Art or Science? An Evidence-Based Approach to Human Facial Beauty a Quantitative Analysis Towards an Informed Clinical Aesthetic Practice

Understanding clinical meaningfulness when targeting the depressor anguli oris muscle (DAO) with neuromodulators: a clinical prospective interventional study

BACKGROUND

Neuromodulator injections in the US increased by 24% from 2021 to 2022. This rise is attributed to new products and growing acceptance of minimally invasive aesthetic treatments. Recent studies emphasize the importance of facial anatomy for precision and, consequently, a higher efficacy of neuromodulator treatments. This study aims to evaluate the clinical efficacy of a novel previously proposed injection technique targeting the depressor anguli oris (DAO) muscle to improve oral commissure position. This clinical, prospective study included 34 volunteers from the Shinobu Clinic, São Paulo, Brazil. Patients received 3 units of onabotulinumtoxinA per side, injected mid-distance between the oral commissure and jawline, following the labiomandibular sulcus (LMS). Standardized photographs and assessments using the Oral Commissure Severity Scale (OCSS) and Global Aesthetic Improvement Scale (GAIS) were conducted before and 30 days post-treatment. Statistical analyses included t-tests, Wilcoxon Signed Rank test, and generalized linear models. The average increase in commissural height was 5.22% (p < 0.001). OCSS ratings improved significantly from baseline (clinician: 1.21 to 0.72, p < 0.001; patient: 0.93 to 0.69, p < 0.001). However, GAIS scores indicated no significant change (patient: 0.32, observer: 0.38; p = 0.491). The proposed injection technique improves perioral aesthetics objectively and subjectively. However, the lack of significant change in GAIS scores suggests that perceived improvements may not be clinically meaningful to patients. Future studies should focus on patient-centered evaluation methods to better assess aesthetic outcomes.

What is the Minimal Perceptible Change for the Dimensional Alteration of Facial Structures in the Frontal View?

BACKGROUND

A better understanding of the perceptibility of dimensional changes in facial structures is of interest to all involved in facial esthetics.

PURPOSE

We aimed to determine the minimal perceptible change (MPC) in the dimensional alterations of the facial structures in the frontal view and the influential factors.

STUDY DESIGN, SETTING, SAMPLE

This cross-sectional study was conducted on individuals accompanying the patients at the outpatient department of a tertiary-care hospital and students in art and science. Those with impaired cognition, craniofacial anomalies, history of esthetic facial surgeries and health professionals working on facial esthetics were excluded.

INDEPENDENT VARIABLE

The observers assessed the frontal photographs of 2 models and their modifications. The independent variables were the anatomic structure modified (mouth, nose, ears, eyes), the percentage change (5, 10, 15%), and the type of modification (magnification or reduction).

MAIN OUTCOME VARIABLES

The outcome variables were the MPC (perceived by at least 50% of the observers) and the perceptibility of changes (Yes/No) COVARIATES: The age of the observer, the sex of the observer and the model were the covariates.

ANALYSES

The intergroup differences in perceptibility of changes and the influence of independent variables and covariates were analyzed with χ2/Cochran's Q test and generalized estimating equations, respectively, with statistical significance set at P < .05.

RESULTS

The sample comprised 110 males and 110 females, aged 23.9 ± 5.8 years. The MPC was 5% for the mouth, nose, and eyes and 15% for the ears. The changes in the nose [OR = 0.68 (0.56 to 0.83), P < .001], ears [OR = 0.29 (0.24 to 0.36), P < .001], and eyes [OR = 0.78 (0.64 to 0.95), P = .015] were less perceptible than the mouth. The perceptibility was higher in female than male observers [OR = 1.37 (1.11 to 1.69), P = .003] and reduction than magnification [OR = 1.11 (1.00 to 1.23) P = .036]. Compared to a 5% change, the perceptibility was higher for 10 and 15% [OR = 2.00 (1.76 to 2.27), 3.33 (2.84 to 3.91), respectively, P < .001].

CONCLUSION AND RELEVANCE

The MPC was 5% for the mouth, nose, and eyes and 15% for the ears. The perceptibility of change was influenced by the structure, the extent and type of modification and the observer's sex. These findings may be of use to all professionals involved in esthetic facial corrections.

There Is no Universal Standard of Beauty

This article discusses the various factors that contribute to facial beauty and the different contexts in which they are significant. The authors examine the roles of the golden ratio, ideal proportions, symmetry, and specific facial features in what constitutes an attractive face. They also investigate the influence of cultural and evolutionary perspectives on facial beauty and the impact of social media on our perception of beauty. The article provides a comprehensive overview of the topic and emphasises the significance of facial beauty and its impact on our lives. The authors acknowledge that the concept of beauty is difficult to define with absolute precision, and that the objective-subjective argument regarding facial beauty remains unsolved. However, they argue that physical attributes undoubtedly influence perceptions of attractiveness, but beauty extends beyond surface-level features. They also suggest that embracing diversity in beauty standards fosters a more inclusive society that celebrates the unique qualities of every person.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 .

