Three-dimensional anthropometric analysis of eyelid aging among Chinese women

Gender- and Age-Related Characterization of Lower Eyelid Morphology: Three-Dimensional Analysis in a Chinese Population

BACKGROUND

The lower eyelid region is a critical component of the face. It is essential to establish anthropometric reference values for the evaluation of aging, surgical planning and assessment of outcomes in periocular esthetic and rejuvenation procedures. This study aims to provide comprehensive anthropometric data on the Chinese lower eyelid region, into account factors such as sex and age, through three-dimensional imaging analysis.

METHOD

Three-dimensional facial images were obtained from 84 healthy Chinese individuals aged between 20-35 and 50-65 years, as well as eight patients aged between 20 and 35 who presented with eyelid bags. A total of 27 landmarks were identified, leading to the generation of corresponding 21 lines, 5 curves, 4 angles, 2 areas and 5 ratios. The measurements were compared among different age groups, genders and young patients with or without eyelid bags.

RESULTS

Compared to females, males exhibited a more elongated palpebral fissure, lower tear trough and lid-cheek junction, smaller inner and outer canthus angles, as well as a larger area and proportion of the lower palpebral region. As age progressed, the height and width of the palpebral fissure and inner canthus angle decreased gradually, which was accompanied by sagging of the tear trough and lid-cheek junction, an increase in lower eyelid area and swelling of the lower eyelid. Young patients undergoing eyelid bags demonstrated larger and more swelling lower eyelid which held clinical significance for rejuvenation surgery.

CONCLUSION

Males exhibited a higher proportion of the brow-eye unit occupied by the lower eyelid region compared to females. Elderly individuals displayed noticeable drooping of the tear trough and lid-cheek junction, accompanied by swelling in the lower palpebral region. These findings can serve as standard references for esthetic procedures and reconstructive periocular operations.

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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Upper eyelid morphology and age-related changes in Japanese and Chinese females

BACKGROUND

Many consumers use cosmetic eye products to counteract age-related changes in appearance. Measurements of eyelid shape in Asian women have been reported in the frontal view or 45-degree profile only. The aim of this study was to describe morphological characteristics of the upper eyelid in Japanese and Chinese females from the frontal and profile aspects and examine morphological changes with age.

MATERIALS AND METHODS

Standardized digital photographs of 772 Japanese and 346 Chinese women (15-79 years of age) were acquired in frontal and 90-degree profile aspects. Eleven upper eyelid parameters (e.g., width, length, depth, aperture, and curvature) were measured using image analysis to determine age-related changes and compare by ethnicity.

RESULTS

Eyelid width, area between eyebrow and eyelid, and eyelid curvature were comparable for both ethnicities under age 40, but the aging effect was more pronounced in Chinese subjects. Eyelid height, depth, and upper eyelid aperture angle were also comparable for both ethnicities under age 40, but the aging effect was more evident in Japanese subjects. Upper eyelid incline angle, eye orientation, and upper eyelid protrusion angle changed comparably with age for both ethnicities. No prominent age-related changes were evident for eyelid length or area between eyebrow and eye with the eye closed.

CONCLUSION

Upper eyelid morphology changes with age in Japanese and Chinese females, starting around 40 years of age. Ethnic differences are limited in younger age groups but become more prominent with age. The findings suggest that aging affects some upper eyelid features earlier than others.

Establishment and application of perceived age prediction model for the periocular aging research of Chinese Han women

BACKGROUND

The assessment of skin aging through skin measurements faces limitations, making perceived age evaluation a more valuable and direct tool for assessing skin aging. Given that the aging process markedly affects the appearance of the eye contour, characterizing the eye region could be beneficial for perceived age assessment. This study aimed to analyze age-correlated changes in the eye contour within the Chinese Han female population and to develop, validate, and apply a multiple linear regression model for predicting perceived age.

MATERIALS AND METHODS

A naïve panel of 107 Chinese women assessed the perceived ages of 212 Chinese Han women. Instrumental analysis evaluated periorbital parameters, including palpebral fissure width (PFW), palpebral fissure height (PFH), acclivity of palpebral fissure (AX), angle of inner canthal (AEN), and angle of outer canthal (AEX). These parameters were used to construct a multiple linear regression model for predicting the perceived ages of Chinese Han women. A combined treatment using Fotona 4D and an anti-aging eye cream, formulated with plant extracts, peptides, and antioxidants, was conducted to verify the cream's anti-aging efficacy and safety. This eye cream was then tested in a large-scale clinical trial involving 101 participants. The prediction model was employed in this trial to assess the perceived ages of the women after an 8-week application of the eye cream.

