Facial analysis — Lines, angles and proportions in each view
What is measured in each view, against what and in which order, the assessment by subunits and the cautions that keep numbers from replacing judgement.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- The eye does not seek beauty: it detects anomalies. What holds attention in a face is disharmony between the parts, not failure to meet a canon.
- Every measurement requires a reproducible head orientation. Without that reference the angles are not comparable between patients or between occasions.
- Projection is calculated against a normal lip. Where there is labial imbalance it must be corrected in the calculation, or the measurement is falsified.
- For rotation the nasolabial angle is used rather than the columellolabial: the columella may be altered and shift the reading.
- The analysis is not confined to the nose: any modification of one facial structure has repercussions on the others, and forehead, maxilla, chin and lip enter the calculation.
How the eye reads a face
This deserves establishing before any measurement, since it determines what must be corrected and what must not. Before a face the gaze makes two passes: at a distance, a global survey seeking a familiar whole; close to, a halt on anomalous, near or luminous points. What holds attention is therefore not beauty but what departs from the expected. Whence the aim of a well-planned rhinoplasty: not to construct an ideal nose but to return the nose to the background so that it ceases to capture the gaze.
The canon and its scope
Egyptians, Greeks and Renaissance authors sought to translate into numbers the balance between the parts and the whole. Leonardo gave the ideal man eight heads in height and Dürer seven. The face divides into three equivalent parts — forehead, nose and mouth — and the ear shares inclination and length with the nose. The relation that recurs most constantly is the divine proportion, verifiable between the width of the nose and that of the mouth, or between the distance from hairline to nasal base and from there to the chin. Its scope deserves stating: it does not indicate that planning should be done with a calculator, but that the perception of harmony answers to recognisable proportions rather than to arbitrary appreciation.
Why no canon resolves rhinoplasty
Attempts to fit facial proportions into fixed rules have failed repeatedly for the same reason: no two faces are equivalent. The surgeon faces two difficulties of different nature. The technical one is resolved by study and experience. The aesthetic one demands a judgement that may limit the outcome of a technically impeccable operation. With routine approaches set aside, what remains is the individual study of each case, and that study cannot be confined to the nose: modifying one facial structure has repercussions on the rest.
The photographic series and head orientation
The series comprises six views — frontal, both profiles, both obliques, dorsal and basal — to which a seventh, often omitted, should be added: the patient smiling. The smile reveals what the resting view does not show — descent of the tip, elevation of the alae and the labial folds — and those dynamic changes condition the result as much as static anatomy. For photographic standardisation the Frankfort plane is traditionally used; it should be noted, however, that for sagittal projection references the current reference orientation is natural head position, as developed in Orthofacial surgery and harmonisation.
Two errors of position that invalidate the measurement
Chin raised: it falsifies the nasolabial angle and conceals the dorsum. Pupils at different heights: it gives a straight nose a deviated appearance. Both are frequent and both invalidate the analysis irrespective of the technical quality of the photograph, so checking for them precedes any measurement.
Frontal view
It is the view of greatest weight, for a specific reason: it is the image the patient receives in the mirror. It is considered aesthetically correct when two dorsal aesthetic lines can be traced continuously from the medial brows to the domes. Their interruption, asymmetry or divergence is what the gaze reads as a deviated or wide nose, even with a straight dorsum.
What is measured in the frontal view
| Parameter | Reference |
|---|---|
| Symmetry | Deviations of the axis and depressions of the contour |
| Width of the bony base | Equivalent to the intercanthal distance |
| Width of the dorsal ridge | The most anterior border of the dorsum; assessed independently of the base |
| Alar width | Also the intercanthal. It is reduced if excessive or after decreasing projection |
| Thickness of the alar rim | Seldom treated; only in markedly prominent cases |
| Labial competence | At rest 3-4 mm of upper incisor is shown in women and 2-3 mm in men |
Profile: the nasofrontal angle
It measures around 120 degrees, but the figure of greatest practical use is not the number but the position of its vertex: the deepest point should lie at the level of the supratarsal fold or the upper border of the iris. It is an immediate check that indicates whether the radix is high or low without any tracing. An excessively deep radix gives a normal dorsum the appearance of a hump; an excessively high one apparently shortens the nose.
Projection: what determines it
Projection is the distance from the most posterior part of the ala to the most anterior part of the dome. Two elements determine it directly: the length of the medial crura and the anterior nasal spine, that is, the columella. And indirectly skin thickness, the shape and strength of the alar cartilages, the length of the infratip lobule — the intermediate crura — and the descent of the cartilaginous dorsum. The distinction has therapeutic consequence: each cause is corrected by a different route, and projection is not gained in the same way in a tip with short crura as in one with weak cartilage. The technical development is in The tip: resection, sutures and support.
Methods of calculating projection
| Method | Procedure | Reference |
|---|---|---|
| Simons | Compares projection with the height of the cutaneous upper lip | 1 : 1 · the fastest check in consultation |
| Crumley and Lanser | Nasion-tip as hypotenuse, nasion-alar groove and a perpendicular from the tip | 3 : 4 : 5 triangle |
| Goode | Ratio of projection to nasal length | 0.55-0.60 |
| Basal check | Seen from below, the tip describes an equilateral triangle | A rapid cross-check of the preceding methods |
Projection is measured against a normal lip
All three methods rest on a normal upper lip: lying anterior to the lower one, slightly thinner and with both in contact at rest. That position depends on the development of maxilla and mandible and on dental position. Where there is labial imbalance it must be corrected in the calculation, since otherwise the nose is measured against an already displaced reference. It is the mechanism by which a correctly projected tip may be read as short, and the reverse. Where the imbalance is skeletal in origin, assessment belongs to Orthofacial surgery and harmonisation.
