A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty

Abstract

Importance

Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions.

Objectives

To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions.

Design, Setting, and Participants

A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected.

Main Outcomes and Measures

A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status.

Results

A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (–1.04 years; 95% CI, –1.70 to –0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty.

Conclusions and Relevance

This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty.

Level of Evidence

NA.

This web-based survey study examines the effect of blepharoplasty on facial perceptions and measures patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions.

Key Points

Question

Does blepharoplasty improve ratings of age, attractiveness, health, and energy level in female patients?

Findings

This web-based survey study of 401 participants evaluating photographs of 10 patients showed that women who underwent blepharoplasty were rated as appearing significantly younger and more attractive than their preoperative counterparts; individuals were also perceived to be healthier and less fatigued after blepharoplasty. In addition, patients noted improvements in perceived energy level after blepharoplasty as measured by a validated patient-reported outcomes tool.

Meaning

This pilot study demonstrates that blepharoplasty significantly improves casual observer ratings of age, attractiveness, health, and energy level in women, and that patients perceive significant improvements in energy level following blepharoplasty.

Introduction

Blepharoplasty consistently ranks among the most popular cosmetic services sought by both men and women, with more than 200 000 procedures performed in 2015. Although blepharoplasty is commonly regarded as a procedure to rejuvenate the aging face, for some individuals, visual impairment due to dermatochalasis makes blepharoplasty medically necessary to restore visual functioning. Despite the prevalence of this procedure, there exists little evidence aimed at quantifying the surgical effect of blepharoplasty.

The eyes play a crucial role in social functioning, as they can provide cues to social contacts indicating interest and engagement. Therefore, changes in the appearance of the eyes may affect these daily interactions. Age-related changes are known to alter the appearance of the eyes; excess eyelid skin, fat herniation, and wrinkles around the eyes have all been noted to signal aging. Previous efforts to measure the effect on perceived age of surgery for the aging face found that blepharoplasty yields a mean age reduction of 2 years. Aging has also been shown to be associated with decreasing ratings of attractiveness, which may have broader social implications.

Fatigue is also appreciated in changes in the appearance of the eyes. When individuals are asked to judge how fatigued an individual appears, they spend most of their time fixating on the eyes. A study exploring the specific cues for fatigue cited hanging eyelids, dark circles, and more wrinkles and fine lines. Interestingly, a primary concern of patients before they undergo blepharoplasty is that they appear tired, and fatigue is one of the major patient-reported outcomes captured on the Blepharoplasty Outcomes Evaluation (BOE) questionnaire. Furthermore, understanding how blepharoplasty changes ratings of energy level will prove important, as a 2016 survey by the American Academy of Facial Plastic and Reconstructive Surgery uncovered a new trend: patients are seeking procedures with the hopes of appearing less tired.

The appearance of fatigue has also been shown to cause decrements in ratings of perceived attractiveness and health, which further links the appearance of the eyes to social functioning. Individuals who are considered to be more attractive have been shown to receive preferential treatment in a variety of social and professional settings. From an evolutionary perspective, increases in perceived health may prove beneficial in mate selection. These associations provide further incentive for patients to reverse the appearance of fatigue.

The primary objective of this study was to measure the effect of blepharoplasty on several facial perception domains. We aimed to quantify the effect of surgery on the traditional domains of age and attractiveness, and also explored how surgery can affect ratings of perceived health and fatigue. Understanding these clinical effect sizes will position surgeons well to guide patient expectations before the procedure. Furthermore, we explored patient-reported ratings of fatigue before and after blepharoplasty. By examining ratings of fatigue from both the patient and the observer perspective, physicians will be better able to counsel patients regarding this important domain.

Methods

Two studies were performed to better understand how blepharoplasty alters facial perceptions. The first was a web-based experiment in which casual observers rated photographs of faces before and after blepharoplasty, and the second was a patient perspective pilot study comparing patient-reported ratings of fatigue.

Prospective Randomized Web-Based Experiment

Participants

A total of 401 participants completed the study from January to February 2017. Survey takers were excluded from the study if they were younger than 18 years or had psychiatric conditions such as schizophrenia or an autism spectrum disorder owing to differences in how these individuals direct attention toward a face. Only surveys that were completed in their entirety were included in the final analysis. Approval was obtained for this study from the Johns Hopkins University School of Medicine Institutional Review Board.

