Aesthetic Facial Analysis

• A detailed understanding of aesthetic facial analysis is important to any cosmetic or reconstructive surgeon
• Clear knowledge of soft tissue and bony anatomic landmarks is the basic language for surgeons

Nasal Considerations

• Nasal and nasofacial angles are critical in rhinoplasty analysis and planning
• Aesthetic subunits and relaxed skin tension lines guide surgical incisions and repairs

Defining Beauty Through History

• Mankind has always tried to define beauty
• Surgeons require a scientific approach to beauty for successful surgical outcomes
• Common reference points enable collegial communications and medical record keeping
• Identifying and defining specific characteristics that deviate from the norm is essential for identifying congenital anomalies and facial deformities
• Aesthetic facial proportions were idealized in ancient Egyptian art initially
• Formal study of beauty began in the era of Greek philosophy
• Symmetry, harmony, and geometry defined beauty for Plato and Aristotle
• 5th century BCE Greek sculptor Polyclitus defined "perfect beauty" as mutual harmony of all parts, where nothing could be added or subtracted
• Renaissance artists revisited these ideas to define ideal human form proportions
• Leonardo da Vinci's drawings, particularly the Vitruvian Man, exemplify this trend
• Da Vinci formulated ideal facial proportions by studying anatomy and dividing the profile into equal thirds
• Da Vinci's scientific accuracy was unmatched, and the beauty of his artistry remains unchallenged
• German printmaker Albrecht Dürer, another Renaissance artist, constructed a proportional system using his own finger as a unit of measurement
• Dürer published a four-book treatise on human proportions in 1528, dividing the facial profile into four equal parts and noting that nose length equals ear length
• Artistic canons from antiquity and the Renaissance dominated Western art for centuries
• 20th century anthropometrist Leslie Farkas and colleagues challenged classic canons by measuring facial proportions of 200 women
• Farkas' work concluded that some canons are artistic idealizations
• Social and cultural factors influence each generation's concept of beauty
• Aesthetic canons have withstood the test of time
• Parameters in facial plastic surgery literature are based predominately on Powell and Humphreys' work, which crystallized the topic in 1984

Anatomic Facial Landmarks

• Facial analysis relies on soft tissue and skeletal anatomic landmarks
• Soft tissue reference points are illustrated in Figure 16.3 and listed in Box 16.1
• Skeletal reference points are defined by cephalometric analysis, shown in Figure 16.4, and listed in Box 16.2
• The nasal root and dorsum have multiple identifying names

Key Soft Tissue Anatomic Landmarks

• Trichion (Tr): Anterior hairline in the midline
• Glabella (G): Most prominent point of the forehead on profile
• Nasion (N): Deepest depression at the root of the nose and corresponds to the nasofrontal suture
• Radix: The root of the nose region begins at the superior orbital ridge and continues along the lateral nasal wall
• Rhinion (R): Soft tissue correlate of the osseocartilaginous junction on the nasal dorsum
• Sellion: Osseocartilaginous junction on the nasal dorsum
• Supratip: Point cephalic to the tip
• Tip (T): Ideally, the most anterior projection of the nose on profile
• Subnasale (Sn): Junction of columella and upper lip
• Labrale superius (Ls): Vermilion border of upper lip
• Stomion (S): Central portion of interlabial gap
• Stomion superius: Lowest point of upper lip vermilion
• Stomion inferius: Highest point of lower lip vermilion
• Labrale inferius (Li): Vermilion border of lower lip
• Mentolabial sulcus (Si): Most posterior point between lower lip and chin
• Pogonion (Pg): Most anterior midline soft tissue point of chin
• Menton (Me): Most inferior soft tissue point on chin
• Cervical point (C): Innermost point between the submental area and the neck
• Nasion, radix, rhinion, and sellion are subtle but important
• The Frankfurt horizontal plane is the standard reference for patient positioning in photographs and cephalometric radiographs
• The Frankfurt line goes from the superior aspect of the external auditory canal to the inferior border of the infraorbital rim when the patient’s gaze is parallel to the floor
• Soft tissue definition for the inferior aspect of the infraorbital rim is the transition point between lower eyelid and cheek skin

Key Cephalometric Reference Points

• Sella (S): Midpoint of the hypophysial fossa
• Orbitale (Or): Most inferior point on the infraorbital rim
• Porion (P): Most superior point on the external auditory meatus
• Condylion (Cd): Most superior point on the head of the mandibular condyle
• Articulate (Ar): Intersection of the posterior margin of the ascending mandibular ramus and the outer margin of the cranial base
• Anterior nasal spine (ANS)
• Posterior nasal spine (PNS)
• Point A, subspinale (A): Deepest point in the concavity of the premaxilla
• Prosthion (Pr): Lowest, most anterior point on the alveolar portion of the premaxilla
• Infradentale (Id): Highest, most anterior point on the alveolar portion of the mandible
• Point B, supramentale (B): Most posterior point in the outer contour of the mandibular alveolar process
• Pogonion (Pg): Most anterior point on the bony chin in the midline
• Gnathion (Gn): Point between the most anterior (Pg) and inferior (Me) points on the chin
• Menton (Me): Lowest point on the mandible
• Gonion (Go): Midpoint at the angle of the mandible

