Contribution of lip proportions to facial aesthetics in different ethnicities: a three-dimensional analysis

Anthropometry and Current Aesthetic Concept of the Lower Third of the Face and Lips in Caucasian Adult Population: A Systematic Review and Meta-Analysis

BACKGROUND

The lack of standardization of the norms and aesthetic concept of the lower third of the face and lips creates challenges in reconstructive surgery and aesthetic procedures. A large-scale, anthropometric measurements summary poses an alternative for establishing universal patterns.

METHODS

A systematic review was conducted by searching PubMed, Embase, Google Scholar and Web of Science using keywords: lip, face, aesthetics, beauty, anthropometry and Caucasian. Seventy records were included in the review and checked in detail in terms of available data.

RESULTS

The study contains a meta-analysis of twelve parameters with sufficient quantitative data-lip width, nose width, facial width, lower third of the face height, midline mandible height, total height of the upper and lower lip, upper and lower vermilion height, cutaneous upper lip height and nasolabial and mentolabial angle.

CONCLUSIONS

The review provides a detailed database of primary anthropometric studies of lips and perioral regions of the healthy Caucasian population. The attractiveness of the region is focused on uniformity of proportions. Notably, results acquired with different methods of measurement are not interchangeable. Despite many published anthropometric studies, systems for conducting the measurements and reporting the results are not sufficiently unified to quantitatively assess meticulous key aesthetic clinical parameters.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Enhancing Aesthetic Harmony: Comprehensive Anthropometric Lip Measurements in Youthful and Attractive Indonesian Adults for Precision Cosmetic Procedures

Lips are an important part of our perception of beauty, youthfulness and attractiveness. Aesthetic lips, as with the rest of the face, differs according to age, ethnicity and sex. The aim of this study was to evaluate the anthropometric measurements of the lips of young and attractive Indonesian adults. Photographs of faces were taken at an anterior neutral position for 100 participants; 47 men and 53 women volunteered to participate in this study. Seven landmarks were used in this study: stomion (st), sublabiale (sl), subnasale (sn), labiale superius (ls), labiale inferius (li), crista philtre (cp) and chelion (ch). Using these landmarks, lower lip height, upper lip height, philtrum length, upper vermillion height, lower vermillion height, cutaneous lower lip height, philtrum width and mouth width were measured. The results were analysed using independent t-test and Mann-Whitney test. Significant differences in lip size were observed between men and women in all the measurements st-sl (lower lip height), sn-st (upper lip height), sn-ls (philtrum length), li-sl (cutaneous lower lip height), sn-ls/ls-st (philtrum length and upper vermillion height) and ls-li/ch-ch (cutaneous lower lip height and mouth width) with a significance of p=0.003, p=0.007, p<0.001, p=0.05, p=0.005 and p=0.021, respectively. Male lip measurements of ch-ch (overall lip width) and ls-st/li-st (overall lower lip height) were significantly smaller than those of female lips. The lip ratios calculated in this study were congruent with aesthetic parameters reported in other populations. This study suggests that the same measurement standards cannot be used on different populations, but these ratios may offer a better framework for precision cosmetic procedures. We believe that the results obtained in this study on lip anthropometry will help in optimising the standard values that can be used for the Indonesian population aged 20 to 35 years.

Eyelash length attractiveness across ethnicities

Eyelashes evolved to protect eyes. An optimum eyelash length functions to protect eyes from external hazards such as contaminations, excessive evaporation or shear stress from airflow. They can also be an indicator of a person's health as various congenital and noncongenital diseases can lead to short or long eyelashes. The current study aimed to extend a recent investigation on the preference for eyelash length in humans from an evolutionary adaptive perspective. Specifically, the current study tested whether the inverted-U function for eyelash length preference recently reported for White faces, generalises to other ethnicities, and whether ethnic background modulates preference for eyelash lengths. To investigate this question, men and women of Asian, Black, and White ethnicities from the U.S. rated the attractiveness of female Indian, Asian, Black, and White faces with varying eyelash lengths. The eyelashes ranged in length from no eyelashes to half the width of an eye. Results showed that Asian, Black, and White men and women preference for eyelash length followed an inverted-U function across all four ethnicities, supporting a general preference for human eyelash length that is approximately one-third the width of an eye. In addition, the results showed that the most attractive eyelashes for Black women were skewed toward a greater eyelash-length to eye-width ratio when compared to the other images. The source of this skew is presently unknown, as it could reflect a change in perceptual sensitivity to eyelash length with skin colour or changes in preference related to perceptions of participants' ethnicity.

Long-term efficacy and safety of a hyaluronic acid dermal filler based on Tri-Hyal technology on restoration of midface volume

INTRODUCTION

Art Filler Volume (AFV) is a hyaluronic acid (HA)-based filler formulated with "Tri-Hyal" technology, a unique combination of three sizes of HA chains. This study assessed AFV efficacy and safety over 18 months when used to restore midface volume.

