The Beautiful EyeCharles R. Volpe, MD

a, Oscar M. Ramirez, MDa,b,*

& Facial esthetics as scienceQualitative analysis of facial beautyQuantitative analysis of facial beauty

& Defining the beautiful eyePeriorbital skinUpper eyelidsLower eyelidsPalpebral apertureCanthal tiltIntercanthal distanceScleral showLashes

& Esthetics of the forehead and browForehead

EyebrowsCorrection of the brow versus the lidBrow position

& Esthetic considerations in the Asianpatient

Eyelid estheticsEpicanthal folds

& Periorbital esthetics in the male patientForehead and brow estheticsEyelid estheticsThe tear-trough deformity

& Summary& References

The word esthetic, derived from the Greek aisthe-tikos for ‘‘of sense perception,’’ is defined as respon-sive to or appreciative of what is beautiful orpleasurable to the senses. Esthetic surgeons arealways striving to achieve beautiful results that arepleasurable to the senses. This goal is particularlytrue in the realm of periorbital rejuvenation.According to the 2004 procedural statistics releasedby the American Society of Plastic Surgeons (www.plasticsurgery.org), esthetic blepharoplasty ranked asthe third most performed cosmetic procedure amongwomen and the third most among men in 2004.For patients aged 51 to 64 years, esthetic blepharo-plasty was the most commonly performed proce-dure in 2004. Overall, a 3% rise in the number ofblepharoplasty procedures was noted from 2003 to2004. If the trend continues, greater numbers ofpatients will present to plastic surgeon offices seek-ing periorbital rejuvenation.Successful periorbital rejuvenation should restore

the patient’s inner sense of beauty and youthfulness

and provide an outward appearance that is estheticor pleasurable to the senses. To accomplish thislofty goal, the esthetic surgeon must strive to create‘‘the beautiful eye.’’ This task requires a clear under-standing of facial beauty or esthetics in subjectiveand objective terms. Subjective factors influencingfacial beauty include individual taste, racial andcultural preferences, and current fashion trends.These subjective factors make it difficult to establishan esthetic ideal; however, scientific evidence sug-gests that objective measures of beauty can be usedto develop qualitative and quantitative expressionsof the esthetic ideal.

Facial esthetics as science

Qualitative analysis of facial beauty

The adage that ‘‘beauty is in the eye of thebeholder’’ has been challenged scientifically overthe past 20 years. Research on human beauty has

F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 13 (2005) 493–504

a Esthétique Internationale, 2219 York Road, Suite 100, Timonium, MD 21093, USAb Division of Plastic Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA* Corresponding author. Esthétique Internationale, 2219 York Road, Suite 100, Timonium, MD 21093.E-mail address: oscar@ramirezmd.com (O.M. Ramirez).

1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.06.001facialplastic.theclinics.com

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refuted the traditionally held notions of facialesthetics (ie, the neoclassical canons) developedby the Greeks and popularized by Renaissanceartists and anatomists of the fifteenth and sixteenthcenturies. Investigators have demonstrated that per-ception of the attractiveness or beauty of an indi-vidual face is largely consistent between observers,regardless of their age, sex, or cultural background[1,2]. Specific visual attributes that contribute tothe attractiveness of an individual face includeaverageness, symmetry, and feature size.Langlois and Roggman [3] postulated that facial

beauty equated to an average of facial featuresseen in a population. Their study demonstratedthat composite portraits created with digital imag-ing techniques gained higher attractiveness ratingswhen compared with the individual portraits. Inaddition, the greater the number of components(individual portraits) incorporated into the compo-site, the higher the attractiveness rating. Furtherwork has shown that ‘‘attractiveness benefitedfrom averageness either at an overall level or formany individual features (eg, eyes, nose, mouth,face shape) [4].Rhodes and coworkers [5] evaluated the role that

symmetry has in facial beauty. Normal full- faceimages were compared with composites generatedfrom their mirror images maintaining neutral ex-pressions only. Chimerical symmetrical faces (com-posites) were judged more attractive than theiroriginal (unaltered) images [Figs. 1 and 2]. Thefaces with greatest asymmetry were judged leastattractive. Baudouin and Tiberghien [4] evaluatedthe phenomenon further and found that only ver-tical and horizontal asymmetry of the eye region

