Cosmetic Balanced Angular Profile Analysis Seung Chul Rhee, M.D., So Ra Kang, M.D., Ph.D., and Heung Sik Park, M.D., Ph.D. Seoul, Republic of Korea To evaluate current preferences and ethnic differences of female soft-tissue profiles, 71 profile photographs of famous female models were collected from Internet Web pages and divided into four groups (Korean, 22; Japanese, 15; Chinese, 16; and Western, 18). Eleven soft-tissue landmarks were recorded on each photograph and 16 angular measurements were made by using V-ceph (CyberMed, Inc., Seoul, Korea). Data from each group are presented to show the means, ranges, p and F values, standard deviations, and standard errors of each measurement. In addition, individual measurements for each group were compared with those of the other groups by one-way analysis of variance using a p value corrected for multivariable testing. Between-group mean value differences were calculated using a Tukey s studentized range test (HSD), at a significance level of p 0.05. Most of the variables were similar in the groups. Significant between-group differences (p 0.05) were found for angle of alar curvature point, profile convexity, interlabial contour, and nasolabial contour. In addition, we divided all data into two groups (Western and Asian). The t test (with significance level set to p 0.05) was performed to compare the two. Significant between-group differences (p 0.05) were found for angle of alar curvature, angle of labiale inferius, profile convexity, and lower lip projection angle, but no significant racial differences were found in terms of several profile angles. These findings suggest that point of ala curvature point, subnasale, and the labiale inferius of Asian models may differ from those of Western models. These peculiar angular patterns of Asian models led the authors to create a new characteristic angular concept, termed the ethnic pyramid, which is composed of softtissue profile points of alar curvature point, subnasale, pronasale, and labiale inferius. This ethnic pyramid describes the characteristic patterns of the ethnic differences. The results of this study suggest that the soft-tissue profiles of famous female models have some common features but also show differences among ethnic groups and races. This simple method of profile analysis may provide aesthetic surgeons with a simple formula and reference data for creation and application of an attractive face. On the basis of their balanced angular profile analysis data, the authors suggest that appropriate and harmonious aesthetic operations reflecting these differences should be considered. (Plast. Reconstr. Surg. 114: 535, 2004.) The face is the most variable part of the body and permits distinction between races and ethnic groups. Variability is manifested by the different sizes and shapes of individual features and even more by the relationships of these features to each other. Facial quantities such as harmony, disharmony, or disproportion, previously only verbally defined, can be determined quantitatively. 1 The surgical procedure composed of a sequence of techniques aimed at the correction of defective facial features is called profileplasty. Maxillofacial plastic surgeons make extensive use of both hard-tissue and soft-tissue cephalometrics during the planning and in the evaluation of their preoperative and postoperative results. Since the introduction of a standardized method for obtaining skull radiographs, cephalometrics has become one of the major diagnostic tools of facial plastic surgeons. However, most facial plastic surgeons are concerned with total facial aesthetics and work primarily from photographs, not radiographs. 2 Data available from various studies are difficult to compare directly because of the different settings used to obtain profile views and because of racial variations. 3 The prime purpose of the present study was to determine whether there are any racial or ethnic differences in the profiles of famous Western and Asian women and to provide aesthetic surgeons with a simple method of profile analysis and reference data for creation and application of an attractive face. MATERIALS AND METHODS Profile photographs were collected from Internet Web pages and divided into four groups From the Department of Plastic and Reconstructive Surgery, Cosmetic Plastic Surgery Center, Dongdaemoon Hospital, Medical College of Ewha Women s University. Received for publication April 22, 2003; revised August 18, 2003. Presented at the 21st Congress of the Korean Society of Aesthetic Plastic Surgery, in Seoul, Korea, March 29, 2003. DOI: 10.1097/01.PRS.0000131873.98390.36 535