Dorsal Preservation versus Component Dorsal Hump Reduction Rhinoplasty: An Assessment of Patient-reported Outcomes

Background

The literature on patient-reported outcomes (PROs) discussing dorsal preservation rhinoplasty (DPR) and component dorsal hump reduction (CDHR) is scarce. This study aims to fill the gap in PROs between these techniques.

Methods

A systematic review was conducted to investigate PROs of DPR and CDHR. A proportion meta-analysis was conducted using Stata statistical software.

Results

A total of 25 studies met our inclusion criteria, pooling 1706 participants, with 13 studies on CDHP and 12 studies on DPR. Overall satisfaction rates were high, varying from 84% to 100% across studies. A subgroup analysis revealed that both techniques exhibited equally high satisfaction with no statistical differences (P = 0.18). A random-effects model revealed that about two of 100 treated patients underwent revisions across our cohort (95% interquartile range: 0-4). Notably, the CDHR technique was associated with a significant 53.7-point reduction in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS)-cosmetic domain [95% confidence interval (CI): -62.7 to -44.8, P < 0.001], along with a meaningful improvement in SCHNOS-obstructive scores by -27.3 points (95% CI: -50.5 to -4.04, P = 0.02). Conversely, the DPR was linked to a 55.3-point reduction in the SCHNOS-cosmetic domain (95% CI: -60.7 to -49.9, P < 0.001), and a -19.5 point change in the SCHNOS-obstructive domain (95% CI: -27.9 to -11.1, P < 0.001).

Conclusion

Although PROs are comparable, the literature suggests that CDHR outcomes may be better than DPR in alleviating obstructive symptoms, potentially offering an evidence-based choice for addressing functional concerns in rhinoplasty.

Can the Upper Vermilion and the Nasolabial Fold Be Changed With Orthognathic Surgery?

BACKGROUND

Retrusive profiles show an appearance of aging with an under-projected vermilion and pronounced nasolabial folds due to deficient bone support.

PURPOSE

A study was made of the association between orthognathic surgery and changes in the nasolabial and vermilion areas in patients with retrusive profiles.

STUDY DESIGN, SETTING, SAMPLE

A retrospective cohort study evaluated patients subjected to bimaxillary surgery according to the Barcelona Line (BL) protocol during 2021 at Teknon Medical Center (Barcelona, Spain). Subjects with craniofacial syndromes, facial esthetic procedures, and dental rehabilitations involving lip changes, were excluded.

PREDICTOR VARIABLE

The predictor variable was the timing of cephalometric measures, reported as T0 (preoperatively), T1 (1 month after surgery), and T2 (after 1 year of follow-up).

MAIN OUTCOME VARIABLE

The outcome variable corresponded to the soft tissue changes of the nasolabial and vermilion area, reported as the nasolabial fold length and angle, nasolabial angle, upper lip concavity, vermilion length, and upper lip sagittal distance from BL.

COVARIATES

The covariates comprised patient demographic data, the surgical-orthodontic protocol, and the magnitude and direction of the skeletal movements.

ANALYSES

Descriptive and inferential analyses were performed based on analysis of variance, the Bonferroni test, Pearson's linear coefficient, the nonparametric Mann-Whitney U-test, Kruskal-Wallis test, and multiple linear regression models. Statistical significance was considered for P < .05.

RESULTS

The sample comprised 27 subjects with a mean age of 32.5 ± 11.2 years. A mean decrease in nasolabial angle of 5.5 ± 6° was recorded (P < .001), with a shortening of the nasolabial fold length of 4.4 ± 7.6 mm (P = .019). An increase in upper lip concavity angle of 14.4 ± 12° was recorded (P < .001), along with a vermilion lengthening of 1.6 ± 1.3 mm (P < .001) and an increase in upper lip sagittal distance to BL of 5.7 ± 7.3 mm (P = .001), indicating a more projected and everted upper vermilion.

CONCLUSIONS AND RELEVANCE

When adequate dentoskeletal support is provided by specific positional changes of the jaws planned through orthognathic surgery, the length of the nasolabial fold decreases, and the upper vermilion lengthens and becomes slightly everted.

Orthognathic Surgery Trending: Retrospective Ten Years Cases Analysis in Nineveh Province, Iraq

AIMS

The study aimed at analyzing patient's case sheets in regard to the incidence of skeletal discrepancy present in cases and its relation with the demographic profile of the sample. All these are chronicled for more than 10 years periods.

METHODOLOGY

This is a retrospective study analysis of the orthognathic case sheets for more than 10 years period. The total numbers of patients are 678. Patient's case sheet was already prepared by the Multi-Disciplinary Team Orthognathic Surgery Clinic in Al-Salam Teaching Hospital, which is the only authorized committee in Nineveh Health Directorate.

RESULTS

The highest age percentage is between (18 and 27 y/76%). Angle class III cases are the uppermost cases (36%) from the total. A significant P value is clear at the level ≤0.05 and ≤0.01 between surgery type and discrepancy in anterior segmental osteotomies (upper and lower) which is performed in bi-maxillary protrusion cases and Angle class II cases (0.01**). Similarly, anterior segmental osteotomies (upper jaw only) which are indicated in both open bite and Angle Class II cases documented as a statistically significant P value (0.02*). The positive correlation is shown in all variables with the disharmony or facial discrepancies. Esthetic and beauty as causes for treatment recorded more than function in relation to time series.