METHODS

During this open-label study, a maximum of 1.8 mL AFV was injected into each cheek area on Day 0 (D0). Subjects were evaluated at D21, when, if necessary, a retouch could be performed (maximum 1.2 mL per cheek). Subjects were evaluated at seven follow-up visits through to D540. The primary assessment was based on the evolution of the Medicis Midface Volume Scale (MMVS) grade on D21. Secondary outcomes were local and general adverse events, investigator- and subject-assessed Global Aesthetic Improvement Scale scores and changes in self-esteem.

RESULTS

Of the 79 healthy Caucasians enrolled (mean age 54.8 years), 25 required a second injection. In the intention-to-treat population, mean overall MMVS scores improved significantly from D0 (3.2 ± 0.4) to D21 (1.8 ± 0.6) and D42 (1.7 ± 0.6) (all p < 0.0001). MMVS scores for each cheek also improved significantly, irrespective of retouch on D21: 22% of injections showed a persistent benefit at D540 without retouch. The most common adverse events were pain on palpation (19%), erythema (15%) and edema (13%); most were mild or moderate and resolved within 2 weeks.

CONCLUSION

AFV produces a sustained objective and subjective midface volume restoration in female and male subjects, often without retouching, and was well tolerated.

Exploration of surgical approach to reconstruct smile-like lip shape in East-Asian women

BACKGROUND

To investigate the clinical effects of surgical treatment to improve the lip morphology for a smile-like appearance (joy and happiness) in East-Asian women.

METHODS

From October 2016 to April 2020, 63 patients who had received surgery to lift the commissure of the mouth and adjust the shape of the upper red lip to form a smile-like shape were analyzed and evaluated.

RESULTS

The lip shape of enrolled patients was improved to a certain extent after surgery without any obvious scar hyperplasia, and the satisfaction rate of people after the surgery was 85.71%.

CONCLUSION

For East-Asian women with thin and flat lips, surgical approach can be used to improve the shape of lip, such that the appearance of the lip is in a smile-like shape, which can enhance affinity and also exhibit the aesthetic characteristics of East-Asian women. This treatment can be used for clinical reference.

LEVEL OF EVIDENCE

Level IV.

Systematic Review and Meta-analysis of Facial Anthropometric Variations Among Cisgender Females of Different Ethnicities: Implications for Feminizing Facial Gender Affirming Surgery

BACKGROUND

Feminizing Facial Gender-Affirming Surgery (FFGAS) is gaining popularity among the diverse population of patients impacted by gender incongruence. However, most studies examining facial femininity are based on Caucasians. Thus, it is unclear if ethnic differences exist in anthropometric measures relevant to FFGAS procedures. This study aims to analyze ethnic anthropometric variations in the cisgender female face to identify differences that are potentially relevant to FFGAS.

METHODS

A systematic review and meta-analysis of the PubMed, EMBASE, and Cochrane databases was performed following PRISMA guidelines on June 25, 2021. Original studies reporting facial anthropometry in cisgender women were included. Anthropometric measures of interest included mandibular and zygomatic width, facial and forehead height, and nasolabial angle. A meta-analysis was performed using a linear mixed-effects model for each anthropometric measure.

RESULTS

A total of 1246 abstracts were screened, yielding 21 articles that met the inclusion criteria. Facial anthropometric data of 4792 cisgender females of 16 different ethnicities were analyzed. This meta-analysis demonstrated that compared with Caucasian cisgender women, Japanese, Chinese, and Korean cisgender women had a wider mandible (Japanese +20.13 mm [SE 4.43, P<0.001, P value adjusted for multiple comparisons (p-adj)=0.002], Chinese +16.22 mm [SE 4.39, P=0.002, p-adj=0.013]; and Korean +14.46 mm [SE 3.97, P=0.002, p-adj=0.014]). Further, when compared with Caucasian cisgender women, Chinese cisgender women demonstrated a larger zygomatic width, African American cisgender women tended to have smaller nasolabial angles, and Indian and Japanese cisgender women tended to have a smaller and larger facial height, respectively. However, following P value adjustment for multiple comparisons, these differences were not found to be statistically significant.

CONCLUSIONS

We found that mandibular width tends to be greater for Japanese and Chinese cisgender women relative to Caucasian cisgender women. This data may be useful in counseling patients during preoperative evaluations ahead of mandibular reduction. No other anthropometric features were found to be significantly different among the ethnic groups studied. This portends that current approaches to FFGAS, which emphasize patient-specific needs and maintenance of a harmonious appearance, may require minimal or no adjustment to account for ethnic facial anthropometric differences.

Introduction of the Lip Classification of Tubercles: A Novel Approach to Minimally Invasive Aesthetic Lip Treatments

Background

Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic treatments. However, current trends are associated with unnatural results and involve increased risks of complications and compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function.

Objectives

To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification of Tubercles (LCT).

Methods

To test the reliability of the LCT, a total of 214 high-definition photographs of patients' lips with no previous histories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions 3 months apart; the second followed a more detailed explanation of the classification.

Results

When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was considered the standard, the average score for the remaining 3 showed some individual variation but improved significantly from 58% to 85%.

Conclusions

The LCT is a reliable way to classify lip types based on the morphology of tubercles.

