Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: https://www.tandfonline.com/loi/ijcl20

A validated facial grading scale: The future of facial

ageing measurement tools?

Alastair Carruthers & Jean Carruthers

To cite this article: Alastair Carruthers & Jean Carruthers (2010) A validated facial grading scale:
The future of facial ageing measurement tools?, Journal of Cosmetic and Laser Therapy, 12:5,
235-241, DOI: 10.3109/14764172.2010.514920

To link to this article: https://doi.org/10.3109/14764172.2010.514920

© 2010 The Author(s). Published by Taylor &

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Published online: 08 Sep 2010.

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Journal of Cosmetic and Laser Therapy, 2010; 12: 235–241

REVIEW ARTICLE

A validated facial grading scale: The future of facial ageing

measurement tools?

ALASTAIR CARRUTHERS1 & JEAN CARRUTHERS2

1Department of Dermatology and Skin Science, University of British Columbia,Vancouver, BC, Canada, and
2Department of Ophthalmology and Visual Sciences, University of British Columbia,Vancouver, BC, Canada

Abstract
Validated, standardized scales for measurement of ageing and response to cosmetic procedures are lacking. Numerous scales
have been published and, while they allow intra-study comparisons, almost all remain non-validated, and their heterogene-
ity makes comparisons across studies impossible. A set of validated, objective, quantitative scales has been developed in
association with experts from different specialties within aesthetic medicine. These scales allow evaluation of the key signs
of ageing that cause individuals to seek cosmetic procedures. Each scale is a five-point photonumeric scale based on
computer-simulated photographs incorporating each aspect to be evaluated in a stepwise manner. Validation studies show
that these scales have good intra- and inter-rater reliability, with intra-class correlation coefficients generally in the range
0.85–0.95, and similar test–retest correlations.

Key Words: aesthetic medicine, facial wrinkles, rating scales, skin ageing, validation

Introduction
In recent years, the use of botulinum neurotoxins
(BoNTs) and facial fillers to improve the appearance
of facial wrinkles has become common. Indeed, since
1997, the number of cosmetic procedures performed
in the USA has increased by 446%, and data from
2005 showed that 66% of all cosmetic procedures per-
formed were non-surgical (1). In general, patients
present for such treatment, and return for retreatment,
because they notice signs of ageing, which includes
both intrinsic ageing and photo-ageing. The increased
interest in non-surgical cosmetic procedures has
necessitated the development of scales to measure the
degree of ageing and the severity of facial wrinkles.
Scales are also necessary to evaluate the level of
improvement resulting from cosmetic procedures. In
the past, the scales used by clinicians have often been
non-validated, and a wide range of such scales exist.
Additional scales were developed by pharmaceutical
companies during the regulatory approval processes
for cosmetic products, but these scales are proprietary
and not available for general use. Thus, there is a need
for properly validated scales that are freely available to
clinicians. Today, such a set of scales exists, which can
be used by all to measure the ageing process itself and
the effects of treatments designed to improve the signs
of ageing, and can also be used as part of the regula-
tory approval process for new products.
Validated scales are also important for assessing
patient-reported outcomes, such as quality of life and
satisfaction with treatment. These are more subjective
measures but are important for assessing the success of
cosmetic procedures. However, objective tools, which
are more reliable and not influenced by the subjective
assessment of the patient, have to be considered supe-
rior. Importantly, recent systematic literature reviews
have demonstrated the heterogeneous nature of meth-
ods used to rate patient satisfaction, and highlight the
need for validated reliable measures for reporting it
(2,3). For example, a systematic review by Kosowski et
al. identified 47 patient-reported outcome measures
assessing facial appearance after a cosmetic procedure,
from 442 articles (3). None of the measures identified
satisfied all relevant international guidelines for the
development and validation of health outcomes ques-
tionnaires (3). Similarly, Fagien and Carruthers identi-
fied 17 separate outcome measures in 23 studies of
treatment with BoNT (2). Most of these were based on
Likert-type scales, ranging from three-point to 11-point
scales, and many focused on the glabellar area.