and vertical asymmetry of the facial edges affectedperceptions of attractiveness. In other words, theydetermined that eyes that were at equal height in asuperoinferior dimension and equidistant from themidline were judged to be the most attractive alongwith facial halves of equal size.Baudouin and Tiberghien [4] also evaluated how

the size of certain facial features correlates withfacial attractiveness in women. The study hypothe-sized that facial beauty is defined by a combinationof averageness, symmetry, and feature size. In theperiorbital region, eye width as well as cheekboneprominence and height positively correlated withattractiveness, and brow thickness negatively corre-lated with attractiveness. It was concluded thatattractiveness of the female face depends on theaverageness of the majority of the features anddeviation from the average of some local features.In addition, the implications of the deviation de-pend on the feature that deviates and the directionof the deviation. The results support the view that,although an average face is attractive, the mostattractive faces are not average [6]. Those indi-viduals have features that deviate from the normin a positive direction.Contemporary scientific research clearly dis-

counts the notion that beauty is ‘‘a trivial andephemeral quality that should be ignored whenmaking judgments about other individuals’’ [7].From this scientific perspective, facial beauty canbe defined by averageness, symmetry, and featuresize. More significantly, the averageness, symmetry,

Fig. 1. Symmetry of the facial features has a significantrole in the perception of beauty. Note how the asym-metric facial features reduce the attractiveness of anotherwise beautiful face.

Fig. 2. A chimeric image created from the originalimage in Fig. 1 is shown. Using computer software,the right half of the face in Fig. 1 has been duplicatedand reversed to create a mirror image. The twoimages are combined, creating a truly symmetricface. The resulting face (chimera) is more attractivethan the original unaltered image shown in Fig. 1.

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and feature size of the periorbital structures exerta profound influence on perceived ideals of beauty.

Quantitative analysis of facial beauty

Early attempts to define human beauty in mathe-matical terms can be traced back to the ancientEgyptians. The Greek civilization of the fourth andfifth centuries is credited with producing humansculpture that demonstrates proportions that fol-low defined rules or ‘‘canons’’ [8]. During the sameperiod, the concept of the ‘‘divine’’ or ‘‘golden pro-portion’’ was introduced. The golden proportionrefers to a unique mathematical ratio that providesan esthetically pleasing or harmonious relationshipof horizontal and vertical structures that appearthroughout nature. In brief, the golden proportionis the point on a given line at which the ratio of thesmaller to larger proportion is exactly the same asthat of the larger section to the original line [Fig. 3].This golden proportion mathematically equatesto a ratio of 1:1.61803 where the Greek letter phi(Φ) represents the value 1.61803 [9].By analyzing cephalometric data and photo-

graphs of beautiful faces, Ricketts [10] proposedthat the golden proportion, with its unique geo-metric and numerical properties, could be usedto define accurately facial beauty or the estheticideal. Although elegant in description, the scientificmethod was questioned. Critics argued that quan-titative measurements of facial beauty requiredan analysis of the three-dimensional soft-tissuestructures as viewed by the outside world. Thecephalograms and photographs provided purelytwo-dimensional data. In addition, cephalograms

provided dentofacial skeletal information thatfailed to predict adequately the soft-tissue measure-ments necessary to define the esthetic ideal.Perhaps the most credible attempt to provide a

quantitative definition of the esthetic ideal comesfrom the anthropometric work of Farkas. His earlystudies challenged the validity of the neoclassicalcanons that for centuries had been accepted as areference for the esthetic goal. In fact, he discoveredthat the neoclassical canons were absent in ahealthy general population or occurred as one ofmultiple variations [11]. When evaluating the mostattractive faces, most of the neoclassical canons didnot apply [12].Anthropometric analyses were then used to gen-

erate a set of ideal measurements and proportionsto better define attractiveness. Faces judged to beattractive and most attractive were compared withthe established set of normative values of beauty.Surprisingly, statistically significant differenceswere found in three of measured facial proportions[12]. In males, the most attractive faces revealedhighly significant differences in the measurementsand proportions of the nasal region, whereas infemales, highly significant differences were foundin the orbital and labio-oral regions of the mostattractive faces [13]. The findings suggest that aver-ageness, symmetry, and feature size have roles indefining attractiveness or beauty, even as mea-sured anthropometrically.Farkas referred to these facial qualities as har-

mony (averageness and symmetry), disharmony(asymmetry), and disproportion (feature size). Hebelieved that each quality could be measured quan-titatively. Harmony could be determined by thequality or ratio of the relationships between indi-vidual facial measurements. Alterations in theserelationships, especially in sensitive areas of theface (nose, orbits, lips), generated disharmonyand disproportion that reduced the esthetic qualityof the face [12].

Defining the beautiful eye

Successful results in esthetic blepharoplasty can belikened to a world-class chef’s creation of an exqui-site meal. The chef requires a thorough knowledgeof the ingredients needed to create the meal and thegustatory and olfactory interplay of componentingredients. Similarly, the esthetic surgeon requiresthorough knowledge of the periorbital anatomy(ie, the ingredients) and the defining characteris-tics of beautiful eyes (ie, the esthetic interplay ofthose ingredients). The following sections present abreakdown of the components found in the beau-tiful eye.

Fig. 3. A golden section is a line segment divided intwo parts such that the ratio of the short segment(B) to the long segment (C ) is equal to the long seg-ment (C ) to the whole line (A) (or B/C=C/A). Mathe-matically, this ratio equals 1.0/1.61803. Fascinated byits simplicity and esthetic quality, Greek mathemati-cians discovered examples of this ratio existing withinnature, and Greek architects applied this relation-ship to the construction of great buildings such asthe Parthenon.

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Periorbital skin

The periorbital skin should be smooth and free ofcontour defects (eg, rhytids, redundant folds). Theglabellar region should be free of wrinkles. Thereshould be a smooth transition from the lower lid tothe upper cheek. Concavities and convexities in thisarea detract from the overall esthetic presentationand give the appearance of fatigue or dissipation.

Upper eyelids

A depressed crease and hollowing of the upper lidbetween the medial and central compartments havelong been considered classic components of thebeautiful eye [14]. Nevertheless, current teachingssuggest that the beautiful youthful upper lid is ‘‘full,not hollow, with a crisp tarsal upper lid crease andelastic support of the underlying soft tissue, creat-ing a smooth, taut pretarsal and preseptal uppereyelid’’ [Fig. 4] [15]. Shorr and Enzer [16] point outthat the upper eyelid margin when viewed in directgaze should cover the upper 1 to 2 mm of the iris.The medial portion of the upper lid margin shouldbe in a more oblique plane than the lateral upperlid margin, and the upper lid crease should parallelthe lash line and divide the upper lid into an upper

two thirds and a lower one third. The medial exten-sion of the upper lid crease should not exceed theinner extent of the medial canthus, and the lateralextension of the upper lid crease should not extendbeyond the lateral orbital rim [17]. The crisp tarsalupper lid crease should be 8 to 10 mm from the lidmargin, and the visible pretarsal skin should mea-sure from 3 to 6 mm [Fig. 5] [14,18]. The apex(highest vertical point) of the upper lid should becentered over the medial limbus [Fig. 6] [19].In addition to the aforementioned characteristics,

symmetry of the upper lids has a significant role inestablishing beautiful eyes. Symmetry is mentionedlast to stress its importance when designing uppereyelid incisions. Slight asymmetries in upper lidposition are easily perceptible and should be con-sidered unacceptable esthetically.

Lower eyelids

The esthetically pleasing lower lid has a smoothappearance that blends into the upper cheek with-out contour irregularities. The presence of a slightpretarsal subciliary muscle bulge gives the lower lida particularly youthful appeal [20]. The lower lidmargin should bow gently from medial to lateral,with the lowest point located between the pupil

Fig. 4. The esthetically pleasing eye demonstrates afull upper lid that covers the upper 1 to 2 mm of thesuperior limbus as shown.

