Clinical-Anthropometric and Aesthetic Analysis of Nose and Lip in UnilateralCleft Lip and Palate Patients

M. Heller, M. Schmidt, C.K. Mueller, M. Thorwarth, M.D., D.M.D., P.D., S. Schultze-Mosgau, M.D., D.M.D., Ph.D.

Objective: Presentation of a technique to determine objectively the degree ofsymmetry in the area of nose and lip in cleft patients based on analysis ofphotographs. To compare the objective measurements with the subjectiveimpression.

Design: This was a retrospective study using a predefined photo documen-tation standard to capture images of the area of nose and lip.

Setting: Department of Oral and Maxillofacial Surgery, University of Jena,Germany.

Patients: Unilateral cleft patients following primary lip repair (group 1; n = 36)or secondary correction (group 2; n = 23).

Main Outcome Measures: Measurements were taken on standardizedphotographs of three dimensions in the area of the nose and two dimensionsin the upper lip region. Sign tests were used to ascertain differences betweenthe cleft and unaffected sides separately for each group. Subjective impres-sions regarding symmetry were gathered and quantified by means of a visualanalog scale (VAS). The Mann-Whitney U test was employed to compare theobservers’ impressions between the two groups.

Results: While significant side differences were found for all distances ingroup 1, only the side differences in the height of the nostril remainedsignificant in group 2. Subjective evaluation of the nostril area improvedsignificantly following corrective surgery. However, no such change in the areaof the upper lip was recognized by the observers.

Conclusions: We were able to demonstrate that the measurable symmetry ofthe nostril area, as well as the upper lip, was significantly enhanced bycorrective surgery. However, only the subjective impression of the nostril wasimproved.

KEY WORDS: aesthetics, cleft lip and nose, landmark positioning, unilateral cleft

lip and palate

Cleft lip and palate is the most frequent congenital

malformation. This deformity of the face leads not only to

functional but also to aesthetic impairments, which become

manifest mainly in the area of the nose and the upper lip

(Hupfner-Hierl et al., 2003). The face plays an essential role

in our society. Hence, its aesthetic reconstruction is of

outstanding importance for the child’s or adolescent’s

social integration. The parents’ negative emotions towards

their child’s facial deformity are also relevant. To date, only

a few data on photo documentation and anthropometric

analysis of cleft nose and lip have been published (Farkas et

al., 1993; Farkas et al., 2000; Hupfner-Hierl et al., 2003;

Kazinczy, 2003).

There is no international consensus concerning the

different surgical techniques. Subjective evaluation is not

sufficient to describe the aesthetic results. Complex

objective analyses using a variety of distances and angles

(Hupfner-Hierl et al., 2003) or three-dimensional measure-

ments have been proposed (Krimmel et al., 2002; Sawyer et

al., 2008; Stauber et al., 2008). However, easy and

reproducible standards for objective analysis are missing.

Taking this into account, the study presented herein aims

to establish a photo documentation standard for the lip and

nose area. Furthermore, we present a new scheme for an

anthropometric analysis of lip and nose, which allows

objective comparison of the unaffected with the cleft side

following primary lip repair as well as corrective surgery.

The measurement protocol developed by Farkas was used

to establish our aesthetic analysis (Farkas et al., 1993).

Heller, Schmidt, and Mueller are research assistants, Department of

Oral and Maxillofacial Surgery/Plastic Surgery, University of Jena, Jena,

Germany. Dr. Thorwarth is contract teacher, Department of Oral and

Maxillofacial Surgery/Plastic Surgery, University of Jena, Jena, Germany.

Dr. Schultze-Mosgau is Head of Department, Department of Oral and

Maxillofacial Surgery/Plastic Surgery, University of Jena, Jena, Germany.

The study was orally presented at the 21st Interdisciplinary Symposium

of the German Cleft Palate Craniofacial Association (GCPA), October 4,

2008, Mainz, Germany.

Submitted September 2009; Accepted June 2010.

Address correspondence to: Maria Heller, Department of Oral and

Maxillofacial Surgery/Plastic Surgery, University of Jena, Jena, Germany,

Postfach 07740 Jena. E-mail maria.heller@uni-jena.de.

DOI: 10.1597/09-176

388

In order to complete the anthropometric analysis, an

observer-associated subjective evaluation of the aesthetics

was performed by means of the visual analog scale (VAS)

described by Handschel et al. (2005). The possibledifferences between objective analysis and subjective

evaluation were an essential question.

