J Oral Maxillofac 50:606-620.
Surg
1992
Maxillofacial Esthetics: Anthropometrics of the Maxillofacial Region MICHAEL
E. KOURY,
DDS,* AND BRUCE
N. EPKER,
DDS, PHDt
Many artists, orthodontists, and surgeons have proposed guidelines for esthetic facial evaluation, but few have shown a scientific basis for their criteria. Farkas, however, made a substantial contribution to anthropometric facial measurements of adult whites. His raw data were used to develop a comprehensive set of ratios to define the esthetic face. A systematic maxillofacial evaluation derived from Farkas’s data is presented, along with a brief description of its clinical application.
Many artists (da Vinci,’ Dureq2 Armenini,3 Cennini4), surgeons (Gonzalez-Ullou,5 Lee,6 Powell and Humphreys’) and orthodontists (Ricketts,’ Menifield9) have proposed guidelines for drawing or evaluating facial esthetics. However, few have made clinical measurements of a large number of people to develop accurate guidelines for a more scientific esthetic facial evaluation. Farkas did make detailed anthropometric maxillofacial esthetic measurements of normal and attractive adults, but despite his detailed anthropometric studies of facial esthetics, his material is difficult to apply clinically because of the extensive, and often linear, nature of his measurements, the multitude of manuscripts in which he reported his data, and the fact that most of his publications are in nonclinical journals. Farkas and his colleagues’2 studied young, adult, North American whites with a make up similar to the Canadian population. A single group was not used for all measurements, but each group generally consisted of 50 males or 50 females. The majority of the sample consisted of 18-year-olds, with a range of 18 to 25 years. The group was predominantly Anglo-Saxon, often 40% to 50%, with Slavic, Germanic, and Latin descents dominating the remainder. 1o-‘5 The major ethnic
subgroups in this population were studied for variation, and the researchers determined that ethnic origin was not a major concern with regard to planning surgery. Of the 155 proportions measured, only 14 differed significantly, and a distinct variation of one ethnic group
* Resident, Oral and Maxillofacial Surgery, - _ Parkland Memorial, Dallas, and John Peter Smith Hospitals, Fort Worth, TX. i Director. Oral and Maxillofacial Suraerv and Center for Correction of Den&l Facial Deformities, John Peter Smith Hospital, Fort Worth, TX. Address correspondence and reprint requests to Dr Koury: Center for Correction of Dental Facial Deformities, John Peter Smith Hospital, Fort Worth, TX 76 104. 0 1992 American Association of Oral and Maxillofacial Surgeons FIGURE 1. Full frontal face horizontal and vertical landmarks.
0278-2391/92/5008-0008$3.00/O
808
807
KOURY AND EPKER
Table 1. Index of Anthropometric Landmarks AC: Al: c: C’: Ch: Cph: En: Ex: Eu: Ft: G: Gn: Go: Li: Ls: Mf: N: Obi: Obs: Or: 0s: P: Pa: Pi: Po: Pra: Pm: Ps: Sa: Sba: SI: Sn: St: Tr: v: zy:
alar curviture point alare cervicomental point most anterior point of the columella cheilion crista philti endocanthion exocanthion eurion frontotemperale glabella gnathion gonion labiale inferius labiale super&s maxillofrontale nasion otobasion inferius otobasion superius orbitale orbitale superius potion postaurale palpebrale inferius pogonion preaurale pronasale palpebrale superius superaurale subaurale sublabiale subnasale stomion trichion vertex zygion
could not be determined. Differences between extreme groups were found, but not between the intermediates, and significant overlap occurred between all groups.r5 This does not infer that these proportions should be used universally for all ethnic groups. For example, considerable difference in nasal morphology is seen between whites, asians, and blacks.16 The proportions are justified for young adult whites, but must be used judiciously with other ethnic groups. Likewise, these indices must be used carefully in age groups other than young adults because of changes with growth and aging. The difference between above and below average women were investigated by Farkas and his coworkers” in a group of 200 adult women. They were placed in three groups, above average, average, and below average, by 75 evaluators using a six-point scoring system. Only 12% of the 3 55 indices differed significantly between the above- and below-average women.“*r5 The researchers found that the attractive women had more proportions closer to the normal mean even when both groups’ indices were within the normal range. Thus,
values in the normal range were less deviant from the mean even though not abnormal when gauged by a Gasserian curve. Ward and Jamison” evaluated the precision and reliability of linear anthropometric measurements. In general, measurements were reliable, and in no case did separate measurements differ by more than 4%. However, two factors led to poor reliability. The first was linear measurements of small magnitude, because any given error produced a greater percent deviation from the true distance. The second was difficulty in identifying the landmarks, because it manifested poor repeatability and led to inconsistent measurements. The least reliable distances were philtral width, columella width, nasal root width, and nasal protrusion. Although not evaluated in this study, this same rationale can be applied to small angles and poorly defined landmarks. The researchers suggested that multiple trials and averaging of the closest two out of three values would increase reliability.” Usually, converting linear measurements into proportions will decrease error, but in a worst case scenario can amplify it. Great care must be exercised when making measurements. In clinical practice, when measuring soft-tissue relations, calipers are placed without structural distortion, whereas when measuring between bony landmarks, calipers are pressed firmly to bone. In this article, we report an assimilation of Farkas’ esthetic facial measurements in normal adult whites that systematically organizes them for clinical utility, with the measurements converted to proportions and rounded off for homogeneity and ease of usage. The complete index is for normal females, with additional values for males and attractive females, when available, and differing by more than 4%. This figure was chosen because of the error in reproducibility reported above.” Also, average difference (2.8%) between the sexes is scarcely noticeable when expressed as a proportion, except in the orolabial area.15 Because no values have
Table 2.
Total Vertical Facial Esthetics Value (7%)
Measurements
Anthropometrics
Head Neurocranium Facial height Total face Forehead Upper face Lower face Face Upper face Lower face
V-Gn V-N N-Gn Tr-Gn Tr-G G-Sn Sn-Gn G-Gn G-Sn Sn-Gn
Females
Males
50 50
30 35 35 50 50
45 55
808
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
Table 3.
Total Vertical/Horizontal Facial Esthetics Value (%) Measurements
Total face Forehead width/total face height Zygoma width/total face height Bigonial width/total face height Face Forehead width/face height Zygoma width/face height BigoniaI width/face height Total facial thirds Forehead width/forehead height Zygoma width/upper face height Bigonial width/lower face height
Anthropometrics
Males
Ft-Ft/Tr-Gn Zy-Zy/Tr-Gn Go-Go/Tr-Gn
65 75 55
Ft-Ft/G-Gn Zy-Zy/G-Gn Go-Go/G-Gn
90 105 75
Ft-Ft/Tr-G Zy-Zy-G-S Go-Go/&t-Gn
220 220 140
been determined for disharmony producing poor facial esthetics, standard deviations, ranges, and critical values indicating the need for surgical correction are not presented. These proportions are an attempt to take the subjective nature out of facial evaluation and should be used as a guide to evaluate disharmony. As Farkas’* has suggested, bringing more of these values closer to the normal mean may produce harmony and thus attractiveness, but the surgeon’s eye must still be used to determine if differences are significant in each individual case. An attractive feature should not be altered simply because it deviates from a proportion.
VERTICAL/HORIZONTAL
Attractive Females
80
230
PROPORTIONS
The width of the face can be measured between three points bilaterally (Fig 1). The frontotemperale, the landmarks on either side of the forehead indicated by the slight elevation of the linea temporalis, defines the forehead width. Zygion is the most lateral point of the zygomatic arch, and bilaterally these points delineate the midface width. The distance between the gonions defines the lower facial width. The bizygomatic width is normally the widest portion of the face. These horizontal measurements respectively comprise 65%, 75%,
Total Facial Esthetic% VERTICAL PROPORTIONS
The vertex of the head is defined as the highest point when Frankfurt horizontal is parallel with the true horizontal. The height of the head is measured between this landmark and gonion (Fig l).“-‘* Vertically, the head can be divided at several landmarks. da Vinci used nasion to create the neurocranium, vertex to nasion, and the face height, nasion to gnathion, each comprising 50% of the total head height (Tables 1, 2).1,‘o-‘2 Trichion is a landmark of the midforehead where the hairline starts in the youthful adult. The crown is the 20% of the head above trichion. Below, the total face makes up the remaining head, trichion to gnathion, and is broken into three segments by glabella and subnasion.r@‘* The middle face, glabella to subnasion, and lower face, subnasion to gnathion, each make up 35% of the total face.“,‘* The face is defined by glabella and subnasion, and can be divided into an upper and lower segment by subnasion.“-‘* Each compose equal portions of the face (Fig 1) (Table 2).“,‘*
FIGURE 2. Lateral full-face landmarks.
