Photo-Assisted Anthropometric Analysis of Double Eyelid Blepharoplasty in Young Chinese

Abstract

Background:

Double eyelid blepharoplasty has gained popularity over decades among Asians. Quantitative assessment of the morphologic changes after double eyelid blepharoplasty remains obscure. A photo-assisted digital method was introduced to measure the outcomes of double eyelid surgery in young Chinese.

Methods:

A total of 168 Chinese patients who underwent esthetic upper blepharoplasty were recruited from October 2018 to October 2020. The participants were divided into mini-incision, full-incision, and full-incision double with epicanthoplasty (FIDE) groups. Changes in the eyeball exposure area (EEA), brow eyelid margin distance [brow eyelid distance (BED)], and palpebral crease height after surgery were analyzed using ImageJ software.

Results:

There was an overall increase in EEA in the 3 groups after upper blepharoplasty surgery. The FIDE group showed the most increase in EEA among these groups. Furthermore, BED was significantly decreased in each group after upper eyelid blepharoplasty; however, the mini-incision double group showed the least BED reduction. The palpebral crease height at 90 days was significantly lower than that at 7 days after surgery.

Conclusions:

The photo-assisted anthropometric analysis offers a simple and objective measurement for double eyelid blepharoplasty. The eyes appear larger because of the increase in EEA and decrease in BED after double eyelid blepharoplasty. Distinct results were produced by different surgical techniques. The FIDE group showed the maximum increase in EEA and a decrease in BED. These findings provide important references for preoperative planning and postoperative measurement.

Upper blepharoplasty in Asians is often synonymous with double eyelid surgery. Double eyelid blepharoplasty is performed to create a well-defined supratarsal crease. Millions of Asians with single and bulky eyelids undergo double eyelid surgery annually to enlarge their eyes and enhance their attractiveness. Although double eyelid surgery has gained popularity because of the influence of western culture, most Asians with single eyelids currently receive this type of surgery simply for improvement of their appearance, for example, less bulky, more visible irises and natural-looking double eyelid folds. To date, there is difficulty in objectively quantifying the morphologic changes after double eyelid blepharoplasty. There is seldom a quantitative tool to assess the esthetic effects after surgery. In this study, a digital photometric method, based on the relative parameter of the iris, was developed to investigate the surface and other palpebral parameters that are altered after double eyelid blepharoplasty. This method for the measurement of upper eyelid parameters can facilitate preoperative planning and postoperative evaluation of double eyelid blepharoplasty.

METHODS

A total of 223 patients (with 446 eyes) who underwent esthetic upper blepharoplasty in our plastic department from October 2018 to October 2020 were included in this study. All these operations and photographs were performed by a senior surgeon. The patient consent form was obtained before surgery, and the research contents were authorized by the ethics committee.

To lessen the dermatochalasis effect of aging, only subjects under the age of 30 years were included. The mean age of patients was 22.51 ± 4.95 years at the time of surgery. Only those patients who had undergone primary double eyelid blepharoplasty were included. Patients with any previous eyelid surgery or blepharoptosis were excluded from this study. The follow-up period was postoperative 90 days. Some patients were lost to follow-up because of travel distance or personal reasons. Consequently, 168 cases (151 females and 17 males) were included in this study.

The patients were categorized into 3 groups according to the techniques used for surgery: (1) mini-incision double (MID) eyelid blepharoplasty, (2) full-incision double (FID) eyelid blepharoplasty, and (3) FID eyelid blepharoplasty and epicanthoplasty [FID with epicanthoplasty (FIDE)]. The patients with tight and thin upper eyelids underwent MID. Patients with loose or bulky upper eyelids underwent FID. Patients who had an epicanthus underwent FIDE simultaneously according to their desires. Furthermore, the height and curve of the double eyelid crease were determined after completing a consultation with the patient. Consequently, 66 patients were enrolled in the FID group, 72 patients in the FIDE group, and 30 patients in the MID group.

SURGICAL TECHNIQUES

The Following Surgical Techniques Were Used. Mini-Incision Double Eyelid Blepharoplasty

Briefly as described in our previous study,¹ one short incision was located between the medial limbus and the middle pupillary line, with a length of 6 mm. A minimal incision was placed just adjacent to the lateral limbus, with a length of 1 mm. Surgery was performed under local anesthesia. The pretarsal orbicularis oculi muscle (OOM), anterior tarsal fascia, and part of the lateral orbital fat pad were removed through the incisions. Debulking of the OOM extended over almost the whole tarsal plate. The skin, dermis, and orbicularis oculi were sutured together with the pretarsal fascia with 8-0 nylon (Ethicon).

