Aesthetic Facial Analysis-19

SECTION 1 FACIAL SURGERY
Aesthetic Facial Analysis 19

Marc S. Zimbler
Key Points
A detailed understanding of aesthetic facial analysis is imperative to any cosmetic or reconstructive
surgeon.
The names of both soft tissue and bony anatomic landmarks must be clear and are the basic

language in which surgeons communicate.
Both nasal and nasofacial angles are the cornerstone to rhinoplasty analysis and planning.

Aesthetic subunits and relaxed skin tension lines are critical in designing surgical incisions and repairs.
T hroughout history, mankind has tried to define beauty. idealizations. Nevertheless, although social and cultural factors
Poets, philosophers, and artists have pondered its elusive influence every generations concept of beauty, these aesthetic
quality while attempting to quantify that which is evident to canons have withstood the test of time. Currently, the param-
all of us. As surgeons, however, we are required to have a more eters established in the facial plastic surgery literature are based
scientific approach to beauty to formulate operative plans predominately on the works of Powell and Humphreys,2 who
with successful surgical outcomes. Common reference points in 1984 crystallized this topic into a single text, Proportions of the
are essential in both communications with colleagues and in Aesthetic Face.
medical record keeping. Furthermore, we must be able to
accurately define specific characteristics that deviate from the
norm so that we may identify congenital anomalies and facial
deformities.
As early as ancient Egypt, aesthetic facial proportions have
been idealized in art. However, it was not until the era of Greek
philosophy that the study of beauty became a formal discipline.
To Plato and Aristotle, beauty meant symmetry, harmony, and
geometry. In the fifth century bce, the Greek sculptor Polyclitus
defined perfect beauty as the mutual harmony of all parts,
such that nothing could be added or subtracted. Such har-
monic proportions were held to be beautiful in themselves,
independent of any observer.
These ideas were later revisited by the Renaissance artists,
who began to define ideal proportions for the human form.
This example is nowhere more evident than in the drawings of
Leonardo da Vincis and his Vitruvian Man (Fig. 19-1). It was
da Vinci who formulated ideal facial proportions through the
study of anatomy and divided the profile into equal thirds (Fig.
19-2). Leonardos scientific accuracy rivaled that of Vesalius,
and the beauty of da Vincis artistry remains unchallenged.
Another Renaissance artist inspired by the Vitruvian notion of
perfect proportions was the German printmaker Albrecht
Drer, who used his own finger as a unit of measurement to
construct a proportional system for the entire body; in 1528,
Drer published a four-book treatise on human proportions,
wherein he divided the facial profile into four equal parts and
recognized that the length of the nose equals that of the ear.
The artistic canons set forth in antiquity and during the
Renaissance dominated Western art for centuries. In the twen-
tieth century, anthropometrist Leslie Farkas and colleagues1 FIGURE 19-1. The proportions of the body according to Vitruvius, ca.
challenged these classic canons by measuring the facial propor- 1490; a study by Leonardo da Vinci. Pen and ink with touches of wash over
tions of 200 women, including 50 models. His results concluded stylus, 34.4 24.5cm. (Courtesy the Galleria dell Accademia, inv.228, Venice,
that some of the canons are nothing more than artistic Italy.)
273
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274 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY
Box 19-2. CEPHALOMETRIC REFERENCE POINTS

