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Arch Aesthetic Plast Surg > Volume 24(3); 2018 > Article
Park, Lee, and Jung: Photogrammetric Facial Analysis of Attractive Celebrities Using the Glabella for Planning Rhinoplasty and Analyzing Surgical Outcomes

Abstract

Background

Identifying problems and making a surgical plan through a preoperative analysis is important in facial aesthetic surgery. Thus, popular conceptions of an attractive face must be analyzed beforehand. The landmarks used as reference points may change after rhinoplasty, resulting in errors in the prediction and assessment of outcomes. To reduce such errors, it is advantageous to use reference points and landmarks that are subject to minimal variation. This study measured and analyzed landmarks with little preoperative and postoperative variation in rhinoplasty, and established appropriate standards for landmarks indicative of ideal profiles.

Methods

A photogrammetric analysis was performed of 80 famous and attractive celebrities from Korea, Southeast Asia, Japan, China, and America. The nasofrontal angle, nasal angle, nasolabial angle, angle of facial convexity, and angle of total facial convexity were measured.

Results

The angle of total facial convexity differed significantly among countries (P=0.013). No significant difference in nasal angle, facial convexity, or total facial convexity was observed between Western and Eastern countries. A significant difference in the nasofrontal angle (Asian: 138.66°, Western: 134.35°; P=0.006) was observed. The nasolabial angle (Asian: 97.09°, Western: 104.59° degrees; P=0.007) was significantly more acute in Asian than in Western subjects.

Conclusions

In this study, we performed a more accurate analysis using the glabella instead of the nasion to measure the facial profiles of patients planning to undergo rhinoplasty and proposed standard values through an analysis of ideal and attractive facial profiles.

INTRODUCTION

The nose plays an important role in facial beauty; thus, rhinoplasty is currently one of the most frequently performed aesthetic surgical procedures in the world. Previously, rhinoplasty focused on improving certain parts of the nose, such as via the augmentation of the dorsum or tip plasty; however, it is now considered more important for rhinoplasty results to be harmonious and balanced with the face overall.
East Asians, unlike Caucasians, tend to have a short retruded columella, wide and flaring nostrils, a broad and ill-defined nose tip, low dorsal profile, obtuse nasofrontal angle, acute nasolabial angle, and greater forward placement of the upper lip with midface retrusion [1-3]. In a previous study, Western subjects tended to have a protruding forehead, while Asians had a retruded midface and less chin prominence [4,5]. The Asian concept of facial beauty has changed over the years, largely due to the influence of Western culture [6].
In order to make a surgical plan that would yield harmonious rhinoplasty results for patients of various ethnicities, whose demands have been undergoing dynamic changes, it is necessary to perform a detailed analysis of the patients’ angular and proportional profiles prior to surgery. Thus, many authors have suggested utilizing soft tissue analysis as a reliable guide for aesthetic rhinoplasty. To establish standards of attractive faces that are broadly acceptable, studies on various facial angles and proportions using cephalometry, anthropometry, and photogrammetry have been performed [7-11]. Various angular profiles exhibit interrelationships with one another, and as a result, critical errors may occur in the assessment of preoperative and postoperative profiles. Reference points and landmarks that can minimize these interrelationships are necessary to reduce errors during surgical planning and the assessment of surgical outcomes.
We developed a system for assessing rhinoplasty results by measuring facial angular profiles using reference points with little variation before and after surgery. The goal of this study was to propose standards for attractive profiles in association with those reference points.

METHODS

Study subjects

To establish standards for various ethnicities and countries, a photogrammetric analysis was performed of famous and attractive celebrities, not only from Korea, but also from Southeast Asia, Japan, China, and the United States, to obtain mean measurements. Pictures were obtained from the Internet as JPG files. Attractive celebrities were chosen as subjects regardless of whether they had previous cosmetic surgery. The criteria for the selection of celebrities and pictures used in the analysis are presented below.
  • 1. Celebrities whose nose shape and facial balance were considered attractive based on questionnaires completed by patients admitted to a hospital in the corresponding country.

  • 2. Pictures in which the angle of the chin (pogonion) was uniformly measured during the photogrammetric analysis, and thus, had little variation due to occlusion or hypergnathism/hypognathism of the maxilla or mandible.

  • 3. Pictures in which the glabella, nasion, pronasale, columella, subnasale, labium superius, and pogonion, which were the reference points for angle measurement, could be clearly seen. These points were defined as follows:

  • • Glabella: The most prominent point of the forehead in the midline between the eyebrows.

  • • Nasion: The midline point of the junction of the frontonasal suture and the superior nasal bones. Externally, the nasion often corresponds to the point of greatest concavity of the nasal dorsum near a line level with the upper lid lash line.

  • • Pronasale: The most prominent point of the nasal tip.

  • • Columella: The point of the base of the nose.

  • • Subnasale: The deepest point at the junction of the base of the columella and the upper lip in the midline.

  • • Labium superius: The midpoint on the vermilion line of the upper lip.

  • • Pogonion: The most prominent point of the chin in the midline.

  • 4. Pictures in which both eyelashes were positioned parallel to one another, and the opposite side of the midline was invisible or barely visible; in other words, the rotation about the cervical/axial axis was close to the true lateral profile. The opposite pupil, eyebrow, or eyelash was not visible.

  • 5. Pictures in which there was no facial expression and the lips were normally closed.

A total of 80 subjects, consisting of 37 Koreans, 10 Chinese, 8 Japanese, 14 Southeast Asians (8 Thais, 2 Malaysians, 2 Filipinos, 1 Indonesian, and 1 Vietnamese), and 11 Americans, were included in this study.

Measurements

All profile photograph views were analyzed by one of the authors (C.W.P.). Seven soft tissue surface landmarks, including the glabella (g), nasion (n), pronasale (prn), columella (cm), subnasale (sn), labium superius (ls), and pogonion (pg) were marked on the profile photographs using Adobe Photoshop CS5 (Adobe Systems Inc., San Jose, CA, USA) (Fig. 1). Thereafter, each dot was connected for angle measurement. To measure the nasofrontal angle, nasal angle, and nasolabial angle, glabella-nasion-pronasale, nasion-pronasale-columella, and columella-subnasale-labium superius were connected in a line, respectively. To measure facial convexity, glabella-subnasale-pogonion was connected in a line. For the measurement of total facial convexity, glabella-pronasale-pogonion was connected. The angles formed by these lines were measured using the ruler tool in Adobe Photoshop CS5 (Fig. 2 and Table 1).

Statistical analysis

The Kruskal-Wallis test was used to compare angle measurements for each country. The Mann-Whitney U-test was used to compare the measurements between Asian and Western countries. The data were analyzed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA). P-values <0.05 were considered to indicate statistical significance.

RESULTS

Measurements by country and region are shown in Table 2. The angle of total facial convexity differed significantly among the countries/regions (P=0.013). A comparison of Asian and Western countries is shown in Table 3. No significant differences in nasal angle (nasion-pronasale-columella; Asian: 111.97°±5.65°, Western: 112.55°±3.49°), facial convexity (glabella-subnasale-pogonion; Asian: 169.11°±2.67°, Western: 170.67°±3.12°), or total facial convexity (glabella-pronasale-pogonion; Asian: 142.88°±2.95°, Western: 142.17°±3.73°) were found between the Western and Asian countries. A significant difference in the nasofrontal angle (glabella-nasion-pronasale; Asian: 138.66°±4.09°, Western: 134.35°±4.93°; P=0.006) was found between the Western and Asian countries, with Asians having more obtuse angles than Western subjects. The nasolabial angle (columella-subnasale-labium superius; Asian: 97.09°±7.22°, Western: 104.59°±9.19°; P=0.007) was significantly more acute in Asian than in Western subjects.