Full-Incision Double Eyelid Blepharoplasty

The selective neurovascular preservation FID eyelid method was performed.² Briefly, after local anesthesia, the incision was made through the skin along the marked line. A strip of skin and preseptal OOM were removed subcutaneously, with care taken to preserve the major spreading nerves and vessels. The lateral orbital septum was opened, and the herniated septum fat pad was removed. Next, the retro-orbicularis oculus fat was partially resected in patients with an excessively bulky eyelid. Four to 6 anchoring points were made to reach the pretarsal fascia. Skin-OOM–pretarsal fascia sutures were placed on the anchoring points using 8-0 nylon. The remaining incision was closed with an interrupted skin suture.

Full-Incision Double Eyelid Blepharoplasty and Epicanthoplasty

Briefly, “Z” epicanthoplasty was designed over the medial canthal area.³ Marking was determined by the elasticity of the skin and pulling of the ectopic medial canthal ligament. After local anesthesia, the medial canthal skin was completely separated from the thickened orbicularis oculi muscle and the superficial head of the ectopic medial canthal ligament. The tension of the skin was released through the transposition of 2 tiny triangle flaps. Further, 8-0 monofilament nylon suture was used to suture the skin and the free angle of the triangle flap. Then, surgical procedures of double eyelid blepharoplasty, which have been described previously, were performed.

Anthropometry and Photographic Analysis

Preoperative frontal view digital photographs were obtained in all patients using a digital camera with a standardized lens (D7000 Nikon, 24–120 mm) by the same photographer. While taking the photographs at our studio, patients sat ~1.0 m away from the camera with eyes in an upright position, and the same horizontal axis was used. The patient’s face was kept at rest; hence, the periorbital relationship could not be affected by facial expressions. Photographs were taken at 3 time points (preoperative, postoperative day 7, and postoperative day 90). The preoperative and postoperative images were calculated and analyzed using Java-based image processing software (ImageJ; National Institutes of Health).

The Measurement of the Eyeball Exposure Area

The diameter of the iris through the center of the patient’s right eye pupil was defined as the reference value. Accordingly, eyeball exposure area (EEA) was measured carefully with a manual definition of the upper and lower eyelid margins and the inner and outer canthi; then EEA was measured with the reference value (Fig. 1A). The same technique was repeated three times for the same eye to obtain the average value.

FIGURE 1.

Anthropometric measurement of the periorbital region. (A) Blue area represents the EEA. (B) Vertical black line represents the BED. (C) Short vertical green line represents the PCH. BED indicates brow eyelid distance; EEA, eyeball exposure area; PCH, palpebral crease height.

The Measurement of the Brow Eyelid Margin Distance

The reference value was set as described previously. The brow eyelid margin distance [brow eyelid distance (BED)] was defined as a vertical dimension between the upper eyelid margin and the edge of the eyebrow arch which through the pupil midpoint was marked in the photo. The value was calculated by ImageJ using the same reference value. The same technique was repeated three times for the same eye to obtain the average value (Fig. 1B).

The Measurement of Palpebral Crease Height

The reference value was set as described previously. A vertical line was made through the midpoint of the pupil, and 2 horizontal lines were made through the upper eyelid margin and the palpebral crease. The palpebral crease height (PCH) was defined as the vertical distance between the two lines (Fig. 1C).

Statistical Analyses

Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 22.0 for Windows. The changes in preoperative and postoperative EEA, BED, and PCH were compared using paired t tests and array research. The statistical significance of the difference was determined when P was <0.05, based on a 95% CI.

RESULTS

A total of 168 patients (17 males and 151 females) were enrolled in this study, with a mean age of 22.51 ± 4.95(17–30). Sixty-six patients received FID surgery, 72 patients had FIDE surgery, and 30 patients had MID surgery. The incidence of complications related to eyelid surgery was low (Supplemental Digital Content 1, Table 1, http://links.lww.com/SCS/F355). Two patients in the MID group had a unilateral loss of fold within 5 months after surgery, both received revision surgery. Two patients in the FIDE group experienced temporal scar hyperplasia at the epicanthus region after surgery, both resolved spontaneously within 6 months with topical use of silicone dressing.

The difference in the preoperative EEA between the two eyes was analyzed. A total of 55.95% of cases showed larger right EEA. The difference was more than 5% in 60.7% of cases (Supplemental Digital Content 2, Table 2, http://links.lww.com/SCS/F356). The analysis of the preoperative BED showed a longer right BED in 52.38% of cases. The difference between the two eyes was more than 5% in a total of 58.4% of cases (Supplemental Digital Content 3, Table 3, http://links.lww.com/SCS/F357).

There was an overall increase in EEA in the 3 groups after upper blepharoplasty surgery. The increase in EEA at postoperative 90 days was more significant than that at 7 days in each group. The MID group (Fig. 2) exhibited an ~10.4% increase in EEA 90 days after surgery. The FIDE group (Fig. 3) showed the maximum increase in EEA among the groups, at 23.1% after 90 days, and the FID group (Fig. 4) showed an 18.9% increase after 90 days. The results were statistically significant (P < 0.05) (Supplemental Digital Content 4, Table 4, http://links.lww.com/SCS/F358).

FIGURE 2.

Measurement of MID eyelid blepharoplasty (a 26-year-old Chinese woman). (A) Preoperative measurement. (B) Seven days postoperative measurement. (C) Ninety days postoperative measurement. MID indicates mini-incision double.

FIGURE 3.

Measurement of FID eyelid blepharoplasty and epicanthoplasty (a 23-year-old Chinese woman). (A) Preoperative measurement. (B) Seven days postoperative measurement after. (C) Ninety days postoperative measurement. FID indicates full-incision double.

FIGURE 4.

Measurement of FID eyelid blepharoplasty (a 21-year-old Chinese woman). (A) Preoperative measurement. (B) Seven days postoperative measurement. (C) Ninety days postoperative measurement. FID indicates full-incision double.

We found that BED was significantly decreased in each group after upper eyelid blepharoplasty. The decrease in BED at postoperative 90 days was more significant than that at 7 days in each group. More reduction in BED was shown after the FIDE or FID (P > 0.05). As such, BED decreased by 24.5% in the FID group and 23.3% in the FIDE group at postoperative 90 days, whereas BED in the MID group decreased by around 13.7%. The results were statistically significant (P < 0.05) (Supplemental Digital Content 5, Table 5, http://links.lww.com/SCS/F359).

The PCH at 90 days after surgery was significantly lower than that at 7 days in each group (P < 0.05). There were no differences in its reduction among the 3 groups (P > 0.05) (Supplemental Digital Content 6, Table 6, http://links.lww.com/SCS/F360).

DISCUSSION

Typical mongoloid eyes in Chinese subjects are characterized by upper eyelid puffiness and narrow palpebral fissure.⁴ An absent palpebral crease (single eyelid) and upper eyelid skin laxity, as well as the presence of medial epicanthal folds, are commonly found in East Asians. Regardless of the ethnic or cultural influence, the presence of a double eyelid crease is perceived as being more attractive than an absent eyelid crease.⁵ For decades, double eyelid blepharoplasty has been the most popular cosmetic surgery in China. Various double eyelid blepharoplasty techniques have been described for Asian patients. These techniques have been generally classified into the nonincision method, mini-incision method, and incision method.^6–8 Objective and accurate pre and postoperative measurements could facilitate the need for plastic surgeons to improve preoperative planning and reduce complications.