Correspondence: Alastair Carruthers, Suite 820 - 943 West Broadway, Vancouver, BC, Canada V5Z 4E1. Fax: 1 604 714 0223. E-mail: alastair@carruthers.net

(Received 17 February 2010 ; accepted 8 August 2010 )

ISSN 1476-4172 print/ISSN 1476-4180 online © 2010 Informa UK, Ltd.
DOI: 10.3109/14764172.2010.514920
236 A. Carruthers & J. Carruthers
Wrinkle assessment scales used to date
The scientific literature is severely lacking a stan-
dardized tool for the measurement of ageing, and
numerous different instruments have been published.
For example, a study of BoNT A for the treatment
of hyperkinetic facial lines used an objective six-point
scale of the presence or absence of expression lines
at rest and the ability to recreate the expression lines
with effort (4). Most patients requiring treatment
were categorized as Grade 3 (an expressive patient
who could create an unwanted expression repeatedly,
but not presenting an obvious line at rest) or Grade
6 (troublesome expression lines, even at rest). No
evaluation of the reliability of the scale or validation
was performed. As part of the same study, a ques-
tionnaire of patient acceptance, impression of ther-
apy, and short-term results and complications was
used, although no further details of the questionnaire
were provided (4).
Honeck et al. developed a four-point scale (0 ⫽
no facial wrinkles; 3 ⫽ severe facial wrinkling) for
glabellar frown lines, based on standardized photo-
graphic documentation, which was used to develop a
consensus atlas of glabellar frown lines for training 28
dermatologists (5). Overall, the authors concluded
that the scale had good inter-observer (κ ⫽ 0.62,
Fleiss method (6)) and intra-observer (κ ⫽ 0.57–0.91,
Cohen method (7); κ ⫽ 0.68–0.94, Cicchetti and
Allison method (8)) reproducibility. Similarly, Hund
et al. evaluated two four-point scales used to deter-
mine the severity of lateral canthal lines (crow’s feet)
(0 ⫽ none; 3 ⫽ severe) (9). The first scale was used
with the face at rest, the second at maximum smile.
Each scale was based on a consensus atlas of stan-
dardized photographs and rated by nine investigators
on Day 1 and eight investigators on Day 2. Intra-
rater reproducibility (Cohen method) was 0.47–0.86
for the at-rest scale and 0.62–0.81 for the maximum
smile scale, although variability was greater among
male than female investigators. Inter-rater reproduc-
ibility was 0.60 and 0.58 (Fleiss method), and 0.63–
0.91 and 0.71–0.85 (Cicchetti and Allison method)
for the at-rest and maximum smile scales, respec-
tively, again with greater variability among male rat-
ers. No assessment of scale validity or responsiveness
was made.
In a randomized, comparative study, Narins et al.
(10) compared hyaluronic acid gel (Restylane®) with
bovine collagen (Zyplast®) for the treatment of indi-
viduals with prominent nasolabial folds (n ⫽ 138)
(10). Outcomes were assessed with the investigator-
based Wrinkle Severity Rating Scale and Global
Aesthetic Improvement Scale. The former is a photo-
graph-based five-point scale that is designed for quan-
tifying facial folds (1 ⫽ absent; 5 ⫽ extreme), which
has been previously validated by Day et al. (11), while
the latter is a five-point relative improvement scale,
ranging from ‘worse’ to ‘very much improved’.
To provide objective quantification of improve-
ment in facial wrinkles after injection of filler, Lem-
perle et al. developed a six-point photonumeric rating
scale in which the grade of the wrinkle in reference
photographs was compared with the wrinkle in a
patient’s face (12). Reliability of the scale was assessed
by nine observers based on the evaluation of 76 wrin-
kles. Overall, 92.7% of all wrinkles received the same
rating from each observer. Subsequently, photographs
of 130 wrinkles were evaluated by eight observers,
who rated 89.4% of all wrinkles equally.When observer
judgement was correlated with objective wrinkle depth
measured by profilometry on 40 silicone impressions,
a significant correlation of 87% was found.
Numerous other objective, quantitative rating
scales have been developed that measure three-
dimensional details of the skin surface through the
use of skin replicas (12,13), and optical (14,15)
or computer-assisted analyses (16). The significant
equipment requirements for these scales, however,
limit their utility in clinical practice. Finally, some
authors have developed subjective rating scales, such
as the description of crow’s feet by Kane (17) or the
quantitative rating scale for evaluating general changes
in facial skin by Alexiades-Armenakas (18).
Advantages of current scales
The scales that are currently available do offer a
number of advantages. First, they allow intra-study
comparisons to be made, such as the comparison of
hyaluronic acid gel and bovine collagen referred to
earlier (10). In this study, results for the Wrinkle
Severity Rating Scale showed that hyaluronic acid gel
was superior at 6 months after cosmetic correction
in 56.9% of patients, compared with 9.5% for bovine
collagen, while the Global Aesthetic Improvement
Scale showed that hyaluronic acid gel and bovine
collagen were superior in 62.0% and 8.0% of patients,
respectively. The existing rating scales also allow an
assessment to be made of patient satisfaction with
treatment, an important (though highly subjective)
outcome (2). Finally, some of the available instru-
ments can accommodate changes in the extent
of wrinkles with facial movement. For example, as
discussed above, Hund et al. developed two related
scales for the evaluation of crow’s feet at rest and at
maximum smile (9).
Limitations of current scales
Several of the available scales are based on a four-
point Likert scale. These instruments are limited in
their lack of a mid-point, forcing raters to select a
rating either above or below average which makes
them less sensitive. Furthermore, most of the
published scales have not undergone any formal

