The Influence of Sagittal Head Tilt on Periorbital Appearance: Implications for Clinical Photography and the Evaluation of Postoperative Results

Abstract

Background: Consistency in standardized periorbital photography-specifically, controlling for sagittal head tilt-is challenging yet critical for accurate assessment of preoperative and postoperative images.

Objectives: To systematically assess differences in topographic measurements and perceived periorbital attractiveness at varying degrees of sagittal head tilt.

Methods: Standardized frontal photographs were obtained from 12 female volunteers (mean age 27.5 years) with the Frankfort plane between -15° and +15°. Unilateral periorbital areas were cropped, and topographic measurements were obtained. The images of each individual eye, at varying head tilt, were ranked in order of attractiveness by 11 blinded evaluators.

Results: Inter-rater and intra-rater reliability was excellent (intraclass correlation > 0.9). Downward sagittal head tilt was linearly associated with an improved aesthetic rating (Spearman's correlation; ρ = 0.901, P < 0.001). However, on subgroup analysis, eyes with lower lid bags received the highest aesthetic score at neutral head tilt. Pretarsal show and upper lid fold heights progressively decreased (P < 0.001), positive intercanthal tilt became more pronounced (P < 0.001), and the apex of the brow (P < 0.001) and lid crease (P = 0.036) arcs lateralized with downward sagittal head tilt, contributing to a more angular appearance of the eye. Marginal reflex distance (MRD) 1 was maintained, while MRD2 progressively increased (P < 0.001) with downward head tilt.

Conclusions: Negative sagittal head tilt significantly improves periorbital aesthetics; however, in the presence of lower eyelid bags, this also increases demarcation of the eyelid cheek junction which may be aesthetically detrimental. Controlling for sagittal head tilt is critical to reliably compare preoperative and postoperative clinical photographs.

Figure 1.

Frontal female model photograph (age unknown, image rights obtained from Shutterstock) demonstrating attractive periorbital features with a positive intercanthal tilt, smooth eyelid cheek-junction transition, and relatively homogeneous height of the pretarsal space from the nasal to lateral aspects of the upper lid. Additionally, note the aesthetically pleasing smooth and youthful arcs of the upper lid crease and brow, with the peak of the lid crease arc located lateral to the midpupil and peak of the brow arc located approximately at the lateral canthus. Importantly, note the subjects ear position—the cephalad margin of the tragus reveals that the subject is tilting her head downward (ie, negative sagittal head tilt). This head position increases the apparent angularity of the eyes and accentuates her positive intercanthal tilt.

Figure 2.

Pictogram demonstrating the standardized photograph acquisition process. An observer was situated lateral to a 28-year-old Caucasian female (90° to the subject’s right) to obtain photographs with the subjects Frankfort plane at 5° increments between −15° and +15°. The camera was placed at eye level directly in front of the subject with a focal length of 80 mm (Video 1). Artwork created by E.E.V.

Figure 3.

Periorbital topographic analysis in a 23-year-old Hispanic female. (Left) The scleral limbus was standardized to a diameter of 11.5 mm (gray circle). The lid crease and inferior brow margins were traced (white), and the vertical heights of the pretarsal space (green) and upper lid fold (blue) were measured at the lateral canthus, lateral limbus, midpupil, medial limbus, and punctum. The upper and lower marginal reflex distances (MRD1 and MRD2, respectively) were measured from the center of the circle corresponding to the scleral limbus to the upper and lower lid margin, respectively. (Right) The interbrow height was measured as vertical height discrepancy between the brow peak and medial brow cephalic margin. The intercanthal height was measured as the vertical height discrepancy between the medial and lateral canthus. The lashline peak, lid crease peak, and brow peak were also identified (red circles), and their horizontal location was measured using the midpupil and lateral canthus as a reference point, respectively. Of note, the peak locations were objectively determined utilizing the “measure” tool in Adobe Illustrator by determining where tracings of the brow and lid crease changed from a positive to negative slope (ie, 0-degree tangent).

Figure 4.

The graph illustrates 3-View, globe vector vs aesthetic rating. Error bars indicate 95% confidence intervals. Asterisk (*) denotes statistically significant values.

Figure 5.

The graph illustrates 3-View, presence of lower eyelid bags vs aesthetic rating. Error bars indicate 95% confidence intervals. Asterisk (*) denotes statistically significant values.

Figure 6.

The graph illustrates 7-View, sagittal head tilt vs aesthetic rating. Error bars indicate 95% confidence intervals.

Figure 7.

The graph illustrates 7-view, presence of lower lid bags vs aesthetic rating at varying sagittal head tilt. Error bars indicate 95% confidence intervals. Asterisk (*) denotes statistically significant values.

Figure 8.

The graph illustrates 7-view, globe vector vs aesthetic rating at varying sagittal head tilt. Error bars indicate 95% confidence intervals. Asterisk (*) denotes statistically significant values.

Figure 9.

Effect of sagittal head tilt on periorbital measurements. Upper and lower lid marginal reflex distance (MRD1 and MRD2, respectively). Note that intercanthal height, interbrow height, vertical palpebral height (ie, MRD1 + MRD2), MRD2, and scleral show significantly increase with negative sagittal head tilt. There was no significant change in MRD1. Of note, scleral show was calculated using MRD2 – 5.75 mm (radius of scleral limbus). Error bars indicate 95% confidence intervals. Asterisk (*) denotes statistically significant values.