J Oral Maxillofac Surg

50:606-620. 1992

Maxillofacial Esthetics:
Anthropometrics of the Maxillofacial Region
MICHAEL E. KOURY, DDS,* AND BRUCE N. EPKER, DDS, PHDt

Many artists, orthodontists, and surgeons have proposed guidelines for esthetic
facial evaluation, but few have shown a scientific basis for their criteria. Farkas,
however, made a substantial contribution to anthropometric facial measurements
of adult whites. His raw data were used to develop a comprehensive set of ratios
to define the esthetic face. A systematic maxillofacial evaluation derived from
Farkas’s data is presented, along with a brief description of its clinical application.

Many artists (da Vinci,’ Dureq2 Armenini,3 subgroups in this population were studied for variation,
Cennini4), surgeons (Gonzalez-Ullou,5 Lee,6 Powell and the researchers determined that ethnic origin was
and Humphreys’) and orthodontists (Ricketts,’ not a major concern with regard to planning surgery.
Menifield9) have proposed guidelines for drawing or Of the 155 proportions measured, only 14 differed sig-
evaluating facial esthetics. However, few have made nificantly, and a distinct variation of one ethnic group
clinical measurements of a large number of people to
develop accurate guidelines for a more scientific esthetic
facial evaluation. Farkas did make detailed anthro-
pometric maxillofacial esthetic measurements of nor-
mal and attractive adults, but despite his detailed an-
thropometric studies of facial esthetics, his material is
difficult to apply clinically because of the extensive,
and often linear, nature of his measurements, the mul-
titude of manuscripts in which he reported his data,
and the fact that most of his publications are in non-
clinical journals.
Farkas and his colleagues’2 studied young, adult,
North American whites with a make up similar to the
Canadian population. A single group was not used for
all measurements, but each group generally consisted
of 50 males or 50 females. The majority of the sample
consisted of 18-year-olds, with a range of 18 to 25 years.
The group was predominantly Anglo-Saxon, often 40%
to 50%, with Slavic, Germanic, and Latin descents
dominating the remainder. 1o-‘5 The major ethnic

* Resident, Oral and Maxillofacial Surgery,

- _ Parkland Memorial,
Dallas, and John Peter Smith Hospitals, Fort Worth, TX.
i Director. Oral and Maxillofacial Suraerv and Center for Correc-
tion of Den&l Facial Deformities, John Peter Smith Hospital, Fort
Worth, TX.
Address correspondence and reprint requests to Dr Koury: Center
for Correction of Dental Facial Deformities, John Peter Smith Hos-
pital, Fort Worth, TX 76 104.

0 1992 American Association of Oral and Maxillofacial Surgeons

0278-2391/92/5008-0008$3.00/O FIGURE 1. Full frontal face horizontal and vertical landmarks.