809
KOURY AND EPKER
FIGURE 4. Lateral full-face comprehensive profile angulations. FIGURE 3.
Lateral full-face general profile angulations.
and 55% of the total face height (trichion to gonion) and 90%, 105%, and 75% of the face height (glabella to gnathion). These widths also can be compared with the height of the facial thirds in which they are found (Table 3). The forehead width is 220% of its height, while the zygomatic and bigonial widths are 220% and 140% of the middle and lower face heights, respectively (Fig 1) (Table 3).‘“,‘2,‘8 LATERALTOTALFACEANGULATIONS
pogonion.‘“*““4 The middle third of the face, glabella to subnasion, is aligned with the vertical (Fig 3) (Table 4). A more detailed evaluation of the face can be made by encompassing the nose and the neck. From top to bottom, the nasofrontal angle is 135” measured between the nasal dot-sum, nasion to pronasale, and a line tangent to the inferior glabellar surface from nasion.“,’ ‘,I4 The nasal dorsum and a line between pogonion and pronasale form the nasomental angle, which is 125’.’ Finally, the cervical mental angle is 110” as measured between the anterior neck and a line from gnathion to the cervical point (Fig 4) (Table 4).9
Several angulations are useful to quantify profile or lateral total face esthetics (Fig 2). The anterior plane of the forehead and of the general facial line grossly outline the profile. A forehead slope of -5” is measured between a tangent to the forehead and the vertical.roJ4 The general facial profile forms a -5 o angle measured between the vertical and a line defined by glabella and
Table 4.
Lateral Total Face Angulations
Angular Measurements
Anthropometrics
Forehead General facial Middle face Nasofrontal Nasomental Cervical mental
Tr-G/Vertical G-Pg/Vertical G-Sn/Vertical N-Pm/N-G N-Pm/Pm-Pg Gn-C/ant. Neck
Degrees for Females -5” -5” 0” 135” 125”
I IO”
FIGURE 5. marks.
Midface frontal vertical and vertical/horizontal land-
Table 5.
Middle Third Vertical Facial Esthetics Values Measurements
Anthropometrics
Females
Os-Or/G-Sn Os-Ps/Os-Or sulcus/Ps Ps-Pi/OS-Or Ps/Iris Pi/Iris Pi-Or/OS-Or
40% 10 mm 35% 2mm 2mm 25%
N-Sri/G-Sn N-Pm/G-Sn N-Pm/N-Sn
85% 80% 90%
Eyes Orbit height/upper face height Upper lid height/orbit height Lid sulcus/lid margin Eye fissure height/orbit height Upper lid/iris Lower lid/iris Lower lid height/orbit height Nose Nose length/middle third height Dorsum length/middle third height Dorsum length/nose length
Table 6.
Attractive Females
50%
90%
Middle Third Horizontal Facial Esthetics Value (%) Measurements
Eyes Biocular width/head width Intercanthal width/biocular width Intercanthal width/zygomatic width Fissure width/intercanthal width Fissure width/biocular width Interpupillary width/biocular width Eye fissure cant/horizon Nose Nasal root width/alar width Nasal root width/intercanthal width Alar width/intercanthal width Columella width/alar width
Table 7.
Anthropometrics
Females
Ex-Ex/Eu-Eu En-En/Ex-Ex En-En/Zy-Zy En-Ex/En-En En-Ex/Ex-Ex Mid Pupil/Ex-Ex En-Ex/Horizon
60 34 25 95 33 70 5
Mf-Mf/Al-Al Mf-Mf/En-En Al-Al/En-En Columella/Al-Al
50 50 100 25
Males
Attractive Females
60 60 105
Middle Third Vertical/Horizontal Facial Esthetics Value (%) Measurements
Anthropometrics
Females
Males
Orbit height/biocular width Orbit height/fissure width Fissure height/fissure width Nose Alar width/nose length Alar width/dorsum length
Os-Or/Ex-Ex Os-Or/En-Ex Ps-Pi/En-Ex
35 95 35
90
Al-Al/N-Sn Al-Al/N-Pm
65 70
Attractive Females
be
Table 6.
60
Middle Third Lateral Facial Esthetics
Measurements Sagittal Nasal root/nasal protrusion Vertical/Sag&al Nasal protrusion/nasal length Angulations Nasofrontal Nasofacial Nasolabial
Anthropometrics
Females
En-Dorsum/Sn-Pm
75%
Sn-Pm/N-Sn
40%
N-Pm/N-Gt G-Pg/N-Pm Sn-C/Sri-Ls
135” 35” 100”
810
Males
130%
811
KOURY AND EPKER
FIGURE 8.
FIGURE 6. marks.
Midface and lower face frontal and horizontal land-
Middle Third Facial Esthetics VERTICAL
PROPORTIONS
The eyes and the nose are the major entities in the midface providing landmarks for vertical division. Orbitale superius is the highest point on the lower border
Basal nose landmarks.
of the eyebrow, and generally corresponds to the highest point of the supraorbital rim in the youthful adult (Fig 5). It normally is located at the lateral and middle third junction of the eyebrow.” The orbital height from the orbitale superius to the orbitale is 50% of the upper face height.10~19The upper lid is 40% of the orbital height, and is that portion of the orbit above the superior lid margin, palpebrale superius. The palpebrale superius and inferius define the sulcus to be 35% of the orbit height, and the lower lid height, the palpebrale inferius to orbitale, makes up the remaining 25%.” The lid sulcus normally is 10 mm above the lid margin, and the upper and lower lid margins cover approximately 2 mm of the iris (Fig 5) (Table 5)” The length of the nose is that distance from nasion to subnasale, whereas the dorsal length is measured from nasion to pronasale (Fig 5). The former is 85% of the middle third face height, and the latter is 80% Middle Third Facial Esthetics: Nasal Base
Table 9.
FIGURE 7.
Midface lateral landmarks.
Measurements
Anthropometrics
Value for Females
Tip length/nasal protrusion Columella length/nasal protrusion Columella length/alar length Nasal tip width/alar width Nasal protrusion/alar width Nasal protrusion/alar length Alar thickness Columella thickness
Pm-C’/Pm-Sn C’-Sri/Pm--Sn Sn-C’/Ac-Pm Tip Width/Al-Al Pm-Sri/Al--Al Pm-Sn/Ac-Pm Ala Columella
45% 55% 35% 75% 60% 60% 5mm 8mm
812
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
Table 10.
Middle Third Facial Esthetics: Ear Value Measurements
Anthropometrics
Location Vertical Horizontal Proportions Width to length Attachment length/vertical length Angles Medial long axis to horizontal Lateral protrusion from malar bone
Table 11.
V-PO N-Obs
Females
Males
130 mm 115 mm
135 mm 120 mm
Pra-Pa/Sa-Sba Obs-Obi/Sa-Sba
55% 85%
Sa-Sba/Horizontal
80%
100” 25”
Lower Vertical Facial Esthetics Value (%)
Measurements
Anthropometrics
Lower face Upper lip Lower lip Chin Lips Upper lip/lower lip Skin upper/upper lip Skin lower/lower lip Vermillion upper/lower
Table 12.
Sn-Gn Sn-St0 sto-Sl SI-Gn
Females
Males
Attractive Females
30 25 45
Sn-sto/sto-Sl Sn-Ls/Sn-St0 Li-Sl/Sto-Sl Ls-Sto/Sto-Li
120 70 60 85
105 65
Lower Horizontal Facial Esthetics Value (%) Measurements
Anthropometrics
Females
Mouth width/bigonial width Mouth width/zygoma width Mouth width/biocular width Alar base width/mouth width Philtrum width/mouth width Columella width/philtrum width
Ch-Ch/Go-Go Ch-ChfZy-Zy Ch-Ch/Ex-Ex AI-AI/Ch-Ch ChpChp/Ch-Ch Columella/ChpChp
55 40 60 65 20 75
of the middle face height and 90% of the nose length (Fig 5) (Table 5).‘*-12 HORIZONTAL
PROPORTIONS
da Vinci divided the head horizontally into fifths by the endocanthions and exocanthions at the orbital level.’ Farkas found that these segments were rarely equal, but these landmarks produce useful subdivision points for comparison. ‘* The head width is measured from em-ion to em-ion, the most lateral points on the side of the skull in the area of the parietal and temporal bones (Fig 6). The biocular width, exocanthion to exocanthion, is 60% of the head width (Table 6).“,” The intercanthal width is defined by the endocanthion bi-
Attractive Females
60
laterally and is 34% of the biocular width and 25% of the bizygion width. The fissure width, endocanthion to exocanthion, is 33% of the biocular width and 95% of the intercanthal width.‘0,“*20,2’ The interpupillary width is 70% of the biocular width (Fig 6) (Table 6).“*” In frontal view, the eye fissures slant upward and outward at 5” to the horizon based on a line drawn from the endocanthon to exocanthon (Fig 6) (Table 6). lo The nose increases in width from the nasal root to the nasal base at alare, the most lateral point of the alar contour. The width of the nasal root between the maxillofrontale, or the base of the nasal root at the margin of the orbit where the maxillofrontal and nasofrontal sutures meet, is 50% of the alar base width as measured between alare. The width of the nasal root
KOURY
813
AND EPKER
TiWe 13. Lower Vertical/Horizontal Facial Esthetics Value(o/o) Anthropometrics F.%Il&S Males
Measurements Upper lip height/mouth width Lower face height/mouth width
Sn-Sto/Ch-Ch Sn-Gn/Ch-Ch
40 130
135
35% of the fissure width. The alar width is 65% of the nose length and 70% of the dorsum length (Fig 5) (Table 7)_12.W6.19 LATERAL VIEW
FIGURE
9.
