A study of anthropometric measures before and after external septoplasty in children: a preliminary study.

OBJECTIVE: To test the hypothesis that surgery on the growing nasal septum does not adversely affect nasal and midfacial dimensions. DESIGN: Paired study. SETTING: Tertiary care center. PARTICIPANTS: Children treated consecutively during a 4-year period; all had significant nasal obstruction and cosmetic disfigurement secondary to skeletal septal deformities. INTERVENTION: Nasal septal surgery (using an external approach), in which the quadrilateral cartilage was removed, remodeled, and reinserted as a free graft. OUTCOME MEASURES: Anthropometric linear measurements and indexes of the face and nose preoperatively and postoperatively; nasal dorsum length, nasal height, nasal dorsum index, nasal tip protrusion, columellar length, facial height, face width, upper face height, facial index, nose-upper face height index, and columellar length-nasal tip protrusion index. Continuous measurements were transformed into ordered categories with reference to normative data. Data were analyzed using Wilcoxon signed rank sum test (alpha level of.05) and by applying the Bonferroni adjustment for multiple testing. RESULTS: Twenty-six children were studied (12 females and 14 males); age at surgery ranged from 4.5 to 15.5 years (mean age, 9.5 years); average age at postoperative measurement, 12.5 years; mean follow-up, 3.1 years. Only nasal dorsum length (P =.007) and nasal tip protrusion (P =.04) were decreased by a statistically significant level before the Bonferroni adjustment. The change was not considered clinically significant. Thus, relative to age-appropriate norms, the dimensions of the nose and midface and their proportionality did not change after surgery. CONCLUSIONS: Appropriate nasal septal surgery involving excision and subsequent reinsertion of a remodeled segment of the quadrilateral cartilage has no deleterious effects on development of the nose and midface. We question the absolute dogma that nasal surgery in children must always be avoided.

Surface anatomy of the face in Down's syndrome: anthropometric proportion indices in the craniofacial regions.

The objective of the study was to identify the proportions closest to normal and those indicating mild-to-moderate and severe degrees of disproportion. Eight proportion indices were analyzed in five craniofacial regions of 125 Down's syndrome patients, based on a total of 985 data points. More than two thirds of the patients fell within the normal range, although more than one quarter were abnormal (disproportionate). All statistical summaries were based on z-scores (adjusting for age and sex differences), converted into descriptive anthropometric categories to yield a simplified frequency distribution for each proportion index. Normal proportions were harmonious in 55.9% of patients. Disproportions were mild to moderate in 66.4%, severe in 33.6%. The highest frequency of harmony was found in the head (70.2%), the lowest in the orbits (40.8%). The highest percentage of mild-moderate disproportion was found in the face (79.3%). The highest percentage of severe disproportions was recorded in the intercanthal index of the orbits (44.7%) and the smallest frequency in the face (20.7%). In the five craniofacial regions among the normal proportions, harmonies were more frequent than disharmonies. Among the disproportions, the percentage of mild-moderate ones was greater than those of severe degree.

Surface anatomy of the face in Down's syndrome: linear and angular measurements in the craniofacial regions.

Measurements (23 projective linear, 2 angular) taken in the 6 craniofacial regions of 127 patients with Down's syndrome showed that 63.1% (1,836 of 2,908) were within normal limits and 36.9% (1,072) were outside them. Abnormal measurements were subnormal in 90.8% (973) and supernormal in 9.2% (99). All statistical summaries were based on z scores (adjusting for age and sex differences) classified into a small number of ranges to yield a simplified frequency distribution for each measurement. The purpose of the study was to identify the measurements closest to normal and those indicating the most severe degrees of sub- or supernormality. Approximately a quarter of normal measurements were classified as optimal, and half the subnormal or supernormal measurements were classified as severe. Intercanthal width had the highest frequency of optimal measurements (93.7%, 119 of 127), head circumference the smallest (28.6%, 36 of 126). Knowledge of the frequency of extreme abnormalities in the craniofacial regions will help during visual examination of patients with Down's syndrome. This study found the highest percentage of severely subnormal measurements in the orbital region (57.8%, 74 of 128) and the smallest in the labio-oral region (32.7%, 16 of 49). The measurement with the highest proportion of severely subnormal to all subnormal values was the palpebral fissure length (68%, 51 of 75), and the nose width had the smallest proportion (14.3%, 1 of 7).

