Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

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Journal of Cranio-Maxillo-Facial Surgery

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Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches

Nina Franka Berlin a, Philipp Berssenbrgge a, *, Christoph Runte a, Kai Wermker b, Susanne Jung c, Johannes Kleinheinz c, Dieter Dirksen a
a Department of Prosthetic Dentistry and Biomaterials (Prof. Dr. Med. Dr. Med. Dent. Ludger Figgener), University of Mnster, Albert-Schweitzer-Campus 1, Building W30, 48149 Mnster, Germany b Fachklinik Hornheide fr Tumoren und Wiederherstellung an Gesicht und Haut, University of Mnster, Dorbaumstr. 300, 48157 Mnster, Germany c Department of Maxillofacial Surgery, University of Mnster, Albert-Schweitzer-Campus 1, Building W30, 48149 Mnster, Germany

a r t i c l e i n f o
Article history: Paper received 31 October 2012 Accepted 17 July 2013 Keywords: Review Face Facial asymmetry

a b s t r a c t
Introduction: Symmetry has been found to play a crucial role in attractiveness assessment and so its restoration is an essential problem in oral maxillofacial surgery. This paper presents an overview of recent 2D asymmetry analysis techniques. These are techniques which are based on the evaluation of two-dimensional data, like photos. The aim of this paper is to nd the most precise and practical techniques to investigate facial asymmetry. Materials and methods: For this purpose studies addressing symmetry investigations are collected and categorized by the type of data they extract from the photos. The reference points on the facial surface, which are frequently used in these studies, are presented and calculation methods are described. Results: Three kinds of techniques using vertical or horizontal reference lines or centres of bilateral points appear to be most appropriate. Recommendations are made, which aspects should be taken into account when calculating symmetry/asymmetry indices from photos. Advantages and disadvantages of the three selected methods are summarized in a table. Conclusions: Using one of the three recommended approaches denoted by FA, AI and z-score allows calculating meaningful asymmetry values. The proper selection and identication of reference points is crucial. For highest accuracy, a sufcient number of evenly distributed and reproducible reference points should be used. 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

1. Introduction For centuries a key to making concepts like beauty and attractiveness measurable has been searched for (Koury and Epker, 1992). Artists, like da Vinci, as well as physicians have dealt with this subject. They have tried to combine single factors of attractive faces in norms or principles and thus understand them (Farkas et al., 2005; Bashour, 2006b; Edler et al., 2006; Mizumoto et al., 2009). Several theories, like the golden ratio as a basic principle of harmonious shapes (Mizumoto et al., 2009), rules of harmonious facial proportions (Koury and Epker, 1992; Farkas et al., 2005; Hnn and Gz, 2007) or baby faceness as a factor of attractiveness in female faces (Braun et al., 2001) have been investigated in this context. Beyond that, it is known that potential rules for attractive

* Corresponding author. Tel.: 49 251 8343753; fax: 49 251 8347182. E-mail address: berssenbruegge@uni-muenster.de (P. Berssenbrgge).

faces are not universal but differ in different ethnic groups. Farkas et al. (2007) have researched this topic. Bashour (2006a) has tried to determine attractiveness objectively as the measurable correspondence of a face with a pattern (phi mask) postulated as being ideal. The pattern was created based on the golden ratio and other mathematical features like the Fibonacci sequence or logarithmic spirals. Recently, there is growing evidence in the anthropological research that symmetry and averageness are important additional keys to the attractiveness of human faces (Enquist and Arak, 1994; Mller and Thornhill, 1998; Thornhill and Gangestad, 1999; Faure et al., 2002; Baudouin and Tiberghien, 2004; Farkas et al., 2005; Edler et al., 2006; Bashour, 2006b; Rhodes, 2006; Little and Jones, 2006; Jones et al., 2007; Hnn and Gz, 2007; Zaidel and Deblieck, 2007; Springer et al., 2007; Komori et al., 2009). At the same time, the question arises as to how the aspects of symmetry and averageness are related to each other and which of them is more important (Hnn and Gz, 2007; Jones et al., 2007; Borelli and

1010-5182/$ e see front matter 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.07.033

Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

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Berneburg, 2010). Enquist and Arak (1994) were able to prove that symmetric abstract patterns are rated more attractive than asymmetric ones. They assumed that this preference in perception arises as a by-product of the need to recognize objects irrespective of their position and orientation in the eld of vision. Proofs have been found that symmetry occurring in different parts of the face has varying signicance. Generally, its inuence near the midline is larger, while in the marginal areas of very attractive faces minor asymmetric features can possibly even increase the aesthetics (Hnn and Gz, 2007; Springer et al., 2007; Borelli and Berneburg, 2010). Naevi, known as beauty marks can have this effect. Perfectly symmetric faces are not perceived as maximally attractive (Zaidel and Deblieck, 2007). In surgery, symmetry investigations make an important contribution to the planning of operations and evaluation of different surgical procedures (Bashour, 2006b). As reported in the literature, such investigations are often linked with surgical procedures concerning the correction of a cleft lip and palate (Stauber et al., 2008; Nkenke et al., 2006; Schwenzer-Zimmerer et al., 2008). Until now, 2D analysis techniques have been mainly used. Usually photos are surveyed, and in most cases points of the face in a frontal view are determined and their symmetry is investigated, often by means of a base line. Some authors additionally or exclusively utilize radiographs of the cranium without being able to analyse any external soft tissue. Newer approaches, evaluating 3D data, are not mentioned in this paper because the measuring systems are still not very common and the comparability of the different methods has still to be investigated. A face specic symmetry/asymmetry value is calculated from the acquired data using different techniques. This can be used to compare the symmetry characteristics of a face before and after an operation and with other faces. In this paper an overview is given of techniques recently published and their applicability is discussed. To address the problem of some vague descriptions found in the literature, the main relations are summarized concisely in unambiguous mathematical formulas. 2. Materials and methods 2.1. Selection of the studies In this paper, only studies addressing symmetry investigations of human faces, which are available in the PubMed data base, are taken into account. The primary goal of this work is to nd 2D analysis techniques which determine a face specic, objective and quantitative symmetry/asymmetry value based on soft-tissue landmarks. Terms used for the search in PubMed were: facial asymmetry, facial symmetry, analysis, soft-tissue analysis, 2D-analysis, 2Dmeasurements, photographs, diagnostic methods. To be included, studies had to contain detailed descriptions of the techniques applied concerning the following aspects: - selection of subjects (age, sex, number, state of health (healthy, pre-/postoperative, genetic disorders, other diseases), ethnic heritage - usage of photos taken especially for the investigation or already existing ones or measurement directly at the subject - investigation of the entire face or aspects of it, respectively - photography of the subjects: used camera, positioning of the camera and the subjects, lighting conditions, camera settings, neutral facial expression - image processing, image resolution, image size, documented and considered reproduction scale, digital or analogue processing

- repetitions of the measurements in order to enhance the accuracy (on the same or different day) - precise description and reproducible selection of facial reference points - comprehensible documentation of the calculations. All publications only met these criteria partially, sometimes lacking crucial information necessary for the understanding. Not all authors made calculations to obtain an objective symmetry value. However, these studies were included as well in order to nd out typically used face reference points and measuring techniques. The publications date from 1994 to 2011 and include 11 to 1282 subjects aged between >1 and 41.7 years. 3. Results After presenting an illustration of the most commonly used anatomical reference points the different concepts for a description of facial symmetry aspects are explained. For each we describe how quantitative parameters for an evaluation of facial symmetry are calculated. 3.1. Frequently used reference points Fig. 1 shows an overview of the most frequently used reference points. 3.2. Usage of horizontal distances from a vertical reference line (median sagittal plane) One method described is to measure the distances from bilateral points to the reference plane. This is an analysis of the horizontal component (Nakamura et al., 2001; Song et al., 2007; Little et al., 2008). A second technique determines the difference in height of lines which pass through bilateral points and are perpendicular to

Fig. 1. Some reference points frequently used: upper centre of the hair line tr, upper centre of the eyebrow eup, inner corner of the eye en, outer corner of the eye ex, nasion n, upper corner of the ear aup, outermost point of the zygomatic arch zy, lower corner of the ear ado, lateral margin of the nasal wing, outermost point an, lowermost point of the centre of the nose, subnasale sn, corner of the mouth ch, topmost centre of the upper lip lup, lowermost point of the lower lip ldo, centre of the lips st, outermost point of the angle of the mandible m, gnathion gn, pupil p.

Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

N.F. Berlin et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

the median sagittal line. This gives an analysis of the vertical component. Fig. 2 illustrates these two approaches. 3.2.1. Calculation of a symmetry value For this purpose, Nakamura et al. (2001) introduced the asymmetry index AI given as a percentage. A median sagittal line is constructed and subsequently the distances of bilateral points from this line are measured. The asymmetry index is calculated as follows:

being the bipupillary line and the y-axis being the median sagittal line. Its origin is located approximately at n as depicted in Fig. 3. 3.3.1. Calculation of a symmetry value Calculations of a symmetry value obtained by using only a horizontal reference line have not been published. However, the combination of values obtained via the median sagittal line and a horizontal reference line has been mentioned in literature. Baudouin and Tiberghien (2004) use a technique which involves single points (points lying more or less on the median sagittal line) as well as bilateral pairs of points. The symmetry index calculated by Baudouin does not represent an absolute value, but rather a relative measure with respect to the group of faces under investigation. This technique takes into account vertical as well as horizontal symmetry by using signed x- and y-coordinates. Initially, for each pair of values an individual symmetry value is calculated: For bilateral points it is dened as the absolute value of the sum of their x-coordinates (vertical component) or as the absolute value of the difference between their y-coordinates (horizontal component). For single points, only the vertical symmetry can be specied as the absolute value of the x-coordinate. The symmetry value of the entire face (named z-score) is then calculated as:
n 1X xi xi : n i 1 si

  d R d L   AI  d d :
R L

dR and dL denote the measured distances on the right side and on the left side of the face, respectively. As this formula contains the ratio of the difference of the distances to their sum, an overweighting of large distances is avoided. A perfectly symmetric face would result in AI 0%. Increasing asymmetry means an increasing value of AI. Due to the absolute value, AI does not indicate in which direction single components of the face deviate from symmetry. Nakamura et al. (2001) have specied an individual AI for each pair of bilateral reference points. An overall face specic asymmetry index has not been calculated by the authors although it could easily be done by averaging multiple AI. 3.3. Use of vertical distances from a horizontal reference line A vertical asymmetry is dened by means of differing distances of bilateral points from the bipupillary line, which serves as a horizontal reference line (Altuc-Atac et al., 2008; Yamashita et al., 2009; Gosla-Reddy et al., 2011). Both techniques involving a reference line (either vertical or horizontal) are also applied in combination (Baudouin and Tiberghien, 2004; Fong et al., 2010). Baudouin and Tiberghien use a coordinate system with the x-axis

z score

Here, xi denotes the symmetry value of a single point or of a pair of points for one direction calculated for an individual face, while xi denotes the average of this variable over the reference group and si its standard deviation. In this way, a partial z-score is calculated for each measured variable of the regarded face. Subsequently, a total face specic z-score is obtained by averaging over all variables of

Fig. 2. First, the median sagittal line, which passes through n and sn in this case, is constructed. Then the differences in height and the distances from the vertical of bilateral points can be measured.

Fig. 3. By constructing a horizontal reference line (passing through points rarely affected by asymmetries) as well as a vertical reference line, measurements in vertical and horizontal directions are possible. Fong et al. (2010) additionally use line segments which can be measured on both sides and may be compared in the same way as the distances. Moreover, they compare bilateral angles.

Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

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one face. The analogous calculations of an overall vertical symmetry and an overall horizontal symmetry are described in (Baudouin and Tiberghien, 2004), too. As the z-score denes a relative symmetry value in comparison to a reference group, z-score values <0 indicate a lower symmetry than the average, while values >0 indicate a higher symmetry. The AI described above (Section 3.2) could also be utilized in a combined investigation of vertical and horizontal asymmetry as it has been done by Fong et al. (2010). However, neither this author nor others have applied the AI in this context. 3.4. Usage of distances without a reference line For this method, bilateral points are connected by straight lines. The distance in the horizontal direction between the centres of two lines is then measured in pixels or millimetres (Fig. 4). This gives a measure of the symmetry as described in (Grammar and Thornhill, 1994; Rikowski and Grammar, 1999; Scheib et al., 1999; PentonVoak et al., 2001). 3.4.1. Calculation of a symmetry value The centres mi of bilateral points (i.e. the absolute values of the x-coordinates) on the left xli and on the right xri are calculated as:

