ANTHROPOMETRIC ANALYSIS OF LIP-NOSE

COMPLEX AMONG THE IGBO POPULATION

IN UMUAHIA, ABIA STATE

BY

DR. UGOCHUKWU OGBONNA

A DISSERTATION SUBMITTED TO THE FACULTY OF SURGERY, NATIONAL

POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL

FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE

FELLOWSHIP OF THE COLLEGE IN PLASTIC SURGERY

MAY, 2015

DECLARATION

1

I hereby declare:

1. That I am the sole author of this dissertation.

2. That all the references cited were consulted by me.

3. That I conducted this research work and acknowledge any assistance received in

the course of the study.

4. That this dissertation has not been submitted to any other institution for a higher

degree or submitted for publication in part or in full.

UGOCHUKWU OGBONNA

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ATTESTATION

We hereby attest that this research work was conducted by Dr. UgochukwuOgbonna under our direct supervision.

1. DR. R. E. NNABUKO, FMCS------

Chief Consultant Plastic Surgeon,

National Orthopaedic Hospital, Enugu and

Federal Medical Centre, Umuahia

2. DR. B. C. OKWOR, FMCS------

Consultant Plastic Surgeon, National Orthopaedic Hospital, Enugu

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TABLE OF CONTENTS

Declaration i

Attestation ii

Table of contents iii

List of Tables vi

List of Figures vii

Acknowledgement viii

Abstract ix

CHAPTER ONE

1.1 Introduction 1

1.2 Justification for the study 2

1.3 Scope and Limitations 3

CHAPTER TWO

2.1 Aim of the study 4

2.2 Objectives of study 4

CHAPTER THREE

3.1 History 5

3.2 Neoclassical canons 6

3.3 Development of the facial structures 11

3.4 Anatomy 16

3.4a External nose 18

3.4b Muscles of the nose 21

3.4c Nasal Skeleton 22

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3.4d The lip anatomy 22

3.4e External anatomy of the lips 24

3.4f Muscles of the lips 24

3.5a Terms related to anthropometry 26

3.5b Anthropometry of the face 27

3.5c Craniofacial landmarks of the nose 27

3.5d Craniofacial landmarks of the orolabial region 29

3.5e Lip-nose anthropometric studies 29

3.5f Applications 32

3.5g Anthropometric measurements 32

3.5h Anthropometric indices 33

3.5i Sources of error in anthropometry 34

CHAPTER FOUR SUBJECTS AND METHODS

4.1 Subjects selection 35

4.2 Sampling Method 35

4.2a Sample Size 35

4.2b Inclusion Criteria 36

4.2c Exclusion Criteria 36

4.3 Methodology 36

4.4 Data analysis 38

CHAPTER FIVE 5.1 Results 39

5.1a Anthropometric measurements 39

5.1b Anthropometric Indices 44

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CHAPTER SIX 6.1 Discussion 48

6.2 Clinical Application 53

6.3 Conclusions 54

6.4 Recommendation 55

REFERENCES 56

Appendix A: Ethical Committee Clearance

Appendix B: Informed Consent Form

Appendix: C: Proforma for Data Collection

LIST OF TABLES

1. Table 5.1: Age distribution of subjects------39

2. Table 5.2:Distribution of subjects according to state of origin------40

3. Table 5.3: Comparing male and female values for measurements around the lips------49

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4. Table 5.4 Comparison of male and female values for nose measurements------43

5. Table 5.5: A comparison measurements in this study with other published data------45

6. Table 5.6: Comparing the calculated proportion indices among male and female subject----46

7. Table 5.7: Comparing the measured and calculated findings among the different age groups47

LIST OF FIGURES

1. Fig 3.1: Illustrating the three section canon------9

2. Fig 3.2: The four section canon------10

3. Fig 3.3: The naso-oral proportion canon------11

4. Fig 3.4: Illustrates Tessier’s classification of craniofacial clefts------15

5. Fig 3.5: Muscles of the face------17

6. Fig 3.6 a&b: Landmarks of the nose------19-20

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7. Fig 3.7: Surface anatomy of the lips------23

8. Fig 3.8: Anthropometric soft-tissue landmarks of the face------28

9. Fig 5.1: Bar chart illustrating the mean for lip measurements------42

10. Fig 5.2: Illustrating the male and female values for nose measurements ------44

ACKNOWLEDGEMENTS

I would like to express my profound gratitude and appreciation to Dr. R. E. E.

Nnabuko, Chief Consultant Plastic Surgeon, National Orthopaedic Hospital (NOH),

Enugu and Federal Medical Centre (FMC), Umuahia; and to Dr. B. C Okwor,

Consultant Plastic Surgeon, NOH, Enugu, both of whom ably supervised and guided me through this work. I also thank immensely my other teachers, namely Drs. J.U. Achebe,

E.E.C. Echezona, I.S. Ogbonnaya and I.I. Onah, for making indelible impressions in my life.

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Dr. J.A. Akindipe will always be remembered for his friendship and invaluable encouragement. My thanks also go to Dr. GodswillUko of Department of Public Health,

FMC, Umuahia for assisting with the statistical analysis. Also appreciated are: Dr

Innocent Iwegbu of Maxillofacial Department, FMC, Umuahia, for his useful suggestions; the Head of Department and all staff of Surgery Department, FMC,

Umuahia, my immediate constituency; Christian Art, Umuahia, for assisting with illustrations.

Nonye and Ozy, my immediate family, have been very supportive and will always remain very dear to me. Finally, I give glory and honour to God Almighty with whom everything is possible.

ABSTRACT

INTRODUCTION: This study aims to establish normal lip-nose parameters and some proportion indices among the Igbo ethnic group resident in Umuahia, Abia State,

Nigeria. It also aims to establish gender and intra-ethnic variation and to compare results with those already published. Eight parameters of the lip-nose complex were directly measured while 2 indices were calculated from measured parameters.

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METHODS: This is a twelve months prospective study carried out in Umuahia, Abia

State, Nigeria. Participants were chosen by computer generated random sampling from those attending the outpatient clinics of Federal Medical Centre, Abia State Specialist

Hospital and Amachara General Hospital, all in Umuahia. Measurements were taken using landmarks identified by Farkas.

RESULTS: Four hundred and eight (408) adults were enlisted, out of whom 177 were males (43.4%) while 231 were females (56.6%). The age range was18-69 years. Three hundred and sixty four (89.2%) were of Abia State origin; 32(7.8%) were from Imo

State; 6(1.5%) were from Enugu State; while Anambra, Ebonyi and Delta states contributed 3(0.7%), 2(0.5%) and 1(0.3%) participants respectively.

The overall average measurement of upper lip height was 19.2mm, with males having

20.2mm and females 18.4mm. The mean Cupid’s bow width was 14.4mm; males had a higher figure of 15.2mm while females had 13.7mm. The average width of mouth

(intercommissural distance) was 58.7mm; 61.0mm in males and 56.9mm in females. The mean columellar height was 11.9mm; 12.4mm in males and 11.5mm in females. The mean columellar width was 8.4mm, with male and female values of 9.0mm and 7.4mm respectively. Nasal dome height average was 24.8mm; with males having 25.5mm and females 24.3mm. The average nasal tip protrusion was 18.7mm; males had 19.5mm while females had 18.1mm. Nasal width had a population average of 44.9mm with male and female averages of 46.5mm and 43.8mm respectively.

The naso-oral proportion index had an average value of 75.8% with male value of

75.9% and female value of 76.2%. For upper lip height/ width of mouth index the average was 32.8% with male value of 33.4% and 21.2% for females. Sexual dimorphism was observed in all parameters investigated with males generally having higher figures (p<0.05).

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CONCLUSION: Most values obtained were similar to those obtained elsewhere for the black race. Results obtained will form a data base for future reference. They will also aid surgeons in planning and execution of aesthetic and reconstructive surgeries like rhinoplasty and cleft lip repair. Community based studies and other studies that include younger age groups are recommended.

CHAPTER ONE

1.1 INTRODUCTION

The dimensions of the facial soft tissue structures (nose, lips, chin, etc) and their relative proportions are important components in the description of human morphology. These measurements and proportions are also useful in the assessment of patients and planning for reconstructive and aesthetic facial surgery. A greater appreciation of the whole of the face is achieved by the study of its component parts and their interrelationships. By the study of the relationships of the different regions of the face, a better understanding can be achieved regarding decisions related to surgery.

Anthropometry is the study of the human body form, defining size and weight measurements, and proportional relationships. Ales Hrdlicka1 defined anthropometry as “the conventional art or system of measuring the human body and its parts”. He posited that the object of anthropometry is to complement visual observation, which is always more or less limited and uncertain. Anthropometry of the face examines the dimensions and relationships of the face by use of soft tissue landmarks. Lip-nose anthropometry provides measurements that serve as guidelines for reconstruction of various deformities of these structures, which could be congenital or acquired. They also serve as reference guides for cosmetic surgeries of these structures.

