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Anthropometric nasal analysis of Han Chinese young adults
Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 153e158
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Anthropometric nasal analysis of Han Chinese young adults Ke-zhu Li, Shu Guo*, Qiang Sun, Shi-feng Jin, Xin Zhang, Ming Xiao, Chen-chao Wang, Xu Sun, Meng-zhu Lv Department of Plastic and Reconstructive Surgery, The First Affiliated Hospital of China Medical University, No.115 of Nanjing North Road, Heping District, The City of Shenyang 110001, People’s Republic of China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 October 2012 Accepted 8 April 2013
Background: There are varying degrees of racial differences in the size, shape, proportions of the facial structures. Methods: A total of 900 Han Chinese young adults (501 females and 399 males) were included in the analysis. Measurements taken of the soft tissue of the external nose included 12 items of linear distance and 5 angles. Six proportion indices of the soft tissue of the external nose were determined. Results: In the 12 parameters of linear measurement, females were found to have significantly smaller nasal base width, nasal ala length, nasal ala thickness, columella height, columella width, and nasal tip width in comparison to males (all, P < 0.01). In the five angular measurements, females were found to have a smaller nasal tip angle and nasolabial angle (both, P < 0.05) and a larger nostril tilt angle, nasofrontal angle, and nasal tip angle (all, P < 0.001). Nasal depthenasal width and columella heightenasal depth were both significantly less in males than females (53.25 8.2 vs. 54.56 9.7 and 51.61 11.92 vs. 53.37 12.56, respectively); whereas nasal ala lengthenasal height was significantly less in females than in males (29.41 8.95 vs. 30.9 7.02). Conclusion: Significant differences are present in nasal indices of males and females of Han Chinese ancestry. These data may serve as a reference standard for nasal reconstructive and aesthetic surgery. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Anthropomorphic measurement Nose Rhinometry
1. Introduction The form, size, and ratios of nasal soft tissue play an important role in facial aesthetics, facial plastic surgery, and forensic identification, and the nasal indices and parameters including nasal length, height, ratios and angles also are important parameters in anthropometric facial analysis. For a relatively long period, plastic surgeons have considered the neoclassical aesthetic standard developed during the European Renaissance as a standard of plastic surgery. Recently, many scholars have systematically studied the faces of different ethnic groups using anthropometry and found that there are varying degrees of racial differences in the size, shape, proportions of the facial structures (Choe et al., 2004; Leong and White, 2004; Farkas et al., 2005; Choe et al., 2006; Uzun et al., 2006; Ercan et al., 2007; Farkas et al., 2007; He et al., 2009; Zhuang et al., 2010; Tuncel et al., 2012). For example, there are variations in nasal shape based on race. The Caucasian (leptorrhine) nose has increased tip * Corresponding author. Tel.: þ86 (0) 13897903975; fax: þ86 (0) 24 83282592. E-mail address: [email protected] (S. Guo).
projection and more vertically oriented nostrils when compared with the African (platyrrhine) and the Asian (mesorrhine) has intermediate features, i.e., nostril to infralobule ratios decrease when progressing from leptorrhine to platyrrhine nose (Romo and Abraham, 2003). A recent study has reported that the contemporary ideal female face is shorter than the male face, which is the opposite of the ideals of antiquity (Mommaerts and Moerenhout, 2011). It is therefore very important for plastic surgeons to develop a relative aesthetic standard for individual patients that includes both subjective and objective measures (Chung et al., 2009; Nassif and Lee, 2010; Rohrich and Bolden, 2010; Springer et al., 2008). At present, diagnosis and evaluation of the plastic surgery outcomes are primarily based on qualitative or simple quantitative measurements, and there is a lack of reliable measurement data as a reference for maxillofacial surgery, especially during reconstruction of secondary nasal deformity after cheiloplasty (Wang et al., 2008). To overcome this deficit, authors are developing databases of craniofacial indices and proportions (Moate and Darendeliler, 2002; De Greef et al., 2006; Etöz et al., 2008; Springer et al., 2008). Research has also been performed to
1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.04.005
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develop standardized photogrammetry techniques to represent anthropometric measurements reliably (Han et al., 2010). China is the world’s most populous country, and Han Chinese make up the majority of the population in China. Equally importantly, Han Chinese have a worldwide of distribution. With economic and cultural development in China, the Chinese people are demanding a greater aesthetic standard about their own appearance and they are gradually becoming more accepting towards receiving cosmetic/plastic surgery and those with superior economic conditions prefer to undergo cosmetic/plastic surgery abroad. There are few anthropometric studies in China (Xiong et al., 2006; He et al., 2009), so it has become important to carry out anthropometric research regarding the soft tissue of the external nose for normal population in China. The objective of this study was to measure major nasal external soft tissue parameters in a large Chinese Han population to serve as a reference and standard for nasal reconstruction and aesthetic surgery. 2. Material and methods 2.1. Material All participants were Chinese college students of Han ancestry who studied in the city of Shenyang, China. The inclusion criteria were:
to two decimal points. Gross errors such as outliers were removed using the Pauta criteria. 2.3. Marked points of measurement, measurement items, and proportion indices Based on the marked points of measurement defined by Farkas and Deutsch (1996) for the soft tissue of the head and face, 10 marked points of measurement were selected, five non-paired and five paired (Table 1, Fig. 1A, B). Measurement items of the soft tissue of the external nose included 12 items of linear distance and 5 angles (Table 2, Fig. 1C). There were two pairs of paired items, as described by Farkas and Deutsch (1996). The six proportion indices of the soft tissue of the external nose determined were those as described by Farkas and Deutsch (1996). Nasal index ¼ nasal width 100/nasal height; Nasal depthenasal width index ¼ nasal depth 100/nasal width; nasal bridge index ¼ nasal length 100/ nasal height; nasal ala lengthenasal height index ¼ nasal ala length 100/nasal height; columella widthenasal width index ¼ columella width 100/nasal width; columella heighte nasal depth index ¼ columella height 100/nasal depth. As these measurements have been widely recognized and applied (Farkas and Deutsch, 1996), no reliability and validity assessment was deemed necessary. 2.4. Statistical analysis
1) 2) 3) 4) 5) 6)
parents and grandparents were Han Chinese, no congenital or postnatal craniofacial deformities, no history of surgery or trauma to the maxillofacial region, no nasal infection, rhinitis, or other nasal allergic diseases, no skin disease in nasolabial area, and normal occlusion.
Data were presented as mean with standard deviation, and comparisons were performed with t-tests. Data were analyzed with using SPSS 15.0 statistics software (SPSS Inc, Chicago, IL, US), and a value of P < 0.05 was considered statistically significant. 3. Results
The exclusion criteria were: 1) hypodevelopment or hypergenesis of the middle and lower one-third part of the face, 2) obvious asymmetry (height, length, or width) of the eyes, ears, nose, or lip area, 3) deviation of nasal septum and nasal flaring, 4) absence of enough teeth to caused insufficient height of the lower one-third of the face.
A total of 900 Han Chinese young adults (501 females and 399 males) ranging in age from 17 to 24 years old were included in the analysis. First, we measured 12 linear nasal external soft tissue parameters and 5 nasal angles (Table 3). In the 12 parameters of
Table 1 Marked points of measurement. Point
2.2. Measurement tools and methods Measurement tools used were a 125 mm vernier calliper (accuracy, 0.02 mm), stainless steel scale (accuracy, 0.5 mm), dividers, and spring dividers. For obtaining measurements, the subject was sitting with the head kept horizontal with the Frankfurt plane (FH) parallel to the ground. The subject was instructed to relax their body and look forward naturally with their mouth closed and breathing was steady such that there was no movement of the nasal muscle. A point was marked with eyeliner on the external nose of the subject, with the diameter of the marked point being about 0.5 mm. The linear distance was measured by the direct measurement method (Rudolf Martin). During measurements, the measurement tool just touched but did not compress the soft tissue surface. A picture of the left profile of the subject was taken with a Canon digital camera (focal length, 720 mm; object distance, 160 mm). The angle was measured using Adobe Photoshop CS3 software. Every measurement item was performed by the same measurer who measured each item twice. The lower value was selected from the paired measurements and recorded. For paired items, the value of the left side was used for analysis. After all subjects were measured, the mean value was statistically analyzed
Non-paired Highest point of the columella (c) Nasion point (n)
Nasal tip point (prn)
Subnasal point (sn)
Upper lip point (ls)
Paired Alinasal point (alr, all) Measurement point of the ala thickness (al’r al’l) Outmost point of the curve of nasal ala (acr, acl) The inner canthus points (enr, enl) Midpoint of the columella (sn’r, sn’l)
Description Intersection between the long axis of the columella and the line connecting the anterior points of bilateral nostrils. Intersection of the nasofrontal seam and the midsagittal plane, which can be identified by touching with the finger tip. Most protruded point of the nasal tip when the head Frankfurt plane is parallel to the horizontal plane. Apex of the angle between the inferior margin of the columella and the upper lip skin in the midsagittal plane. Intersection of the midsagittal plane and the boundary line between the mucosa and skin of the upper lip. Outmost point of the nasal ala. Midpoint of a line from the nasal tip point to the alinasal point. Outmost point of the basal curve of the nasal ala. Intersection of the inner ends of the upper and lower eyelids with the eyes normally open. Midpoint of the lateral margin of both sides of the columella.
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Fig. 1. Landmarks and measurement of nasal external soft tissue. A) Measurement landmarks in frontal view, B) measurement landmarks viewed from bottom to top, C) measurement of nasal angles in lateral view (1 ¼ nasofrontal angle, 2 ¼ nasal tip angle, 3 ¼ nasal tilt angle, 4 ¼ nasolabial angle). Abbreviations as in Table 1.
linear measurement, females were found to have significantly smaller nasal base width, nasal ala length (prn-acr prn-acl), nasal ala thickness (al’r-al’r, al’l-al’l), columella height (c-sn), columella width (sn’r-sn’l), and nasal tip width in comparison to males (all, P < 0.01). In the five angular measurements, females were found to have a smaller nasal tip angle and nasolabial angle (c-sn-ls) (both, P < 0.05) and a larger nostril tilt angle, nasofrontal angle, and nasal tip angle (all, P < 0.001). There were no significant differences in other parameters between females and males (all, P > 0.05). Results of the determination of nasal proportion indices of Han Chinese young adults are shown in Table 4. Nasal depth-nasal width and columella height-nasal depth were both significantly less in males than females (53.25 8.2 vs. 54.56 9.7 and 51.61 11.92 vs. 53.37 12.56, respectively; whereas nasal ala lengthenasal height was significantly less in females than in males (29.41 8.95 vs. 30.9 7.02). There were no differences in the other indices between males and females. The distribution of nasal shape in female and male adult Han Chinese based on nasal index is shown in Fig. 2. About 60% of Chinese adult males or females have a narrow nose (nasal index: 55.0e70.0) and 30% have moderate nose (nasal index: 70.0e85.0). The mean nasal index in both males and females was 67. 4. Discussion Numerous anthropometric studies have shown that there are significant racial and ethnic differences in the size, shape, and
proportions of the head and face and the external nose, which requires plastic surgeons to consider racial and ethnic specificities when developing a treatment plan (Le et al., 2002; Porter and Olson, 2003; Choe et al., 2004; Leong and White, 2004; Farkas et al., 2005; Mori et al., 2005; Choe et al., 2006; Uzun et al., 2006; Ercan et al., 2007; Tan et al., 2007; Malkoç et al., 2008; Milosevics et al., 2008; He et al., 2009; Li et al., 2009; Mizumoto et al., 2009; Wang et al., 2009). As with other parts of the body, the external nose and the head and face have a rapid development period during adolescence. It is very important to know the pattern of development and timing of maturity to determining the best time for the reconstruction nasal deformities. Farkas et al. (1992) reported that the width and height of the nose essentially stop growing at the age of 12 in women and 14 or 15 in men, and the size and shape of the external nose is less likely change after maturity. We selected normal young Han Chinese aged between 17 and 24 years old and performed an anthropometric study for providing reliable reference data during reconstruction of secondary nasal deformity after cheiloplasty, nasal reconstruction and repair of nasal defects and rhinoplasty in adults for Chinese population. Compared to previous studies (Xiong et al., 2006; Chung et al., 2009; He et al., 2009; Li et al., 2009), we added two linear measurement items (the width of nasal root and the width of nasal tip), and two angular measurement items (the nasal tilt angle and the nostril tilt proportion) in order to reflect the three-dimensional morphology of the soft tissue of nose more accurately which we
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Table 2 Measurement items. Item Linear distance Nasal height (n-sn) Nasal length (n-prn) Nasal depth (sn-prn) Nasal width (alr-all) Innercanthal distance (enr-enl) Nasal ala length (prn-acr prn-acl) Nasal ala thickness (al’r-al’r, al’l-al’l) Columella height (c-sn) Columella width (sn’r-sn0 l) Nasion width
Nasal tip with
Angles Nasofrontal angle Nasal tip angle Nasal tilt angle
Nasolabial angle (c-sn-ls) Nostril tilt
Description Distance between the nasion point and the subnasal point. Distance between the nasion point and the nasal tip point. Distance between the subnasal point and the nasal tip point. Distance between bilateral inner canthi. Distance between the bilateral outmost points of the nasal ala. Distance between the nasal tip point and the outmost point of the nasal ala curve. Distance between the ipsilateral measurement points of the ala thickness. Distance between the highest point of the columella and the subnasal point. Distance between bilateral midpoints of the columella. Horizontal distance between left and right sides of the nose and the turning point of skin in the nasal base at the inner canthus plane. Horizontal distance between the inferior margin of the nasal base and the anterior intersection of bilateral alar sulci. Angle between the nasal dorsum line and the oblique plane from the forehead to the nasal root. Angle between the nasal dorsum line and the columella line. Angle between the horizontal plane and the line connecting the nasal tip point and the subnasal point. Angle between the columella line and the line connecting the subnasal point and the upper lip point. Angle between the line connecting the subnasal point and the outmost point of the nasal ala curve and the line connecting the outmost point of the nasal ala curve and the highest point of the nostril.
believe is important for nasal reconstructive and aesthetic surgeries. We believe it is important for nasal plastic surgery, and especially for rhinoplasty. Chen et al. (2011) studied craniofacial soft tissue thickness (CFSTT) and nasal profile in Chinese people of
Han population and found significant differences between males and females with the mean values of nasal length, nasal height, nasal depth and nasal breadth in males were all greater than those in females. Furthermore, both CFSTT and nasal profile showed good correlation with age. Interestingly, the thickest CFSTT of males was found at 45e59 years of age, whereas in females it was found at 35e44 years of age. Gu et al. (2011) compared the craniofacial characteristics of typical Chinese and Caucasian young adults and found that there were significant differences in hard and soft tissue characteristics. In general, surgeons decide the surgical method of external nose reconstruction based on their clinical practice experience, which combines subjective and objective factors (Leong and Eccles, 2010). The subjective factor of the nasal aesthetics varies with ethnic background and geographical and cultural differences. Springer et al. (2009) reported that there were genderrelated effects with respect to the assessment of nasal shape with women, as compared to men, more critical in assessing the appearance of their own nose as opposed to the noses of other people. Farkas et al. (2005) pointed out that the neoclassical aesthetic standard developed during the European Renaissance is not completely suitable for Asian and African ethnic groups. Similarly, although the aesthetics of the people in various regions of China are influenced by the traditional Han culture, there are still some differences between them. To consider objective factors in external nose reconstruction, systematic anthropometric methods are commonly used for measuring the soft tissue of the external nose before surgery. Preoperative evaluation and surgical planning should be carried out according to the shapes of face, mouth, eyes and body, while also referring to the measurement values of the normal population in the same gender and ethnic to decide the degree of reconstruction and the morphology of implant and objectively guide the actual surgery (Rohrich and Bolden, 2010; Raschke et al., 2012). Although the subjects included in this study were all Han Chinese, they all came from northern China. The data in this study might not represent whole Chinese population, especially those adult Han Chinese who live in southern China such as those in Guangdong and Guangxi provinces.
Table 3 Nasal external soft tissue measurement of Han Chinese young adults. Females (n ¼ 501) Age, y Height, cm Weight, kg Linear measurement, mm Nasal height (n-sn) Nasal length (n-prn) Nasal depth (sn-prn) Nasal width (alr-all) Innercanthal distance (enr-enl) Nasal base width Nasal ala length (prn-acr prn-acl) Nasal ala thickness (al’r-al’r, al’l-al’l) Columella height (c-sn) Columella width (sn’r-sn’l) Nasion width Nasal tip width Angles, Nasal tip angle Nasofrontal angle Nasal tip angle Nasolabial angle (c-sn-ls) Nostril tilt angle Data presented as mean standard deviation (range). *Indicates statistical significance, P < 0.05.
19.99 1.05 (17e23) 161.85 3.23 (150e170) 54.92 5.43 (39e78) 53.87 48.34 19.26 35.8 3.55 24.93 15.72 4.44 10.13 6.11 17.33 21.29
4.43 4.71 2.31 4.13 0.35 3.35 4.41 0.63 1.98 0.91 2.38 2.72
32.39 4.51 138.7 7.51 90.85 8.47 98.97 9.74 39.76 12
(22.85e67.12) (31.29e62.18) (12.43e28.8) (15.5e55.4) (2.33e5.52) (14.22e37.42) (3.02e30.94) (2.43e6.21) (3.11e18.04) (3.54e8.82) (9.14e24.83) (13e29.41) (17.97e45.82) (114.6e163.88) (25.4e114.2) (46.3e133) (3.89e93.7)
Males (n ¼ 399) 20.08 1.14 (17e24) 176.03 3.06 (166e184) 66.14 5.03 (50e82)
P 0.2501 <0.0001* <0.0001*
54.19 4.02 48.43 4.43 19.09 2.45 36.12 3.29 3.56 0.35 25.67 2.79 16.68 3.71 4.7 0.74 9.71 1.9 6.1 0.94 17.3 2.2 20.77 3.03
(41.39e63.9) (34.59e60.78) (11.16e25.77) (21.99e48) (2.14e4.5) (16.54e34.42) (6.68e28.13) (2.55e6.8) (4.98e15.7) (3.24e9.2) (9.63e23.45) (12.77e28.4)
0.2674 0.7569 0.2781 0.2141 0.7686 0.0003* 0.0004* <0.0001* 0.0011* 0.8784 0.8307 0.0061*
34.78 5.63 132.6 9.06 87.94 8.69 100.99 15.33 34.74 8.49
(21.1e53.9) (93.2e154.61) (59.88e113.2) (25.9e143.26) (10.89e59.2)
<0.0001* <0.0001* <0.0001* 0.0165* <0.0001*
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Table 4 Nasal proportion indices of Han Chinese young adults. Index
Females (n ¼ 501)
Males (n ¼ 399)
P
Nasal Nasal depth-nasal width Nasal bridge Nasal ala length-nasal height Columella width-nasal width Columella height-nasal depth
67.04 11.12 54.56 9.7 90.41 12.82 29.41 8.95 17.26 3.15 53.37 12.56
67.02 8 53.25 8.2 89.82 10.2 30.9 7.02 17.01 2.98 51.61 11.92
0.9767 0.0283* 0.4376 0.0052* 0.2149 0.0331*
(29.22e182.67) (31.5e128.52) (51.94e222.16) (5.59e85.21) (9.72e38.71) (18.95e111.18)
(40.67e103.4) (29.78e90.63) (62.11e132.66) (13.49e54.75) (8.77e27.01) (23.4e106.63)
Data presented as mean standard deviation (range). *Indicates statistical significance, P < 0.05.
Fig. 2. The distribution of nasal shape in female and male adult Han Chinese based on nasal index: <55.0, over-narrow nose; 55.0e70.0, narrow nose; 70.0e85.0, moderate nose; >85.0, broad nose.
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Anthropometric nasal analysis of Han Chinese young adults Ke-zhu Li, Shu Guo*, Qiang Sun, Shi-feng Jin, Xin Zhang, Ming Xiao, Chen-chao Wang, Xu Sun, Meng-zhu Lv Department of Plastic and Reconstructive Surgery, The First Affiliated Hospital of China Medical University, No.115 of Nanjing North Road, Heping District, The City of Shenyang 110001, People’s Republic of China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 October 2012 Accepted 8 April 2013
Background: There are varying degrees of racial differences in the size, shape, proportions of the facial structures. Methods: A total of 900 Han Chinese young adults (501 females and 399 males) were included in the analysis. Measurements taken of the soft tissue of the external nose included 12 items of linear distance and 5 angles. Six proportion indices of the soft tissue of the external nose were determined. Results: In the 12 parameters of linear measurement, females were found to have significantly smaller nasal base width, nasal ala length, nasal ala thickness, columella height, columella width, and nasal tip width in comparison to males (all, P < 0.01). In the five angular measurements, females were found to have a smaller nasal tip angle and nasolabial angle (both, P < 0.05) and a larger nostril tilt angle, nasofrontal angle, and nasal tip angle (all, P < 0.001). Nasal depthenasal width and columella heightenasal depth were both significantly less in males than females (53.25 8.2 vs. 54.56 9.7 and 51.61 11.92 vs. 53.37 12.56, respectively); whereas nasal ala lengthenasal height was significantly less in females than in males (29.41 8.95 vs. 30.9 7.02). Conclusion: Significant differences are present in nasal indices of males and females of Han Chinese ancestry. These data may serve as a reference standard for nasal reconstructive and aesthetic surgery. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Anthropomorphic measurement Nose Rhinometry
1. Introduction The form, size, and ratios of nasal soft tissue play an important role in facial aesthetics, facial plastic surgery, and forensic identification, and the nasal indices and parameters including nasal length, height, ratios and angles also are important parameters in anthropometric facial analysis. For a relatively long period, plastic surgeons have considered the neoclassical aesthetic standard developed during the European Renaissance as a standard of plastic surgery. Recently, many scholars have systematically studied the faces of different ethnic groups using anthropometry and found that there are varying degrees of racial differences in the size, shape, proportions of the facial structures (Choe et al., 2004; Leong and White, 2004; Farkas et al., 2005; Choe et al., 2006; Uzun et al., 2006; Ercan et al., 2007; Farkas et al., 2007; He et al., 2009; Zhuang et al., 2010; Tuncel et al., 2012). For example, there are variations in nasal shape based on race. The Caucasian (leptorrhine) nose has increased tip * Corresponding author. Tel.: þ86 (0) 13897903975; fax: þ86 (0) 24 83282592. E-mail address: [email protected] (S. Guo).
projection and more vertically oriented nostrils when compared with the African (platyrrhine) and the Asian (mesorrhine) has intermediate features, i.e., nostril to infralobule ratios decrease when progressing from leptorrhine to platyrrhine nose (Romo and Abraham, 2003). A recent study has reported that the contemporary ideal female face is shorter than the male face, which is the opposite of the ideals of antiquity (Mommaerts and Moerenhout, 2011). It is therefore very important for plastic surgeons to develop a relative aesthetic standard for individual patients that includes both subjective and objective measures (Chung et al., 2009; Nassif and Lee, 2010; Rohrich and Bolden, 2010; Springer et al., 2008). At present, diagnosis and evaluation of the plastic surgery outcomes are primarily based on qualitative or simple quantitative measurements, and there is a lack of reliable measurement data as a reference for maxillofacial surgery, especially during reconstruction of secondary nasal deformity after cheiloplasty (Wang et al., 2008). To overcome this deficit, authors are developing databases of craniofacial indices and proportions (Moate and Darendeliler, 2002; De Greef et al., 2006; Etöz et al., 2008; Springer et al., 2008). Research has also been performed to
1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.04.005
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develop standardized photogrammetry techniques to represent anthropometric measurements reliably (Han et al., 2010). China is the world’s most populous country, and Han Chinese make up the majority of the population in China. Equally importantly, Han Chinese have a worldwide of distribution. With economic and cultural development in China, the Chinese people are demanding a greater aesthetic standard about their own appearance and they are gradually becoming more accepting towards receiving cosmetic/plastic surgery and those with superior economic conditions prefer to undergo cosmetic/plastic surgery abroad. There are few anthropometric studies in China (Xiong et al., 2006; He et al., 2009), so it has become important to carry out anthropometric research regarding the soft tissue of the external nose for normal population in China. The objective of this study was to measure major nasal external soft tissue parameters in a large Chinese Han population to serve as a reference and standard for nasal reconstruction and aesthetic surgery. 2. Material and methods 2.1. Material All participants were Chinese college students of Han ancestry who studied in the city of Shenyang, China. The inclusion criteria were:
to two decimal points. Gross errors such as outliers were removed using the Pauta criteria. 2.3. Marked points of measurement, measurement items, and proportion indices Based on the marked points of measurement defined by Farkas and Deutsch (1996) for the soft tissue of the head and face, 10 marked points of measurement were selected, five non-paired and five paired (Table 1, Fig. 1A, B). Measurement items of the soft tissue of the external nose included 12 items of linear distance and 5 angles (Table 2, Fig. 1C). There were two pairs of paired items, as described by Farkas and Deutsch (1996). The six proportion indices of the soft tissue of the external nose determined were those as described by Farkas and Deutsch (1996). Nasal index ¼ nasal width 100/nasal height; Nasal depthenasal width index ¼ nasal depth 100/nasal width; nasal bridge index ¼ nasal length 100/ nasal height; nasal ala lengthenasal height index ¼ nasal ala length 100/nasal height; columella widthenasal width index ¼ columella width 100/nasal width; columella heighte nasal depth index ¼ columella height 100/nasal depth. As these measurements have been widely recognized and applied (Farkas and Deutsch, 1996), no reliability and validity assessment was deemed necessary. 2.4. Statistical analysis
1) 2) 3) 4) 5) 6)
parents and grandparents were Han Chinese, no congenital or postnatal craniofacial deformities, no history of surgery or trauma to the maxillofacial region, no nasal infection, rhinitis, or other nasal allergic diseases, no skin disease in nasolabial area, and normal occlusion.
