ORIGINAL ARTICLE
Analysis of Lower Eyelid Aging in an Asian Population for Customized Lower Eyelid Blepharoplasty Hwa Lee, MD, PhD,* So Min Ahn, MD,* Minwook Chang, MD, PhD,Þ Minsoo Park, MD, PhD,þ and Sehyun Baek, MD, PhD* Purpose: The objectives of this study were to evaluate the factors that contribute to aging in the lower eyelids and periorbital changes in Asians and to analyze the contribution of different anatomic factors before surgery. Methods: We analyzed photographs and examination findings of 108 patients older than 80 years who had consultations for lower eyelid blepharoplasty. Structural changes were categorized to 7 anatomical categories, and each category was scored from 0 to 3 based on severity. The total point for each category for all patients was divided by the 456 total possible points and was considered a cumulative contribution score for that category. ‘‘A uniqueness score’’ for each patient was calculated as the maximum score in 1 category divided by the patient’s total score to reflect the percentage contribution of the patient’s most severe anatomic problem. Results: A total of 108 cases (51 male and 57 female patients) were evaluated. The mean age was 57 T 11 years (age range, 30Y75 years). The cumulative contribution score for each category was as follows: orbital fat prolapse 33.8 (medial 15.3, central 11.7, lateral 6.8), skin laxity 22.3%, periorbital hollow 20.8 (tear trough 15.5, lateral orbital rim 5.3), septal confluence 9.5, orbicularis oculi muscle hypertrophy 3.6, triangular malar mound 3.4, and eyelid fluid 0.5. The average uniqueness score was 40.1%, and skin laxity and orbital fat prolapse had the highest average uniqueness score, but no single category played a dominant role in most patients. Medial orbital fat prolapse and skin laxity had the highest proportion of grade 3 scores of 9.5% and 6.7%, respectively. When the patients were grouped according to age, either younger than 50 years or older than 50 years, there was a
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From the *Department of Ophthalmology, Korea University College of Medicine, Seoul; †Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang; ‡Department of Ophthalmology, KEPCO Medical Center, Seoul, Korea. Received August 24, 2013. Accepted for publication September 30, 2013. Address correspondence and reprint requests to Dr. Sehyun Baek, Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 80, Guro-dong, Guro-gu, Seoul, South Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.scs.0000436736.60042.92
348
prominent difference in orbital fat prolapse and skin laxity between the 2 groups. Conclusions: Various anatomic factors were related to periorbital changes in Asian patients. Understanding of the complex factors that contribute to periorbital changes during the aging process may allow for adequate and customized surgery for each patient and help in prevention of postoperative complications. Key Words: Aging, deflation, lower eyelid, tear trough deformity (J Craniofac Surg 2014;25: 348Y351)
T
he periorbital changes associated with aging have been explained by gravitational descent, such as laxity of the supporting ligaments, descent of the midface, and inferoforward movement of orbital fat. Most lower lid blepharoplasty techniques rely on removal of excess skin, muscle, and herniated fat pads.1 However, the concepts of lower eyelid aging and the goals and methods of lower eyelid surgery have evolved dramatically over the past 30 years. Lambros2,3 has articulated the concept that focal volume loss, often in areas of cutaneous attachment of the skin to deep structures, can mimic the descent of soft tissue. In the periorbital area, focal volume loss along the orbital rim can reveal the contours of the orbital fat bound by the arcus marginalis and the subYorbicularis oculi fat limited by the orbitomalar ligament. Removal of fat can increase an already hallow appearance, particularly of the superior sulcus, without really rejuvenating the periorbital area. The facial bones in the lower periorbital region also lose volume, contributing to focal deflation and loss of eyelid support in the inferior orbital rim area.4Y7 Goldberg et al8 evaluated 6 anatomic categories that contributed to lower eyelid bags, such as tear trough depression, orbital fat prolapse, loss of skin elasticity, eyelid fluid, orbicularis prominence, and triangular malar mound in 114 consecutive patients. They concluded that eyelid bags are a complex problem and that several anatomic changes may contribute to eyelid bags. Because of the anatomic differences between Asian and white faces, these populations have different processes of lower eyelid aging. These differences are thought to have originated from inner anatomical relationships. Therefore, the goals of rejuvenating lid surgery are different between the 2 races. However, there have been few studies to have analyzed lower lid aging in Asian populations. The purpose of this study was to analyze the pattern of lower eyelid aging and evaluate the anatomic factors that contribute to periorbital change in Asians.