validation process, and many are subjective in their
assessment of wrinkle severity (2). In addition, anal-
ysis using some instruments requires equipment
that may not be widely available. For example, some
instruments rely on skin replicas using silicone rub-
ber or similar materials (12,13), while others use
optical systems to evaluate the three-dimensional
topography and morphology of the skin (14,15).
Importantly, there is currently no standard approach
to the assessment of wrinkles, making direct com-
parisons between studies impossible (3).
A set of new, validated facial grading scales
Clearly, there is a need for a validated, objective,
quantitative rating scale for evaluating the aesthetic
signs of ageing. Furthermore, the ideal scale would
allow the response of wrinkles to cosmetic treatment
to be monitored. Recently, a set of validated grading
scales have been published for brow positioning (19),
forehead lines (20), melomental folds (marionette
lines) (21) and crow’s feet (22). The scales are designed
to be used in everyday clinical practice, and could
also be used in clinical trials to assess the outcomes
of treatment with BoNT or facial fillers.
Each scale was developed as a five-point scale
using computer-simulated photography. Specific
anatomical changes resulting from ageing were iden-
tified in consultation with a clinician, and were incor-
porated into photographs to create five representative
images, with the aspect under consideration showing
a stepwise variation (Figures 1–4). When ‘lines’ were
formed as a result of movement of different muscle
groups (e.g. crow’s feet and forehead lines), static
and dynamic pictures were included. Approximately
50 images (per scale validation set) were selected
from a database of photographs from 100 individu-
als, based on quality and equal distribution across
each representative scale. Using a standardized com-
puter randomization program, 35 images per target
area or validation set were randomly selected from
the 50 for final inclusion in the pool.
The scales were assessed and validated at an
international meeting of physicians involved in aes-
thetic medicine, representing a number of special-
ties, including dermatology, ophthalmology, plastic
surgery and dermatologic surgery (1). As part of the
development process, the expert panel, all of whom
were formally trained in using the scales, discussed
each scale and graded them twice using an over-
night break between the two ratings. Intra- and
Figure 1. Reference images for the five-point Brow Positioning Grading Scale (19). (Reproduced with permission from Dermatologic
Surgery, Wiley-Blackwell, and Merz Pharmaceuticals GmbH.)
A validated facial grading scale 237
inter-rater variability analysis was performed for
each scale.
The Brow Positioning Grading Scale was devel-
oped to provide objective quantification of the sever-
ity of eyebrow malposition (19). The scale ranges
from 0 (youthful, refreshed look and high-arch eye-
brow) to 4 (flat eyebrow with barely any arch, marked
visibility of folds and very tired appearance) (Figure 1).
Intra-class correlation coefficients (ICCs) for the two
evaluations of the scale were 0.697 and 0.660, sug-
gesting an acceptable level of agreement between the
experts. Test–retest correlation coefficients ranged
from 0.678 to 0.912.
The Forehead Lines Grading Scale was developed
to objectively quantify resting (static) and hyperki-
netic (dynamic) forehead lines, and ranges from 0 (no
wrinkles) to 4 (deeper wrinkles at rest and deeper
furrows with facial expression) (Figure 2) (20). ICCs
were calculated for the first and second ratings,
respectively, for static (0.846 and 0.863) and dynamic
(0.852 and 0.892) forehead lines, with a high level
of agreement between the experts. The test–retest
correlation coefficients (static forehead lines, 0.846–
0.942; dynamic forehead lines, 0.859–0.941) were
also high for each expert.
The Marionette Lines Grading Scale ranges from
0 (no visible fold, continuous skin line) to 4 (extremely
long and deep folds detrimental to facial appearance)
(Figure 3) (21). As with the Forehead Lines Grading
Scale, agreement between the experts was high, with
ICCs of 0.873 and 0.891 after the first and second
grading, respectively. Intra-rater test–retest correla-
tions were also high (0.845–0.966).
The Crow’s Feet Grading Scale was developed to
quantify the severity of lateral canthal lines at rest
(static) and at maximum contracture of the orbicu-
laris oculi muscle (dynamic) (22). The scale grades
wrinkles from 0 (none) to 4 (severe) (Figure 4).
Based on the ICCs, there was considerable agree-
ment between the experts. For the static scale, the
ICCs were 0.893 and 0.882 for the first and second
ratings, respectively, while those for the dynamic
scale were 0.879 and 0.892. Intra-rater test–retest
correlation coefficients were 0.904–0.968 for the
static scale and 0.888–0.951 for the dynamic scale.
Advantages of this approach
This approach to creating a series of grading scales
to evaluate various aesthetic parameters has numer-
ous advantages. Importantly, the scales were validated
238 A. Carruthers & J. Carruthers