MATERIALS AND METHODS

Study Design and Study Collective

The project was approved by the Clinical Ethics

Committee of the University of Jena (Reg. Nr.: 2177-12/

07).

A retrospective study was conducted utilizing 191 cleft

lip and palate patients who were treated between April 2005and April 2008. Fifty-nine children with unilateral, non-

syndromal cleft were selected randomly. Patients with other

malformations or aesthetic variations (piercings, injuries,

additional scars) were excluded. Any makeup was removed.

All the patients had primary lip repair performed by a

single surgeon. Secondary corrective surgery was per-

formed by two different surgeons, one of whom also did

the primary lip repairs. Because of the small number ofpatients involved, surgeon-related selection was impossible.

The median age of the study group was 5 years.

Study Groups

Patients were divided into two groups according to

treatment: group 1 (n 5 36) included patients who received

primary lip repair, and group 2 (n 5 23) included patients

who received additional corrective surgery.

Photo Documentation

Two-dimensional photometry was employed for the

evaluation of the nose and perioral region of the cleft

patient’s face. To avoid methodologic parallax errors,

photographers were instructed in detail on how to create

reproducible standardized pictures. The distance between

the photographer and the patient was marked with lines on

the ground. All the pictures were produced with the same

camera (Nikon D 80, objective: Nikon AF Micro Nikkor

105 mm 1:2.8 D; aperture: f13; Nikon Corp., Tokyo,

Japan), in the same room, and with consistent illumination.

We produced pictures of the nostril area, formally

known as the ‘‘submental oblique view’’ (Ettore et al.,

2006; Schaaf et al., 2006). Particular care was taken for

horizontal alignment of the interpupillary line and preven-

tion of rotation of the head (Schaaf et al., 2006). As

demonstrated in Figure 1, the photos were produced with a

retroverted head and the nose and the forehead in one

plane. The eyes were oriented to the ceiling. The center of

the picture was located between the red border of the upper

lip and the columella (Ettore et al., 2006).

Previously published techniques for digital photography

were modified to provide a photo standard of the perioral

region. The patients were aligned to the Frankfort

horizontal line to avoid rotational artifacts (Ettore et al.,

2006; Schaaf et al., 2006). Patients were instructed to avoid

squeezing their lips. The middle of the bridge of the nose

constituted the top margin of the photo. The lower margin

was in the area of the chin (Fig. 2). Tables 1 and 2 show the

relevant points for taking the pictures.

Objective, Clinical-Anthropometric Analysis

The photographs were imported into Microsoft Power-

Point 97 SR-1 for Windows XP, (Microsoft Corporation,

Redmond, WA) and magnified by the same factor (200%).

FIGURE 1 View of the nostril area. FIGURE 2 View of the perioral region.

TABLE 1 Photo Documentation Standard for the

Interdisciplinary Concept

Standard Documentation Further Photographs

En face Nostril area (‘‘submental oblique view’’)

En profile Perioral region

Intraoral (cleft palate)

Heller et al., AESTHETIC ANALYSIS OF UNILATERAL CLEFT LIP AND PALATE 389

As the measures were used to calculate proportional indices

of asymmetry, particular scaling was not necessary.

Measurements in the Nostril Area

In the ‘‘submental oblique view,’’ five distances were

defined in order to perform exact measurements of the nose

and to allow for comparison between the cleft side and the

unaffected side (Fig. 3).

Vertical tangents were drawn on both sides of the

columella, and the distance between the tangents was

measured as columella width. Afterwards, this line was

bisected and a vertical line starting from this point leading

to the tip of the nose was measured as the length of the

columella. In the middle of the columella, the width of the

middle of the nose was measured. Following this, a tangent

was applied on the most lateral point of the ala of the nose.

Between these two points, a horizontal line was drawn on

the level of the insertion points of each ala of the nose.

When those two points were not at the same level, the

highest point was chosen. This distance represented the

width of the base of the nose.

To analyze the problem of the cross-oval nostril, the

height of the nostril was measured as described in the

literature (Hupfner-Hierl et al., 2003). On the upper and

lower inner margins of the nostril, horizontal tangents

were applied, and the distance was measured. The same

procedure was used to determine the width of the nostril.

Vertical tangents were applied on the medial and lateral

inner margins of the nostrils, and the distances measured

(Fig. 3).

Measurements in the Perioral Region

In addition to the measurements described in the area of

the nostril, two distances were measured in the perioral

photographs following the technique reported by Kazinczy

et al. (2003), (Fig. 4). In the alar area of the nose, vertical

tangents were applied bilaterally and connected at the level

of the ala insertion. This line was divided into quarters.