The beauty of the eyelid is determined not only by the anthropometric measurement but also by the harmony with the face, personal preference, and social culture. The quantitative tool to assess the effects after blepharoplasty may assist in the understanding and analysis of the surgery. Although some morphologic or anthropometric analyses of East Asian eyes have been reported,^5,9,10 few studies have shown the accurate effect associated with double eyelid blepharoplasty. Conventional eyelid measurement using a ruler can be highly variable. The accuracy depends on both the skill and experience of researchers. Furthermore, photographic measurement using accessible digital software is important to investigate the outcomes after double eyelid blepharoplasty. Coombes and colleagues introduced a standardized digital photography system based on a digital camera and bracket mounted on a Haag-Streit slit lamp. The study showed that digital photographic analysis offered advantages over traditional handheld ruler measurement.¹¹ However, these methods require either a learning curve or expensive equipment. Starck and colleagues reported an objective evaluation method for eyelids and eyebrows after blepharoplasty. They measured 30 eyes in 15 white patients and found that the upper iris coverage was slightly improved (6%) by upper eyelid blepharoplasty.¹² Park and Park’s¹³ research also showed that blepharoplasty with skin excision could increase the area of corneal exposure. Many measurements of the upper eyelid were performed using linear parameters, such as marginal reflex distance, marginal limbal distance, and vertical palpebral height.¹⁴ Chen and colleagues reported the assessment for double eyelid surgery using the vertical ratio of subunit below the double eyelid fold peak to measure the visually perceived proportion of the eye and concluded that double eyelid blepharoplasty can enlarge the vertical dimension of the palpebral fissure by 27.9%. Eyes with double eyelids are perceived to be larger because of the assimilated illusion of eyelid folds and relative proportions of the eyebrow-eye unit.¹⁵ However, they only used vertical height to assess the dimension of the palpebral fissure. All these measurements are 1-dimensional parameters that measure the linear distance. Actual changes after double eyelid blepharoplasty remain obscure. However, digital measurement of the ocular surface area proved to be a better reference for double eyelid blepharoplasty. Recent research has introduced a digital photographic analysis method using EEA, which can be more accurate for the measurement of the palpebral fissure area.¹⁶ Therefore, we used EEA in our study for the assessment of the 2-dimensional palpebral surface change after double eyelid blepharoplasty. This seems to be a substantially more convenient and objective measurement for the assessment of the palpebral fissure. An anthropometric study by Park et al¹⁷ showed that the area of cornea exposure continuously decreased after it reached the peak level between the age of 20 and 29 years. To prevent the influence of age, only young Chinese patients under the age of 30 were included in this study. We used the diameter of the iris as the standard reference for the measurement using the ImageJ software. The anthropometric measurements were expressed as the ratio of the reference value. This method could eliminate the distortion produced by photographs; thus, the ratio value with the respective reference could lead to a more objective analysis.

The preoperative measurement indicated that 60.7% of cases showed visible (>5%) EEA asymmetry and 55.95% of cases presented a larger right EEA. However, longer right BED was found in 52.38% of the cases. This finding suggested that more than half of the candidates with a single eyelid crease presented with eyelid asymmetry, which should be addressed in preoperative planning.

In our study, the ocular surface area, BED, and palpebral crease were associated with eyelid appearance. The postoperative measurements suggested an overall EEA increase in each group after double eyelid blepharoplasty. A more significant increase could be noticed 90 days after surgery, possibly because of the amelioration of periorbital edema. Double eyelid surgery cannot improve the opening force of the eyelid. However, the formation of a double eyelid crease acts like folding of the upper eyelid prolapsing skin, which could slightly increase EEA. For different operative techniques, the mini-incision group exhibited the least increase in EEA, whereas the FIDE group showed the maximum increase in EEA. This result suggested that plication of certain palpebral skin could contribute to around a 10% increase in EEA, whereas additional resection of loose palpebral skin and enlargement of the epicanthus could result in a greater increase in EEA. Together with the visual effect of the eyelid fold, the double eyelid blepharoplasty could make the eyes appear larger substantially.

A previous investigation by Matsushita et al¹⁸ showed that closer eyebrows to the eyes made the eyes appear larger and higher eyebrows made the eyes appear smaller. A longer BED indicated a larger area between the palpebral margin and brow, which implied a bulky eyelid appearance. There was a significant BED reduction after double eyelid blepharoplasty. A more significant reduction in BED was found after the FID or FIDE eyelid blepharoplasty. Resection of the upper eyelid skin and subcutaneous tissue could directly facilitate a reduction in BED. The formation of a double eyelid crease could visually increase the palpebral fissure; subsequently, the increased palpebral fissure to BED ratio led to a less bulky appearance. This result indicated that the decrease in BED contributed to the enlargement effect of double eyelid blepharoplasty. The initial PCH after surgery was apparent because of postoperative edema. It declined significantly after recovery. We used to believe that the full-incision method (including FIDE and FID) may lead to more prominent swelling than the mini-incision method. However, there was no significant difference in swelling among the mini and full-incision methods in our study. Our study had a limitation in that manual selection of both distance and area may also produce measurement variance. Consequently, it is difficult to eliminate all unnoticed facial expression changes before the camera.

CONCLUSION

Photo-assisted anthropometric analysis of double eyelid blepharoplasty could produce objective outcomes. The preoperative measurement suggested that more than half of single-eyelid crease Asians presented with eyelid asymmetry. The results showed an increase in EEA and a decrease in BED after double eyelid blepharoplasty. Distinct results were produced by different surgical techniques. The FIDE group showed the maximum increase in EEA and a decrease in BED. These findings provide an important reference for preoperative planning and postoperative analysis.