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Anthropometry of the lip-nose complex has been extensively studied for the European,

American and some Asian populations. Racial and ethnic differences in the facial traits of

American and European Caucasians, Afro-American, Turkish, Arabian, Chinese and other populations have been reported.2,3 The work of Farkas4has provided a large amount of information that is relevant to this field of study. His publication on an international anthropometric study of the facial morphology of twenty-six ethnic groups/races constitutes a large reference data base. Ofodile and Bokhari5,6have done considerable work among the

African American population and generated significant information on the structure and dimensions of the African nose.

There is growing interest in this field of study among local workers and considerable information is already being generated for various ethnic groups in Nigeria. Akpa7 studied the nasal parameters in Nigerian Igbos while Oladipo8-11 has published the nasal parameters of a number of ethnic groups in Nigeria. He compared the nasal indices of three major ethnic groups in Nigeria (Igbo, Ijaw and Yoruba). Garandawaet al12 also published a work on the morphometric nose parameters in adult Nigerians. However, a greater number of published works on facial anthropometry in Nigeria dwell on nasal parameters and nasal indices, and other facial measurements with little attention given to lip measurements and proportions.

The field of Plastic and Reconstructive Surgery, Maxillofacial Surgery and other related fields have experienced considerable growth in recent times, with many surgeons already involved in aesthetic and reconstructive surgery of the face. The need to develop local reference data in this field cannot be overemphasized. This study broadens the scope of investigation to include some nasal and lip measurements and deriving some proportion indices related to the lip-nose complex. Data generated will be compared with those already published in literature both locally and internationally. It is hoped that knowledge will be advanced by information generated by this study and that surgeons will be assisted with

12 relevant data in the planning and execution of aesthetic and reconstructive surgeries around the lip-nose complex.

1.2 JUSTIFICATION FOR THE STUDY

Congenital anomalies of the lip-nose complex such as cleft lip, and injury due to trauma require accurate and proportional reconstruction. In addition, aesthetic surgeries involving the lip-nose complex also require accurate measurement and maintenance of proportional relationships. Plastic surgeons are frequently involved in reconstructive and aesthetic surgeries of this area. There is no published data of this nature from Umuahia or indeed Abia

State of Nigeria and this study is an attempt to fill that gap.

1.3 SCOPE AND LIMITATIONS

This is a twelve months prospective study carried out in Umuahia, Abia State of Nigeria.

It is a hospital based study and the study population consists of adults (18 years to 69 years) of Igbo ethnic origin selected by a computer generated random sampling.

LIMITATIONS: Being a hospital based study limits our sample to only those attending clinics which is only a segment of the population. This may have a negative impact on the eventual outcome. Secondly, the study is limited to the adult population and will therefore not capture data in the paediatric population, and the changes associated with growth.

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CHAPTER TWO

2.1 AIM OF THE STUDY

The aim of the study is to obtain normal values of the lip-nose complex parameters among the adult population of Igbos living in Umuahia, Abia State. Parameters evaluated in this study will provide important data for forensic medicine, physical anthropometry database and guide surgeons in rhinoplasty, nasal and lip reconstruction, and cleft lip repair.

2.2 OBJECTIVES OF STUDY

The objectives for this study are:

1. To directly measure and document relevant dimensions of the lip-nose complex

among adult Igbos living in Umuahia.

2. To calculate proportion indices related to the lip-nose complex.

3. To identify gender based variations in the dimension and indices.

4. To identify intra-ethnic variation in the measurements and indices.

5. To compare results with those from other studies both of same race in different

locations and other races.

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CHAPTER THREE

LITERATURE REVIEW

3.1 HISTORY

The history of facial anthropometry dates back to the Renaissance period when artists such as Albrecht Durer and Leonardo da Vinci attempted to define the ideal face by dividing the face into symmetrical sections and mathematical proportions13,14 .They were influenced by earlier Egyptian, Greek and Roman artists who also portrayed the human body in terms of canons and proportions. However, anthropometry, the measurement of living subjects, was first developed by a German anatomist, Johanne Sigismund Elsholtz for his doctoral thesis at the University of Padua in 165415.

Modern day anthropometry grew out of the work done by Czech anthropologist and physician, Ales Hrdlicka (1869-1943)1,16-18. He lived and worked in the United States of

America after his family had moved there in 1881. He was involved with extensive anthropological and anthropometric investigations among a wide range of people and races, and this included measurements on living people and on skeletal remains. His contributions can be summarised as follows17:

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1. Establishment of normal physical and physiological standards on the three

principal stocks of the American people: White, Indian-Eskimo and Negro.

2. Determination of the normal variation in the human body and skeleton.

3. Preservation of older American skeletal material.

4. Establishment of an ample brain collection, human and comparative.

5. Gathering of reliable data on and of replicas of the remains of early man.

6. Clearing the subject of geologically ancient man in America.

7. Sanitization and modernization of anthropometric procedures

8. Promotion of anthropological publication and instruction

9. Laying foundations for a future museum of man under the Smithsonian Institution

in the U. S. A.

Karl Hajnis, another anthropologist at Charles University in Prague, in present day Czech

Republic, studied children with cleft lip and palate using Hrdlicka’s anthropometric principles. It was with Hajnis that Leslie Farkas, a plastic surgeon, began his studies with anthropometry.19-21

Farkas22 is widely considered a pioneer in modern craniofacial anthropometry. He made a major contribution to current understanding of how anthropometry relates to the face and head in normalcy, beauty and deformity. His work examined the anthropometric relationships and measurements of children, adults, normal and attractive individuals and subjects of different ethnic groups. He has delineated the anthropometric differences of subjects with cleft lip and palate and other craniofacial deformities23-27. Following these early foundations, anthropometry has become an integral part of Plastic Surgery practice and research. The need for more accurate data for various ethnic and people groups has engendered the current interest in this field.

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3.2 NEOCLASSICAL CANONS

Renaissance artists such as Da Vinci and Durer introduced the concept of facial canons13.

This was a method of defining the ideal facial form in art28-30. A pleasing face was seen as divisible into two, three or four equal sections horizontally, the two, three section and four section cannon respectively. Figures 3.1 and 3.2 illustrate the three and four section cannons respectively. The distance between the eyes were estimated to be the same as the width of either of the eyes, and the ear and the nose as having the same inclination31. The width of the

1 mouth was supposed to be one and half times (1 /2 x) the width of the nose (fig 3.3).

Originally, there are nine neoclassical proportion canons and they are the precursors of present day anthropometric proportion indices32. The canons are as follows:

1. Two section canon

2. Three section canon

3. Four section canon

4. Nasoaural proportion canon (s-sn=sa-sba: length of nose=length of ear)

5. Nasoaural inclination canon (nose bridge inclination=ear axis inclination)

6. Orbital proportion canon (en-en=ex-en)

7. Orbitonasal proportion canon (en-en=al-al)

1 8. Naso-oral proportion canon(ch-ch=1 /2al-al)

1 9. Nasofacial proportion canon(al-al= /4zy-zy)

The canons are an attractive way of approaching facial evaluation because they are relatively easy to remember and have application for general assessment. The canons attempt to apply mathematical relationships to achieve a formula for facial balance and beauty. In the past the facial profile as seen by artists had influenced surgeons in their creative work of rebuilding a severely damaged face or correcting aesthetic errors of nature29. However, the anthropometric testing of the validity of the neoclassical canons in healthy individuals

17 revealed that they cannot be wholly accepted as valid guides in reconstructive procedures of the face.

Farkas29-32studied the neoclassical canons and found them to be variably represented in actual human subjects. The two section canon was valid in 10% of whites. The three- and four- section canons could not be validated in any of the 100 blacks and 103 whites examined in two different investigations31,32. Fig 3.1 and fig 3.2 illustrate the canon ratios and the variations obtained in actual subjects. The naso-aural proportion canon was valid in only 1% of blacks and 4.9% of whites while the naso-aural inclination canon was found to be valid in

3% of blacks and 8.9% of whites. Similarly, the orbital proportion canon was valid in 13% of blacks and 33% of whites. The naso-oral proportion canon (fig 3.3) was valid in 1% of blacks and 20.4% of whites while the nasofacial proportion canon was not valid in any of the blacks tested but was valid in 36.9% of whites. Finally, the orbitonasal proportion canon was valid in 3% of blacks and 40.8% of whites. Vegter and Hage14 examined the historical perspective of anthropometry and canons of the face and concluded that the canons represented what the artist wanted to present rather than the objective representation.

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Canon Ratio Measured Ratio M F

1 1 1

1 0.8 0.8

1 1.1 1

Fig. 3.1: Illustrates the three section canon which divides the face into equal proportions at the trichion, nasion, subnasale and gnathion.

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Canon Ratio Measured Ratio

M F

1

1 1 1

1 1.2 1.2

1 1.3 1.2

Fig.3.2: The four section canon divides the face into four equal proportions at the vertex,

trichion, glabellar, subnasale and gnathion

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X

X + ½ X

Fig 3.3: The naso-oral proportion canon.