PATIENTS AND METHODS One hundred twenty-five consecutive patients who were older than 80 years and who had undergone consultation for lower eyelid blepharoplasty were included in the study. Standardized photographs in 3 views (frontal, profile, oblique) and close-up views (frontal,
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Lower Eyelid Aging in an Asian
TABLE 1. Cumulative Score of 9 Anatomical Problems Comparing the Results of Goldberg’s Study Categories Skin laxity Orbital fat medial/central/lateral Periorbital hollow Tear trough Septal confluence Lateral orbital rim Zygomatic hollow Orbicularis oculi hypertrophy Triangular malar mound Eyelid fluid
Our Study (%)
Goldberg et al8 (%)
22.3 15.3/11.7/6.8 (Total 33.8)
35 48
15.5 9.5 5.3 6.3 3.6 3.4 0.5
52
20 13 32
profile) were obtained and used for vector analysis. The preoperative parameters measured are noted in Table 1. Structural changes were categorized to 7 anatomical categories, and each category was scored from 0 to 3 based on severity (Fig. 1, 2). Measurements were taken by the same examiner (H.L.) in all cases and repeated 2 times for each patient to determine a mean value. The total points in each category for all patients were divided by the 456 total possible points and were considered a cumulative contribution score for that category. The uniqueness score was calculated for each patient as the maximum score in 1 category divided by the patient’s total score to reflect the percentage contribution of the patient’s most severe anatomic problem.
Skin Laxity The skin loses elasticity and tone with aging and sun damage, permitting wrinkles to easily form in response to the underlying facial muscles. Asian individuals usually have a thicker dermis with more collagen and darker pigment, which protects skin against photoaging.9 This thicker skin hides irregularities of underlying structures such as the orbicularis muscle, orbital fat, and the tear trough. Some wrinkling is also related to volume loss in the subcutaneous tissues.10 Conversely, the addition of volume can improve the apparent skin quality.
Orbicularis Oculi Hypertrophy Orbicularis oculi prominence contributes to dynamic and static rhytides. In these patients, horizontal and oblique wrinkles are accentuated by dynamic facial expression such as smiling.
Orbital Fat Prolapse Orbital fat has 3 compartments and is demarcated above at the junction with the orbicularis oculi muscle and below at the junction
FIGURE 2. Sixty-eight-year-old woman was scored to have a prominent septal confluence, mild skin laxity, central orbital fat prolapse, and tear trough deformity. The uniqueness score was 0.43.
with the septum at the orbital rim. The lateral and central components of the orbital fat are divided by the arcuate expansion of the inferior oblique, and the central and medial components are separated by the oblique muscle itself. Excess fat seems to accumulate in both the superior and inferior postseptal fat compartments with aging. Previously, these fat prolapses have been thought to be caused by excessive fat or weakening of the orbital septum. However, it is now thought that these prolapses are due to the weakening of the fibrous septa composing the orbital support and suspensory system.11 Apparent fat protrusion of the lower eyelids is aggravated by the gravitational descent of the midface, contributing to double convexity and tear trough deformity with aging.12
Tear Trough Deformity and Lateral Orbital Rim Hollow The orbital rim hollow matches up with the location of the orbital rim or orbitomalar ligament. It is bound by the prominence of the orbital fat above and by the subYorbicularis oculi fat and cheek fat pads below, and it follows the contour of the inferior orbital rim.13 Sometimes the medial half of the hollow is more prominent, and this is synonymous with the ‘‘tear trough’’ depression described by Flowers.14 If the lateral orbital fat pad is full, then the lateral half is prominent.
Zygomatic Hollow The zygomatic hollow corresponds to the location of the orbitozygomatic ligament and lines up approximately with the origin of the levator labii superioris and zygomatic muscles. It is bound by the triangular malar fullness above and by the lateral cheek fat below.
Septal Confluence The septal confluence is bound by the orbital fat pad below and the orbicularis roll above, which sometimes contains prominent subcutaneous fat. It is not associated with bony skin attachment, but rather it overlies a different type of deep attachment such as the lower eyelid retractors, orbital septum, or tarsal plate.