Fig. 5. The youthful lower lid should demonstrate aslight pretarsal subciliary muscle bulge. Visible pretar-sal skin on the upper lid should measure 3 to 6 mmfrom the lash line cephalad.

Fig. 6. The upper lid apex should be centered over themedial limbus (line A), and the lowest point of thelower lid (line B) should lie at the lateral limbus.(Adapted from Wolfort FG, Baker T, Kanter WR. Aes-thetic goals in blepharoplasty. In: Wolfort FG, KanterWR, editors. Aesthetic blepharoplasty. Boston: LittleBrown; 1995. p. 28; with permission.)

Fig. 7. The intercanthal axis drawn through the medialand lateral canthi should demonstrate an approxi-mate 4 degree upward lateral tilt.

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and the lateral limbus [see Fig. 6] [19]. This gentlecurve of the lower lid has been described as form-ing the shape of a lazy ‘‘S’’ [21].

Palpebral aperture

The palpebral aperture is defined by the free mar-gins of the upper and lower eyelids and the medialand lateral commissures. Despite considerable eth-nic variability, the most pleasing aperture is that ofan asymmetric ellipse or almond shape [21,22].

Canthal tilt

The intercanthal axis is defined as the line gener-ated by connecting the medial and lateral canthi.The intercanthal axis can be measured as a distance(millimeters) or an angle (degrees) as comparedwith the true horizontal plane [Fig. 7]. A positivevalue designates an upward tilt of the lateralcanthus and a negative value a downward tilt. Inwomen, the intercanthal axis averages +4.1 mm or+4 degrees [Fig. 8] [23]. This upward tilt of theintercanthal axis is one of the most distinctive

qualities of the beautiful eye. When one looks atany truly beautiful face, this upward tilt is found tobe present.

Intercanthal distance

The intercanthal distance is ideally one-fifth thefacial width at eye level, one-eighth the verticalheight of the face, and should equal the widthof the eye [24]. Eye width ranges from 25.5 to37.5 mm, and minor asymmetry is normal [25].A vertical line dropped from the medial canthishould approximate the width of the alar lobulesin Caucasians [14].It has been the authors’ observation that mild

orbital hypertelorism can be an attractive quality.The increased intercanthal distance in these womengives the perception that the orbits are larger andmore stunning. This observation tends to correlatewith anthropometric findings of the most attractivefemale faces. Farkas found that eyes judged to bemost attractive typically demonstrated a greatertotal orbital width and occupied a greater propor-tion of the facial width [13].

Scleral show

In most situations, there should be minimal or noscleral show between the lower lid and iris on directgaze. Evidence of scleral show in the absence ofprevious oculoplastic surgery, although suggestiveof Grave’s ophthalmopathy, can be a normal vari-ant. In fact, some scleral show can create a dramaticappearance that some may interpret as attractive.Flowers points out that ‘‘such eyes are engaging incharacter, and their ‘attractiveness’ usually pos-sesses an aura of ‘melancholy’ or ‘sadness’.’’ Never-theless, he warns that the attractiveness ofmelancholic eyes tends to deteriorate with timebecause of attenuation of the canthal tendons andprogressive descensus of lid posture [22].

Lashes

Mascara advertisements found in typical fashionmagazines provide considerable insight into therole that lashes have in eyelid esthetics. Long,dark, full lashes that gently curve away from theglobe impart an overwhelming sense of beauty. Inthe upper and lower lids, the lashes should form anangle no greater than 90 degrees to the vertical axisof the body. Exceeding this limit can lead to lideversion and a visible gray line, both of whichdetract from the esthetic ideal [14].

Esthetics of the forehead and brow

The forehead and brow are inextricably connectedto the orbital region functionally and esthetically.This intimate relationship often fails to be ac-

Fig. 8. The numerical values associated with the esthe-tically pleasing or ideal brow position. The brow tohairline (A) should measure 5 to 6 cm, the brow tosupraorbital rim (B) should measure 1 cm, the browto upper eyelid crease (C ) should measure 1.6 cm, andthe brow to midpupil distance (D) should measure2.5 cm. (Adapted from Matarasso A, Terino EO. Fore-head-brow rhytidoplasty: reassessing the goals. PlastReconstr Surg 1994:93(7);1378–89; with permission.)

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knowledged, leading to incorrect surgical decisionmaking and suboptimal esthetic results. One can-not overemphasize the need for a thorough sys-tematic evaluation of the forehead and browwhen evaluating any patient’s periorbital esthe-tic concerns [see Fig. 8].

Forehead

The forehead forms an elliptically shaped subunitthat averages 114 by 51 mm, or has a width that istwice its height [14]. The forehead has an estheti-cally pleasing quality in women when it is free ofdeep transverse rhytids or expression lines. Thepresence of these lines gives the face an aged, some-times haggard appearance.

Eyebrows

The eyebrows function as an expressive indicator ofa person’s current emotional state. From an estheticstandpoint, the eyebrows bestow a sense of beautyto the face when properly shaped and positioned.Beautifully shaped female brows begin with medialfullness and gradually taper laterally following thecourse of a gentle arc. An esthetically pleasing browposition proves more difficult to define.Traditionally, the ideal brow position has been

described in relation to imaginary lines drawnthrough specific anatomic points [Fig. 9]. Wolfortand coworkers [14] have provided the follow-ing guidelines:

The medial brow, the medial canthus, andthe nasal ala should fall on the same verti-cal plane.

The medial and lateral aspects of the eyebrowshould lie on the same horizontal plane.

The brow peak is optimal when a line is drawnfrom the most lateral point of the alathrough the lateral limbus to the brow.

The lateral limit of the eyebrow should termi-nate on a continuation of a diagonal linedrawn between the lateral canthus of theeye and the lateral ala of the nose.

Alternatively, McKinney and coworkers [26,27]have established numerical guidelines to describethe ideal brow position. In their view, the eyebrowto hairline distance should equal 5 to 6 cm, theeyebrow to eyelid distance should measure 1.6 cm,and the eyebrow to supraorbital rim distanceshould measure 1.0 cm.More recently, Gunter and Antrobus [19] have

defined precise bony anatomic landmarks in rela-tion to the ideal brow position. They provide thefollowing criteria for the esthetic brow:

The ideal position of the medial brow presentsas a continuation of the esthetic dorsal line of

the nose as it curves laterally onto the super-ciliary ridge toward the medial brow.

The medial brow should start above the medialcanthus between the most prominent por-tion of the superciliary ridge and the supra-orbital arch.

The eyebrow should ascend laterally toward thesupraorbital notch, which is located on thesupraorbital arch.

The inferior margin of the brow should crossthe notch and continue upward above thearch to peak somewhere between the laterallimbus and a point just beyond the la-teral canthus.

The (brow) peak should rarely be more than10 mm above a horizontal line off the mostcaudal portion of the medial brow.

In every case, the medial brow should be lowerthan the lateral peak.

Correction of the brow versus the lid

An apparent excess of upper eyelid skin must beapproached with care and forethought. The appear-ance of upper eyelid skin excess is influenced by theposition and volume of the upper lid, the positionof the brow, and the reduction in skin elasticity[28]. Decisions regarding upper lid blepharoplastymust be made in context to accurate positioning ofthe eyebrow. Shorr and Enzer noted that eyebrowelevation can yield up to 5 mm of eyelid elevation[16]. Errors in judgment when upper blepharo-plasty is performed rather than brow-lifting typi-cally transfer the thicker brow skin onto the upper

Fig. 9. The geometric relationships of the estheticallypleasing brow. The medial brow should fall in linewith the medial canthus and the lateral edge of theipsilateral nasal ala (line A–B). The medial and lateralbrow should fall in a true horizontal plane (line B–C ).The apex of the brow should be in located in a verticalplane from the lateral limbus (line D–E ). (Adaptedfrom Gunter JP, Antrobus SD. Aesthetic analysis ofthe eyebrow. Plast Reconstr Surg 1997:99(7);1808–16;with permission.)

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lid, causing further decent to the brow, a decidedlyunacceptable result. These mistakes can be avoidedby simple manual brow positioning when theupper lids are evaluated.Matarasso and Terino have offered a useful set of

visual criteria for evaluating ideal brow position inrelation to the upper eyelid. These criteria includethe following:

The extent of the medial upper lid skin fold inrelation to the nose should not exceed theinner extent of the eyelashes.

