Facial aesthetics from Cummings

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Here is a comprehensive summary of Aesthetic Facial Analysis from Cummings Otolaryngology Head and Neck Surgery (Chapter 16, Marc S. Zimbler):

Aesthetic Facial Analysis — Cummings Otolaryngology

Key Points

A detailed understanding of aesthetic facial analysis is imperative for any cosmetic or reconstructive surgeon.
Soft tissue and bony anatomic landmarks form the basic language of surgical communication.
Nasal and nasofacial angles are the cornerstone of rhinoplasty analysis and planning.
Aesthetic subunits and relaxed skin tension lines are critical for designing incisions and repairs.

Historical Background

The study of beauty as a formal discipline began with Greek philosophers — to Plato and Aristotle, beauty meant symmetry, harmony, and geometry. The Renaissance expanded this: Leonardo da Vinci formulated ideal facial proportions through anatomical study, dividing the profile into equal thirds (Vitruvian Man). Albrecht Dürer divided the facial profile into four equal parts and noted that the length of the nose equals that of the ear.

In the 20th century, anthropometrist Leslie Farkas challenged classical canons by measuring 200 women (including 50 models), concluding that some canons are artistic idealizations. Current surgical parameters are based predominantly on Powell and Humphreys (1984) — Proportions of the Aesthetic Face.

Anatomic Landmarks

Soft Tissue Reference Points (Box 16.1)

Key points include:

Trichion – hairline midpoint
Glabella – most prominent point of forehead
Nasion – soft tissue depression at the nasal root
Radix – root of the nose (deepest point)
Rhinion – the osseocartilaginous junction (nasal tip)
Subnasale – junction of columella and upper lip
Labrale superius/inferius – vermilion borders
Stomion – midpoint of mouth opening
Menton – lowest point of chin
Cervical point – innermost point between submental area and neck

Skeletal (Cephalometric) Reference Points (Box 16.2)

Sella (S) – midpoint of hypophysial fossa
Nasion (N) – frontonasal junction
ANS/PNS – anterior/posterior nasal spine
Point A (subspinale) – deepest concavity of premaxilla
Pogonion (Pg) – most anterior bony chin point
Gnathion (Gn) – between most anterior and inferior chin points
Menton (Me) – lowest mandibular point
Gonion (Go) – midpoint at mandibular angle

Frankfurt Horizontal Plane

Standard reference for patient positioning in photos and cephalometric X-rays — drawn from the superior external auditory canal to the inferior border of the infraorbital rim, with the patient's gaze parallel to the floor.

Facial Proportions

Facial Width — Rule of Fifths

The face is divided into five equal vertical fifths (Fig. 16.7). The width of one eye = one-fifth of total facial width = intercanthal distance = nasal base width.

Facial Height — Rule of Thirds

Two methods:

Da Vinci method — three equal thirds: trichion → glabella → subnasale → menton
Excluding hairline method — from nasion (not glabella): midface = 43% of facial height; lower face = 57%

Subunit Analysis

The face is divided into aesthetic units, each further subdivided:

Unit	Subunits
Nose	Tip, dorsum, paired sidewalls, paired alar lobules, soft tissue triangles, columella
Lip	Philtrum, paired lateral upper lips, lower lip, chin-lip complex
Eyelids	Upper and lower lids (left and right)
Forehead	Forehead, temporal fossa (bilateral)
Cheeks	Bilateral
Ear	Bilateral

Surgical principle: When >50% of a subunit is deficient, reconstruct the entire subunit (Burget and Menick principle) for optimal aesthetic result.

Relaxed Skin Tension Lines (RSTLs)

Run perpendicular to the underlying muscle fiber direction
Incisions placed within RSTLs heal with minimal scarring
Contrasted with Langer's lines, which are cadaver-derived and less reliable for live tissue

Nasofacial Relationships (Powell & Humphreys)

Nasofrontal Angle

The angle at the nasal root between the forehead and nasal dorsum.

Nasolabial Angle

Angular inclination of the columella meeting the upper lip — formed between a line tangent to labrale superius/subnasale and a line tangent to subnasale/columella tip.

Women: 95–110°
Men: 90–95°

Fig. 16.16 Nasolabial angle. (A) Male, 90–95 degrees. (B) Female, 95–110 degrees.

Nasofacial Angle

The incline of the nasal dorsum relative to the facial plane — angle from a vertical line (glabella–pogonion) intersecting a line from nasion through nasal tip.

Ideal: 36° (range 30–40°)

Fig. 16.17 Nasofacial angle: 30–40 degrees.

Nasomental Angle

Formed by the nasion-to-tip line intersecting with the tip-to-pogonion line.

Range: 120–132°

Nasal Rotation and Projection

Tip rotation occurs along an arc with radius based at the external auditory canal.

Projection methods:

Simons' method: nasal projection ≈ upper lip length (ratio 1:1)
Goode's method: vertical line from nasion to alar groove; ratio of perpendicular (alar groove → tip) to nasal length (nasion → tip) = 0.55–0.60; when achieved, nasofacial angle ≈ 36°
Crumley-Lanser: 3-4-5 triangle — hypotenuse = nasal length, projection = smallest arm

Alar-Columellar Complex

On lateral view:

Alar-to-tip/lobular ratio: optimal at 1:1
Columellar show: 3–5 mm is acceptable

Chin Analysis

The chin is assessed in relation to the nose and lips. Ideal position:

The chin (pogonion) should lie on or slightly posterior to the nasofacial vertical plane
A microgenia (underprojected chin) worsens perceived nasal projection
Chin evaluation is integral to rhinoplasty planning (nose-chin relationship)

Facial Symmetry

True facial symmetry is rare. Midline points (nasion, tip, philtrum, menton) should lie on the midsagittal axis. Subtle asymmetries are noted preoperatively and disclosed to the patient.

Source: Cummings Otolaryngology Head and Neck Surgery, 7th ed. — Chapter 16: Aesthetic Facial Analysis (Marc S. Zimbler), pp. 332–338

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