When assessing a patient’s face during a cosmetic consult, assessment of photoaging is vital, as this can affect treatment selection and outcome following treatment. Photoaging forms a key part of the Glogau classification system,1 which considers many of the key signs of photoaging including degree of wrinkling, scarring, pigmentary changes, and actinic damage. It also considers the requirement for make-up and the age group, but not gender or specific patient’s age. It does not provide information on prior or required treatment, although this would be a useful addition. The ideal classification system should guide treatment and facilitate comparison of results of different treatments between patient groups. There are some other useful classification systems other than the Glogau system. These include the Fitzpatrick,2,3 the Shiftman,4 and the Ellenbogen5 systems. There are two different Fitzpatrick’s classifications relevant to photoaging. The most commonly used system assesses different skin types, ranging from I to VI, with white individuals representing types I to III and those with darker skin tones representing types IV to VI. This system is often used as a measure of patients’ susceptibility to sun damage with respect to skin cancer.2 There is also a separate Fitzpatrick classification (not the same author) for wrinkles that has three grades ranging from fine to deep wrinkles.3 The Shiftman4 classification is used to assess facial aging and considers four factors: tear-trough depth, cheek fat loss, nasolabial fold depth, and jowl prominence. The Ellenbogen classification considers aspects of the neck that change with age: the cervicomental angle, the inferior mandibular border, the presence of subhyoid depression, and the visibility of thyroid cartilage and sternocleidomastoid.5,6
The Fibonacci sequence is a set of numbers starting with a 1 or 0. The number sequence proceeds as 1, 2, 3, 5, 8, 13 …, where two consecutive numbers add up to form the next number. The so-called golden ratio between a given number and the preceding number is 1:1.62. (e.g., 13/8 = 1.62). This ratio, termed Phi, is characteristic of forms with aesthetically pleasing proportions and is highly relevant to relative facial proportions. Many examples are found in nature; a good example is the external ear, which displays a spiral pattern conforming to Fibonacci ratios (Fig. 102.1).1
The facial canons of proportion were formulated and documented by artists of the Renaissance (Fig. 102.2). According to these descriptions, the length of the ear and nose is equal. The head can be divided into equal horizontal halves or quarters and the face can be divided into equal horizontal thirds. The horizontal midpoint of the head is the nasal bridge and not the nasal base. Nasal width at the alar base is one quarter of the facial width. The mouth is 1.5 times the width of the nasal base.1 Upper head height Lower face height Forehead Nasal length Lower face Calvaria Forehead Upper face Lower face Nasal length Ear length Intraocular distance Nasal width Intraocular distance Eye fissure length Nasal width 1½ Face width Nasal width 1:3 1:4 Fig. 102.2 Neoclassical canons. 1, The head can be divided into equal halves at a horizontal line through the eyes. 2, The face can be divided into equal thirds, with the nose occupying the middle third. 3, The head can be divided into equal quarters, with the middle quarters being the forehead and nose. 4, The length of the ear is equal to the length of the nose. 5, The distance between the eyes is equal to the width of the nose. 6, The distance between the eyes is equal to the width of each eye (the face width can be divided into equal fifths). 7, The width of the mouth is 1½ times the width of the nose. 8, The width of the nose is one-fourth the width of the face. 9, The nasal bridge inclination is the same as the ear inclination. 10, The lower face can be divided into equal thirds. 11, The lower face can be divided into equal quarters. (From Gunther JP, Rohrich RJ, Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis, MO: CRC Press, 2002.)