808
KOURY AND EPKER 807

Table 1. Index of Anthropometric Landmarks values in the normal range were less deviant from the
mean even though not abnormal when gauged by a
AC: alar curviture point
Gasserian curve.
Al: alare
cervicomental point
Ward and Jamison” evaluated the precision and re-
c:
C’: most anterior point of the columella liability of linear anthropometric measurements. In
Ch: cheilion general, measurements were reliable, and in no case
Cph: crista philti did separate measurements differ by more than 4%.
En: endocanthion
However, two factors led to poor reliability. The first
Ex: exocanthion
Eu: eurion
was linear measurements of small magnitude, because
Ft: frontotemperale any given error produced a greater percent deviation
G: glabella from the true distance. The second was difficulty in
Gn: gnathion identifying the landmarks, because it manifested poor
Go: gonion repeatability and led to inconsistent measurements.
Li: labiale inferius
Ls: labiale super&s
The least reliable distances were philtral width, colu-
Mf: maxillofrontale mella width, nasal root width, and nasal protrusion.
N: nasion Although not evaluated in this study, this same ratio-
Obi: otobasion inferius nale can be applied to small angles and poorly defined
Obs: otobasion superius landmarks. The researchers suggested that multiple
Or: orbitale
0s: orbitale superius trials and averaging of the closest two out of three values
P: potion would increase reliability.” Usually, converting linear
Pa: postaurale measurements into proportions will decrease error, but
Pi: palpebrale inferius in a worst case scenario can amplify it. Great care must
Po: pogonion
be exercised when making measurements. In clinical
Pra: preaurale
Pm: pronasale
practice, when measuring soft-tissue relations, calipers
Ps: palpebrale superius are placed without structural distortion, whereas when
Sa: superaurale measuring between bony landmarks, calipers are
Sba: subaurale pressed firmly to bone.
SI: sublabiale
In this article, we report an assimilation of Farkas’
Sn: subnasale
St: stomion esthetic facial measurements in normal adult whites
Tr: trichion that systematically organizes them for clinical utility,
v: vertex with the measurements converted to proportions and
zy: zygion rounded off for homogeneity and ease of usage. The
complete index is for normal females, with additional
values for males and attractive females, when available,
could not be determined. Differences between extreme and differing by more than 4%. This figure was chosen
groups were found, but not between the intermediates, because of the error in reproducibility reported above.”
and significant overlap occurred between all groups.r5 Also, average difference (2.8%) between the sexes is
This does not infer that these proportions should be scarcely noticeable when expressed as a proportion,
used universally for all ethnic groups. For example, except in the orolabial area.15 Because no values have
considerable difference in nasal morphology is seen
between whites, asians, and blacks.16 The proportions
are justified for young adult whites, but must be used Table 2. Total Vertical Facial Esthetics
judiciously with other ethnic groups. Likewise, these
indices must be used carefully in age groups other than Value (7%)
young adults because of changes with growth and aging. Measurements Anthropometrics Females Males
The difference between above and below average
women were investigated by Farkas and his coworkers” Head V-Gn
in a group of 200 adult women. They were placed in Neurocranium V-N 50
Facial height N-Gn 50
three groups, above average, average, and below av-
Total face Tr-Gn
erage, by 75 evaluators using a six-point scoring system. Forehead Tr-G 30
Only 12% of the 3 55 indices differed significantly be- Upper face G-Sn 35
tween the above- and below-average women.“*r5 The Lower face Sn-Gn 35
researchers found that the attractive women had more Face G-Gn
proportions closer to the normal mean even when both Upper face G-Sn 50 45
Lower face Sn-Gn 50 55
groups’ indices were within the normal range. Thus,
808 OBJECTIVE ESTHETIC EVALUATION OF THE FACE

Table 3. Total Vertical/Horizontal Facial Esthetics

Value (%)
Measurements Anthropometrics Males Attractive Females

Total face
Forehead width/total face height Ft-Ft/Tr-Gn 65
Zygoma width/total face height Zy-Zy/Tr-Gn 75
Bigonial width/total face height Go-Go/Tr-Gn 55
Face
Forehead width/face height Ft-Ft/G-Gn 90
Zygoma width/face height Zy-Zy/G-Gn 105
BigoniaI width/face height Go-Go/G-Gn 75 80
Total facial thirds
Forehead width/forehead height Ft-Ft/Tr-G 220
Zygoma width/upper face height Zy-Zy-G-S 220 230
Bigonial width/lower face height Go-Go/&t-Gn 140

been determined for disharmony producing poor facial VERTICAL/HORIZONTAL PROPORTIONS

esthetics, standard deviations, ranges, and critical val-
ues indicating the need for surgical correction are not
presented. These proportions are an attempt to take
the subjective nature out of facial evaluation and should
be used as a guide to evaluate disharmony. As Farkas’*
has suggested, bringing more of these values closer to
the normal mean may produce harmony and thus at-
tractiveness, but the surgeon’s eye must still be used
to determine if differences are significant in each in-
dividual case. An attractive feature should not be al-
tered simply because it deviates from a proportion.
The width of the face can be measured between three
points bilaterally (Fig 1). The frontotemperale, the
landmarks on either side of the forehead indicated by
the slight elevation of the linea temporalis, defines the
forehead width. Zygion is the most lateral point of the
zygomatic arch, and bilaterally these points delineate
the midface width. The distance between the gonions
defines the lower facial width. The bizygomatic width
is normally the widest portion of the face. These hor-
izontal measurements respectively comprise 65%, 75%,

Total Facial Esthetic%

VERTICAL PROPORTIONS

The vertex of the head is defined as the highest point

when Frankfurt horizontal is parallel with the true
horizontal. The height of the head is measured between
this landmark and gonion (Fig l).“-‘* Vertically, the
head can be divided at several landmarks. da Vinci
used nasion to create the neurocranium, vertex to na-
sion, and the face height, nasion to gnathion, each
comprising 50% of the total head height (Tables 1,
2).1,‘o-‘2 Trichion is a landmark of the midforehead
where the hairline starts in the youthful adult. The
crown is the 20% of the head above trichion. Below,
the total face makes up the remaining head, trichion
to gnathion, and is broken into three segments by gla-
bella and subnasion.r@‘* The middle face, glabella to
subnasion, and lower face, subnasion to gnathion, each
make up 35% of the total face.“,‘* The face is defined
by glabella and subnasion, and can be divided into an
upper and lower segment by subnasion.“-‘* Each com-
pose equal portions of the face (Fig 1) (Table 2).“,‘* FIGURE 2. Lateral full-face landmarks.
KOURY AND EPKER 809

FIGURE 4. Lateral full-face comprehensive profile angulations.

