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British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560

Anthropometric study of the upper lip of 1500 healthy

children in Chengdu, Western China
Lu-ying Zhu a,b , Tian Meng a,b,∗ , Bing Shi a,b,∗ , Dian-zhi Deng b
a State Key Laboratory of Oral Disease, West China College of Stomatology, Sichuan University, Chengdu 610041, The People’s Republic of China
b Department of Cleft Lip and Palate Surgery, West China Stomatological Hospital, Sichuan University, Chengdu 610041, The People’s Republic of China

Accepted 21 February 2008

Available online 9 June 2008

Abstract

The aim of this study was to measure and analyse morphological data about the upper lips of healthy children in Chengdu, Western China.
The characteristics and patterns of growth and development of the upper lip may be helpful in guiding the treatment of cleft lip. A total
of 1500 healthy children aged between 2 and 12 were divided into 11 groups according to their age. Seven points on the upper lip were
measured directly: the length from the alar base to the commissure, the length of the philtrum, the length from the tip of the Cupid’s bow to
the commissure, the width of one limb of the Cupid’s bow, the length from the alar base to the central columella, the area of the unilateral
upper lip, and the angle of the line of the alar base to the commissure and the line of the tip of the Cupid’s bow to the commissure. Five
aspects were significantly different among the groups: the length from the alar base to the commissure (p = 0.04), the length from the tip of
the Cupid’s bow to the commissure (p = 0.02), the width of the upper lip (p = 0.02), the area adjacent to the lip (p = 0.03), and the area of the
unilateral upper lip (p = 0.04). These data may be useful for reference to cleft lip repair.
© 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Anthropometry; Morphology; Upper lip; Cleft lip; Development

Introduction
Anthropometry can reflect the regularity of changes to organs
during the development of the human body. It is necessary to
obtain the anthropometric criteria of the organs to assess the
degree of disharmony and imbalance in their development.
Many research workers have done morphological and
anthropometric research on the upper lip. Farkas1 made facial
measurements of 6–18 year-old North American people. Cho
et al2 studied the anthropometry of the upper lips and noses
of infants less than a year old in Korea. Characteristics, mor-
phometry and aesthetics of the lips are different for different
ages, places, and races. We have studied normal children
2–12 years old in Western China. The results should indicate
development of the upper lip of children in this area.
There are still are many plastic surgeons who have dif-
ferent opinions about the repair of the cleft lip, including
the appropriate age for the operation and the best method or
design of the repair. Data about the growth rate of the cran-
iofacial soft tissues, particularly the upper lip, are therefore,
important in treating a cleft lip. The regularity of morpholog-
ical change in the normal upper lip could guide the surgeon
to choose the accurate time, design, and principle of cleft
lip repair, and it also would be a criterion to compare with
postoperative results.

∗
Subjects and methods
Corresponding author. No. 14, Section 3, Ren Min Nan Road, Chengdu
610041, The People’s Republic of China. Tel.: +86 28 61153005;
fax: +86 28 85502570.
A total of 1500 healthy children aged between 2 and 12
E-mail addresses: tianmeng scu@yahoo.com.cn (T. Meng), years who were all Han people, and who had no craniofacial
shibingcn@sina.com (B. Shi). malformations were studied. All were chosen randomly

0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.02.014
 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560 555