The lateral extension of the supratarsal uppereyelid skin fold should not go far beyondthe lateral orbital rim.

The position of the thickened transitional browskin should not rest on the eyelid skin.

If these parameters are noted during examinationof the upper eyelid, it can be expected that the browwill negatively affect proper eyelid balance; there-fore, the brow should be addressed [17].

Brow position

Given the expressive nature of the eyebrows, itbecomes evident that their proper positioning isparamount. Symmetric brows, much like sym-metric lids, improve the esthetic quality of theface. Improperly positioned brows are not onlydifficult to correct but also impart an expressivenature that patients will not appreciate or approveof. Overelevation of the brows conveys a surprisedunintelligent appearance, whereas low medial browpositioning with a high lateral peak imparts anangry appearance [Figs. 10 and 11]. Although

slight asymmetry of the brows is well tolerated,significant brow asymmetry will convey a chronicinquisitive look [Fig. 12].Extreme caution should be exercised when elevat-

ing the brow in patients with deep-set eyes. Elevat-ing the brow in these patients can exaggerate theprominence of the supraorbital rim and unmaskdeep hollowing above the globe, creating a gauntemaciated appearance [19].

Fig. 10. This line drawing depicts the chronic look ofsurprise or astonishment that results when the browsare symmetrically overelevated following browlift.

Fig. 11. This line drawing demonstrates the angryor menacing appearance that results when the tailof the brow is excessively elevated bilaterally follow-ing browlift.

Fig. 12. Although slight brow asymmetry is tolerable,gross asymmetry caused by unilateral overelevation ofthe brow results in a permanent inquisitive appear-ance that is cosmetically unacceptable.

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Esthetic considerations in the Asian patient

Eyelid esthetics

The periorbital esthetics in the Asian populationdiffer considerably from the Western ideal. Ana-tomically, the orbital septum inserts into the leva-tor aponeurosis at a more inferior point in theAsian eyelid. This insertion allows the downwardextent of preaponeurotic fat in the upper lid to begreater. As a result, the lid crease is absent or lowerin Asian individuals [29]. Associated esthetic char-acteristics of the Asian eyelid, as described by Flow-ers [22], can be summarized as follows:

The upward lateral tilt of the Asian eye hasconsiderable ethnic variation, with an exag-gerated canthal tilt seen frequently amongKoreans and others of Mongolian ancestry,whereas the Japanese characteristically have a‘‘pleasant upward intercanthal axis tilt,’’ andthe Chinese frequently demonstrate a trans-verse intercanthal axis or occasionally a slightdownward axis tilt.

The face tolerates the transverse or minimallytilted axis well, but as the axis begins to tiltdownward laterally, the eye assumes a sad-dened or unhappy appearance.

A crisp and precise lid fold is a desirable featurethat is present naturally in the majority ofyouthful Asians.

A fold that displays a generous distance betweenits visualized invagination and the lid marginimparts youthfulness on the eyelid.

From the midpoint of the lid extending laterally,the lid fold should parallel the lid margin.Medially, the lid fold should come closer tothe lid margin (within 2–3 mm).

By closing on the lid margin nasally, the foldimparts to the eye an illusion of a greater medial to

lateral tilt, a most esthetically pleasing characteristic[Fig. 13].

Epicanthal folds

Epicanthal folds are a defining characteristic of theAsian face. As Flowers points out, epicanthal foldsappear sporadically in Caucasians and African-Americans, and occur irregularly among Filipinos,Indonesians, and certain other groups from SouthEast Asia. When excessively prominent, epicanthalfolds can create the illusion of telecanthus and in-ternal strabismus, characteristics that detract fromthe esthetic goals of these patients. Optimally, sur-gical correction should focus on diminishing theprominence of these epicanthal folds. By modifyingthe epicanthus, the eye can be made less round andmore almond shaped [22].By contrast, Chen [30] believes that surgeons

should refrain from correcting epicanthal foldsgiven that Asians tend to have hypertrophic scar-ring in the area of the thick medial canthal skin.Additionally, he points out that a nasally taperedcrease that merges with the epicanthal fold providesan esthetically natural eyelid.