Landmarksfor evaluatingthe ear.
is also 50% of the intercanthal width, and the alar width is 100% of the latter. The thinnest width of the columella makes up 25% of the alar width (Fig 6) (Table 6).‘“-‘2,‘6 VERTICAL/HORIZONTAL PROPORTIONS
The orbital height is 35% of the biocular width and 95% of the fissure width, whereas the fissure height is
FIGURE10. Lowerfaceverticaland vertical/horizontallandmarks.
The projection of the nasal bridge, as measured from endocanthion, affects the nasofrontal angle as well as the apparent length of the nose, whereas the nasal projections, subnasion to pronasale, alters the profile balance of the face. The nasal bridge projection is 75% of the nasal protrusion, and the latter is 40% of the nasal length (Fig 7) (Table 8).” The nasal profile is defined by several angles. The nasofrontal angle is formed by the nasal dorsum, nasion to pronasale, and a line tangent to the glabellar surface from nasion and is 135”. The nasofacial angle is 35”. It is produced by the general facial profile line and the nasal dorsum, nasion to pronasale. The inferior columella surface and the upper lip from subnasale to labiale superius forms the nasolabial angle and is 100” (Fig 7) (Table 8).‘“*“,‘4 NASAL BASE
Topinard originally classified the nares into six basic groups. 22Farkas expanded this classification and found that most (53%) whites had type 11nares, and 42% had type 1 (the small remaining group was type lll.).lo*’‘JW* Nostril symmetry was found in 86% of whites. From type 1 to 111,the nares inclination, tip protrusion, and columella length decrease, and the width of the nose and columella increase. Type 1 noses have primarily (77%) short and curved alar tissue with a lesser degree (2 1%) of full and curved ones, whereas type 11had 47% of the former and 45% of the latter.16 The nasal protrusion is divide into a tip and columella portion by the most anterior point of the nares. These segments comprise 45% and 55% of the nasal protrusion, respectively. The columella length is also 35% of the alar length, alar curvature point to pronasale.‘“,16 The width of the nasal tip as measured just above the nasal ala is 75% of the nasal base,2” whereas the nasal protrusion is 60% of the latter and 60% of the alar length, alar curvature point to pronasale.‘0,‘2,‘6
814
OBJECTIVEESTHETICEVALUATIONOF THE FACE Lower Third Facial Esthetics VERTICALPROPORTIONS
FIGURE11. Lateral lower face angulations.
The lower third of the face is divided into the upper and lower lip and chin by stomion and sublabiale (Fig 10). The latter point is defined by the depth of the mandibular vestibule or the mental groove externally. The upper and lower lip are 30% and 25% of the lower face, respectively, whereas the chin comprises the remaining 45% (Table 11). 10,‘1,‘3The upper lip is 120% of the height of the lower. The lips are divided into a skin and vermilion portion by labiale superius and inferius, which lie at the midpoint of the cutaneous-vermilion junction of the upper and lower lip, respectively. The skin makes up 70% of the upper lip and 60% of the lower lip. The vermilion of the upper lip is 85% of that of the lower lip. Laterally, the cutaneous upper lip is slightly longer than the medial (Fig 10) (Table 11).lo31 3
The alar and columella thicknesses are 5 and 8 mm, respectively (Fig 8) (Table 9).” EARS The vertical position of the ears can be defined in several ways (Fig 9). The distance from vertex to porion is a useful linear measurement, and is found to be 130 mm.24 The Leibers classification also delineates the normal position of the ears.25If a line originating from porion and perpendicular to a line connecting glabella to the upper lip passes between the free margin of the lower eyelid and the upper edge of the nasal ala, then the ear is at a normal level. Furthermore, the ear is said to be at a normal level when a horizontal line that passes through the pupil also intersects the superiormost point of the ear attachment, otobasion st~perius.~~ Horizontally, this landmark is located 115mm from nasion (Fig 9) (Table lo).” The ears achieve full size in the male at age 15 years and in the female at 13.24 In the adult, the width of the ear is measured between preaurale and postaurale, which are the most anterior and posterior points of the ear. Likewise, the vertical length is measured between the highest and lowest points of the ear, superaurale and subaurale. The length to width ratio is 55% in the adult.‘0,24 The attachment length, otobasion superius to inferius, is 85% of the ear length.” Two angles define the orientation of the ears on the face. The first is the inclination of the medial longitudinal axis of the ear, as defined by superaurale and subaurale to Frankfurt horizontal. This angle is 100”. The second is the lateral protrusion from the mastoid bone as measured from the posterior medial surface of the ear. This angle is 25” (Fig 9) (Table lo).“*”
HORIZONTAL PROPORTIONS The width of the mouth is defined by cheilion bilaterally, and is 55% of the bigonial, 40% of bizygomatic, and 60% of the biocular widths (Fig 10). The philtrum is 20% and the alar width is 65% of the mouth width. The columella is 75% of the philtral width (Fig 10) (Table 12).‘“*‘1,12 VERTICAL/HORIZONTALPROPORTIONS The upper lip height is 40%, and the lower face height is 130%, of the mouth width (Fig 10) (Table 13).10~‘1 LATERAL COMPARISONS Several vertical angulations define the normal soft tissues of the lower face. The upper lip, subnasion to labiale superius, is aligned with the vertical (Fig 11). The lower face angulation can be measured from subnasion or labiale infer& the lower margin of the vermilion, to pogonion. The former measures - 15” to the vertical and the latter -20”. The cervical mental angle is 1lo”, as previously stated (Fig 11) (Table 14).‘oT”*‘4
Table 14.
Lower Facial Esthetics: Angulation
Measurements
Anthropometrics
Upper lip/vertical Lower half face/vertical Lower third face/vertical Cervical mental
Sn-LsJVertical Sn-P&Vertical Li-PgJVertical Gn-C/Ant. Neck
Values for Females 0” -15” -20”
110”
FIGURE 12. Before (A and B) and after (C and D) esthetic cheek augmentation to improve bizygomatic width and the associated facial length-to-width abnormalities.
815
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
FIGURE 13. Before (A) and after (B) coronal brow lift and supraorbital rim reduction.
Discussion Use of specific anthropometric data is an invaluable adjunct in the diagnosis of functional and esthetic maxillofacial deformities. The systematic incorporation of this evaluation into the workup of patients will supplement the more traditional subjective clinical esthetic and cephalometric’evaluations. Evaluation of the anthropometric maxillofacial data is best achieved by sequencially using Tables 1 through 14, first evaluating the full face in the vertical, horizontal, and sag&al directions and then evaluating the upper, middle, and lower thirds of the face separately. The vertical full face evaluation is accomplished first (Fig 1) (Table 2). In general, the clinician evaluates the patient for pathological alterations in the height of the facial thirds. Although the crown and forehead can be altered greatly by hair line and style, full-face balance is desired and can be altered by midface and lower face osteotomies. Next, the width of the face is evaluated (Table 3). The broadest area of the face is normally the bizygomatic width and the thinnest is the bigonial (Fig 1). Commonly, width deficiency at the bizygion level is encountered, creating the illusion of a long face. This
deformity is readily correctable with esthetic cheek augmentation (Fig 12). The width-to-height relations in Table 3 are a significant aid in assessment of this type of esthetic defect. The lateral anthropometric data provides a similar benefit for the objective evaluation of the face (Fig 2) (Table 4). The forehead, midface, and general facial angulations are used to evaluate the anterior-posterior position of the facial thirds for treatment planning forehead recontouring and maxillary and mandibular advancements and setbacks (Fig 3). The nasofrontal and nasomental angulations demonstrate the presence or lack of balance between the nose and the chin (Fig 4). The cervical mental angle is used to decide if the neck must be addressed to sharpen the definition of the mandibular line and chin. Importantly, the facial thirds data permits the detailed independent evaluation of facial units so important in the area of esthetic maxillofacial surgery. The middle third of face evaluation primarily involves the eyes and nose (Fig 5). Vertically, the eye measurements are used to evaluate lid and brow ptosis and vertical dystopias for soft and hard tissue correction (Fig 5) (Table 5). Also, these measures permit decisions
KOURY AND EPKER
FIGURE 14. Before (A and E) and after (C and D) augmentation rhinoplasty used to alter vertical position of nasion
817
818
OBJECTIVE
regarding the appropriateness of independently performed blepharoplasties or the simultaneous need for a brow-lifting procedure (Fig 13). The vertical nasal measurements evaluate nasal and dorsal length and specifically the position of nasion and the nasal tip. Nasal length measurements may show the need for dorsal grafts or ostectomies to change the vertical position of nasion, whereas the dorsal length evaluates the need for nasal tip rotation after nasal length and, specifically, the proper vertical position of nasion have been established (Fig 14). Horizontally, the ratios involved with the eyes and nose are used in conjunction with radiographs for the evaluation of canthal and orbital wall position to evaluate the need for osteotomies, revision of traumatic telecanthus, and the like (Fig 6) (Table 6). The nasal width ratios are used when planning nasal osteotomies, alar width soft-tissue procedures, and for the control of alar width during maxillary osteotomies. Sag&ally, ratios and angulations are aimed specifically at optimizing nasal esthetics for rhinoplastic procedures (Fig 7) (Table 8). These numbers are most useful for evaluating the anterior and vertical position of nasion and
FIGURE
15.