Triangular Malar Mound The zygomatic hollow meets the orbital rim hollow centrally, and the triangular malar mound is in the triangular zone between the orbital rim and zygomatic hollows.
Eyelid Fluid FIGURE 1. Seventy-six-year-old male patient was scored to have mild skin laxity and prominent orbital fat prolapse in the medial, central, and lateral fat pads. The uniqueness score was 0.90.
Eyelid fluid is a fluid accumulation that occurs with systemic or local edema. It is worse in the morning or after salty meals. Eyelid fluid can be limited inferiorly by the orbital rim. It often has a purplish color and does not increase during up-gaze. Orbital fat is compartmentalized and separated by the arcuate expansion of
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
349
The Journal of Craniofacial Surgery
Lee et al
& Volume 25, Number 2, March 2014
TABLE 2. Uniqueness Score of 9 Anatomical Problems Categories
Uniqueness Score
Skin laxity Orbital fat medial/central/lateral Periorbital hollow Tear trough Septal confluence Lateral orbital rim Zygomatic hollow Orbicularis oculi hypertrophy Triangular malar mound Eyelid fluid
47.9 14.2/16.9/12.3 33.9 29.6 29.1 25.2 36.2 13 40
inferior oblique muscle laterally and the inferior oblique muscle valley medially, but eyelid fluid maintains an even contour and is not compartmentalized.
RESULTS A total of 108 cases (51 male and 57 female patients) were evaluated. The mean age was 57 T 11 years (age range, 30Y75 years). The cumulative contribution score for each category was as follows: skin laxity 22.3%, orbicularis oculi muscle hypertrophy 3.6%, periorbital hollow 20.8% (tear trough 15.5%, lateral orbital rim 5.3%), septal confluence 9.5%, orbital fat prolapse 33.8% (medial 15.3%, central 11.7%, lateral 6.8%), triangular malar mound 3.4%, and eyelid fluid 0.5% (Table 1). The average uniqueness score was 40.1% (range, 16.7%Y 63.0%), and skin laxity and orbital fat prolapse had the highest average score, but no one category played a dominant role for most patients (Table 2). The proportion of grade 3 scores was higher in the medial orbital fat prolapse (9.5%) and skin laxity (6.7%) categories (Fig. 3). When the patients were grouped according to age, either younger than 50 years or older than 50 years, there was a prominent difference in orbital fat prolapse and skin laxity between the 2 groups (Fig. 4.).
DISCUSSION Several aging models have been proposed to explain the appearance of lower eyelid aging. These include progressive orbital fat hyperplasia,15 hypertrophy or swelling caused by edema, weakening of the orbital septum causing an anterior herniation of orbital fat,16 and globe descent with orbital fat compression and subsequent anterior herniation. Another proposed model for lower eyelid prominence focuses on globe descent.17 The progressive lengthening of the
FIGURE 3. The proportion of grade 3 for each category was higher in skin laxity (6.7%) and medial orbital fat prolapse (9.5%).
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FIGURE 4. Orbital fat prolapse and skin laxity showed the most change between patients younger than 50 years and patients older than 50 years.