DISCUSSION

Anthropometric analysis is important for guiding the rhinoplastic surgeon to achieve satisfactory results for a harmonious face.
Data available from various studies are difficult to compare directly because of the different settings required to obtain a profile view and because of racial variations. However, the natural head position is relatively constant and reliable [12]. Legan and Burstone [13] described the angle of convexity, which is formed by the glabella, subnasale, and pogonion. The Powell analysis, involving the nasofrontal, nasofacial, nasomental, and mentocervical angles, was developed to provide insights into the ideal facial profile. Arnett and Bergman defined frontal and lateral analysis procedures using photographic records taken in the natural head position [14,15]. They used the nasolabial angle and the angle of the contour of the maxillary and mandibular sulcus. They also described the facial profile in different types of malocclusion according to the angle of facial convexity (glabella-subnasale-pogonion) [14,15].
Auger and Turley [16] attempted to determine significant changes in the female soft tissue profile as presented in fashion magazines of the 1990s. Rhee et al. [7] also conducted angular profile analysis using profile photographs of famous female models obtained from internet sites, proposing upper, anterior, and posterior angles of a pyramid by marking soft tissue landmarks in the lateral profile and comparing the angles.
The existing methods of measurement for planning rhinoplasty and assessing the results are limited. Assessing surgical outcomes using landmarks limited to the nose alone may lead to overall imbalance in the face and awkward results. No assessment standard has been established due to controversy regarding the terminology related to facial convexity in previous facial anthropometry studies.
During an angular profile analysis of a patient, the angle of facial convexity (nasion-subnasale-pogonion or glabella-subnasale-pogonion) and angle of total facial convexity (nasion-pronasale-pogonion or glabella-pronasale-pogonion) are commonly measured from the lateral side to assess the balance between the face and nose. Arnett and Bergman [15] claimed that the general harmony of the forehead, midface, and lower face can be appraised with the profile angle (glabella-subnasale-pogonion). This profile angle is the most important factor in assessing surgical correction postoperatively.
However, when using the nasion as a reference point for convexity in the assessment of rhinoplasty results, the angle representing facial convexity may be affected, as the location of the nasion changes following dorsal augmentation. We were able to perform a more accurate analysis by using the glabella instead of the nasion to measure the facial profiles of patients who underwent rhinoplasty. Hans et al. also employed the glabella, since the location of the nasion was altered by surgery and was not reliable [17]. Rhinoplasty planning and assessment of surgical outcomes must not be limited to the nose, but should also take facial convexity into account. When using the nasion as a reference point for convexity, it must be noted that as the location of the nasion changes due to dorsal augmentation, the angle that represents facial convexity may be affected. We assessed rhinoplasty results by measuring facial angular profiles using the glabella as a reference point, since it undergoes minimal changes after surgery.
According to the results of our study, there was no significant difference in facial convexity between subjects from Asian and Western countries (Asian: 169.11°±2.67°, Western: 170.67°±3.12°; P=0.070). In other studies, Fernández-Riveiro et al. [18] reported results of 168.2°±4.96° (male) and 167.0°±5.36° (female), and Anić-Milosević et al. [9] reported values of 168.78°±4.97° (male) and 169.05°±4.69° (female). However, in Asians, the angle of facial convexity is generally about 175° to 180° [1]. This discrepancy occurs because the premaxillary area is hypoplastic in many Asians, which, along with a retracted columella, often results in an acute nasolabial angle [2]. For the above reasons, the attractive level of facial convexity is similar between Asian and Western countries, and facial convexity plays a crucial role in promoting harmony of the face and nose.
The methods we employed enabled measurements to be made easily, with only a lateral profile and Adobe Photoshop or a protractor. Because this method required simply marking a few soft tissue landmarks and measuring a few angles, it avoided challenges caused by overlapping reference points. Although it would be ideal to accurately fit the natural head position, an objective comparison using photogrammetric analysis was sufficient since the angles between soft tissue landmarks were compared without marking the Frankfort plane. In addition, since total facial convexity and facial convexity were measured relative to the glabella—a fixed point—the comparison between preoperative and postoperative results was more objective.
Although 80 subjects (37 Koreans, 10 Chinese, 8 Japanese, 14 Southeast Asians, and 11 Americans) were included in this study, this number seemed too small to make a definitive comparison between Asian and Western subjects. Furthermore, pictures of the subjects were obtained from the Internet, since we could not directly take pictures of them. Moreover, as we could not obtain their accurate lateral profiles and the obtained pictures had differences in angles and lighting, there may have been errors in our findings. These limitations should be considered when interpreting our results and should be addressed in future research. Better rhinoplasty planning and ideal surgery outcomes can be achieved by setting reference points suitable for producing an attractive nose that would be satisfactory for patients.
Although the sample size was small, our results indicate that the facial lateral profile angles that were considered attractive were similar among the countries analyzed.
We proposed standards for beautiful faces through an analysis of ideal and attractive celebrity facial profiles in association with suitable reference points. This can serve as a guide for the treatment goals of aesthetic rhinoplasty.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig. 1.
The 7 profile landmarks that were used. g, glabella; n, nasion; prn, pronasale; cm, columella; sn, subnasale; ls, labium superius; pg, pogonion.
aaps-2018-24-3-105f1.jpg
Fig. 2.
The 5 angles that were measured. g, glabella; n, nasion; prn, pronasale; cm, columella; sn, subnasale; ls, labium superius; pg, pogonion.
aaps-2018-24-3-105f2.jpg
Table 1.
Definition of the seven profile landmarks and five angles of measurement
Landmark Definition
Glabella (g) The most prominent point of the forehead in the midline between the eyebrows.
Nasion (n) The midline point of the junction of the frontonasal suture and the superior nasal bones. Externally, the nasion often corresponds to the point of greatest concavity of the nasal dorsum near a line level with the upper lid lash line.
Pronasale (prn) The most prominent point of the nasal tip.
Columella (cm) The point of the base of the nose.
Subnasale (sn) The deepest point at the junction of the base of the columella and the upper lip in the midline.
Labiale superius (ls) The midpoint on the vermilion line of the upper lip.
Pogonion (pg) The most prominent point of the chin in the midline.
NFA The angle of the nasal tip, radix, and most prominent point of the forehead; g-n-prn.
NA The angle between the line from the glabella to the pronasale and the line from the pronasale to the columella; n-prn-cm.
NLA The angle between the line from the anterior columella to the subnasale and the line from the subnasale to the labiale superius; cm-sn-ls.
FC The angle between the line from the glabella to the subnasale and the line from the subnasale to the pogonion; g-sn-pg.
TFC The angle between the line from the glabella to the pronasale and the line from the pronasale to the pogonion; g-prn-pg.