Periorbital esthetics in the male patient

Most, if not all, of the previously described estheticcharacteristics apply to the periorbital region ofthe female visage; however, these principles fail toapply when dealing with the periorbita of malepatients. Men demonstrate esthetic features thatare characteristically distinct from those previouslydescribed for the female periorbital region. Al-though men are more likely than are women toseek eyelid surgery for functional reasons [31], menare becoming increasingly comfortable with thenotion of surgery for purely esthetic reasons. Asevidenced by the statistics presented previously, es-thetic surgery has become increasingly popularamong male patients. Periorbital rejuvenation fol-lowed only rhinoplasty and hair transplantation asthe most commonly performed cosmetic procedureamong men in 2004.Clearly, the esthetic goals of periorbital rejuvena-

tion differ in the male patient. In the authors’practice, male patients frequently seek consultationto free themselves from the fatigued, sad, or angryvisage their aged periorbital region creates. Rarelydo these patients seek restoration of a youth-ful periorbital appearance. In fact, male patientsshould be advised against seeking such an estheticgoal. Creation of youthful lids has a feminizingeffect that will be objectionable to most male pa-tients; therefore, esthetic surgery in the perior-bital region of the male patient should focus

Fig. 13. The esthetically pleasing Asian eyelid. Notethat the upper lid crease tapers medially towardthe medial canthus. In contrast, most Caucasian lidfolds follow a parallel course to the lid margin medi-ally and laterally.

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on maintaining a natural, rugged, and mascu-line appearance.

Forehead and brow esthetics

The average male forehead forms an ellipse thatmeasures 116 mm in width and 57 mm in height,with an inclination of −9.8 degrees [13]. The fore-head has also been described as a spherical subunitwhose radius measures 7 to 8 cm [14]; however,describing an esthetic ideal forehead proves tobe more difficult. Factors such as male-patternbaldness and the presence of expression lines canadd to the male esthetic as much as detract fromit. For example, the deep transverse furrows orcreases created by frontalis muscle function (hyper-activity) can add to the appearance of ruggednessand masculinity in the male patient. The samefindings in a female patient contribute to an agedunattractive appearance.As mentioned in the discussion of the female

esthetic, the brow region also contributes signifi-cantly to periorbital esthetic sensibilities in themale patient. When malpositioned, the brows cangive the chronic appearance of sadness, anger, fa-tigue, surprise, and so on. The properly positionedmale brow is lower than the female eyebrow and istypically at the level of the supraorbital rim [19].Elevation above the supraorbital rim will give themale brow a feminizing quality. In contrast to thefemale eyebrow, the shape of the male brow is lessarched and usually flat or nearly horizontal, andthe lateral brow is more prominent [Fig. 14][32,33]. Straighter, thicker, and lower-set eyebrowsconnote a more rugged and masculine appearance[16]. Nevertheless, as Flowers points out, the browsshould not crowd the eyelids. In the more maturepatient, crowding of the eyelids or obliteration ofthe upper lids by the brow will ‘‘carry an aura oftiredness, dissipation and fatigue’’ [31]. Corrugatorand procerus muscle hyperactivity will also detractfrom the periorbital esthetic ideal. Deep verticaland transverse rhytids in the glabellar region,along with a low position of the medial brows,will contribute to an angry countenance [Fig. 15].Obliteration of the corrugator and procerus muscle

hyperactivity creates a smooth glabellar region thatcontributes to a youthful, rested, and relaxed ap-pearance. Treatment options include temporarycorrection with Botox injections (Allergan, Irvine,California) and the endoscopic brow-lift procedurefor definitive (permanent) correction [Fig. 16].

Fig. 15. Medial brow ptosis and corrugator and pro-cerus muscle hyperactivity contribute to an angryappearance in this 48-year-old man.

Fig. 14. Normal shape and position of the male brow.Note that the brow is at the level of the supraorbitalrim. The brow is relatively flat, and the lateral brow ismore prominent (does not taper).