lateral canthal tendon that occurs with aging causes an inferior globe shift, compressing the inferior orbital fat and displacing it anteriorly against the lower eyelid. A newly suggested alternative concept of aging is deflation.13 The most important aspect of lower eyelid aging may be the unveiling of deeper contours caused by focal volume loss. Removing fat without really rejuvenating the periorbital area can cause more hollowness. The most common anatomic problems that cause aging in the lower eyelids are skin laxity, orbital fat prolapse and tear trough deformity. These findings are very similar to the results of Goldberg’s study upon white patients. In contrast, eyelid fluid, orbicularis oculi hypertrophy, and triangular malar mound did not play a major role in lower eyelid aging in Asians (Table 1). The proportion of grade 3 scores for each category was higher in orbital fat prolapse (9.5%) and skin laxity (6.7%). The average uniqueness score reflects the contribution of the worst anatomic problem compared with other coexisting anatomic problems. The average uniqueness score was 40.1%. Skin laxity and orbital fat prolapse had the highest average uniqueness score. However, no particular category played a dominant role for most patients. Instead, multiple anatomic problems contributed to lower eyelid aging. Oriental eyelids have distinctive contours that differentiate them from occidental eyelids. These differences are thought to have originated from inner anatomical relationships.18 Shirakabe et al19 reported that Asian faces have thicker skin, weaker skeletal support, heavier soft tissue, and larger amounts of malar fat and are thus subjected to greater gravitational force. They resisted that there were fewer rhytides in Asians than in whites because of the greater elastic nature and solar protection that Asian skin affords. Instead, the Asian face tends to age principally because of gravitational descent. However, there were no differences in the anatomical problems that contribute to lower eyelid aging. Skin laxity and orbital fat prolapse were the main factors in lower eyelid aging, regardless of race. Although a greater amount of malar fat is present in the cheek region of most Asians,19 it does not play a major role in lower lid aging. We subdivided the lower eyelid fat prolapse as medial, central, and lateral. The cumulative score of the medial and central fat was higher than that of lateral fat. There have been no reports about the
FIGURE 5. (A) A 45-year-old man with grade 2 orbital fat prolapsed and lower eyelid skin laxity before the surgery. (B) Orbicularis oculi muscle tightening was performed with upper and lower eyelid blepharoplasty. (C) Photograph of postoperative 1 month.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
FIGURE 6. (A) A 45-year-old woman with grade 1 tear trough deformity and lower eyelid skin laxity before the surgery. (B) Postoperative photograph 1 month after hyaluronic acid (Restylane; Q-Med AB, Uppsala, Sweden) injection with skin excision by subciliary incision.
prevalence of lower lid fat prolapse. In the upper eyelids, the medial fat pad becomes prominent, whereas the central fat pad atrophies in patients older than 70 years.20 However, the uniqueness scores of the medial, central, and lateral fat pads were similar. More studies on the pattern of differential fat pad alteration with aging in the lower eyelid are necessary. When the patients were grouped according to age (aged G50 or 950 years), there was a prominent difference between medial orbital fat prolapse and skin laxity between the 2 groups. In contrast, tear trough deformity, skin laxity, and triangular malar mound were significantly more common in white patients.8 Traditional transcutaneous blepharoplasty with skin pinch techniques plays a role for patients with prominent orbital fat with loss of skin elasticity and skin redundancy (Fig. 5). Fat repositioning through transconjunctival approach is a good option for patients with adequate orbital fat and a significant tear trough depression.21,22 If there is quite deflation or descent of the malar and periorbital tissues, midface lift, fat injection, and filler injection are good treatment options (Fig. 6).23Y26 Identifying anatomic problems involved with lower eyelid aging could be able to choose customized surgical plan for each patient. Aging is a dynamic process, rather than a linear process, and involves interactions between changes in various anatomic structures. Complex anatomic factors contribute to lower eyelid aging in Asians. Understanding the complex factors that contribute to periorbital changes during the aging process can allow for the development of adequate and customized surgery for each patient and aid in the prevention of postoperative complications.
REFERENCES 1. Shorr N, Hoenig JA, Goldberg RA, et al. Fat preservation to rejuvenate the lower eyelid. Arch Facial Plast Surg 1999;1:38Y39 2. Lambros VS. Models of facial aging and implications for treatment. Clin Plast Surg 2008;35:319Y327; discussion 317 3. Lambros VS. The dynamics of facial aging. Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Las Vegas, Nevada, 2002. 4. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg 2000;106:479Y488; discussion 489Y490
Lower Eyelid Aging in an Asian
5. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular globe-to-orbital rim position with age: implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg 1999;23: 337Y342 6. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg 1998;102:205Y212 7. Zadoo VP, Pessa JE. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg 2000;106:460Y466; discussion 467Y468 8. Goldberg RA, McCann JD, Fiaschetti D, et al. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115: 1395Y1402; discussion 1394Y1403 9. Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 2002;24:183Y189 10. Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg 2000;26:1107Y1112 11. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96:354Y362 12. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch Facial Plast Surg 1999;1:33Y37 13. Goldberg RA. The three periorbital hollows: a paradigm for periorbital rejuvenation. Plast Reconstr Surg 2005;116:1796Y1804 14. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20:403Y415 15. Castanares S. Blepharoplasty for herniated intraorbital fat; anatomical basis for a new approach. Plast Reconstr Surg (1946) 1951;8:46Y58 16. Camirand A, Doucet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid fat pads. Plast Reconstr Surg 1997;100:1535Y1546 17. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 1988;81:677Y687 18. Doxanas MT, Anderson RL. Oriental eyelids. An anatomic study. Arch Ophthalmol 1984;102:1232Y1235 19. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthetic Plast Surg 2003;27:397Y402 20. Oh SR, Chokthaweesak W, Annunziata CC, et al. Analysis of eyelid fat pad changes with aging. Ophthal Plast Reconstr Surg 2011;27:348Y351 21. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg 1999;15:225Y229 22. Kawamoto HK, Bradley JP. The tear ‘‘TROUF’’ procedure: transconjunctival repositioning of orbital unipedicled fat. Plast Reconstr Surg 2003;112:1903Y1907; discussion 1908Y1909 23. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109:329Y340; discussion 329Y341 24. Williams EF 3rd, Vargas H, Dahiya R, et al. Midfacial rejuvenation via a minimal-incision brow-lift approach: critical evaluation of a 5-year experience. Arch Facial Plast Surg 2003;5:470Y478 25. De Pasquale A, Russa G, Pulvirenti M, et al. Hyaluronic acid filler injections for tear-trough deformity: injection technique and high-frequency ultrasound follow-up evaluation. Aesthetic Plast Surg 2013;37:587Y591 26. Lambros VS. Hyaluronic acid injections for correction of the tear trough deformity. Plast Reconstr Surg 2007;120:74SY80S
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
351
Analysis of Lower Eyelid Aging in an Asian Population for Customized Lower Eyelid Blepharoplasty Hwa Lee, MD, PhD,* So Min Ahn, MD,* Minwook Chang, MD, PhD,Þ Minsoo Park, MD, PhD,þ and Sehyun Baek, MD, PhD* Purpose: The objectives of this study were to evaluate the factors that contribute to aging in the lower eyelids and periorbital changes in Asians and to analyze the contribution of different anatomic factors before surgery. Methods: We analyzed photographs and examination findings of 108 patients older than 80 years who had consultations for lower eyelid blepharoplasty. Structural changes were categorized to 7 anatomical categories, and each category was scored from 0 to 3 based on severity. The total point for each category for all patients was divided by the 456 total possible points and was considered a cumulative contribution score for that category. ‘‘A uniqueness score’’ for each patient was calculated as the maximum score in 1 category divided by the patient’s total score to reflect the percentage contribution of the patient’s most severe anatomic problem. Results: A total of 108 cases (51 male and 57 female patients) were evaluated. The mean age was 57 T 11 years (age range, 30Y75 years). The cumulative contribution score for each category was as follows: orbital fat prolapse 33.8 (medial 15.3, central 11.7, lateral 6.8), skin laxity 22.3%, periorbital hollow 20.8 (tear trough 15.5, lateral orbital rim 5.3), septal confluence 9.5, orbicularis oculi muscle hypertrophy 3.6, triangular malar mound 3.4, and eyelid fluid 0.5. The average uniqueness score was 40.1%, and skin laxity and orbital fat prolapse had the highest average uniqueness score, but no single category played a dominant role in most patients. Medial orbital fat prolapse and skin laxity had the highest proportion of grade 3 scores of 9.5% and 6.7%, respectively. When the patients were grouped according to age, either younger than 50 years or older than 50 years, there was a
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Department of Ophthalmology, Korea University College of Medicine, Seoul; †Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang; ‡Department of Ophthalmology, KEPCO Medical Center, Seoul, Korea. Received August 24, 2013. Accepted for publication September 30, 2013. Address correspondence and reprint requests to Dr. Sehyun Baek, Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 80, Guro-dong, Guro-gu, Seoul, South Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.scs.0000436736.60042.92