536 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004 (Korean, Japan, Chinese, and Western). We typed model photo into several Web search engines (e.g., Yahoo, Naver, Empas, Google, Altavista, MSN, Daum, Simmani, Lycos, Dreamwiz) and visited all of the sites and Web pages. Photographs that frequently appeared at different Web sites were stored in a computer [800-MHz central processing unit, Windows ME (Microsoft Corp., Redmond, Wash.), 128 M of random access memory, LG IBM, Multinet, Korea] in JPG format using Adobe Photoshop 5.5 (Adobe Systems, San Jose, Calif.), if the photograph met the following criteria: 1. The soft-tissue profile showed the following landmarks (Fig. 1). These fiducials are derived from traditional photogrammetric points 4 and some additional points that have been used commonly by facial plastic surgeons. Glabella: the most prominent or anterior point of the forehead between the eyebrows. Tragion: most anterior portion of the supratragal notch. Sellion: the most concave point in the tissue overlying the area of the frontonasal suture. Pronasale: the most prominent or anterior projection point of the nose. Highest point of columella (or columella FIG. 1. Profile points: t, tragion; g, glabella; se, sellion; prn, pronasale; ac, alar curvature point (alar crest point); c', columella breakpoint; sn, subnasale; ls, labiale superius; li, labiale inferius; pg, pogonion; dc, distant chin. breakpoint of Daniel): the most anterior and highest part of the columella. Subnasale: the junction of the columella and the upper cutaneous lip. Ala curvature (or alar crest) point: the most lateral point in the curved baseline of each ala, indicating the facial insertion of the nasal wing base. Labiale superius: the mucocutaneous junction or midpoint of the upper vermilion line. Labiale inferius: the mucocutaneous junction or midpoint of the lower vermilion line. Pogonion: the most anterior point of the soft-tissue chin. Distant chin: the most distant point of the chin from the tragion (a new fiducial; menton and gnathion are not so easy to identify in indirect photogrammetry because of point alternation according to the neck positions or dermatochalasia). 2. Sagittal view shows the full head, anterior to the ear and extending vertically from the soft-tissue chin to the glabella and tragion. 3. To limit the rotation around the cervical axis, the opposite pupil, eyebrow, or eyelash was not visible. 4. One philtral column was visible. 5. Lips were closed smoothly. 6. There were no silhouettes, and facial features were visible. All accepted photographs of famous models were numbered and catalogued by nationality or race. Seventy-one photographs for profile analysis (Korean, 22; Japanese, 15; Chinese, 16; Western, 18) were selected for analysis. From each photograph, 11 anatomical landmarks (Fig. 1 and Table I) were analyzed by V-ceph (CyberMed, Inc., Seoul, Korea) for angular profile analysis (Figs. 2 and 3 and Table II). Using user-defined analysis, we marked the profile points correctly and measured angles. The analyzed polygonal chart was exported to Microsoft Excel data automatically. Data from each group were analyzed to determine the mean, range, p and F values, standard deviation, and the standard error of each measurement. SPSS for Windows Version 10.0 (SPSS, Inc., Chicago, Ill.) and SAS 8.1 (SAS Institute, Inc., Cary, N.C.) were used for establishing data files and statistical analysis. In addition, the individual measurements for each group were compared with the other groups by one-way analysis of variance. Between-group
Vol. 114, No. 2 / BALANCED ANGULAR PROFILE ANALYSIS 537 TABLE I Defined Points on Figure 1 Name Abbreviation Description Glabella g The most prominent or anterior point of forehead between the eyebrows Tragion t Most anterior portion of supratragal notch Sellion se The most concave point in the tissue overlying the area of the frontonasal suture Pronasale prn Most prominent or anterior projection point of nose Columella breakpoint c Highest point of the columella or breakpoint of Daniel Subnasale sn Junction of columella and upper cutaneous lip Alar curvature point (alar crest point) ac The most lateral point in the curved base line of each ala, indicating the facial insertion of the nasal wing base Labiale superius ls Mucocutaneous junction and vermilion border of upper lip Labiale inferius li Mucocutaneous junction and vermilion border of lower lip Pogonion pg Most anterior point of soft-tissue chin Distant chin dc Most distant point of chin from tragion mean value differences were calculated using Tukey s studentized range test (HSD), with a significance level of p 0.05. In addition, we divided all data into two groups (Western and Asian). The t test (p 0.05) was performed to compare the two groups. To test the level of error involved in the methodology, photographs from each group were randomly selected and measurements were repeated by another plastic surgeon. RESULTS Data from each group are presented in Tables III through V. Analysis of variance showed no statistically significant differences between groups in terms of the angle of sellion, angle of pronasale, angle of subnasale, angle of labiale superius, angle of labiale inferius, angle of pogonion, angle of distant chin, three angles of the aesthetic triangle (lower, upper, and anterior), upper lip projection angle, and lower lip projection angle (Table III). These findings suggest that the soft-tissue profiles of famous women are not significantly different among ethnic groups. Analysis of variance showed significant intergroup differences for angle of alar curvature point, profile convexity, interlabial contour, and nasolabial contour. The angle of alar curvature point of Koreans was much narrower than that of Westerners (Korean, 84.08 degrees; Western, 89.40 degrees). Westerners and Chinese show significant differences in profile convexity. Westerners and Japanese show significant differences in the same angle. For profile convexity, Chinese, and Japanese had more acute angles than FIG. 2. V-ceph (Cybermed) was used for angular profile analysis.