Fig. 16. An endoscopic forehead (brow-lift) procedurewas performed in the patient shown in Fig. 15. Notethe improved brow position resulting in a morerested, youthful appearance. This patient's signi-ficant alopecia made him an ideal candidate forthe endoscopic procedure. Operative incisions arehardly noticeable.

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Eyelid esthetics

The eyelid esthetics of the male patient parallelthose applied to female patients. The upper lidshould drop in repose to cover 2 to 3 mm of theiris. Minimal scleral show should be present inrelation to the lower lid. The lower lid shouldmaintain a tight posture to the globe such thatthe lid margin does not sag. The supratarsal fold,along with a substantial portion of the pretarsal lidsegment, should be visualized on direct forwardgaze [31]. The supratarsal fold should formapproximately 6 to 8 mm above the lid margin[16]. There should be a slight incline or tilt to theintercanthal axis from medial to lateral, with anaverage value of 2.1 mm (+3 degrees) in men[23]. This slight inclination cannot be overempha-sized, because greater tilt to the intercanthal axiswill give the male eyelids a feminine appearance.In contrast, the upper eyelids will appear more

masculine when kept fuller and slightly moreredundant [19]. Adherence to this principle is par-ticularly important for older male patients. Ag-gressive skin or orbital fat pad resection will leavethe male patient with a feminine emaciated appear-

ance that will be out of balance with the rest ofthe face.

The tear-trough deformity

During the evaluation of the lower eyelids, theinfraorbital rims should be palpated. A deficientor hypoplastic infraorbital rim will predispose thepatient to a ‘‘tear-trough’’ deformity. This deformitycan be visualized as a deep depression at the transi-tion of the lower eyelid and upper cheek. Thedeformity imparts a fatigued appearance to theorbital region [Fig. 16]. This underappreciatedfinding is common in men (and women) and isaccompanied by a marked scleral show beneath theiris that becomes worse with aging. Flowers coinedthe term ‘‘hemiexopthalmos’’ to describe this defor-mity [22,31]. A common misconception is that thedeformity can be corrected with skin resection andinfraorbital fat pad debulking; however, propertreatment requires augmentation of the otherwisedeficient infraorbital rim. If the deficit is related tolack of infraorbital rim support the authors preferto correct the deformity with porous polyethyleneimplants (MEDPOR; Porex Surgical, Newnan, Geor-gia) designed to fit the contour of the infraorbitalrim. These implants can be placed easily through atransconjunctival approach, lateral crow’s foot inci-sion, or an intraoral approach [Figs. 17 and 18].

Fig. 17. This 30-year-old man demonstrates the clas-sic tear-trough deformity in the upper preoperativeview (A). The deformity was treated with a porouspolyethylene (MEDPOR) infraorbital rim implantplaced through a transconjunctival approach. Theresult 6 weeks postoperatively is shown in the lowerframe (B).

Fig. 18. Corresponding three-quarter views of thepatient shown in Fig. 17 (A) preoperatively and(B) postoperatively.

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Summary

The subjective nature of ideal beauty has beenespoused since the time of antiquity. The objectivemeasure of ideal beauty has been sought after sincethe beginning of recorded history. A contemporaryanalysis of facial beauty discounts the notion thatthe esthetic ideal is an individual pursuit. Scientificevidence would seem to reject the validity of theaphorism that ‘‘beauty is in the eye of the be-holder.’’ Psychologists suggest that facial beauty isinfluenced by averageness, symmetry, and featuresize, among other variables. The results of morequantitative anthropometric analyses seem to lendcredible support to these findings.When the surgeon is armed with a general un-

derstanding of beauty or the esthetic ideal, effec-tive cosmetic results can be achieved. Improvedesthetic results in the periorbital region can beaccomplished with a thorough knowledge of thefeatures of the beautiful eye. The information pro-vided in this article, culled from the literature andyears of clinical experience, should allow the readerto develop an improved esthetic sensibility asapplied to the periorbital region. Deviations fromthe ‘‘ideal’’ can be identified properly and ad-dressed appropriately, leading to improved esthe-tic outcomes.

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