CONCLUSION

This study documents that patients with skeletal class III accounted for the largest percentage (64%) in the study group. A high increase in patients number seeking treatment for their discrepancy is obvious with time from 2009 till 2022.

A Modified Algorithm-Based Levator Aponeurectomy in Mild to Moderate Congenital Blepharoptosis

BACKGROUND

Levator aponeurectomy is a common operation for mild to moderate blepharoptosis. The accuracy of ptosis correction relied on intraoperative judgement when patients were under local anesthesia. For patients who must receive the operation under general anesthesia, it would be an issue to determine how much length of levator aponeurosis to shorten. To solve this issue, we collected data from patients who underwent the operation under local anesthesia and concluded an algorithm.

METHODS

This single-center, prospective bivariate regression study allocated patients of mild to moderate congenital blepharoptosis who received levator aponeurectomy under local anesthesia. Preoperative MRD1 and levator function, intraoperative amount of levator aponeurotic shortening, and postoperative MRD1 were measured. The follow-up period was right after the operation.

RESULTS

Twenty-nine patients were included in this trial. Two subjects exited because of not receiving allocated operation and data of the other 27 subjects (including 34 eyelids) were analyzed. A scatter diagram was drawn where x axis referred to levator function and y axis referred to the ratio of the amount of shortening of levator aponeurosis over the height of MRD1 correction. Linear regression showed y = - 0.2717*x + 5.026, R2 = 0.8553.

CONCLUSION

A modified algorithm to predict the amount of shortening of levator aponeurosis based on levator function and height of ptosis correction was concluded with better accuracy and clinical feasibility.

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 .

Truth Lies in the Depths: Novel Insights into Facial Aesthetic Measurements from a U.S. Survey Panel

BACKGROUND

Aesthetic facial bone surgery and facial implantology expand the boundaries of conventional facial surgery that focus on facial soft tissue. This study aimed to reveal novel aesthetic facial measurements to provide tailored treatment concepts and advance patient care.

METHODS

A total of n=101 study participants (46 females and 55 males) were presented with 120 patient portraits (frontal images in natural head posture; 60 females and 60 males) and asked to assess the facial attractiveness (scale 0-10; "How attractive do you find the person in the image?") and the model capability score (MCS; scale 0-10; "How likely do you think the person in the image could pursue a modelling career?"). For each frontal photograph, defined facial measurements and ratios were taken to analyse their relationship with the perception of facial attractiveness and MCS.

RESULTS

The overall attractiveness rating was 4.3 ± 1.1, while the mean MCS was 3.4 ± 1.1. In young males, there was a significant correlation between attractiveness and the zygoma-mandible angle (ZMA)2 (r= - 0.553; p= 0.011). In young and middle-aged females, MCS was significantly correlated with facial width (FW)1-FW2 ratio (r= 0.475; p= 0.034). For all male individuals, a ZMA1 value of 171.79 degrees (Y= 0.313; p= 0.024) was the most robust cut-off to determine facial attractiveness. The majority of human evaluators (n=62; 51.7%) considered facial implants a potential treatment to improve the patient's facial attractiveness.

CONCLUSION

This study introduced novel metrics of facial attractiveness, focusing on the facial skeleton. Our findings emphasized the significance of zygomatic measurements and mandibular projections for facial aesthetics, with FI representing a promising surgical approach to optimize facial aesthetics.

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 .

Artificial Intelligence for Rhinoplasty Design in Asian Patients

BACKGROUND

Rhinoplasty is one of the most challenging plastic surgeries because it lacks a uniform standard for preoperative design or implementation. For a long time, rhinoplasties were done without an accurate consensus of aesthetic design between surgeons and patients before surgery and consequently brought unsatisfactory appearance for patients. In recent years, three-dimensional (3D) simulation has been used to visualize the preoperative design of rhinoplasty, and good results have been achieved. However, it still relied on individual aesthetics and experience. The preoperative design remained a huge challenge for inexperienced surgeons and could be time-consuming to perform manually. Therefore, we adopted artificial intelligence (AI) in this work to provide a new idea for automated and efficient preoperative nasal contour design.

METHODS

We collected a dataset of 3D facial images from 209 patients. For each patient, both the original face and the manually designed face using 3D simulation software were included. The 3D images were transformed into point clouds, based on which we used the modified FoldingNet model for deep neural network training (by pytorch 1.12).

RESULTS

The trained AI model gained the ability to perform aesthetic design automatically and achieved similar results to manual design. We analysed the 1027 facial features captured by the AI model and concluded two of its possible cognitive modes. One is to resemble the human aesthetic considerations while the other is to fulfil the given task in a special way of the machine.

CONCLUSION

We presented the first AI model for automated preoperative 3D simulation of rhinoplasty in this study. It provided a new idea for the automated, individual and efficient preoperative design, which was expected to bring a new paradigm for rhinoplasty and even the whole field of plastic surgery.

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 .

Photoanthropometric study: are non-professional photographs suitable for objective and reliable analysis of facial features?