348
prominent difference in orbital fat prolapse and skin laxity between the 2 groups. Conclusions: Various anatomic factors were related to periorbital changes in Asian patients. Understanding of the complex factors that contribute to periorbital changes during the aging process may allow for adequate and customized surgery for each patient and help in prevention of postoperative complications. Key Words: Aging, deflation, lower eyelid, tear trough deformity (J Craniofac Surg 2014;25: 348Y351)
T
he periorbital changes associated with aging have been explained by gravitational descent, such as laxity of the supporting ligaments, descent of the midface, and inferoforward movement of orbital fat. Most lower lid blepharoplasty techniques rely on removal of excess skin, muscle, and herniated fat pads.1 However, the concepts of lower eyelid aging and the goals and methods of lower eyelid surgery have evolved dramatically over the past 30 years. Lambros2,3 has articulated the concept that focal volume loss, often in areas of cutaneous attachment of the skin to deep structures, can mimic the descent of soft tissue. In the periorbital area, focal volume loss along the orbital rim can reveal the contours of the orbital fat bound by the arcus marginalis and the subYorbicularis oculi fat limited by the orbitomalar ligament. Removal of fat can increase an already hallow appearance, particularly of the superior sulcus, without really rejuvenating the periorbital area. The facial bones in the lower periorbital region also lose volume, contributing to focal deflation and loss of eyelid support in the inferior orbital rim area.4Y7 Goldberg et al8 evaluated 6 anatomic categories that contributed to lower eyelid bags, such as tear trough depression, orbital fat prolapse, loss of skin elasticity, eyelid fluid, orbicularis prominence, and triangular malar mound in 114 consecutive patients. They concluded that eyelid bags are a complex problem and that several anatomic changes may contribute to eyelid bags. Because of the anatomic differences between Asian and white faces, these populations have different processes of lower eyelid aging. These differences are thought to have originated from inner anatomical relationships. Therefore, the goals of rejuvenating lid surgery are different between the 2 races. However, there have been few studies to have analyzed lower lid aging in Asian populations. The purpose of this study was to analyze the pattern of lower eyelid aging and evaluate the anatomic factors that contribute to periorbital change in Asians.
PATIENTS AND METHODS One hundred twenty-five consecutive patients who were older than 80 years and who had undergone consultation for lower eyelid blepharoplasty were included in the study. Standardized photographs in 3 views (frontal, profile, oblique) and close-up views (frontal,
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Lower Eyelid Aging in an Asian
TABLE 1. Cumulative Score of 9 Anatomical Problems Comparing the Results of Goldberg’s Study Categories Skin laxity Orbital fat medial/central/lateral Periorbital hollow Tear trough Septal confluence Lateral orbital rim Zygomatic hollow Orbicularis oculi hypertrophy Triangular malar mound Eyelid fluid
Our Study (%)
Goldberg et al8 (%)
22.3 15.3/11.7/6.8 (Total 33.8)
35 48
15.5 9.5 5.3 6.3 3.6 3.4 0.5
52
20 13 32
profile) were obtained and used for vector analysis. The preoperative parameters measured are noted in Table 1. Structural changes were categorized to 7 anatomical categories, and each category was scored from 0 to 3 based on severity (Fig. 1, 2). Measurements were taken by the same examiner (H.L.) in all cases and repeated 2 times for each patient to determine a mean value. The total points in each category for all patients were divided by the 456 total possible points and were considered a cumulative contribution score for that category. The uniqueness score was calculated for each patient as the maximum score in 1 category divided by the patient’s total score to reflect the percentage contribution of the patient’s most severe anatomic problem.
Skin Laxity The skin loses elasticity and tone with aging and sun damage, permitting wrinkles to easily form in response to the underlying facial muscles. Asian individuals usually have a thicker dermis with more collagen and darker pigment, which protects skin against photoaging.9 This thicker skin hides irregularities of underlying structures such as the orbicularis muscle, orbital fat, and the tear trough. Some wrinkling is also related to volume loss in the subcutaneous tissues.10 Conversely, the addition of volume can improve the apparent skin quality.
Orbicularis Oculi Hypertrophy Orbicularis oculi prominence contributes to dynamic and static rhytides. In these patients, horizontal and oblique wrinkles are accentuated by dynamic facial expression such as smiling.