Sella (S): The midpoint of the hypophysial fossa
Orbitale (Or): The most inferior point on the infraorbital rim
Porion (P): The most superior point on the external auditory meatus
Condylion (Cd): The most superior point on the head of the
mandibular condyle
Articulate (Ar): The point of 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): The deepest point in the concavity of the
premaxilla
Prosthion (Pr): The lowest, most anterior point on the alveolar portion
of the premaxilla
Infradentale (Id): The highest, most anterior point on the alveolar
portion of the mandible
Point B, supramentale (B): The 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): A point between the most anterior (Pg) and inferior
FIGURE 19-2. The proportions of the head, ca.1490; a study by Leonardo (Me) points on the chin
da Vinci. Pen and ink over black chalk, 28.0 22.2cm. (Courtesy the Galleria Menton (Me): The lowest point on the mandible
dell Academia, inv.236v, Venice, Italy.) Gonion (Go): The midpoint at the angle of the mandible
ANATOMIC LANDMARKS aspect of the infraorbital rim is the point of transition between
lower eyelid and cheek skin.
AND REFERENCE POINTS
Facial analysis is dependent on both soft tissue and skeletal
anatomic landmarks. Soft tissue reference points are shown in
FACIAL PROPORTIONS
Figure 19-3 and listed in Box 19-1. Skeletal reference points are The initial assessment of the face evaluates symmetry, which is
defined by cephalometric analysis and are shown in Figure 19-4 rarely perfect when comparing halves through a midsagittal
and listed in Box 19-2. The nasal root and dorsum have mul- plane (Fig. 19-6); nevertheless, midline points should lie on the
tiple identifying names, and the reader should be aware of axis line. Facial width is evaluated by dividing the face into
subtle but important differences. Examples include nasion, equal fifths (Fig. 19-7). The width of one eye should equal one
radix, rhinion, and sellion.. fifth of the total facial width and should be the same as the
The Frankfurt horizontal plane (Fig. 19-5) is the standard intercanthal distance or nasal base width.
reference point for patient positioning in photographs and Facial height is commonly assessed by one of two methods.
cephalometric radiographs. The Frankfurt line is drawn from The first method divides the face into equal thirds (Fig. 19-8)
the superior aspect of the external auditory canal to the infe- as described by da Vinci. Measurements are made in the
rior border of the infraorbital rim while the patients gaze is midline, from the trichion to the glabella, from the glabella to
parallel to the floor. A soft tissue definition for the inferior the subnasale, and from the subnasale to the menton. The
second method excludes the upper third of the face because
of common variability regarding hairline position. Measure-
Box 19-1. SOFT TISSUE ANATOMIC LANDMARKS ments are made from the nasion (as opposed to the glabella)
to the subnasale and from the subnasale to the menton (Fig.
Trichion (Tr): Anterior hairline in the midline 19-9). With this method the midface represents 43% of the
Glabella (G): Most prominent point of the forehead on profile
Nasion (N): The deepest depression at the root of the nose; typically
height, with the lower face representing 57%.
corresponds to the nasofrontal suture
Radix: Root of the nose, a region and not a point; part of an unbroken
curve that begins at the superior orbital ridge and continues along
SUBUNIT ANALYSIS
the lateral nasal wall The face is divided into aesthetic units (Fig. 19-10) that are
Rhinion (R): Soft tissue correlate of the osseocartilaginous junction on further divided into subunits. The major units that are classi-
the nasal dorsum cally defined for facial analysis include the forehead, eyes, nose,
Sellion: Osseocartilaginous junction on the nasal dorsum lips, chin, ears, and neck. The units and subunits are based on
Supratip: Point cephalic to the tip skin thickness, color, texture, and underlying structural contour.
Tip (T): Ideally, the most anterior projection of the nose on profile
Subnasale (Sn): Junction of columella and upper lip
Precise planning of surgical incisions and reconstructions
Labrale superius (Ls): Vermilion border of upper lip require analysis of the entire unit or subunit. Incisions parallel
Stomion (S): Central portion of interlabial gap to relaxed skin tension lines (RSTLs; Fig. 19-11) and within unit
Stomion superius: Lowest point of upper lip vermilion or subunit borders result in the most favorable scars.
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 FOREHEAD
chin The boundaries of the forehead are from the hairline to the
Pogonion (Pg): Most anterior midline soft tissue point of chin glabella and make up the upper third of the face. The contour
Menton (Me): Most inferior soft tissue point on chin
Cervical point (C): The innermost point between the submental area
anatomy of the forehead is most aesthetically pleasing with a
and the neck gentle convexity on profile. The nasofrontal angle (Fig. 19-12)
is created by a line tangent to the glabella through the nasion
19 | AESTHETIC FACIAL ANALYSIS 275
Trichion
Glabella
Nasion
Radix
Rhinion
Supratip
Tip
Subnasale
Labrale superius
Stomion
Labrale inferius
Menton
A
Trichion
Glabella
Nasion
Rhinion
Supratip
Tip
Subnasale
Labrale superius
Stomion
Labrale inferius
Mentolabial sulcus
Pogonion
Menton
Cervical point B
FIGURE 19-3. Soft tissue reference points. A, Frontal view. B, Lateral view.
and intersecting with a line tangent to the nasal dorsum. The point may actually lie anywhere from the lateral limbus to the
range of aesthetic measurements for this angle is from 115 to lateral canthus. Sheen3 describes the eyebrow arc as most pleas-
135 degrees. ing when it extends as an unbroken line from the brow down
to the lateral nasal tip (Fig. 19-14).
The boundaries of the orbits are in the lower third of the
EYES upper face and the upper third of the midface. The width of
The ideal eyebrow shape follows a smooth and gently curving one eye from medial to lateral canthus should equal one fifth
arc. The brow should begin medially in a slight clublike con- of the facial width. The intercanthal distance should equal the
figuration and should continue in a gradual taper toward its width of one eye. Normal intercanthal distances for women and
lateral end. Lateral position for a female is well above the men are 25.5 to 37.5mm and 26.5 to 38.7mm, respectively. In
supraorbital rim, whereas for a male it is at or close to the rim. general, the eye should be almond shaped with the lateral
The medial edge of the eyebrow lies on a perpendicular line canthus slightly more superior than the medial canthus. The
that passes through the lateralmost portion of the nasal ala and average palpebral opening is 10 to 12mm in height and 28 to
approximately 10mm above the medial canthus (Fig. 19-13). 30mm in width. The upper lid crease is the line created by the
In women, the highest point of the eyebrow arc is at a line insertion of the levator aponeurosis and orbital septum into the
drawn tangentially from the lateral limbus. However, this ideal orbicularis oculi and dermis. The location of the crease aver-
eyebrow position can vary with fashion trends, and the highest ages approximately 11mm from the lash line but can vary
S
P
Or Cd
Ar
ANS
A PNS
Pr
ld
Pg Go
Gn
Me
FIGURE 19-5. Frankfurt horizontal plane. A line is drawn from the superior
aspect of the external auditory canal to the most inferior aspect of the infra-
orbital rim.
FIGURE 19-4. Cephalometric reference points. See Box 19-2 for defini-
tions of all abbreviations.
1/5 1/5 1/5 1/5 1/5
FIGURE 19-6. Facial symmetry through the midsagittal plane. FIGURE 19-7. Facial width. The facial width is divided into equal fifths.
Trichion
1/3
Glabella
1/3
Subnasale
1/3
Menton
FIGURE 19-8. Facial height. The facial height is divided into equal thirds. From trichion to glabella, from glabella to subnasale, and from subnasale to menton.
Nasion
43%
Subnasale
57%
Menton
FIGURE 19-9. Middle and lower facial height. Division of height is unequal and is measured from the nasion to subnasale and from the subnasale to the
menton.
Hairline or
superior border of
frontalis m.
Orbital rim
Preauricular
Nasofacial groove crease
Melolabial fold
Mentolabial sulcus
FIGURE 19-10. Aesthetic units of the face.
115-135
FIGURE 19-12. Nasofrontal angle (115 to 135 degrees).
FIGURE 19-11. Relaxed skin tension lines of the face.
Side
Dorsum
Ala
Tip
Soft triangle
FIGURE 19-13. Ideal eyebrow position. Medial brow head lies along the
horizontal tangent with medial canthus and nasal ala. The highest point of
brow arch is located above the lateral limbus.
FIGURE 19-15. Nasal aesthetic subunits adapted from Burgets description.