Data were presented as mean with standard deviation, and comparisons were performed with t-tests. Data were analyzed with using SPSS 15.0 statistics software (SPSS Inc, Chicago, IL, US), and a value of P < 0.05 was considered statistically significant. 3. Results
The exclusion criteria were: 1) hypodevelopment or hypergenesis of the middle and lower one-third part of the face, 2) obvious asymmetry (height, length, or width) of the eyes, ears, nose, or lip area, 3) deviation of nasal septum and nasal flaring, 4) absence of enough teeth to caused insufficient height of the lower one-third of the face.
A total of 900 Han Chinese young adults (501 females and 399 males) ranging in age from 17 to 24 years old were included in the analysis. First, we measured 12 linear nasal external soft tissue parameters and 5 nasal angles (Table 3). In the 12 parameters of
Table 1 Marked points of measurement. Point
2.2. Measurement tools and methods Measurement tools used were a 125 mm vernier calliper (accuracy, 0.02 mm), stainless steel scale (accuracy, 0.5 mm), dividers, and spring dividers. For obtaining measurements, the subject was sitting with the head kept horizontal with the Frankfurt plane (FH) parallel to the ground. The subject was instructed to relax their body and look forward naturally with their mouth closed and breathing was steady such that there was no movement of the nasal muscle. A point was marked with eyeliner on the external nose of the subject, with the diameter of the marked point being about 0.5 mm. The linear distance was measured by the direct measurement method (Rudolf Martin). During measurements, the measurement tool just touched but did not compress the soft tissue surface. A picture of the left profile of the subject was taken with a Canon digital camera (focal length, 720 mm; object distance, 160 mm). The angle was measured using Adobe Photoshop CS3 software. Every measurement item was performed by the same measurer who measured each item twice. The lower value was selected from the paired measurements and recorded. For paired items, the value of the left side was used for analysis. After all subjects were measured, the mean value was statistically analyzed
Non-paired Highest point of the columella (c) Nasion point (n)
Nasal tip point (prn)
Subnasal point (sn)
Upper lip point (ls)
Paired Alinasal point (alr, all) Measurement point of the ala thickness (al’r al’l) Outmost point of the curve of nasal ala (acr, acl) The inner canthus points (enr, enl) Midpoint of the columella (sn’r, sn’l)
Description Intersection between the long axis of the columella and the line connecting the anterior points of bilateral nostrils. Intersection of the nasofrontal seam and the midsagittal plane, which can be identified by touching with the finger tip. Most protruded point of the nasal tip when the head Frankfurt plane is parallel to the horizontal plane. Apex of the angle between the inferior margin of the columella and the upper lip skin in the midsagittal plane. Intersection of the midsagittal plane and the boundary line between the mucosa and skin of the upper lip. Outmost point of the nasal ala. Midpoint of a line from the nasal tip point to the alinasal point. Outmost point of the basal curve of the nasal ala. Intersection of the inner ends of the upper and lower eyelids with the eyes normally open. Midpoint of the lateral margin of both sides of the columella.