Assessing Proportions

• Initial face assessment evaluates symmetry by comparing halves through a midsagittal plane; midline points should lie on the axis line
• Facial width is evaluated by dividing the face into equal fifths
• The width of one eye should equal one-fifth of the total facial width, matching the intercanthal distance or nasal base width
• Facial height is commonly assessed by dividing the face into equal thirds
  • Measurements are from the trichion to the glabella, the glabella to the subnasale, and subnasale to the menton
• A second method excludes the upper third of the face due to hairline variability, measuring from the nasion to the subnasale (43%) and the subnasale to the menton (57%)

Facial Subunits

• The face is divided into aesthetic units, with major units including the forehead, eyes, nose, lips, chin, ears, and neck
• Units and subunits are based on skin thickness, color, texture, and underlying structural contour
• Surgical incisions and reconstructions require analysis of the entire unit or subunit

Forehead Analysis

• Forehead boundaries extend from the hairline to the glabella, forming the upper third of the face
• Aesthetically, a gentle convexity on profile is most pleasing
• The nasofrontal angle is formed by the intersection of a line tangent to the glabella through the nasion and a line tangent to the nasal dorsum
• Typical nasofrontal angle measurements range from 115 to 135 degrees

Eye Considerations

• Eyebrow shape is a smooth, gently curving arc, beginning medially in a slight clublike configuration and tapering laterally
• Lateral position for a female is well above the supraorbital rim, while for a male it's at or near the rim
• The medial edge of the eyebrow lies on a perpendicular line through the lateral-most portion of the nasal ala, about 10 mm above the medial canthus
• The highest point of the eyebrow arc is at a line tangentially from the lateral limbus
• Eyebrow arc should extend in an unbroken line from the brow to the lateral nasal tip
• Orbit boundaries are in the lower third of the upper face and upper third of the midface
• Eye width from medial to lateral canthus should equal one fifth of the facial width, and also the intercanthal distance
• Normal intercanthal distances for women and men are 25.5 to 37.5 mm and 26.5 to 38.7 mm, respectively
• Eyes should be almond-shaped with the lateral canthus slightly more superior than the medial canthus
• Average palpebral opening is 10 to 12 mm in height and 28 to 30 mm in width
• The upper lid crease averages about 11 mm from the lash line
• The upper eyelid normally covers a small portion of the iris, without covering the pupil
• The lower eyelid is within 1 to 2 mm of the iris on neutral gaze, with no sclera visible below the iris margin

Nasal Analysis

• Nose boundaries lie within the middle third of the face
• The nasal starting point is located at the nasion, corresponding to the upper eyelid’s superior palpebral fold
• The nose ends at the subnasale
• The nose is the central and most prominent aesthetic unit of the face
• Key relationships: chin, lips, and eyebrows
• The nose's topographic subunits are important when planning reconstructive procedures

Nasofacial relationships

• Powell and Humphreys defined relationships between the nose and face
• These key angles include the nasofrontal, nasolabial, nasofacial, and nasomental angles

Nasofrontal Angle

• Nasofrontal angle is the angle between the forehead and nose

Nasolabial Angle

• The angle is formed between the intersection of a line tangent to the labrale superius and subnasale and a line tangent to the subnasale and the most anterior point of the columella
• This measures 95 to 110 degrees in women and 90 to 95 degrees in men

Nasofacial Angle

• The incline of the nasal dorsum in relation to the facial plan
• The angle is formed from a vertical line tangent to the glabella through the pogonion intersecting a line from the nasion through the nasal tip
• This ideally measures 36 degrees, but it can vary from 30 to 40 degrees

Nasomental Angle

• The nasomental angle describes the angle formed by a tangent line from the nasion to the nasal tip intersecting with a line from the tip to the pogonion
• The range of this angle is from 120 to 132 degrees
• Disharmonies can be masked by the chin or lip position

Nasal Rotation and Projection

• Nasal rotation and projection are essential for determining nasal aesthetics
• Tip rotation generally occurs along an arc produced by a radius based at the external auditory canal
• Rotation increases along the upper portion of the arc and decreases along the lower portion