538 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004 FIG. 3. Angular measures used in this study: (1) angle of sellion, (2) angle of pronasale, (3) angle of alar curvature point, (4) angle of subnasale, (5) angle of labiale superius, (6) angle of labiale inferius, (7) angle of pogonion, (8) angle of distant chin, (9) profile convexity, (10) lower angle of aesthetic triangle, (11) upper angle of aesthetic triangle, (12) anterior angle of aesthetic triangle, (13) interlabial contour, (14) nasolabial contour, (15) lower lip projection angle, (16) upper lip projection angle, (17) aesthetic triangle, and (18) ethnic pyramid. TABLE II Angular Measures Used in This Study Measure Description Angle of sellion (A1) The acute angle formed by profile points tragion, sellion, and glabella Angle of pronasale (A2) The acute angle formed by profile points tragion, pronasale, and glabella Angle of alar curvature point (A3) The acute angle formed by profile points tragion, alar curvature point, and glabella Angle of subnasale (A4) The acute angle formed by profile points tragion, subnasale, and glabella Angle labiale superius (A5) The acute angle formed by profile points tragion, labiale superius, and glabella Angle labiale inferius (A6) The acute angle formed by profile points tragion, labiale inferius, and glabella Angle of pogonion (A7) The acute angle formed by profile points tragion, pogonion, and glabella Angle of distant chin (A8) The acute angle formed by profile points tragion, distant chin, and glabella Profile convexity (A9) The acute angle formed by profile points sellion, subnasale, and pogonion Lower angle of aesthetic triangle (A10) The acute angle around the chin; the apices of the are glabella, pogonion, and pronasale Upper angle of aesthetic triangle (A11) The acute angle around the glabella; the apices of the are glabella, pogonion, and pronasale Anterior angle of aesthetic triangle (A12) The acute angle around the nasal tip; the apices of the are glabella, pogonion, and pronasale Interlabial contour (A13) The acute angle formed between the line(sn-ls) and the line(li-pg) Nasolabial contour (A14) The acute angle formed by profile points columella breakpoint, subnasale, and labiale superius Lower lip projection angle (A15) The acute angle formed by profile points pogonion, glabella, and labiale inferius Upper lip projection angle (A16) The acute angle formed by profile points pogonion, glabella, and labiale superius, aesthetic triangle; line(sn-ls), line joining points subnasale and labiale superius; line(li-pg), line joining points labiale inferius and pogonion.
Vol. 114, No. 2 / BALANCED ANGULAR PROFILE ANALYSIS 539 TABLE III Variables Showing Between-Group Differences (Korea, Japanese, Chinese, and Western)* Variable F Pr F Group Mean Range SD SE A1 1.33 0.2711 KOR 107.20 97.75 114.48 4.4054 0.9392 JAP 110.21 94.88 119.65 7.7193 1.9931 CHI 107.48 100.88 115.57 4.2169 1.0542 WEST 106.76 97.73 114.48 5.0558 1.1917 A2 0.32 0.8189 KOR 64.75 56.18 72.71 4.3518 0.9278 JAP 66.10 57.60 75.22 6.1900 1.5982 CHI 65.84 60.89 71.98 3.2316 0.8079 WEST 65.60 56.47 72.29 4.3448 1.0241 A3 4.08 0.0102 KOR 84.08 74.84 91.28 4.7131 1.0048 JAP 87.22 76.94 95.21 6.0590 1.5644 CHI 86.17 80.77 90.95 3.5168 0.8792 WEST 89.40 82.16 99.20 4.9891 1.1759 A4 0.68 0.5685 