ORIGINAL http://dx.doi.org/10.14730/aaps.2014.20.1.20 aaps Arch Aesthetic Plast Surg 2014;20(1):20-25 Archives of ARTICLE pISSN: 2234-0831 Aesthetic Plastic Surgery The Relationship Between Eyebrow Elevation and Height of the Palpebral Fissure: Should Postoperative Brow Descent be Taken into Consideration When Determining the Amount of Blepharoptosis Correction? Edward Ilho Lee1, Nam Ho Kim2, Background Combining blepharoptosis correction with double eyelid blepharoplasty Ro Hyuk Park2, Jong Beum Park2, is common in East Asian countries where larger eyes are viewed as attractive. This Tae Joo Ahn2 trend has made understanding the relationship between brow position and height of the palpebral fissure all the more important in understanding post-operative re- 1 Division of Plastic Surgery, Baylor sults. In this study, authors attempt to quantify this relationship in order to assess College of Medicine, Houston, TX, USA; whether the expected postoperative brow descent should be taken into consider- 2Gyalumhan Plastic Surgery, Seoul, Korea ation when determining the amount of ptosis to correct. Methods Photographs of ten healthy female study participants were taken with brow at rest, with light elevation and with forceful elevation. These photographs were then viewed at 2×magnification on a computer monitor and caliper was used to measure the amount of pull on the eyebrow in relation to the actual increase in vertical fissure of the eye. Results There was a positive, linear correlation between amount of eyebrow eleva- tion and height of the palpebral fissure, which was statistically significant. Brow ele- vation increased vertical fissure, and thereby aperture of the eye, by 18%. Conclusions Although the eye-opening strength as well as height of the palpebral fis- sure is improved with ptosis repair, the true effectiveness of ptosis surgery is dimin- ished by the associated descent of the brow from relief of the involuntary frontalis This article was presented at the 71th Con- muscle action and this should be taken into account prior to surgical intervention. gress of the Korean Society of Plastic and Re- Regardless, the combination of frontalis muscle relaxation and the increased eye- constructive Surgeons (1st Asian blepharo- plasty forum) on November 1-3, 2013 in opening strength from ptosis repair gives the eye and the periorbital region a more Seoul, Korea. natural look. No potential conflict of interest relevant to this article was reported. Keywords Blepharoptosis, Muscles, Face INTRODUCTION The importance of the eye in defining a person’s impression is well Received: Jan 14, 2014 Revised: Feb 15, 2014 Accepted: Feb 17, 2014 Correspondence: Tae Joo Ahn Gyalumhan Plastic Surgery, 21st Mijinplaza, known. In East Asian countries, the desire to look westernized 390 Gangnam-daero, Gangnam-gu, Seoul 135-934, Korea. brought the advent of double eyelid surgery around turn of the E-mail: [email protected] 19th century, with Mikamo publishing the first report of double- Copyright © 2014 The Korean Society for Aesthetic Plastic Surgery. eyelid surgery in Japan [1]. As a specific form of blepharoplasty, This is an Open Access article distributed under the terms of the Creative Commons At- the double-eyelid surgery has evolved over time to adapt to inno- tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any vations in technique as well as changing cultural and social prefer- medium, provided the original work is properly cited. www.e-aaps.org ences. Moreover, it has become increasingly common in East Asian 20 Archives of Lee EI et al. Eyebrow Elevation and Eye Opening aaps Aesthetic Plastic Surgery A B Fig. 1. 30 year old female. (A) pre-operative image shows involuntary elevation of eyebrows at rest; (B) 1 week post-operative image after simultaneous blepharoptosis correction and double eyelid blepharo- plasty with Muller’s muscle tucking through triangular stitch meth- od (2). One can already see the natural descent of eyebrows at rest; (C) 42-day post-operative image shows more rested and natural ap- C pearance around the periorbital region. countries to utilize blepharoptosis repair techniques in conjunc- dition, the extent of this relationship is quantified to assess wheth- tion with double eyelid blepharoplasty for the aesthetic purpose of er the expected postoperative brow descent should be taken into increasing the aperture of the eye, which is viewed as more attrac- account when determining the amount of blepharoptosis to cor- tive in this patient population [2-4]. However, the concept of com- rect. bining these techniques is not new and is used around the world [5-7]. METHODS One important outcome of such combination of procedures is the evidence for the intimate