TABLE 2 Criteria on Standardized Photos of the Nostril and Perioral Region

Perioral Region Nostril Area

Horizontal interpupillary line Horizontal interpupillary line

No rotation of the head No rotation of the head

Relaxed lips, no squeezing Retroverted head, nose and forehead in one plane

Patients view directly to focus of the camera Eyes adjusted to the ceiling

Center of the picture: between the red-white border of the upper lip and the

columella Center of the picture: between the red border of the upper lip and the columella

Top margin: in the middle of the back of the nose Top margin: includes the forehead

Lower margin: includes the underlip Lower margin: at the level of the earlobes

FIGURE 3 Standard measurements in the nostril area (CH = columella

height; CB = columella width; NLH = nostril height; NLB = nostril width;

NB = nose base).

FIGURE 4 Standard measurements in the perioral region (LP = philtrum

length; BL = lip width).

390 Cleft Palate–Craniofacial Journal, July 2011, Vol. 48 No. 4

Starting from the highest point of the cupid arch (Fig. 4),

the length of the philtrum and the width of the upper lip

were measured in the first and third quarter of the line.

Subjective, Aesthetic Analysis

The same pictures that were used for the clinical-anthropometric analysis were subjected to separate aes-

thetic analysis of the nose and the lip by eight blinded

observers (three medical professionals and five nonmedical

volunteers).

The VAS was employed to express aesthetics on a scaleranging from 0 (poorest result) to 10 (ideal result) (Quinn et

al., 1995; Handschel et al., 2005).

Statistics

The cleft side and unaffected side were compared by

means of the sign test. Furthermore, the results of the

patients with primary lip repair and those with corrective

surgery were compared by means of a two-sided Mann-

Whitney U test. Probabilities of p # .05 were consideredsignificant. All calculations were made using SPSS version

15 for Windows (SPSS, Chicago, IL).

RESULTS

Objective, Clinical-Anthropometric Analysis

A significant difference (p , .001) in the width of the

nasal base between cleft side and unaffected side was

obvious among patients after primary lip repair. In contrast

to those results, no significant difference could be identified

among patients following corrective surgery.

The width and height of the nostril exhibited a highly

significant (NLB: p , .001, NLH: p , .001) difference

between the unaffected and the cleft side after primary lip

repair. After corrective surgery, there was no significant

difference between unaffected and cleft side in NLB.

However, the asymmetry in NLH remained significant

(p , .001).

A significant difference (p , .001) between the cleft side

and the unaffected side was seen in the length of the

philtrum in patients after primary lip repair. In contrast, no

significant asymmetry regarding philtrum length was found

following corrective surgery.

The width of the upper lip showed a significant difference

(p , .001) between the cleft side and the unaffected side

after primary lip repair. Following corrective surgery this

side difference resolved.

Subjective, Aesthetic Analysis

During the course of the treatment, different observers’

evaluations of the nostril area could be shown. A

significant difference (p 5 .035) between patients following

primary lip repair and those who received secondary

corrective surgery was found for the nostril area. In

contrast to patients following primary lip repair, the

pictures of the patients who had undergone corrective

surgery received a better evaluation by the observer

regarding symmetry and aesthetics. The results for both

groups are presented in Figure 5.

The VAS-evaluation showed only differences for the nose;

the measured changes of the lips were not subjectively

perceived. No significant difference between the two ref-

erence groups could be shown in relation to the subjective

evaluation of the lips.

DISCUSSION

The selected area of the cleft patient’s face was evaluated

by means of objective, clinical-anthropometric, and sub-

jective aesthetic analysis of photographs. The cleft-nose, as

described in the literature, was verified. With regard to the

nasal base, a significant difference could be seen following

primary lip repair. In contrast, the patients showed no

statistically significant difference with regard to this

measurement following corrective surgery. In the course

of the study, the height and width of the nostril were

analyzed. After primary lip repair, a highly significant

difference between the unaffected and the cleft side was

seen. This phenomenon is described as a cross-oval nostril

(Hupfner-Hierl et al., 2003). Regarding the width of the

nostril, no significant side difference was found following

corrective surgery. Our results indicate that in most study

group patients, the cross-oval nostril was adjusted to the

unaffected side by corrective surgery. This finding is in

accordance with data published by Hupfner-Hierl et al.,

FIGURE 5 Evaluation of the nose after primary lip repair and corrective

surgery using the VAS.