3.3 DEVELOPMENT OF THE FACIAL STRUCTURES

The formation of the structures of the head and neck begins around the fourth week of development. The branchial apparatus is the part of the growing embryo that is responsible for the formation of future head and neck region33. The branchial arches (Pharyngeal arches)

21 are derived from the neural crest cells as those cells migrate into the future head and neck region early in the fourth week33-35. The branchial apparatus consists of:

1 The Branchial arches

2 The Pharyngeal pouches

3 The Branchial grooves and

4 The Branchial membranes.

During the fourth week, the cranial region of the human embryo resembles fish embryo of comparable age33.

The five facial primordia appear as five prominences (elevations) around the stomodeum

(primitive mouth)33,34. These prominences are:

1. The fronto-nasal prominence, which will form the cranial boundary of stomodeum.

2. The paired maxillary prominences of the first branchial arch form the lateral boundaries

or sides of the stomodeum.

3. The paired mandibular prominences of the same arch will form the caudal boundary

of the stomodeum.

The mesoderm of the five facial primordia is continuous, that is there is no internal divisions corresponding to the grooves that demarcate the prominences externally34,35.

The development of the face occurs mainly between the fifth and the eighth week while facial proportions develop during the foetal period. Facial proportions continue to develop until adulthood due to changes in the sizes of the air sinuses and the brain size34. Bilateral thickenings of the surface ectoderm, called nasal placodes, develop at the inferior, lateral aspect of the frontonasal prominence by the end of the fourth week. With further elevation of the margins of the nasal placodes the sides develop into the medial and lateral nasal prominences, respectively while the depressed central region of the placodes develop into the nasal pits. The nasal pits, initially in contact with the stomodeum, are precursors of the nares.

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Fusion of the medial nasal, lateral nasal, and maxillary prominences produces continuity between the nose, the upper lip, and the palate33,36. By the end of the sixth and seventh weeks, the medial nasal prominences merge with each other and form the inter-maxillary segment.

This segment will give rise to:

1. The philtrum and upper lip.

2. The pre-maxilla and its associated gingiva, and

3. The primary palate.

The lateral parts of the upper lip, most of the maxilla and the secondary palate form from the maxillary prominences. These prominences merge laterally with the mandibular promience35.The mesenchyme of the second branchial arch invades the primitive lips and cheeks giving rise to the facial muscles. These muscles of facial expression are supplied by the facial nerve, the nerve of the second branchial arch. The mesenchyme of the first pair of branchial arches gives rise to the muscles of mastication, which are innervated by the

Trigeminal, the nerve of the first branchial arch34,35.

A unilateral cleft lip results from failure of fusion of the medial nasal prominence and the maxillary prominence on one side. A bilateral cleft lip results from failure of fusion of the medial nasal prominence and the maxillary prominence on both sides37. The maxillary and mandibular prominences join at the lateral commissure of the mouth. Failure of union of these prominences produces macrostomia. This is number 7 facial cleft by Tessier classification36,38. Failure of the mandibular prominences to unite in the midline produces a central defect of the lower lip and chin, which is referred to as number 30 cleft by the Tessier classification37,38.

The foregoing is the Classical theory espoused by Durscy and Wilhelm His39. An alternative concept is the Mesodermal penetrationtheory introduced by Pohlmann, modified

23 by Veau, and popularised by Stark40. From their works and those of others the following can be deduced:

1. Branchial membranes represent transient bilamellar structures ordinarily destined to

be reinforced and filled out by mesoderm in the first three months of embryonic and

foetal life. The membrane or epithelial wall will ordinarily be reinforced by

mesoderm that migrates around both sides of the head, as well as over it. When an

insufficient deposit of mesoderm is made, the unreinforced bilamellar branchial

membrane splits apart. The failure of reinforcement may be total or partial, leading to

complete or partial rupture respectively.

2. In the anlage of the lip, mesoderm is delivered according to chronologic schedule of

priorities; first in the neighbourhood of the incisive foramen, then in the nostril floor,

next the nostril sill, the upper part of the lip, and lastly the vermilion.

3. If in the lip, delivery fails totally, a complete rupture of the epithelial wall will occur,

and the infant will be born with a cleft extending all the way back to the incisive

foramen. If the deficiency is minimal, the resulting defect will also be minimal- a

notched vermilion, a subcutaneous lip furrow, or a “cleft lip nostril” without signs of a

cleft lip.

4. If lateral delivery fails on both sides, a bilateral cleft lip results. If the delivery failure

is central, the infant will be born with a median cleft lip- Tessier’s type 0.3,38,40,41

In 1976 Paul Tessier38 described an anatomic classification system whereby a number is assigned to each of the malformations according to its position relative to the midline (fig

3.4). In Tessier’s classification, the orbit is used as the primary structure of reference. Fifteen locations for clefts can be differentiated. Their course through soft tissue and bone is described in detail. Also combinations of several types of clefts and associated malformations are discussed.

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13 14 12

11 10 9 10 12 11 13 9

8 8

6 5 4 3 1 2 6 3 7 7

0 4 6 5

3 2 1

30

Fig. 3.4: Illustrates Tessier’s classification of craniofacial clefts. The left half depicts the skeletal locations of numerical clefts, while the right half outlines the clinical locations of the clefts on soft tissue landmarks.

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3.4 ANATOMY

The face is the anterior aspect of the head that extends from the forehead, from the hairline or where it should be, to the chin, and from one ear to the other35. Bones of the facial skeleton determine the shape of the face. This is augmented by buccal fat pads and facial muscles. The facial muscles are in the subcutaneous tissue; they are attached to the bones of the skull34,35.

The muscles of facial expression (fig. 3.5) are developed from the mesoderm of the second pharyngeal arch, from which they migrate to their adult positions. They are supplied by the nerve of the second arch, seventh cranial nerve (Facial Nerve)33-35. These muscles differentiate to form groups around the orifices. The orifices of the orbit, nose and mouth are guarded by eyelids, nostrils and lips respectively, and there is a sphincter and an opposing dilator arrangement peculiar to each. The purpose of the facial muscles is to control these orifices35.The following section on anatomy will concentrate on the anatomy around the lip- nose complex.

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Occipito frontalis Temporal Procerus Corrugator supercili Orbicularsi oculi

Nasalis Levatorlabiisuperioris L.L. Sup Zygomaticus minor and major Zygomaticus minor Buccinator Zygomaticus maj. Masseter Orbicoris Orbicularis oris Mentalis Risoris Depressor ang. Depressor L. inf Sternocleidomastoid

Platysma

Occipto-frontalis

Corrug. Sup. Orbic.oculi

Nasalis L.L. Sup.

Zygomaticus major Zygomaticus minor Orb.oris Buccinator

Depressor L. Mentalis Depressor ang.oris

Platyma

Fig.3.5: Muscles of the face. Top: Anteroposterior view; Bottom: Lateral view.

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3.4a EXTERNAL NOSE

The external nose projects forwards from the face. Its upper end or root is continuous with the forehead. At its lower end (base) are the nostrils. The sides of the nose meet in the midline anteriorly to form the dorsum. The upper part of the dorsum is the bridge of the nose, while at the end of the dorsum is the tip of the nose35 (fig. 3.6). The nose can be divided into thirds according to its underlying skeletal structure. The upper one-third rests on the nasal bones; the middle one third lies over the upper lateral cartilages; while the lower third or lobule includes the nasal tip and the alae overlying the membranous septum. The upper and most projecting part of the lobule is the nasal tip42. The columella is supported by the medial crura of the alar cartilages; the soft triangle spans the junction of the ala with the columella on either side; and the entrance of the vestibule is the sill.

The skin of the nose is thinnest at its upper part where it is loosely attached to the nasal bones and the upper lateral cartilages, while it is thickest at the lower part where it has an abundance of sebaceous glands. Nerve supply to the skin of the nose is by the anterior ethmoidal, the terminal branch of nasocilliary which in turn is a branch of the ophthalmic division of trigeminal nerve, with contributions from the infratrochlear and infra-orbital nerves. Blood supply is by the dorsal nasal artery at the root, and lower down by the external nasal, and by the lateral nasal and septal branches of the facial and its superior labial branch respectively35.

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n

Nasal Midline (m’)

al al sn

Fig 3.6a: Landmarks of the nose. sn: subnasale; al: alare; n: nasion

29

prn . cl c .cl . . al. . .al sn

Fig 3.6b: Landmarks of the nose prn: pronasale; c’:highest point on columella; c: midpoint of c’- c’; sn: subnasale; al: alare.

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3.4b MUSCLES OF THE NOSE (fig 3.5)

Procerus (Pyramidalisnasi): A small pyramidal slip arising by tendinous fibres from the fascia covering the lower part of the nasal bone and the upper part of the lateral nasal cartilage, it is inserted into the skin over the eyebrows, its fibres decussating with those of frontalis34.

Nasalis (compressor naris): It consists of two parts, transverse and alar. The transverse part arise from the maxilla above and lateral to the incisive fossa; its fibres proceed upward and medial, expanding into a thin aponeurosis which is continuous on the bridge of the nose with that of the muscles of the opposite side, and with the aponeurosis of the procerus. The alar part is attached by one end to the greater alar cartilage, and by the other to the integument at the point of the nose.

The depressor septi (depressor alae nasi) arises from the incisive fossa of the maxilla. Its fibres ascend to be inserted into the septum and back part of the ala of the nose. It lies between the mucous membrane and muscular structure of the lip.