between 7 and 15mm. The upper eyelid normally covers a
small portion of the iris but not the pupil. The lower eyelid is
within 1 to 2mm of the iris on neutral gaze, with the sclera
invisible below the iris margin. upper eyelids superior palpebral fold (see Fig. 19-3), and it
ends at the subnasale. Because the nose is the central and most
prominent aesthetic unit of the face, it is always analyzed in
NOSE relationship to other facial structures, most importantly the
The boundaries of the nose are within the middle third of the chin, lips, and eyebrows. The topographic subunits of the nose
face. On the lateral view, the nasal starting point begins at the (Fig. 19-15) have been described by Burget4 and are essential
nasion, which ideally corresponds to the same level as the when planning reconstructive procedures. The borders of nasal
subunits allow for scar camouflage when incisions lie along
subunit margins.
NASOFACIAL RELATIONSHIPS
Powell and Humphreys2 formulated relationships between the
nose and face and included the nasofrontal angle, nasolabial
angle, nasofacial angle, and nasomental angle. The nasofrontal
angle (see Fig. 19-12) is described in the forehead section of
this chapter. The nasolabial angle defines the angular inclination
of the columella as it meets the upper lip. The angle is formed
between the intersection of a line tangent to the labrale super-
ius and subnasale and a line tangent to the subnasale and the
most anterior point of the columella (Fig. 19-16). This angle
should measure 95 to 110 degrees in women and 90 to 95
degrees in men. The nasofacial angle is the incline of the nasal
dorsum in relation to the facial plane (Fig. 19-17). It represents
the angle formed from a vertical line tangent to the glabella
through the pogonion intersecting a line from the nasion
through the nasal tip. This angle ideally measures 36 degrees,
but it can vary from 30 to 40 degrees. 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 (Fig. 19-18). The range of this angle is from 120 to
132 degrees, and it can clearly be obscured if the chin or lip
position is in facial disharmony.
Nasal Rotation and Projection
Nasal rotation and projection are essential measurements in
FIGURE 19-14. An unbroken aesthetic line goes from the eyebrow to the determining nasal aesthetics. Tip rotation generally occurs
nasal tip. along an arc produced by a radius based at the external
95-110
90-95
A B
FIGURE 19-16. Nasolabial angle. A, Male, 90 to 95 degrees. B, Female, 95 to 110 degrees.
36
FIGURE 19-17. Nasofacial angle: 30 to 40 degrees.
auditory canal (Fig. 19-19). Rotation increases along the upper

