The gateway of our soul

Emphasis on the Eyes

The eyes are said to be the gateway of our soul and studies confirm that we spend more time looking at a person’s eyes than any other feature on a face. The eyebrows and lid fold lines are highly visible features framing the eyes. Our orbicularis, corrugators, procerus and frontalis muscles act intricately around the eyes, making tiny but perceptible adjustments to the eye aperture and brow shape. Even subtle deviations in their positioning are markers of emotion, alertness, and age. Pet owners know that even animals focus on the eyes to send and receive signals.

The ideal position of the youthful female eye-brow has been described by many. Westmore’s 1975 model of the ideal eyebrow has been refined by 3 decades of critical assessment and pattern recognition among attractive faces.

T.A. Cook (1989) modified Westmore’s definition and described the ideal brow position as follows:

The medial brow should begin in the same vertical plane as the ala and medial canthus; the temporal brow should end along an oblique line extending from the ala through lateral canthus and lie at approximately the same horizontal level as the medial beginning; the apex of the brow should lie lateral to the lateral limbus approximately over the lateral canthus.

What Makes a Face Attractive?(2)

Average and Non Average Features of Attractive Faces

Our current understanding is that attractive faces possess both average and non average characteristics. Average features display balance and symmetry and are biased by the beholder’s surrounding social environment.(Newton JT et al 2005) This average mental template for either male or female faces forms a baseline image from which all other faces are compared, permitting efficient differentiation between the faces of different people. (Little et al 2005) Although average faces have been shown to be less memorable, this same averageness also increases attractiveness (Vokey and Read 1992). Non-average characteristics include youth, virility, energy and positive expressions.(Baudouin JY et al 2004 ) Faces expressing positive emotions (smiling, relaxed) are perceived as more attractive than those with negative emotions (sad, angry, or worried). (Tatarunaite et al 2005)

What makes a face attractive?

The concept that beauty lies in the eye of the beholder, has received significant attention over the past few decades. We are born with an innate ability to perceive faces and babies can recognize facial attractiveness by the age of 5 months. (Geldart et al 1999)

The speed and accuracy with which humans both recognize and judge faces remains one of the most sophisticated fruits of evolution. The quest to understand and replicate the precision of human facial recognition is of great interest to the biometric technologists and the security industry. This same process of teaching a computer to analyze a face may potentially be used to determine which faces we may also find attractive.

Asian Blepharoplasty

I spent a few months this year training under Dr. Qingfeng Li, the head of Facial Plastic Surgery at Shanghai’s 9th People’s Hospital. He and his colleagues are the world’s experts on facial reconstructive surgery for Asian patients, and treat some of the toughest burn cases in all of China. As Shanghai’s largest plastic surgery hospital, they see more than their fair share of cosmetic cases as well. During my visit I witnessed over 200 procedures performed in just one day in the minor surgery center. Over one third of these cases were Asian upper eyelid blepharoplasties or “double eyelid” surgeries (a procedure that creates a crease in the upper eyelid for the 50-80% of Asian patients who do not have one). Another quarter were lower lid blepharoplasties (a procedure to remove some of the bulge caused by prolapsing orbital fat against the lower eyelid). In this setting, I had the chance to learn from over 15 different attending surgeons, each of whom had developed their own modifications and pearls to performing eyelid surgeries for the Asian patient. As with my experience with Dr. Julian Perry at the Cleveland Clinic, I am truly indebted to their willingness to share and teach.

Asian Blepharoplasty Revision

The surgeons at the 9th People’s Hospital, with their enormous patient volume as well as their national recognition as reconstructive specialists, also had more than their fair share of patients seeking to fix “botched” eyelid surgery. In China, cosmetic surgery is still unregulated. “Beauty shops” are opening on every street offering beautifying procedures. The vast majority are not performed by a physician let alone a surgeon. The “double-eyelid” surgery is already the number one plastic surgery of Asian patients. As cultures continue to blend, I believe these eyelid procedures will gain even greater acceptance. This will inevitably result in greater numbers of people who become disfigured by untrained hands. The need for reconstructive surgeons who specialize in the repair of Asian eyelids will continue to grow.

Reconstruction involves removing scar tissue and is far more complex an operation. Dissection requires a significantly more advanced appreciation of the individual tissue layers in the Asian eyelid. As scars vary with every patient, each reconstructive procedure is unique. As an ophthalmologist who specializes in plastic surgery around the eyes, I found this type of scar revision to be most rewarding.

What makes Asian eyes look different?

The Asian periocular anatomy is very different from that of a Caucasian or African American on many levels. Firstly, the shape of the orbital bones makes a tremendous impact on the 3D shape and angle of the eyelids. In an Asian, the lateral orbital rim, or the rim of bone that can be felt at the outer corner of the eye, sits on average 3mm more anterior than in Caucasians, and 5mm more anterior than in African Americans (Migliori and Gladstone 1984, Tsai et al 2006). This difference in the skull shape significantly affects the angular corners of Asian eyelids, as explains the more rounded outer corners in Caucasians and African Americans.

Secondly, the fibrous strip of tissue that defines the upper and lower lid margins, called the tarsus, is significantly narrower in the Asian patient (6-8mm) compared to Caucasians and African Americans (10-12mm). The upper edge of tarsus is where fine filamentous attachments link the eyelid skin to the eyelid, and corresponds to the height of the lid crease. It is these attachments that can be weak in Asians who do not have a visible lid crease, often called a “single eyelid” configuration.

Another difference is the additional layer of fatty tissue in the Asian eyelid that is not found in either Caucasians or African Americans. This extra layer of fat helps to separate the eyelid skin from the muscle and tarsus, which is typically firmly attached in Non-Asians. By increasing the thickness of Asian eyelids, this layer may also prevent a lid crease from forming at the upper border of tarsus.