Correlation Between Brow Lift Outcomes and Aesthetic Ideals for Eyebrow Height and Shape in Females.
Robert M. Freund,M.D., amd WIlliam B. NOlan, III, M.D.
This study correlates brow lift outcomes published in the plastic surgical literature with aesthetic criteria for ideal female eyebrow height and shape. Aesthetic criteria were determined by testing the opinions of 11 cosmwetic surgeons and 9 cosmetologists. Eyebrow height and shape were alteres with computer graphics to isolate those changes as the only variables of appearance.
Plastic surgeons and cosmetologists preferred (p = 0.01) medial eyebrows below or at the supraorbital rim and disliked the medial eyebrow above the rim. Both groups preferred (p = 0.01) eyebrow shape to have an apex lateral slant.
One hundred preoperative and 100 postoperative photographs from 16 frequently referenced articles on browlifts were evaluated. There was a significant (p = 0.0008) increase in the number of medial eyebrows elevated above the rim. The number of medial apex eyebrowsincreased, and the number of flat brows decreased (p= 0.01). There was no significant increase in the number of apex lateral eyebrows.
Three conclusions are made about female eyebrows: (1) The medial eyebrow should be located at or below the supraorbital rim but not above it. (2) Eyebrow shape should have an apex lateral slant. (3) Standard open and endoscopic brow lift operations frequently result in unsatisfactory eyebrow height and shape. judged by these criteria.( Plast. Reconstr. Surg. 97:1343, 1996)
Coronal incision and endoscopic browlift techniques can change eyebrow height and shape. However, the aesthetic criteria for ideal height and shape are not adequately defined in the plastic surgical medical literature.
The primary purpose of this study was to determine valid aesthetic criteria for an attractive eyebrow. We were interested in determining if plastic surgeons have common aesthetic preferences. If aesthetic preferences exist for plastic surgeons as a group, do they also exist for another group of professionals who focus their attention on facial beauty ( cosmetologists)?
Finally, we wanted to evaluate the aesthetic outcome of brow lift surgery. Regardless of the aesthetic likes and dislikes of plastic surgeons, the effect of brow lift surgery can be determined by analyzing the results reported in 30 years of plastic surgical medical literature. If measurable aesthetic criteria can be established, the success or failure of a cosmetic operation can be evaluated.
Materials and Methods
Eleven aesthetic plastic surgeons and nine cosmetologists were chosen to participate in this study. Criteria for selecting representatives
of these two groups were established. The surgeons are board certified in plastic surgery, perform more than 100 cosmetic procedures per
year, and do more than 12 brow lifts per year. Each cosmetologist is a senior aesthetician at internationally renowned beauty centers in New York.
Each subject viewed a series of young female faces from three ethnic groups (Anglo-Saxon, Slavic, and Hispanic) (Fig. 1). The study faces
were chosen because of their stereotypical features and for the absence of any signs of facial rhytides. Each face was altered by computer
graphics (Apple Power Mac 8100 with Hewlett- Packard ScanJet IIcx color scanner and Adobe Photoshop LE) so that the eyebrows were
changed in two ways: (1) The eyebrow height was altered so that the medial aspect of the brow was placed at, above, or below the supraorbital rim. Eyebrow shape remained constant. The eyebrow shape, relative height of the medial and lateral eyebrow, and relative height of the right and left eyebrows were not changed .(2) The eyebrow was altered so that the apex, defined as the highest point of the eyebrow, was medial to or lateral to a vertical line through the lateral limbus. In a third picture, the eyebrow was flattened so that no distinguishable apexix was present. Eyebrow height remained
constant. The average eyebrow height and the relative height of the medial and lateral eyebrow were not altered.
The preferences of each subject being tested in the study were recorded independently. The subjects were a~kedto look at the photographs with altered eyebrow height one at a time. They were asked to score the eyebrow appearance as "aesthetically pleasing" on a scale from 1 (worst) to 10 (best).
Next, they viewed the faces with the altered eyebrow shape, using the same ranking system. Prior to viewing the computer-generated faces,
no discussions or opinions were solicited or offered regarding eyebrow aesthetics.
In the next part of our study, 100 preoperative and 100 postoperative photographs from 16 frequently referenced articles on brow lift surgery
were evaluated. The evaluation was double blind, by a subject, not a plastic surgeon, cosmetologist, or primary investigator. The subject
was not informed of the purpose of this study prior to testing. The subject was asked to evaluate four variables of eyebrow appearance
in randomly sorted preoperative and postoperative photographs taken from the 16 articles:
- Is the position of the most medial eyebrow
at, above, or below the supraorbital rim? It
was demonstrated that the supraorbital
rim is the most prominent part of the eye
socket above the eye and explained that
the position of the eyebrow was the midpoint
between the caudal and cephalic
hairs.
- Is the position of the eyebrow vertically
above the lateral limbus at, above, or below
the supraorbital rim?
- Is the position of the most lateral eyebrow
at, above, or below a horizontal line drawn
through the medial eyebrow?
- Is the shape of the eyebrow, as defined by
the location of the apex of the eyebrow,
relative to a vertical line at the lateral limbus
apex lateral, apex medial, or flat?
Statistical significance for each part of the study was determined by the Mann-Whitney nonparametric test and chi-squared analysis. All test parameters were determined in advance to eliminate any need for correction of multiple testing.
Results
Plastic surgeons preferred the medial eyebrow below the supraorbital rim (8.4 + 1.8) and at the supraorbital rim (7.8 +- 1.8) in comparison
with eyebrows that were above the supraorbital rim (4.4 5 2.1; p = 0.01). Cosmetologists preferred the eyebrow height that was at thesupraorbital |
rim ( 7.9 ± 1.6) and below the supraorbital rim (6.7 ± 2.2) in comparison with eyebrows that were above the supraorbital rim (3.7 ± 2.6; p= 0.01). Both plastic surgeons and cosmetologusts prefeferd eyebrows with lateral apex (8.7 ± 1.8 and 8.2 ± 1.7, respectively) over either eyebrows with a medially based apex (4.8 ± 2.7 and 4.9 ± 2.6; p = 0.005)
A double-blind analysis of 100 preoperative and 100 postoperative photographs revealed that, preoperatively, 58 eyebrows were "below"
the supraorbital rim and 30 eyebrows were "at" the supraorbital rim in the medial position, with 12 "above" the rim. Postoperatively, 12 eyebrows remained in the "below" position, 39 were in the "at" position, and 49 were in the "above" position (p = 0.0008). No brow that is in the "at" or "above" position on preoperative photographs was moved to the "below" position on postoperative photographs. Only one brow in the "above" position was recorded in the "at" position in the postoperative photographs.
The changes in the relative position of the lateral eyebrow reflected the tendency of the medial eyebrow to move up with brow lift surgery.
Relative to the medial brow, 24 lateral eyebrows are moved down in location. Nineteen "at" brows are moved "below" and five "above7'
eyebrows are moved to the "at" location (p = 0.01).
With respect to shape, preoperatively, there were 43 eyebrows with a lateral apex, and postoperatively, 15 (30 percent) of these brows became flat and 1 had a medial apex (p = 0.1). Of the 57 eyebrows that had a flat or medial apex shape preoperatively, 26 (49 percent) were transformed to lateral apex shape after surgery (p = 0.1).
Discussion
A beautiful face is composed of many physical characteristics. We are interested in aesthetic criteria that are of the greatest utility to plastic surgeons. The most useful criteria relate to the physical features that standard surgical procedures can change. Over the past 30 years, many articles on brow lift surgery have been published in the medical literature. Most articles describe the surgical technique and illustrate
the results. Commonly, these articles avoid stating specific aesthetic objectives or are unsatisfactory in their attempts.
Several authors have attempted to define aesthetic objectives, but their likes and dislikes are not well supported and are nothing more than
individual preferences. To obscure the aesthetic objectives further, the opinions are not consistent among the authors. This could be interpreted to mean that all judgments of beauty are subject to perception and all attempts to define aesthetic ideals are futile. However, the practice of aesthetic surgery relies on the assumption that some facial features can be made more attractive with an operation. At its most fundamental level, this study tested that assumption.