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Fig. 1. Landmarks and measurement of nasal external soft tissue. A) Measurement landmarks in frontal view, B) measurement landmarks viewed from bottom to top, C) measurement of nasal angles in lateral view (1 ¼ nasofrontal angle, 2 ¼ nasal tip angle, 3 ¼ nasal tilt angle, 4 ¼ nasolabial angle). Abbreviations as in Table 1.
linear measurement, females were found to have significantly smaller nasal base width, nasal ala length (prn-acr prn-acl), nasal ala thickness (al’r-al’r, al’l-al’l), columella height (c-sn), columella width (sn’r-sn’l), and nasal tip width in comparison to males (all, P < 0.01). In the five angular measurements, females were found to have a smaller nasal tip angle and nasolabial angle (c-sn-ls) (both, P < 0.05) and a larger nostril tilt angle, nasofrontal angle, and nasal tip angle (all, P < 0.001). There were no significant differences in other parameters between females and males (all, P > 0.05). Results of the determination of nasal proportion indices of Han Chinese young adults are shown in Table 4. Nasal depth-nasal width and columella height-nasal depth were both significantly less in males than females (53.25 8.2 vs. 54.56 9.7 and 51.61 11.92 vs. 53.37 12.56, respectively; whereas nasal ala lengthenasal height was significantly less in females than in males (29.41 8.95 vs. 30.9 7.02). There were no differences in the other indices between males and females. The distribution of nasal shape in female and male adult Han Chinese based on nasal index is shown in Fig. 2. About 60% of Chinese adult males or females have a narrow nose (nasal index: 55.0e70.0) and 30% have moderate nose (nasal index: 70.0e85.0). The mean nasal index in both males and females was 67. 4. Discussion Numerous anthropometric studies have shown that there are significant racial and ethnic differences in the size, shape, and
proportions of the head and face and the external nose, which requires plastic surgeons to consider racial and ethnic specificities when developing a treatment plan (Le et al., 2002; Porter and Olson, 2003; Choe et al., 2004; Leong and White, 2004; Farkas et al., 2005; Mori et al., 2005; Choe et al., 2006; Uzun et al., 2006; Ercan et al., 2007; Tan et al., 2007; Malkoç et al., 2008; Milosevics et al., 2008; He et al., 2009; Li et al., 2009; Mizumoto et al., 2009; Wang et al., 2009). As with other parts of the body, the external nose and the head and face have a rapid development period during adolescence. It is very important to know the pattern of development and timing of maturity to determining the best time for the reconstruction nasal deformities. Farkas et al. (1992) reported that the width and height of the nose essentially stop growing at the age of 12 in women and 14 or 15 in men, and the size and shape of the external nose is less likely change after maturity. We selected normal young Han Chinese aged between 17 and 24 years old and performed an anthropometric study for providing reliable reference data during reconstruction of secondary nasal deformity after cheiloplasty, nasal reconstruction and repair of nasal defects and rhinoplasty in adults for Chinese population. Compared to previous studies (Xiong et al., 2006; Chung et al., 2009; He et al., 2009; Li et al., 2009), we added two linear measurement items (the width of nasal root and the width of nasal tip), and two angular measurement items (the nasal tilt angle and the nostril tilt proportion) in order to reflect the three-dimensional morphology of the soft tissue of nose more accurately which we
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Table 2 Measurement items. Item Linear distance Nasal height (n-sn) Nasal length (n-prn) Nasal depth (sn-prn) Nasal width (alr-all) Innercanthal distance (enr-enl) Nasal ala length (prn-acr prn-acl) Nasal ala thickness (al’r-al’r, al’l-al’l) Columella height (c-sn) Columella width (sn’r-sn0 l) Nasion width
Nasal tip with
Angles Nasofrontal angle Nasal tip angle Nasal tilt angle
Nasolabial angle (c-sn-ls) Nostril tilt
Description Distance between the nasion point and the subnasal point. Distance between the nasion point and the nasal tip point. Distance between the subnasal point and the nasal tip point. Distance between bilateral inner canthi. Distance between the bilateral outmost points of the nasal ala. Distance between the nasal tip point and the outmost point of the nasal ala curve. Distance between the ipsilateral measurement points of the ala thickness. Distance between the highest point of the columella and the subnasal point. Distance between bilateral midpoints of the columella. Horizontal distance between left and right sides of the nose and the turning point of skin in the nasal base at the inner canthus plane. Horizontal distance between the inferior margin of the nasal base and the anterior intersection of bilateral alar sulci. Angle between the nasal dorsum line and the oblique plane from the forehead to the nasal root. Angle between the nasal dorsum line and the columella line. Angle between the horizontal plane and the line connecting the nasal tip point and the subnasal point. Angle between the columella line and the line connecting the subnasal point and the upper lip point. Angle between the line connecting the subnasal point and the outmost point of the nasal ala curve and the line connecting the outmost point of the nasal ala curve and the highest point of the nostril.
