Association of Frontal and Lateral Facial Attractiveness.

IMPORTANCE: Despite the large number of studies focused on defining frontal or lateral facial attractiveness, no reports have examined whether a significant association between frontal and lateral facial attractiveness exists. OBJECTIVES: To examine the association between frontal and lateral facial attractiveness and to identify anatomical features that may influence discordance between frontal and lateral facial beauty. DESIGN, SETTING, AND PARTICIPANTS: Paired frontal and lateral facial synthetic images of 240 white women (age range, 18-25 years) were evaluated from September 30, 2004, to September 29, 2008, using an internet-based focus group (n = 600) on an attractiveness Likert scale of 1 to 10, with 1 being least attractive and 10 being most attractive. Data analysis was performed from December 6, 2016, to March 30, 2017. The association between frontal and lateral attractiveness scores was determined using linear regression. Outliers were defined as data outside the 95% individual prediction interval. To identify features that contribute to score discordance between frontal and lateral attractiveness scores, each of these image pairs were scrutinized by an evaluator panel for facial features that were present in the frontal or lateral projections and absent in the other respective facial projections. MAIN OUTCOMES AND MEASURES: Attractiveness scores obtained from internet-based focus groups. RESULTS: For the 240 white women studied (mean [SD] age, 21.4 [2.2] years), attractiveness scores ranged from 3.4 to 9.5 for frontal images and 3.3 to 9.4 for lateral images. The mean (SD) frontal attractiveness score was 6.9 (1.4), whereas the mean (SD) lateral attractiveness score was 6.4 (1.3). Simple linear regression of frontal and lateral attractiveness scores resulted in a coefficient of determination of r2 = 0.749. Eight outlier pairs were identified and analyzed by panel evaluation. Panel evaluation revealed no clinically applicable association between frontal and lateral images among outliers; however, contributory facial features were suggested. Thin upper lip, convex nose, and blunt cervicomental angle were suggested by evaluators as facial characteristics that contributed to outlier frontal or lateral attractiveness scores. CONCLUSIONS AND RELEVANCE: This study identified a strong linear association between frontal and lateral facial attractiveness. Furthermore, specific facial landmarks responsible for the discordance between frontal and lateral facial attractiveness scores were suggested. Additional studies are necessary to determine whether correction of these landmarks may increase facial harmony and attractiveness. LEVEL OF EVIDENCE: NA.

A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness.

IMPORTANCE: Aesthetic proportions of the lips and their effect on facial attractiveness are poorly defined. Established guidelines would aid practitioners in achieving optimal aesthetic outcomes during cosmetic augmentation. OBJECTIVE: To assess the most attractive lip dimensions of white women based on attractiveness ranking of surface area, ratio of upper to lower lip, and dimensions of the lip surface area relative to the lower third of the face. DESIGN, SETTING, AND PARTICIPANTS: In phase 1 of this study, synthetic morph frontal digital images of the faces of 20 white women ages 18 to 25 years old were used to generate 5 varied lip surface areas for each face. These 100 faces were cardinally ranked by attractiveness through our developed conventional and internet-based focus groups by 150 participants. A summed ranking score of each face was plotted to quantify the most attractive surface area. In phase 2 of the study, 4 variants for each face were created with 15 of the most attractive images manipulating upper to lower lip ratios while maintaining the most attractive surface area from phase 1. A total of 60 faces were created, and each ratio was ranked by attractiveness by 428 participants (internet-based focus groups). In phase 3, the surface area from the most attractive faces was used to determine the total lip surface area relative to the lower facial third. Data were collected from March 1 to November 31, 2010, and analyzed from June 1 to October 31, 2016. MAIN OUTCOMES AND MEASURES: Most attractive lip surface area, ratio of upper to lower lip, and dimension of the lips relative to the lower facial third. RESULTS: In phase 1, all 100 faces were cardinally ranked by 150 individuals (internet-based focus groups [n = 130] and raters from conventional focus groups [conventional raters] [n = 20]). In phase 2, all 60 faces were cardinally ranked by 428 participants (internet-based focus groups [n = 408] and conventional raters [n = 20]). The surface area that corresponded to the range of 2.0 to 2.5 × 104 pixels represented the highest summed rank, generating a pool of 14 images. This surface area was determined to be the most attractive and corresponded to a 53.5% increase in surface area from the original image. With the highest mean and highest proportions of most attractive rankings, the 1:2 ratio was deemed most attractive. Conversely, the ratio of 2:1 was deemed least attractive, having the lowest mean at 1.61 and the highest proportion of ranks within 1 with 310 votes (72.3%). CONCLUSIONS AND RELEVANCE: Using a robust sample size, this study found that the most attractive lip surface area represents a 53.5% increase from baseline, an upper to lower lip ratio of 1:2, and a surface area equal to 9.6% of the lower third of the face. Lip dimensions and ratios derived in this study may provide guidelines in improving overall facial aesthetics and have clinical relevance to the field of facial plastic surgery. LEVEL OF EVIDENCE: NA.

