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Ideal Soft Tissue Facial Prole in Iranian Males and
Females: Clinical Implications
Amir Ali Ma1, Reza Shahverdiani2, Parviz Ma2*
A BS TR AC T
BAC KGROUN D
Proper pre-operative facial analysis that includes a thorough
evaluation of both the bony and soft tissue anatomy is paramount
to success in performing aesthetic surgery of the face. Ethnic
variations in soft tissue prole add an important variable to pre-
operative facial analysis. The aim of our study was to determine
the role of ethnic variations in soft tissue facial proles through
prole analysis of Iranian male and female patients.
METHODS
Photographs of 100 Iranian males and 100 Iranian females (16
to 40 years old) were carried out. A review committee selected
10 male images and 10 female images, which they believed to be
most ideal. The soft tissue proles were then analyzed. A total of
21 measurements were analyzed and statistically compared with
North American Caucasian males and females.
RESULTS
The upper lip projection and lower lip projection were signicantly
more prominent in Iranian males as compared with North
American Caucasian males. In addition, Iranian males had longer
face as compared with North American Caucasian males along
with a more drooping nasal tip. The frontonasal area is straighter
and the lower face is longer in Iranian females compared with
North American Caucasian in addition to more convex faces
along with a shorter upper face.
CONCLUSION
Signicant differences in ideal soft tissue proles exist between
Iranian and Caucasian males. These differences should be recognized
as they may play an important role in performing facial aesthetic
and reconstructive procedures, particularly rhinoplasty, genioplasty,
midface/facelifts, lip augmentation, and maxillofacial surgery.
KEY WORDS
Soft tissue; Facial prole; Caucasian; Aesthetic surgery
Please cite this paper as:
Ma AA, Shahverdiani R, Ma P. Ideal Soft Tissue Facial Prole in
Iranian Males and Females: Clinical Implications. World J Plast Surg
2018;7(2):17 9 -185.
INTRODUCTION
1. Clinical Research and Development
Center, Shahid Beheshti Universit y of
Medical Sciences, Tehran, Iran
2. Department of Plastic Surgery, Shah id
Beheshti University of Medical Science,
Tehran, Iran
*Corresponding Author:
Parviz Ma, MD, FACS;
Department of Plastic Surgery,
15th Khordad Hospital,
Shahid Beheshti University of Medical
Sciences,
South Aban Ave, Karim Khan Zand
Blvd, Tehran, Iran
Tel: +9 8-21- 889 02155
Fax: +98 -21-88909193
E-mail:
parvizma@yahoo.com
Received: May 11, 2017
Revised: March 20, 2018
Accepted: April 2, 2018
Original Article
Although the underlying skeleton denes the shape and size of
the face, the overlying soft tissue is as important as the skeleton
180 Soft tissue facial prole in Iranians
www.wjps.ir /Vol.7/No.2/May 2018
in facial appearance.1 Ideal facial proles have
been studied in medicine and art by Ricketts.2
Attention has also been given to details about
the morphological and proportional upper,
middle, and lower thirds of the face.3-6 The
frontonasal angle, columellar-lip angle, lip-
chin relationship, nose-chin-lip relationships,6
projection of the chin and maxilla in relation
to the facial plane have all been described as
important parameters when evaluating the face
for cosmetic procedures.3,5,6
In particular, rhinoplasty, genioplasty, and
lip augmentation procedures, require detailed
knowledge of the normative values of the specic
ethnic subgroup that is to be operated on. In
addition, the importance of proper, individual
pre-operative evaluation cannot be over-
emphasized. In order to properly treat congenital
or post-traumatic facial disgurements,
surgeons may benet from access to facial
prole databases for specic ethnic populations,
that are based on accurate anthropometric and
morphologic measurements.2 -19
Previously, a comparison of these databases
with the established norms of North American
Caucasians has offered a suitable way to select
a method for successful treatment.1 The purpose
of this study is to analyze and describe the ideal
aesthetic facial prole in Iranian males and
females. This prole analysis may assist plastic
surgeons who want to perform aesthetic and
reconstructive surgery on Iranian and Middle
Eastern faces and may help decrease the risk of
creating post-operative “racial incongruity”.
MATER IAL AND METHODS
This study was carried out on 200 photographs
of Iranian males (n=100) and females (n=100).
None of the study patients had noticeable facial
disgurements or trauma. The age of the subjects
ranged from 16 to 40 years and no signicant
differences were seen between male or female
age ranges. Each photograph was scanned, the
image was projected onto a computer monitor,
and computerized sketches were obtained based
on the photographs.
An independent review committee was
created that included the following: plastic
surgeon (n=12), sculptors (n=10), hair dressers
(n=12), artists (n=16) and randomly selected
individuals from the general population (n=15).