BACKGROUND

The face has been widely investigated using professionally taken frontal and lateral photographs, however, there is a lack of studies of non-professional facial photographs. It is not known if they could be suitable for facial analysis. The analysis of non-professional photographs could allow the performance of cost- effective longitudinal studies.

AIM

To determine if non-professional photographs could be used for a reliable analysis of facial features.

SUBJECTS AND METHODS

The frontal profiles of 18-21-year-olds (35 males, 39 females) were measured by direct anthropometry, in addition, professional photographs were taken and non-professional photographs were obtained. Anthropometric landmarks were superimposed on those photographs. The indices calculated on the basis of the measurements of direct anthropometry and both types of photographs were compared.

RESULTS

The comparison of the measurements of direct anthropometry and professional photographs showed no difference between 14 out of 25 male and 10 out of 25 female facial indices (p > 0.05) after comparing the results of direct anthropometry with those of non-professional photographs, no difference was found in 8 out of 25 male and 7 out of 25 female indices. These indices were mostly composed of vertical parameters and eye measurements.

CONCLUSION

Vertical facial dimensions and eye measurements may not only be used interchangeably for both facial photographs and direct anthropometry, but may also be suitable for objective and reliable facial analyses.

Laypersons' Esthetic Perception of Different Dentogingival Characteristics Based on Smile Dynamics: Cross-Sectional Study

This study aimed to evaluate laypersons' esthetic perception of different dentogingival characteristics based on smile dynamics. Six voluntary models were selected, with only one presenting dentogingival characteristics within esthetic standards: white teeth, good alignment, and adequate gingival contour. Two videos were then produced. One video focused on the mouth, whereas the other focused on the entire face of the model, to ensure that the dynamics of the smile could be evaluated. For the evaluation, 200 laypeople were asked to rank the models from first to sixth place in their order of preference. Laypeople were required to justify their reasons for choosing the first and last places. The obtained data were subjected to descriptive and inferential statistical analyses. The results showed that smile and face dynamics influenced the perception of dentogingival characteristics and facial esthetics. No significant changes were observed. However, a gummy smile accompanied by dental alterations was observed in the video of the mouth and was masked by the facial set exposed in the video of the face. A diastema between the central incisors was decisive for negative evaluation of both the mouth and face. The standard model was rated as the most pleasing. Smiles and facial dynamics influence the perception of dentogingival characteristics. Smile and facial dynamics influence the perception of dentogingival alterations among Brazilian laypeople. Diastema is an alteration that interferes with the isolated evaluation of the lower third of the face and the facial set.

Long-Term Control of Nasal Tip Position: Quantitative Assessment of Caudal Septal Extension Graft

BACKGROUND

Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG.

METHODS

A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length.

RESULTS

Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years).

CONCLUSIONS

Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preoperative Eyelid and Eyebrow Asymmetry: A Potential Pre-Operation Inform Consent Option: A Descriptive Cross-Sectional Study

Background

We aimed to determine the prevalence of pre-existing asymmetry in our patients and investigate the impact of age and sex on upper facial asymmetry.

Methods

We collected images from 155 patients who were undergoing upper eyelid blepharoplasty and MRD1 (marginal reflex distance 1), TPS (tarsal plate show), and BFS (brow fat span) measurements were extracted by ImageJ software. The relationship between asymmetry and age and gender was assessed by comparing the mean differences of these metrics. A generalized linear model (GLM) was used to compare the outcomes of the study. P-value < 0.05 was considered significantly different in all tests.

Results

Pre-operative asymmetry was present in 112 (72%) patients. Among the cases, 61 (39%), 40 (26%), and 24 (15.5%) patients had more than 1mm of asymmetry in BFS, TPS, and MRD1, respectively. Males under 50 years old had the most asymmetry in the preorbital area. Comparing men under 50 years old with the other groups showed that the mean ± SD of absolute differences of TPS was significantly higher in this group (all P< 0.00), but pairwise comparison for MRD1 and BFS indicated no significant correlation between age, gender, and the mean asymmetry of these parameters (overall test P = 0.70 for MDR1 and P = 0.45 for BFS).

Conclusion

Most patients have asymmetry before surgery without being aware of it. Awareness of this asymmetry and the relationship between facial asymmetry and age and gender is essential to prevent dissatisfaction due to the probable post-operative asymmetry and unrealistic expectations.

Focus on evidence-based anatomy in contemporary anatomy education: Arguments in favor of a pragmatic approach

The concept of evidence-based anatomy (EBA) emerged in 2014 and has become a significant element in contemporary anatomy education. The evolving fabric of the medical education curriculum has necessitated critical changes in practice. EBA enables these changes to be incorporated seamlessly and implemented congruently into anatomy education programs. However, in parallel, non-evidence-based (classical) knowledge that has been built up through centuries of anatomical practice continues to be the core element of anatomy education in some countries/regions. Its inherent limitations hinder integration with clinical practice, leading to a rise in misadventures in the clinical setting. This viewpoint commentary highlights the strengths of EBA vis-à-vis the related attributes of classical anatomy. Appropriate arguments show that EBA helps to reduce cognitive load and enables knowledge to be delivered through innovative education tools. EBA also helps to create an inclusive learning environment in a technology-driven era. Moreover, empowered by robust resources, it is driving the pertinent amalgamation of anatomy knowledge with clinical practice. This viewpoint article endorses the adoption of EBA in contemporary anatomy education on the basis of its potential for shaping future anatomical practice.