NFA, nasofrontal angle; NA, nasal angle; NLA, nasolabial angle; FC, facial convexity; TFC, total facial convexity; g, glabella; n, nasion; prn, pronasale; cm, columella; sn, subnasale; ls, labium superius; pg, pogonion.

Table 2.
Comparison of angle measurements between regions
Variable n Value of parameters (°)
P-valuea)
Mean Standard deviation Standard error
NFA 0.050
 Korean 37 138.69 3.97 0.65
 Chinese 10 140.37 4.22 1.34
 Japanese 8 137.69 4.59 1.62
 Southeast Asian 14 137.91 4.08 1.09
 American 11 134.35 4.93 1.49
NA 0.203
 Korean 37 112.93 5.27 0.87
 Chinese 10 108.99 6.91 2.18
 Japanese 8 110.50 4.60 1.63
 Southeast Asian 14 112.40 5.90 1.58
 American 11 112.55 3.49 1.05
NLA 0.091
 Korean 37 97.30 7.32 1.20
 Chinese 10 98.09 7.47 2.36
 Japanese 8 96.33 5.58 1.97
 Southeast Asian 14 96.24 8.18 2.19
 American 11 104.59 9.19 2.77
FC 0.151
 Korean 37 168.68 2.70 0.44
 Chinese 10 169.01 2.89 0.91
 Japanese 8 170.34 2.91 1.03
 Southeast Asian 14 169.63 2.26 0.60
 American 11 170.67 3.12 0.94
TFC 0.013
 Korean 37 142.24 2.69 0.44
 Chinese 10 141.50 3.57 1.13
 Japanese 8 145.18 2.01 0.71
 Southeast Asian 14 144.26 2.57 0.69
 American 11 142.17 3.73 1.12

NFA, nasofrontal angle; NA, nasal angle; NLA, nasolabial angle; FC, facial convexity; TFC, total facial convexity.

a) Kruskal-Wallis test.