ESTHETIC
EVALUATION
OF THE FACE
pronasale. The nasal base evaluation is also important (Fig 8) (Table 9). The columella and nasal tip ratios will guide the use of columellar struts and tip grafts to gain nasal projection, while the alar and columellar thickness measurements are particularly useful in blacks and Orientals for planning soft-tissue excisions. The ear is evaluated for position, orientation and proportions (Fig 9) (Table 10). These measurements are used to recognize anomalies (syndrome identification) and for planning procedures to reposition, tuck, and change the size of the attachment and the proportions of the ear (Fig 15). The lower facial third is next addressed. Vertical proportions are evaluated first (Fig 10) (Table 11). The lip and chin lengths are used in conjunction with clinical tooth show and cephalometric analysis to optimize esthetic correction. Specifically, these data permit the vertical alteration of the chin to be more precisely planned. The exposed lip vermilion measurements are used to plan incision placements during orthognathic procedures as well as the need for V-Y advancements or possible reduction cheiloplasties (Fig 16). Horizontal measurements are best used for planning soft-tissue
Before (A) and after (B) otoplasty.
819
KOURY AND EPKER
FIGURE 16. Before (A) and after (B) V-Y augmentation cheiloplasty of the upper lip to improve the vermilion-cutaneous
procedures to change the mouth and philtral widths (Fig 6) (Table 12). Laterally, the lip and lower face angulations are useful evaluations for the effects of dental tipping and the anterior-posterior chin position (Fig 11) (Table 14). Application of these data and the principles to both esthetic maxillofacial surgery, orthognathic surgery, and reconstructive surgery are significant. In the orthognathic surgery patient they permit the clinician not only to improve on facial esthetics but also to incorporate adjunctive esthetic procedures into the treatment plan, such as cervical facial liposuction, cheiloplasty, rhinoplasty, and cheek augmentation. References 1. da Vinci L: Leonardo on Painting. New Haven, Yale University Press, 1989, pp 123-125 2. Durer A: About the proportions of human limbs, in WM Conway (ed): The Writing of Albrecht Durer. New York, Philosophical Library Inc, 1958, pp 166 3. Annenini G: On the True Precepts of the Art of Painting. New York, NY, Burt Franklin, 1977, pp 165-166 4. Cennini C: The Craftman’s Handbook. New York, NY, Dover, 1960, pp 48-49 5. Gonzalez-Ullou M: Quantitative principles in cosmetic surgery of the face (profileplasty). Plast Reconstr Surg 29: 186, 1962
ratios.
6. Lee L. Lee W: A study of facial proportions and sketching of facial contours. Ear Nose Throat J 58: 12. 1979 7. Powell N, Humphreys B: Proportions of the Aesthetic Face. New York, NY, Thieme-Stratton, 1984, pp 5 l-57 8. Ricketts RM: Divine proportions in facial esthetics. Clin Plast Surg 9:401, 1982 9. Merrifield LL: The profile line as an aid in critically evaluating facial esthetics. Am J Orthod 52:806, 1966 10. Farkas LG: Anthropometrics of the Head and Face in Medicine. New York, NY, Elsevier. 1981, pp 8-59, 108-202 1 1. Farkas LG, Kolar JC: Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg 14:599, 1987 12. Farkas LG. Hreczko TA. Kolar JC. et al: Vertical and horizontal proportions of the face in young adult North American caucasians: Revision of neoclassical canons. Plast Reconstr Surg 75:328. 1985 13. Farkas LG, Katie MJ, Hreczko TA, et al: Anthropometric proportions in the upper-lower lip-chin area of the lower face in young white adults. Am J Orthod 86:52, 1984 14. Farkas LG. Sohm P, Kolar JC, et al: Inclinations of the facial profile art versus reality. Plat Reconstr Surg 75:509, 1985 15. Farkas LG, Munro IR: Anthropometric Facial Reconstruction in Medicine. Springfield, IL, Thomas, 1987, pp 3-8, 19-26, 49-55, 119-129, 166-319 16. Farkas LG, Hreczko TA, Deutsch CK: Objective assessment of standard nostril types- a morphometric study. Ann Plast Surg 11:381, 1983 17. Ward RE, Jamison PL: Measurement precision and reliability in craniofacial anthropometry: implications and suggestions for clinical applications. J Craniofac Gen Dev Biol 11:156, 1991 18. Farkas LG, Lindsay WK: Morphology of the adult face following
820
19.
20. 21. 22.
DlSCUSSlON
repair of bilateral cleft lip and palate in childhood. Plast Reconstr Surg 47:25, 197 1 Whitaker LA, Morales L, Farkas LG: Aesthetic surgery of the supraorbital ridge and forehead structures. Plast Reconstr Surg 78~23, 1986 Laestadius ND, Aase JM, Smith DW: Normal inner canthal and outer orbital dimensions. J Pediatrics 74:465, 1969 Pryor HB: Objective measurement of interpupillary distance. Pediatrics 44:973, 1969 Topinard P: Elements d’Anthropologie Generale. Paris, Delahaye and Lacrosnier, 1885
J Oral Maxillofac 50:820,
23. Stella JP, Epker BN: Systematic aesthetic evaluation of the nose for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2: 273, 1990 24. Farkas LG: Anthropometrics of the normal and defective ear. Clin Plast Surg 17:213, 1990 25. Leibers B: Ohrmuscheldystopie, ohrmuscheldysplasie und’ohrmuschelmissbildung-klinische wertung and bedeutung als symptom. Arch Klin Exp 202:51, 1972
26. Broadbent TR, Mathews VL: Artistic relationships in surface anatomy of the face. Plast Reconstr Surg 20: 1, 1957
Surg
1992
Discussion Maxillofacial Esthetics: Anthropometrics of the Maxillofacial Region Timothy A. Tuwey, DDS
The Universityof North Carolina at Chapel Hill In the quest to improve facial balance and harmony, surgeons rely on many guidelines, including the classical canons developed by the Renaissance artists. Some use linear or an-
gular cephalometric measurements and a few use anthropometric data. Others rely on their own esthetic judgment, in the belief that it is as reliable as any other method. Few remarkable individuals have the talent to envision proposed facial changes abstractly. Most of us do not possess this ability and will find anthropometric proportions helpful in planning treatment. This manuscript brings to our attention an objective means of assessing facial form and balance from both the frontal and profile views. Anthropometric proportions, not absolute measurements, are emphasized. According to Tessier, “Harmony or disharmony does not lie within angles, distances, lines, surfaces or volumes. They arise from proportion.“’
The article adequately reminds the readers of ethnic, racial, gender, and other demographic differences. It also warns of the problems of extrapolating the data to other groups and of using only the measurements and proportions to make treatment planning decisions. The authors credit Farkas for his contribution to anthropometric measurements. In my opinion, they have understated the usefulness of the proportions that he and Munro have already published in their textbook.’ The proportions described in this article complement those already published by Farkas and coworkers. Readers are reminded that they, too, can use Farkas’s raw data to develop their own set of facial proportions suited to the needs of their patients and their practices.2
References 1. Farkas LG, Munro IR: Anthropometric Facial Proportions in Medicine. Springheld, IL, Charles Thomas, 1986 2. Farkas LG: Anthropometry of the Head and Face. New York, NY, Elsevier, 198 1
Surg
1992
Maxillofacial Esthetics: Anthropometrics of the Maxillofacial Region MICHAEL
E. KOURY,
DDS,* AND BRUCE
N. EPKER,
DDS, PHDt
Many artists, orthodontists, and surgeons have proposed guidelines for esthetic facial evaluation, but few have shown a scientific basis for their criteria. Farkas, however, made a substantial contribution to anthropometric facial measurements of adult whites. His raw data were used to develop a comprehensive set of ratios to define the esthetic face. A systematic maxillofacial evaluation derived from Farkas’s data is presented, along with a brief description of its clinical application.
Many artists (da Vinci,’ Dureq2 Armenini,3 Cennini4), surgeons (Gonzalez-Ullou,5 Lee,6 Powell and Humphreys’) and orthodontists (Ricketts,’ Menifield9) have proposed guidelines for drawing or evaluating facial esthetics. However, few have made clinical measurements of a large number of people to develop accurate guidelines for a more scientific esthetic facial evaluation. Farkas did make detailed anthropometric maxillofacial esthetic measurements of normal and attractive adults, but despite his detailed anthropometric studies of facial esthetics, his material is difficult to apply clinically because of the extensive, and often linear, nature of his measurements, the multitude of manuscripts in which he reported his data, and the fact that most of his publications are in nonclinical journals. Farkas and his colleagues’2 studied young, adult, North American whites with a make up similar to the Canadian population. A single group was not used for all measurements, but each group generally consisted of 50 males or 50 females. The majority of the sample consisted of 18-year-olds, with a range of 18 to 25 years. The group was predominantly Anglo-Saxon, often 40% to 50%, with Slavic, Germanic, and Latin descents dominating the remainder. 1o-‘5 The major ethnic
subgroups in this population were studied for variation, and the researchers determined that ethnic origin was not a major concern with regard to planning surgery. Of the 155 proportions measured, only 14 differed significantly, and a distinct variation of one ethnic group
* Resident, Oral and Maxillofacial Surgery, - _ Parkland Memorial, Dallas, and John Peter Smith Hospitals, Fort Worth, TX. i Director. Oral and Maxillofacial Suraerv and Center for Correction of Den&l Facial Deformities, John Peter Smith Hospital, Fort Worth, TX. Address correspondence and reprint requests to Dr Koury: Center for Correction of Dental Facial Deformities, John Peter Smith Hospital, Fort Worth, TX 76 104. 0 1992 American Association of Oral and Maxillofacial Surgeons FIGURE 1. Full frontal face horizontal and vertical landmarks.
0278-2391/92/5008-0008$3.00/O
808
807
KOURY AND EPKER
Table 1. Index of Anthropometric Landmarks AC: Al: c: C’: Ch: Cph: En: Ex: Eu: Ft: G: Gn: Go: Li: Ls: Mf: N: Obi: Obs: Or: 0s: P: Pa: Pi: Po: Pra: Pm: Ps: Sa: Sba: SI: Sn: St: Tr: v: zy:
alar curviture point alare cervicomental point most anterior point of the columella cheilion crista philti endocanthion exocanthion eurion frontotemperale glabella gnathion gonion labiale inferius labiale super&s maxillofrontale nasion otobasion inferius otobasion superius orbitale orbitale superius potion postaurale palpebrale inferius pogonion preaurale pronasale palpebrale superius superaurale subaurale sublabiale subnasale stomion trichion vertex zygion
could not be determined. Differences between extreme groups were found, but not between the intermediates, and significant overlap occurred between all groups.r5 This does not infer that these proportions should be used universally for all ethnic groups. For example, considerable difference in nasal morphology is seen between whites, asians, and blacks.16 The proportions are justified for young adult whites, but must be used judiciously with other ethnic groups. Likewise, these indices must be used carefully in age groups other than young adults because of changes with growth and aging. The difference between above and below average women were investigated by Farkas and his coworkers” in a group of 200 adult women. They were placed in three groups, above average, average, and below average, by 75 evaluators using a six-point scoring system. Only 12% of the 3 55 indices differed significantly between the above- and below-average women.“*r5 The researchers found that the attractive women had more proportions closer to the normal mean even when both groups’ indices were within the normal range. Thus,
values in the normal range were less deviant from the mean even though not abnormal when gauged by a Gasserian curve. Ward and Jamison” evaluated the precision and reliability of linear anthropometric measurements. In general, measurements were reliable, and in no case did separate measurements differ by more than 4%. However, two factors led to poor reliability. The first was linear measurements of small magnitude, because any given error produced a greater percent deviation from the true distance. The second was difficulty in identifying the landmarks, because it manifested poor repeatability and led to inconsistent measurements. The least reliable distances were philtral width, columella width, nasal root width, and nasal protrusion. Although not evaluated in this study, this same rationale can be applied to small angles and poorly defined landmarks. The researchers suggested that multiple trials and averaging of the closest two out of three values would increase reliability.” Usually, converting linear measurements into proportions will decrease error, but in a worst case scenario can amplify it. Great care must be exercised when making measurements. In clinical practice, when measuring soft-tissue relations, calipers are placed without structural distortion, whereas when measuring between bony landmarks, calipers are pressed firmly to bone. In this article, we report an assimilation of Farkas’ esthetic facial measurements in normal adult whites that systematically organizes them for clinical utility, with the measurements converted to proportions and rounded off for homogeneity and ease of usage. The complete index is for normal females, with additional values for males and attractive females, when available, and differing by more than 4%. This figure was chosen because of the error in reproducibility reported above.” Also, average difference (2.8%) between the sexes is scarcely noticeable when expressed as a proportion, except in the orolabial area.15 Because no values have
Table 2.
Total Vertical Facial Esthetics Value (7%)
Measurements
Anthropometrics
Head Neurocranium Facial height Total face Forehead Upper face Lower face Face Upper face Lower face
V-Gn V-N N-Gn Tr-Gn Tr-G G-Sn Sn-Gn G-Gn G-Sn Sn-Gn
Females
Males
50 50
30 35 35 50 50
45 55
808
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
Table 3.
Total Vertical/Horizontal Facial Esthetics Value (%) Measurements
Total face Forehead width/total face height Zygoma width/total face height Bigonial width/total face height Face Forehead width/face height Zygoma width/face height BigoniaI width/face height Total facial thirds Forehead width/forehead height Zygoma width/upper face height Bigonial width/lower face height
Anthropometrics
Males
Ft-Ft/Tr-Gn Zy-Zy/Tr-Gn Go-Go/Tr-Gn
65 75 55
Ft-Ft/G-Gn Zy-Zy/G-Gn Go-Go/G-Gn
90 105 75
Ft-Ft/Tr-G Zy-Zy-G-S Go-Go/&t-Gn
220 220 140
been determined for disharmony producing poor facial esthetics, standard deviations, ranges, and critical values indicating the need for surgical correction are not presented. These proportions are an attempt to take the subjective nature out of facial evaluation and should be used as a guide to evaluate disharmony. As Farkas’* has suggested, bringing more of these values closer to the normal mean may produce harmony and thus attractiveness, but the surgeon’s eye must still be used to determine if differences are significant in each individual case. An attractive feature should not be altered simply because it deviates from a proportion.
VERTICAL/HORIZONTAL
Attractive Females
80
230
PROPORTIONS
The width of the face can be measured between three points bilaterally (Fig 1). The frontotemperale, the landmarks on either side of the forehead indicated by the slight elevation of the linea temporalis, defines the forehead width. Zygion is the most lateral point of the zygomatic arch, and bilaterally these points delineate the midface width. The distance between the gonions defines the lower facial width. The bizygomatic width is normally the widest portion of the face. These horizontal measurements respectively comprise 65%, 75%,
Total Facial Esthetic% VERTICAL PROPORTIONS
The vertex of the head is defined as the highest point when Frankfurt horizontal is parallel with the true horizontal. The height of the head is measured between this landmark and gonion (Fig l).“-‘* Vertically, the head can be divided at several landmarks. da Vinci used nasion to create the neurocranium, vertex to nasion, and the face height, nasion to gnathion, each comprising 50% of the total head height (Tables 1, 2).1,‘o-‘2 Trichion is a landmark of the midforehead where the hairline starts in the youthful adult. The crown is the 20% of the head above trichion. Below, the total face makes up the remaining head, trichion to gnathion, and is broken into three segments by glabella and subnasion.r@‘* The middle face, glabella to subnasion, and lower face, subnasion to gnathion, each make up 35% of the total face.“,‘* The face is defined by glabella and subnasion, and can be divided into an upper and lower segment by subnasion.“-‘* Each compose equal portions of the face (Fig 1) (Table 2).“,‘*
FIGURE 2. Lateral full-face landmarks.
809
KOURY AND EPKER
FIGURE 4. Lateral full-face comprehensive profile angulations. FIGURE 3.
Lateral full-face general profile angulations.
and 55% of the total face height (trichion to gonion) and 90%, 105%, and 75% of the face height (glabella to gnathion). These widths also can be compared with the height of the facial thirds in which they are found (Table 3). The forehead width is 220% of its height, while the zygomatic and bigonial widths are 220% and 140% of the middle and lower face heights, respectively (Fig 1) (Table 3).‘“,‘2,‘8 LATERALTOTALFACEANGULATIONS
pogonion.‘“*““4 The middle third of the face, glabella to subnasion, is aligned with the vertical (Fig 3) (Table 4). A more detailed evaluation of the face can be made by encompassing the nose and the neck. From top to bottom, the nasofrontal angle is 135” measured between the nasal dot-sum, nasion to pronasale, and a line tangent to the inferior glabellar surface from nasion.“,’ ‘,I4 The nasal dorsum and a line between pogonion and pronasale form the nasomental angle, which is 125’.’ Finally, the cervical mental angle is 110” as measured between the anterior neck and a line from gnathion to the cervical point (Fig 4) (Table 4).9
Several angulations are useful to quantify profile or lateral total face esthetics (Fig 2). The anterior plane of the forehead and of the general facial line grossly outline the profile. A forehead slope of -5” is measured between a tangent to the forehead and the vertical.roJ4 The general facial profile forms a -5 o angle measured between the vertical and a line defined by glabella and
Table 4.
Lateral Total Face Angulations
Angular Measurements
Anthropometrics
Forehead General facial Middle face Nasofrontal Nasomental Cervical mental
Tr-G/Vertical G-Pg/Vertical G-Sn/Vertical N-Pm/N-G N-Pm/Pm-Pg Gn-C/ant. Neck
Degrees for Females -5” -5” 0” 135” 125”
I IO”
FIGURE 5. marks.
Midface frontal vertical and vertical/horizontal land-
Table 5.
Middle Third Vertical Facial Esthetics Values Measurements
Anthropometrics
Females
Os-Or/G-Sn Os-Ps/Os-Or sulcus/Ps Ps-Pi/OS-Or Ps/Iris Pi/Iris Pi-Or/OS-Or
40% 10 mm 35% 2mm 2mm 25%
N-Sri/G-Sn N-Pm/G-Sn N-Pm/N-Sn
85% 80% 90%
Eyes Orbit height/upper face height Upper lid height/orbit height Lid sulcus/lid margin Eye fissure height/orbit height Upper lid/iris Lower lid/iris Lower lid height/orbit height Nose Nose length/middle third height Dorsum length/middle third height Dorsum length/nose length
Table 6.
Attractive Females
50%
90%
Middle Third Horizontal Facial Esthetics Value (%) Measurements
Eyes Biocular width/head width Intercanthal width/biocular width Intercanthal width/zygomatic width Fissure width/intercanthal width Fissure width/biocular width Interpupillary width/biocular width Eye fissure cant/horizon Nose Nasal root width/alar width Nasal root width/intercanthal width Alar width/intercanthal width Columella width/alar width
Table 7.
Anthropometrics
Females
Ex-Ex/Eu-Eu En-En/Ex-Ex En-En/Zy-Zy En-Ex/En-En En-Ex/Ex-Ex Mid Pupil/Ex-Ex En-Ex/Horizon
60 34 25 95 33 70 5
Mf-Mf/Al-Al Mf-Mf/En-En Al-Al/En-En Columella/Al-Al
50 50 100 25
Males
Attractive Females
60 60 105
Middle Third Vertical/Horizontal Facial Esthetics Value (%) Measurements
Anthropometrics
Females
Males
Orbit height/biocular width Orbit height/fissure width Fissure height/fissure width Nose Alar width/nose length Alar width/dorsum length
Os-Or/Ex-Ex Os-Or/En-Ex Ps-Pi/En-Ex
35 95 35
90
Al-Al/N-Sn Al-Al/N-Pm
65 70
Attractive Females
be
Table 6.
60
Middle Third Lateral Facial Esthetics
Measurements Sagittal Nasal root/nasal protrusion Vertical/Sag&al Nasal protrusion/nasal length Angulations Nasofrontal Nasofacial Nasolabial
Anthropometrics
Females
En-Dorsum/Sn-Pm
75%
Sn-Pm/N-Sn
40%
N-Pm/N-Gt G-Pg/N-Pm Sn-C/Sri-Ls
135” 35” 100”
810
Males
130%
811
KOURY AND EPKER
FIGURE 8.
FIGURE 6. marks.
Midface and lower face frontal and horizontal land-
Middle Third Facial Esthetics VERTICAL
PROPORTIONS
The eyes and the nose are the major entities in the midface providing landmarks for vertical division. Orbitale superius is the highest point on the lower border
Basal nose landmarks.
of the eyebrow, and generally corresponds to the highest point of the supraorbital rim in the youthful adult (Fig 5). It normally is located at the lateral and middle third junction of the eyebrow.” The orbital height from the orbitale superius to the orbitale is 50% of the upper face height.10~19The upper lid is 40% of the orbital height, and is that portion of the orbit above the superior lid margin, palpebrale superius. The palpebrale superius and inferius define the sulcus to be 35% of the orbit height, and the lower lid height, the palpebrale inferius to orbitale, makes up the remaining 25%.” The lid sulcus normally is 10 mm above the lid margin, and the upper and lower lid margins cover approximately 2 mm of the iris (Fig 5) (Table 5)” The length of the nose is that distance from nasion to subnasale, whereas the dorsal length is measured from nasion to pronasale (Fig 5). The former is 85% of the middle third face height, and the latter is 80% Middle Third Facial Esthetics: Nasal Base
Table 9.
FIGURE 7.
Midface lateral landmarks.
Measurements
Anthropometrics
Value for Females
Tip length/nasal protrusion Columella length/nasal protrusion Columella length/alar length Nasal tip width/alar width Nasal protrusion/alar width Nasal protrusion/alar length Alar thickness Columella thickness
Pm-C’/Pm-Sn C’-Sri/Pm--Sn Sn-C’/Ac-Pm Tip Width/Al-Al Pm-Sri/Al--Al Pm-Sn/Ac-Pm Ala Columella
45% 55% 35% 75% 60% 60% 5mm 8mm
812
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
Table 10.
Middle Third Facial Esthetics: Ear Value Measurements
Anthropometrics
Location Vertical Horizontal Proportions Width to length Attachment length/vertical length Angles Medial long axis to horizontal Lateral protrusion from malar bone
Table 11.
V-PO N-Obs
Females
Males
130 mm 115 mm
135 mm 120 mm
Pra-Pa/Sa-Sba Obs-Obi/Sa-Sba
55% 85%
Sa-Sba/Horizontal
80%
100” 25”
Lower Vertical Facial Esthetics Value (%)
Measurements
Anthropometrics
Lower face Upper lip Lower lip Chin Lips Upper lip/lower lip Skin upper/upper lip Skin lower/lower lip Vermillion upper/lower
Table 12.
Sn-Gn Sn-St0 sto-Sl SI-Gn
Females
Males
Attractive Females
30 25 45
Sn-sto/sto-Sl Sn-Ls/Sn-St0 Li-Sl/Sto-Sl Ls-Sto/Sto-Li
120 70 60 85
105 65
Lower Horizontal Facial Esthetics Value (%) Measurements
Anthropometrics
Females
Mouth width/bigonial width Mouth width/zygoma width Mouth width/biocular width Alar base width/mouth width Philtrum width/mouth width Columella width/philtrum width
Ch-Ch/Go-Go Ch-ChfZy-Zy Ch-Ch/Ex-Ex AI-AI/Ch-Ch ChpChp/Ch-Ch Columella/ChpChp
55 40 60 65 20 75
of the middle face height and 90% of the nose length (Fig 5) (Table 5).‘*-12 HORIZONTAL
PROPORTIONS
da Vinci divided the head horizontally into fifths by the endocanthions and exocanthions at the orbital level.’ Farkas found that these segments were rarely equal, but these landmarks produce useful subdivision points for comparison. ‘* The head width is measured from em-ion to em-ion, the most lateral points on the side of the skull in the area of the parietal and temporal bones (Fig 6). The biocular width, exocanthion to exocanthion, is 60% of the head width (Table 6).“,” The intercanthal width is defined by the endocanthion bi-
Attractive Females
60
laterally and is 34% of the biocular width and 25% of the bizygion width. The fissure width, endocanthion to exocanthion, is 33% of the biocular width and 95% of the intercanthal width.‘0,“*20,2’ The interpupillary width is 70% of the biocular width (Fig 6) (Table 6).“*” In frontal view, the eye fissures slant upward and outward at 5” to the horizon based on a line drawn from the endocanthon to exocanthon (Fig 6) (Table 6). lo The nose increases in width from the nasal root to the nasal base at alare, the most lateral point of the alar contour. The width of the nasal root between the maxillofrontale, or the base of the nasal root at the margin of the orbit where the maxillofrontal and nasofrontal sutures meet, is 50% of the alar base width as measured between alare. The width of the nasal root
KOURY
813
AND EPKER
TiWe 13. Lower Vertical/Horizontal Facial Esthetics Value(o/o) Anthropometrics F.%Il&S Males
Measurements Upper lip height/mouth width Lower face height/mouth width
Sn-Sto/Ch-Ch Sn-Gn/Ch-Ch
40 130
135
35% of the fissure width. The alar width is 65% of the nose length and 70% of the dorsum length (Fig 5) (Table 7)_12.W6.19 LATERAL VIEW
FIGURE
9.