Figure 2. Reference images for the five-point Forehead Lines Grading Scale: (A) static grading scale; (B) dynamic grading scale (20).
(Reproduced with permission from Dermatologic Surgery, Wiley-Blackwell, and Merz Pharmaceuticals GmbH.)

by a team of international physicians representing a
cross-section of age, experience and sex. As noted
above, all were experts practicing aesthetic medicine,
trained in different disciplines. This was essential to
bring in different perspectives and expertise in assess-
ing beauty during the ageing process (1). Each instru-
ment was designed as a five-point scale that, unlike
the common four-point scales used in this area,
includes a mid-point. The grading of a continuous
process such as ageing is facilitated if there are clearly
identified centre and end points to the scale (1).
Development of the scales was based on computer-
simulated photography using similar methodology for
each instrument. For each scale, anatomical features
specific to the aspect being evaluated were incorpo-
rated into the photographs in a stepwise manner.
Importantly, for those aspects where lines are formed
as a result of movement of different muscle groups
(such as crow’s feet and forehead lines), static and
dynamic pictures were included (1). This is especially
important for assessing the efficacy of botulinum tox-
ins, which affect muscle activity, while validation of
scales when the muscles are at rest is more important
for facial fillers.
During the validation process, each of the nine
participants graded each scale twice, with an over-
night break between the two ratings. This allowed
intra- and inter-rater variability to be evaluated,
with the former depicted visually as bubble graphs
(Figure 5). These provide an informative method of
comparing grading between the different raters (1).
For forehead lines, test–retest reliability coefficients
were high, indicating sufficiently high stability of
the ratings after an overnight interval (20). For the
dynamic rating of forehead maximum lift, scores of
3 (fine wrinkles present at rest and deeper lines with
facial expression) and 4 (deeper wrinkles at rest and
deeper furrows with facial expression) showed a

Figure 3. Reference images for the five-point Marionette Lines Grading Scale (21). (Reproduced with permission from Dermatologic
Surgery, Wiley-Blackwell, and Merz Pharmaceuticals GmbH.)