Orbital Fat Prolapse Orbital fat has 3 compartments and is demarcated above at the junction with the orbicularis oculi muscle and below at the junction
FIGURE 2. Sixty-eight-year-old woman was scored to have a prominent septal confluence, mild skin laxity, central orbital fat prolapse, and tear trough deformity. The uniqueness score was 0.43.
with the septum at the orbital rim. The lateral and central components of the orbital fat are divided by the arcuate expansion of the inferior oblique, and the central and medial components are separated by the oblique muscle itself. Excess fat seems to accumulate in both the superior and inferior postseptal fat compartments with aging. Previously, these fat prolapses have been thought to be caused by excessive fat or weakening of the orbital septum. However, it is now thought that these prolapses are due to the weakening of the fibrous septa composing the orbital support and suspensory system.11 Apparent fat protrusion of the lower eyelids is aggravated by the gravitational descent of the midface, contributing to double convexity and tear trough deformity with aging.12
Tear Trough Deformity and Lateral Orbital Rim Hollow The orbital rim hollow matches up with the location of the orbital rim or orbitomalar ligament. It is bound by the prominence of the orbital fat above and by the subYorbicularis oculi fat and cheek fat pads below, and it follows the contour of the inferior orbital rim.13 Sometimes the medial half of the hollow is more prominent, and this is synonymous with the ‘‘tear trough’’ depression described by Flowers.14 If the lateral orbital fat pad is full, then the lateral half is prominent.
Zygomatic Hollow The zygomatic hollow corresponds to the location of the orbitozygomatic ligament and lines up approximately with the origin of the levator labii superioris and zygomatic muscles. It is bound by the triangular malar fullness above and by the lateral cheek fat below.
Septal Confluence The septal confluence is bound by the orbital fat pad below and the orbicularis roll above, which sometimes contains prominent subcutaneous fat. It is not associated with bony skin attachment, but rather it overlies a different type of deep attachment such as the lower eyelid retractors, orbital septum, or tarsal plate.
Triangular Malar Mound The zygomatic hollow meets the orbital rim hollow centrally, and the triangular malar mound is in the triangular zone between the orbital rim and zygomatic hollows.
Eyelid Fluid FIGURE 1. Seventy-six-year-old male patient was scored to have mild skin laxity and prominent orbital fat prolapse in the medial, central, and lateral fat pads. The uniqueness score was 0.90.
Eyelid fluid is a fluid accumulation that occurs with systemic or local edema. It is worse in the morning or after salty meals. Eyelid fluid can be limited inferiorly by the orbital rim. It often has a purplish color and does not increase during up-gaze. Orbital fat is compartmentalized and separated by the arcuate expansion of
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
349
The Journal of Craniofacial Surgery
Lee et al
& Volume 25, Number 2, March 2014
TABLE 2. Uniqueness Score of 9 Anatomical Problems Categories
Uniqueness Score
Skin laxity Orbital fat medial/central/lateral Periorbital hollow Tear trough Septal confluence Lateral orbital rim Zygomatic hollow Orbicularis oculi hypertrophy Triangular malar mound Eyelid fluid
47.9 14.2/16.9/12.3 33.9 29.6 29.1 25.2 36.2 13 40
inferior oblique muscle laterally and the inferior oblique muscle valley medially, but eyelid fluid maintains an even contour and is not compartmentalized.
RESULTS A total of 108 cases (51 male and 57 female patients) were evaluated. The mean age was 57 T 11 years (age range, 30Y75 years). The cumulative contribution score for each category was as follows: skin laxity 22.3%, orbicularis oculi muscle hypertrophy 3.6%, periorbital hollow 20.8% (tear trough 15.5%, lateral orbital rim 5.3%), septal confluence 9.5%, orbital fat prolapse 33.8% (medial 15.3%, central 11.7%, lateral 6.8%), triangular malar mound 3.4%, and eyelid fluid 0.5% (Table 1). The average uniqueness score was 40.1% (range, 16.7%Y 63.0%), and skin laxity and orbital fat prolapse had the highest average score, but no one category played a dominant role for most patients (Table 2). The proportion of grade 3 scores was higher in the medial orbital fat prolapse (9.5%) and skin laxity (6.7%) categories (Fig. 3). When the patients were grouped according to age, either younger than 50 years or older than 50 years, there was a prominent difference in orbital fat prolapse and skin laxity between the 2 groups (Fig. 4.).
DISCUSSION Several aging models have been proposed to explain the appearance of lower eyelid aging. These include progressive orbital fat hyperplasia,15 hypertrophy or swelling caused by edema, weakening of the orbital septum causing an anterior herniation of orbital fat,16 and globe descent with orbital fat compression and subsequent anterior herniation. Another proposed model for lower eyelid prominence focuses on globe descent.17 The progressive lengthening of the
FIGURE 3. The proportion of grade 3 for each category was higher in skin laxity (6.7%) and medial orbital fat prolapse (9.5%).