Table 3.
Comparison of angle measurements between the Asian and Western subjects
Variable n Value of the parameters (°)
P-valuea)
Mean Standard deviation Standard error
NFA 0.006
 Asian 69 138.66 4.09 0.49
 Western 11 134.35 4.93 1.49
NA 0.878
 Asian 69 111.97 5.65 0.68
 Western 11 112.55 3.49 1.05
NLA 0.007
 Asian 69 97.09 7.22 0.87
 Western 11 104.59 9.19 2.77
FC 0.070
 Asian 69 169.11 2.67 0.32
 Western 11 170.67 3.12 0.94
TFC 0.375
 Asian 69 142.88 2.95 0.36
 Western 11 142.17 3.73 1.12

NFA, nasofrontal angle; NA, nasal angle; NLA, nasolabial angle; FC, facial convexity; TFC, total facial convexity.

a) Mann-Whitney U-test.

REFERENCES

1. Lee MJ, Song HM. Asian rhinoplasty with rib cartilage. Semin Plast Surg 2015;29: 262–8.
crossref pmid pmc pdf
2. Ishii CH. Current update in asian rhinoplasty. Plast Reconstr Surg Glob Open 2014;2: e133.
crossref pmid pmc
3. Gao Y, Niddam J, Noel W, et al. Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: an esthetic surgeon’s perspective. Asian J Surg 2018;41: 4–11.
crossref pmid
4. Chao JW, Lee JC, Chang MM, et al. Alloplastic augmentation of the Asian face: a review of 215 patients. Aesthet Surg J 2016;36: 861–8.
crossref pmid pdf
5. Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences in the soft tissue profile of Korean and European-American adults with normal occlusions and well-balanced faces. Angle Orthod 2002;72: 72–80.
pmid
6. Koh KS, Choi JW, Ishii CH,Asian facial cosmetic surgery. Neligan PC, editors. Plastic surgery. 3rd ed. New York, NY: Elsevier; 2013. p.163–83.

7. Rhee SC, Kang SR, Park HS. Balanced angular profile analysis. Plast Reconstr Surg 2004;114: 535–44.
crossref pmid
8. Nechala P, Mahoney J, Farkas LG. Digital two-dimensional photogrammetry: a comparison of three techniques of obtaining digital photographs. Plast Reconstr Surg 1999;103: 1819–25.
crossref pmid
9. Anić-Milosević S, Lapter-Varga M, Slaj M. Analysis of the soft tissue facial profile by means of angular measurements. Eur J Orthod 2008;30: 135–40.
crossref pmid pdf
10. Wang JH, Jang YJ, Park SK, et al. Measurement of aesthetic proportions in the profile view of Koreans. Ann Plast Surg 2009;62: 109–13.
crossref pmid
11. Park SS. Fundamental principles in aesthetic rhinoplasty. Clin Exp Otorhinolaryngol 2011;4: 55–66.
crossref pmid pmc
12. Larrabee WF Jr, Maupin G, Sutton D. Profile analysis in facial plastic surgery. Arch Otolaryngol 1985;111: 682–7.
crossref pmid
13. Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980;38: 744–51.
pmid
14. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod Dentofacial Orthop 1993;103: 299–312.
crossref
15. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning--Part II. Am J Orthod Dentofacial Orthop 1993;103: 395–411.
crossref pmid
16. Auger TA, Turley PK. The female soft tissue profile as presented in fashion magazines during the 1900s: a photographic analysis. Int J Adult Orthodon Orthognath Surg 1999;14: 7–18.
pmid
17. Holmström H, Gewalli F. Long-term behavior of three different grafts in nasomaxillary reconstruction of binder syndrome: an analysis by digitalized measurements. Plast Reconstr Surg 2008;122: 1524–34.
crossref pmid
18. Fernández-Riveiro P, Smyth-Chamosa E, Suárez-Quintanilla D, et al. Angular photogrammetric analysis of the soft tissue facial profile. Eur J Orthod 2003;25: 393–9.
crossref pmid pdf
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