portion of the arc and decreases along the lower portion. Alar-Columellar Complex
Several methods have been used to analyze tip projection, and On lateral view, the ala-to-tip/lobular complex ratio is consid-
these have defined nasal length. Simons5 measures tip projec- ered optimal at 1:1 (Fig. 19-22); a columella shown at 3 to
tion in relation to the length of the upper lip (Fig. 19-20). Nasal 5mm is considered acceptable. From the basal view, the nose
projection is approximately equal to the length of the upper should be triangular and is divided into three equivalent units
lip, giving a ratio of 1:1. Goodes2 method uses a vertical line (Fig. 19-23).
drawn 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 (Fig. 19-21). The ratio comparing the length
LIPS
of the perpendicular line (alar groove to tip) with that of the The boundaries of the lips are contained within the lower one
nasal length (nasion to tip) should be 0.55 to 0.60. When these third of the face. The upper lip is measured from the subnasale
ratios are observed, the nasofacial angle is approximately 36 to the stomion superius, whereas the lower lip and chin are
degrees. Crumley and Lanser6 use a similar method and use a measured from the stomion inferius to the menton (Fig. 19-24).
3-4-5 triangle, in which the hypotenuse is the nasal length, and The subunits of the lip are well defined (Fig. 19-25), whereas
the projection is the smallest arm of the triangle. the height of the upper lip relative to the lower lip should have
120-132
4 mm FIGURE 19-20. Using Simons method, nasal projection is approximately

equal to the length of the upper lip, with a ratio of 1:1.
2 mm
CHIN
The boundaries of the chin lie in the lower one third of the
face and can be measured from the mentolabial crease to the
menton. The chin is a pivotal facial unit when analyzing
FIGURE 19-18. Nasomental angle: 120 to 132 degrees. The lips should fall the nose or neck. Most rhinoplasty analysis begins with proper
just behind this line at a distance of 4mm for the upper lip and 2mm for
chin position in relation to nasal projection and facial harmony.
the lower lip.
Gonzalez-Ulloa7 described the ideal chin position by a tangen-
tial line through the nasion to pogonion, which is almost per-
a ratio of approximately 1:2. Horizontal lip position can be pendicular to the Frankfurt horizontal plane (Fig. 19-27). An
determined by two separate methods: the first constructs a line alternative method for analyzing chin position is described in
from the subnasale through the labrale inferius to the pogo- the lip section (see Fig. 19-26); in this method, the mentolabial
nion (Fig. 19-26), a perpendicular line through the anterior- sulcus lies approximately 4mm behind this line.
most point of each lip defines its horizontal position, and the
upper and lower lip should lie 3.5 and 2.2mm anterior to this
line, respectively; the second method uses the nasomental
NECK
angle to determine horizontal lip position, and the lips should The ideal neck has a well-defined mandible from the pogonion
fall just behind this line at a distance of 4mm for the upper lip to the angle of the mandible with an acute mentocervical angle.
and 2mm for the lower lip (see Fig. 19-18). 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 (Fig. 19-28). The cervical point
is defined as the innermost point between the submentum and
Tip
Ala
0.55-0.60
FIGURE 19-19. Tip rotation generally occurs along an arc produced by a