The dilator naris posterior is placed partly beneath the quadratus labisuperioris. It arises from the margin of the nasal notch of the maxilla, and from the lesser alar cartilages, and is inserted into the skin near the margin of the nostril.

The dilator naris anterior is a delicate fasciculus, passing from the greater alar cartilage to the integument near the margin of the nostril; it is situated in front of the dilator naris posterior.35

Actions:

The procerus draws down the medial angle of the eyebrows and produces traverse wrinkles over the bridge of the nose. The two dilators enlarge the aperture of the nares. Their action in ordinary breathing is to resist the tendency of the nostril to close from atmospheric

31 pressure, but in difficult breathing, as well as in some emotions such as anger, they contract strongly.

The depressor septi is a direct antagonist of the other muscles of the nose drawing the ala of the nose downward, and thereby constricting the aperture of the nares. The nasalis depresses the cartilaginous part of the nose and draws the ala toward the septum. All these muscles are supplied by the facial nerve.34

3.4c NASAL SKELETON

The skeletal framework of the nose is highly variable among individuals and frequently assymetrical42-44. It consists of the nasal bones and ascending processes of the maxilla in the upper one third, the paired upper lateral cartilages in the middle third, and the lower lateral, or alar cartilages in the lower one third34,35. The upper lateral cartilages are attached to the caudal edge of the nasal bones and the nasal septum. The paired alar, or lower lateral cartilages, support the lower one third of the nose by uniting to form a tripod configuration.

The paired medial crura form the central leg of the tripod and are attached to the anterior nasal spine and septum in the midline. The lateral crura comprise the two lateral legs of the tripod, and they are attached firmly to the piriform aperture. The dome defines the apex of the alar cartilage. It supports the nasal tip and is responsible for the light reflex of the tip34,35,42,43.

3.4d THE LIP ANATOMY

The lips are two fleshy folds surrounding the oral orifice34. The lip consists of four basic components: the skin and subcutaneous tissue, the muscles, the mucosa, and the vermilion.

The skin is typical of facial skin. It is hair bearing with the hair being mostly vellus in women and children, with a downward direction of growth. The skin is of intermediate thickness for facial skin and is rich in sebaceous and sweat glands. The skin thickness and number of

32

appendages decrease with age. Deep to the skin is the subcutaneous fat that makes up the

bulk of lip thickness.35,37

In the central region the superior border of the upper lip corresponds to the inferior

margin of the base of the nose. Laterally, their limbs follow the alar sulci and the upper and

lower lips join at the oral commissures. The inferior limit of the lips in the central region is

the mentolabial sulcus; anatomically, the philtrum and its pillars are a part of the upper lip45

(fig. 3.7). The normal shape of the lips varies with age, and is influenced by ethnicity.35

Philtral ridge

Vermilion border

Upper lip Philtrum ls Crista philtre (chp) Upper lip Oral commissure(ch) vermilion Lower lip vermilion Labial inferius(li)

Mentolabialsulcus

Fig 3.7: Surface anatomy of the lips. Ls: labial superius.

33

3.4e EXTERNAL ANATOMY OF THE LIPS (fig. 3.7)

Vermilion: The red part of the lips. It is covered with a specialized stratified squamous epithelium, which is in continuity with the oral mucosa at the gingivolabial groove.

Vermilion border: The rim of paler skin that demarcates the vermilion from the surrounding skin.

Cupid’s bow: The contour of the line formed by the vermilion border of the upper lip.

Frontally, this line resembles an archer’s bow, which curves medially and superiorly from the commissures to the paramedian peaks located at the bases of the pillars of the philtrum (crista philtrae) with an inferior convexity lying between those peaks.

The philtrum is the vertical groove in the midline of the upper lip bordered by the lateral pillars (ridges).45

Mouth: The oral aperture that opens into the oral cavity proper34. The opening is bound by the upper and lower vermillion.

Oral Commissure: The place where the lateral aspects of the vermilions of the upper and lower lips join. The cheilion is the anthropological landmark located at this site.45

Labial fissure (oral vestibule): Slit like space between the lips.

Oral mucosa: Stratified squamous, non-keratinizing epithelium covering of the inner aspect of the oral cavity.34,45

3.4f MUSCLES OF THE LIPS (fig.3.5)

Orbicularis oris: They are paired, mostly horizontally oriented muscles that originate just lateral to the commissure at the modiolous. Orbicularis oris was so named because it was once assumed that the oral tissue was surrounded by a series of complete ellipses of striated muscle which acted together in the manner of a sphincter. However, it is now recognized that

34 the muscle actually consists of four substantially independent quadrants: upper, lower, left and right, each of which contains a larger pars peripheralis and a smaller pars marginalis.34

Marginal and peripheral parts are apposed along lines that correspond externally to the lines of junction between the vermilion zone of the lip and the skin. Thus, orbicualrisoris is composed of eight segments, each of which is named systematically according to its location.

Each segment resembles a fan that has its stem at the modiolus and is open in peripheral segment and almost closed in marginal segments.35The two oribicularsoris muscles join in midline of the lower lip in a raphe. In the upper lip, it crosses the midline and inserts into the opposite philtral column. It also sends fibers to the skin at the base of the ala, nasal sill, and septum and is the most important muscle for oral competence. It also provides for pouting and eversion of the lip, and some elevation of the lower lip35.

Orbicularis oris is supplied mainly by the superior and inferior labial branches of the facial artery, the mental and infraorbital branches of the maxillary artery and the transverse facial branch of the superficial temporal artery. The nerve supply is by the buccal and mandibular branches of the facial nerve.34,41

Levatorlabiisuperiorisalaequenasi, zygomaticus major and minor are other elevators of the upper lip. The mentalis muscle elevates the lower lip; while the depressor angulioris

(triangularislabiiinferioris) and platysma participate in depressing the lower lip. All these muscles receive their motor innervation from branches of the facial nerve. The sensory innervation of the lower lip is provided by the mental and infraorbital nerves. The mental nerve is the terminal branch of the inferior alveolar nerve which is, in turn, a branch of the mandibular division of the trigeminal nerve. The upper lip receives its sensibility from the inferior orbital nerve, which is a branch of the maxillary division of the trigeminal nerve.35

3.5a TERMS RELATED TO ANTHROPOMETRY.

35

Anthropometry is the systematic quantitative representation of the human body.

Anthropometric techniques are used to measure the absolute and relative variability in size and shape of the human body.3,46

Morphometry is the quantitative measurement of the external body form.47

Anthroposcopy is the analysis of the human body by visual inspection or observation of physical characteristics.3,46,48,49

In photogrammetry, measurements are taken between standardised anthropometric landmarks on life size frontal and lateral view photographs.3,48,49 Life size photographs can be generated by computer manipulation with a reference mark, such as a ruler, included in the photograph. They can also be made from a standard photographic negative.

Cephalometrics is the scientific measurement of the head and face by use of specific bone and soft tissue reference points derived from a specific standardised and reproducible radiograph.3,50

Each of these techniques has its draw backs. Direct measurement (anthropometry, morphometry and anthroposcopy) techniques could be flawed with human measurement errors. Variability in the facial expression especially in the mobile parts of the face as well as improper positioning may also affect both the anthropometric and cephalometric, as well as the photogrammetric measurements. In addition, measurements from photographs could be marred by errors in the marking technique or the identification of land marks3,48,49.

Recent innovations in linear scanning technology provide a potentially useful technique for accurate three-dimensional documentation of the face51. The three-dimensional measurements were found to be reliable. Data from the 3D-scanned images can be used to derive all of the traditional anthropometric measurements, such as linear distances and angle and surface contours; but its use is still limited because of cost.

36

3.5b ANTHROPOMETRY OF THE FACE

Anthropometric evaluation begins with the identification of particular locations on a subject called landmark points, defined in terms of visible or palpable features (skin or bone) on the subject3,49(fig 3.8). A series of measurements between these landmarks is then taken using carefully specified procedure and measuring instruments such as callipers, levels and measuring tape. Repeated measurements in the same individual can give reliable results, when the mean is taken. The selection of potential measurements is almost limitless but is usually guided by the scope of the study.

[ 3.5c CRANIOFACIAL LANDMARKS OF THE NOSE

1. Alare (al): The most lateral point on the nasal ala.

2. Columella apex (c’): The most anterior, or the highest point on the columella crest at

the apex of the nostril.

3. Nasal midline (m’): The midline of the bridge of the nose.

4. Pronasale (prn):- The most protruded point of the nasal tip

5. Subnasale (sn):- The junction between the lower border of the nasal septum, the

partition that divides the nostrils and the cutaneous portion of the upper lip in the

midline.

Some of the landmarks are illustrated in figs. 3.6a&b and 3.8.