Figure 4. Reference images for the five-point Crow’s Feet Grading Scale: (A) static grading scale; (B) dynamic grading scale (22).
(Reproduced with permission from Dermatologic Surgery, Wiley-Blackwell, and Merz Pharmaceuticals GmbH.)
large cluster and therefore a good result in the
correlation coefficients (Figure 5). For marionette
lines (21) and crow’s feet (22), test–retest reliability
coefficients were also high, again indicating good
stability of the ratings after the overnight break.
Regarding inter-rater variability, ICCs were found
to be high for forehead lines, crow’s feet and
marionette lines, and moderately high for brow
positioning (19–22).
Possible limitations
Computer-processed, morphed images, although
standardized to a site-specific area, do not translate
clinically to the multiple physical changes that occur
in an ageing face (20–22). The photographic evalu-
ation and live patient evaluation are distinct, and thus
evaluations using the scale in the context of a clinical
trial should be performed on standardized photo-
graphs rather than (live) physical examination.
Using the Brow Positioning Grading Scale,
test–retest reliability was moderate, indicating
rather weak stability of the ratings after an over-
night interval (19). The ICCs for brow positioning
were also of a moderate level, and it may be that
the number of possible variations in eyebrow shape,
arch and upper eyelid, together with sex differ-
ences, explain why the consensus among the eval-
uators was not higher during the grading process.
The wide range of differences in size of the brow
(artificially thinned in females and bushy/broad
in males), placement (determined by genetic and
racial differences) and shape (arched or straight),
makes it harder to set standardized grading. For
the Forehead Line Grading Scale (20), compari-
son of the distribution of results for static and
A validated facial grading scale 239
dynamic forehead lines suggests that scoring of
both components is essential to provide an accu-
rate assessment.
Important considerations
The assessment of lines and wrinkles is performed
from photographs, and it is therefore critical that
the before and after pictures are standardized care-
fully. Quan et al. have documented a simple method
by which facial lesions and other features can be
documented accurately using only a single land-
mark, based on a ‘clock-face’ technique (23). When
combined with a method such as the Frankfort
horizontal (a line joining the upper external audi-
tory meatus and the infraorbital rim), simple and
accurate positioning of facial features can be
achieved (24).
Advancing assessments in aesthetics
The four validated scales described herein have
been presented at a number of international meet-
ings, where they have been well received by clini-
cians working in aesthetic medicine. Indeed, the
scales are now in clinical use in the USA. When
presented in Europe there has been great interest
and a desire for further information, and it is hoped
that European clinicians will start to use these
scales in their daily practice. Looking to the future,
it seems likely that aesthetic doctors will see the
introduction of further scales to measure the impact
of their interventions, starting with the face/neck
and then broadening to include other areas of the
body. These new scales will, of course, present new
240 A. Carruthers & J. Carruthers

VIEW = Forehead Max Lift EXPERT_NO = 1 VIEW = Forehead Max Lift EXPERT_NO = 2 VIEW = Forehead Max Lift EXPERT_NO = 3

4 4 4

3 3 3
Rating time 1

Rating time 1

Rating time 1
2 2 2

1 1 1

0 0 0
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Rating time 2 Rating time 2 Rating time 2

VIEW = Forehead Max Lift EXPERT_NO = 4 VIEW = Forehead Max Lift EXPERT_NO = 5 VIEW = Forehead Max Lift EXPERT_NO = 6

4 4 4

3 3 3
Rating time 1

Rating time 1

Rating time 1
2 2 2

1 1 1

0 0 0
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Rating time 2 Rating time 2 Rating time 2

VIEW = Forehead Max Lift EXPERT_NO = 7 VIEW = Forehead Max Lift EXPERT_NO = 8 VIEW = Forehead Max Lift EXPERT_NO = 9

4 4 4

3 3 3
Rating time 1

Rating time 1

Rating time 1

2 2 2

1 1 1

0 0 0
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Rating time 2 Rating time 2 Rating time 2

Figure 5. Example of bubble graphs comparing raters of the Forehead Lines Grading Scale (dynamic rating) (20). The size of each ‘bubble’
corresponds to the frequency of each pair of scores on the initial grading and subsequent re-grading. (Reproduced with permission from
Dermatologic Surgery, Wiley-Blackwell, and Merz Pharmaceuticals GmbH.)

challenges, but they will also help to refine aesthetic soon, where we look forward to sharing them more
practice and drive the search for new solutions. widely with colleagues.

Conclusion Acknowledgements
Four validated scales for grading of facial lines and Editorial support for the preparation of this manu-
wrinkles have been developed. These five-point pho- script was provided by Ogilvy 4D; funding was pro-
tonumeric scales span the severity of wrinkles in each vided by Merz Pharmaceuticals GmbH.
position for which patients commonly seek correc-
tion. Each scale is well stratified for consistent rating
and, together, they represent an advance in aesthetic Conflicts of interest: The authors are consultants
procedures. The scales are currently being used with and investigators to Allergan Medical, Bioform
success in the USA and are likely to come to Europe Medical and Merz Pharmaceuticals GmbH.

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