radius based at the external auditory canal. FIGURE 19-21. Goodes method of plotting tip projection. N, nasion.
1/3
1/3
1/3
FIGURE 19-23. Nasal base divided into equal thirds.
A B
FIGURE 19-22. Nasal ala. A, Ala-to-tip lobule ratio complex should be 1:1.
B, The columella is shown between 3 and 5mm.
Subnasale
1/3
Stomion
2/3
Menton
FIGURE 19-24. Lip ratio and lower facial thirds.
Philtrum dimple
Philtrum column Sn
Melolabial fold
Cupids bow
Li
Vermilion border Si
Pg
Labiomental crease
FIGURE 19-26. Horizontal lip position. The mentolabial sulcus (Si) should
lie 4mm posterior to a vertical line dropped from the subnasale (Sn) through
FIGURE 19-25. Lip aesthetic subunits. the labrale inferius (Li) and extending to the pogonion (Pg).
Pg
FIGURE 19-29. Long axis of the ear parallels the long axis of the nasal
FIGURE 19-27. The zero meridian of Gonzalez-Ulloa. Ideal chin position dorsum.
is on a vertical line from the nasion (N) to the pogonion (Pg), which is per-
pendicular to the Frankfurt horizontal.
neck. It is also important to evaluate chin position when analyz- is noted to have a posterior rotation of approximately 15
ing the neck, because an obtuse mentocervical angle may cause degrees from the vertical plane. The ear protrudes from the
the perception of poor chin projection. skull at an angle of approximately 20 to 30 degrees, which
usually translates into a measurement of 15 to 25mm from the
helix to the mastoid skin.
EARS
The width of the ear is approximately one half its length. The
ear length should approximate the length of the nose mea-
SKIN AND RHYTIDS
sured from the nasion to the subnasale. The superior aspect of When analyzing the face, evaluation of the skin deserves special
the ear lies at the level of the eyebrow, whereas its inferior attention. Skin texture, thickness, elasticity, and solar damage
aspect is at the level of the nasal ala. The long axis of the ear are all critical factors that contribute to the overall facial
is parallel to the long axis of the nasal dorsum (Fig. 19-29) and appearance. In 1988, Fitzpatrick8 established a skin-type classi-
fication (Table 19-1), and in 1994, Glogau9 categorized photo-
aged skin (Box 19-3). However, in the examination of the skin,
the analysis of facial rhytids is most important. Rhytids, or wrin-
kles, originate from a wide variety of sources that can include
chronologic aging, photoaging or solar damage, and skin
folding secondary to loss of underlying skeletal or soft tissue
support. Hyperdynamic facial lines (Fig. 19-30) are specific
wrinkles caused by long-term facial muscle animation. Exam-
ples of these include horizontal forehead creases, crows feet,
and glabellar lines. Each line is caused by repeated underlying
muscle contraction. Hyperdynamic lines should be distin-
G guished from other facial lines, such as the melolabial fold and
mentolabial sulcus and the fine crisscross wrinkling found on
the cheek and under the eyelids.
TABLE 19-1. Fitzpatrick Classification of Sun-Reactive

Skin Type
Skin Type Skin Color Characteristics
I White Always burns, never tans
80-95
Pg II White Usually burns, tans with difficulty
III White Sometimes burns, sometimes tans
Me C IV White Rarely burns, tans with ease
V Brown Very rarely burns, tans very easily
FIGURE 19-28. Mentocervical angle (80 to 95 degrees). C, cervical point;
VI Black Never burns, always tans
G, glabella; Me, menton; Pg, pogonion.
Box 19-3. GLOGAU PHOTOAGING CLASSIFICATION