Repair of bilateral complete cleft lip: intraoperative nasolabial anthropometry.

Synchronous repair of bilateral complete cleft lip and nasal deformity requires conception of three-dimensional form and fourth-dimensional changes with growth, as distorted by the malformation. The aim is to obviate typical postoperative nasolabial stigmata. The strategy is to construct fast-growing features on a smaller scale and slow-growing features on a normal or slightly larger scale. In this study, intraoperative alterations in nasolabial dimensions were documented by anthropometry in 46 consecutive infants with bilateral complete cleft lip. These values were averaged and compared with measures from normal Caucasian infants at ages 0 to 5 months and 6 to 12 months. Nasal height (n-sn) and nasal width (al-al), both fast-growing features, were set smaller (88 percent and 96 percent, respectively) than those of age-matched normal infants. In contrast, the slow-growing features, nasal protrusion (sn-prn) and columellar length, were constructed longer than normal (130 percent and 167 percent, respectively). Because all labial features grow rapidly, they were made diminutive in this study, with the exception of central vermilion-mucosal height (median tubercle), which was purposively made full. These maneuvers resulted in a normal, average overall upper-lip height (sn-sto). Two technical refinements also are described: (1) construction of deepithelialized bands flanking the philtral flap to improve surface contour; and (2) positioning and fixation of the dislocated alar cartilages, performed entirely through superiomedial nostril rim incisions.

Revision of neoclassical facial canons in young adult Afro-Americans.

The validity of seven neoclassical facial canons was tested in 100 young, adult, Afro-American (A-A) males and females, and the results were compared with 103 North American Caucasians, producing the first reliable information about the differences of facial proportions in the two populations. Although the canons should not be regarded as strict directives in reconstructive and esthetic surgery, the data obtained from the study offered the first information about the facial proportion qualities of Afro-Americans in relation to the white population. In the absence of a detailed facial proportion study in A-As, the findings in canons can assist in planning the surgery. Comparison of the two populations revealed that the three sections of the facial profile were not equal in either population. In an A-A sample it showed the prevalence of the long lower face height also in relation to the height of the forehead. In horizontal canons of the orbital regions, the similarity between the two populations was demonstrated by the great frequency of intercanthal spaces to be wider than the length of the palpebral fissures [1]. The facial canons, including the nose width, relatively wider [2] in A-A than in white subjects, prompted the difference between A-A and Caucasians in frequency and degree in the dominant canon variations. The greater inclination of the nasal bridge than that of the medial longitudinal axis of the ear was a very frequent canon variation in both populations. Generally, the frequency of valid canons was greatly surpassed by their variations.

Comparison of the morphology of the "cleft face" and the normal face: defining the anthropometric differences.

Morphological characteristics of the "cleft face" were analyzed by calculating proportion indices in young adults who had undergone surgery in childhood for cleft lip and/or palate: 592 in 37 subjects with unilateral clefts and 432 in 27 with bilateral clefts. Three areas of the face with 16 indices based on 12 projective linear measurements were analyzed in each subject: 5 indices in the general face, 6 in the upper face, and 5 in the lower. Although a balanced relationship was found in two thirds of the indices assessed, severe disproportions, which greatly influence appearance, were noted in about one quarter. In the general face, the most frequent abnormal anthropometric findings contributing to severe disproportions were small upper-face height and a severely high or moderately narrow mandible. In the soft tissues, disproportions included wide nose, small nasal tip protrusion, and short or long columella. Deviations from normality were rarely noted in the nose and upper-lip height, mouth width, total facial height, and width of the upper face. In the upper face, severe disproportions occurred much more frequently in bilateral cleft subjects (67.6%) than in unilateral clefts (30.3%). In the lower face, however, severe disproportions were twice as frequent among unilateral clefts (39.4%) than bilateral (14.7%). The results, although interesting, require complementary preoperative data for reliable analysis of the adult "cleft face."

Comparison of anthropometric and cephalometric measurements of the adult face.

To tabulate and assess quantitative differences between anthropometric and corresponding radiographic cephalometric measurements obtained from the same persons, 19 projective linear measurements were taken from the surface of the heads and faces of 41 patients with cleft lip, cleft palate, or both, all of whom were white North Americans aged 14 to 29 years. They underwent radiographic examination shortly afterward, and corresponding cephalometric measurements were obtained. Differences between the methods were assessed by the numeric differences between the mean values of concurrent measurements. Statistical difference was assessed by paired t test, Pearson product-moment correlations, and intraclass index for degree of agreement between findings. By numeric difference, 6 of 19 anthropometric measurements were similar to (within 2% of) those taken from radiographs. Paired t tests disclosed significant differences between 16 of 19 measurements. Half of the six surface measurements similar to their skeletal counterparts showed no statistical difference; the other half showed only moderately significant differences. Differences between the 13 "dissimilar" measurement pairs (differences > 2%) were highly significant. Good correlations were found in five of the six similar measurements, which may have an important prognostic value in understanding changes in the craniofacial measurements of the face. Knowledge of the correlations between all major measurements of the head and face on the surface and skeleton is essential for anticipating changes in the morphologic characteristics of the growing face.

Digital two-dimensional photogrammetry: a comparison of three techniques of obtaining digital photographs.

Three methods of obtaining digital photographs in a clinical setting were compared using direct anthropometry as a reference standard. The methods included a digital camera, scanning negatives from a 35-mm single-lens reflex camera, and scanning Polaroid photographs taken with a Polaroid camera designed for medical documentation. A total of 11 angular and linear anthropometric measurements obtained from 30 healthy volunteers were used for the comparison. The data were analyzed using a variance covariance approach to repeated measures. The analysis revealed that the three cameras were not statistically different from each other. Other advantages and disadvantages, such as cost and ease of use, are discussed.

Anthropometry of soft-tissue orbits in Bulgarian newborns: norms for intercanthal and biocular widths and length of palpebral fissures in 100 boys and 100 girls.

OBJECTIVE: To establish early postnatal norms for the main measurements of the soft-tissue orbits for the Slavic Bulgarian population (9 million), we measured intercanthal (en-en) and biocular width (ex-ex) and length of the palpebral fissures (ex-en) in a representative sample of newborns less than six days old. METHOD: Eye measurements were taken with a sliding caliper from randomly chosen subjects by the senior author using standard anthropometric methods. Findings were compared to those published for other Caucasian ethnic groups of infants (Germans and two groups of North American Caucasians). RESULTS: The mean values of all three soft orbital measurements were greater in newborn Bulgarian boys than girls. Measurements of Bulgarian intercanthal width (en-en) were greater in both sexes but those of biocular width (ex-ex) and palpebral fissure length (ex-en) were less than those that have been reported for North American Caucasian infants. Bulgarian intercanthal and biocular measurements were wider than German babies in both sexes. Differences, although small, were statistically highly significant but greatly influenced by differing sample sizes and subject age among the four Caucasian populations. CONCLUSION: Anthropometric differences between ethnic groups of Caucasians already exist shortly after birth. Knowledge of the soft orbital data in early stages of the postnatal development in healthy populations is essential for determination in individuals of deviations from normal data. These Bulgarian norms can be helpful in anthropometric studies of the ethnically mixed Caucasian populations of North America.

Craniofacial variability index: a simple measure of normal and abnormal variation in the head and face.

We propose a numerical means of increasing the objectivity of describing, characterizing, and evaluating craniofacial morphology, including dysmorphology. A craniofacial variability index (CVI) can be created for an individual by obtaining a series of anthropometric measurements of the head and face, converting each measurement value to a standardized z-score, and then calculating the standard deviation for the whole set of these z-score values. This value is lowest for those faces in which all of the z-scores are in the same direction and of relatively the same magnitude and highest for faces with pronounced difference in direction and size of the individual z-scores. The CVI has a range of values with an approximately normal distribution in a reference population of 1,312 individuals. Examination of a small sample of individuals with known craniofacial syndromes indicates that the CVI in such cases consistently falls outside of the normal range of the index, and its value is highest in individuals with the greatest subjective degree of facial involvement. Finally, the CVI is robust: age, sex, size of the individual, and changes in the number of variables used in its calculation have little impact on its distribution. When used in conjunction with traditional clinical assessment, the CVI has a number of potential clinical applications including initial diagnostic screening, demonstrating age-related changes in postnatal development of patients with facial syndromes, and pre- and post-surgical assessments of individuals with craniofacial anomalies.

Maxillozygional anthropometric landmark: a new morphometric orientation point in the upper face.

A new anthropometric landmark of the face, called the maxillozygion (mz; right, left) is presented. The bilateral landmark is the most prominent point of the maxillozygomatic suture line, identified by palpation of the most anterior protruding contours on the frontal aspect of the face, located below the lateral third of the right and left bony orbits. The reliability of locating the landmark on both sides of the face by palpation is discussed. Preliminary data determining the position of the maxillozygion in the vertical, sagittal, and horizontal planes in white and Asian sample populations is presented. In general, the Asian face tends to be the same width (zygion [zy]-zy) as the white face; however, the maxillozygion is located more laterally on the Asian face compared with the white face.

Photogrammetric comparison of two methods for synchronous repair of bilateral cleft lip and nasal deformity.

The principle of synchronous repair of bilateral complete cleft lip and nasal deformity is established, and the techniques are evolving. We undertook photogrammetric comparison of the method described by Mulliken (group I, n = 15) and that described by Trott (group II, n = 10). Facial proportions and angles were measured on preoperative and postoperative photographs using defined anthropometric points. The following criteria were quantified for each test group: nasolabial angle, nasal tip angle and projection, nasal width, columellar length and width, and philtral width. All parameters in both groups were compared against each other and against normal age-matched values. Results were analyzed by t test. The nasolabial angle, nasal tip angle, and nasal width were abnormally wide for both techniques (p < 0.01 for both), and there was no difference between them. Nasal tip projection was greater than normal in both techniques (p < 0.01); group I had significantly greater projection than group II (p = 0.02). Columellar length as a proportion of nasal tip protrusion approached normal in group I but was significantly shorter than normal in group II (p < 0.001). Columellar width, as a proportion of nasal width, was normal for both groups. Philtral width, in proportion to nasal width, was normal in group I and abnormally high in group II (p < 0.001). This difference was significant between the two groups (p < 0.001). In a separate cohort of 10 group I patients, the nasolabial angle was measured on lateral photographs taken 1 year post-repair and at intervals to late childhood and adolescence. Nasolabial angle changed with age from obtuse to normal in 7 of 10 patients followed to 9 years of age and in 5 of 6 patients followed until age 15 years. Columellar and upper labial inclination to the vertical were measured in 7 of these patients at 3 to 4 years and again at 13 to 15 years. There was an increase in inclination of both columella and the upper lip, between the ages of 3 to 4 and 13 to 15 years, reflecting improved lip support and growth of septum and lateral cartilages.

Differences in horizontal, neoclassical facial canons in Chinese (Han) and North American Caucasian populations.

To better our ability to analyze the facial disproportions of patients of Chinese ancestry, we compared the validity of four neoclassical canons of facial proportion in Chinese and North American Caucasians populations. We tested the frequency of four horizontal facial canons and their eight variations in 206 healthy adults (105 males and 101 females, 18-25 years old) belonging to the predominant ethnic group (Han: 400 million) of the Chinese population, and compared them to those of 103 healthy young North American Caucasian adults. The nose width corresponded to one-quarter of the face width (the nasofacial canon) significantly more frequently in Chinese participants (51.5%) than in Caucasian adults (36.9%). The nose was narrower than one-quarter of the face width in 38.8% of North American Caucasians and in 21.8% of Chinese; this difference was also statistically significant. In defiance of the naso-oral canon, the mouths of Chinese people were significantly more often narrower than 1.5 times the nose width (71.8%), while in North American Caucasian ethnics the mouth was significantly more frequently wider (60.2%).

Nasal growth after external septoplasty in children.

OBJECTIVE: To assess the impact of external septoplasty surgery on nasal growth in children. DESIGN: Twelve anthropometric measurements (9 linear and 3 angular) were obtained in patients who previously underwent external septoplasty surgery for severe nasal obstruction caused by septal deviation anterior to the nasal spine. Surgery consisted of excision, refashioning, and reinsertion of the quadrilateral cartilage. From these 12 measurements, 5 proportional indexes were calculated, and then all measurements and proportions were compared with previously published norms. Follow-up measurements were taken at least 2 years after surgery (average, 3.4 years). SETTING: The Hospital for Sick Children, Toronto, Ontario, a tertiary care children's hospital. PARTICIPANTS: Twenty-eight patients who underwent external septoplasty surgery between the ages of 6 and 15 years. RESULTS: The principal measurements of the face and nose were within 1 SD of the normative mean for the majority of those in the study group. This was true for nasal height, nasal tip protrusion, nasal width, columella width, columella length, upper face height, face height, face width, inclination of the upper face, inclination of the nasal dorsum, and inclination of the columella. Values for 4 of the 5 proportional indexes were also overwhelmingly in the normal range. Twenty-nine percent of nasal dorsum measurements and 57% of nasal dorsum indexes were more than 2 SDs from the mean, indicating a predominance of short nasal dorsums. CONCLUSIONS: External septoplasty does not affect most aspects of nasal and facial growth, but it may negatively influence growth of the nasal dorsum. Prospective studies are needed to clarify this issue.

Accuracy of anthropometric measurements: past, present, and future.

Experience, based on anthropometric examination of over 1000 children with facial syndromes and more than 2400 healthy subjects of both sexes and various ages, has led me to diverge in some points from the more usual views found in the physical anthropologic literature. The purpose of this paper is to discuss the major controversial topics associated with anthropometric measurement. These include the problems associated with formation of a representative population sample, the relative validity of longitudinal and cross-sectional studies, the interpretation of intraobserver and interobserver testings, and the questionable judgments of mensurative skill in clinical practice. The factors influencing the accuracy of anthropometric measurements, definitions of both the consistent and less reliable measurements, and the duration of validity of anthropometric normative data are also discussed.

Anthropometric craniofacial pattern profiles in Down syndrome.

A series of 21 anthropometric craniofacial measurements was performed on 199 individuals with Down syndrome (DS), age 6 months to 61 years. These were compared to age and sex-matched normal standards, and Z score pattern profiles were constructed. These profiles confirmed brachycephaly and reduced ear length. With increasing age, maxillary growth was reduced in comparison to mandibular growth. Clinically, this was manifested by a change in facial shape from the characteristic round face of infancy to an oval shape in later life. Stepwise forward discriminant function analysis identified a subset of three variables (ear length, maxillary arc, and upper facial depth) which could accurately classify greater than 99% of the individuals in the combined sample of affected and unaffected individuals. Of the subjects with DS, 96.8% were classified correctly. These findings demonstrate the usefulness of anthropometric craniofacial pattern profiles in defining abnormal facial dimensions in particular syndromes and documenting the changes that occur with age. The technique should facilitate syndrome recognition, identification of carriers, and comparisons between syndromes.

External septorhinoplasty in children: Outcome and effect on growth of septal excision and reimplantation.

Outcome and effect on nasal growth of external septorhinoplasty was evaluated in 32 children. All had septal disease anterior to the nasal spine. In all cases, the cartilaginous septum was totally excised, refashioned, and then reinserted. Sixteen children with follow-up for more than 2 years were identified. Nine children had preoperative and postoperative nasal airflow studies and demonstrated a reduction in total nasal airway resistance, from a mean untreated value of 6.1 cm of water per centimeter per second preoperatively to a mean of 2.5 cm of water per centimeter per second postoperatively. IN 10 of these 16 children, six postoperative anthropometric measures and one index were determined, and these measurements were within the range of age- and sex-specific normative data from the Craniofacial Measurements Laboratory at the Hospital for Sick Children, Toronto, Ontario.