KOR 71.42 61.18 80.35 4.4721 0.9534 JAP 72.30 62.44 80.66 6.0156 1.5532 CHI 71.64 65.99 75.39 3.0086 0.7521 WEST 73.43 65.63 82.09 4.4941 1.0593 A5 1.42 0.2447 KOR 64.98 55.86 73.86 4.0879 0.8715 JAP 66.67 56.82 75.21 5.6723 1.4646 CHI 66.62 62.39 71.10 2.9544 0.7386 WEST 67.68 61.40 75.29 3.9630 0.9341 A6 2.14 0.1039 KOR 59.75 52.00 68.48 3.8247 0.8154 JAP 61.05 51.10 69.97 5.7655 1.4886 CHI 61.06 55.57 65.48 3.0599 0.7650 WEST 63.06 57.33 68.78 3.6724 0.8656 A7 1.39 0.2524 KOR 53.96 46.22 62.35 3.7865 0.8073 JAP 55.18 46.49 62.26 5.1225 1.3226 CHI 54.34 49.46 59.89 2.8848 0.7212 WEST 56.34 51.26 62.21 3.6166 0.8524 A8 1.06 0.3736 KOR 51.73 44.72 59.13 3.5443 0.7556 JAP 52.79 44.06 60.27 5.1635 1.3332 CHI 52.05 47.32 57.44 3.1113 0.7778 WEST 53.77 49.47 60.02 3.3994 0.8012 A9 3.46 0.0211 KOR 166.24 157.51 176.09 5.2056 1.1098 JAP 164.03 156.42 171.74 4.4071 1.1379 CHI 164.21 161.28 172.36 2.7858 0.6965 WEST 168.35 161.69 177.36 4.7674 1.1237 A10 0.71 0.5469 KOR 17.37 13.89 21.28 2.0291 0.4326 JAP 16.70 13.24 21.79 2.7743 0.7163 CHI 16.69 13.66 20.82 1.7773 0.4443 WEST 16.46 12.54 19.36 1.7135 0.4039 A11 1.56 0.2064 KOR 17.93 14.96 23.16 2.0351 0.4339 JAP 16.96 11.80 20.95 3.0442 0.7860 CHI 16.79 13.77 20.36 2.0748 0.5187 WEST 18.27 15.31 24.88 2.4454 0.5764 A12 0.78 0.5069 KOR 146.52 142.09 152.55 3.4031 0.8508 JAP 146.34 138.00 154.69 5.6899 1.4691 CHI 146.52 142.09 152.55 3.4031 0.8508 WEST 145.27 135.76 152.16 3.8072 0.8974 A13 4.38 0.0071 KOR 151.87 136.04 173.92 8.4083 1.7927 JAP 151.74 136.68 168.06 10.7543 2.7768 CHI 162.00 130.60 182.63 13.0589 3.2647 WEST 158.90 140.40 174.81 8.8605 2.0884 A14 3.34 0.0242 KOR 103.43 82.36 135.84 12.1855 2.5980 JAP 99.87 80.29 115.96 9.1681 2.3672 CHI 113.51 78.69 133.15 15.8607 3.9652 WEST 106.52 77.35 126.15 12.55 2.9586 A15 2.35 0.0805 KOR 2.32 0.36 4.39 0.8903 0.1898 JAP 2.53 0.32 4.78 1.4520 0.3749 CHI 2.31 3.82 3.54 1.0089 0.2522 WEST 1.63 0.20 3.26 1.6300 0.2142 A16 2.56 0.0622 KOR 5.70 3.12 7.71 1.3329 0.2842 JAP 5.62 2.68 8.23 1.7383 0.4488 CHI 4.83 2.41 6.93 1.3300 0.3325 WEST 4.67 1.61 6.50 1.2838 0.3026 * Statistical significance at p 0.05 by use of a one-way analysis of variance. Between-group mean value differences were calculated using a Tukey s studentized range test (HSD), with the significance level set to p 0.05. Korean and Western groups show statistically significant differences in angle of alar curvature point. Western and Chinese show significant differences in profile convexity. Western and Japanese show significant differences in profile convexity. Korean and Chinese show significant differences in interlabial angle. Japanese and Chinese show significant differences in interlabial contour. Chinese and Japanese show significant differences in nasolabial contour. A1, angle of sellion; A2, angle of pronasale; A3, angle of alar curvature point; A4, angle of subnasale; A5, angle of labiale superius; A6, angle of labiale inferius; A7, angle of pogonion; A8, angle of distant chin; A9, profile convexity; A10, lower angle of aesthetic triangle; A11, upper angle of aesthetic triangle; A12, anterior angle of aesthetic triangle; A13, interlabial contour; A14, nasolabial contour; A15, lower lip projection angle; A16, upper lip projection angle; KOR, Korean; JAP, Japanese; CHI, Chinese; WEST, Western.