The review committee was compiled with the
premise that it would include those who are
considered experts on facial beauty, aesthetic
Fig. 1: Soft tissue landmarks on facial prole. Soft
tissue glabella (G’): most prominent or anterior
point in the mid sagittal plane of the forehead.7 Soft
tissue nasion (N’): The most concave point of the
tissue overlying the area of the frontonasal suture.7
Pupil (P): The most anterior point in the midsagittal
plane of the lens of the eye.7 Pronasale (Pn): The most
prominent or anterior point on the midsagittal prole
of the nose.8 Subnasale (SN): A point located at the
junction between the lower border of the nose and
the beginning of the upper lip at the mid sagittal
plane.7 Soft tissue A-Point (A’): The deepest point on
the upper lip determined by a line joining SN with
the upper vermilion border.7 Upper vermilion border
(UV): The point at which the upper lip tissue merges
with ver milion tissue. Upper lip anterior (ULA): The
most anterior point of the upper lip vermilion tissue.9
Lip commissure (LC): The most lateral point in the
tran sverse plane of the l ips.10 Stomion (St): The median
point of the oral embrasure when the lips are closed.9
Lower lip anterior (LLA): The most anterior point
of the lower lip vermilion tissue.9 Lower vermilion
border (LV): The point at which the lower lip tissue
merges with vermilion tissue. Soft tissue B-point
(B’): the point at the deepest concavity between the
lower vermilion border and the soft tissue pogonion.7
Soft tissue pogonion (Pg’): The most prominent or
anterior point of the soft tissue chin in the midsagittal
plane.7 Soft tissue menton (Me’): The most inferior
point on the soft tissue chin.7
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preference, and facial proportions. A selection
of the 20 most ideal computerized sketches (10
males and 10 females) was chosen and then
systematically analyzed using standardized
soft tissue prole measurements. The following
soft tissue landmarks were identiable on the
computerized sketches (Figure 1).
The soft tissue landmarks listed above were
measured with respect to each photographic-
derived sketch. Each prole was modied so that
the distance between the soft tissue nasion and
the subnasale (N’- Sn) was equivalent to 54 mm.
A total of 21 angular and linear measurements
were calculated (Figure 2 and 3). A standard
protractor and millimeter ruler were used for
all measurements. Angular measurements
were made to the nearest 0.5 degree and linear
measurements were taken to the nearest 0.5 mm
and the denitions for angular measurements on
soft tissue prole were as follows (Figure 2).
Frontonasal angle (FNA): Angle formed by
the intersection of lines drawn from soft tissue
glabella to nasion and from nasion tangent with
the superior surface of the nose.7 Nasal tip angle
(NTA): Angle formed by the inter section of a
line passing from nasion tangent to the superior
surface of the nasal tip and a line passing along
the greatest tangent of columella.8 Nasal base
Fig. 2: Angular measurements on soft tissue prole: a- FNA, NTA and NLA; b- ILA and LMA; c- LLP and ULP;
d- NBA; e- TFA. 1. Frontonasal angle (FNA).7 Nasal tip angle (NTA).8 Nasal ba se angle (N BA).8 Nasolabial angle
(NL A).8 Inter labial angle (ILA).6 Labiomental angle (LMA).8 Total facial angle (TFA).9 Upper Lip projection
(U LP).6 Lower lip projection (LLP).6
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angle (NBA): Angle formed by the inter section
of a line passing along the greatest tangent of
columella and a line passing from soft tissue
nasion to soft tissue pogonion.8 Nasolabial angle
(NLA): Angle formed by the intersection of
lines drawn from SN to the greatest tangent of
the columella of the nose and from SN to the
most anterior point on the upper lip.8 Inter labial
angle (ILA): Angle formed by the inter section
of lines drawn from A’ to UVB and from LVB
to the B’ point.6
Labiomental angle (LMA): Angle formed
by the intersection of lines drawn from LVB to
B’ and from B’ to Pg. Total facial angle (TFA):
Angle formed by the intersection of lines drawn
from soft tissue glabella to SN and from SN
to soft tissue pogonion.9 Upper Lip projection
(ULP): Angle formed by the intersection of lines
from Pg’ to nasion and from nasion to ULA.6
Lower lip projection (LLP): Angle formed by the
intersection of lines from nasion to Pg’ and from
nasion to LLA.6
The denitions for linear measurements were
as follows (Figure 3): Upper lip anterior (ULA)
to prole root vertical line (PRV) (pogonion to
glabella);2 Lo w e r l i p ant er i o r ( L LA) to PRV. UL A
to Stei n e r (S) li n e (pogon i o n to colu mella);11 LLA
to S-line; ULA to esthetic (E)-plane (pogonion
to pronasale);12 LLA to E-plane; Upper lip length
(UL): SN to St; Lower lip length (LL): St to B’;
Chin length (C): B’ to Me’; Upper facial height
(UF): P to Sn; Middle facial height (MF): Sn to
St; Lower facial height (LF): St to Me’.