RESULTS

All parameters were observed to decrease with age. An intergroup comparison indicated that eyelid aging in Chinese Han women accelerates beyond the age of 50. Consequently, a linear regression model was constructed and validated, with the perceived age being calculated as 183.159 - 1.078 * AEN - 4.487 * PFW + 6.061 * PFH - 1.003 * AX - 0.328 * AEX. The anti-aging efficacy and safety of the eye cream were confirmed through combined treatment with Fotona 4D, showing improvements in wrinkles, elasticity, and dark circles under the eyes. In a large-scale clinical evaluation using this eye cream, a perceived age prediction model was applied, suggesting that 8 weeks of use made participants appear 2.25 years younger.

CONCLUSION

Our study developed and validated a multiple linear regression model to predict the perceived age of Chinese Han women. This model was successfully utilized in a large-scale clinical evaluation of anti-aging eye cream, revealing that 8 weeks of usage made participants appear 2.25 years younger. This method effectively bridges the gap between clinical research and consumer perceptions, explores the complex factors influencing perceived age, and aims to improve anti-aging formulations.

Protocol Establishment and Reliability Verification of Three-Dimensional Digital Stereophotogrammetry in Lower Eyelid Anthropometry

BACKGROUND

Three-dimensional (3D) stereophotogrammetry has been widely used in anthropometry for both medical and esthetic purposes. However, no studies have assessed its reliability on measuring the lower eyelid by 3D imaging. This study aimed to establish a standardized 3D anthropometric protocol for lower eyelid region and validate its reliability.

METHODS

Fifty-eight participants (116 eyes) were recruited with mean age of 39.14 ± 11.25 years. Two sets of VECTRA 3D images were taken for each subject, and each set of images was individually measured twice by two raters. Twenty-seven landmarks were identified in the lower eyelid region, and then 19 linear, 4 curvilinear, 7 angular and 2 areal metrics were assessed for intrarater, interrater and intramethod reliability.

RESULTS

High reliability was found in this 3D imaging-based lower eyelid anthropometry. The mean absolute difference within 2 intrarater measurement were 0.22 and 0.08 units, the technical errors measurement were 0.31 and 0.15 units, the relative errors of measurement were 0.90% and 0.31%, the relative technical errors of measurement were 1.53% and 0.64%, and the intra-group correlation coefficient was 0.99 and 0.99. The results for interrater measurement were 0.53 units, 0.59 units, 2.94%, 3.41% and 0.96, and for intramethod measurement were 0.71 units, 0.77 units, 4.12%, 4.05% and 0.95 units, respectively.

CONCLUSION

3D stereophotogrammetry is reliable for lower eyelid anthropometry. The standardized protocol can be further applied for many purposes such as lower eyelid aging evaluation, surgical related assessment and periocular rejuvenation plan.

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 .

Facial cosmetic injection: A bibliometric analysis of research status and hotspots

BACKGROUND

The increasing popularity of cosmetic injections using various fillers and neuromodulators for facial rejuvenation has brought both new opportunities and challenges to this field.

AIM

Our study was designed to employ bibliometric and visual analysis for a qualitative and quantitative evaluation of facial cosmetic injections, as well as to identify research trends and hotspots in this field.

METHODS

All publications covering facial cosmetic injection during 2002-2023 were retrieved and extracted from the Web of Science database. The VOSviewer 1.6.18 software and the online tool (http://bibliometric.com/) were applied to analyze the publication trend.

RESULTS

A total of 3797 articles related to facial cosmetic injection were identified during the period 2002-2023. The United States had the largest volume of publications (1520, 40.0%), followed by China (333, 8.8%) and Germany (282, 7.3%). Among the institutions and journals, the University of California system and Plastic and Reconstructive Surgery accounted for the most papers related to facial cosmetic injection, respectively. Facial anatomy and injection techniques, prevention and management of complications, regenerative medicine, efficacy and safety of various soft-tissue fillers, as well as botulinum toxin injections for facial rejuvenation were identified as hotspots for facial cosmetic injections.

CONCLUSIONS

Facial cosmetic injections are showing an increasing trend in terms of both the number of published papers and operations performed. Despite the notable advancements in this field, numerous challenges persist, including safety concerns and the level of research evidence. With the emergence of novel technologies and materials, scholars from diverse countries and institutions should engage in more extensive collaboration, thereby directly expediting the progress of this field.

A Quantitative Three-Dimensional Tear Trough Deformity Assessment and Its Application in Orbital Septum Fat Transposition

BACKGROUND

Existing evaluation tools of tear trough deformity are based on subjective impression of clinicians. More accurate quantitative assessment methods are needed. This study aimed to propose a quantitative three-dimensional assessment method for the tear trough deformity in comparison with the Barton's grading system and apply it to the efficacy evaluation of orbital septum fat transposition.