In the first part of this study, we tested for objective and reliable criteria as those features which are preffered with statistically significant regularity among professionals working in independent fields of facial beauty. We studied two groups of professionals: (1) plastic surgeons
were chosen because they are the effective means of producing a brow lift, and (2) cosmetologists were selected because they work in the area of facial aesthetics that is independent of the medical profession.
Unlike plastic surgeons, cosmetologists produce reversible changes with topically applied cosmetics and hair styling. The transient nature
of their work makes them potentially more responsive than plastic surgeons to changes in cultural aesthetic norms.
The variables we studied were eyebrow height and shape, with the plan to evaluate these changes in facial appearance independent of
concurrent changes that result from a brow lift. For example, brow lifts also may make the eye more attractive by a reduction of the soft-tissue
fold in the upper eyelid sulcus. The improvement in upper eyelid appearance might lead one to say that the patient has become more
attractive despite the fact that the new eyebrow appearance could be judged as the same or worse. This study was designed to make eyebrow height and shape independent variables by using computer graphics to alter medical photographs. All other aspects of the individual's appearance remained the same.
Some prior studies have attempted to use millimeter measurements relative to other anatomic landmarks to evaluate eyebrow height. We found that the use of a millimeter ruler was subject to significant laboratory error. Different examiners reported measurement
differences of 2 to 3 mm when measuring an eyebrow that changed less than 10 mm after a brow lift. We either need to have more precise
ways to measure the position of soft-tissue structures or rely on measurements that are less sensitive but easier to record accurately.
We changed eyebrow height relative to a fixed, easily identifiable facial landmark, the supraorbital rim. We chose to move the eyebrow below, at, or above the orbital rim. This measurement has two advantages: (1) It is not a measured distance from another anatomic landmark; therefore, it can relate the position of the eyebrow independent from the size of the face. (2) It is easy for both the trained aesthetic expert and the layperson to identify the eyebrow height relative to the supraorbital rim.
Eyebrow shape also was changed without otherwise altering the facial appearance. The apex of the brow was noted to be medial or lateral to
a vertical line drawn through the lateral limbus. Flat eyebrows without a discrete apex were recorded as flat.
We found that although there is little agreement in the medical literature about aesthetic objectives, plastic surgeons and cosmetologists agree in their preferences for eyebrow height and shape. Both groups prefer (p = 0.01) the medial eyebrow to be below or at the supraorbital rim and disliked the medial eyebrow above the orbital rim. Both groups preferred ( p = 0.01) eyebrow shape to have an apex lateral slant rather either a medial apex or flat shape.
The consistency of the preferences supports the conclusion that these views represent valid aesthetic criteria. These findings also support
the contention that beauty is not completely subject to perception and that there are common criteria for an attractive appearance that can be identified.
In the second part of this study, we examined the outcomes of conventional and endoscopic brow lift procedures. The last 30 years of plastic surgical medical literature is a rich source of data regarding brow lift outcomes. In 16 frequently cited medical articles on brow lift procedures, we had an independent examiner, in a double-blind fashion, evaluate 100 preoperative and 100 postoperative photographs. We were interested in seeing if the aesthetic preferences of plastic surgeons and cosmetologists would be achieved by a brow lift operation.
Although both professional groups prefer the medial eyebrow at the orbital rim with a shape with an apex lateral slant, brow lift surgery
does not usually produce these results. The eyebrows are frequently placed too high relative to the preferences of plastic surgeons and cosmetologists. The shape is frequently changed from an apex lateral slant to the less desirable flat or apex medial slant.
We conclude that the brow lift procedure, as documented in the plastic surgical literature, does not reliably achieve the most desirable
aesthetic results for eyebrow height and shape. The operative techniques reported in the literature are accepted as surgical standards. However, the changes in postoperative appearance are significantly undesirable as judged by the criteria established in the first part of the study.
As we develop new technologies such as endoscopy, we again have an opportunity to question our surgical objectives. New instruments and surgical techniques allow us to customize an operation and achieve the desired aesthetic objectives. If there are changes that our current
procedures effect that are not part of our surgical objectives, we should alter our procedures to satisfy these criteria. We are currently testing
a variation of the conventional and endoscopic brow lift that will relieve the forehead and brow rhytides while maintaining a desirable brow
shape and height.
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