Instrument

Surveys were built using Qualtrics Survey Software (Qualtrics). As described previously, a link was disseminated via various public access websites. The first page of the survey described the task and relevant exclusion criteria. Participants were instructed that they would be looking at photographs of faces, some of which had undergone blepharoplasty and some that had not. At this time, respondents were notified that continuing on to the survey would serve as informed consent for their participation. Survey takers were also informed that they would be eligible to enter a drawing for a gift card of nominal value on successful completion of the survey.

Photographs of 21 female patients who underwent upper and/or lower blepharoplasty, for either cosmetic or functional reasons, were selected from photograph databases at a tertiary academic medical center or private practice clinic. Patients in the photographs provided informed consent for the use of their images and had not undergone additional cosmetic surgery. Using the Delphi method, 5 expert graders (I.D.P, T.C.K., P.J.B., K.D.O.B., and L.E.I.) provided ratings of patient candidacy and surgical outcomes, and these were used to narrow the image pool to reflect optimal surgical outcomes. The experts identified 13 patients who had surgical outcomes in the upper quartile. Three sets of photographs were excluded owing to poor standardization between the preoperative and postoperative photographs or nonneutral facial expressions.

Of the 10 individuals selected for inclusion in the final survey (mean age, 59.8 years), 7 had undergone upper blepharoplasty and 3 had combined upper and lower blepharoplasty. For all patients, bilateral upper blepharoplasty was performed, and 1 patient was noted to have ptotic lacrimal glands that were repositioned during surgery. Lower blepharoplasties were performed using the transconjunctival approach, with 1 patient also undergoing a concurrent laser resurfacing peel. None of the patients was noted to have periorbital botox or fillers between the 2 photographs. Observers were randomly shown either the preoperative or the postoperative photograph of each patient to reduce the possibility of bias due to priming. Sample preoperative and postoperative photographs are in Figure 1.

Figure 1. Example Patient Photographs.

Left column shows patients before blepharoplasty and right column shows patients after blepharoplasty.

For each photograph, observers were asked to estimate the age of the face using a slider bar ranging from 30 to 80 years that could be moved up or down at 1-year increments. Participants were then asked to rate perceived attractiveness, health, and energy level of the individual in the image using a 100-point visual analog scale with 1-point increments for attractiveness (range, 0 to 100, where 0 indicates least attractive and 100 indicates most attractive) and for health and energy level (range, –50 to 50, where –50 indicates least energy and 50 indicates most energy).

Statistical Analysis

Statistical analysis was performed using STATA, version 13 SE (StataCorp). A multivariate mixed effects regression model was used to measure the effect size of blepharoplasty on the domains of interest. This type of model was of particular value as it allowed us to parse out the differences in domain ratings due to surgical effect while accounting for participant biases.

Next we aimed to quantify the clinical effect size of changes in each of the domains using the ordinal rank change approach, as previously described. Using the residual variance from the mixed effects regression model, we plotted the probability density function for the gaussian distribution of ratings for each domain that could then be integrated and scaled in Mathematica, version 10.4 (Wolfram). The area under the curve represents a proportion of the population, and the difference in area under the curve between the mean preoperative and postoperative ratings provides the estimated ordinal rank change for a given domain as a measure of effect size. The integration that yields the ordinal rank change is shown pictorially in a work by Bater et al.

Patient Perspective Pilot Study

Participants

A total of 161 patients who presented to a facial plastic surgery clinic with eye-related concerns (45 functional [28.0%] and 116 cosmetic [72.0%]) from January to February 2017 were eligible to complete a survey that included the BOE questionnaire.

Instrument

Relevant to our study of how the casual observer perceives energy level in the patients who have undergone blepharoplasty, 1 question on the BOE specifically addresses the common concern of appearing fatigued by asking patients to evaluate the following statement: “Do you feel like the appearance of your eyes makes you look tired?” Patients are offered a 5-point Likert scale ranging from “not at all” to “completely.” To probe the dimension of fatigue from the patient perspective, we extracted the answers to this question along with operative status (new patient, return patient with no blepharoplasty, return patient with blepharoplasty) to determine if blepharoplasty leads to significantly improved ratings in this domain.

Statistical Analysis

Statistical analysis was performed using STATA, version 13 SE (StataCorp). Responses to the BOE represent ordinal data; therefore, a Kruskal-Wallis test was used to determine if statistically significant differences existed between the 3 patient groups. This test was followed by planned posthypothesis testing to measure differences between each of the groups. Bonferroni correction was applied to account for multiple comparisons. P < .05 was considered significant.