37

Trichion (tr)

Glabella (g)

Nasion (n) Endocanthion (en) Frankfort horizontal (FH) Pronasale (prn) Subnasale (sn)

Stomion (sto) Sublabiale (si)

Gnathion (gn) Pogonion (pg)

Vertex (v)

Trichion (tr)

Glabella (g)

Nasion (n) Endocanthion (en) Frankfort horizontal (FH) (Porion-Orbitale) Pronasale (prn) Subnasale (sn)

Stomion (sto) Sublabiale (si) Pogonion (pg) Gnathion (gn)

Fig 3.8: Anthropometric soft tissue landmarks of the face. Top: Anteroposterior view Bottom: Lateral view 38

3.5d CRANIOFACIAL LANDMARKS OF THE OROLABIAL REGION

1. Cheilion (ch): The outer corner of the month where the outer edges of the upper and

lower vermilion meet.

2. Crista philtre (cph): The point on the crest of the philtrum, the vertical groove in the

median portion of the upper lip, just above the vermilion border.

3. Labial inferius (li): The midpoint of the vermilion border of the lower lip.

4. Labial superius (ls):- The midpoint of the vermilion border of the upper lip.

5. Stomion (sto):- The midpoint of the labial fissure when the lips are closed naturally.

6. Sublabiale (sl): The midpoint of the labiomental sulcus.

Some of these landmarks are illustrated in fig 3.7 and fig 3.8.

3.5e LIP-NOSE ANTHROPOMETRIC STUDIES

Leslie G. Farkas led an international team of investigators to study craniofacial morphological characteristics across the globe4. They measured 14 anthropometric parameters in 1470 subjects selected from Europe (Caucasian), Middle-east, Asia, and peoples of African origin. The results were compared with already established norms of

North American Whites (NAW).31

Among other findings, it was found that the width of mouth was identical to that of NAW in 12 of 13 Caucasian groups (92.3%), 4 of 5 Asian groups (80%), and all Middle-eastern and

African groups. The width of the nose in both sexes of the Caucasians was identical to the

NAW normal range. The nose width was extremely significantly greater in both sexes of three African ethnic groups. The nose height was identical to NAW in all African ethnic groups’ males, and in female Angolans and Afro-Americans.

Farkas4 examined the factors influencing the variations in facial morphology which have been suggested to include environmental conditions, socioeconomic status, and nutritional

39 habits of the populations52,53,54. He queried theories that suggest that in hot, moist climates the nasal apertures become wider as found in African and Asian ethnic groups55. Farkas asserts that this theory cannot be proved, referring to African Americans who have maintained a wide nose in spite of living in North America for centuries. He insists that the great similarities which exist between the NAW and the European Caucasians, together with the stable characteristics the Asians and Africans maintained throughout their ethnic groups, can be explained only by inherited genetic factors4,56,57.

Khandekaret al58 measured dimensions of the lip-nose complex of inhabitants of Mumbai in the western part of India. The study was done mainly to establish the normal values of various parameters related to the lip-nose complex. They measured height of upper lip,

Cupid’s bow width, total width of mouth, columellar height, columellar width, nasal width and nasal dome height. The results were compared with available data for the Chinese,

Blacks and Caucasians and Southern Indians. It was shown that for all age groups the results resembled the Chinese but differed in all parameters from Blacks and Caucasians. Columellar height and nasal width were found to be significantly higher among Southern Indians. The study also demonstrates the changes associated with growth pattern.

Prasad and Reddy59 measured lip-nose dimensions of five hundred normal individuals from Andra Pradesh (Southern India). They compared their results with Blacks, Whites and

Chinese, and found them to closely resemble those of Chinese in all dimensions except columellar height, which resembled that of Whites. In their study using 3-dimensional computerized system with landmark representation of soft tissue facial surface, Ferrarioet al60 compared different lip dimensions between male and female subjects of varying age groups.

They found out that within each age group all lip dimensions were significantly higher in males, the only exceptions being in the earlier age groups when growth spurt occurs earlier in females.

40

Ofodile and Bhokari5,6 found that the African Americans had wider noses than the Caucasian

Americans, while the length approximated that found by Farkas and co-workers4 for North

American Caucasians. They were able to establish intra-ethnic differences among Blacks.

This they attributed to the extensive mixing of the races due to inter-racial marriages between

Blacks and other races. In that light, Blacks of Afro-Indian descent had features related to

Indians; while Blacks of Afro-Caucasian descent had features related to whites.

Ethnic differences have been documented in the anthropometric parameters measured among Nigerians. Oladipo8-11 compared the nasal indices of three major ethnic groups in

Southern Nigeria (Igbo, Ijaw and Yoruba). He found that the Ijaw had higher values for both male and female adults (Ijaw: 96.4, Igbo: 94.1, Yoruba: 89.2). This study also established sexual dimorphism with males having higher nasal indices for all three ethnic groups.

Sexual dimorphism, the existence of physical differences between the sexes other than differences in sex organs61, was also established by Akpaet al7 in a study of the nasal parameters in Nigerian Igbos. They established significant differences in nasal length and nasal width with males having higher figures. Also in a study of the facial and nasal length of adult Igbos,Olutu and others62 established sexual dimorphism in both facial and nasal heights, male values being higher than female. Osunwokeet al63 also demonstrated sexual dimorphism in all seven parameters mentioned in their study. These differences that exist between the sexes have been reported by some authors to be a result of genetic make-up and inheritance.61,64 Conversely,Garandawa, et al12 in a study of the morphometric nose parameters of adult Nigerians found no significant differences between male and female for length of nose, nasal tip protrusion, length of columella and width of columella. It is only width of the nose that showed a difference with higher male value.

41

3.5f APPLICATIONS

There is a lot of clinical application of anthropometry. The method used should be tailored to the specific type of application. The applications include:-

1. Improving the clinical evaluation of the patient. This is done through better

assessment of facial morphology, using quantitative tools, rather than using visual

impression and scanty measurement.

2. Improving surgical planning and correction of dysmorphology due to using the

quantitative tools.

3. Improving follow-up of patients. Follow-up of patients using anthropometric

procedure is enormously important. Since the proportion indices are sensitive

indicators of any growth disturbances, using them in follow-up can detect areas that

are severely behind the normal development in the face of a young child. It will also

show whether the facial proportion became worse with age.

4. Pooling the quantitative data from patients with the same diagnosis to identify

characteristic patterns of dysmorphology and the extent of morphological variation in

these syndromes.

3.5g ANTHROPOMETRIC MEASUREMENTS

There is an almost inexhaustible number of anthropometric measurements possible in the face, most of which will be beyond the scope of this study. However, the following have been chosen based on their relevance to the lip-nose complex.

1. vertical height of lip

2. cupid’s bow width

3. Width of mouth (Inter commissural distance)

4. Columellar height

42

5. Columellar width

6. Dome height

7. Nasal width

8. Nasal tip protrusion

3.5h ANTHROPOMETRIC INDICES

Indices are sensitive and useful description of facial proportions. They can demonstrate the degree of disproportion in various parts of human body caused by hormonal and other disorders, congenital anomalies and trauma. The importance of seeing the face in proportions has been emphasized by many surgeons65,66. With rapid advancement in techniques of correcting multiple facial anomalies, surgical planning has become more sophisticated, and knowledge of the exact relationship between the various areas of the head and face is now indispensable31. The number of indices is unlimited and depends on the requirement of the medical or other biological discipline and the target of the investigator.

In formulating the index, the smaller measurement is expressed as a percentage of the larger, that is, the small measurement is multiplied by 100 (numerator) and divided by the larger measurement (denominator).i.e:

퐒퐦퐚퐥퐥퐞퐫 퐦퐞퐚퐬퐮퐫퐞퐦퐞퐧퐭 풊풏풅풆풙 = X 100 퐋퐚퐫퐠퐞퐫 퐦퐞퐚퐬퐮퐫퐞퐦퐞퐧퐭

Indices evaluated in this study are:

퐍퐨퐬퐞 퐰퐢퐝퐭퐡 1. 푵풂풔풐 − 풐풓풂풍 풑풓풐풑풐풓풕풊풐풏 풊풏풅풆풙(푵푶푷푰) = X 100 퐖퐢퐝퐭퐡 퐨퐟 퐦퐨퐮퐭퐡

This will be of relevance in restoring facial anatomy during reconstruction. In cases of unilateral and bilateral cleft lip and trauma, being aware of the desired naso-oral proportion

43 will be of immense benefit in achieving an aesthetically acceptable repair. One of the canon states that the width of the mouth equals one and half times the width of the nose.

퐔퐩퐩퐞퐫 퐥퐢퐩 퐡퐞퐢퐠퐡퐭 2. 푼풑풑풆풓 풍풊풑 풉풆풊품풉풕/ 풎풐풖풕풉 풘풊풅풕풉 풊풏풅풆풙 = X 100 퐖퐢퐝퐭퐡 퐨퐟 퐦퐨퐮퐭퐡

This is also relevant in cleft lip repair and in reconstruction following lip trauma.

3.5i SOURCES OF ERROR IN ANTHROPOMETRY

1. Improper identification of landmark. Though these soft- tissue landmarks are readily

identifiable in normal subjects, they become more difficult in deformed faces.

2. Inadequate use of measuring equipment. Non- availability or non- affordability of

these equipment may be the main reason for use of non-standard alternatives. The

measurement will then not conform to acceptable standard.