Each angular and linear category was
measured ve times by the investigator, and was
blindly repeated by the co-investigator. All of the
measurements were averaged for a mean of each
category, which was then used as the value for
the study. Statistical analysis was performed on
each variable including the least, greatest, mean,
and standard deviation data-points. Student
unpaired t-test analysis was used to compare
these results from those of comparative studies in
the literature. The level of statistical signicance
was set at p-value equal to 0.05. The results of
our study were compared with the results of the
Farkas
17
and Sutter and Turley
18
study on North
American Caucasian males and females and
unpaired students t-test were used to determine
the differences between all of the groups.
Fig. 3: Linear measurement on soft tissue prole. a- Reference lines for measuring linear measurements: PRV
line, S-line and E-line; b- facial heights according to PRV line. Upper lip anterior (ULA) to prole root vertical
line (PRV) (pogonion to glabella);2 Lower lip anterior (LLA) to PRV. ULA to Steiner (S) line (pogonion to
colu mella);11 LLA to S-line; ULA to esthetic (E)-plane (pogonion to pronasale);12 LLA to E-plane; Upper lip
length (UL): SN to St; Lower lip length (LL): St to B’; Chin length (C): B’ to Me’; Upper facial height (UF): P to
Sn; Middle facial height (MF): Sn to St; Lower facial height (LF): St to Me’.
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RESULTS
The mean, ranges, and standards deviations for
all measurements are reported in Table 1 for
males and Table 2 for females. In Iranian males,
the NLA, ILA, and TFA all measured less than
North American Caucasians (p<0.05). On the
other hand, Iranian males ULP, LLP, ULA-E,
LLA-E, ULA-S, LLA-S, ULA-PRV, and LLA-
PRV all measured greater than North American
Table 1: Results in Iranian males and comparison to Caucasian males.
Variable MIN MAX MEAN SD p value
FNA 114 152 140.8±3.20 10.27 >0.05
NTA 60 94 75.6±3.39 11.52 >0.05
NBA 92 120 106.8±3.05 9.35 >0.05
NLA 80 118 97.7±3.23 10.46 <0.05
ILA 100 136 121.8±3.39 11.53 <0.05
LMA 118 144 132±3.05 9.36 >0.05
TFA 158 172 165±4.42 4.42 <0.05
ULP 511 7.3±1.37 1.88 <0.05
LLP 364.1±0.93 0.87 <0.05
ULA-E 2 7 4.4±1.19 1.42 <0.05
LLA-E 06 2.9±1.36 1.85 <0.05
ULA-S 0 4 1.4±1.12 1.26 <0.05
LLA-S -2 3 0.8±1.32 1.75 <0.05
ULA-PRV 6 11 8.9±1.28 1.66 <0.05
LLA-PRV 296±1.50 2.26 <0.05
UL 19 30 23.1±1.72 2.99 <0.05
LL 14 21 18.3±1.45 2.11 <0.05
C 25 39 32.5±2.10 4.45 <0.05
UF 44 52 46.9±1.50 2.28 <0.05
MF 19 30 23.1±1.41 1.99 <0.05
LF 42 57 50.8±2.21 4.91 <0.05
Table 2: Results in Iranian females and comparison to Caucasian females.
Variable MIN MAX MEAN SD p value
FNA 144 154 149.1±1.92 3.69 <0.05
NTA 62 91 74.1±3.1 10.2 >0.05
NBA 93 124 106.5±3.43 11.6 *
NLA 93 131 110.4±3.53 12.5 >0.05
ILA 98 144 123±3.75 14.1 >0.05
LMA 118 149 133.8±3.02 9.13 >0.05
TFA 151 170 161±2.24 5.03 <0.05
ULP 4 10 6.9±1.42 2.02 >0.05
LLP 0 7 3.8±1.46 2.14 >0.05
ULA-E -8 -1 -4.3±1.58 2.5 >0.05
LLA-E -8 2 -3.35±1.64 2.69 >0.05
ULA-S -5 1 -1.8±1.41 2 >0.05
LLA-S -6 3-1.6±1.56 2.46 >0.05
ULA-PRV 4 13 9.3±1.63 2.67 >0.05
LLA-PRV 0 10 6.05±1.64 2.71 >0.05
UL 19 23 20.9±1.13 1.29 >0.05
LL 12 23 16±1.90 3.62 >0.05
C 23 32 27.5±1.69 2.88 >0.05
UF 36 46 41.1±1.64 2.72 <0.05
MF 19 23 20.9±1.13 1.29 <0.05
LF 39 49 44.1±1.81 3.28 <0.05
*NBA value for Caucasian females was not available
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Caucasians (p<0.05).