Results

Prospective Randomized Controlled Experiment

A total of 401 participants successfully completed the study and were eligible for inclusion. The mean age of survey participants was 25.9 years (range, 18.0-73.0 years) and the majority identified as white (315 [78.6%]) and female (243 [60.6%]). Complete participant demographics are presented in Table 1.

Table 1. Demographic Characteristics of 401 Web-Based Study Participants.

Observer Characteristics	Participants, No. (%)
Age, mean (range), y	25.9 (18.0-73.0)
Sex
Male	152 (37.9)
Female	243 (60.6)
Prefer not to specify	6 (1.5)
Race/ethnicity
Asian	35 (8.7)
African American	10 (2.5)
Hispanic	15 (3.7)
White	315 (78.6)
Other or prefer not to specify	26 (6.5)
Educational level
<High school	9 (2.2)
High school or GED	53 (13.2)
Some college	120 (29.9)
2-y College degree	22 (5.5)
4-y College degree	143 (35.7)
Master’s degree	43 (10.7)
Doctoral degree	11 (2.7)
Annual household income, $
<25 000	107 (26.7)
25 000-50 000	100 (24.9)
>50 000-75 000	76 (19.0)
>75 000-100 000	48 (12.0)
>100 000-150 000	44 (11.0)
>150 000-200 000	10 (2.5)
>200 000	15 (3.7)
Cosmetic procedures
Personal history of procedure to enhance facial appearance	22 (5.5)
History of friends or relatives having undergone procedure to enhance facial appearance	107 (26.7)

Abbreviation: GED, general education development certificate.

The established associations between age, attractiveness, health, and fatigue led us to use a multivariate mixed effects model to understand the interplay between the domains after blepharoplasty. Our model found that individuals undergoing blepharoplasty are rated as appearing 1.04 years younger (95% CI, 0.37-1.70 years) after surgery. They were also rated as appearing significantly more attractive (coefficient, 4.92; 95% CI, 3.91-5.93), healthy (coefficient, 4.33; 95% CI, 3.28-5.37), and energetic (coefficient, 9.83, 95% CI, 8.51-11.16) compared with their preoperative counterparts. Regression results are summarized in Table 2.

Table 2. Mixed Effects Multivariate Regression Model.

Variable and Covariate		Coefficient (SE) [95% CI]	P Value
Fixed Effects
Estimated agea
Surgery		−1.04 (0.339) [−1.70 to −0.37]	.002
Constant		55.55 (0.258) [55.04 to 56.06]	<.001
Attractivenessb
Surgery		4.92 (0.516) [3.91 to 5.93]	<.001
Constant		41.99 (0.717) [40.58 to 43.39]	<.001
Healthc
Surgery		4.33 (0.532) [3.28 to 5.37]	<.001
Constant		7.12 (0.496) [6.15 to 8.10]	<.001
Energy levelc
Surgery		9.83 (0.677) [8.51 to 11.16]	<.001
Constant		−3.73 (0.535) [−4.78 to −2.68]	<.001
Random Effects		Estimate (SE) [95% CI]
Parameter
Variance, observer (age)		4.211 (1.08) [2.55 to 6.97]	NA
Variance, residual (age)		111.93 (2.61) [106.93 to 117.16]	NA
Variance, observer (attractiveness)		155.32 (12.44) [132.76 to 181.71]	NA
Variance, residual (attractiveness)		248.03 (5.90) [236.73 to 259.86]	NA
Variance, observer (health)		43.68 (4.64) [35.46 to 53.80]	NA
Variance, residual (health)		268.88 (6.41) [256.60 to 281.74]	NA
Variance, observer (energy)		25.00 (4.62) [17.41 to 35.91]	NA
Variance, residual (energy)		444.33 (10.56) [424.10 to 465.53]	NA
Covariance, residual (age, attractiveness)		−50.64 (2.86) [−56.24 to −45.02]	<.001
Covariance, residual (age, energy)		−45.50 (3.70) [−52.75 to −38.25]	<.001
Covariance, residual (age, health)		−40.37 (2.91) [−46.08 to −34.66]	<.001
Covariance, residual (attractiveness, energy)		132.62 (5.99) [120.88 to 144.36]	<.001
Covariance, residual (attractiveness, health)		134.35 (4.90) [124.74 to 143.97]	<.001
Covariance, residual (health, energy)		183.74 (6.54) [170.91 to 196.58]	<.001

Abbreviation: NA, not applicable.