FIGURE 3. Lateral full-face general profile angulations.

and 55% of the total face height (trichion to gonion)
and 90%, 105%, and 75% of the face height (glabella
to gnathion). These widths also can be compared with
the height of the facial thirds in which they are found
(Table 3). The forehead width is 220% of its height,
while the zygomatic and bigonial widths are 220% and
140% of the middle and lower face heights, respectively
(Fig 1) (Table 3).‘“,‘2,‘8
LATERALTOTALFACEANGULATIONS
pogonion.‘“*““4 The middle third of the face, glabella
to subnasion, is aligned with the vertical (Fig 3) (Table
4). A more detailed evaluation of the face can be made
by encompassing the nose and the neck. From top to
bottom, the nasofrontal angle is 135” measured be-
tween the nasal dot-sum, nasion to pronasale, and a
line tangent to the inferior glabellar surface from na-
sion.“,’ ‘,I4 The nasal dorsum and a line between po-
gonion and pronasale form the nasomental angle,
which is 125’.’ Finally, the cervical mental angle is
110” as measured between the anterior neck and a line
from gnathion to the cervical point (Fig 4) (Table 4).9

Several angulations are useful to quantify profile or

lateral total face esthetics (Fig 2). The anterior plane
of the forehead and of the general facial line grossly
outline the profile. A forehead slope of -5” is measured
between a tangent to the forehead and the vertical.roJ4
The general facial profile forms a -5 o angle measured
between the vertical and a line defined by glabella and

Table 4. Lateral Total Face Angulations

Degrees
for
Angular Measurements Anthropometrics Females

Forehead Tr-G/Vertical -5”

General facial G-Pg/Vertical -5”
Middle face G-Sn/Vertical 0”
Nasofrontal N-Pm/N-G 135”
Nasomental N-Pm/Pm-Pg 125”
Cervical mental Gn-C/ant. Neck I IO” FIGURE 5. Midface frontal vertical and vertical/horizontal land-
marks.
Table 5. Middle Third Vertical Facial Esthetics

Values

Measurements Anthropometrics Females Attractive Females

Eyes
Orbit height/upper face height Os-Or/G-Sn 50%
Upper lid height/orbit height Os-Ps/Os-Or 40%
Lid sulcus/lid margin sulcus/Ps 10 mm
Eye fissure height/orbit height Ps-Pi/OS-Or 35%
Upper lid/iris Ps/Iris 2mm
Lower lid/iris Pi/Iris 2mm
Lower lid height/orbit height Pi-Or/OS-Or 25%
Nose
Nose length/middle third height N-Sri/G-Sn 85% 90%
Dorsum length/middle third height N-Pm/G-Sn 80%
Dorsum length/nose length N-Pm/N-Sn 90%

Table 6. Middle Third Horizontal Facial Esthetics

Value (%)

Measurements Anthropometrics Females Males Attractive Females

Eyes
Biocular width/head width Ex-Ex/Eu-Eu 60
Intercanthal width/biocular width En-En/Ex-Ex 34
Intercanthal width/zygomatic width En-En/Zy-Zy 25
Fissure width/intercanthal width En-Ex/En-En 95
Fissure width/biocular width En-Ex/Ex-Ex 33
Interpupillary width/biocular width Mid Pupil/Ex-Ex 70
Eye fissure cant/horizon En-Ex/Horizon 5
Nose
Nasal root width/alar width Mf-Mf/Al-Al 50 60
Nasal root width/intercanthal width Mf-Mf/En-En 50 60
Alar width/intercanthal width Al-Al/En-En 100 105
Columella width/alar width Columella/Al-Al 25

Table 7. Middle Third Vertical/Horizontal Facial Esthetics

Value (%)

Measurements Anthropometrics Females Males Attractive Females

be
Orbit height/biocular width Os-Or/Ex-Ex 35
Orbit height/fissure width Os-Or/En-Ex 95 90
Fissure height/fissure width Ps-Pi/En-Ex 35
Nose
Alar width/nose length Al-Al/N-Sn 65 60
Alar width/dorsum length Al-Al/N-Pm 70