METHODS

117 healthy Chinese adults (234 eyes) were enrolled and divided into four groups according to the Barton's grading system. Three-dimensional facial images were captured using Vectra H1 handheld camera. 6 anthropometric landmarks were identified on each eye and 8 linear measurements were generated accordingly. Intra-observer reliability was determined and measurements were compared between groups. Pre- and post-operative three-dimensional measurements were compared in 19 patients who received lower blepharoplasty with orbital septum fat transposition.

RESULTS

The severity of tear trough was positively correlated with age (P < 0.001) but not BMI (P = 0.145) or gender (P = 0.280). Intra-rater reliability of the 8 linear measurements was excellent except for the vertical distance between the palpebrale inferioris margin and the tear trough below the pupillary center. Intergroup comparison showed that the horizontal distance between the lateral end of tear trough (P < 0.001) and medial canthus and the sagittal vector from tear trough point toward eyelid bag point (P = 0.009) increased with grade, while the vertical distance from mid-pupil to palpebrale inferioris margin decreased gradually (P = 0.001). Orbital septum fat transposition significantly improved the tear trough deformity as assessed by these three-dimensional measurements.

CONCLUSIONS

We demonstrated a novel quantitative evaluation method of the tear trough deformity using three-dimensional stereophotogrammetry and proved it to be valid and reliable. It showed good value of clinical application and might help with periorbital rejuvenation planning and outcome assessment.

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 .

Individualized High Double Eyelid Fold Correction in Secondary Blepharoplasty: A Free-Style Design

BACKGROUND

High crease correction is difficult to achieve in secondary blepharoplasty. Currently, patients tend to have more precise requirements for crease-lowering procedures, such as low in-fold or low out-fold creases. For the out-fold crease, the height of the central crease is similar with the height of the medial crease, whereas for the in-fold crease, the height of the medial crease is lower than the height of the central crease.

OBJECTIVES

In this study, the authors developed a strategy to create low in-fold or out-fold creases to satisfy patients' individualized requirements.

METHODS

The medical records of patients who received crease-lowering secondary blepharoplasty from January 2015 to January 2021 were reviewed. The results were grouped by preoperative condition (high in-fold/out-fold) and patients' expectations for postoperative outcome (low in-fold/out-fold). Preoperative and postoperative images were collected, and patient satisfaction, complications and revisions were evaluated.

RESULTS

In total, 297 consecutive patients were included in this study with an average follow-up duration of 12.3 months. Eighteen patients had high in-fold creases, and 279 patients had high out-fold creases. Regarding patients with high out-folds, 233 patients wanted to have low out-folds, and 46 patients wanted to have low in-folds. Two hundred and sixty-six (89.6%) patients were satisfied with their results. Complications included complete crease loss (n = 3, 1.0%), partial crease loss (n = 5, 1.7%), multiple creases (n = 6, 2.0%), asymmetric creases (n = 7, 2.4%), and upper eyelid skin laxity (n = 10, 3.4%).

CONCLUSIONS

This flexible, novel technique for customizing low out-fold or in-fold creases is reliable in high double-eyelid crease correction based on preoperative upper eyelid skin tightness, scar positions, and the patient's expected double-eyelid crease shape.

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 .

Long-Term Effects of Extended Upper Blepharoplasty Combined With Subbrow Skin Removal for Correction of Lateral Hooding in Asian Women

Upper eyelid aging with lateral hooding is common among Asian women older than 40 years. Since Asians tend to develop more visible scars than White people, we used an extended upper blepharoplasty technique to correct lateral hooding and conceal the scar, combined with the removal of the thick subbrow skin for women over 60 years of age, to achieve a stable, improved outcome. An extended cutaneous scalpel-shaped excision was designed and hid the extended part of the excision in the patient's upward crow's feet to address the redundant skin of lateral hooding. For patients older than 60 years, we used a crescent-shaped excision and simultaneously removed the thick skin under the eyebrow to reduce the likelihood of long-term postoperative pseudoexcess. A retrospective study was conducted on 40 Asian women who underwent upper eyelid rejuvenation surgery with the above methods from July 2020 to March 2021 (follow-up, 12-15 mo). Extended blepharoplasty notably corrected the lateral hooding and achieved a natural double eyelid. The postoperative scar was inconspicuous. For patients older than 60 years, the long-term rejuvenation outcome was stable when associated with subbrow skin removal. However, two patients older than 60 years in whom the subbrow skin was not removed developed pseudoexcess of the upper eyelid 1 year postoperatively. Extended blepharoplasty is a simple and effective technique for improving periorbital aging in Asian women, and the postoperative scarring was inconspicuous. For patients older than 60 years, we recommend removal of the thick subbrow skin to avoid long-term postoperative pseudoexcess.