540 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004 TABLE IV Variables Showing Significant Between-Group Differences (Asian and Western)* Variable t Value Pr t Group Mean Range SD SE A1 0.93 0.3582 ASIAN 108.13 94.88 119.65 5.5457 0.7618 WEST 106.76 97.73 114.48 5.0558 1.1917 A2 0.11 0.9133 ASIAN 65.46 56.18 75.22 4.6212 0.6348 WEST 65.60 56.47 72.29 4.3448 1.0241 A3 2.82 0.0062 ASIAN 85.60 74.84 95.21 4.9249 0.6765 WEST 89.40 82.16 99.20 4.9891 1.1759 A4 1.34 0.1839 ASIAN 71.78 61.18 80.66 4.5324 0.6226 WEST 73.43 65.63 82.09 4.4941 1.0593 A5 1.50 0.1378 ASIAN 65.95 55.86 75.21 4.3150 0.5927 WEST 67.68 61.40 75.29 3.9630 0.9341 A6 2.27 0.0262 ASIAN 60.51 51.10 69.97 4.2407 0.5825 WEST 63.06 57.33 68.78 3.6724 0.8656 A7 1.83 0.0719 ASIAN 54.42 46.22 62.35 3.9390 0.5411 WEST 56.34 51.26 62.21 3.3166 0.8524 A8 1.29 0.1164 ASIAN 52.13 44.06 60.27 3.9035 0.5362 WEST 53.77 49.47 60.02 3.3994 0.8012 A9 2.72 0.0082 ASIAN 165.00 156.42 176.09 4.4180 0.8974 WEST 168.35 161.69 177.36 4.7674 0.6069 A10 0.90 0.3721 ASIAN 16.97 13.24 21.79 2.1814 0.2996 WEST 16.46 12.54 19.36 1.7135 0.4039 A11 1.46 0.1480 ASIAN 17.31 11.80 23.16 2.3849 0.3276 WEST 18.27 15.31 24.88 2.4454 0.5764 A12 0.39 0.6950 ASIAN 145.72 135.55 154.69 4.3127 0.5924 WEST 145.27 135.76 152.16 3.8072 0.8974 A13 1.35 0.1810 ASIAN 154.89 130.60 182.63 11.4514 1.5730 WEST 158.90 140.40 174.81 8.8605 2.0884 A14 0.29 0.7730 ASIAN 105.47 78.69 135.84 13.6315 1.8724 WEST 106.52 77.35 126.15 12.5523 2.9586 A15 2.60 0.0114 ASIAN 2.37 0.28 4.78 1.0913 0.1499 WEST 1.63 0.20 3.26 0.9089 0.2142 A16 1.90 0.0621 ASIAN 5.42 2.41 8.23 1.4814 0.2035 WEST 4.67 1.61 6.50 1.2838 0.3026 * All data were divided into two groups (Western and Asian) and the t test (with significance level set to p 0.05) was used to compare the two (Western versus Asian). Eastern and Western groups show statistically significant differences in angle of alar curvature point (Pr t : 0.0062), angle of labiale inferius (Pr t : 0.0262), profile convexity (Pr t : 0.0082), and lower lip projection angle (Pr t : 0.0114). A1, angle of sellion; A2, angle of pronasale; A3, angle of alar curvature point; A4, angle of subnasale; A5, angle of labiale superius; A6, angle of labiale inferius; A7, angle of pogonion; A8, angle of distant chin; A9, profile convexity; A10, lower angle of aesthetic triangle; A11, upper angle of aesthetic triangle; A12, anterior angle of aesthetic triangle; A13, interlabial contour; A14, nasolabial contour; A15, lower lip projection angle; A16, upper lip projection angle; WEST, Western. Westerners statistically (Japanese, 164.03 degrees; Chinese, 164.21 degrees; Korean, 166.24 degrees; Westerners, 168.35 degrees). For interlabial contours, Korean and Japanese models had more acute angles than Chinese models statistically (Japanese, 151.74 degrees; Korean, 151.87 degrees; Westerners, 158.90 degrees; Chinese, 162.00 degrees). For nasolabial contours, Chinese models had much wider angles than Japanese models (Japanese, 99.87 degrees; Korean, 103.43 degrees; Westerners, 106.52 degrees; Chinese, 113.51 degrees). Summarizing, the profile angles of the Korean models were similar to those of the other groups, although the angles of the alar curvature point of Korean models were more acute than those of Western models and the interlabial angles of Korean models were more acute than those of Chinese models. The t test (Table IV) shows that the Asian and Western groups show statistically significant differences in terms of angle of alar curvature point, angle of labiale inferius, profile convexity, and lower lip projection angle. Asian models had much more acute angles than Western models in terms of angle of alar curvature point, angle of labiale inferius, and profile convexity. Lower lip projection angles of Asian models were much wider than those of Western models. These findings suggest that the point of alar curvature point, subnasale, and labiale inferius may differ between theses two groups. These angular patterns of Asian models led us to create a new angular characteristic called the ethnic pyramid (Figs. 3 and 4 and Table V). This pyramid describes the characteristic patterns of ethnic differences of the famous soft-tissue profile. The pyramid is composed of the alar curvature, subnasale, pro-
Vol. 114, No. 2 / BALANCED ANGULAR PROFILE ANALYSIS 541 TABLE V Angles of Aesthetic Triangle and Angles of Ethnic Pyramid* Angles Groups Mean Range SD Lower angle of aesthetic triangle KOR 17.37 13.89 21.28 2.03 JAP 16.70 13.24 21.79 2.77 CHI 16.69 13.66 20.82 1.78 WEST 16.46 12.54 19.36 1.71 Upper angle of aesthetic triangle KOR 17.93 14.96 23.16 2.04 JAP 16.96 11.80 20.95 3.04 CHI 16.79 13.77 20.36 2.07 WEST 18.27 15.31 24.88 2.45 Anterior angle of aesthetic triangle KOR 146.52 142.09 152.55 3.40 JAP 146.34 138.00 154.69 5.69 CHI 146.52 142.09 152.55 3.40 WEST 145.27 135.76 152.16 3.81 Anterior angle of the pyramid KOR 134.54 122.32 142.19 5.82 JAP 136.93 134.43 138.59 1.79 CHI 134.19 115.77 144.24 9.03 WEST 136.07 124.44 147.67 8.52 Posterior angle of the pyramid KOR 111.98 105.70 122.79 7.19 JAP 108.66 105.37 114.66 4.21 CHI 111.40 99.16 129.56 9.78 WEST 118.19 107.40 133.26 8.38 Upper angle of the pyramid KOR 113.49 99.78 123.90 8.83 JAP 114.42 106.75 119.42 5.61 CHI 114.62 96.69 125.07 9.25 WEST 105.54 98.79 120.87 4.76 * See Figure 4 for definitions. KOR, Korean; JAP, Japanese; CHI, Chinese; WEST, Western. nasale, and labiale inferius soft-tissue profile points. (Pronasale should be taken into consideration according to Hsu s study in 1993 regarding the reference lines of the horizontal lip position. 5 ) Soft-tissue point ala curvature, pronasale, and labiale inferius are apices of the pyramid, and the center of the ethnic pyramid is the subnasale. From the center of the pyramid, one can measure the angles to the apices of the pyramid. These three angles were named the upper, anterior, and posterior angles of the pyramid. Table V shows that the anterior angle is wider than the upper angle and that the upper angle is wider than the posterior angle in Asian models. The order is changed in Western models (anterior posterior upper). This important ethnic difference should be considered for profileplasty. To test the level of error involved in our methodology, photographs from each group were randomly selected and measurements were repeated by another plastic surgeon. The amount of error in marking the soft-tissue profile was shown not to be statistically significant by the t test (p 0.3607, t 0.93). The error in measurement was 0.2 degree. DISCUSSION Cephalometric radiographs are usually obtained with a head-holding apparatus. This apparatus is somewhat expensive and cumbersome and interferes with visualization of the face. Maxillofacial plastic surgeons make extensive use of both hard-tissue and soft-tissue cephalometrics for planning and evaluating their preoperative and postoperative results. Since the introduction of a standardized method for obtaining skull radiographs, cephalometrics has become one of the major diagnostic tools of facial plastic surgeons. 2 However, most facial plastic surgeons are concerned with total facial aesthetics and work primarily from photographs, not radiographs. Data available from various studies are difficult to compare directly because of the different settings required for obtaining a profile view and the racial variations. 3 Many studies have been conducted to study the facial profile. Auger et al. 6 tried to determine significant changes in the female soft-tissue profile as presented in fashion magazines of the 1900s. Moorrees and Kean thoroughly tested the hypothesis that the natural head position was relatively constant and found it extremely reliable. 3 The use of the natural head position allows very reproducible head position results without a head-holding apparatus for cephalometric radiographs. In 1862, Broca defined this position as when a man is standing and when his visual axis is horizontal, he (his head)
542 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004 FIG. 4. Three angles of the aesthetic triangle and ethnic pyramid. The apices of the aesthetic triangle are the glabella, pogonion, and pronasale. The lower angle of the aesthetic angle is the acute angle around the chin, the upper angle is around the glabella, and the anterior angle is around the nasal tip. The pyramid is composed of the ala curvature point (ac), subnasale (sn), pronasale (prn), and labiale inferius (li) profile points. Point ac, prn, and li are apices of the pyramid, and the center of the ethnic pyramid is sn. From the center of the pyramid, one can measure the angles to the apices of the pyramid. These three angles were named the upper, the anterior, and the posterior angles of the pyramid. g, glabella; se, sellion; prn, pronasale; ac, alar curvature point (alar crest point); c', columella breakpoint; sn, subnasale; ls, labiale superius; li, labiale inferius; pg, pogonion; dc, distant chin. is in the natural position. 3 Recent studies have documented the reproducibility of the natural head position. 3 Direct measurements have also shown that photogrammetry (indirect anthropometry), even under the most standardized conditions, offers only a limited number of reliable measurements, because of distortion and the twodimensional nature of the photographs. 7 11 This is especially true in the case of frontal views. Although face recognition using profile views in not as accurate as using frontal views or three-dimensional surface data according to Fromherz, it is useful for fast preliminary searches of large databases, to reduce the computational load for subsequent processing using sophisticated algorithms, or as part of hybrid systems to improve the accuracy of frontal image analysis technique. Facial profile analysis is therefore still important for face recognition. 12 Powel and Humphries recently added to the literature on measurement of the aesthetic face, and presented both hard- and soft-tissue measurements. The authors proposed a new concept: the aesthetic triangle. The aesthetic triangle is an excellent screen for facial aesthetics; in addition, all measurement are relative and therefore no external axis is required. 