3. Improper measuring techniques. When the examiner is not familiar with the

equipment or its use this creates a lot of error.

44

CHAPTER FOUR

SUBJECTS AND METHODS

4.1 SUBJECTS SELECTION

This study was carried out in Umuahia, the capital of Abia State. The metropolis comprises two local government areas, Umuahia North and Umuahia South. There are three government hospitals in the metropolis, one federal- and two state-owned. These are the Federal Medical

Centre (Queen Elizabeth Specialist Hospital) at the heart of the city, Abia Specialist Hospital in Umuahia North, and Amachara General Hospital in Umuahia SouthThese three hospitals serve as the major health facilities for the metropolis and its environs. Individuals attending the General Outpatient Departments (GOPD) of the three hospitals during the study period were sampled.

4.2 SAMPLING METHOD

Based on the 2006 National population census, Umuahia North and South have a combined projected 2012 population of 851,188, made up of 426,649 males and 424,539 females67. Simple random sampling method was used to select subjects for the study. All eligible individuals attending the GOPD were given serial numbers. A computer generated randomization was done using Microsoft Excel 2007 program.

4.2a SAMPLE SIZE

This is based on the calculation for reference population more than 10,000. 68,69

N= z2 x Pq

d2

Where:

N= desired sample size (population more than 10,000)

45

Z= standard normal deviation, usually set at 1.96 and corresponds to a confidence level of

95%.

P= the proportion of the target population estimated to have a particular characteristic, 50% is used when there is no reasonable estimate. q= 1 – P = 0.5 d= degree of accuracy desired, usually set at 0.05

Therefore,

1.962 x 0.52

0.052= 384.16

This represents the minimum sample size that will give a statistically significant result based on the population under review. A total of 408 subjects were used as sample for this study.

4.2b INCLUSION CRITERIA

1. Male and female Igbos living in Umuahia metropolis.

2. All subjects were 18 years and above at the time of measurement.

3. No previous history of surgery to the nose or around the mouth and no history of

significant injury to the nose or lower face.

4.2c EXCLUSION CRITERIA

1. Non Igbos or mixed parentage

2. Age below 18 years or above 69 years

3. Congenital anomalies or significant injury to the lip-nose complex or history of

surgery to the area.

4.3 METHODOLOGY

1. Ethical clearance was obtained from Research Ethics Committee of Federal Medical

Centre, Umuahia

46

2. The detailed procedure for the measurements was explained to each individual

selected for the study and written consent was obtained.

3. Relevant bio data was obtained and recorded. These include: gender, age, and

residential address, state of origin, hometown of respondent and that of each parent.

4. The subject was then made to sit in a well lit room on a low stool with head in

anatomical position, resting on the wall.

5. All measurements were taken by the same observer to eliminate inter-observer error.

6. Measurements were taken with a digital electronic Vernier calliper. To minimize

intra-observer error, each measurement was taken twice and the average taken and

recorded. For the intercommissural distance, measurements were taken with closed

mouth(a), and then with open mouth(a’); the average was then calculated as a + a’

2

For columella length, measurements were taken on the right and left sides and the

average taken as the mean columella length for the individual.

7. Data was entered into the proforma designed for this purpose.

8. The calliper blades were cleaned with 70% alcohol in between subjects to minimize

transfer of skin contaminants.

The following measurements were taken.

1. Vertical height of lip (columellar base to cupid’s bow peak, sn-ls)

2. Width of mouth (intercommissural distance, ch-ch)

3. Cupid’s bow width (philtrum peak to peak, cph-cph)

4. Columellar width (sn’-sn’)

5. Columellar height

6. Nasal dome height

47

7. Nasal width (al-al)

8. Nasal tip protrusion (sn-prn)

The following indices were then calculated:

1. Naso-oral proportion index

2. Upper lip height/width of mouth index

These measurements of the lip-nose complex and proportion indices were chosen from the myriad of possible measurements because of their considered clinical significance as it relates to reconstruction and repair of both congenital and post-traumatic deformities and in rhinoplasty.

4.4 DATA ANALYSIS

Descriptive and inferential analysis was performed on the data obtained using Statistical

Package for the Social Sciences (SPSS) version 22. The results were subjected to statistical z- test and p-value less than 0.05 is considered significant.

Results are presented in form of tables, frequency polygons, bar charts, pie charts as indicated.

48

CHAPTER FIVE

5.1 RESULTS

A total of four hundred and eight (408) adult Igbos were includedin this study. One hundred and seventy seven (177) were males which constituted 43.4% while two hundred and thirty one (231) were females (56.6%). The age range is 18years to 69years (18-69yrs), with a mean age of 39.2 years.The age distribution is as shown in Table 5.1.

The sample population had subjects from six states with Igbo-speaking populations. The distribution is as in table 5.2.

Table 5.1: Age distribution of subjects

NO. OF PERCENTAGE

AGE(YEARS) PARTICIPANTS Less than 20 29 7.1% 20-29 83 20.3%

30-39 119 29.2%

40-49 75 18.4%

50-59 57 14.0%

60-69 45 11.0%

TOTAL 408 100.0%

5.1a ANTHROPOMETRIC MEASUREMENTS

The average height of upper lip was found to be 19.2mm+2.7mm and ranged from

11.9mm to 28.5mm. For males the mean upper lip height (ULH) was 20.2mm+ 2.6mmwith a range of 14.1mm-28.5mm. Females had mean ULH of 18.4mm+2.5mmwith range of

11.9mm-25.7mm.

49

Cupid’s bow width ranged from 9.2mm-21.4mm with a mean of 14.4mm+2.3mm. For males the mean was 15.2mm+2.5mm ranging from 10.2mm-21.4mm; while for females mean was

13.7mm+ 1.8mmand rangedfrom 9.2mm-18.7mm

Table 5.2: Distribution of subjects according to state of origin

STATE NO. OF PARTICIPANTS PERCENTAGE

ABIA 364 89.2%

IMO 32 7.8% ENUGU 6 1.5%

ANAMBRA 3 0.7%

EBONYI 2 0.5%

DELTA 1 0.3%

TOTAL 408 100.0%

Intercommissural distance ranged from 42.4mm to 71.9mm with average of 58.7 +5.5mm.

Males had mean intercommissural distance of 61.0+4.9mm with rangeof 48.2mm-71.9mm; for females the mean value was 56.9+5.2mm while the rangewas 42.4mm-71.3mm.

Table 5.3 illustrates the upper lip measurements, showing the mean values, the range and standard deviation and the p-value; while Fig. 5.1 compares the mean values for male and female.

The mean columellar height was found to be 11.9mm+1.6mm with a range of 7.4mm-

16.4mm. For males the mean columellar height was 12.4mm+1.4mm with a range of 8.9mm-

16.4mm; while for females the mean was 11.5mm+1.7mm with a range of 7.4mm-14.9mm.

50

Columellar width ranged from 6.3mm to 12.2mm with a mean of 8.4mm+1.0mm. Males had a mean of 9.0mm+0.7mm with range of 7.0mm-12.0mm; while for females the mean was

7.8mm+0.9mm and range of 6.3mm-12.2mm.

The average nasal dome height was found to be 24.8mm+3.5mm, ranging from 14.6mm to

34.7mm. Males had mean value of 25.5mm+3.4mm with range of14.6mm-34.7mm; while for females the mean was 24.3mm+3.4mm, ranging from 15.1mm to 33.5mm.

Table 5.3: Comparing male and female values for measurements around the lips(SD: standard deviation)

MALE FEMALE COMBINED P value

Male / Female

Mean Range(SD) Mean Range(SD) Mean Range(SD)

Vertical height of 20.2 14.1-28.5 18. 4 11.9- 19.2 11.9-28.5 0.0000 upper lip(mm) (2.6) 25.7(2.5) (2.7)

Cupid’s bow 15.2 10.2- 13.7 9.2-18.7 14.4 9.2- 0.0000 width(mm) 21.4(2.5) (1.8) 21.4(2.3)

Intercommissural 61.0 48.2-71.9 56.9 42.4- 58.7 42.4-71.9 0.0000 distance(mm) (4.9) 71.3(5.2) (5.5)

Nasal tip protrusion (NTP) had a mean of 18.7mm+2.1mm with a range of 13.8mm-

26.4mm. Males had a mean NTP of 19.4mm+2.1mm with range from 14.3mm to 26.4mm; while female NTP ranged from 13.8mm to 26.1mm with a mean of 18.1mm+1.8mm. The average nasal width was found to be 44.9mm+4.4mm, ranging from 30.5mm to 60.8mm.

Males had an average of 46.5mm+4.2mm and range of 31.3mm-60.8mm; while mean for females was 43.8mm+4.2mm and range was 30.5mm-54.5mm. See table 5.4 for a

51 comparison of the male and female nasal measurements and their p-values, and figure 5.2 illustrates the mean values for the nose measurements. Results of measurements recorded from this study were compared with some data already published from other regions (table

5.5). Table 5.7 shows all the findings tabulated according their age groups.

70

60

50

40 male female 30 combined

20

10

0 ULH CBW WOM

Fig. 5.1:Bar chart illustrating the mean values for lip measurements (mm). ULH: upper lip height; CBW: Cupid’s bow width; WOM: width of mouth.

52

Table 5.4: Comparison of male and female values for nose measurements(SD: standard deviation)

MALE FEMALE COMBINED p-value

Male / Female

Mean Range(SD) Mean Range(SD) Mean Range(SD)

Columellaheight(mm) 12.4 8.9- 11.5 7.4- 11.9 7.4- 0.0000

Columella 16.4(1.4) 14.9(1.7) 16.4(1.6) width(mm)

9.0 7.0-12.0 7.8 6.3-12.2 8.4 6.3- 0.0000

Nasal width(mm) (0.7) (0.9) 12.2(1.0)

Nasal dome 46.5 31.3- 43.8 30.5-54.5 44.9 30.5-60.8 0.0000 height(mm) 60.8(4.2) (4.2) (4.4)

Nasal tip 25.5 14.6- 24.3 15.1- 24.8 14.6- 0.0007 protrusion(mm) 34.7(3.4) 33.5(3.4) 34.7(3.5)

19.4 14.3- 18.1 13.8- 18.7 13.8- 0.0000

26.4(2.1) 26.1(1.8) 26.4(2.1)

53

50

45

40

35

30 male 25 female 20 combined

15

10

5

0 CH CW NW NDH NTP

Fig. 5.2: Illustrating the male and female values for nose measurements (mm). CH: columella height: CW: columella width; NW: nasal width; NDH: nasal dome height; NTP: nasal tip protrusion.

5.1b ANTHROPOMETRIC INDICES

The naso-oral proportion index ranged from 50.8-102.8 with a mean of 75.8+9.1. Males had an average of 75.9+8.4 with range of 52.8-102.8; while females had mean value of

76.2+8.0 with range of 50.8-96.7. The average value for upper lip height/ width of mouth index was 32.8+4.8 with a range of 21.2-48.8. Males had a mean of 33.4+ 4.7, ranging from

22.6 to 47.9; while females had 32.4+4.9 with range being 21.2-48.8. These results are shown in table 5.6.

54

Table 5.5: A comparison of measurements in this study with other published data.

West Indians South Chinese Caucasian Blacks Present study

Indians s

M F M F M F M F M F M F

Vertical height of 16.2 14.2 17.0 16.0 16.0 13.0 22.0 15.0 21.0 21.0 20.2 18.4 lip (mm)

Cupid’s bow 11.7 11.8 13.0 11.0 12.0 11.0 15.0 13.0 12.0 13.0 15.2 13.7 width (mm)

Oral 53.5 47.0 52.0 48.0 56.0 53.0 63.0 57.0 72.0 57.0 61.0 56.9 commissure(mm)

Columellar 9.8 8.6 12.0 10.0 6.0 5.0 13.0 11.0 10.0 9.0 12.4 11.5 height(mm)

Columellar 5.7 5.7 6.0 6.0 6.0 7.0 8.0 6.0 9.0 7.0 9.0 7.8 width(mm)

Nasal width 32.3 30.5 43.0 37.0 43.0 39.0 36.0 33.0 44.0 45.0 46.5 43.8

(mm)

Nasal dome 20.4 16.9 ------25.5 24.3 height(mm)

Nasal tip ------19.5 19.7 17.5 16.1 19.4 18.1 protrusion(mm)

55

Table 5.6: Comparing the calculated proportion indices among male and female subjects (SD: standard deviation)

MALE FEMALE COMBINED p-value

Male/Female

Mean Range(SD) Mean Range(SD) Mean Range(SD)

Naso-oral 75.9 52.8-102.8 76.2 50.8- 75.8 50.8-102.8 0.8010 proportion (8.4) 96.7(8.0) (9.1) index (%)

Upper lip 33.4 22.6-47.9 32.4 21.2- 32.8 21.2- 0.0363 height/width (4.7) 48.8(4.9) 48.8(4.9) of mouth index (%)

56

Table 5.7: Comparing the measured and calculated findings among the different age groups. (SD: standard deviation)

Less than 20 20-29 30-39 40-49 50-59 60-69

Mean Range(SD) Mean Range(SD) Mean Range(SD) Mean Range(SD) Mean Range(SD) Mean Range(SD)

Height of upper 17.8 14.3-22.8 19.1 12.6-24.6 18.9 11.7-28.5 19.1 14.2-25.4 19.7 15.5-26.5 20.6 15.2-25.7 lip(mm) (2.2) (2.6) (3.0) (2.5) (2.3) (2.8) Cupid’s bow 14.1 10.6-21.2 14.4 10.0- 14.2 9.4-18.8 14.2 9.2-18.2 14.2 10.5-20.0 15.3 10.2-21.4 width (mm) (2.5) 20.1(2.4) (2.1) (2.1) (2.3) (2.5) Oral 57.3 48.4- 58.8 47.2- 58.9 49.9-71.9 58.6 42.5-71.3 58.8 47.4-70.9 59.1 48.2-70.6 commissure(mm 65.9(5.3) 70.3(5.7) (5.4) (5.3) (5.9) (5.1) ) Columellar 11.4 8.6-14.2(1.7) 12.0 7.4- 11.9 7.9-15.4 11.8 8.7. -14.9 12.1 9.0-16.4 11.8 7.9-14.7 height (mm) 15.2(1.6) (1.7) (1.6) (1.5) (1.6) Columellar 8.0 6.7-10.3(0.9) 8.6 6.7- 8.5 6.5-12.0 8.1 6.3-114 8.2 6.6-10.7 8.3 6.4-10.1 width (mm) 12.2(1.1) (1.1) (0.9) (0.9) (0.9) Nasal width 44.8 38.1- 44.4 30.5- 45.4 33.8-58.4 45.3 32.9-54.0 44.2 31.3-56.2) 45.7 37.4-54.5 (mm) 60.8(4.7) 52.2(4.3) (4.2) (4.3) (5.4) (3.7) Nasal dome 24.5 20.0- 24.2 16.1- 24.5 14.6-31.8 249 18.2-32.0 25.1 17.9-32.2 26.7 20.5-34.7 height (mm) 30.2(2.9) 31.2(3.4) (3.6) (3.4) (3.4) (3.3)

Nasal tip 18.4 138-22.5(2.4) 18.8 15.2- 18.9 15.2-25.5 18.5 14.5-25.6 19.1 14.5-26.1 17.9 15.4-20.7 protrusion(mm) 24.1(2.0) (2.1) (2.2) (2.3) (1.4) Naso-oral 77.7 58.6- 75.1 50.9- 76.7 55.7-94.0 76.7 57.2-96.67 74.7 52.8-96.3 75.9 58.3-88.9 proportion index 93.1(8.5) 102.9(9.1) (7.4) (7.7) (9.2) (7.5) (%)

Upper lip height/ 31.2 24.8- 326 24.8- 32.0 23.2-47.3 32.7 23.7-48.7 34.1 26.3-45.1 35.2 23.8-47.9 width of mouth 42.4(3.8) 47.4(4.2) (4.9) (4.9) (4.3) (5.8) index (%)

47

CHAPTER SIX

6.1 DISCUSSION

The study population comprises of adult Igbos resident in Umuahia, the capital of Abia state in South- Eastern Nigeria. Most of the residents of the small capital city are indigenes with little contributions from other states. This is clearly reflected in the distribution of respondents by state of origin (table 5.2). Females were more willing to participate in the study and subject themselves patiently to be measured. This is probably because they were frequently less in a hurry than men, and also because females are usually more interested in procedures that have to do with facial appearance and looks.

The average upper lip height (cutaneous upper lip height) of 19.2+2.7mm is lower than value recorded for blacks Americans (21.0mm).58 It is, however, higher than the figures recorded for Caucasians, Chinese and Indians.58,70,71 (fig. 5.7). Males have taller upper lips than females. This is reflected in all the literature consulted. Farkas72 recorded upper lip height of 16.4mm for males and 15.9mm for femalesamong white Americans, and 14.0mm and 13.8mm for male and female black Americans respectively.Similarly, in a study of

Malaysian Indians, Ngeow and Aljunid70,71 recorded upper lip height of 12.9+2.5mm for males and 11.1+ 1.6mm for females, affirming sexual dimorphism for this parameter.

The Cupid’s bow width in this study (14.4+2.3mm) is similar to that found among

Caucasians (14.0mm), but is higher than that of blacks (12.5mm)3.It is also higher than the figures for South Indians, West Indians and Chinese58 (fig 5.5). Males have wider Cupid’s bow than females. The male Cupid’s bow width in this study is 15.2mm as against female value of 13.7mm. This finding is corroborated by Farkas3 who recorded Cupid’s bow width of 13.0mm for males and 12.0mm for females among young African Americans, and 10.4mm

48 for males and 9.7mm for females among Caucasians. It is also in consonance with Prasad and

Reddy’s59 finding in Andra Pradesh, southern India.