Type I: No keratoses, few wrinkles, age 20 to 30 years, rarely wears Frontalis m.
makeup Procerus m.
Type II: Early lentigenes, wrinkles on animation, age 30 to 40 years,
sometimes wears makeup
Corrugator m.
Type III: Advanced photoaging, wrinkles present at rest, age 50 to 60
years, always wears makeup Horizontal
Type IV: Severe photoaging, severe wrinkling, age 60 to 70 years, forehead
makeup has minimal benefit creases Orbicularis
occuli m.
Glabellar
lines
COMPUTER IMAGING AND Crows

DIGITAL PHOTOGRAPHY feet
Technologic advances in digital photography and computer
graphics have revolutionized the way many surgeons obtain
and process patient photographs. The immediate availability
of photographs for review and the ability to generate computer-
modified images provide an easy and effective means of
preoperative analysis. Routine office consultations typically
include patient imaging, which has become a vital tool for
preoperative education. It also provides the surgeon an oppor-
tunity to strengthen communication with the patient regarding FIGURE 19-30. Hyperdynamic facial lines caused by repeated underlying
muscle contraction.
realistic expectations of surgical outcome. Added benefits of
computer imaging include photoarchiving and use as an
instructional tool for residents and fellows. Over the past few measure and analyze facial angles for assistance in preopera-
years, this technology has evolved from being costly, cumber- tive analysis and planning (Fig. 19-31). The cost of such com-
some, and slow to being highly efficient, user-friendly, and mercially available systemscomplete with computer, camera,
reasonably priced. and softwareis several thousands of dollars; however, more
The essential components for a computer imaging system basic systems may be pieced together to maintain a more
include a computer, an image-capture device or camera, and modest price.
imaging software. Computer specifications are dependent on Computer imaging and its ability to generate altered images
the demands and expectations of the surgeon. Additional com- for patient education can be particularly helpful during the
ponents that are highly recommended include a compact disc preoperative rhinoplasty consultation. Computer-generated
(CD) burner for archiving and storage, a graphics board, digital changes are compared with preoperative images and are
drawing tablet, and a high-resolution color printer. reviewed with the patient. The surgeon must be conservative
As with 35-mm photography, the clarity of digital photogra-
phy is dependent on the sophistication of the camera and its
lens. The resolution of digital cameras is described in pixels,
and it currently ranges up to 12.0 megapixels. However, a
3.0-megapixel camera is sufficiently suited for the demands of
most medical photography, and a 3.0-megapixel image printed
on 4- by-6inch glossy photo paper is nearly indistinguishable
from a conventional photograph. For a more professional look
with quality and control similar to a 35-mm camera, a true
single-lens reflex (SLR) camera with higher megapixels is pre-
ferred. The additional capabilities include interchangeable
lenses and through-the-lens (TTL) metering. The price for
advanced digital SLR cameras has dropped dramatically over 135
the past several years, and a 6.0-megapixel camera can be pur-
chased, lens included, for around $700. Lighting, background,
and patient positioning are similar to conventional photogra- 35
phy, and shoe-mount external flashes are suggested for
improved results with minimal shadow.
Once the photographic images are downloaded onto the
computer, a variety of image or graphics software may be used
85
to open and alter images. The Mirror Suite (Image Manage-
ment Plus Simulation; Canfield Scientific, Fairfield, NJ) is
sophisticated but user-friendly high-end software designed for
medical professionals. Once downloaded, image files from the
camera are automatically tethered into the Mirror software
and are saved into patients charts. The ease and speed of
image alteration lies at the heart of this sophisticated software,
which makes patient consultations streamlined and informa- FIGURE 19-31. Facial angle analysis, including nasofrontal angle, nasofacial
tive. Furthermore, this advanced software has the ability to angle, and mentocervical angle. (Courtesy Canfield Clinical Systems.)
computer-generated images assist patients in visualizing the

overall improvement in facial harmony.
For a complete list of references, see expertconsult.com.
SUGGESTED READINGS
Burget GC: Aesthetic restoration of the nose. Clin Plast Surg 12(3):463
480, 1985.
Crumley RL, Lanser M: Quantitative analysis of nasal tip projection.
Laryngoscope 98(2):202208, 1988.
Farkas LG, Hreczko TA, Kolar JC, et al: Vertical and horizontal propor-
tions of the face in young adult North American caucasians: revision
of neoclassical canons. Plast Reconstr Surg 75(3):328338, 1985.
FIGURE 19-32. Preoperative (left) and postoperative (right) computer Fitzpatrick TB: The validity and practicality of sun-reactive skin types I
imaging of combined rhinoplasty and chin augmentation. (Courtesy Canfield through VI. Arch Dermatol 124(6):869871, 1988.
Clinical Systems.) Glogau RG: Chemical peeling and aging skin. J Geriatr Dermatol 2:3035,
1994.
Gonzalez-Ulloa M: Quantitative principles in cosmetic surgery of the
face (profileplasty). Plast Reconstr Surg Transplant Bull 29:186198,
with computer-generated changes and must avoid overzealous
1962.
alterations. In this manner, realistic expectations are nurtured, Powell N, Humphreys B: Proportions of the aesthetic face, New York, 1984,
and a common outcome concept can be reached between Thieme-Stratton.
surgeon and patient. Computer imaging can be particularly Sheen JH: Aesthetic rhinoplasty, St. Louis, 1978, Mosby.
helpful to demonstrate to the rhinoplasty patient with micro- Simons RL: Nasal tip projection, ptosis and supratip thickening. J Ear
genia the added benefit of chin augmentation (Fig. 19-32). The Nose Throat 61:452455, 1982.
19 | AESTHETIC FACIAL ANALYSIS 285.e1
5. Simons RL: Nasal tip projection, ptosis and supratip thickening.

REFERENCES J Ear Nose Throat 61:452, 1982.
1. Farkas LG, Hreczko TA, Kolar JC, et al: Vertical and horizontal 6. Crumley RL, Lanser M: Quantitative analysis of nasal tip projection.
proportions of the face in young adult North American caucasians: Laryngoscope 98:202, 1988.
revision of neoclassical cannons. Plast Reconstr Surg 75:328, 1985. 7. Gonzalez-Ulloa M: Quantitative principles in cosmetic surgery of the
2. Powell N, Humphreys B: Proportions of the aesthetic face, New York, face (profileplasty). Plast Reconstr Surg 29:186, 1962.
1984, Thieme-Stratton. 8. Fitzpatrick TB: The validity and practicality of sun-reactive skin types
3. Sheen JH: Aesthetic rhinoplasty, St. Louis, 1978, Mosby. I through VI. Arch Dermatol 124:869, 1988.
4. Burget GC: Aesthetic restoration of the nose. Clin Plast Surg 12:463, 9. Glogau RG: Chemical peeling and aging skin. J Geriatr Dermatol 2:30,
1985. 1994.

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Aesthetic Facial Analysis-19

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SECTION 1 FACIAL SURGERY

Aesthetic Facial Analysis 19

Box 19-2. CEPHALOMETRIC REFERENCE POINTS

1/5 1/5 1/5 1/5 1/5

FIGURE 19-10. Aesthetic units of the face.

FIGURE 19-12. Nasofrontal angle (115 to 135 degrees).

FIGURE 19-11. Relaxed skin tension lines of the face.

FIGURE 19-15. Nasal aesthetic subunits adapted from Burgets description.

FIGURE 19-17. Nasofacial angle: 30 to 40 degrees.

auditory canal (Fig. 19-19). Rotation increases along the upper

4 mm FIGURE 19-20. Using Simons method, nasal projection is approximately

FIGURE 19-19. Tip rotation generally occurs along an arc produced by a

FIGURE 19-23. Nasal base divided into equal thirds.

FIGURE 19-24. Lip ratio and lower facial thirds.

TABLE 19-1. Fitzpatrick Classification of Sun-Reactive

Box 19-3. GLOGAU PHOTOAGING CLASSIFICATION

COMPUTER IMAGING AND Crows

computer-generated images assist patients in visualizing the

For a complete list of references, see expertconsult.com.

5. Simons RL: Nasal tip projection, ptosis and supratip thickening.

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