^aObserver estimated age coded on visual analog scale from 30 to 80 years with 1-year increments.

^bObserver perceived attractiveness coded on visual analog scale from 0 to 100 with 1-unit increments.

^cObserver perceived health and energy level coded on visual analog scale from −50 to 50 with 1-unit increments.

The multivariate mixed effects analysis also allowed us to account for bias in participant gradings, which allowed us to more precisely calculate the clinical effect size using ordinal rank changes. As previously described, ordinal rank is obtained by randomly sampling a group of 100 individuals and ranking them in the domain of interest, with 1 being the lowest rank and 100 the highest rank. The ordinal rank change provides a measure of how much an average individual will improve in the domain’s ranking after blepharoplasty. Our data show that if 100 people were randomly sampled and ranked from least attractive to most attractive, the individual ranked 50th (average) would be expected to shift to position 62 in attractiveness following surgery, with this higher value representing a more positive ranking. For the domains of health, an individual ranked 50th would be expected to shift to position 60 and for the domain of energy level, an individual ranked 50th would be expected to shift to position 68. Ordinal rank changes in the domains of attractiveness, health, and energy level are displayed pictorially in Figure 2.

Figure 2. Ordinal Rank Changes.

Ordinal rank changes demonstrate improvement in domain rankings of attractiveness, health, and energy level following blepharoplasty. The figure surrounded by yellow shading respresents the average preoperative rating, and the figure surrounded by green shading respresents the average postoperative rating.

Patient Perspective Pilot Study

Data from the 161 patients (77 new patients, 59 returning without blepharoplasty, and 25 returning with blepharoplasty) who completed the BOE questionnaire are depicted pictorially in Figure 3. The initial Kruskal-Wallis test indicated that there were statistically significant differences between the patient groups (χ²₂ = 19.89; P < .001). Planned posthypothesis comparisons using Mann-Whitney tests showed that there was no significant difference in energy level ratings between the new patients and the return patients who did not undergo blepharoplasty (z = –1.456; P = .15). There were, however, statistically significant differences in ratings between new patients and post-operative blepharoplasty patients (z = –4.528; P < .001) and return patients who did not undergo blepharoplasty and those who did undergo blepharoplasty (z = –3.381; P < .001).

Figure 3. Differences in Patient-Reported Tiredness Scores Based on Operative Status.

Box and whisker plots demonstrate differences in patient-reported tiredness scores based on operative status. Patient responses were coded from 0 to 4, with 0 indicating strong agreement (“completely”) and 4 indicating strong disagreement (“not at all”). Statistics are the result of Mann-Whitney tests. Boxes contain values within the 25th to 75th percentile. The solid line within the box represents the median value; whisker lines represent the range of values falling below the 25th percentile and above the 75th percentile.

^aP > .05 compared with group returning without blepharoplasty.

^bP < .001 compared with group returning with blepharoplasty.

Discussion

To our knowledge, this is the largest study aimed at quantifying the clinical effects of blepharoplasty on facial perceptions. Our data suggest that after blepharoplasty, female patients are perceived as more youthful, attractive, healthy, and energetic by the casual observer.

Societal perceptions can provide key insight into domain ratings that would otherwise prove challenging to measure. To quantify changes in the domains of interest, we rely on the vox populi principle described by Galton. His theory posits that when surveying a large crowd, the collective (ie, mean) judgment of a group represents a value that each of the group’s individual members may not have been able to discern independently. The broad application of this theory across many disciplines increases our confidence that the mean value the group assigned to each domain rating should closely approximate the true value attributed to each face by society.

We believe that our understanding of changes in ratings of age and attractiveness, more traditional domains in the field of cosmetic surgery, will provide a meaningful addition to the existing literature. Evidence suggests that attractiveness ratings decrease as a function of age; our data suggest that blepharoplasty leads to a decrease in perceived age, which may then contribute positively to ratings of attractiveness. Our data also demonstrate that, after blepharoplasty, patients are perceived as significantly more attractive than their preoperative counterparts. This finding may have broad implications for these patients, as attractiveness has been shown to confer both social and professional benefits.