Table 6. Middle Third Lateral Facial Esthetics

Measurements Anthropometrics Females Males

Sagittal
Nasal root/nasal protrusion En-Dorsum/Sn-Pm 75%
Vertical/Sag&al
Nasal protrusion/nasal length Sn-Pm/N-Sn 40%
Angulations
Nasofrontal N-Pm/N-Gt 135” 130%
Nasofacial G-Pg/N-Pm 35”
Nasolabial Sn-C/Sri-Ls 100”

810
KOURY AND EPKER 811

FIGURE 8. Basal nose landmarks.

FIGURE 6. Midface and lower face frontal and horizontal land-

of the eyebrow, and generally corresponds to the highest
marks. point of the supraorbital rim in the youthful adult (Fig
5). It normally is located at the lateral and middle third
junction of the eyebrow.” The orbital height from the
Middle Third Facial Esthetics orbitale superius to the orbitale is 50% of the upper
face height.10~19The upper lid is 40% of the orbital
VERTICAL PROPORTIONS
height, and is that portion of the orbit above the su-
perior lid margin, palpebrale superius. The palpebrale
The eyes and the nose are the major entities in the superius and inferius define the sulcus to be 35% of the
midface providing landmarks for vertical division. Or- orbit height, and the lower lid height, the palpebrale
bitale superius is the highest point on the lower border inferius to orbitale, makes up the remaining 25%.”
The lid sulcus normally is 10 mm above the lid margin,
and the upper and lower lid margins cover approxi-
mately 2 mm of the iris (Fig 5) (Table 5)”
The length of the nose is that distance from nasion
to subnasale, whereas the dorsal length is measured
from nasion to pronasale (Fig 5). The former is 85%
of the middle third face height, and the latter is 80%

Table 9. Middle Third Facial Esthetics:

Nasal Base

Value for
Measurements Anthropometrics Females

Tip length/nasal protrusion Pm-C’/Pm-Sn 45%

Columella length/nasal protrusion C’-Sri/Pm--Sn 55%
Columella length/alar length Sn-C’/Ac-Pm 35%
Nasal tip width/alar width Tip Width/Al-Al 75%
Nasal protrusion/alar width Pm-Sri/Al--Al 60%
Nasal protrusion/alar length Pm-Sn/Ac-Pm 60%
Alar thickness Ala 5mm
Columella thickness Columella 8mm
FIGURE 7. Midface lateral landmarks.
812 OBJECTIVE ESTHETIC EVALUATION OF THE FACE

Table 10. Middle Third Facial Esthetics: Ear

Value

Measurements Anthropometrics Females Males

Location
Vertical V-PO 130 mm 135 mm
Horizontal N-Obs 115 mm 120 mm
Proportions
Width to length Pra-Pa/Sa-Sba 55%
Attachment length/vertical length Obs-Obi/Sa-Sba 85% 80%
Angles
Medial long axis to horizontal Sa-Sba/Horizontal 100”
Lateral protrusion from malar bone 25”

Table 11. Lower Vertical Facial Esthetics

Value (%)

Measurements Anthropometrics Females Males Attractive Females

Lower face Sn-Gn

Upper lip Sn-St0 30
Lower lip sto-Sl 25
Chin SI-Gn 45
Lips
Upper lip/lower lip Sn-sto/sto-Sl 120 105
Skin upper/upper lip Sn-Ls/Sn-St0 70 65
Skin lower/lower lip Li-Sl/Sto-Sl 60
Vermillion upper/lower Ls-Sto/Sto-Li 85

Table 12. Lower Horizontal Facial Esthetics

Value (%)

Measurements Anthropometrics Females Attractive Females

Mouth width/bigonial width Ch-Ch/Go-Go 55

Mouth width/zygoma width Ch-ChfZy-Zy 40
Mouth width/biocular width Ch-Ch/Ex-Ex 60
Alar base width/mouth width AI-AI/Ch-Ch 65 60
Philtrum width/mouth width ChpChp/Ch-Ch 20
Columella width/philtrum width Columella/ChpChp 75