Level of Evidence 3

Impact of facial components on the attractiveness of face: A perception-based study

INTRODUCTION

Magazines and television displays are not merely crammed with faces-they are filled with appealing faces, and both men and women are interested in a suitable partner's appearance. This study investigated what makes a face attractive and whether perception-related differences exist between facial attractiveness and facial components.

METHODS

In this descriptive-analytical study, frontal and lateral view photographs of 18 young adults (9 male and 9 female) in Class I, II, and III malocclusions were assessed by 90 orthodontists, dentists, models, and laypeople using a 7-point Likert scale in terms of attractiveness. Based on scores, attractive and unattractive groups were formed. Using image analysis software, a range of defined length, angles, perimeter, and area for lips, nose, and chin were measured for the attractive group. For statistical analysis, each group was compared using a 1-way analysis of variance. Logistic regression was performed to analyze the factors of different parameters to the attractiveness of facial components.

RESULTS

Overall full-face width, upper lip angle, lip area, and mentolabial angle was significantly different in all the 3 classes (P ≤0.05). In Class I malocclusion, nasolabial angle among orthodontists, nasofrontal angle among dentists, lower lip among models, and full-face width among laypeople were responsible for facial attractiveness variation. In Class II malocclusion, nose to upper lip among orthodontists, Cupid's bow among dentists, wider face among models, and upper lip among layperson were responsible for variation in facial attractiveness. In Class III malocclusion, lower lip angle among orthodontists and dentists, Cupid's bows among models and layperson was responsible for variation in facial attractiveness.

CONCLUSIONS

In Class I faces, lips (Cupid's bows, lower lips, lip areas), nose (nasolabial, nasofrontal, and nasomental angles), and chin (lower lip to chin) contributed to the overall attractiveness of the face, while in Class II faces, lips (upper lip length, interbow distance, lower lip angle), nose (full facial convexity), and chin (mentolabial sulcus), as well as a greater full-face width contributed to the overall attractiveness of the face. In Class III faces, lips (lower lip angle, upper lip length), nose (nose tip angle, full facial convexity), and chin (mentolabial sulcus depth) contributed to the overall attractiveness of the face.

Reliability of cone beam CT for morphometry of nasolabial soft tissue in patients with skeletal class III malocclusion: A qualitative and quantitative analysis

OBJECTIVE

To assess reliability of cone-beam CT (CBCT) for nasolabial soft tissue measurements in patients with skeletal class III malocclusion based on 3-dimensional (3D) facial scanner results.

METHODS

CBCT and 3D facial scan images of 20 orthognathic patients are used in this study. Eleven soft tissue landmarks and 15 linear and angular measurements are identified and performed. For qualitative evaluation, Shapiro-Wilk test and Bland-Altman plots are applied to analyze the equivalence of the measurements derived from these two kinds of images. To quantify specific deviation of CBCT measurements from facial scanner, the latter is set as a benchmark, and mean absolute difference (MAD) and relative error magnitude (REM) for each variable are also calculated.

RESULTS

Statistically significant differences are observed in regions of nasal base and lower lip vermilion between two methods. MAD value for all length measurements are less than 2 mm and for angular variables < 8°. The average MAD and REM for length measurements are 0.94 mm and 5.64%, and for angular measurements are 2.27° and 3.78%, respectively.

CONCLUSIONS

The soft tissue results measured by CBCT show relatively good reliability and can be used for 3D measurement of soft tissue in the nasolabial region clinically.

Lip Reshaping with LOVE Approach: A Prospective Analysis Based on Two Hyaluronic Acid Fillers

Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups.

A Guide to Bilateral Cleft Lip Markings: An Anthropometric Study of the Normal Cupid's Bow

OBJECTIVE

The aim of this study was to define the ratio of the heights of the vermilion between the peaks and trough of the Cupid's bow and hence assist in defining the point of closure on the lateral lip element to achieve a balanced Cupid's bow in bilateral lip repair based on our findings.

DESIGN

This study is a retrospective observational study of the anthropometrics of the upper lip's Cupid's bow. Three-dimensional (3D) images of toddlers between 2009 and 2016 were extracted from a normative 3D image database of toddlers at the Royal Children's Hospital, Melbourne.

PATIENTS

Participants from the normative 3D image database at the age of 1 year were studied. This excluded any patients with prior trauma or surgical intervention of the nasolabial region.

INTERVENTION

Landmarks measured were right and left crista philtri (cphR and cphL), labial superius (ls), stomion (sto), right and left chelion, and labial fissure (lf).

OUTCOME

Vermilion height of the right peak, trough, and left peak of the Cupid's bow was calculated by analyzing the vertical linear distance between cphR-lf, ls-sto, and cphL-lf. The ratio between the median and paramedian heights were recorded.

RESULTS

The paramedian height of the upper lip vermilion is consistently greater than the midline height. There was no significant sexual dysmorphism between ratio of paramedian to midline height on the right (P = .538) and left (P = .410).

CONCLUSION

We describe an anthropometric observation of the vermilion relationship at the Cupid's bow and define a specific lateral lip marking for bilateral cleft lip repair based on our anthropometric findings.