Heller et al., AESTHETIC ANALYSIS OF UNILATERAL CLEFT LIP AND PALATE 391

who reported on anatomically correct positioning following

corrective surgery (Hupfner-Hierl et al., 2003). Further-

more, the lip is of outstanding importance for facial

balance. The appearance of the mouth is crucial for the

mien and the expression of emotions (Zimbardo, 1992). In

contrast to corrective surgery patients, primary lip repair

patients show a disturbance in upper lip symmetry in the

anthropometric analysis.

Subjective evaluation revealed an improvement in the

appearance of the nose following corrective surgery.

Despite the objective difference in lip symmetry between

the two study groups, no significant difference was seen

subjectively. Consequently, either the measurable changes

were not noticed subjectively, or the nose is more important

for total facial harmony. It has been said that the nose is

the most important aesthetic unit of the face because of its

central position in the frontal view and prominence in the

lateral view. As a matter of fact, minor variances are more

important than in other facial regions. It has been shown

that facial attractiveness is significantly affected by the

nose. Patients and independent viewers also evaluated the

nose worst in other studies (Fuhrmann, 2009). Symmetric

faces are more attractive to viewers (Penton-Voak et al.,

2001; Baudouin and Tiberghien, 2004). Some authors have

shown a proportional relationship between symmetry and

attractiveness (Grammer and Thornhill, 1994; Perrett et al.,

1999; Rhodes, 2006), but based on the appreciation of the

nose, some other facts are perhaps relevant. The definition

of the ‘‘ideal face’’ consists not only of measurements.

Numbers alone cannot explain the human face (Greenberg

and Prein, 2002), but balanced symmetry of proportions is

very important (Kastenbauer and Tardy, 2003). Essential

for art and architecture, symmetry is central to aesthetics.

The nose should show a balanced relationship to the face.

For example, variances in the area of the nose can influence

the appearance of a sloping forehead (Behrbohm and

Tardy, 2003).

With the help of the data compiled, it was shown that the

objective long-term results can be improved by corrective

surgery. Furthermore, the subjective feeling of the observer

is essential and differs from the objective data in the area of

the lip. Only in the nostril area could the subjective

impression be improved by corrective surgery.

The study has some limitations. It is well known that

standard photometric analysis projects a complex three-

dimensional structure onto a two-dimensional plane

causing a loss of facial depth. Consequently, parallax

errors are likely to occur when the film plane and the face

are not completely parallel. In the present study those

errors were partially eliminated by standardizing the

submental-oblique and frontal photos according to the

methods described by Ettore et al. (2006) and Schaaf et al.

(2006). In addition to parallax errors, the application of

landmarks can also be a source of error. The definition of

landmarks in soft tissue areas can be difficult. Individual

variations are possible even if the measurements are taken

with extreme care by a single examiner (Schuck, 2007). The

landmark definitions we used in the present study were

necessary to identify the exact points repeatedly. Regions

which show only a few reference points are a problem. The

measurement of asymmetries in these areas is poor (Staufer,

2009). Advancements in three-dimensional (3D) techniques

could be relevant for these facial areas. The 3D method

described by Schuck (2007) is an alternative to x-ray

cephalometry (Aduss and Pruzansky, 1967; Freihofer,

1977) or anthropometric analysis (Lindsay and Farkas,

1972; Katsuki et al., 1981) for evaluating facial malforma-

tions, but there are some disadvantages to 3D representa-

tion. At the moment, the cameras (3D-Shape, Dolphin

Imaging, 3-G-Scan) image plane surfaces very well.

However, artifacts are produced by imaging the human

face especially in the orbital and perioral region. The poor

compliance of the mostly young patients is another

significant difficulty. It is already difficult to position

young patients for standard photography, but the 3D view

takes much more time, up to 15 seconds. At the moment,

high-quality 3D photos are nearly impossible to take for

these patients. Some authors describe the need for sedation

when using this special method. According to this, a

reduction of the recording time is desirable. To verify the

quality of this method, it is necessary to implement more

studies (Honigmann, 2005). In this context, implementation

is limited by a lack of comparable data. Further

development of the 3D method can improve the imaging

and evaluation of soft tissue areas. In this context a

landmark independent analysis, as described by Benz

(2005), could become more important. If sufficient compa-

rable data become available, preoperative and postopera-

tive analyses could modify surgical methods. The surgical

outcome could be quantified and controlled by comparison

of the preoperative with the postoperative facial structure

(Benz, 2005).

Acknowledgments. The authors are very grateful to John C. Kolar,

Ph.D., Clinical Anthropologist, Children’s Specialty Center, Medical City

Children’s Hospital, for language editing.

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