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FIGURE 4. Orbital fat prolapse and skin laxity showed the most change between patients younger than 50 years and patients older than 50 years.
lateral canthal tendon that occurs with aging causes an inferior globe shift, compressing the inferior orbital fat and displacing it anteriorly against the lower eyelid. A newly suggested alternative concept of aging is deflation.13 The most important aspect of lower eyelid aging may be the unveiling of deeper contours caused by focal volume loss. Removing fat without really rejuvenating the periorbital area can cause more hollowness. The most common anatomic problems that cause aging in the lower eyelids are skin laxity, orbital fat prolapse and tear trough deformity. These findings are very similar to the results of Goldberg’s study upon white patients. In contrast, eyelid fluid, orbicularis oculi hypertrophy, and triangular malar mound did not play a major role in lower eyelid aging in Asians (Table 1). The proportion of grade 3 scores for each category was higher in orbital fat prolapse (9.5%) and skin laxity (6.7%). The average uniqueness score reflects the contribution of the worst anatomic problem compared with other coexisting anatomic problems. The average uniqueness score was 40.1%. Skin laxity and orbital fat prolapse had the highest average uniqueness score. However, no particular category played a dominant role for most patients. Instead, multiple anatomic problems contributed to lower eyelid aging. Oriental eyelids have distinctive contours that differentiate them from occidental eyelids. These differences are thought to have originated from inner anatomical relationships.18 Shirakabe et al19 reported that Asian faces have thicker skin, weaker skeletal support, heavier soft tissue, and larger amounts of malar fat and are thus subjected to greater gravitational force. They resisted that there were fewer rhytides in Asians than in whites because of the greater elastic nature and solar protection that Asian skin affords. Instead, the Asian face tends to age principally because of gravitational descent. However, there were no differences in the anatomical problems that contribute to lower eyelid aging. Skin laxity and orbital fat prolapse were the main factors in lower eyelid aging, regardless of race. Although a greater amount of malar fat is present in the cheek region of most Asians,19 it does not play a major role in lower lid aging. We subdivided the lower eyelid fat prolapse as medial, central, and lateral. The cumulative score of the medial and central fat was higher than that of lateral fat. There have been no reports about the
FIGURE 5. (A) A 45-year-old man with grade 2 orbital fat prolapsed and lower eyelid skin laxity before the surgery. (B) Orbicularis oculi muscle tightening was performed with upper and lower eyelid blepharoplasty. (C) Photograph of postoperative 1 month.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
FIGURE 6. (A) A 45-year-old woman with grade 1 tear trough deformity and lower eyelid skin laxity before the surgery. (B) Postoperative photograph 1 month after hyaluronic acid (Restylane; Q-Med AB, Uppsala, Sweden) injection with skin excision by subciliary incision.
prevalence of lower lid fat prolapse. In the upper eyelids, the medial fat pad becomes prominent, whereas the central fat pad atrophies in patients older than 70 years.20 However, the uniqueness scores of the medial, central, and lateral fat pads were similar. More studies on the pattern of differential fat pad alteration with aging in the lower eyelid are necessary. When the patients were grouped according to age (aged G50 or 950 years), there was a prominent difference between medial orbital fat prolapse and skin laxity between the 2 groups. In contrast, tear trough deformity, skin laxity, and triangular malar mound were significantly more common in white patients.8 Traditional transcutaneous blepharoplasty with skin pinch techniques plays a role for patients with prominent orbital fat with loss of skin elasticity and skin redundancy (Fig. 5). Fat repositioning through transconjunctival approach is a good option for patients with adequate orbital fat and a significant tear trough depression.21,22 If there is quite deflation or descent of the malar and periorbital tissues, midface lift, fat injection, and filler injection are good treatment options (Fig. 6).23Y26 Identifying anatomic problems involved with lower eyelid aging could be able to choose customized surgical plan for each patient. Aging is a dynamic process, rather than a linear process, and involves interactions between changes in various anatomic structures. Complex anatomic factors contribute to lower eyelid aging in Asians. Understanding the complex factors that contribute to periorbital changes during the aging process can allow for the development of adequate and customized surgery for each patient and aid in the prevention of postoperative complications.
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Lower Eyelid Aging in an Asian
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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