The true benefits of being rated as more attractive are not limited to receiving more judicial leniency or increasing the likelihood of winning an election, as perceived attractiveness can also provide vital clues signaling health status. Perceived attractiveness may represent a phenotypic marker of health; this association is supported by our findings that attractiveness ratings and ratings of perceived health both increase as a result of blepharoplasty.

Casual observer ratings of fatigue provide further insight into the association between the domains. A study on the effect of “beauty sleep” found that sleep-deprived individuals appeared more tired, less attractive, and less healthy than when they were well rested, suggesting that appearing tired may confer a large social penalty. These consequences may be, in part, why restoring a more energized look to the face was a rising trend in plastic surgery clinics in 2016. Knoll et al aimed to understand features of the eyes associated with tiredness; their findings suggested that tiredness ratings were associated with ptosis of the upper eyelid. Our pilot effort could not parse the contributions of individual features of the eye, but this is an interesting area for future study and could help surgeons better identify patients who might benefit most from blepharoplasty.

Restoring a more energized look to the face through cosmetic procedures might have been considered a new trend in 2016, but historically, the patient planning to undergo blepharoplasty has been concerned about appearing tired. Using the BOE, we were also able to probe the domain of fatigue from the patient perspective. Analysis of a small sample of patients in our clinic who were interested in improving the appearance of their eyes demonstrated that individuals have significantly poorer ratings of fatigue related to the appearance of their eyes before surgery than do those who have undergone blepharoplasty. This finding highlights that blepharoplasty not only improves the appearance of fatigue from the observer perspective, but also from the patient perspective, which most surgeons would argue is paramount.

Ratings of fatigue are important to the patient, and our study demonstrated that casual observers perceive significant changes in energy level after blepharoplasty. The relative decrement in perceived age of 1.04 years may seem small compared with the change in fatigue ratings after surgery. We suspect this finding may be explained by the fact that isolated blepharoplasty changes only the appearance of the eyes, and does not change other facial features that are used to estimate age. The changes in energy level ratings, however, seemed robust to the other facial cues that remained, perhaps signaling the increased importance of the eyes when judging how tired a face appears. Uncovering this distinction may prove valuable to clinicians as they aim to manage patient expectations following surgery.

Limitations

This pilot effort is not without limitations. Our survey distribution method likely led to a skewed population that tended toward young, white participants. Although the vox populi principle states that with a large sample size of independent observers the mean value obtained for each domain should still closely approximate the true rating of the face, expanding our distribution channels and recruiting more diverse participants will be an aim for future efforts; there are likely age-related and cultural nuances that influence ratings not fully captured within this pilot study.

We also had a small photograph pool of only 10 female patients before and after surgery. To characterize the effect size in this initial study, we opted to employ the Delphi method, in which 5 expert cosmetic surgeons selected the optimal outcomes from our patient pool. This photographic selection method limited the number of photographs displayed to only those with outcomes deemed optimal and did not ensure equal representation of upper, lower, and combined blepharoplasties. A larger-scale study will be required to understand more specifically how facial perceptions change within these subgroups of blepharoplasty. Our photograph pool was further diminished when we eliminated pairs of photographs that were not adequately standardized, as these could have led to bias in our study results. Although we aimed for standardization between the photograph pairs, confounders such as hair color and style, makeup, and jewelry can alter participant ratings and likely contribute to the regression residuals.

Use of the Delphi method also causes the effect size presented here to have limited generalizability to the overall population of individuals seeking blepharoplasty. We expect that selecting the best candidates will optimize the effect size measured in each domain. Further study will be required to examine how patient candidacy and surgical outcomes influence changes across these domains. However, we believe this effort can serve as a preliminary guide for surgeons who wish to educate patients regarding the effects of blepharoplasty.

Despite these limitations, we believe that this study represents a meaningful effort to characterize the effect of blepharoplasty on perceptions of age, attractiveness, health, and energy level. Understanding the statistical and clinical effect sizes in each of these domains can aid surgeons in counselling and expectation management prior to blepharoplasty.

Conclusions

The data presented in this study demonstrate that individuals are rated as appearing more youthful, attractive, and healthy after blepharoplasty. The casual observer also perceived a significant improvement in energy level after surgery, which has been shown to align with patient perceptions after blepharoplasty. Furthermore, ordinal rank changes in each domain represent measures that can be used to more effectively guide preoperative conversations regarding patient expectations.