The Ideal Lips: Lessons Learnt from the Literature

Defining the ideal dimensions and proportions of the human face has been attempted for centuries, popularised in the Renaissance period by artists including Leonardo Da Vinci. The lips are part of the lower third of the face and are central to lower face aesthetics and the overall symmetry of the face. They also place an important part in conveying facial emotions and expressions. Full lips with well-defined Cupid's bow have always been associated with youth and beauty. The approval of hyaluronic acid use for tissue augmentation and the prevalence of social media have caused an exponential increase in lip augmentation procedures (Linkov et al. in Arch Plast Surg 46(3):248-254, 2019), as such researchers and aestheticians have focused on characterising the ideal lips mathematically to help guide clinicians. This narrative review will summarise the available evidence in the literature pertaining to the ideal lips, taking into account age, ethnicity and gender differences. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic Enhancement of the Vermilion Using Dermofat Graft in Patients With Cleft Lip Deformity

BACKGROUND

There is an increasing patient expectation for better esthetics, manifesting through anatomical harmony, projection, and volume of the upper lip relative to the lower lip, in patients with cleft deformity. The aim of this study is to investigate the outcome of vermilion augmentation using autologous dermofat graft (DFG) to enhance the lip using both quantitative and qualitative assessment.

METHODS

Patients with secondary cleft lip deformity who received the surgical treatment in our institution from 2015 to 2018 were recruited. Panel assessment was performed on standardized preoperative and postoperative digital photographs. A patient questionnaire was used for the reported outcome. Image processing and analyses were applied to measure the lip change. Statistical analyses were performed.

RESULTS

A total of 91 patients were included. The mean age at operation was 22.7 years, and postoperative follow-up was 3.6 years. There were no complications in the study group. The panel assessment showed significant improvement (P < .00001) on upper lip vermilion in both frontal and lateral profile views. Ninety-five percent of patients reported improvement of the upper lip projection and volume. Quantitative image analysis showed an increase in the upper lip vermilion ratio in 97% of the cases in frontal views and improvement of the vermilion projection in 87% of the cases in the superimposed lateral views.

CONCLUSIONS

The use of DFG is an effective and reproducible method for vermilion augmentation and aesthetic enhancement in patients presenting with upper lip insufficiency relative to the lower lip.

Analysis of upper lip appearance after surgical lip augmentation procedure "VY in VY": Progress of results

INTRODUCTION

Many materials and techniques were used for lip augmentation, whereas in the last years all attention is paid for filling material, and long-lasting surgical techniques were ignored.

MATERIALS AND METHODS

This study includes 12 candidate patients for upper lip augmentation; all are females, their age range 21-24 years. Standardized anterior and lateral photographs of each subject were taken at: preoperative, 2, 4, and 12 months later, and were analysed using digital imaging software to quantify postoperative changes. We used t-test of correlated samples to detect any statistical significance and Interclass correlation coefficient test (ICC) for reliability that proved the reliability and reproducibility of our method.

RESULTS

there were statistically significant improvements in al parameters that characterize the fullness of the upper lip. These changes was observed from the 2^nd month (P<0.05) and continued improving until the 4^th month (P<0.05), after that they appeared to be stable (P>0.05). These changes were at the 12^th month postoperative in: upper white lip (-9%), upper red lip (53%), upper red lip area (63%), protrusion (41%) and nasolabial angle (-7%). There was no statistical significance in the change of Cupid's bow curvature (P-value = 0.104 > 0.05).

CONCLUSIONS

VY in VY for upper lip augmentation improves the parameters that define the youthful and fully appearance of the upper lip and the progress of results may be predictable. These improvements appear to be stable from the 4th month. Also, it doesn't change the Cupid's bow curvature.

Measurement of three-dimensional changes in lip vermilion in adult female patients after orthodontic extraction: a retrospective longitudinal study

Background

3D facial scanning has changed the way facial aesthetic is evaluated and has numerous advantages for facial analysis. The specific relationship between lip vermilion morphological changes after orthodontic extraction treatment has not been fully explained. The objective of this study was to evaluate 3D morphological changes after orthodontic extraction treatment in lip vermilion of adult females with dentoalveolar protrusion using a structured light-based scanner.

Methods

Forty-two female subjects (25.2 ± 1.9 years) were recruited as the treatment group; these patients had undergone extraction treatment and achieved better sagittal profiles. Twenty female subjects (25.5 ± 2.1 years) were enrolled in the non-treatment group; these patients did not require any orthodontic treatment. The follow up time for the treatment group was more than 24 months and for the non-treatment group was more than 12 months. 3D facial scans were captured using 3D CaMega. Six landmarks (Ls, Li, R.Chp, L.Chp, R.Ch, and L.Ch), three linear measurements (mouth height, philtrum width, and mouth width), and three area measurements (upper, lower, and total vermilion area) were measured. The spatial deviations of three volumetric measurements (upper, lower, and total vermilion) were constructed for quantitative analysis. Color-coded displacement map were constructed for visualization of the soft-tissue displacement as qualitative evaluation.