Morphometric facial analysis: a methodology to create lateral facial images.

INTRODUCTION: Currently, the majority of research in facial analysis using computational morphing methods focuses exclusively on analysis of frontal facial projections. Lateral facial morphing analysis has not been extensively investigated, and landmark features critical to specify registry points are unknown. This study aims to (1) determine the quantity of registry points (RP) required to create realistic lateral faces and (2) determine key facial registry point landmarks required to create synthetic lateral faces. METHOD: 36 synthetic lateral faces with a 50 to 250 RP were created to determine the ideal quantity of RP to create a realistic lateral image; ear, eyebrow, eye, nose, lips, hairline, facial outline, and overall outline were evaluated by an expert panel of seven evaluators using a 1 to 5 point Lickert scale rating system. RESULT: ANOVA single-variable analyses revealed significant differences when comparing templates of 200 and 250 RP with 50 and 100 RP templates (p < 0.05). Furthermore, analysis of all key landmark areas of the face indicated significant differences between different registry points except for 200 and 250 registry point markers. Kruskal-Wallis statistical analysis revealed the landmarks varied significantly from 50 to 200 RP,but had no significance with 200 and 250 RP. CONCLUSION: The most ideal quantity of RP used for the creation of realistic lateral faces was in the range of 200 RP. Defined lateral facial registry point landmarks generated successful realistic faces.

The virtual focus group: a modern methodology for facial attractiveness rating.

BACKGROUND: Traditional focus groups have been essential to facial aesthetics research. Although they are currently the criterion standard in acquiring facial attractiveness ratings, they retain many shortcomings. This study's objectives were twofold: to determine whether attractiveness scores obtained from a social network site correlate with those from the traditional focus group method; and to evaluate whether this methodology could be a superior tool in evaluating facial attractiveness. METHODS: Forty facial portraits were rated for attractiveness scores using three different subject recruitment methods: traditional live focus groups (n = 123 raters), Internet-based rating (n = 857 raters), and a novel method using a combination of focus groups and a social network site (i.e., Facebook) (n = 1775 raters). Each facial image was scored on a 10-point Likert scale. Regression analysis compared each approach to the traditional method. RESULTS: The methods varied in terms of data accrual time, rater demographics/ages, researcher's accessibility, necessity for subject incentives, researcher labor, and rater effort/accuracy. A strong correlation (0.922) existed between the online social network-based rating and focus group method. A minimum of 992 raters achieved stabilization of the attractiveness scores using social network-based rating. CONCLUSIONS: This study shows significant advantages to using a social network site-based method over both Internet-based rating and traditional focus groups for evaluating facial attractiveness. The main benefits include exponential increase in raters, minimized researcher time/labor, rater scores comparable to those of the focus group method, nonnecessity of rater monetary incentives, and selectable demographics/ages of raters.

The Persian woman's face: a photogrammetric analysis.

BACKGROUND: The aim of this study was to establish normative quantitative anthropometric measurements of the Persian woman's face and assess differences from established North American White women's measurements. METHODS: Standard photographs (frontal, left lateral, and base views) of 107 Persian women volunteers (both parents of Persian ancestry) between the ages of 18 and 40 were digitally acquired. Twenty-six standard anthropometric measurements were obtained using Adobe Photoshop. The results were compared with those previously published for North American White women using an unpaired t test with differences being considered significant if p<0.05. RESULTS: A statistically significant difference was found between Persian women and North American White women in 18 of 26 anthropometric measurements. CONCLUSION: The anthropometric differences between Persian women and North American White women reflect fundamental differences in the osseochondrous scaffold and soft tissue covering of the face. These differences partially account for the disharmony and loss of ethnic identity that occurs when surgery is planned using classical canons. For patients wishing to maintain their ethnic features following aesthetic surgery, access to ethnicity-specific normative anthropometric data will help guide the surgeon to achieve this goal. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Nasal tip projection and facial attractiveness.

OBJECTIVES/HYPOTHESIS: Six nasal tip projection (NTP) ratios from Goode, Simons, Baum, Powell, and Crumley guide clinical and academic practice on quantifying NTP, but none have been empirically correlated with facial attractiveness. This study's objectives were to determine: 1) if there is a correlation between these ratios and facial attractiveness; and 2) which of the six ratios has the greatest linkage to overall facial attractiveness. STUDY DESIGN: Basic research study. METHODS: There were 300 digital portraits of women (ages 18-25 years) randomly paired and morphed to create 300 synthetic lateral facial images rated by 78 raters in the community. NTP ratios were measured in each portrait. RESULTS: None of the ratios correlated with facial attractiveness. For the Baum, Powell, and Simons ratio, facial attractiveness increased as NTP deviated 1 and 2 standard deviations from the ideal, whereas facial attractiveness decreased as NTP deviated from the Goode and Crumley ideal ratios. The most attractive faces had NTP ratios consistent with previous expert opinion findings. CONCLUSIONS: To our knowledge, this is the first study to empirically correlate these six landmark NTP ratios with facial attractiveness. Although there was no correlation with any of the six ratios, the ideal ratios proposed by Goode and Crumley impacted facial aesthetics the most. Although the ideal ratios are useful in establishing rhinoplasty guidelines, they should only be used as a part of the management in achieving an aesthetic face on the whole, as they may not be robust enough to correlate with overall facial attractiveness.

Needle electrode-based electromechanical reshaping of rabbit septal cartilage: a systematic evaluation.

Electromechanical reshaping (EMR) provides a means of producing shape change in cartilage by initiating oxidation-reduction reactions in mechanically deformed specimens. This study evaluates the effect of voltage and application time on specimen shape change using needle electrodes. Rabbit septal cartilage specimens (20 x 8 x 1 mm, n = 200) were bent 90 degrees in a precision-machined plastic jig. Optimal electrode placement and the range of applied voltages were estimated using numerical modeling of the initial electric field within the cartilage sample. A geometric configuration of three platinum needle electrodes 2 mm apart from each other and inserted 6 mm from the bend axis on opposite ends was selected. One row of electrodes served as the anode and the other as the cathode. Constant voltage was applied at 1, 2, 4, 6, and 8 V for 1, 2, and 4 minutes, followed by rehydration in phosphate buffered saline. Samples were then removed from the jig and bend angle was measured. In accordance with previous studies, bend angle increased with increasing voltage and application time. Below a voltage threshold of 4 V, 4 minutes, no clinically significant reshaping was observed. The maximum bend angle obtained was 35.7 ± 1.7 º at 8 V, 4 minutes.

Optical coherence tomography of cholesteatoma.

OBJECTIVES: To image cholesteatoma using optical coherence tomography (OCT) and correlate the results with clinical findings and conventional observations obtained using binocular microscopy and histology. OCT is a high-resolution optical imaging modality that generates cross-sectional images of turbid media, such as tissue with resolution approaching that of light microscopy. OCT relies on intrinsic differences in tissue optical properties for image contrast. STUDY DESIGN: In vivo prospective clinical study. SETTING: University Medical Center. PATIENTS: Patients with cholesteatoma undergoing otologic surgery. INTERVENTION: Using a commercial OCT imaging system, we obtained cross-sectional images (resolution, approximately 10 microm; depth penetration, approximately 1 mm) of cholesteatomas. MAIN OUTCOME MEASURES: Images are obtained by raster scanning a single mode fiber across the interior of the probe. The imaging probe is sterilized and inserted into the middle ear or mastoid under microscopic guidance, and still images of the middle ear or mastoid mucosa and cholesteatoma when present were obtained. RESULTS: OCT images of cholesteatomas demonstrate differences in signal intensity, which are distinct from those of normal or inflamed middle ear/mastoid mucosa. Identification of keratin in cholesteatoma, even if very thin, distinguished it from inflamed mucosa. CONCLUSION: This is the first study that systematically used OCT to image cholesteatoma during otologic surgery. Cholesteatomas can be distinguished from normal or inflamed adjacent mucosa.

A web-based method for rating facial attractiveness.

OBJECTIVES/HYPOTHESIS: To determine if facial attractiveness scores from a novel Internet-based facial attractiveness rating method correlate with those from the traditional focus group rating method, and whether this method can be an alternative for rating and evaluating facial attractiveness. STUDY DESIGN: Basic research study. METHODS: Eighty facial portraits were posted on a commercial Internet-based facial rating website to obtain facial attractiveness scores. These scores were correlated and compared with traditional focus group scores. RESULTS: In 21 days an average sample size of 857 raters were recruited and the attractiveness scores reached a stable mean on the Web. There was a strong correlation (0.90) and attractiveness score quartile match between the Internet-based and traditional focus group scores, with the most attractive and unattractive faces having the highest correlation and quartile match. The inter-rater variability of the Internet-based method was low (P = .82). CONCLUSIONS: The Internet-based method can be an effective alternative to the traditional live focus group method of evaluating facial attractiveness. It also has five main advantages: 1) profoundly increases rater count; 2) increases rate of data accrual and analysis; 3) results are reproducible; 4) eliminates logistical and monetary obstacles; and 5) enables the experimenter to sweep broad demographics, acquire background data from raters, and locate raters with specific expertise.

A new approach in determining lateral facial attractiveness.

INTRODUCTION: The current literature on facial attractiveness focuses on anterior-posterior facial portraits, with lateral facial analysis limited to comparing facial attractiveness scores with various facial measurements. Here we use a novel approach to more rigorously study lateral facial attractiveness by combining morphing software and a genetic algorithm with web-based facial attractiveness scoring to evolve attractive lateral facial images. OBJECTIVE: The objectives of this study were to: 1) identify the key lateral facial landmarks that produce realistic lateral facial images; and 2) determine if a genetic algorithm combined with morphing software can progressively evolve lateral facial attractiveness. METHODS: A cohort of lateral facial portraits were selectively paired by a genetic algorithm biased towards more attractive faces, and "bred" with morphing software to create a cohort of faces more attractive than the original. By repeating this process facial attractiveness was "evolved" through several cohorts. RESULTS: Key facial landmarks are: trichion to glabella, nasion to tip of nose, subnasale to labrale inferius, and pogonion to menton. Facial attractiveness scores increased in each successive cohort. CONCLUSION: Using these landmarks and methodologies, realistic lateral facial portraits were created and progressively increased in facial attractiveness. This technique is a robust alternative to traditional approaches in the analysis of lateral facial attractiveness.

Antibiotics in head and neck surgery in the setting of malnutrition, tracheotomy, and diabetes.

OBJECTIVES/HYPOTHESIS: The objectives of this study are to compare short vs. long antibiotic prophylaxis in the setting of malnutrition, diabetes, and tracheotomy. STUDY DESIGN: Retrospective chart review. METHODS: The charts of 407 patients undergoing clean-contaminated head and neck surgery were reviewed for disease type, operation performed, length of antibiotic prophylaxis, wound complications, and length of hospital stay. Three intrinsic patient risk factors for infection (malnutrition, diabetes mellitus, and tracheotomy) were evaluated for an effect on the optimal length of antibiotic prophylaxis. The data was statistically analyzed using the two-tailed Fisher's exact test. RESULTS: Overall, the incidence of infection was 7% in short-course antibiotics and 13% in long-course antibiotics (P = .06). The incidence of infection was 18% in malnourished patients and 3% in well-nourished patients (P < .0001). In malnourished patients, the incidence of infection was 16% in short-course antibiotics and 19% in long-course antibiotics (P = 1). The incidence of infection was 11% in diabetics and 23% in nondiabetics (P = .13). In diabetic patients, the incidence of infection was 0% on short-course antibiotics and 16% on long-course antibiotics (P = .55). The incidence of pneumonia was 14% in patients with tracheotomy and 5% in patients without tracheotomy (P = .0014). In patients with tracheotomy, the incidence of pneumonia was 8% on short-course antibiotics and 15% on long-course antibiotics (P = .6931). CONCLUSIONS: Malnutrition and tracheotomy were associated with a higher infection rate while diabetes was not found to be a risk factor. Prolonged antibiotics were not associated with a lower infection rate in the overall group or in any subgroup.

Evolving attractive faces using morphing technology and a genetic algorithm: a new approach to determining ideal facial aesthetics.

OBJECTIVES: The objectives of this study were to: 1) determine if a genetic algorithm in combination with morphing software can be used to evolve more attractive faces; and 2) evaluate whether this approach can be used as a tool to define or identify the attributes of the ideal attractive face. STUDY DESIGN: Basic research study incorporating focus group evaluations. METHODS: Digital images were acquired of 250 female volunteers (18-25 y). Randomly selected images were used to produce a parent generation (P) of 30 synthetic faces using morphing software. Then, a focus group of 17 trained volunteers (18-25 y) scored each face on an attractiveness scale ranging from 1 (unattractive) to 10 (attractive). A genetic algorithm was used to select 30 new pairs from the parent generation, and these were morphed using software to produce a new first generation (F1) of faces. The F1 faces were scored by the focus group, and the process was repeated for a total of four iterations of the algorithm. The algorithm mimics natural selection by using the attractiveness score as the selection pressure; the more attractive faces are more likely to morph. All five generations (P-F4) were then scored by three focus groups: a) surgeons (n = 12), b) cos-metology students (n = 44), and c) undergraduate students (n = 44). Morphometric measurements were made of 33 specific features on each of the 150 synthetic faces, and correlated with attractiveness scores using univariate and multivariate analysis. RESULTS: The average facial attractiveness scores increased with each generation and were 3.66 (+0.60), 4.59 (+/-0.73), 5.50 (+/-0.62), 6.23 (+/-0.31), and 6.39 (+/-0.24) for P and F1-F4 generations, respectively. Histograms of attractiveness score distributions show a significant shift in the skew of each curve toward more attractive faces with each generation. Univariate analysis identified nasal width, eyebrow arch height, and lip thickness as being significantly correlated with attractiveness scores. Multivariate analysis identified a similar collection of morphometric measures. No correlation with more commonly accepted measures such as the length facial thirds or fifths were identified. When images are examined as a montage (by generation), clear distinct trends are identified: oval shaped faces, distinct arched eyebrows, and full lips predominate. Faces evolve to approximate the guidelines suggested by classical canons. F3 and F4 generation faces look profoundly similar. The statistical and qualitative analysis indicates that the algorithm and methodology succeeds in generating successively more attractive faces. CONCLUSIONS: The use of genetic algorithms in combination with a morphing software and traditional focus-group derived attractiveness scores can be used to evolve attractive synthetic faces. We have demonstrated that the evolution of attractive faces can be mimicked in software. Genetic algorithms and morphing provide a robust alternative to traditional approaches rooted in comparing attractiveness scores with a series of morphometric measurements in human subjects.