Aesthetic Changes of Brow-Eyelid Continuum After Correction of Moderate-Severe Blepharoptosis with Conjoint Fascial Sheath Suspension

BACKGROUND

As periorbital aesthetic commonly improved in blepharoptosis patients after correction surgery, the aim of this study was to elaborate the brow-eyelid continuum changes in moderate-severe ptosis patients who underwent conjoint fascial sheath suspension systematically.

METHODS

Patients with moderate-severe ptosis who underwent conjoint fascial sheath suspension were assessed by using pre- and post-operative digital photographs in the primary gaze position of the eye. The main outcome measurements included marginal reflex distance1 (MRD1), palpebral fissure height (PFH), eyebrow position, the symmetry of face and the horizontal forehead lines condition.

RESULTS

There were 43 patients (53 eyelids) in our study, including 33 unilateral and 10 bilateral patients. The mean levator function was 3.00 ± 1.07 mm. Before surgery, the mean MRD1 and PFH were 0.60 ± 1.14 mm and 6.75 ± 1.71 mm, respectively. The mean eyebrow height at medial, center, lateral position was 33.16 ± 3.95 mm, 35.99 ± 4.02 mm and 34.35 ± 4.80 mm, respectively. It was found that MRD1 and PFH symmetry both were 23.26% and eyebrow symmetry was 62.79%. For forehead wrinkles, 48.84% of the patients was mild, 34.88% was moderate, and 16.28% was severe. The average follow-up was 12.78 months (ranged from 12 to 18 months). One month after surgery, the mean MRD1 and PFH were 5.68 ± 0.86 mm, 11.61 ± 0.97 mm, respectively, both of which improved significantly (P < 0.0001). The mean eyebrow height at medial, center, lateral position descended to 28.22 ± 4.77 mm (P = 0.017), 31.41 ± 4.58 mm (P = 0.033) and 30.28 ± 3.41 mm (P = 0.018), respectively. The result showed that the rate of patients with MRD1 symmetry was 32.56%, PFH symmetry was 30.23%, and eyebrow symmetry was 90.7%. For forehead wrinkles, 69.77% was mild and 30.23% was moderate. Then, patients' eyebrow gradually elevated, while their upper eyelid dropped. At the last follow-up, the mean MRD1 and PFH were 3.83 ± 0.98 mm and 9.84 ± 1.56 mm, respectively. The mean eyebrow height at medial, center, lateral position improved to 30.52 ± 4.59 mm (P = 0.031), 32.40 ± 4.68 mm (P = 0.033), 31.19 ± 4.16 mm (P = 0.028), respectively. The patients with MRD1 symmetry accounted for 86.05%, PFH symmetry 86.05%, and eyebrow symmetry 90.7%. For forehead wrinkles, 67.44% was mild and 32.56% was moderate.

CONCLUSION

CFS suspension can effectively reconstruct moderate-severe ptosis patients' aesthetics of the brow-eyelid continuum by descending elevated eyebrow, improving facial symmetry and reducing forehead rhytids.

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 .

Three-dimensional facial scanner in the hands of patients: validation of a novel application on iPad/iPhone for three-dimensional imaging

Background

Three-dimensional (3D) photography plays an important role in surgical planning and postoperative evaluation. Commercial 3D facial scanners are expensive, and they require patients to come to the clinics for 3D photography. To solve this problem, we developed an iPad/iPhone application to enable patients to capture 3D images of themselves on their own. This study aimed to evaluate the validity and reproducibility of this novel imaging system.

Methods

3D images were taken on 20 volunteers using the novel imaging system. Twenty-one anthropometric parameters were measured using calipers (direct measurement) and 3D photographs (3D photogrammetry). The results were compared to assess the accuracy and bias of 3D photogrammetry. The reproducibility was evaluated by testing intra- and interobserver reliabilities. Furthermore, 3D virtual models obtained by the novel imaging system and Vectra H1 camera were compared by performing heat map analysis.

Results

The 3D photogrammetric results showed excellent correlations with direct measurements. Most anthropometric parameters did not show statistically significant differences between the two methods. The 95% limits of agreement exceeded 2 mm in some parameters, especially those with large numbers, although their relative error measurements were very small. Intra- and interobserver reliabilities were high enough to ensure good reproducibility. The comparison of 3D models obtained by the novel imaging system and Vectra H1 camera showed that the mean distance and the mean RMS were 0.08 and 0.67 mm, respectively.

Conclusions

The novel 3D facial scanning system is validated to enable patients to take 3D images on their own. The imaging quality of the subnasale region needs further improvement. Future clinical applications include surgical planning, postoperative evaluation, and early diagnosis of diseases that affect facial appearance.