of the middle face height and 90% of the nose length
(Fig 5) (Table 5).‘*-12
HORIZONTAL PROPORTIONS
da Vinci divided the head horizontally into fifths by
the endocanthions and exocanthions at the orbital
level.’ Farkas found that these segments were rarely
equal, but these landmarks produce useful subdivision
points for comparison. ‘* The head width is measured
from em-ion to em-ion, the most lateral points on the
side of the skull in the area of the parietal and temporal
bones (Fig 6). The biocular width, exocanthion to exo-
canthion, is 60% of the head width (Table 6).“,” The
intercanthal width is defined by the endocanthion bi-
laterally and is 34% of the biocular width and 25% of
the bizygion width. The fissure width, endocanthion
to exocanthion, is 33% of the biocular width and 95%
of the intercanthal width.‘0,“*20,2’ The interpupillary
width is 70% of the biocular width (Fig 6) (Table 6).“*”
In frontal view, the eye fissures slant upward and out-
ward at 5” to the horizon based on a line drawn from
the endocanthon to exocanthon (Fig 6) (Table 6). lo
The nose increases in width from the nasal root to
the nasal base at alare, the most lateral point of the
alar contour. The width of the nasal root between the
maxillofrontale, or the base of the nasal root at the
margin of the orbit where the maxillofrontal and na-
sofrontal sutures meet, is 50% of the alar base width
as measured between alare. The width of the nasal root
KOURY AND EPKER
FIGURE 9. Landmarksfor evaluatingthe ear.
is also 50% of the intercanthal width, and the alar
width is 100% of the latter. The thinnest width of
the columella makes up 25% of the alar width (Fig 6)
(Table 6).‘“-‘2,‘6
VERTICAL/HORIZONTAL PROPORTIONS
The orbital height is 35% of the biocular width and
95% of the fissure width, whereas the fissure height is
FIGURE10. Lowerfaceverticaland vertical/horizontallandmarks.
813
TiWe 13. Lower Vertical/Horizontal
Facial Esthetics
Value(o/o)
Measurements Anthropometrics F.%Il&S Males
Upper lip height/mouth width Sn-Sto/Ch-Ch 40
Lower face height/mouth width Sn-Gn/Ch-Ch 130 135
35% of the fissure width. The alar width is 65% of
the nose length and 70% of the dorsum length (Fig 5)
(Table 7)_12.W6.19
LATERAL VIEW
The projection of the nasal bridge, as measured from
endocanthion, affects the nasofrontal angle as well as
the apparent length of the nose, whereas the nasal pro-
jections, subnasion to pronasale, alters the profile bal-
ance of the face. The nasal bridge projection is 75% of
the nasal protrusion, and the latter is 40% of the nasal
length (Fig 7) (Table 8).”
The nasal profile is defined by several angles. The
nasofrontal angle is formed by the nasal dorsum, nasion
to pronasale, and a line tangent to the glabellar surface
from nasion and is 135”. The nasofacial angle is 35”.
It is produced by the general facial profile line and the
nasal dorsum, nasion to pronasale. The inferior colu-
mella surface and the upper lip from subnasale to la-
biale superius forms the nasolabial angle and is 100”
(Fig 7) (Table 8).‘“*“,‘4
NASAL BASE
Topinard originally classified the nares into six basic
groups. 22Farkas expanded this classification and found
that most (53%) whites had type 11nares, and 42% had
type 1 (the small remaining group was type lll.).lo*’‘JW*
Nostril symmetry was found in 86% of whites. From
type 1 to 111,the nares inclination, tip protrusion, and
columella length decrease, and the width of the nose
and columella increase. Type 1 noses have primarily
(77%) short and curved alar tissue with a lesser degree
(2 1%) of full and curved ones, whereas type 11had 47%
of the former and 45% of the latter.16
The nasal protrusion is divide into a tip and colu-
mella portion by the most anterior point of the nares.
These segments comprise 45% and 55% of the nasal
protrusion, respectively. The columella length is also
35% of the alar length, alar curvature point to prona-
sale.‘“,16 The width of the nasal tip as measured just
above the nasal ala is 75% of the nasal base,2” whereas
the nasal protrusion is 60% of the latter and 60% of