Does medium matter? Investigating the impact of viewing ideal image or short-form video content on young women's body image, mood, and self-objectification

There is a rising prevalence of short-form videos on social media, particularly since the advent of TikTok. Viewing appearance-ideal images has harmful effects on young women's body image. However, the impacts of viewing appearance-ideal short-form videos on body image are largely unknown. This study investigated the impact of viewing appearance-ideal short-form social media video content on young women's (Mage = 19.19, SD = 1.80) state appearance satisfaction, negative mood, self-objectification, and related constructs, compared to viewing appearance-ideal image content and appearance-neutral content. Young women (N = 211) were shown either: (1) appearance-ideal images, (2) appearance-ideal videos, (3) appearance-neutral images, or (4) appearance-neutral videos. Viewing appearance-ideal content regardless of the medium led to decreased appearance satisfaction, and increased negative mood, and self-objectification, and more state internalisation of appearance ideals compared to viewing appearance-neutral content. Further, if women perceived the appearance-ideal content they viewed to be unedited or unenhanced, they reported less appearance satisfaction after viewing video than image content. Thus, the impact of viewing ideal video and image content taken from social media may have similar effects on young women. However, when ideal content is low in perceived enhancement, viewing videos may be more harmful for appearance satisfaction than viewing images.

A Systematic Review of Randomized Clinical Trials Evaluating the Efficacy of Minimally Invasive Surgery for Soft Tissue Management: Aesthetics, Postoperative Morbidity, and Clinical Results

Background and Objectives: The necessity for less invasive and patient-friendly surgical therapies guided the development of the "minimally invasive surgical technique" (MIST). The aim of this systematic review was to evaluate the efficacy of MIST for soft tissue management considering aesthetic results, postoperative morbidity, and clinical outcomes. Materials and Methods: Several databases were used to conduct a thorough analysis of the scientific evidence. To investigate randomized clinical trials (RCTs), MeSH terms and keywords were provided. Results: Eleven RCTs were chosen. These experiments included 273 patients. The trials that explored MIST for papilla preservation presented greater efficacy in increasing papillary height (p < 0.05). MIST showed stable clinical outcomes for the management of excessive gingival display and with a flapless technique for single implant placement. Considering the treatment of gingival recessions, some RCTs presented greater root coverage with MIST (p < 0.05), while other trials did not show differences between groups. Regarding aesthetic perception, five RCTs indicated high patient satisfaction with MIST (p < 0.05). Similarly, six RCTs reported that patients in the MIST group presented significantly less post-surgical pain and lower wound healing scores (p < 0.01). Conclusions: It was concluded that using MIST resulted in more clinical studies reporting better clinical outcomes. Considering aesthetic appearance, slightly more than half of the clinical trials also showed improved results with MIST. Likewise, regarding postoperative morbidity, 60% of the clinical trials also described better scores with MIST. All of this indicates that MIST is a good alternative for the management of soft tissues.

Rhinofiller: Fat Grafting (Surgical) Versus Hyaluronic Acid (Non-Surgical)

BACKGROUND

The author presented his experience using "fat grafting" (FG) and "hyaluronic acid" (HA) techniques in nasal remodeling.

OBJECTIVES

The paper aimed to evaluate the efficacy and safety of the use of FG and HA in nasal remodeling for aesthetic improvement.

METHODS

A randomized controlled trial was conducted. 15 patients affected by soft defects of the dorsum, low and boxy nasal tip, and hidden columella, were treated with FG (study group-SG), comparing results with the control group (CG) (n = 17) treated with hyaluronic acid (HA). Post-operative follow-up took place at 1, 2, 4, weeks, 3, 6, 12 months, and then annually.

RESULTS

73.7% of SG patients showed excellent cosmetic results after 1 year compared with only 29.7% of CG patients. At one-month, major part of people who underwent the treatments (FG and HA) referred to satisfaction with the resulting volume contours (p = 0.389). 88.3% of CG patients versus 53.8% of SG described the HA and FG injection, respectively, as a very comfortable and non-invasive procedure. As expected, patient satisfaction with the appearance of nasal contouring was higher in the FG group at 1 year.

CONCLUSIONS

FG and HA were safe and effective in this series of cases performed.

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.

Perception of Nasal Aesthetics: Nose or Face?

BACKGROUND

Aesthetic assessment of the nose might not be limited to the nose as an isolated facial unit but might be the result of a broader perception of the whole facial image. The aim of this study was to investigate if the aesthetic evaluation of a nose is made by sole observation of the nose or influenced by the other features of the face.

METHODS

Nose and face photographs of 20 voluntary models were taken from five different angles and merged into a single image of just the noses and whole faces of each model. First the nose and then the face photos were sent to a reviewer group consisting of 100 individuals from different professions to evaluate the nose's beauty on standard questionnaires with a four-week interval to complicate the recall process.

RESULTS

Aesthetic evaluation of the isolated nose (Group 1) and the nose with the whole face (Group 2) were compared through Visual Analog Scale (VAS) scores ranging from 1 to 10 (1: the least, 10: the highest). The mean VAS score of the Whole Face Group (5.26 ± 1.28) was significantly higher than the score of the Isolated Nose Group (4.50 ± 1.32) (p 0.001). There was no significant difference between the scores of reviewers considering their gender, profession, or experience of having an aesthetic operation previously.

CONCLUSION

Current study revealed that in the evaluation of the beauty of the nose, the holistic perception of the face is as important as the perfection of the angles and proportions within the nose itself.

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 .

Aesthetic Science of Rhinoplasty: Three Principles

Aesthetic science is a rapidly growing discipline that involves plastic surgery as much or more than other disciplines of science. Fortunately, how and why the human brain responds to the visual world is better understood now than ever before. Of necessity plastic surgery is a part of that aesthetic science movement because it deals directly with the application of aesthetic principles. Therefore, it behooves the surgeon to be familiar with the principles of aesthetic science so as to both delineate and attain the aesthetic goal at the same time any functional goal is part of the operation. There are three important principles for rhinoplasty: (1) symmetry, (2) continuity and (3) persistence. This study provides examples of how they apply in the preop, intraop and postop phase of performing aesthetic rhinoplasty. A firm understanding of these principles can then guide the surgeon through the difficult maze of decision making, operative planning and surgical execution that arguably makes aesthetic rhinoplasty the most difficult aesthetic operation in plastic surgery. 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 .

The Concept of an Ideal Lips of Caucasian Male: An Anthropometric Analysis of the Lower Third of the Face

BACKGROUND

The lips play a significant role in determining the aesthetic perception of a human face. However, there is little data on the perioral region morphometry of attractive males.

OBJECTIVES

This study investigates the morphology of the lower third of the face, including the lips and jawline, of attractive young Caucasian males.

METHODS

A complex semi-automatic photogrammetric analysis of faces of male photo models (n=300) of the Caucasian race, aged 18-39 years old, was performed. Linear, angular, and surface area parameters were evaluated. In addition, an Average Body Contours (ABC) image was created, providing the graphical summarization of facial size and shapes of all analyzed individuals.

RESULTS

The height of the lower third of the face equaled 0.35 ± 0.03 of the total facial height. The average lip width was 50.98 ± 3.74 mm. The upper vermilion height was found significantly lower than the lower vermilion height (5.9 ± 1.62 vs. 11.15 ± 1.88 mm, p<0.01). The lip obliquity angle was found to be 1.01 o ± 0.73 o. The area surface of the lower lip vermilion was considerably larger than the vermilion of the upper lip (p<0.01).

CONCLUSIONS

The vast amount of morphometric data, including the novel presentation method as an ABC image, on the attractive male's lower third of the face, may provide the surgeons with practical guidelines for lips surgical and nonsurgical rejuvenation procedures. It may also support the perioral region reconstruction and sex reassignment surgery in achieving satisfactory results.

Historical Tools of Anthropometric Facial Assessment: A Systematic Raw Data Analysis on the Applicability of the Neoclassical Canons and Golden Ratio

BACKGROUND

The fundamental tenets of facial aesthetic surgery education have not changed in centuries. Research is beginning to demonstrate that the Neoclassical Canons and the Golden Ratio, Phi, have limited utilization in populations other than those of White European extraction.

OBJECTIVES

The purpose of this study was to analyze comparable raw data in the literature to determine (1) if there is interethnic variability in Neoclassical Canon and Phi measurements, and (2) if the measurements in these representative samples differ from the "ideal."

METHODS

A PubMed/Scopus search was performed. Manuscripts with raw data and individuals aged ≥16 were included. Measurements were extracted and employed to calculate the Neoclassical Canons and Phi. One-way analysis of variance (ANOVA) tests were conducted to compare mean measurements across 6 ethnic groups (P < 0.05).

RESULTS

Twenty-seven articles were included. Every continent was represented except Antarctica and Australia. Men were less commonly studied than women. Participant ages ranged from 16 to 56. Averaged Canons 2, 6-8 measurements had significant interethnic differences in males, whereas Canons 5-8 had significant differences across ethnicities in females. For men, there was significant interethnic variability in measurements of Phi 2, 5, 8, 10, and 17. For women, Phi 1, 2, 5, 8, 10, and 17 varied across ethnicities. No ethnic/gender group showed consistent approximation of the "ideal" for both the Neoclassical Canons and Phi.

CONCLUSIONS

Today, the utility of the Neoclassical Canons and Phi is limited. It is incumbent on our field to systematically study and define the anthropometric measures that define the "ideal."

Validating a Series of Photonumeric Rating Scales for Use in Facial Aesthetics Using Statistical Analysis of Intra- and Inter-rater Reliability

Background

Growing demand for minimally invasive aesthetic procedures to correct age-related facial changes and optimize facial proportions has been met with innovation but has created an unmet need for objective assessment tools to evaluate results empirically.

Objectives

The purpose of this study is to establish the intra- and inter-rater reliability of ordinal, photonumeric, 4-, or 5-point rating scales for clinical use to assess facial aesthetics.