FA is the so-called overall facial asymmetry, which is the sum of horizontal differences between all centres. The central facial asymmetry (CFA), on the other hand, is the sum of horizontal differences only between neighbouring centres. In this case, multiple values per face are obtained. They allow analysis of the local symmetry characteristics of the face (Grammar and Thornhill, 1994; Scheib et al., 1999). Similar to the description above, the vertical symmetry can be investigated as well. The vertical deviations of corresponding points are measured in pixels or millimetres. The sum of these values results in a variable, specifying the symmetry. Grammar and Thornhill (1994) described this technique in detail. Scheib et al. (1999) use a similar method for a vertical analysis of symmetry by means of differences in height of reference points, but it remains unclear whether or not a horizontal reference line has been used. 3.5. Usage of angles Here, the angles between straight lines, each connecting two reference points, are evaluated. In the case of an ideal symmetry these lines would be parallel. This technique is applied using horizontal lines (Hwang et al., 2007; Song et al., 2007; Altuc-Atac et al., 2008; Yamashita et al., 2009; Yu et al., 2009) as well as vertical lines (Danel and Pawlowski, 2007; Yu et al., 2009; Fig. 5). In some cases, reference lines, such as the median sagittal line or the bipupillary line are used. Vertical reference lines are used especially in order to investigate the midface and the lower face (Danel and Pawlowski, 2007; Yu et al., 2009). 3.5.1. Calculation of a symmetry value In one paper the asymmetry is estimated as the sum of angles as well. Both vertical and horizontal angles are included. Examples are: the angle between the bipupillary line and the line connecting

  xri xli   mi   2 :
In the next step, the horizontal distances between the centres are determined. This obviates the need for the construction of a median sagittal line. The sum of absolute values of all differences of the N centres mi provides the face specic asymmetry value:

FA

X i; j 1; N j<i

  mi mj 

Fig. 4. Centres of bilateral points for a determination of symmetry without using a reference line.

Fig. 5. Investigation of the symmetry characteristics in the lower face using the median sagittal line: The angle between the nearly vertical line through two points and the vertical reference line is measured.

Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

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the corners of the mouth; the angle between a vertical reference line and the line passing through the nasion and a second point, which in the ideally symmetric case would be located on the median sagittal line. In the symmetric face the sum of angles equals zero. Song et al. (2007) use only the rst angle. The sign of the angle denes which side of the face is dominant. Yu et al. (2009) use multiple angles, one horizontal and three vertical. 3.6. Area of the face in the frontal view Area measurements of parts of both sides of the face (Legovi c et al., 2001), of the lower face (Edler et al., 2001, 2002, 2003; Good et al., 2006) as well as of the nares (by using a photo taken from below) (Gosla-Reddy et al., 2011) have been published. In order to calculate the area, rst the outline has to be determined. As the adjacent hair can interfere with measurement, the authors Edler et al. (2001, 2002, 2003) and Good et al. (2006) restrict the measurement to the lower face. In addition to the outline and the area, the latter authors calculate the compactness, which is the squared length of the outline divided by the area, the centre of area and its distance from the median line. Using these variables allows them to make statements about symmetry. 3.6.1. Calculation of a symmetry value The method proposed by Legovi c et al. (2001) does not require the identication of any reference points except for those used for the determination of a line of symmetry. Parts of the left and right side of the face areas are calculated and compared using millimetre paper on photos. Edler et al. (2001, 2002, 2003) and Good et al. (2006) use only a few reference points (point ado on both sides) and utilize the outline, the area, the compactness and the centre of the area as described above. 3.7. Other methods In some reported cases parts of the outline of the face on both sides are also utilized. For example, Altug-Atac et al. (2008) measure the length of the outline between bilateral points (Fig. 6). In several of the articles considered no face specic symmetry value is calculated and only single variables are analysed (Edler et al., 2001, 2002, 2003; Altug-Atac et al., 2008; Yamashita et al., 2009; Gosla-Reddy et al., 2011). Eskelsen et al. (2009) assign faces to the categories symmetric or asymmetric. Danel and Pawlowski (2007) determine the facial symmetry characteristics by just one single vertical angle in order to decide whether the left or the right side of the face is dominant. 4. Discussion The techniques chosen to measure the variables inevitably result in different methods to obtain a face specic, quantitative symmetry value. Techniques which only measure single angles or the outline, or calculate the facial area cannot be recommended for an analysis of the entire face. However, they may be adequate for investigating partial aspects of facial symmetry. This is because these methods use too few reference points or omit features inside the outline of the face. When analysing the face without the use of a reference line, the technique of calculating the FA (overall facial asymmetry, see 3.4) seems most recommendable (Grammar and Thornhill, 1994; Rikowski and Grammar, 1999; Scheib et al., 1999; Penton-Voak et al., 2001). When multiple faces are to be compared, a reproducible alignment of the faces should be ensured. This is quite similar to the use of a reference line.

