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Corresponding author at: Doheny and Stein Eye Institutes, Division of Orbital and Oculoplastic Surgery, David Geffen School of Medicine at UCLA, 300 Stein Plaza, University of California, Los Angeles, Los Angeles, CA 90095, USA.
Achieving patient satisfaction after oculofacial surgery requires sensitivity to ethnic anthropometric variation. While differences between the Caucasian and East Asian eyelid configurations are often discussed, there is a relative paucity of discussion related to characteristics of the Middle Eastern eyelid and periocular region. This study aims to understand differences between the eyelids and periocular region of patients of mixed Iranian extraction, versus those of mixed European descent.
In this cross-sectional cohort study, external photographs were collected from a prospectively maintained database at an oculofacial plastic surgery practice. Ethnicity, age, gender, and photographic data were extracted from patient charts. Iranian-American patients were compared to Caucasian-American patients. From full-face photographs, brow position (pupil-to-brow, PTB), eyelid position (margin-to-reflex distance 1 and 2, MRD1 and MRD2), and tarsal platform show (TPS) were analyzed. Mixed effect ANOVA modeling was employed.
The Iranian-American eyelid complex was found to maintain a lower MRD1 (-0.34 mm, p < 0.01), higher MRD2 (+0.48 mm, p < 0.01), and longer TPS (+0.74 mm, p < 0.01) compared to Caucasian-American patients. Further, pupil-to-brow (PTB) distance was noted to be 1.46 mm higher (p < 0.01) in Iranian-Americans.
Patients with Iranian-American ethnicity, compared to those of mixed European extraction, demonstrate distinctive eyelid anthropometric features. An understanding of these features may help to guide aesthetic surgical planning.
little has been written regarding the periocular features of Iranians and other Middle Easterners.
Among the prerequisites for achieving satisfactory results following eyelid surgery, particularly for East Asian patients, the preservation of “ethno-specific” facial features ranks paramount. For instance, upper eyelid procedures that deliberately avoid creating a long tarsal platform show (TPS) are, broadly speaking, preferred in East Asian patients, as a long TPS (i.e., high crease) is ostensibly less “ethno-specific” to that population as compared to European populations. Quantitative anthropometric data thus can be used as a guide in customizing each procedure to each patient's background and desires. A paucity of such anthropometric data is evident with respect to Middle Eastern faces, and the present study aims to fill that knowledge gap.
In this cross-sectional study, patients presenting to a single tertiary oculofacial plastic surgery practice in Los Angeles that serves a large expatriate Iranian population were screened for inclusion. Two groups of patients were selected: Iranian and Caucasian. In order to identify Iranian subjects, an institutional database was queried by surname. Common Iranian surnames were distinguished from other Middle Eastern surnames by suffix, including “zadeh”, “pour”, “bakhsh”, “far”, and “nejad.”. In order to identify individuals of Caucasian descent, the database was queried for typical Caucasian surnames, including “Thompson,” “Smith,” “Johnson,” “Miller,” and “Jones.” Institutional records were further assessed for documentation of self-reported ethnicity, where available. Patients in the Caucasian-American cohort were selected if they self-reported “White” or “Caucasian” ethnicity, and patients in the Iranian-American cohort were selected if they self-reported “Iranian” or “Middle Eastern” ancestry.
Patients with a history of orbital disease, such as Graves’ orbitopathy, or history of other obvious facial deformities, such as upper eyelid ptosis, facial weakness due to facial palsy, orbito-facial trauma, and patients with a history of eyelid or brow surgery were excluded. Notes were examined to identify patients with stated history of facial botulinum toxin or periocular filler injection, and these patients were additionally excluded. Patients with photographically obvious frontalis elevation were excluded. Iranian-American and Caucasian-American patients were age matched within approximately 10 years and sex matched in an approximately 1:1 ratio.
Frontal photographs obtained in repose with a neutral facial expression and the eyes in primary position were extracted. Image analysis was performed using ImageJ (National Institutes of Health, USA) software. Calibration of pixel to mm conversion was performed on each photograph using sex-specific average horizontal width of the cornea as a standard reference.
Anthropometric measurements were performed including margin-to-reflex distance 1 (MRD1), margin-to-reflex distance 2 (MRD2), pupil-to-brow (PTB), and TPS. MRD1 and MRD2 were defined as the vertical distance from the geometric center of the pupil to the upper and lower eyelid margins, respectively. PTB was similarly defined as the vertical distance from the geometric center of the pupil to the lowest visible margin of the eyebrow cilia, and TPS was defined as the distance from the eyelid margin to lower border of the lowest upper eyelid fold.
A total of 182 patients were included, including 83 Iranian-American and 99 Caucasian-American. Mean (SD) age was 46.22 y (11.11) for Iranian-Americans and 50.21 y (10.53) for Caucasian-Americans. There was no significant difference in age between the two groups (p = 0.16). Of the Iranian-American patients, 83% were female, and of the Caucasian-Americans, 78% were female; this difference was not significant (p = 0.29). A summary of the anthropometric measurements is provided in Table 1, and representative images are shown in Figure 1.
Table 1Summary of measurements. Bold numbers indicate the greater mean value.
In multivariate analysis, when compared to Caucasian-Americans, Iranian-American ethnicity was a significant predictor of MRD1, MRD2, TPS, and PTB (Figure 2). Given a particular age and gender, a patient of Iranian-American descent was found to demonstrate a 0.34 mm lower MRD1 (p < 0.01), 0.48 mm greater MRD2 (p < 0.01), 0.74 mm longer TPS (p < 0.01), and 1.46 mm greater PTB (p < 0.01).
The Iranian-American patients studied herein exhibited periocular features distinguishing them from Caucasian-Americans. Particularly, Iranian-Americans were measured to have more inferiorly positioned upper and lower eyelids (MRD1 and MRD2, respectively), longer TPS height, and PTB distance.
Surgical planning in blepharoplasty surgery requires artistic decisions that benefit from an intimate understanding of population level anatomic differences. Data from the present investigation suggest that, compared to Caucasian-Americans, the Iranian-American phenotype is characterized by a relatively more ptotic upper eyelid and a longer TPS. Management of TPS has been shown to be one of the critical determining factors in patients’ perception of surgical success,
for East Asian descent patients aims to increase TPS judiciously, that is, without raising the TPS to a level typical of a Caucasian eyelid. Based on this, one may argue that reconstructive and aesthetic blepharoplasty for Iranian descent patients could include measures that would lead to a somewhat greater TPS than would be typically observed in Caucasian patients. Such measures might include upper blepharoplasty incision design with the inferior border of the incision placed at a more superior position or, in select cases, might involve more liberal sculpting of the upper eyelid and anterior orbital fat, with higher tolerance for a deeper superior sulcus.
Like TPS, PTB was found to be significantly greater in the Iranian-American population as compared to the Caucasian-American population. The anatomic reasons for this may be related to differences in brow ridge and orbital anatomy between Iranians and Caucasians or alternatively may be due to group differences in eyebrow hair density and grooming patterns. These two explanations are not mutually exclusive. In either case, similar to preserving slightly higher TPS during upper blepharoplasty, this finding suggests that an aesthetic surgeon considering interventions aimed at rejuvenating the eyebrow may wish to pay particular attention to creating a higher brow position in Iranian-American patients undergoing, for instance, surgical forehead lift. Conversely, chemo-denervation strategies that include relaxing the frontalis muscle and lowering the eyebrow may produce particularly undesirable brow depression in the Middle Eastern patient.
The finding that Iranian-American patients demonstrate a larger MRD2, and thus a more inferiorly displaced lower eyelid margin has several possible anatomic explanations. One possibility is that these patients may on average have relatively less anterior projection of the body of the maxilla and inferior orbital rim. Negative midface vector has been associated with a more inferior eyelid margin position relative to the globe.
Similarly, a smaller volume orbit resulting in relative axial proptosis may also lead to such a phenotype. Future studies examining Caucasian versus Middle Eastern orbital volume, orbital aperture, axial globe position, and maxillary volumetric structure may reasonably be considered to better understand the anatomic basis of the greater MRD2 in Middle Eastern patients.
One limitation of this study is that expatriate Iranians in Los Angeles,
Thus, the conclusions drawn from the study of Los Angeles expatriate Iranians may not be firmly generalizable to the Iranian population at large. Another limitation of this study is that surname was used as a screening tool to identify patients of a given ethnicity, a strategy that does not take into account for intermarriage between Iranians and Caucasians. With respect to the two groups being compared, however, last name might be expected to be highly correlated with ethnicity, given the historically high rates of endogamy among Los Angeles dwelling expatriate Iranians.
In summary, when compared to Caucasian-American patients, periocular anthropometric measurements in an Iranian-American population demonstrated several notable differences. The Iranian-American population tended to be characterized by a lower MRD1 and longer TPS, as well as higher brow position and longer MRD2. Data regarding such differences, to some extent representative of broader European descent and Middle Eastern populations as a whole, may impact the practice patterns of aesthetic oculofacial surgeons in their quest to make ethnically appropriate decisions before and during surgical and non-surgical upper face procedures.
This work is supported by an Unrestricted Grant from Research to Prevent Blindness, Inc. to the Department of Ophthalmology at UCLA.
This study was approved by the Institutional Review Board (IRB) of the University of California, Los Angeles and was conducted in compliance with the Declaration of Helsinki and adhered to Health Insurance Portability and Accountability Act (HIPAA) guidelines.
Written informed consent was obtained from all patients whose photographs were included in this study's figures.
Declaration of Competing Interest
All authors report no conflicts of interest, financial, or otherwise. The authors alone are responsible for the content and writing of the paper.
The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid.