Preoperative Evaluation and

Facial Analysis in Facial

Plastic Surgery
1

dr. Desti Kusmardiani

Pembimbing:
dr. Nur Akbar Aroeman, M.Kes,
Sp.T.H.T.K.L (K)

DEPARTMENT OF OTOLARYNGOLOGY HEAD AND NECK

SURGERY
FACULTY OF MEDICINE PADJADJARAN UNIVERSITY
HASAN SADIKIN HOSPITAL
BANDUNG
2016

Introduction
2

Purpose in Facial Plastic Surgery:

1. Cosmetics (Modification Changes in the
face of aging)
2. Reconstruction (congenital / acquired)
A surgeon should be able to determine the
candidate patients who really suitable to
carry out plastic surgery procedures based
on various aspects including the
psychological considerations

Preoperative Evaluation
3

INITIAL CONSULTATION
( Establishing a Relationship )
4

The primary goal of the preoperative

interview:
the patients perception of the defect,
the patients motivations,
the patients expectations from surgery
improved patient satisfaction, reduced
legal liability, and better surgical
outcomes

PSYCHOPATHOLOGY IN THE
AESTHETIC PATIENT
5

Depression

FACIAL ANALYSIS
6

The face is a complex balance of

multiple aesthetic units that when taken
together produces a unique appearance.
Facial analysis uses standardized points
to determine relationships between
various aesthetic masses, and to
determine the proportions of each
feature individually

General Facial Assessment

7

Facial assessment begins with an evaluation

of symmetry.
A line drawn through the midsagittal plane
on frontal view provides a side-by-side
comparison of symmetry.
The midline points of the forehead, nose,
lips, and chin should lie on this axis.
Subtle asymmetries are expected and it is
helpful to point these out to the patient
preoperatively.

BASIC ANATOMIC LANDMARKS AS

SEEN ON FRONTAL VIEW
8

Trichion (Tn)
Superior margin of the forehead at
the midline of the frontal hairline

Radix (R)
The region of the root of the nose

Subnasale (Sn)
Soft tissue point at the junction of
the columella and upper lip in the
midline

Superior and inferior vermilion border

(Vs and Vi)

Mucocutaneous junction of the upper

and lower lips

Stomion (St)
Midline point at the embrasure of the
lips when closed

Menton (M)
Soft tissue point at the inferior-most

BASIC ANATOMIC
LANDMARK ON
LATERAL VIEW

General Facial Assessment

10

Assessment of symmetry and proportion

is further accomplished by dividing the
face into vertical fifths equal to the width
of one eye, or the intercanthal distance.
Vertical lines at the lateral canthus should
approximate the width of the neck.
The lateral-most fifth extends from the
lateral canthus to the lateral most point
of the helical rim

BASIC ANATOMIC LANDMARKS

11

Ideal frontal
symmetry and
proportion is
approximated by
dividing the face
into vertical fifths,
with each fifth
approximating the
width of the eye.
The overall width-tolength ratio should

12

Facial height is examined by dividing the face

into horizontal thirds on the frontal and lateral
views
The total facial height is the distance from the
trichion to the menton.
The face is then divided into horizontal thirds at
the glabella and the subnasale.
This creates an upper third from trichion to
glabella, a middle third from the glabella to the
subnasale and a lower third from subnasale to
menton.

The Facial Thirds

13

The face from nasion to subnasale is 47% and from subnasale to

menton is 53% of the total height from nasion to menton

14

The facial profile assessment examines

the relationships of individual
components to the face as a whole.
Lateral view assessment begins with
positioning of the patient in the Frankfort
horizontal

THE FRANKFORT HORIZONTAL

15

The Frankfort horizontal plane

connects the Inferior orbital rim
to the traglon and Is parallel to
the horizon.
Gonzalez-UIIoa defined the
aesthetic profile In relatlon to the
Zero Meridian, a line
perpendicular to the Frankfort
horizontal plane through the
nasion

PROFILE PLANES AND ANGLES

USED IN FACIAL ANALYSIS
16

Facial Plane

Reference plane created that is tangent to glabella

and pogonion

Frankfort Horizontal

Reference line from the superior margin of the

external auditory canal to the inferior border of the
intraorbital rim

Zero-Meridian

Reference line perpendicular to the Frankfort

Horizontal intersecting at the nasion

Nasofrontal angle
(NFA)

Obtuse angle formed by lines tangent to the

glabella and nasal dorsum with the vertex at the
sellion

Nasofacial angle
(NFcA)

Angle of inclination of the nasal dorsum from the

facial plane

Nasolabial angle
(NLA)

Angle of inclination between the columella and the

upper lip

Lower Face-Throat
Angle

Angle formed at the gnation by the intersection of

a line from the cervical point to the menton with a
line from the subnasale to the pogonion

Mentocervical angle
(MCA)

Angle formed by the intersection of a line from the

cervical poit to menton with a line from the

Profile Angles for Facial Analysis

17

Fore Head
18

the most important aspects of the

forehead from a surgical standpoint is
the nasofrontal angle (NFA).
NFA varies from 115 to 135 degrees
in men the NFA ideally measures 115 to
120 degrees whereas women ideally
measure 120 to 135 degrees

Eyebrow
19

The eyebrows function in static

protection of the eye, facial identity, and
saual dimorphism
Eyebrow size, position, and morphology
change dramatically throughout one's
life, and normal
values are useful when performing an
aesthetic evaluation

Eye/Eye Lid
20

The eyes are the seat of beauty, and

changes in this region, whether agerelated or otherwise, often prompt
patients to seek aesthetic evaluation

Appraisal of facial harmony requires

close examination of the symmetry,
shape, proportions, and position of the
eyes

21

A; The Ideal brow

A. The Ideal brow

B. Cook Modification
C. Roth Modification

Characteristic relationship of The

Aesthetically Pleasing Eye
22

The upper eyelid overlaps

the superior limbus of the
Iris by 2 to 3 mm, while the
lower eyelid approximates
or overlaps the Inferior
limbus by 1 mm. The
supratarsal plate Is tallest at
the medial limbus. The nadir
of the lower eyelid lash line
is aligned with the lateral
limbus. The distance from
the urper eyelid lash line to
the supratarsal crease (STC
varies from 7 to 15 mm. The
intercanthal axis is tilted
upward laterally, with the

Ears
23

The auricle reaches 80% of the adult size

by age 5
When analyzing the ears, each auricle is
evaluated relative to the face and
individually, as deformities can be
distinct between each ear

Nose
24

With its central location on the face, the

nose is one of the most important
conttibutors to facial aesthetics.
Small changes to the nose can produce
dramatic differences in overall facial
aesthetics
variations of the nasal proportions are
accepted based on ethnicity, age,
height. and gender.

Nasal Angles
25

Several angles are useful in defining

the relationship of the nose to the
face;
1. NFA
2. NFcA
3. NLA

Nasal Tip Projection

26

Nasal tip
rotation is
defined by
the
movement of
the nasal tip
on an arc
around the
tragion

27

Assessment of nasal
projection
A. The Powell and
Humphries method
B. The Goode
Method

Nasal Widht
28

The nasal width may be described as the

distance between the alar grooves

A proportionate nasal width is estimated

at 70% of the total length

29

Lateral View nasal Tip

Projection

The lateral view of the nose allows one

to assess the nasal profile and the ala-tip
complex.
On lateral view the length of the ala and
tip should be equal, though tip lobular
excess is more acceptable than alar
excess

Nasal Lobule
30

The width of the nasal lobule should be 75%

of the width of the nasal base. The lobule-tocolumella ratio should be 1:2. On lateral
view, the ala-to-lobule ratio should be 1 :1,
and there should be 2 to 4 mm of columellar
show

Chin
31

The chin plays a prominent role in the

balance of the facial profile.
The chin mends from the mentolabial
sulcus to the menton.
Prognathia or rettognathia are defined
by deviation of the pogonion from these
positions.

Lip
32

The lips are an essential component of

beauty and aid in the display of emotion,
personality, and sexuality.
To achieve facial balance, the vertical
length of the upper lip from subnasale to
stomion should equal onethird of the
lower facial third, whereas the lower lip
and chin from stomion to menton should
compose two-thirds of the lower facial
third

33

The most anterior point of

the upper lip should be 3.5
mm, and that of the lower
lip should be 2.2 mm, from
the SnPg line. Legan and
Burston described the lower
facethroat angle (Sn-Gn-C),
which should be 100
degrees. The lower facial
height (Sn-Gn} to depth
(Gn-C} ratio should
equal1.2:1.

Neck
34

The mentocervical angle (MCA),

described by Powdl and Humphries, is a
tool that better describes the
relationship of the neck to the face

35

METHOD IN FACIAL
ANALYSIS

Cephalometrics
Photometrics
Three-Dimensional Photography

36

THANK YOU