Key points

Introduction

The evaluation and treatment of the aging in the periorbital region necessitate careful consideration of its function and anatomy. The periorbital region plays an important role in human social interactions. It effectively communicates not only emotion but also frequently the human condition. As the periorbital region is one of the first parts of the face to show signs of aging, a frequent complaint is that the patient appears tired, sad, or angry.

The periorbital region is composed of the upper and lower eyelids and eyebrow. This region is bounded by the glabella medially, the forehead superiorly, the temple laterally, and the midface inferiorly. Because of the complex interplay between these facial subunits, safe and effective periorbital surgery requires an understanding of the structural changes of this region with aging and a mastery of the anatomy of the orbit, midface, forehead, and brow. The eyebrow and upper eyelid are so intimately intertwined in their function and esthetics that they are considered 2 parts of a continuum: requiring careful consideration of one when treating the other. The lower eyelid and midface share a similar relationship albeit to a lesser degree. This article details the principles and techniques for treatment of the periorbital region with respect to the upper face and midface; the discussion of the latter will be limited to the aspects that directly impact the periorbital region.

Introduction

The evaluation and treatment of the aging in the periorbital region necessitate careful consideration of its function and anatomy. The periorbital region plays an important role in human social interactions. It effectively communicates not only emotion but also frequently the human condition. As the periorbital region is one of the first parts of the face to show signs of aging, a frequent complaint is that the patient appears tired, sad, or angry.

The periorbital region is composed of the upper and lower eyelids and eyebrow. This region is bounded by the glabella medially, the forehead superiorly, the temple laterally, and the midface inferiorly. Because of the complex interplay between these facial subunits, safe and effective periorbital surgery requires an understanding of the structural changes of this region with aging and a mastery of the anatomy of the orbit, midface, forehead, and brow. The eyebrow and upper eyelid are so intimately intertwined in their function and esthetics that they are considered 2 parts of a continuum: requiring careful consideration of one when treating the other. The lower eyelid and midface share a similar relationship albeit to a lesser degree. This article details the principles and techniques for treatment of the periorbital region with respect to the upper face and midface; the discussion of the latter will be limited to the aspects that directly impact the periorbital region.

Esthetics and aging

There are many changes to the skin, bone, and soft tissues of the face that are associated with aging ( Box 1 ). Facial aging is due to bony atrophy, lipoatrophy, and descent of facial soft tissues. The esthetic ideal for the forehead and eyebrow is a subjective and controversial topic. Because of gender, ethnic, and age-related variations, there are many published statements of the esthetic ideal. Westmore’s ideal female brow position, one of the most popular ideal female brow positions, locates the peak at the lateral limbus. However, current trends place the brow’s peak at a more lateral position closer to the lateral canthus. Given the variance in opinions, an honest dialogue between the patient and surgeon is imperative in establishing a plan of treatment that is both acceptable and achievable.

In youth, there is a smooth transition from the lower eyelid to the cheek. Ideally, the midface convexity is uniform and relatively free of concavities. With aging, there is a loss of continuity due to contour irregularities and volume differences. The bony orbital rim becomes more pronounced due to inferior displacement of midfacial fat caused by ptosis and atrophy combined with the increased prominence of orbital fat and bone superiorly. In the midface, the position of the malar fat pad is the primary distinction between the youthful face and the aging face. In the youthful face, the malar fat pad should be positioned overlying the zygomatic arch and the orbital component of the orbicularis oculi muscle. Inferiorly, the malar fat pad should be at, but not extending beyond, the nasolabial fold.

Preoperative assessment

Preoperative assessment and planning are critical to achieving safe and effective results. Prior history of facial nerve injury or weakness, neurotoxin injection, facial surgery, or trauma should be elicited. The choice of the rejuvenation technique depends on the patient’s presenting complaints and anatomy, including scalp hair, eyebrow hair, hairline position and shape, forehead length, forehead shape, hairstyle, quality of skin, jowls, depth of nasolabial folds, malar contour, and degree of lift needed. There are additional considerations that should be made when assessing the forehead, brow, and upper eyelids ( Boxes 2 and 3 ). The principle of Hering’s law, which describes the symmetric motor innervation of bilateral levator and frontalis muscles, should also be taken into account, especially when encountering unilateral ptosis or asymmetry. Depending on the patient’s needs, a combination of treatment approaches to the brow, forehead, and midface may be implemented.