3 Farkas et al. 1,7 reported that angular anthropometric measurements were statistically similar and have little distortion from the reference standard. Angular measurements of the softtissue facial profile were once performed by Neger in 1959. 8 In this study, the Frankfort plane was used and the angular relationship was established only between the upper lip, lower lip, and chin. Facial anthropometric studies on Korean youths were performed using Martin s method, 13 15 but these studies are not useful for clinical application. We placed stress on the following important facts: (1) the natural head position is reproducible but the Frankfort plane is hard to mark correctly by photogrammetry; (2) the inclusion of too many soft-tissue points or lines often tends to obscure the areas of primary concern; (3) the soft-tissue points of the glabella and tragion are relatively stationary in profiles; (4) angles in photogrammetry are not distorted by photography itself; and (5) the facial profile is a balanced and harmonized structure composed of several aesthetic subunits. Angular measurements in our study reflect the balance or relationships between the profile fiducials. Our study has some advantages and characteristics in the analysis of the human profile. First, by using two relatively fixed points of the softtissue profile (glabella and tragion), it is possible to measure and standardize the variable facial profile angles uniformly. Second, our method of profile analysis does not need any reference planes and is composed of a minimum of essential fiducials in considering the planning of variable aesthetic operations. Finally, angular measurements are not affected by photographic enlargement. Thus, the technique can be used clinically for both planning and evaluating a patient s preoperative and postoperative results. Angel examined the facial profile as portrayed in classic and contemporary art and derived an icon of facial beauty from classical Greek art. 6 Olds suggested that the aesthetic
Vol. 114, No. 2 / BALANCED ANGULAR PROFILE ANALYSIS 543 ideals portrayed through classical and modern art have remained static over the past several thousand years and correspond to beauty in the living human face. 6 Others, such as Farkas et al., have demonstrated the existence of a large disparity between the aesthetic profile as portrayed through art and that presented in the mass media. Several studies, however, have documented a significant difference between the ideals of the public and the ideals of orthodontists and also suggest that the public s preferences of facial beauty may not be static but change with time. 6 We used various Internet Web sites to collect our data, as we felt that the Internet is a dynamic representation of the public s views and preferences of facial beauty. Our study, nevertheless, has some inevitable limitations. First, we did not analyze the frontal views because angular measurement was not available. Most of the photographs of female models on the Web sites were distorted and angulated in frontal views because of rotation and asymmetric illumination. Because the same goes for frontal views of a real patient, our method is thought to be inappropriate for frontal views. We are now applying a proportional analysis to frontal views. Second, although selected female models are well known in public and they showed similar results in profile analysis, we cannot say that the selected women are standard attractive women. This study, however, for practical purposes, provides information and reference data for many aesthetic surgeons. Third, photographs presented on the Web sites have variable resolution and background illumination. Sometimes, it was difficult for us to identify the precise profile points. The amount of error, however, in marking the points was shown not to be statistically significant in our study. As our data show, the balanced profile angle of attractive Korean models was similar to those of other groups, although the angles of the alar curvature point of Korean models were more acute than those of Western models and the interlabial angles of Korean models were more acute than those of Chinese models. Our study also shows that Asian and Western models do not show statistically significant differences in many measurements. As the data show, angles of aesthetic triangles and several angular measures of the models were similar between races. Therefore, this method could be used as a screen for attractiveness of facial profile. However, using our concept of ethnic pyramid angle, Table V shows that the anterior angle of the ethnic pyramid is wider than the upper angle of the pyramid, and that the upper angle is wider than the posterior angle in Asian models. The order is changed in Western models (anterior posterior upper). This important ethnic difference should be considered for facial plastic surgery. We suppose that three aesthetic triangles might be used as good universal screening values for profile analysis and that the three angles of the pyramid can be used to consider ethnicity. Although beauty itself cannot change with time, the concept