Results

Mouth height and philtrum width decreased (-0.93 mm and − 1.08 mm, respectively) significantly (p = 0.008 and p = 0.027, respectively), and no significant (p = 0.488) change in mouth width was observed in the treatment group. The lower and total vermilion surface areas decreased (-51.00mm² and − 69.82mm², respectively) significantly (p = 0.003 and p = 0.031, respectively) in the treatment group, but no statistically significant (p = 0.752) change was detected in the upper vermilion. In the treatment group, significant retractions were observed in the color-coded displacement map, and three volumetric measurements of vermilion changed significantly (p = 0.012, p = 0.001 and p = 0.004, respectively). Significant differences were found between the treatment group and the non-treatment group in the linear, area and volumetric measurements.

Conclusions

This study established a method for qualitative and quantitative evaluation of the lip vermilion. Significant 3D retraction of the lip vermilion after the extraction treatment was found, with morphological variation between upper and lower vermilion.

Analysis of correlation of 3-dimensional lip vermilion morphology and dentoskeletal forms in young Chinese adults on the basis of sex and skeletal patterns

INTRODUCTION

The objective of this research was to evaluate the correlation between 3-dimensional (3D) lip vermilion (LV) morphology and skeletal patterns as well as incisor measurements in young Chinese adults.

METHODS

In all, 240 young adults were enrolled; these included 80 patients each with skeletal Class I, Class II, and Class III malocclusions, respectively. Each sagittal skeletal pattern included 40 male and 40 female subjects. Twenty-two 3D LV measurements were obtained from 3D facial scans. Skeletal and incisor measurements were evaluated on lateral cephalograms. Correlation and regression analysis were performed between soft and hard tissue measurements.

RESULTS

Six of 22 LV measurements showed significant differences between male and female subjects. The 3D LV morphology showed significant differences with respect to different skeletal patterns and sex. Adults with skeletal Class III malocclusion tended to have thinner upper vermilion and fuller lower vermilion than subjects with skeletal Class II and III malocclusion. The mandibular plane angle negatively correlated with the upper-lower vermilion midsagittal curve length and surface area ratio in adults with skeletal Class I and II malocclusion, yet the vertical facial skeletal type showed no correlation in adults with skeletal Class III malocclusion. The vermilion angle, central bow angle, vermilion height, vermilion midsagittal curve length, vermilion height and width ratio, and vermilion surface area showed a significant correlation with incisor measurements. Regression analysis found that the ANB angle was an important factor affecting the upper and lower vermilion midsagittal curve length and surface area ratio. Further, the vermilion height and height and width ratio were closely correlated with the interincisal (U1/L1) angle, whereas the central bow angle was closely correlated with the maxillary incisor torque.

CONCLUSIONS

Most LV morphology variables were correlated to skeletal patterns and incisor measurements. Skeletal Class III malocclusion showed significant differences in vermilion morphology. Both the sagittal and vertical skeletal pattern have effects on vermilion proportion. The incisor torque was closely correlated to vermilion shape and central bow angle and might influence the vermilion esthetics. However, the proportion of the upper and lower vermilion was mainly affected by the ANB angle.

Implications of Applying New Technology in Cosmetic and Reconstructive Facial Plastic Surgery

The field of facial plastic and reconstructive surgery is privy to a myriad of technological advancements. As innovation in areas such as imaging, computer applications, and biomaterials progresses at breakneck speed, the potential for clinical application is endless. This review of recent progress in the implementation of new technologies in facial plastic surgery highlights some of the most innovative and impactful developments in the past few years of literature. Patient-specific surgical modeling has become the gold standard for oncologic and posttraumatic reconstructive surgery, with demonstrated improvements in operative times, restoration of anatomical structure, and patient satisfaction. Similarly, reductions in revision rates with improvements in learner technical proficiency have been noted with the use of patient-specific models in free flap reconstruction. In the cosmetic realm, simulation-based rhinoplasty implants have drastically reduced operative times while concurrently raising patient postoperative ratings of cosmetic appearance. Intraoperative imaging has also seen recent expansion in its adoption driven largely by reports of eradication of postoperative imaging and secondary-often complicated-revision reconstructions. A burgeoning area likely to deliver many advances in years to come is the integration of bioprinting into reconstructive surgery. Although yet to clearly make the translational leap, the implications of easily generatable induced pluripotent stem cells in replacing autologous, cadaveric, or synthetic tissues in surgical reconstruction are remarkable.

Perioral Ruler in Routine Esthetic Surgery: Convenient and Exact

Lip and perioral surgery, like any other esthetic surgery, requires an exact and convenient measurement tool to ensure reliable and reproducible outcomes. Although three-dimensional measuring equipment has proven its effectiveness in measuring facial parameters over the past two decades, it has some drawbacks, including high cost, long scanning times, and non-portability. Thus, digital photography remains the standard tool of measurement in esthetic surgery to date. Many authors have presented evaluation and measurement methods using digital photography in combination with different tools. However, there are no specific tools for the perioral region. Therefore, we devised a specific ruler for perioral measurements. The ruler has differently colored lines for length and angle measurements and a reference point for correct positioning. It can be used in preoperative consultation, intraoperative orientation, and postoperative evaluation.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