Fig. 6. The partial outline shown here is the most frequently used.

In contrast, when using a technique with one vertical reference line, the calculation of several AI values (Nakamura et al., 2001) and subsequent averaging seems appropriate to obtain a face specic asymmetry value. However, this approach has not been covered in literature so far. When using both a horizontal and a vertical reference line, a technique similar to the calculation of the z-score (Baudouin and Tiberghien, 2004) can be recommended, but instead of calculating a relative symmetry value linked to a reference group, the symmetry value should rather be dened in absolute terms like the AI in order to be more universal. It is essential to choose from the measuring techniques introduced those which are practical and precise. When taking photos of the subjects, a consistent image scale is essential. A comprehensive list of instructions for clinical photography in cranio-maxillo-facial surgery concerning illumination, views, technical advices and common mistakes is described and discussed in (Ettorre et al., 2006) and (Schaaf et al., 2006). Several independent examiners should determine the reference points. This would simplify the detection of mistakes and allow for a determination of statistical accuracy. Only accurately reproducible reference points should be taken into account. The points en, ex, p, ch can be identied unambiguously, while the location of the points zy, sn, lup, ldo, st, m, eup, tr, aup, ado has to be, at least partly, estimated. In general, not all athropometric landmarks are identiable in clinical photogrammetric techniques with high precision and reproducibility. A detailed comparison of anthropometry with photogrammetry is made by Han et al. (2010). All points covered by hair, hidden in some way or cut off from the image are difcult to reproduce. It is crucial to nd the optimal number of reference points. Using a large number of points increases accuracy but also leads to additional expenses. Points with a lower reproducibility can be omitted in order to reduce their overall number. Similar to Fig. 1, the points should be distributed evenly in the face and cover all areas relevant

Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

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Table 1 Advantages and disadvantages of the most recommendable 2D analysis techniques of facial asymmetry. Technique FA overall facial asymmetry as a sum Short description No use of a reference line; vertical and horizontal symmetry characteristics can be determined. Vertical reference line; individual symmetry values for pairs of points; overall asymmetry index could be calculated by averaging; also applicable with a horizontal reference line. Advantages No errors related to the construction of reference lines; simple calculation. Clear results in %; simple calculation. Disadvantages No statement about which is the dominant half of the face; only bilateral points usable; dependency on the number of reference points. Errors associated with the construction of the reference line are possible; no procedure to calculate an overall asymmetry index published; no statement about which is the dominant half of the face; only applicable with bilateral points. Relative values, only useful in connection with the investigated group; no statement about which is the dominant half of the face.

AI asymmetry index in %

z-score relative symmetry value in comparison to a reference group

Use of a horizontal and vertical reference line; relative symmetry value with respect to a reference group.

Horizontal and vertical aspects are taken into account; points lying on the median sagittal line are included.

for the symmetry characteristics, especially the nose, the eyes and the mouth. The construction of a reference line may cause problems as well: When a line is dened that passes through two reference points, errors may occur if these points are not exactly placed on the median in the case of a vertical reference line. The same may happen, if they are not placed at the same height in the case of a horizontal reference line, which can occur in asymmetric faces. According to the criteria mentioned above the techniques regarded as recommendable are summarized in Table 1 along with the advantages and disadvantages of each approach. 5. Conclusions Three techniques denoted by FA, AI and z-score are recommended for determining an asymmetry value of the face from 2D images. For highest accuracy, an adequate number of evenly distributed and reproducible reference points should be used, which cover all areas signicant for symmetry (see Fig. 1). Several independent examiners should determine the reference points in order to reduce the uncertainty of subjective identication. For future work, a comparison of facial asymmetry analysis techniques based on 2D data with those based on 3D data would be an interesting task. A further question that arises in this context is, what relations might exist between objective quantication of facial asymmetry and subjective perception. Financial support Deutsche Krebshilfe (German Cancer Aid). Acknowledgement The presented study has been carried out within the frame of an interdisciplinary project in which the computer aided construction of facial prostheses based on optically acquired data is investigated. Financial support by the Deutsche Krebshilfe (German Cancer Aid) is gratefully acknowledged. References
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Please cite this article in press as: Berlin NF, et al., Quantication of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033