Facial proportions, angles, and contours vary with race, age, and sex, but there are certain measurements considered to represent aesthetic ideals. The width of the mouth and the vertical distance between the stomion and menton should be equal in a patient with a normal chin (Fig. 102.3). The lateral and medial canthi can be used to divide the face into vertical fifths (not thirds). It is the distance between the medial limbus of each cornea and not the distance between the medial canthi that equates to the mouth width. Mouth width is approximately 1.5 times the width of the intercanthal distance. Facial width at the malar level is similar to the vertical distance from the brows (not the anterior hairline) to the menton. The lower lip vermilion (not the upper) marks the vertical midpoint of the lower third of the face.1,2
5. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg 1980;66(6):826–837
6. O’Brien M. Plastic and Hand Surgery in Clinical Practice—Classifications and Definitions. New York, NY: Springer; 2009
excursion? Conscious elevation of the upper eyelid is predominantly achieved by levator palpebrae superioris. This muscle originates from the lesser wing of the sphenoid and inserts on the superior edge of the tarsus. It is innervated by the superior division of cranial nerve III. It is assisted by Müller’s muscle, which arises from the inferior surface of the levator and inserts onto the superior edge of the tarsus. This has sympathetic innervation. Testing of the levator function is performed facing the patient with a thumb gently placed on their brow to limit frontalis function, while asking the patient to look down and then up without moving their head or their brow. Excursion of the upper lid is normally 15 mm or greater. Reduced elevation may be secondary to muscle weakness or disruption of the soft-tissue attachments.1,2
Many facial structures share similar proportions. The intercanthal distance is a good example of this, with a number of other measurements being equal to it. These include eye width, alar base width, nasal projection, and the vertical distance between the infraorbital rim and the nasal base. Ear width is not equivalent to these distances. However, the ear does share some proportions with other facial components; for example, ear length is the same as nose length and ear width is approximately half of ear length in most individuals. Nose width is a nonspecific measurement, as the nose differs in width from root to alar base. The alar base width is the widest part of the nose and this does match the intercanthal distance. The nasal body width is normally 80% of the nasal base width. Mouth and chin widths are essentially the same as one another and are usually 1.5 times the width of the nose at its widest point (i.e., alar base). When any of these typical distances do not match, it is important to identify why this is the case. For example, alar flaring or lack of nasal tip projection can increase the alar base width. Ethnicity also affects these measurements, for example, black patients tend to have broader nasal bridges and more alar flaring.1–4
secondary to a prominent caudal septum. Tip rotation is determined by the degree of the nasolabial angle. The nasolabial angle is measured by drawing a straight line through the most anterior and posterior points of the nostrils on lateral view and noting the point this bisects with a perpendicular line to the natural horizontal facial plane. The angle between these lines represents the nasolabial angle and varies from 90 to 100 degrees, depending on gender and race (Fig. 102.5). It is important to be aware of other factors that may give the appearance of increased tip projection. For example, a prominent caudal septum can give this appearance, even when the nasolabial angle is within normal range. Understanding these principles is key to rhinoplasty. Also, a nose with a high dorsum without a supratip break will appear less rotated than one with a low dorsum and supratip break, even though the degree of rotation is the same. Nasal deviation is best assessed by drawing a plumb line from the mid-glabellar point to the menton. This line should bisect the nasal bridge, nasal tip, and cupid’s bow (Fig. 102.6). Nasal length is the distance from the radix to the tip and should be 1.5 times the nasal tip projection. The dorsal nasal line typically lies 2 mm posterior to and parallel with a line connecting the nasofrontal angle with the desired tip projection. In men, it lies slightly more anteriorly.1–3
antihelix in the anterior view Understanding of external ear aesthetics is critical to ear reconstruction and correction of ear deformities such as prominent ear. In the anterior view, the helix should be slightly more prominent (approximately 5 mm) than the antehelical fold (Fig. 102.7). Overcorrection of the prominent ear can leave the antihelix as the most prominent part of the ear, resulting in an unnatural appearance and increased risk of development of pressure damage to the ear that may result in chondrodermatitis nodularis helicis. The ear usually measures 5–6.5 cm in height and 2–3.5 cm in width. The ratio of width to height is usually 55–60%. The ear is normally placed with its superior aspect level with the upper eyelid and just below the lateral-most part of the eyebrow and around 5–6 cm posterior to the lateral orbital rim. It is inclined posteriorly in the lateral view about 20 degrees. It is inclined laterally from the scalp in the anterior view (20–30 degrees), and this means that the top of the ear is about 1.5–2 cm from the scalp.1,2