the alar length, alar curvature point to pronasale.‘0,‘2,‘6
814
FIGURE11. Lateral lower face angulations.
The alar and columella thicknesses are 5 and 8 mm,
respectively (Fig 8) (Table 9).”
EARS
The vertical position of the ears can be defined in
several ways (Fig 9). The distance from vertex to porion
is a useful linear measurement, and is found to be 130
mm.24 The Leibers classification also delineates the
normal position of the ears.25If a line originating from
porion and perpendicular to a line connecting glabella
to the upper lip passes between the free margin of the
lower eyelid and the upper edge of the nasal ala, then
the ear is at a normal level. Furthermore, the ear is
said to be at a normal level when a horizontal line that
passes through the pupil also intersects the superior-
most point of the ear attachment, otobasion st~perius.~~
Horizontally, this landmark is located 115mm from
nasion (Fig 9) (Table lo).”
The ears achieve full size in the male at age 15 years
and in the female at 13.24 In the adult, the width of
the ear is measured between preaurale and postaurale,
which are the most anterior and posterior points of the
ear. Likewise, the vertical length is measured between
the highest and lowest points of the ear, superaurale
and subaurale. The length to width ratio is 55% in the
adult.‘0,24 The attachment length, otobasion superius
to inferius, is 85% of the ear length.” Two angles define
the orientation of the ears on the face. The first is the
inclination of the medial longitudinal axis of the ear,
as defined by superaurale and subaurale to Frankfurt
horizontal. This angle is 100”. The second is the lateral
protrusion from the mastoid bone as measured from
the posterior medial surface of the ear. This angle is
25” (Fig 9) (Table lo).“*”
OBJECTIVEESTHETICEVALUATIONOF THE FACE
Lower Third Facial Esthetics
VERTICALPROPORTIONS
The lower third of the face is divided into the upper
and lower lip and chin by stomion and sublabiale (Fig
10). The latter point is defined by the depth of the
mandibular vestibule or the mental groove externally.
The upper and lower lip are 30% and 25% of the lower
face, respectively, whereas the chin comprises the re-
maining 45% (Table 11). 10,‘1,‘3The upper lip is 120%
of the height of the lower. The lips are divided into a
skin and vermilion portion by labiale superius and in-
ferius, which lie at the midpoint of the cutaneous-ver-
milion junction of the upper and lower lip, respectively.
The skin makes up 70% of the upper lip and 60% of
the lower lip. The vermilion of the upper lip is 85% of
that of the lower lip. Laterally, the cutaneous upper lip
is slightly longer than the medial (Fig 10) (Table 11).lo31
3
HORIZONTAL PROPORTIONS
The width of the mouth is defined by cheilion bi-
laterally, and is 55% of the bigonial, 40% of bizygo-
matic, and 60% of the biocular widths (Fig 10). The
philtrum is 20% and the alar width is 65% of the mouth
width. The columella is 75% of the philtral width (Fig
10) (Table 12).‘“*‘1,12
VERTICAL/HORIZONTALPROPORTIONS
The upper lip height is 40%, and the lower face height
is 130%, of the mouth width (Fig 10) (Table 13).10~‘1
LATERAL COMPARISONS
Several vertical angulations define the normal soft
tissues of the lower face. The upper lip, subnasion to
labiale superius, is aligned with the vertical (Fig 11).
The lower face angulation can be measured from sub-
nasion or labiale infer& the lower margin of the ver-
milion, to pogonion. The former measures - 15” to the
vertical and the latter -20”. The cervical mental angle
is 1lo”, as previously stated (Fig 11) (Table 14).‘oT”*‘4
Table 14. Lower Facial Esthetics: Angulation
Values for
Measurements Anthropometrics Females
Upper lip/vertical Sn-LsJVertical 0”
Lower half face/vertical Sn-P&Vertical -15”
Lower third face/vertical Li-PgJVertical -20”
Cervical mental Gn-C/Ant. Neck 110”
FIGURE 12. Before (A and B) and after (C and D) esthetic cheek augmentation to improve bizygomatic width and the associated facial
length-to-width abnormalities.