believe is important for nasal reconstructive and aesthetic surgeries. We believe it is important for nasal plastic surgery, and especially for rhinoplasty. Chen et al. (2011) studied craniofacial soft tissue thickness (CFSTT) and nasal profile in Chinese people of
Han population and found significant differences between males and females with the mean values of nasal length, nasal height, nasal depth and nasal breadth in males were all greater than those in females. Furthermore, both CFSTT and nasal profile showed good correlation with age. Interestingly, the thickest CFSTT of males was found at 45e59 years of age, whereas in females it was found at 35e44 years of age. Gu et al. (2011) compared the craniofacial characteristics of typical Chinese and Caucasian young adults and found that there were significant differences in hard and soft tissue characteristics. In general, surgeons decide the surgical method of external nose reconstruction based on their clinical practice experience, which combines subjective and objective factors (Leong and Eccles, 2010). The subjective factor of the nasal aesthetics varies with ethnic background and geographical and cultural differences. Springer et al. (2009) reported that there were genderrelated effects with respect to the assessment of nasal shape with women, as compared to men, more critical in assessing the appearance of their own nose as opposed to the noses of other people. Farkas et al. (2005) pointed out that the neoclassical aesthetic standard developed during the European Renaissance is not completely suitable for Asian and African ethnic groups. Similarly, although the aesthetics of the people in various regions of China are influenced by the traditional Han culture, there are still some differences between them. To consider objective factors in external nose reconstruction, systematic anthropometric methods are commonly used for measuring the soft tissue of the external nose before surgery. Preoperative evaluation and surgical planning should be carried out according to the shapes of face, mouth, eyes and body, while also referring to the measurement values of the normal population in the same gender and ethnic to decide the degree of reconstruction and the morphology of implant and objectively guide the actual surgery (Rohrich and Bolden, 2010; Raschke et al., 2012). Although the subjects included in this study were all Han Chinese, they all came from northern China. The data in this study might not represent whole Chinese population, especially those adult Han Chinese who live in southern China such as those in Guangdong and Guangxi provinces.
Table 3 Nasal external soft tissue measurement of Han Chinese young adults. Females (n ¼ 501) Age, y Height, cm Weight, kg Linear measurement, mm Nasal height (n-sn) Nasal length (n-prn) Nasal depth (sn-prn) Nasal width (alr-all) Innercanthal distance (enr-enl) Nasal base width Nasal ala length (prn-acr prn-acl) Nasal ala thickness (al’r-al’r, al’l-al’l) Columella height (c-sn) Columella width (sn’r-sn’l) Nasion width Nasal tip width Angles, Nasal tip angle Nasofrontal angle Nasal tip angle Nasolabial angle (c-sn-ls) Nostril tilt angle Data presented as mean standard deviation (range). *Indicates statistical significance, P < 0.05.
19.99 1.05 (17e23) 161.85 3.23 (150e170) 54.92 5.43 (39e78) 53.87 48.34 19.26 35.8 3.55 24.93 15.72 4.44 10.13 6.11 17.33 21.29
4.43 4.71 2.31 4.13 0.35 3.35 4.41 0.63 1.98 0.91 2.38 2.72
32.39 4.51 138.7 7.51 90.85 8.47 98.97 9.74 39.76 12
(22.85e67.12) (31.29e62.18) (12.43e28.8) (15.5e55.4) (2.33e5.52) (14.22e37.42) (3.02e30.94) (2.43e6.21) (3.11e18.04) (3.54e8.82) (9.14e24.83) (13e29.41) (17.97e45.82) (114.6e163.88) (25.4e114.2) (46.3e133) (3.89e93.7)
Males (n ¼ 399) 20.08 1.14 (17e24) 176.03 3.06 (166e184) 66.14 5.03 (50e82)
P 0.2501 <0.0001* <0.0001*
54.19 4.02 48.43 4.43 19.09 2.45 36.12 3.29 3.56 0.35 25.67 2.79 16.68 3.71 4.7 0.74 9.71 1.9 6.1 0.94 17.3 2.2 20.77 3.03
(41.39e63.9) (34.59e60.78) (11.16e25.77) (21.99e48) (2.14e4.5) (16.54e34.42) (6.68e28.13) (2.55e6.8) (4.98e15.7) (3.24e9.2) (9.63e23.45) (12.77e28.4)
0.2674 0.7569 0.2781 0.2141 0.7686 0.0003* 0.0004* <0.0001* 0.0011* 0.8784 0.8307 0.0061*
34.78 5.63 132.6 9.06 87.94 8.69 100.99 15.33 34.74 8.49
(21.1e53.9) (93.2e154.61) (59.88e113.2) (25.9e143.26) (10.89e59.2)
<0.0001* <0.0001* <0.0001* 0.0165* <0.0001*
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Table 4 Nasal proportion indices of Han Chinese young adults. Index
Females (n ¼ 501)
Males (n ¼ 399)
P
Nasal Nasal depth-nasal width Nasal bridge Nasal ala length-nasal height Columella width-nasal width Columella height-nasal depth
67.04 11.12 54.56 9.7 90.41 12.82 29.41 8.95 17.26 3.15 53.37 12.56
67.02 8 53.25 8.2 89.82 10.2 30.9 7.02 17.01 2.98 51.61 11.92
0.9767 0.0283* 0.4376 0.0052* 0.2149 0.0331*
(29.22e182.67) (31.5e128.52) (51.94e222.16) (5.59e85.21) (9.72e38.71) (18.95e111.18)
(40.67e103.4) (29.78e90.63) (62.11e132.66) (13.49e54.75) (8.77e27.01) (23.4e106.63)
Data presented as mean standard deviation (range). *Indicates statistical significance, P < 0.05.
Fig. 2. The distribution of nasal shape in female and male adult Han Chinese based on nasal index: <55.0, over-narrow nose; 55.0e70.0, narrow nose; 70.0e85.0, moderate nose; >85.0, broad nose.
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