This case reports the unsuccessful first treatment and the subsequent retreatment of a 35-year old Asian female with a skeletal class II with bimaxillary protrusion, complicated by a deep bite and vertical maxillary excess. This case report highlights the multiple facets of a challenging treatment plan and discusses the ramifications of treatment when treatment does not go as planned. The initial treatment plan consisted of a surgical approach with a maxillary Le Fort I surgery to correct the malocclusion as per the patient's requests without mandibular surgery due to the inherent risk of paraesthesia. The second treatment plan consisted of a bimaxillary surgery with genioplasty. The surgical treatment utilized virtual surgical planning (VSP). The orthodontic treatment was concluded with a corrected overjet and overbite achieving optimum function and balancing the facial profile aesthetically. This case report highlights the need for clear communication of the treatment plan and also the unpredictability of certain treatment outcomes especially when the literature does not provide for definitive conclusions. In addition, it sheds light on the challenge of unpredictable response of soft tissue after surgical treatment and the importance of patient expectations of outcomes. It is hoped that the paper provides a platform for future discussions of difficult malocclusions.

Three-dimensional changes in lip vermilion morphology of adult female patients after extraction and non-extraction orthodontic treatment

Objective

To investigate the three-dimensional lip vermilion changes after extraction and non-extraction orthodontic treatment in female adult patients and explore the correlation between lip vermilion changes and incisor changes.

Methods

Forty-seven young female adult patients were enrolled in this study (skeletal Class III patients were excluded), including 34 lip-protruding patients treated by extraction of four first premolars (18 patients requiring mini-implants for maximum anchorage control and 16 patients without mini-implants) and 13 patients requiring non-extraction treatment. Nine angles, seven distances, and the surface area of the lip vermilion were measured by using pre- and post-treatment three-dimensional facial scans. Linear and angular measurements of incisors were performed on lateral cephalograms.

Results

There were no significant changes in the vermilion measurements in the non-extraction group. The vermilion angle, vermilion height, central bow angle, height/width ratio, and vermilion surface area decreased significantly after the orthodontic treatment in the extraction groups, but the upper/lower vermilion proportion remained unchanged. Significant correlations were found between the changes in incisor position and those in vermilion angles, vermilion height, and surface area.

Conclusions

Extraction of the four first premolars probably produced an aesthetic improvement in lip vermilion morphology. However, the upper/lower vermilion proportion remained unchanged. The variations in the vermilion were closely related to incisor changes, especially the upper incisor inclination changes.

Lip Morphology and Aesthetics: Study Review and Prospects in Plastic Surgery

The lip profile plays an important role in the perception of facial aesthetics; lip morphology and aesthetics research is receiving increasing attention. The advancement of research tools such as three-dimensional imaging technology has led to the clarification of lip morphologic and aesthetic characteristics. After studies of lip characteristics according to gender, ethnicity and age provided basic data, studies on lip aesthetics have been conducted by scholars worldwide. These studies could provide a basic theory to support diagnosis and treatment options, as well as the basis for evaluative criteria for precise treatment and technical improvements. According to the conclusions of the above studies, new ideas for cosmetic surgery design, including lip, perioral and labial-facial relationships, have been discovered.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perception of upper lip augmentation utilizing simulated photography

BACKGROUND

No head to head comparison is available between surgical lip lifting and upper lip filler injections to decide which technique yields the best results in patients. Despite the growing popularity of upper lip augmentation, its effect on societal perceptions of attractiveness, successfulness and overall health in woman is unknown.

METHODS

Blinded casual observers viewed three versions of independent images of 15 unique patient lower faces for a total of 45 images. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses.

RESULTS

Two hundred and seventeen random observers with an average age of 47 years (standard deviation, 15.9) rated the images. The majority of observers were females (n=183, 84%) of white race (n=174, 80%) and had at least some college education (n=202, 93%). The marginal mean score for perceived attractiveness from the natural condition was 1.5 points (95% confidence interval [CI], 0.9-2.18) higher than perceived attractiveness from the simulated upper lip filler injection condition, and 2.6 points higher (95% CI, 1.95-3.24) than the simulated upper lip lift condition. There was a moderate to strong correlation between the scores of the same observer.

CONCLUSIONS

Simulated upper lip augmentation is amenable to social perception analysis. Scores of the same observer for attractiveness, successfulness, and overall health are strongly correlated. Overall, the natural condition had the highest scores in all categories, followed by simulated upper lip filler, and lastly simulated upper lip lift.

Stereophotogrammetric analysis of labial morphology in a young adult Middle-Eastern population

INTRODUCTION

The majority of previous research delineating the morphological characteristics of the orolabial region has been on Caucasian populations, with very minor research on Mediterranean populations, and none on the Lebanese population.

AIM

The primary aim was to collect information on the gender-specific 3D morphology of the mouth and lips in young Middle Eastern adults. The secondary aim was to explore the presence of associations between orolabial morphology and age and body mass index (BMI), and to assess correlations between linear orolabial dimensions and area/volume measures.

METHODS

The study used non-invasive stereophotogrammetry to collect information on gender-specific 3D labial morphology (linear distances, areas, and volumes) for 122 adult Lebanese subjects, aged 18-30 years (47 males, 75 females). Associations between labial morphology and age and body mass index were assessed, in addition to correlations between linear orolabial dimensions and area/volume measures.