Landmarksfor evaluatingthe ear.
is also 50% of the intercanthal width, and the alar width is 100% of the latter. The thinnest width of the columella makes up 25% of the alar width (Fig 6) (Table 6).‘“-‘2,‘6 VERTICAL/HORIZONTAL PROPORTIONS
The orbital height is 35% of the biocular width and 95% of the fissure width, whereas the fissure height is
FIGURE10. Lowerfaceverticaland vertical/horizontallandmarks.
The projection of the nasal bridge, as measured from endocanthion, affects the nasofrontal angle as well as the apparent length of the nose, whereas the nasal projections, subnasion to pronasale, alters the profile balance of the face. The nasal bridge projection is 75% of the nasal protrusion, and the latter is 40% of the nasal length (Fig 7) (Table 8).” The nasal profile is defined by several angles. The nasofrontal angle is formed by the nasal dorsum, nasion to pronasale, and a line tangent to the glabellar surface from nasion and is 135”. The nasofacial angle is 35”. It is produced by the general facial profile line and the nasal dorsum, nasion to pronasale. The inferior columella surface and the upper lip from subnasale to labiale superius forms the nasolabial angle and is 100” (Fig 7) (Table 8).‘“*“,‘4 NASAL BASE
Topinard originally classified the nares into six basic groups. 22Farkas expanded this classification and found that most (53%) whites had type 11nares, and 42% had type 1 (the small remaining group was type lll.).lo*’‘JW* Nostril symmetry was found in 86% of whites. From type 1 to 111,the nares inclination, tip protrusion, and columella length decrease, and the width of the nose and columella increase. Type 1 noses have primarily (77%) short and curved alar tissue with a lesser degree (2 1%) of full and curved ones, whereas type 11had 47% of the former and 45% of the latter.16 The nasal protrusion is divide into a tip and columella portion by the most anterior point of the nares. These segments comprise 45% and 55% of the nasal protrusion, respectively. The columella length is also 35% of the alar length, alar curvature point to pronasale.‘“,16 The width of the nasal tip as measured just above the nasal ala is 75% of the nasal base,2” whereas the nasal protrusion is 60% of the latter and 60% of the alar length, alar curvature point to pronasale.‘0,‘2,‘6
814
OBJECTIVEESTHETICEVALUATIONOF THE FACE Lower Third Facial Esthetics VERTICALPROPORTIONS
FIGURE11. Lateral lower face angulations.
The lower third of the face is divided into the upper and lower lip and chin by stomion and sublabiale (Fig 10). The latter point is defined by the depth of the mandibular vestibule or the mental groove externally. The upper and lower lip are 30% and 25% of the lower face, respectively, whereas the chin comprises the remaining 45% (Table 11). 10,‘1,‘3The upper lip is 120% of the height of the lower. The lips are divided into a skin and vermilion portion by labiale superius and inferius, which lie at the midpoint of the cutaneous-vermilion junction of the upper and lower lip, respectively. The skin makes up 70% of the upper lip and 60% of the lower lip. The vermilion of the upper lip is 85% of that of the lower lip. Laterally, the cutaneous upper lip is slightly longer than the medial (Fig 10) (Table 11).lo31 3
The alar and columella thicknesses are 5 and 8 mm, respectively (Fig 8) (Table 9).” EARS The vertical position of the ears can be defined in several ways (Fig 9). The distance from vertex to porion is a useful linear measurement, and is found to be 130 mm.24 The Leibers classification also delineates the normal position of the ears.25If a line originating from porion and perpendicular to a line connecting glabella to the upper lip passes between the free margin of the lower eyelid and the upper edge of the nasal ala, then the ear is at a normal level. Furthermore, the ear is said to be at a normal level when a horizontal line that passes through the pupil also intersects the superiormost point of the ear attachment, otobasion st~perius.~~ Horizontally, this landmark is located 115mm from nasion (Fig 9) (Table lo).” The ears achieve full size in the male at age 15 years and in the female at 13.24 In the adult, the width of the ear is measured between preaurale and postaurale, which are the most anterior and posterior points of the ear. Likewise, the vertical length is measured between the highest and lowest points of the ear, superaurale and subaurale. The length to width ratio is 55% in the adult.‘0,24 The attachment length, otobasion superius to inferius, is 85% of the ear length.” Two angles define the orientation of the ears on the face. The first is the inclination of the medial longitudinal axis of the ear, as defined by superaurale and subaurale to Frankfurt horizontal. This angle is 100”. The second is the lateral protrusion from the mastoid bone as measured from the posterior medial surface of the ear. This angle is 25” (Fig 9) (Table lo).“*”
HORIZONTAL PROPORTIONS The width of the mouth is defined by cheilion bilaterally, and is 55% of the bigonial, 40% of bizygomatic, and 60% of the biocular widths (Fig 10). The philtrum is 20% and the alar width is 65% of the mouth width. The columella is 75% of the philtral width (Fig 10) (Table 12).‘“*‘1,12 VERTICAL/HORIZONTALPROPORTIONS The upper lip height is 40%, and the lower face height is 130%, of the mouth width (Fig 10) (Table 13).10~‘1 LATERAL COMPARISONS Several vertical angulations define the normal soft tissues of the lower face. The upper lip, subnasion to labiale superius, is aligned with the vertical (Fig 11). The lower face angulation can be measured from subnasion or labiale infer& the lower margin of the vermilion, to pogonion. The former measures - 15” to the vertical and the latter -20”. The cervical mental angle is 1lo”, as previously stated (Fig 11) (Table 14).‘oT”*‘4
Table 14.
Lower Facial Esthetics: Angulation
Measurements
Anthropometrics
Upper lip/vertical Lower half face/vertical Lower third face/vertical Cervical mental
Sn-LsJVertical Sn-P&Vertical Li-PgJVertical Gn-C/Ant. Neck
Values for Females 0” -15” -20”
110”
FIGURE 12. Before (A and B) and after (C and D) esthetic cheek augmentation to improve bizygomatic width and the associated facial length-to-width abnormalities.
815
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
FIGURE 13. Before (A) and after (B) coronal brow lift and supraorbital rim reduction.
Discussion Use of specific anthropometric data is an invaluable adjunct in the diagnosis of functional and esthetic maxillofacial deformities. The systematic incorporation of this evaluation into the workup of patients will supplement the more traditional subjective clinical esthetic and cephalometric’evaluations. Evaluation of the anthropometric maxillofacial data is best achieved by sequencially using Tables 1 through 14, first evaluating the full face in the vertical, horizontal, and sag&al directions and then evaluating the upper, middle, and lower thirds of the face separately. The vertical full face evaluation is accomplished first (Fig 1) (Table 2). In general, the clinician evaluates the patient for pathological alterations in the height of the facial thirds. Although the crown and forehead can be altered greatly by hair line and style, full-face balance is desired and can be altered by midface and lower face osteotomies. Next, the width of the face is evaluated (Table 3). The broadest area of the face is normally the bizygomatic width and the thinnest is the bigonial (Fig 1). Commonly, width deficiency at the bizygion level is encountered, creating the illusion of a long face. This
deformity is readily correctable with esthetic cheek augmentation (Fig 12). The width-to-height relations in Table 3 are a significant aid in assessment of this type of esthetic defect. The lateral anthropometric data provides a similar benefit for the objective evaluation of the face (Fig 2) (Table 4). The forehead, midface, and general facial angulations are used to evaluate the anterior-posterior position of the facial thirds for treatment planning forehead recontouring and maxillary and mandibular advancements and setbacks (Fig 3). The nasofrontal and nasomental angulations demonstrate the presence or lack of balance between the nose and the chin (Fig 4). The cervical mental angle is used to decide if the neck must be addressed to sharpen the definition of the mandibular line and chin. Importantly, the facial thirds data permits the detailed independent evaluation of facial units so important in the area of esthetic maxillofacial surgery. The middle third of face evaluation primarily involves the eyes and nose (Fig 5). Vertically, the eye measurements are used to evaluate lid and brow ptosis and vertical dystopias for soft and hard tissue correction (Fig 5) (Table 5). Also, these measures permit decisions
KOURY AND EPKER
FIGURE 14. Before (A and E) and after (C and D) augmentation rhinoplasty used to alter vertical position of nasion
817
818
OBJECTIVE
regarding the appropriateness of independently performed blepharoplasties or the simultaneous need for a brow-lifting procedure (Fig 13). The vertical nasal measurements evaluate nasal and dorsal length and specifically the position of nasion and the nasal tip. Nasal length measurements may show the need for dorsal grafts or ostectomies to change the vertical position of nasion, whereas the dorsal length evaluates the need for nasal tip rotation after nasal length and, specifically, the proper vertical position of nasion have been established (Fig 14). Horizontally, the ratios involved with the eyes and nose are used in conjunction with radiographs for the evaluation of canthal and orbital wall position to evaluate the need for osteotomies, revision of traumatic telecanthus, and the like (Fig 6) (Table 6). The nasal width ratios are used when planning nasal osteotomies, alar width soft-tissue procedures, and for the control of alar width during maxillary osteotomies. Sag&ally, ratios and angulations are aimed specifically at optimizing nasal esthetics for rhinoplastic procedures (Fig 7) (Table 8). These numbers are most useful for evaluating the anterior and vertical position of nasion and
FIGURE
15.