815

FIGURE 13. Before (A) and after (B) coronal brow lift and supraorbital rim reduction.
Discussion
Use of specific anthropometric data is an invaluable
adjunct in the diagnosis of functional and esthetic
maxillofacial deformities. The systematic incorporation
of this evaluation into the workup of patients will sup-
plement the more traditional subjective clinical esthetic
and cephalometric’evaluations. Evaluation of the an-
thropometric maxillofacial data is best achieved by se-
quencially using Tables 1 through 14, first evaluating
the full face in the vertical, horizontal, and sag&al di-
rections and then evaluating the upper, middle, and
lower thirds of the face separately.
The vertical full face evaluation is accomplished first
(Fig 1) (Table 2). In general, the clinician evaluates the
patient for pathological alterations in the height of the
facial thirds. Although the crown and forehead can be
altered greatly by hair line and style, full-face balance
is desired and can be altered by midface and lower face
osteotomies. Next, the width of the face is evaluated
(Table 3). The broadest area of the face is normally the
bizygomatic width and the thinnest is the bigonial (Fig
1). Commonly, width deficiency at the bizygion level
is encountered, creating the illusion of a long face. This
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
deformity is readily correctable with esthetic cheek
augmentation (Fig 12). The width-to-height relations
in Table 3 are a significant aid in assessment of this
type of esthetic defect.
The lateral anthropometric data provides a similar
benefit for the objective evaluation of the face (Fig 2)
(Table 4). The forehead, midface, and general facial
angulations are used to evaluate the anterior-posterior
position of the facial thirds for treatment planning
forehead recontouring and maxillary and mandibular
advancements and setbacks (Fig 3). The nasofrontal
and nasomental angulations demonstrate the presence
or lack of balance between the nose and the chin (Fig
4). The cervical mental angle is used to decide if the
neck must be addressed to sharpen the definition of
the mandibular line and chin.
Importantly, the facial thirds data permits the de-
tailed independent evaluation of facial units so im-
portant in the area of esthetic maxillofacial surgery.
The middle third of face evaluation primarily involves
the eyes and nose (Fig 5). Vertically, the eye measure-
ments are used to evaluate lid and brow ptosis and
vertical dystopias for soft and hard tissue correction
(Fig 5) (Table 5). Also, these measures permit decisions
KOURY AND EPKER 817