Rotation and the reference angle
Rotation is the position of the tip relative to the vertical plane. Its most direct representation: if the tip moves towards the feet there is inferior rotation or descent; if towards the forehead, superior rotation or elevation. It is measured in degrees against the upper lip, and here two frequently confused angles must be distinguished. The columellolabial angle and the nasolabial angle.
Which of the two angles to use
For assessing rotation the nasolabial angle is used rather than the columellolabial, for a specific reason: the columella may be altered — retracted, hanging or deviated — and in that case the columellolabial angle reports the position of the columella and not that of the tip. The nasolabial angle, drawn on the line joining the ends of the nostril, is independent of that alteration. Confusing them is among the most frequent causes of indicating a rotation the patient did not require.
Contour of the dorsum and columella
The contour of the dorsum admits a range from concave to convex, though the straight line has the widest application. One detail separates a natural profile from a flat one: the lobule sits slightly elevated relative to the supratip, and that minimal step is what confers definition on the tip in profile; its loss produces the impression of an operated nose even with correct measurements. The columella, for its part, should present a double break — the double break — and show 2 to 4 mm of mucosa below the alar margin. Less exposure indicates retraction of the caudal septum; more, a hanging columella or alar retraction.
Basal view: reference proportions
| Element | Proportion |
|---|---|
| Overall shape | Isosceles triangle. A trapezoid contour indicates a wide base or an underprojected tip |
| Columella and lobule | 2/3 of the height for the columella and 1/3 for the lobule |
| Nostrils | Symmetrical and pear-shaped; each one fifth of the width of the base |
| Width of the columella | Also one fifth of the width of the base at its lowest portion |
Assessment by subunits
The measurements from each view are integrated region by region, and that integration is what translates into a surgical plan. The table sets out what is assessed in each subunit and how often it requires intervention, a figure that indicates where to concentrate the analysis.
Analysis by subunits
| Subunit | What is assessed | Frequency of intervention |
|---|---|---|
| Radix | Nasofrontal angle and depth of the starting point | In 80 % no treatment is required; in 15 % it is augmented and in 5 % reduced |
| Dorsum | Height and width; proportion of bony to cartilaginous component of the hump | In 95 % reduction is required. The hump depends more on the cartilaginous component: do not overcorrect the bony one. See Dorsum and osteotomies |
| Tip | Projection, rotation, definition and interdomal width | Tip width bears a ratio of 1:1 to 1:1.2 to the dorsum: always slightly greater than it |
| Base and nostrils | Alar base width, nostril base width and nostril show on frontal view | Decided at the end of the operation and marked with calipers before infiltration |
| Septum and valves | Septal deviation, turbinate hypertrophy and the Cottle manoeuvre | Always. The three causes of postoperative obstruction arise here: see Septoplasty and the nasal valve |
| Skin | Thickness and sebaceous content, especially at the tip | Not operated on. It conditions the definition attainable and the time to the result |
What only palpation provides
No photograph reports the cartilaginous support available. Wide lateral crura confer fullness on the supratip; crura excessively narrowed at a previous operation produce alar retraction and excessive rotation. Lateral crural recurvature and bossae are identified on examination, before operating.
The order of reading
- 1. Overall viewObserve the whole face and record which element first holds attention. That finding usually corresponds to the real reason for consultation
- 2. Thirds and fifthsCheck the facial proportions. If they prove correct and the nose appears large, the problem may not be nasal
- 3. FrontalDorsal aesthetic lines, symmetry, the three widths and labial competence
- 4. ProfileVertex of the nasofrontal angle, dorsal contour, supratip break, projection and rotation
- 5. BasalTriangle, columella-lobule proportion, shape and symmetry of the nostrils
- 6. AnimationSmile: descent of the tip, elevation of the alae and labial folds
- 7. PalpationTip support, strength of the alar cartilages and irregularities of the rhinion
- 8. FunctionInternal and external valves, septum and turbinates. Planning is not completed on aesthetic criteria alone
Two cautions on normative values
Normative figures describe the leptorrhine nose. In mesorrhine and platyrrhine noses projection is lower, the base wider and the nasofrontal angle more closed; the nasal index objectifies that biotype more reliably than visual impression. And a second caution of general scope: normative values orient the analysis but do not determine it. Where measurement and impression diverge, the impression is usually correct. The angles serve to identify and explain the reason for a disharmony, not to replace judgement.
With the analysis complete, the next decision is the technique: preservation or structural, open or closed approach, and the extent of undermining. It is developed in Approach, choice of technique and undermining.
References
- 1.Arquero P. Diagnóstico nasal: medidas y proporciones, la nariz ideal y clasificación de las alteraciones nasales. rinoplastia.eu.
- 2.Piedra Buena IT, Kahn D. Rhinoplasty. En: StatPearls. Treasure Island: StatPearls Publishing; 2024.
- 3.Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope. 1988;98(2):202-208.
- 4.Naini FB, Cobourne MT, Garagiola U, McDonald F, Wertheim D. Nasofrontal angle and nasal dorsal aesthetics: a quantitative investigation of idealized and normative values. Facial Plast Surg. 2016;32(4):444-451.
- 5.Powell N, Humphreys B. Proportions of the Aesthetic Face. New York: Thieme-Stratton; 1984.
- 6.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty