title: The influence of forehead, brow, and periorbital aesthetics on perceived expression in the youthful face.
abstract: BACKGROUND
  The purpose of this study was to characterize the relative influence of eyebrow position and shape, lid position, and facial rhytides on perceived facial expression as related to blepharoplasty, with a specific focus on the perception of tiredness.
  
  
  METHODS
  A standardized photograph of a youthful upper face was modified using digital imaging software to independently alter a number of variables: brow position/shape, upper/lower lid position, pretarsal show, and rhytides. Subjects (n = 20) were presented with 16 images and asked to quantify, on a scale from 0 to 5, the presence of each of seven expressions/emotions as follows: "surprise," "anger," "sadness," "disgust," "fear," "happiness," and "tiredness."
  
  
  RESULTS
  Statistically significant values for tiredness were achieved by changes of increasing and decreasing the pretarsal skin crease, lowering the upper eyelid, and depressing the lateral brow. Happiness was perceived by elevation of the lower lid or the presence of crow's feet. Brow shape had a greater influence than absolute position on perceived expression. Elevation of the lateral brow was perceived as surprise, whereas depression of the medial brow and rhytides at the glabella were perceived as anger and disgust. Elevation of the medial brow elicited a minimal increase for sadness.
  
  
  CONCLUSIONS
  This study showed that the perception of tiredness is most affected by the length of pretarsal lid height (e.g., ptosis). Surprisingly, simulating the skin resection of an upper blepharoplasty results in a paradoxical increase in the perception of tiredness as well. Modifications of brow contour elicit profound changes in perceived facial mood to a greater degree than absolute brow position.
authors.affiliation: New Haven and Greenwich, Conn. From the Department of Surgery, Section of Plastic Surgery, Yale School of Medicine, and Greenwich Hospital.
authors.forename: Bianca I
authors.initials: BI
authors.lastname: Knoll
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Attkiss
authors.forename: John A
authors.initials: JA
authors.lastname: Persing
mesh_terms: D000328:Adult; D000375:Aging / Q000502:physiology*; D004644:Emotions; D004954:Esthetics; D005138:Eyebrows / Q000033:anatomy & histology*; D005143:Eyelids / Q000033:anatomy & histology*; D005149:Facial Expression; D005260:Female; D005546:Forehead / Q000033:anatomy & histology*; D006801:Humans; D008297:Male; D015361:Rhytidoplasty / Q000379:methods*; D015595:Skin Aging / Q000502:physiology; D011795:Surveys and Questionnaires; D014796:Visual Perception