The width of the mouth recorded in this study is higher than what Farkas72had documented as norm for African Americans: 54.6+4.1mm for males and 53.6+4.0mm for females. The norms for Caucasians is just slightly lower (54.5+3.0mm for males and

50.2+3.5mm for females). These similarities may have been influenced by crossing of the races through marriages. What seems obvious from the reports of Farkas3,4,72, Khandekar58,

Prassad59, Ngeow71and this study, is that blacks have the widest intercommissural distance than Caucasians, Chinese and Indians for both males and females. Males have higher values than females. This study records male intercommissural distance of 61.0+4.9mm and

56.9+5.2mm for females.

Some of the disparities noted in the reported data may arise from technicalities of measurement, including quality of measuring instrument, experience of the investigator, and sampling method. For instance, Farkas4 had a sample size of 30 for each of the component groups investigated in his international anthropometric study. This number may be regarded as small considering the populations being investigated. Secondly, these measurements were done by different observers in different locations without the direct supervision of the chief investigator. An experienced observer will most likely obtain more accurate data than someone who is involved in this kind of study for the first time. Genetic differences between the races manifest as different facial anthropometric characteristics while sexual dimorphism is also genetically determined61,63,64.

The mean columella lengthof 11.9+1.6mm recorded in this study is lower than what

Garandawaet al12 recorded in their study (13.8mm). In the Garandawa study, Ibadan in the

West and Maiduguri in the North of Nigeria were used, both towns having different ethnic concentrations. Therefore, the result cannot be attributed to any one ethnic group.

49

Ofodile6had reported an average columella length of 9.2mm for African-Americans of which those of pure African descent had 9.3mm.Farkas3 had recorded average columella length of

11.5mm in NorthAmerican whites and 9.5mm in African Americans. The result from the present study is comparable to that of North American Caucasians.

The columella width of 8.4+1.0mm is comparable to the established norm in African

Americans (8.0+1.0mm for males and 7.5+0.8mm for females)3. Garandawa12 had obtained a higher figure of 9.6mm among Nigerians. Compared to data recorded for Caucasians,

Chinese and Indians by Farkas3 and Khandekar58, Nigerians have thick columella similar to fellow blacks in America. However, this seems to be contradicted by Okwor73 who recorded a narrow columella width of 5.7mm among Igbos living in Enugu, Nigeria. The reason for this disparity is not known.

The average nasal width of 44.9+4.4mm is comparable to the 43.3+2.8mm recorded for

Igbos in Enugu by Okwor73. An earlier study among Igbos in Enugu by Akpaet al7 had an average nasal width of 72.6mm. This result is quite high when compared to other results from

Nigeria and beyond. Garandawa et al12 found nasal width in Nigerians to be 42.1mm while

Anibor et al74 got a mean nasal width of 40.05mm among Isokos of Niger delta region of

Nigeria.Jimohet al75 studied a cross-section of Nigerian adults in Ilorin, North Central Nigeria and found mean nasal width of 46.0mm. Most of the subjects were of Yoruba ethnic group.

Osunwokeet al63also got an average nasal width of 39.24mm among the Binis of Southern

Nigeria.

Farkas3,4,72 had recorded similar values for African Americans and other African groups.

For instance among African Americans nasal width for males was 44.1mm and for females it was 40.1mm. Angolans had 46.3mm and40.8mm for males and female respectively.

Ofodile5,6 also recorded nasal width of 45.9mm for male black Americans and 40.1mm for females. When compared to nasal width of other races as reported by Farkas3,4, Khandekar58,

50

Prassad59, and Ngeow71, blacks have the widest al-al distance. Negroid nose is typically platyrhine, characterised by flaring of the alae nasi, broad nose base and a thick columella5,6.

The nasal tip protrusion (NTP) recorded in this study is 18.7+2.1mm and it is the same average recorded by Jimoh75 among Yorubas in Ilorin, Nigeria. Garandawaet al12 obtained comparable result of 19.5+2.2mm also among Nigerians. Ofodile5,6 had recorded NTP of

20.6mm for black Americans of pure African descent. Asians70,71 have lower NTP than

Africans while the figures documented for Caucasians by Farkas3 is comparable to those of

Africans. For nasal dome height (NDH), the value obtained in this study (24.8+3.5mm) is higher than that obtained for Mumbai Indians by Khandekar58 which is 20.4mm for males and16.9mm for females.

Significant sexual differences were noted in all the parameters measured (p<0.05), (Tables

5.3 and 5.4). Males always had higher figures. This is confirmed by Ofodile6, Oladipo10,

Olutu62, Farkas72 and Okwor73. On the contrary, Garandawaet al12 reported no significant difference between the sexes where males had higher values (p<0.05).

There is no clear relationship between the age groups and the measured parameters (Table

5.7). However, height of upper lip and nasal dome height show some increase with age which is not linear. For upper lip height, there is an increase between the first two age groups. This is truncated at age group 30-39 before another increase that continues to age 69.

For nasal dome height there is a decrease at the second age group of 20-29 before a consistent rise is noted from the third group. Oladipoet al76 studied nasal parameters (nasal height, nasal width and nasal index) among adult Yorubas of Nigeria. Their study showed a relationship between age and the parameters, though it was not always a linear relationship. Generally, the olderage groups had higher measurements. Similarly, Olutuet al62 established some relationship between age and nasal height and facial height of Nigerian Igbos, with older age groups having higher figures.

51

The naso-oral proportion index {ch-ch=1.5(al-al)} was valid in 11 subjects which represents 2.7% of the sample population. Width of mouth (ch-ch) was greater than 1.5(al-al) in 31 subjects representing 7.6% while ch-ch was less than 1.5(al-al) in 366 subjects representing 89.7%. The naso-oral proportion index using the formula: al-al/ch-ch X

100 is an average of 75.82%, having a wide range of 50.8%- 92.9%.This wide range is demonstrative of the differences observed in real life as observed by Vegter and Hage13.

Farkas31 examined the naso-oral proportion canon in young adult North American

Caucasians and found that it was truly represented in 20.4% of individuals examined. In

1 60.2% width of mouth was greater than 1 /2 width of nose {ch-ch>1.5(al-al), while in

1 19.4%width of mouth was less than 1 /2 width of nose {ch-ch<1.5(al-al)}. In African

Americans the naso-oral proportion canon was confirmed in only 1% of individuals32. Porter and Olsen77 examined the nine neoclassical canons in African- American women. As part of their findings the naso-oral proportion canon was true only in 7.4% of the subjects: width of mouth was greater than 1.5(al-al) in 5.7% while width of mouth was less than 1.5(al-aal) in

87.0%

The naso-oral proportion index represents the relationship between the width of the nose and width of the mouth. It should serve as a guide when a surgeon has to reconstruct a badly traumatized face in which the soft-tissue landmarks are severely distorted. Also in cleft lip repair, the repositioning of the flared ala nasi may be guided by the proportion index.

Absolute figures may be less helpful since they necessarily vary with age in the growing child.78

Upper lip height/ mouth width index represents the upper lip as a percentage of the mouth width71. It describes the vertical extension of the upper lip to the horizontal extension of the mouth width. It describes the relationship of the upper lip height to the width of the mouth79.

The mean value in Caucasian males is 41.1% and 39.5% in females3, while in Malaysian

52

Indian females the average value is 42.5%71,79. This study obtained a mean value of 32.8%, males having a higher figure of 33.4% and females 32.4%. The lower figures obtained in this study compared to others is because we used cutaneous upper lip height which is smaller than full upper lip height. The cutaneous upper lip height is more likely to be of value in lip reconstruction and cleft lip repair58.

According to Vegter and Hage14, “ It is more practical to compare a patient’s anthropometric value to the range of values found in a large group of normal subjects” than to rely strictly on the canons as stated, because “there is no excellent beauty that hath not some strangeness in the proportion”80.

6.2 CLINICAL APPLICATION

The clinical importance of the measurements and proportions is their use as guide in reconstructive and aesthetic operations and as an important data base for forensic medicine12.

In facial surgery, determination of any unusual disproportion of the face with the help of indices is invaluable both before and after operation31. Several studies have demonstrated differences in the parameters and indices existing between ethnic groups and in different geographical locations4,55,56. Sex has also been confirmed to influence the parameters61,63.

Thus, a single aesthetic ideal is inadequate77. By obtaining the parameters and indices that are specific for different ethnic groups, gender and age group, it is possible to tailor reconstructive and aesthetic surgeries to as near as possible to what it should be in nature. In the past, most standard measurements have been those obtained from Caucasians, but it is now necessary to have our local standards for guidance of reconstructive and aesthetic surgeries.

53

6.3 CONCLUSIONS

1. Igbos resident in Umuahia have nasal features that are mostly similar to other black

ethnic groups with platyrhine features of wide nose and thick columella.

2. Lip features are more variable with some parameters like Cupid’s bow width tending

towards Caucasian values.

3. There are gender based differences in all the measured parameter, with males always

having higher figures. However, age related variations could not be clearly

established.

4. Treatment of patients should be individualised but can be guided by the data

generated here.

54

6.4 RECOMMENDATIONS

1. A community based study is recommended to give a broader and better sample of the

target population.

2. Similar studies could be conducted in other locations populated by Igbos to get a

wider picture and to compare results

3. Another study designed to capture younger age groups will be useful to observe those

variations associated with growth .

.

55

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