Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results

CHAPTER 2 Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results



Val Lambros, Steven Fagien




Surgical approaches for the cosmetic improvement of the aging periorbita continue to evolve. A combination of factors have added to improved methods that relate to a higher level of understanding of facial aging that has been supported by information gained from the both histologic and gross anatomy dissections as well as observations made through imaging and photography. A large distraction has been a wide variety of personal perception of what occurs with facial aging combined with a surgical interpretation that did not always reflect the most accurate analysis or what would approach the rejuvenated state. Even simply evaluating ‘old’ photographs, although useful, can be deceptive, whereas the illusion of the components of facial aging are actually not supported by reality. Through morph-like techniques pioneered by Lambros1 whereby current and dated posturally matched images are superimposed that more accurately detect the changes in the various facial regions, we now have a better understanding of the truth of facial changes with age that have revealed surprising discoveries. As these findings relate to the periorbita, we have also found it useful to compare the same eyes and periorbital regions as they age, and report on what lessons can be learned from watching this progression.


Val Lambros and Steven Fagien



Introduction


Although there is abundant variation in the aging patterns of the billions of human periorbita (eyes) on the planet, there are also commonalities that influence the way the eye region is perceived. An old Asian is as easily recognized as is an old Caucasian and for similar reasons.2


We have found it more useful to examine the aging face and periorbital region in a linear fashion rather than to look at populations for several reasons. Firstly, population studies are valuable for looking at particular eye regions at a particular point in time, but comparisons are necessarily on different eyes and statistical differences are the usual method of analysis. Tables and charts of measurements are customary in anthropologic studies, but not so in surgery which relies on more direct visual comparisons.3 Secondly and more importantly, seen at a single point in time, the aging face and periorbital region are frequently deceptive. Because finger elevation may make a part look better, the perfectly reasonable but not necessarily true assumption may be that the part has fallen.


It is also easy to underestimate tissue thinning and deflation because their contribution to an aged appearance are not always immediately obvious, and altering these variables is not in the common surgical repertoire.


For several years we have conducted linear comparisons in individuals by means of highly matched old and recent photographs, which are sized and aligned on stable points. The image pairs are then studied by overlaying the images on the computer and transitioning from one to the other. The eye is very sensitive to motion presented this way, and differences in position and shape are easy to see and compare (see Chapter 2, DVD).


Briefly the technique is as follows: As has become customary during consultations, patients are asked to bring in old photographs of themselves. Friends and relatives are also easy targets because of the availability of old pictures. New pictures are then taken and every effort is made to match the orientation of these old photos. This is the most tedious part of the process as it takes many exposures to get within the several degrees necessary to make the technique valid and it takes some time to sort through them on the computer. Straight anterior–posterior (with the head level in primary position) [APs] are the easiest to match; obliques are more difficult and laterals are the most difficult to match because of the lack of reference points.


If not taken on a digital camera, the old and recent prints are digitized and compared in an imaging program, in this study, Adobe Photoshop. The layers function of Photoshop digitally stacks one image on top of the other and is indispensable in accurately matching multiple images. By toggling the upper image on and off, any offset relative to the lower image is quickly visible. In the antero-posterior view, the alignment and sizing points are the medial canthal tendon’s insertion into the nasal side-wall, the interpupillary distance, the base of the columella and other confirmatory points. The two saved images, the old and the recent are then converted into a gif animation using Adobe Image Ready, or other gif animation programs. GIF Construction Set Professional (www.alchemymindworkshop.com) was extensively used in this series. The gif animation automates the process of fading from one aligned and sized image to the other for careful inspection (see Chapter 2, DVD).


As the images are never perfectly aligned, some practice is needed to look at them. If the relative motion is small, within a degree or so, and in an easily understood direction, for example side to side or up and down, the eye compensates for the motion and the images make sense (Animation 1, see DVD). If there is a combination of motions, then the progression is not as intuitive and there is less gained by studying position changes, though shape comparisons may be made. Low-contrast tissue borders on the face are more easily appreciated from a distance rather than close-up and hence these images are best studied from a modest distance.


This method of analysis was not intended to be quantitative, though measurements can be taken. Rather it is a method to visually compare changes in size position and shape of structures. A rule of thumb is that the diameter of the iris is approximately 10½–11½ mm.


More recently we have used a 3-D camera (Canfield scientific) to acquire the entire surface of the face. These images can then be used to match to other 3-D images or to match against 2-D images. Measurements may be taken in any axis with this kind of system and comparing old and recent 3-D images is the logical future of this kind of research. None of these images are used in this article.

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Mar 16, 2016 | Posted by in Craniofacial surgery | Comments Off on Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results

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