males

BACKGROUND

Cranial hair loss is one of the characteristics of age. Hairline recession has been confirmed adversely to affect the perceptions of age in Western males. However, comparatively little is known about the effect of frontal recession on the perceived facial age (PFA) of East Asian males. Moreover, specific roles of different types of hairline recession in PFA of different age groups still remain a mystery.

OBJECTIVE

To investigate and quantify the effect of different types of hairline recession on PFA in East Asian young males of different age groups.

METHODS

Thirty non-bald males were selected and divided equally into three groups (20s, 30s, and 40s). With the aid of modern software, the frontoparietal area of facial images from 30 experimenters was modified into three basic types of hair loss (M₂ , C₂ , and U₂ ) according to the basic and specific classification of androgenic alopecia. In a web-based survey, approximately 900 naive participants were asked to estimate the PFA of males from their original and modified facial images.

RESULTS

Perceived facial age increased to 1.58 ± 0.79, 4.19 ± 1.27, and 5.90 ± 1.00 years when the original facial images were modified to have hair loss types M₂ , C₂ , or U₂ , respectively. In addition, the PFA of males with hair loss type C₂ or U₂ appeared significantly older than the original facial images in the 30s group.

CONCLUSION

Different types of hairline recession can increase the PFA to different degrees in East Asian males of different age groups.

Detecting Happiness Using Hyperspectral Imaging Technology

Hyperspectral imaging (HSI) technology can be used to detect human emotions based on the power of material discrimination from their faces. In this paper, HSI is used to remotely sense and distinguish blood chromophores in facial tissues and acquire an evaluation indicator (tissue oxygen saturation, StO₂) using an optical absorption model. This study explored facial analysis while people were showing spontaneous expressions of happiness during social interaction. Happiness, as a psychological emotion, has been shown to be strongly linked to other activities such as physiological reaction and facial expression. Moreover, facial expression as a communicative motor behavior likely arises from musculoskeletal anatomy, neuromuscular activity, and individual personality. This paper quantified the neuromotor movements of tissues surrounding some regions of interest (ROIs) on smiling happily. Next, we selected six regions—the forehead, eye, nose, cheek, mouth, and chin—according to a facial action coding system (FACS). Nineteen segments were subsequently partitioned from the above ROIs. The affective data (StO₂) of 23 young adults were acquired by HSI while the participants expressed emotions (calm or happy), and these were used to compare the significant differences in the variations of StO₂ between the different ROIs through repeated measures analysis of variance. Results demonstrate that happiness causes different distributions in the variations of StO₂ for the above ROIs; these are explained in depth in the article. This study establishes that facial tissue oxygen saturation is a valid and reliable physiological indicator of happiness and merits further research.

Sleep-Related Attentional Bias for Faces Depicting Tiredness in Insomnia: Evidence From an Eye-Tracking Study

STUDY OBJECTIVES

To date, evidence of an attentional bias in insomnia has mostly been obtained through reaction time tasks, with a limited number of studies using eye tracking. Here, using an eye-tracking paradigm, this study sought to determine whether individuals with insomnia display an attentional bias for novel faces depicting tiredness.

METHODS

Individuals with insomnia (n = 20) and normal sleepers (n = 20) viewed a series of face pairs depicting neutral and tired expressions each for periods of 4000 milliseconds. Eye movements were recorded using eye tracking, and first fixation onset, first fixation duration, total fixation duration, and total gaze duration were examined for three interest regions (eyes, nose, mouth).

RESULTS

Significant group × face interactions for total fixation duration and total gaze duration indicated that, regardless of interest-region, participants with insomnia spent more time fixating on and observing tired faces relative to neutral faces when compared with normal sleepers. Additionally, significant group × face × interest-region interactions for total fixation duration and total gaze duration indicated that participants with insomnia spent more time observing the eye region of the tired faces than the eye region of the neutral faces when compared with normal sleepers.

CONCLUSIONS

Individuals with insomnia display an attentional bias toward tired faces, more specifically for the eye region compared to normal sleepers. These findings contribute to our understanding of face perception in insomnia and provide more objective support for cognitive models of insomnia, suggesting that individuals with insomnia selectively attend to faces for tiredness cues.