In addition to recognizing the esthetic and surgical issues, a detailed history of pre-existing ocular conditions, such as prior ophthalmologic surgery, chronic lid infections, ptosis, or refractive errors, is an important part of the initial assessment. A complete medical history should be elicited to discover any comorbidities that may have ocular manifestations. The physical examination of the patient may also include visual acuity, extraocular muscle assessment, visual fields, lacrimal secretion, corneal sensation, pupillary assessment, lower eyelid position, margin gap, and the presence or absence of a Bell phenomenon. Assessment of the marginal reflex distances (MRD1, MRD2) may be useful in assessing for ptosis and ectropion. MRD1 is the distance from the pupillary light reflex to the upper eyelid. MRD2 is the distance from the pupillary light reflex to the lower eyelid. The margin gap is the distance between the margin of the upper and lower eyelid with involuntary blink and maximal effort. The palpebral fissure height is the distance between the upper and lower eyelid in primary gaze.

Forehead and brow

Anatomy

The eyebrow extends from the glabella medially to the temporal region laterally. The skin and soft tissues of the eyebrow overly the superior orbital rim. The hair of the eyebrow is unique from that of the scalp. These hair follicles have a limited potential for growth and regeneration following injury. The hair of the eyebrow imparts much of the apparent shape to the brow: flat, arched, or sloping laterally. Men typically have thicker brows than women. The female brow is generally more superiorly located with a greater arch. The male brow is generally lower on the superior orbital rim and flatter. The brow contour may be prominent with robust soft tissue and bony contour or flat with atrophy. The muscles of the eyebrow region include the orbicularis oculi, procerus, corrugator supercilii, and depressor supercilii. These muscles are all depressors of the eyebrow and are innervated by the facial nerve. The orbicularis oculi is divided into 3 components (pretarsal, preseptal, orbital) as defined by the periorbital structure that it overlies. The procerus muscle spans the nasion to the midline glabella and is responsible for inferior displacement of the medial brow and horizontal glabellar rhytids ( Fig. 1 ). The corrugator supercilii muscle spans the medial superciliary ridge to the lateral third of the brow and is responsible for inferomedial displacement of the medial brow and vertical glabellar rhytids. The depressor supercilii muscle spans the frontal process of the maxilla to the superior medial canthal region and is responsible for inferior displacement of the medial brow and oblique glabellar rhytids. The frontalis muscle is responsible for brow and forehead elevation and is innervated by the temporal branch of the facial nerve. The frontalis muscles span the galea aponeurotica anteriorly, occipitalis muscles posteriorly, and the temporal fascia laterally. Contraction of the frontalis muscle creates the horizontal rhytids of the forehead region.

Muscles relevant to rejuvenation of the brow and forehead. Brow elevators: frontalis muscle. Brow depressors: orbicularis oculi muscle, corrugator supercilii muscle (with transverse and oblique heads), depressor supercilii muscle, and procerus muscle. Other relevant muscles include the temporalis muscle.

( From Nassif P, Griffin G. The aesthetic brow and forehead. In: Flint P, Haughey B, Lund V, et al, editors. Cummings otolaryngology. Philadelphia: Saunders; 2015. p. 432; with permission.)

The forehead extends from the superior aspect of the eyebrow inferiorly to the hairline superiorly. Laterally, the temporal region bounds the forehead. The forehead shape is impacted by the position of the eyebrows and the hairline. The average male hairline height is 6.5 to 8 cm, whereas the average female hairline height is 5 to 6 cm. The forehead contour may be sloping posteriorly, flat, or protruding anteriorly. The forehead is composed of several layers of soft tissue: skin, connective tissue, aponeurosis, loose areolar tissue, galea, and periosteum.