FIGURE 14. Before (A and E) and after (C and D) augmentation rhinoplasty used to alter vertical position of nasion
818
regarding the appropriateness of independently per-
formed blepharoplasties or the simultaneous need for
a brow-lifting procedure (Fig 13). The vertical nasal
measurements evaluate nasal and dorsal length and
specifically the position of nasion and the nasal tip.
Nasal length measurements may show the need for
dorsal grafts or ostectomies to change the vertical po-
sition of nasion, whereas the dorsal length evaluates
the need for nasal tip rotation after nasal length and,
specifically, the proper vertical position of nasion have
been established (Fig 14).
Horizontally, the ratios involved with the eyes and
nose are used in conjunction with radiographs for the
evaluation of canthal and orbital wall position to eval-
uate the need for osteotomies, revision of traumatic
telecanthus, and the like (Fig 6) (Table 6). The nasal
width ratios are used when planning nasal osteotomies,
alar width soft-tissue procedures, and for the control
of alar width during maxillary osteotomies. Sag&ally,
ratios and angulations are aimed specifically at opti-
mizing nasal esthetics for rhinoplastic procedures (Fig
7) (Table 8). These numbers are most useful for eval-
uating the anterior and vertical position of nasion and
FIGURE 15. Before (A) and after (B) otoplasty.
OBJECTIVE ESTHETIC EVALUATION OF THE FACE
pronasale. The nasal base evaluation is also important
(Fig 8) (Table 9). The columella and nasal tip ratios
will guide the use of columellar struts and tip grafts to
gain nasal projection, while the alar and columellar
thickness measurements are particularly useful in
blacks and Orientals for planning soft-tissue excisions.
The ear is evaluated for position, orientation and
proportions (Fig 9) (Table 10). These measurements
are used to recognize anomalies (syndrome identifi-
cation) and for planning procedures to reposition, tuck,
and change the size of the attachment and the pro-
portions of the ear (Fig 15).
The lower facial third is next addressed. Vertical
proportions are evaluated first (Fig 10) (Table 11). The
lip and chin lengths are used in conjunction with clin-
ical tooth show and cephalometric analysis to optimize
esthetic correction. Specifically, these data permit the
vertical alteration of the chin to be more precisely
planned. The exposed lip vermilion measurements are
used to plan incision placements during orthognathic
procedures as well as the need for V-Y advancements
or possible reduction cheiloplasties (Fig 16). Horizontal
measurements are best used for planning soft-tissue
KOURY AND EPKER
FIGURE 16. Before (A) and after (B) V-Y augmentation cheiloplasty of the upper lip to improve the vermilion-cutaneous
procedures to change the mouth and philtral widths
(Fig 6) (Table 12). Laterally, the lip and lower face
angulations are useful evaluations for the effects of
dental tipping and the anterior-posterior chin position
(Fig 11) (Table 14).
Application of these data and the principles to both
esthetic maxillofacial surgery, orthognathic surgery,
and reconstructive surgery are significant. In the or-
thognathic surgery patient they permit the clinician
not only to improve on facial esthetics but also to in-
corporate adjunctive esthetic procedures into the treat-
ment plan, such as cervical facial liposuction, cheilo-
plasty, rhinoplasty, and cheek augmentation.
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2. Durer A: About the proportions of human limbs, in WM Conway
(ed): The Writing of Albrecht Durer. New York, Philosophical
Library Inc, 1958, pp 166
3. Annenini G: On the True Precepts of the Art of Painting. New
York, NY, Burt Franklin, 1977, pp 165-166
4. Cennini C: The Craftman’s Handbook. New York, NY, Dover,
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5. Gonzalez-Ullou M: Quantitative principles in cosmetic surgery
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6. Lee L. Lee W: A study of facial proportions and sketching of
facial contours. Ear Nose Throat J 58: 12. 1979
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9. Merrifield LL: The profile line as an aid in critically evaluating
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10. Farkas LG: Anthropometrics of the Head and Face in Medicine.
New York, NY, Elsevier. 1981, pp 8-59, 108-202
1 1. Farkas LG, Kolar JC: Anthropometrics and art in the aesthetics
of women’s faces. Clin Plast Surg 14:599, 1987
12. Farkas LG. Hreczko TA. Kolar JC. et al: Vertical and horizontal
proportions of the face in young adult North American cau-
casians: Revision of neoclassical canons. Plast Reconstr Surg
75:328. 1985
13. Farkas LG, Katie MJ, Hreczko TA, et al: Anthropometric pro-
portions in the upper-lower lip-chin area of the lower face in
young white adults. Am J Orthod 86:52, 1984
14. Farkas LG. Sohm P, Kolar JC, et al: Inclinations of the facial
profile art versus reality. Plat Reconstr Surg 75:509, 1985
15. Farkas LG, Munro IR: Anthropometric Facial Reconstruction
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repair of bilateral cleft lip and palate in childhood. Plast Re-
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19. Whitaker LA, Morales L, Farkas LG: Aesthetic surgery of the
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20. Laestadius ND, Aase JM, Smith DW: Normal inner canthal and
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J Oral Maxillofac Surg
50:820, 1992
Discussion
Maxillofacial Esthetics: Anthropometrics
of the Maxillofacial Region
Timothy A. Tuwey, DDS
The Universityof North Carolina at Chapel Hill
In the quest to improve facial balance and harmony, sur-
geons rely on many guidelines, including the classical canons
developed by the Renaissance artists. Some use linear or an-
gular cephalometric measurements and a few use anthro-
pometric data. Others rely on their own esthetic judgment,
in the belief that it is as reliable as any other method. Few
remarkable individuals have the talent to envision proposed
facial changes abstractly. Most of us do not possess this ability
and will find anthropometric proportions helpful in planning
treatment. This manuscript brings to our attention an ob-
jective means of assessing facial form and balance from both
the frontal and profile views. Anthropometric proportions,
not absolute measurements, are emphasized. According to
Tessier, “Harmony or disharmony does not lie within angles,
distances, lines, surfaces or volumes. They arise from pro-
portion.“’
DlSCUSSlON
23. Stella JP, Epker BN: Systematic aesthetic evaluation of the nose
for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2:
273, 1990
24. Farkas LG: Anthropometrics of the normal and defective ear.
Clin Plast Surg 17:213, 1990
25. Leibers B: Ohrmuscheldystopie, ohrmuscheldysplasie und’ohr-
muschelmissbildung-klinische wertung and bedeutung als
symptom. Arch Klin Exp 202:51, 1972
26. Broadbent TR, Mathews VL: Artistic relationships in surface
anatomy of the face. Plast Reconstr Surg 20: 1, 1957
The article adequately reminds the readers of ethnic, racial,
gender, and other demographic differences. It also warns of
the problems of extrapolating the data to other groups and
of using only the measurements and proportions to make
treatment planning decisions.
The authors credit Farkas for his contribution to anthro-
pometric measurements. In my opinion, they have under-
stated the usefulness of the proportions that he and Munro
have already published in their textbook.’ The proportions
described in this article complement those already published
by Farkas and coworkers. Readers are reminded that they,
too, can use Farkas’s raw data to develop their own set of
facial proportions suited to the needs of their patients and
their practices.2
References
1. Farkas LG, Munro IR: Anthropometric Facial Proportions in
Medicine. Springheld, IL, Charles Thomas, 1986
2. Farkas LG: Anthropometry of the Head and Face. New York,
NY, Elsevier, 198 1