Iranian males UL, LL, and C are less and UF,
MF and LF are greater than North American
Caucasians (p<0.05). Other measurements
including FNA, NTA, NBA, and LMA had no
signicant difference from the North American
Caucasians ( p>0.05). Iranian females, FNA,
MF, and LF are greater than North American
Caucasians, while TFA ands UF are less
prominent than North American Caucasians
(p<0.05). Other measurements including NTA,
NLA, ILA, LMA, ULP, LLP, ULA-E, LLA-E,
ULA-S, LLA-S, ULA-PRV, LLA-PRV, UL, LL,
and C had no signicant difference from the
North American Caucasians ( p>0.05).
DISCUSSION
Understanding ethnic variations in facial
skeletal and soft tissue morphology is important
in performing proper pre-operative facial
analysis and in formulating the aesthetic goals in
particular ethnic subgroups. While studies have
been carried out that demonstrate similar cross-
cultural aesthetic preference among various
ethnic groups, recognition of the morphological
differences that exist between various ethnic
groups plays an important role in the aesthetic
evaluation and treatment.11,12
In the current study, the linear and angular
facial measurements between Iranian and North
American Caucasian males and females were
carefully delineated. The upper lip projection
and lower lip projection was signicantly more
prominent in Iranian males as compared with
North American Caucasian males, because ULP,
LLP, LLA-E, ULA-E, ULA-S, LLA-S, ULA-
PRV, and LLA-PRV were greater in Iranian males.
Therefore, Iranian males have lips that are fuller
and more projected as compared with North
American Caucasian males. This may be important
in evaluating soft tissue distribution in the face and
lips, which may dictate the degree to which lip
augmentation or lifting should be carried out.
11,12
UF, MF, LF were greater in Iranian males
than North American Caucasian males, which
indicated that Iranian males have longer face
as compared with North American Caucasian
males, which is important in planning
orthognathic procedures and in balancing the
facial thirds, especially with regard to vertical
maxillary/mandibular osseous advancements
and set-backs.13 -17 NLA was greater in North
American Caucasian males as compared with
Iranian males suggesting that Iranian males
have a more drooping nasal tip compared with
North American Caucasian males.
The morphology of the nose in Middle
Easterners is a whole topic unto itself. However,
a plunging nasal tip (often hyperdynamic
due to depressor septi nasi muscle activity),
once corrected produces a dramatic change
in nasofacial balance. This will often require
depressor septi nasi muscle transaction/
transposition.20 Being sensitive to the prevailing
nasal morphology in ethnic subgroups such as
Iranians will help direct the surgeon to what is
most in need of change.
TFA was greater in North American
Caucasian males as compared with Iranian males,
and therefore, Iranians males demonstrate more
inclination in their general facial prole and have
more convexity in their faces than North Amer ican
Caucasian. This is important with regards to malar
augmentation and evaluating both pre-operatively
and intra-operatively, the magnitude of change in
facial soft tissue redirstribution/augmentation that
is required, without creating racial incongruity.
Other measurements including FNA, NTA,
NBA, and LMA showed no signicant difference
between Iranian males and North American
Caucasian males.
The frontonasal area is straighter and the
lower face is longer in Iranian females based on
a greater. FNA, MF and LF in Iranian females
compared with North American Caucasian
females while the TFA and UF were greater in
North American Caucasian females as compared
with Iranian females indicating that Iranian
females have more convex faces and the upper
face is shorter. Therefore, it may be important to
be especially sensitive to facial modications in
the vertical direction.
For instance, an osseous genioplasty that
increase vertical mandibular height should be
very conservative so that a discrepancy between
the upper, middle, and lower facial heights is
not exaggerated post-operatively. Other linear
and angular measurements in females did not
show signicant difference between our study
and North American Caucasian females. In
summary, the facial prole in Iranian females
was more similar to North American Caucasian
females than the facial prole of Iranian males as
compared to North American Caucasian males.
We believe that plastic surgeons must know the
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standards of beauty and the prole of the ideal
facial soft tissue of specic ethnic subgroups.
This familiarity will help guide the surgeon
in pre-operative planning and intra-operative
assessment of dynamic (“on-table”) changes that
occur, so that racial incongruity is not produced. It
is important, however, to stress that the treatment
plan should always be dictated by individual
assessment.6,15- 20 Ethnic morphological studies
such as the current paper serve as merely a guide
as to the normative values of a particular ethnic
population. The current study may assist the
plastic surgeon for better performance of facial
aesthetic and reconstructive surgery on Iranian
and Middle Eastern patients.
CONFLICT OF INTEREST
The authors declare no conict of interest.
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