ESTHETIC
EVALUATION
OF THE FACE
pronasale. The nasal base evaluation is also important (Fig 8) (Table 9). The columella and nasal tip ratios will guide the use of columellar struts and tip grafts to gain nasal projection, while the alar and columellar thickness measurements are particularly useful in blacks and Orientals for planning soft-tissue excisions. The ear is evaluated for position, orientation and proportions (Fig 9) (Table 10). These measurements are used to recognize anomalies (syndrome identification) and for planning procedures to reposition, tuck, and change the size of the attachment and the proportions of the ear (Fig 15). The lower facial third is next addressed. Vertical proportions are evaluated first (Fig 10) (Table 11). The lip and chin lengths are used in conjunction with clinical tooth show and cephalometric analysis to optimize esthetic correction. Specifically, these data permit the vertical alteration of the chin to be more precisely planned. The exposed lip vermilion measurements are used to plan incision placements during orthognathic procedures as well as the need for V-Y advancements or possible reduction cheiloplasties (Fig 16). Horizontal measurements are best used for planning soft-tissue
Before (A) and after (B) otoplasty.
819
KOURY AND EPKER
FIGURE 16. Before (A) and after (B) V-Y augmentation cheiloplasty of the upper lip to improve the vermilion-cutaneous
procedures to change the mouth and philtral widths (Fig 6) (Table 12). Laterally, the lip and lower face angulations are useful evaluations for the effects of dental tipping and the anterior-posterior chin position (Fig 11) (Table 14). Application of these data and the principles to both esthetic maxillofacial surgery, orthognathic surgery, and reconstructive surgery are significant. In the orthognathic surgery patient they permit the clinician not only to improve on facial esthetics but also to incorporate adjunctive esthetic procedures into the treatment plan, such as cervical facial liposuction, cheiloplasty, rhinoplasty, and cheek augmentation. References 1. da Vinci L: Leonardo on Painting. New Haven, Yale University Press, 1989, pp 123-125 2. Durer A: About the proportions of human limbs, in WM Conway (ed): The Writing of Albrecht Durer. New York, Philosophical Library Inc, 1958, pp 166 3. Annenini G: On the True Precepts of the Art of Painting. New York, NY, Burt Franklin, 1977, pp 165-166 4. Cennini C: The Craftman’s Handbook. New York, NY, Dover, 1960, pp 48-49 5. Gonzalez-Ullou M: Quantitative principles in cosmetic surgery of the face (profileplasty). Plast Reconstr Surg 29: 186, 1962
ratios.
6. Lee L. Lee W: A study of facial proportions and sketching of facial contours. Ear Nose Throat J 58: 12. 1979 7. Powell N, Humphreys B: Proportions of the Aesthetic Face. New York, NY, Thieme-Stratton, 1984, pp 5 l-57 8. Ricketts RM: Divine proportions in facial esthetics. Clin Plast Surg 9:401, 1982 9. Merrifield LL: The profile line as an aid in critically evaluating facial esthetics. Am J Orthod 52:806, 1966 10. Farkas LG: Anthropometrics of the Head and Face in Medicine. New York, NY, Elsevier. 1981, pp 8-59, 108-202 1 1. Farkas LG, Kolar JC: Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg 14:599, 1987 12. Farkas LG. Hreczko TA. Kolar JC. et al: Vertical and horizontal proportions of the face in young adult North American caucasians: Revision of neoclassical canons. Plast Reconstr Surg 75:328. 1985 13. Farkas LG, Katie MJ, Hreczko TA, et al: Anthropometric proportions in the upper-lower lip-chin area of the lower face in young white adults. Am J Orthod 86:52, 1984 14. Farkas LG. Sohm P, Kolar JC, et al: Inclinations of the facial profile art versus reality. Plat Reconstr Surg 75:509, 1985 15. Farkas LG, Munro IR: Anthropometric Facial Reconstruction in Medicine. Springfield, IL, Thomas, 1987, pp 3-8, 19-26, 49-55, 119-129, 166-319 16. Farkas LG, Hreczko TA, Deutsch CK: Objective assessment of standard nostril types- a morphometric study. Ann Plast Surg 11:381, 1983 17. Ward RE, Jamison PL: Measurement precision and reliability in craniofacial anthropometry: implications and suggestions for clinical applications. J Craniofac Gen Dev Biol 11:156, 1991 18. Farkas LG, Lindsay WK: Morphology of the adult face following
820
19.
20. 21. 22.
DlSCUSSlON
repair of bilateral cleft lip and palate in childhood. Plast Reconstr Surg 47:25, 197 1 Whitaker LA, Morales L, Farkas LG: Aesthetic surgery of the supraorbital ridge and forehead structures. Plast Reconstr Surg 78~23, 1986 Laestadius ND, Aase JM, Smith DW: Normal inner canthal and outer orbital dimensions. J Pediatrics 74:465, 1969 Pryor HB: Objective measurement of interpupillary distance. Pediatrics 44:973, 1969 Topinard P: Elements d’Anthropologie Generale. Paris, Delahaye and Lacrosnier, 1885
J Oral Maxillofac 50:820,
23. Stella JP, Epker BN: Systematic aesthetic evaluation of the nose for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2: 273, 1990 24. Farkas LG: Anthropometrics of the normal and defective ear. Clin Plast Surg 17:213, 1990 25. Leibers B: Ohrmuscheldystopie, ohrmuscheldysplasie und’ohrmuschelmissbildung-klinische wertung and bedeutung als symptom. Arch Klin Exp 202:51, 1972
26. Broadbent TR, Mathews VL: Artistic relationships in surface anatomy of the face. Plast Reconstr Surg 20: 1, 1957
Surg
1992
Discussion Maxillofacial Esthetics: Anthropometrics of the Maxillofacial Region Timothy A. Tuwey, DDS
The Universityof North Carolina at Chapel Hill In the quest to improve facial balance and harmony, surgeons rely on many guidelines, including the classical canons developed by the Renaissance artists. Some use linear or an-
gular cephalometric measurements and a few use anthropometric data. Others rely on their own esthetic judgment, in the belief that it is as reliable as any other method. Few remarkable individuals have the talent to envision proposed facial changes abstractly. Most of us do not possess this ability and will find anthropometric proportions helpful in planning treatment. This manuscript brings to our attention an objective means of assessing facial form and balance from both the frontal and profile views. Anthropometric proportions, not absolute measurements, are emphasized. According to Tessier, “Harmony or disharmony does not lie within angles, distances, lines, surfaces or volumes. They arise from proportion.“’
The article adequately reminds the readers of ethnic, racial, gender, and other demographic differences. It also warns of the problems of extrapolating the data to other groups and of using only the measurements and proportions to make treatment planning decisions. The authors credit Farkas for his contribution to anthropometric measurements. In my opinion, they have understated the usefulness of the proportions that he and Munro have already published in their textbook.’ The proportions described in this article complement those already published by Farkas and coworkers. Readers are reminded that they, too, can use Farkas’s raw data to develop their own set of facial proportions suited to the needs of their patients and their practices.2
References 1. Farkas LG, Munro IR: Anthropometric Facial Proportions in Medicine. Springheld, IL, Charles Thomas, 1986 2. Farkas LG: Anthropometry of the Head and Face. New York, NY, Elsevier, 198 1