RESULTS

All linear, angular, area, and volume lip measurements displayed significant variability. Both lip area and volume were smaller in the upper than in the lower lip. Eighteen out of the 20 linear measurements were significantly larger in males. The ratio, area, and volume measurements mostly displayed no statistically significant gender dimorphism.

CONCLUSIONS

Alongside presenting the first documented report on anthropometric labial measurements of a young Lebanese adult population, this research highlights the presence of gender dimorphism in linear and angular measurements, but not in area and volume measurements, and a strong association between certain linear labial measurements and lip area and volume. In addition, it presents pilot data on the association between labial anthropometry and body mass index.

Determining the 2-Dimensional Threshold for Perception of Artificial-Appearing Lips

Importance

Recognizing the perceptual threshold for artificial-appearing lips is important to avoid an undesirable outcome of treatment.

Objective

To characterize the quantitative measurements for the perceptual threshold of artificial- and unnatural-appearing lips.

Design, Setting, and Participants

Photographs of a female model's lips were digitally altered incrementally in 5 sets of features (the upper lip, lower lip, upper and lower lips, and shape of the Cupid's bow). From December 1, 2013, to January 30, 2014, participants viewed the photographs in random sequence using an online survey and responded to 2 questionnaires after each photograph. The participants were prompted to respond whether each altered photograph of the lips appeared to have received any cosmetic treatment, and whether the lips looked attractive and natural or artificial and unnatural. The measurement of each lip at which 50% of the observers perceived the lips as being treated and 50% of the observers perceived the lips as being artificial was determined. The difference in these 2 measurements was defined as dTA50, which represents the threshold differential between the perception of treated lips and artificial lips for 50% of the observers.

Main Outcomes and Measures

Survey responses of the participants to the appearance of the lips in the photographs.

Results

A total of 98 participants (76 females and 22 males; mean age, 42 years) provided usable responses to the survey. Each area of the lips had a unique quantitative measurement at which the observers perceived the lips as being treated and artificial. Enhancement of the upper lip alone had a narrower margin for artificial appearance (dTA50, 0.9 mm) compared with enhancement of both the upper and lower lips (dTA50, 1.5 mm). Any alteration to the Cupid's bow resulted in the narrowest margin for artificial appearance (dTA50, 0.3 mm). The difference in the perceptual threshold between the age of the observers was the most significant for the upper lip.

Conclusions and Relevance

The perceptual threshold for treated and/or artificial appearance is unique for each area of the lips.

Level of Evidence

NA.

Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon's perspective

Objective aesthetic criteria are important for patient evaluation and analysis during aesthetic surgeries, while successful aesthetic surgeries must take into account the underlying ethnic differences. The aim of this study is to help surgeons and scientists better plan facial aesthetic surgeries and understand the aesthetic needs according to different patients by reviewing and comparing the current aesthetic principles and preferences in Caucasian and East Asian populations. PubMed and The Cochrane Library were searched using keywords regarding anthropometric measurements. Only original clinical studies and reviews written in English and Chinese and those that focused on the objective assessment of facial aesthetics in Caucasian and East Asian female populations were retained for review. Reference lists of the selected articles were also reviewed for eligible studies. Sixty-five articles that described objective aesthetic criteria in Caucasian and East Asian female populations were found through PubMed, among which 47 included Caucasian populations and 18 included East Asian populations. Compared with White women, East Asian women prefer a small, delicate, and less robust face, lower position of double eyelid, more obtuse nasofrontal angle, rounder nose tip, smaller tip projection, and slightly more retruded mandibular profile. Various differences exist between objective facial aesthetic criteria in Caucasian and East Asian populations. Further studies that focus on the objective aesthetic criteria of facial attractiveness in different ethnicities need to be conducted, especially in Asian countries. Level V: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Practical Application of Anatomy of the Oral Cavity in Forensic Facial Reconstruction

The oral cavity's importance in defining the facial region makes it a primary feature for forensic facial reconstruction (FFR). The aim of this study is to construct a pattern of reference for dimensions and proportions of the lips and establish parameters that may help estimate the vermilion borders' height dimensions and the mouth's width. By means of cone beam computed tomography, divided into two samples: sample 1 (n = 322; 137 male, 185 female) verified the linear distances delimited by anatomical landmarks in soft tissue. The sample 2 (n = 108; 40 male, 68 female), verified the proportions among the height of the vermilion borders, width of the mouth, and linear distances between craniometric landmarks in hard tissues, both from a Brazilian database. The measurements were completed using OsiriX, and the results were analyzed by means of descriptive statistics at a level of significance of 5%. The height of the vermilion borders corresponded to approximately 26% of the width of the mouth. The width of the mouth increased over the course of time in men and remained stable in women. In men, a mean intercanine distance of 75% of the total mouth's width was found; for women, it was 80%. The parameters of the relations between soft and hard tissues in the oral cavity region presented that the distance between landmarks ID-SM (Infradentale-Supramentale) corresponded to 55% of the height of the vermilion borders of the mouth for both sexes, while the distance between landmarks PM-SD (Philtrum medium-Supradentale) corresponded to 85% in men and 88% in women. Mean values of 97% of the width of the mouth in women and 93% in men were attributed to the distance between the mentonian foramina. It was not possible to estimate the height of the labial vermilion borders by the bone measurements, FIs-Fli (Foramen incisivus superius-inferius) and NS-GN (Nasospinale-Gnathion). Profound knowledge of the anatomy and morphology of the oral cavity may contribute to increasing the precision of FFRs and help with human identification.

Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers

BACKGROUND

Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications.

METHODS

Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers.

RESULTS

The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply.

CONCLUSION

The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations.

CLINCIAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Development and validation of a photographic scale for assessment of lip fullness

BACKGROUND

As lip augmentation becomes more popular, validated measures of lip fullness for quantification of outcomes are needed.

OBJECTIVE

Develop a scale for rating lip fullness and establish its reliability and sensitivity for assessing clinically meaningful differences.

METHODS

The initial Allergan Lip Fullness Scale (iLFS; a four-point photographic scale with verbal descriptions) was validated by eight physicians rating 55 live subjects during two rounds, conducted on one day. In addition, subjects performed self-evaluations. The revised Allergan Lip Fullness Scale (LFS), a five-point scale with a broader range of lip presentations, was validated by 21 clinicians in two online image rating sessions, ≥14 days apart, in which they used the LFS to rate overall, upper, and lower lip fullness of 144 3-dimensional (3D) images. Physician inter- and intra-rater agreement, subject intra-rater agreement (iLFS), and subject-physician agreement (iLFS) were evaluated. Additionally, during online rating session 1, raters ranked 38 pairs of 3D images, taken before and after lip augmentation, as "clinically different" or "not clinically different." The median LFS score difference for clinically different pairs was calculated to determine the clinically meaningful difference.

RESULTS

Clinician inter- and intra-rater agreement for the iLFS and LFS was substantial to almost perfect. Subject self-assessments (iLFS) had substantial intra-rater reliability and a high level of agreement with physician assessments. Median LFS score differences for overall, upper, and lower lip fullness were 1 (mean: 0.63-0.69) for "clinically different" and 0 (mean: 0.28-0.36) for "not clinically different" image pairs; thus, clinical significance of a 1-point difference in LFS score was established.

CONCLUSIONS

The LFS is a reliable instrument for physician classification of lip fullness. A 1-point score difference can detect clinically meaningful differences in lip fullness.

Juvederm ultra for lip enhancement: an open-label, multicenter study

BACKGROUND

Juvéderm Ultra injectable gel (Allergan, Inc, Irvine, California) is approved in the United States to treat moderate to severe wrinkles and folds, such as nasolabial folds. It is also used to enhance the appearance of the lips.

OBJECTIVES

The authors evaluated the safety and effectiveness of Juvéderm Ultra injectable gel for lip enhancement and assessed the utility of 3 new lip-specific effectiveness scales.

METHODS

In this multicenter study, 50 subjects received lip enhancement with Juvéderm Ultra injectable gel. The subjects were observed closely by the treating investigator and results were evaluated by a blinded independent rater and by subject self-assessment for up to 48 weeks to determine the durability of the effects. A validated lip fullness scale (LFS) was used for analysis. Treatment satisfaction was assessed by investigators and subjects using an 11-point scale.

RESULTS

At week 12, 71% of subjects had achieved their goals for lip fullness and had maintained improvement of at least 1 grade on the LFS, which greatly exceeded the a priori criterion of 40% for success. At week 24, improvement in lip fullness was still present for 56% of subjects. Satisfaction and goal achievement exceeded 90% for subjects as well as investigators. Common side effects were predominantly mild or moderate in intensity and resolved within 1 week in the majority of subjects.

CONCLUSIONS

Juvéderm Ultra injectable gel is safe and effective for lip enhancement. Scales for assessing lip fullness provide an objective method to determine the effectiveness of treatment.

Stereophotogrammetric analysis of nasolabial morphology among Asian Malays: influence of age and sex

OBJECTIVE

It is clear that population-specific norms should be used when planning plastic and reconstructive surgery for selected patients. In this study, we aimed to generate nasal and labial reference values by applying a stereophotogrammetric technique. A further aim was to investigate the effect of sexual dimorphism, age-related changes, and the interrelation between nasal and labial morphology.

DESIGN

Cross-sectional study.

SETTING

The data were collected from different locations on the Malaysian peninsula.

PARTICIPANTS

A total of 276 Asian Malays (138 males and 138 females) were included in this study, and a three-dimensional system was used for capturing data. The sample was divided into three age groups: 13 to 14, 15 to 17, and 18 to 36 years.

MAIN OUTCOME MEASURE(S)

Twenty-five dimensions of the nose and lips were measured and analyzed separately in males and females.

RESULTS

Significant differences between males and females were identified in 11 distances, and significant effects of age were found in most of the dimensions (p < .05). Significant correlations between the nasal and labial dimensions were recorded, particularly between lateral lip height and width of the ala insertion. A principal component analysis showed interrelationships between the nasal width distances and upper lip height.

CONCLUSION

This study has provided a new three-dimensional database for nose and lip morphology in Malays and demonstrated patterns of variation that can be used by surgeons to make comparisons within and between different human populations and also to develop treatment plans for their patients.