Sex differences in social cognition: The case of face processing

Several studies have demonstrated that women show a greater interest for social information and empathic attitude than men. This article reviews studies on sex differences in the brain, with particular reference to how males and females process faces and facial expressions, social interactions, pain of others, infant faces, faces in things (pareidolia phenomenon), opposite-sex faces, humans vs. landscapes, incongruent behavior, motor actions, biological motion, erotic pictures, and emotional information. Sex differences in oxytocin-based attachment response and emotional memory are also mentioned. In addition, we investigated how 400 different human faces were evaluated for arousal and valence dimensions by a group of healthy male and female University students. Stimuli were carefully balanced for sensory and perceptual characteristics, age, facial expression, and sex. As a whole, women judged all human faces as more positive and more arousing than men. Furthermore, they showed a preference for the faces of children and the elderly in the arousal evaluation. Regardless of face aesthetics, age, or facial expression, women rated human faces higher than men. The preference for opposite- vs. same-sex faces strongly interacted with facial age. Overall, both women and men exhibited differences in facial processing that could be interpreted in the light of evolutionary psychobiology. © 2016 Wiley Periodicals, Inc.

[Clinical analysis before surgery in facial and neck rejuvenation]

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. A thorough understanding of the anatomy and the natural history of ageing will facilitate the analysis of the face. Not only the degree of ptosis but also the degree of volume loss will need to be assessed, as well as the influence of the facial muscles, the skin quality, and the different causes of rythids. The comprehensive age-related anatomical changes are often perceived and described as tiredness or sadness. Patients very commonly only point out a single anatomical region. During the consultation, the surgeon should provide the patient with the information of the comprehensive interplay of the different anatomical regions and their individual ageing process. Obtaining a harmonious, natural appearing outcome is the result of excellent surgical skills and applied knowledge. The clinical exam should also find out traps and technical difficulties. Although standardized photographs allow a static evaluation of one's result, video may deliver additional information about the postoperative result, and may contribute to the understanding of the technique used. Spending the additional time by performing a thorough facial analysis and preoperative planning is well-invested time. Having a good understanding of the possible surgical improvements and limitations will be beneficial for both, the patient and the surgeon. Managing the expectations of the patient and careful preoperative planning will increase patient's satisfaction. At the same time, the surgeon will able to critically assess his/her own result and taking pleasure improving their own technique.

Preferential attention towards the eye-region amongst individuals with insomnia

People with insomnia often perceive their own facial appearance as more tired compared with the appearance of others. Evidence also highlights the eye-region in projecting tiredness cues to perceivers, and tiredness judgements often rely on preferential attention towards this region. Using a novel eye-tracking paradigm, this study examined: (i) whether individuals with insomnia display preferential attention towards the eye-region, relative to nose and mouth regions, whilst observing faces compared with normal-sleepers; and (ii) whether an attentional bias towards the eye-region amongst individuals with insomnia is self-specific or general in nature. Twenty individuals with DSM-5 Insomnia Disorder and 20 normal-sleepers viewed 48 neutral facial photographs (24 of themselves, 24 of other people) for periods of 4000 ms. Eye movements were recorded using eye-tracking, and first fixation onset, first fixation duration and total gaze duration were examined for three interest-regions (eyes, nose, mouth). Significant group × interest-region interactions indicated that, regardless of the face presented, participants with insomnia were quicker to attend to, and spent more time observing, the eye-region relative to the nose and mouth regions compared with normal-sleepers. However, no group × face × interest-region interactions were established. Thus, whilst individuals with insomnia displayed preferential attention towards the eye-region in general, this effect was not accentuated during self-perception. Insomnia appears to be characterized by a general, rather than self-specific, attentional bias towards the eye-region. These findings contribute to our understanding of face perception in insomnia, and provide tentative support for cognitive models of insomnia demonstrating that individuals with insomnia monitor faces in general, with a specific focus around the eye-region, for cues associated with tiredness.