of beauty can be influenced by time and cultural background. Our study shows that the famous female models have certain uniform characteristics in terms of soft-tissue profile. Although the current preference for the attractive female profile has been gradually standardized, Asian models have much more acute angles than Western models in terms of angle of alar curvature point, angle of labiale inferius, and profile convexity. Lower lip projection angles of Asian models were much wider than those of Western models. Chiu and Clark 16 previously analyzed the facial soft-tissue profiles of dentate southern Chinese adults and investigated the applicability of the existing Caucasian soft-tissue profile values. The data obtained from this study indicated that the lower third of the face presented the greatest ethnic difference; the interlabial contour was more convex and the upper and lower lips were more protrusive among the southern Chinese. These findings are partially in concordance with our results. This concept should be taken into consideration for facial aesthetic surgery of Asians. This study was performed to overcome the clinical limitations of current profile analysis and to propose balanced and standardized attractive soft-tissue profiles by photogrammetric analysis of famous female models. Our angular profile analysis is a simple, reliable, and relatively inexpensive way of analyzing profile photographs. The results of this study suggest that the soft-tissue profiles of famous female models from different races have some common features and differences. Taking our data into consideration and using our method of profile analysis, one can identify delicate profile problems correctly and perform appropriate aesthetic operations integrated into a harmonious
544 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004 whole that produce more satisfactory aesthetic results. CONCLUSIONS We are now trying to identify ethnic characteristics in a concrete way by analyzing the profiles of various patients (candidates for augmentation rhinoplasty, paranasal augmentation, anterior segmental setback ostectomy, or genioplasty). In addition, we are working on the development of standards and ways of determining the amount of protraction or retraction of various soft-tissue segments by using this method of angular analysis. Heung Sik Park, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Cosmetic Plastic Surgery Center Dongdaemoon Hospital Medical College of Ewha Women s University 70, Jongno 6-Ga, Jongno-Gu Seoul, Republic of Korea pseyes@dreamwiz.com ACKNOWLEDGMENT The authors give special thanks to Jung Yeon Yoon, Preventive Medicine, College of Medicine, Korea University, for cordial statistical analysis and advice. REFERENCES 1. Farkas, L. G., and Kolar, J. C. Anthropometric and art in the aesthetics of women s face. Clin. Plast. Surg. 14: 599, 1987. 2. Major, P. W., Johnson, D. E., Hesse, K. L., and Glover, K. E. Landmark identification error in posterior anterior cephalometrics. Angle Orthodont. 64: 447, 1994. 3. Larrabee, W. F., Jr., Maupin, G., and Sutton, D. Profile analysis in facial plastic surgery. Arch. Otolaryngol. 111: 682, 1985. 4. Farkas, L. G. Anthropometry of the Head and Face, 2nd Ed. New York: Raven, 1994. Pp. 20-55, 159-179. 5. Hsu, B. S. Comparisons of the five analytic reference lines of the horizontal lip projection: Their consistency and sensitivity. Am. J. Orthod. Dentofacial Orthop. 104: 355, 1993. 6. Auger, T. A., and Turley, P. K. The female soft tissue profile as presented in fashion magazines during the 1900s: A photographic analysis. Int. J. Adult Orthod. Orthognath. Surg. 14: 7, 1999. 7. Farkas, L. G., Bryson, W., and Klots, J. Is photogrammetry of the face reliable? Plast. Reconstr. Surg. 66: 346, 1980. 8. Neger, M. A quantitative method for the evaluation of the soft-tissue facial profile. Am. J. Orthod. 45: 738, 1959. 9. Nechala, P., Mahoney, J., and Farkas, L. G. Digital twodimensional photogrammetry: A comparison of three techniques of obtaining digital photographs. Plast. Reconstr. Surg. 103: 1819, 1999. 10. Davidson, T. M. Photography in facial plastic and reconstructive surgery. J. Biol. Photo. Assoc. 47: 59, 1979. 11. Hautvast, J. Analysis of the human face by means of photogrammetric methods. Anthropol. Anz. 33: 39, 1971. 12. David, T. J. O. Facial profile analysis: Automated facial metrology. Available at: http://www.cs.uwa.edu.au/ ~davido/chapter6.pdf. Accessed June 2003. 13. Cho, D. H., Ham, K. S., and Cho, Y. J. An anthropometric analysis on the beautiful and ugly faces of the young Koreans. J. Kor. Soc. Plast. Reconstr. Surg. 16: 926, 1989. 14. Kim, C. J., Han, K. S., Kim, Y., and Cho, Y. J. A facial anthropometric study on the Korean youths. J. Kor. Soc. Plast. Reconstr. Surg. 15: 427, 1988. 15. Wee, S. S., Ham, K. S., and Lee, J. U. Anthropometrical studies on the standard beauty of Korean adult female. J. Kor. Soc. Plast. Reconstr. Surg. 8: 283, 1981. 16. Chiu, C. S., and Clark, R. K. The facial soft tissue profile of the southern Chinese: Prosthodontic considerations. J. Prosthet. Dent. 68: 839, 1992.