Nasal Tip Analysis

• Simons measures tip projection in relation to the length of the upper lip, ideally at a 1:1 ratio
• Goode's method uses a vertical line from the nasion to the alar groove, a perpendicular line from the alar groove to the nasal tip, and a line from the tip back to the nasion
• The ratio between the alar groove, tip, and nasal length should be 0.55 to 0.60
• Crumley and Lanser use a 3-4-5 triangle to measure nasal projection, where the hypotenuse is the nasal length and the projection is the smallest arm

Alar-Columellar Complex

• The ala-to-tip/lobular complex ratio is considered optimal at 1:1; a columella shown at 3 to 5 mm is considered acceptable
• From the basal view, the nose should be triangular and is divided into three equivalent units

Lip Considerations

• Boundaries of the lips are contained within the lower one third of the face
• The upper lip is measured from the subnasale to the stomion superius, the lower lip and chin measured from the stomion inferius to the menton
• There are well-defined subunits of the lip
• The height of the upper lip should be approximately half the height of the lower lip

Horizontal Lip Position

• Horizontal lip position constructs a line from the subnasale through the labrale inferius to the pogonion
• A perpendicular line through the anteriormost point of each lip would define its horizontal position
• The upper and lower lip should lie 3.5 and 2.2 mm anterior to this line, respectively
• Alternatively, the nasomental angle may measure horizontal lip position, and the lips should fall just behind this line at a distance of 4 mm for the upper lip and 2 mm for the lower lip

Chin Analysis

• Chin boundaries lie in the lower one third of the face, measured from the mentolabial crease to the menton
• The chin is a pivotal facial unit for analyzing the nose or neck
• Gonzalez-Ulloa described the ideal chin position by a tangential line from the nasion to pogonion, perpendicular to the Frankfurt horizontal plane
• The mentolabial sulcus lies approximately 4 mm behind the tangent.

Neck Considerations

• The ideal neck has a well-defined mandible from the pogonion to the angle of the mandible with an acute mentocervical angle
• This angle is produced by drawing a line from the glabella to the pogonion and intersecting that with a tangent line from the menton to the cervical point

Ear Considerations

• The width of the ear is approximately one half its length
• The ear length should approximate the length of the nose measured from the nasion to the subnasale
• The superior aspect of the ear lies at the level of the eyebrow, its inferior aspect at the level of the nasal ala
• The long axis of the ear is parallels the long axis of the nasal dorsum; it has a posterior rotation of roughly 15 degrees from the vertical plane
• The ear protrudes at 20 to 30 degress; it comes out from the skull at 15 to 25 mm

Skin Wrinkles

• Skin texture, thickness, elasticity, and solar damage are all critical
• Rhytids (wrinkles) stem from chronologic aging, photo-aging or solar damage, and skin folding due to loss of skeletal/soft tissue support
• Hyperdynamic facial lines are from long-term facial muscle animation: horizontal forehead creases, crow's feet, and glabellar lines
• Hyperdynamic lines differ from melolabial fold, mentolabial sulcus, and the crisscross wrinkling under the eyelids

Skin Classifications

• Fitzpatrick skin type assessed in 1988 is based on sun reactivity
• Type I: White skin, always burns, never tans
• Type II: White skin, usually burns, tans with difficulty
• Type III: White skin, sometimes burns, sometimes tans
• Type IV: White skin, rarely burns, tans with ease
• Type V: Brown skin, very rarely burns, tans very easily
• Type VI: Black skin, never burns, always tans
• Glogau photoaging classification divides into four: Type I (few wrinkles, age 20-30, rarely wears makeup), Type II (early wrinkles, age 30-40, sometimes wears makeup), Type III (wrinkles at rest, age 50-60, always wears makeup), Type IV (severe wrinkling, age 60-70, makeup ineffective)

Computer Imaging and Digital Photography in Aesthetics

• Advances in digital photography and computer graphics have changed how surgeons obtain and process patient photos
• These photos are useful for preoperative analysis, patient education, photo archiving, and instruction; imaging systems have become efficient and user-friendly
• Computer imaging system components include a computer, imaging device or camera, and imaging software
• Other valuable components added CD burner, graphics board, digital drawing tablet, and color printer
• Digital photography's clarity depends on camera and lens sophistication
• High resolution depends on megapixels
  • 3.0+ megapixels are sufficient
• Single-lens reflex (SLR) camera has interchangeable lenses and through-the-lens (TTL) metering; a 6.0+ megapixel camera can cost around $700
• Lighting, background, and patient positioning are similar to typical photography; external flashes improve shadow effects
• Downloaded photographic images can be altered using programs such as Mirror Suite (Image Management Plus Simulation; Canfield Scientific, Fairfield, NJ)
• Software helps with facial angle measurement, analysis, and planning
• Computer-generated changes are matched with preoperative images for patient viewing
• Realistic expectations are needed for concept with patient
• Imaging is effective for rhinoplasty with microgenia due to the benefit of chin augmentation
• The computer images help patients visualize the change in facial harmony