Methods

Board-certified plastic surgeons and dermatologists (3 raters) performed live validation of jawline contour, temple volume, chin retrusion, nasolabial folds, vertical perioral lip lines, midface volume loss, lip fullness, and crow's feet dynamic- and at rest-rating scales over 2 rounds, 2 weeks apart. Subjects selected for live validation represented the range of scores and included 54 to 83 subjects for each scale. Test-retest reliability was quantitated through intra- and inter-rater reliability, determined from the mean weighted kappa and round 2 intraclass correlation coefficients, respectively. The clinical significance of a 1-grade difference was assessed through rater comparison of 31 pairs of side-by-side photographs of subjects with the same grade or a different grade on the developed scales.

Results

The study demonstrated substantial to near-perfect intra- and inter-rater reliability of all scales when utilized by trained raters to assess a diverse group of live subjects. Furthermore, the clinical significance of a 1-point difference on all the developed scales was established.

Conclusions

The high test-retest reliability and intuitive layout of these scales provide an objective approach with standardized ratings for clinical assessment of various facial features.

Forehead Contouring as an Adjunct to Rhinoplasty: Evaluation of the Effect on Facial Appearance, Personal Traits and Patient Satisfaction

BACKGROUND

The nose has a great impact on facial beauty and appearance. Therefore rhinoplasty is one of the most performed procedures worldwide. However, considering the varying degrees of cosmetic operations holistic approach to face is essential to achieve more successful results. In order to this, the forehead is noteworthy with its gender-related features and important relation to the nose. The purpose of this study is to assess the effect of forehead contouring with fat grafting adjunct to rhinoplasty on personal traits, facial appearance and patient satisfaction.

METHODS

A total of 15 patients who underwent rhinoplasty and forehead contouring with fat grafting were enrolled in this retrospective study. Facial appearance and personal traits were evaluated via subject Global Aesthetic Improvement Scale (S-GAIS), and patient satisfaction was assessed with custom design Forehead Rhinoplasty Outcome Evaluation Questionnaire (F/ROE-Q). Forehead inclination was calculated as an objective indicator of fat graft survival and contour improvement. Pre- and postoperative photographs were taken and used for evaluation.

RESULTS

According to the F/ROE-Q score, mean total preoperative score was 9,13 and the mean total postoperative score was 24,86 (p < 0,01). High postoperative satisfaction scores were observed in all patients. Statistically significant improvement was observed in attractiveness, femininity, youthfulness, facial harmony, forehead contour, facial profile view parameters based on S-GAIS assessment. The mean forehead inclination angle was 19,04^o preoperatively and 16,74° postoperatively.

CONCLUSION

With the important benefits such as higher patient satisfaction and improvement on facial appearance and personal traits, forehead contouring with fat grafting was an efficient and applicable procedure adjunct to rhinoplasty.

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 .

Outcome Measurement of Beauty and Attractiveness of Facial Aesthetic Rejuvenation Surgery

ABSTRACT

Aesthetic plastic surgery is a most unusual and unique subspecialty. Unlike other medical and surgical specialties driven primarily by objective medical diagnosis and outcome, aesthetic surgery is patient driven; it represents a special exercise in professional competence by adapting objective medical standards to a mostly subjective field. Given the subjectivity of facial beauty and of the projected aesthetic intervention outcome, in addition to be able to determine beauty of the final result as precisely and objectively as possible, it is also essential to be able to assess patient's satisfaction. However, lack of standardized facial measurements and clear definition of aesthetic outcome and beauty are still major obstacles preventing real change in the consultation dynamics to help better serve patients' expectations. Because of the tremendous increase in demand for all types of facial aesthetic procedures, an objective understanding of aesthetics and beauty is becoming of utmost importance. Recognition of the importance of science and evidence-based medicine is long overdue in our specialty. This study aims at identifying the most recently available evidence-based measures to quantitatively assess beauty and measure outcome of rhytidoplasty that can be useful in everyday aesthetic practice.

Current Trends in Orthognathic Surgery in Poland—A Retrospective Analysis of 124 Cases

The analysis aims at assessing the current trends in orthognathic surgery. The retrospective study covered a group of 124 patients with skeletal malocclusion treated by one team of maxillofacial surgeons at the University Hospital in Zielona Góra, Poland. Various variables were analysed, including demographic characteristics of the group, type of deformity, type of osteotomy used, order in which osteotomy was performed and duration of types of surgery. The mean age of the patients was 28 (ranging from 17 to 48, SD = 7). The group included a slightly bigger number of females (59.7%), with the dominant skeletal Class III (64.5%), and asymmetries were found in 21.8% of cases. Types of osteotomy performed during surgeries were divided as follows: LeFort I, segmental LeFort I, BSSO, BSSO with genioplasty, LeFort I with BSSO, LeFort I with BSSO and genioplasty, segmental LeFort I with BSSO, isolated genioplasty. Bimaxillary surgeries with and without genioplasty constituted the largest group of orthognathic surgeries (49.1%), and a slightly smaller percentage were one jaw surgeries (46.7%). A statistically significant correlation was found between the type of surgery and the skeletal class. In patients with skeletal Class III, bimaxillary surgeries were performed significantly more often than in patients with skeletal Class II (57.5% vs. 20.0%; p = 0.0002). The most common type of osteotomy in all surgeries was bilateral osteotomy of the mandible modo Obwegeser–Epker in combination with Le Fort I maxillary osteotomy (42.7%). The order of osteotomies in bimaxillary surgeries was mandible first in 61.3% of cases. The longest surgery was bimaxillary osteotomy with genioplasty (mean = 265 min), and the shortest surgery was isolated genioplasty (mean = 96 min). The results of the analysis show a significant differentiation between the needs of orthognathic surgery and the types of corrective osteotomy applied to the facial skeleton.