relationship and interplay between Ten healthy female study participants were enrolled after obtain- adjacent perioccular muscles. In cases of weak eyelid elevation, ing written consent. All study participants presented to senior au- frontalis muscle is utilized to augment the poorly functioning le- thor of this paper for evaluation for double eyelid surgery. vator palpebrae [8]. The frontalis muscle not only reduces the First, patient was asked to keep her eyes open and to maintain strain on the upper eyelid to compensate for the ptosis, but also this opening at rest (Fig. 2). Next, a medical assistant was asked to assists in opening of the eye. As such, patients with blepharoptosis elevate patient’s eyelid by applying manual pressure on junction of commonly have elevated eyebrows and, in these patients, there is the eyebrow and forehead at mid-pupillary line with her thumb, gradual resolution of this involuntary brow elevation upon ptosis first with light force, followed by maximum force. Photographs correction. Because of such phenomenon, it is often difficult to were taken at these three points – at rest, with light elevation, and assess the true benefit gained from combination of double eyelid with forceful elevation – with a ruler placed in line with medial blepharoplasty and blepharoptosis repair as it relates to the increase canthus at the medial upper eyelid/eyebrow junction. This was re- in height of the palpebral fissure (Fig. 1). peated twice for each patient for total of 3 cycles per patient (9 photo- In this study, the interaction between these various perioccular graphs). The same assistant was used for all patients. muscles is analyzed to assess whether a relationship exists between Photographs were then viewed at 2× magnification on a com- eyebrow elevation and change in vertical fissure of the eye. In ad- puter monitor and caliper was used to measure the amount of pull 21 Archives of aaps Aesthetic Plastic Surgery VOLUME 20. NUMBER 1. FEBRUARY 2014 A B Fig. 2. Photographs were taken at three points in the cycle. (A) at rest; (B) with light elevation; (C) with forceful elevation. A ruler was placed in line with medial canthus at the medial upper eyelid/eyebrow junc- C tion. A B Fig. 3. (A) Photographs were viewed at 2× magnification on a computer monitor such that the increment in the photograph was twice that of the increment on the ruler placed on top of the monitor; (B) Caliper was then used to measure the amount of pull on the eyebrow in relation to the actual increase in vertical fissure of the eye. on the eyebrow in relation to the actual increase in vertical fissure on top of the monitor. This magnification allowed for more accu- of the eye (Fig. 3). The degree of magnification was such that the rate measurement with the caliper. ruler increment in the photograph was twice that of the ruler placed Data points were tabulated measuring the change in brow and 22 Archives of Lee EI et al. Eyebrow Elevation and Eye Opening aaps Aesthetic Plastic Surgery Table 1. Data points were tabulated measuring the change in brow and eyelid height with each cycle and with each incremental force on the brow (at rest, light force, maximum force). Cycle #1 for Patient #8 was excluded from analysis because the images were out of focus and not amenable to accurate measurement Patient Cycle Force Brow elevation (mm) Eyelid elevation (mm) Patient Cycle Force Brow elevation (mm) Eyelid elevation (mm) 1 1 Rest 0.0 0.0 6 1 Rest 0.0 0.0 Light 3.5 0.8 Light 2.8 0.2 Max 5.5 1.3 Max 7.5 0.7 2 Rest 0.0 0.0 2 Rest 0.0 0.0 Light 3.7 1.0 Light 5.3 1.0 Max 6.5 1.2 Max 8.3 1.8 3 Rest 0.0 0.0 3 Rest 0.0 0.0 Light 3.8 1.0 Light 3.3 0.5 Max 5.5 1.2 Max 6.0 1.0 2 1 Rest 0.0 0.0 7 1 Rest 0.0 0.0 Light 3.5 0.2 Light 2.0 0.7 Max 5.0 1.0 Max 5.0 1.2 2 Rest 0.0 0.0 2 Rest 0.0 0.0 Light 2.3 0.3 Light 2.0 0.3 Max 6.8 0.5 Max 4.5 0.8 3 Rest 0.0 0.0 3 Rest 0.0 0.0 Light 4.5 1.0 Light 3.5 0.6 Max 6.0 1.3 Max 7.5 1.0 3 1 Rest 0.0 0.0 8 1 Rest Out of focus Light 5.0 0.8 Light Out of focus Max 7.5 1.0 Max Out of focus 2 Rest 0.0 0.0 2 Rest 0.0 0.0 Light 3.5 0.5 Light 3.5 0.2 Max 6.5 0.6 Max 5.0 1.0 3 Rest 0.0 0.0 3 Rest 0.0 0.0 Light 3.0 0.5 Light 4.2 0.5 Max 8.0 1.5 Max 7.7 1.0 4 1 Rest 0.0 0.0 9 1 Rest 0.0 0.0 Light 3.0 0.4 Light 3.8 0.5 Max 5.3 0.8 Max 7.5 0.7 2 Rest 0.0 0.0 2 Rest 0.0 0.0 Light 3.5 0.6 Light 4.0 0.5 Max 6.5 1.1 Max 6.0 0.8 3 Rest 0.0 0.0 3 Rest 0.0 0.0 Light 2.3 0.5 Light 4.0 0.5 Max 6.4 1.0 Max 6.0 1.2 5 1 Rest 0.0 0.0 10 1 Rest 0.0 0.0 Light 4.5 1.3 Light 4.5 0.5 Max 9.0 2.2 Max 9.0 2.5 2 Rest 0.0 0.0 2 Rest 0.0 0.0 Light 2.8 0.5 Light 4.9 0.7 Max 7.8 2.0 Max 5.6 1.1 3 Rest 0.0 0.0 3 Rest 0.0 0.0 Light 3.7 1.2 Light 3.5 0.5 Max 6.2 2.2 Max 7.0 0.7 eyelid height with each cycle (Table 1).