Profiloplasty in One Session Versus Single Treatment Areas

BACKGROUND

Fillers have been widely used to improve facial profile, and a better result is obtained if the entire profile is treated at the same time.

OBJECTIVE

To compare the outcomes of 2 groups of patients: the former undergoing a treatment in a single area to improve the facial profile, and the latter undergoing a total profiloplasty reharmonization in 1 session.

MATERIALS AND METHODS

The outcomes of this study have been evaluated using both the angle of convexity and the Global Aesthetic Improvement Scale method.

RESULTS

This study demonstrates that the approval rating increases by 56.3% for patients, 81.3% for the practitioner, and 76.3% for an independent practitioner when a synchronous treatment is used to improve the facial profile as compared with a single treatment of 1 profile area.

CONCLUSION

The profiloplasty treatment in 1 session allows the achievement of a more harmonic facial profile and increases the patient's approval as compared with treatments of a single facial area.

The Divine Proportion: Origins and Usage in Plastic Surgery

The aim of this study was to summarize the existing literature on the origin of the concept of the divine proportion and its usage in the plastic surgery field.

A Safe and Effective Lip Augmentation Method: The Step-by-Step Φ (Phi) Technique

The shape and fullness of the lips are essential in facial aesthetics. We describe a safe injection technique of hyaluronic acid (HA), based on the well-known golden number Φ (phi), for lip augmentation.

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness

BACKGROUND

Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment.

METHODS

An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness).

RESULTS

In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both].

CONCLUSION

The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions.

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 .

Facial symmetry in subjects with full dental arches

The universal notion of beauty does not exists, however, the facial symmetry contributes to a better aesthetic effect. This harmony is primarily determined by the relationship between parts of the face and dental parameters. Tooth loss leads to a decrease in the height of the bite and consecutive oncoming of the tip of the nose and chin and a violation of the vertical and horizontal relationship between the maxilla and mandible. The aim of the study was to determine the interrelationship of facial parts in subjects with a full dentition. The study included 60 dental students of both sexes in whom the presence of a complete dentition was determined by clinical examination. Facial parameters of the subjects' profiles were measured, as well as the ratio of bipupillary distance and intercommissural distance. The obtained results partially confirmed the theory of matching the heights of the profile thirds and halves of the face. The values of the distance between the two pupils and the lip commissure did not differ statistically significantly. The obtained results could be used in the reconstruction of intermaxillary relationships after the loss of some or all teeth.

The malleability of beauty: perceptual adaptation

Beauty has many facets, and research shows that there are many biologic, psychologic, cultural, and social aspects that influence how beauty and attractiveness are perceived. Beauty preferences are, in part, an effect of a rudimentary cognitive process that appears quite early in life, with humans having a seemingly automatic ability to categorize a person as beautiful or not. This instantaneous capability of human beauty categorization is partially determined by a function of physical features, such as facial averageness, symmetry, and skin homogeneity. For decades, the mass media platform has introduced certain criteria to what establishes beauty, and more recently, social media, instant photo sharing, and editing apps have further influenced how society adapts to beauty principles.

Geometric morphometrics aided by machine learning in craniofacial surgery

Geometric morphometrics aided by machine learning provide detailed and accurate statistical models of facial form. They promise to be extremely effective tools in surgical planning and assessment; however, a clinical tool to use this information is still to be created.

Applying artificial intelligence to assess the impact of orthognathic treatment on facial attractiveness and estimated age

This observational study aimed to use artificial intelligence to describe the impact of orthognathic treatment on facial attractiveness and age appearance. Pre- and post-treatment photographs (n=2164) of 146 consecutive orthognathic patients were collected for this longitudinal retrospective single-centre study. Every image was annotated with patient-related data (age; sex; malocclusion; performed surgery). For every image, facial attractiveness (score: 0-100) and apparent age were established with dedicated convolutional neural networks trained on >0.5million images for age estimation and with >17million ratings for attractiveness. Results for pre- and post-treatment photographs were averaged for every patient separately, and apparent age compared to real age (appearance). Changes in appearance and facial attractiveness were statistically examined. Analyses were performed on the entire sample and subgroups (sex; malocclusion; performed surgery). According to the algorithms, most patients' appearance improved with treatment (66.4%), resulting in younger appearance of nearly 1year [mean change: -0.93years (95% confidence interval (CI): -1.50; -0.36); p=0.002), especially after profile-altering surgery. Orthognathic treatment had similarly a beneficial effect on attractiveness in 74.7% [mean difference: 1.22 (95% CI: 0.81; 1.63); p<0.001], especially after lower jaw surgery. This investigation illustrates that artificial intelligence might be considered to score facial attractiveness and apparent age in orthognathic patients.