between 2005 and 2006 from kindergartens or primary Table 1

schools in Chengdu. The children were divided into 11 age From 2 to 12 years the area of the whole upper lip increases by 196.8 mm2 ,
and the growth rate is 105.8%
groups according to chronological age (ages 2–12 years
in yearly increments), and each group included about 150 Age (years) Mean (SD) (mm2 )
children. Seven items that were often used as aesthetic (A)
indexes related to the upper lip after cleft lip repair were 2 387.7 (56.7)
3 439.9 (153.7)
measured. 4 453.1 (126.8)
According to the previous study by Shi,3 the differences 5 456.7 (60.1)
between each item for male and female children were not 6 490.9 (71.8)
significant before the age of 13 years. Sex therefore was not 7 496.9 (75.9)
an influencing factor on the growth of the upper lip and its 8 491.5 (73.5)
9 503.4 (82.3)
development. 10 532.6 (79.9)
Vernier calipers, compasses, and a conimeter were used 11 552.6 (73.6)
for the measurements. Their precision was 0.05 mm. Those 12 584.5 (86.1)
who made the measurements were trained in advance, and
they estimated anthropometric measurements three times. Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%)
The subjects were measured in a relaxed state, so that the (B)
lip and the mandible were stable. 2–3 52.2 113.5
3–4 14.2 103.0
The seven items included (Fig. 1): the length of the 4–5 3.6 100.8
philtrum (CF), the length from the alar base to the commis- 5–6 34.3 107.5
sure (AB), the length from the tip of the Cupid’s bow to 6–7 5.9 101.2
the commissure (AF), the width of one limb of the Cupid’s 7–8 −5.2 98.9
bow (FE), the length from the alar base to the base of the 8–9 11.8 102.4
9–10 29.2 105.8
columella (BD), the area of the unilateral upper lip, and the 10–11 20.0 103.8
angle from the lines of the alar base to the commissure and the 11–12 31.9 105.8
tip of the Cupid’s bow to the commissure (∠␣). To simplify
the calculation, the unilateral upper lip was divided into: S1
(ABF), S2 (BCF), S3 ( CDFE). S1 and S2 make up the Analysis of variance and Student’s t test were used to ver-
area adjacent to the lip and S3 is the philtrum. After mea- ify significance among items in each group. P < 0.05 was
surement, we established that the length from C to D was accepted as significant.
a constant: probably 3 mm, and from D to E was probably
the length of CF 1 mm. According to the formulae, the area
of S1 = 1/2 × AB × AF × sin ␣; S2 = 1/2 × CF × (BD-3); and Results
S3 = 3/2 × (2 × CF + 1).
Table 1 shows the area of upper lip. There were signifi-
cant differences among the groups (F = 4.594634, P = 0.04,
P < 0.05). Further analysis showed significant differences
between the 2 and 6, 7, 8, and 9 year groups, and between
the 2 and 10, 11, and 2 year groups. This indicated that the
growth of the area of the upper lip increased after the age of
6, particularly after the age of 10 (Fig. 2).
The length of the philtrum is shown in Table 2. Fig. 3
shows that the main change appeared during the 2–3 year-
old period. From 3 to 9, the change was small, and after 9
it increased slightly. No significant differences were found
among the groups (P = 0.1).
The width of the upper lip (bilateral length from the tip of
the Cupid’s bow to the commissure, and bilateral width of the
Fig. 1. Photograph of the nasolabial area. CF = the length of the philtrum. limb of the Cupid’s bow) (Table 3) were significantly different
AB = the length from the alar base to the commissure. AF = the length from (P = 0.02). Further analysis showed large differences between
the tip of the Cupid’s bow to the commissure. FE = the width of one limb 2 and 5, 6, 7, 8, 9, 10, 11, and 12-year groups (Fig. 4).
of the Cupid’s bow. BD = the length from the alar base to the base of the The length from the tip of the Cupid’s bow to the com-
columella. ∠␣ = the area of the unilateral upper lip, g = the angle made up of
missure (Table 4) is significantly different among the groups
the lines of the alar base to the commissure and the tip of the Cupid’s bow to
the commissure. The unilateral upper lip was divided into several triangles: (P = 0.02).
S1 is ABF a random triangle; S2 is BCF a right angled triangle; and S3 The length from the alar base to the commissure is shown
is a trapezoid CDFE. in (Table 5) (P = 0.04). The width of one limb of the Cupid’s
556 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560

Fig. 2. The growth curve of the area of upper lip of each group.

Fig. 3. The length of philtrum column of each group.

bow (Table 6) and the area of the philtrum (Table 7) shows
no significant differences among the groups (P = 0.2).
The area adjacent to the lip (Table 8) showed significant
differences among the groups (P = 0.03).
No significant association was found between the length
from the alar base to the commissure and the length from
the tip of the Cupid’s bow to the commissure (P = 0.4)
(Table 9).
Discussion
We found that the 2 and 3-year age groups tended to develop
more in each variable measured except the width of one limb
of the Cupid’s bow (Tables 1–8). It showed that the upper
limb peaked between the ages of 1–3 years.
Tables 2 and 3 show that from 2 to 12 the width of the
upper lip developed faster than its height.

Fig. 4. The development tendency of the width of the upper lip.

 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560 557

Table 2 Table 4
From 2 to 12 years the height of the upper lip increases by 2.3 mm, and the From 2 to 12 years the length from the tip of the Cupid’s bow to the com-
growth rate is 120.9% missure increases by 4.9 mm, and the growth rate is 126.5%
Age (years) Mean (SD) (mm2 ) Age (years) Mean (SD) (mm2 )
(A) (A)
2 11.1 (1.3) 2 18.6 (1.6)
3 12.7 (9.5) 3 19.8 (1.8)
4 12.5 (1.6) 4 20.1 (2.2)
5 12.4 (1.5) 5 21.4 (1.7)
6 12.8 (1.7) 6 21.1 (1.8)
7 12.7 (1.5) 7 21.9 (1.6)
8 12.8 (1.9) 8 21.7 (1.8)
9 12.8 (2.0) 9 22.4 (2.0)
10 13.0 (1.9) 10 22.7 (1.9)
11 13.1 (1.6) 11 23.1 (1.9)
12 13.4 (1.9) 12 23.5 (1.9)

Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%) Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%)
(B) (B)
2–3 0.6 109.4 2–3 1.2 106.6
3–4 −0.3 98.0 3–4 0.2 101.4
4–5 −0.1 99.4 4–5 0.3 101.6
5–6 0.4 103.1 5–6 0.7 103.3
6–7 −0.1 99.5 6–7 0.9 104.1
7–8 0.1 100.8 7–8 −0.2 98.9
8–9 −0.02 99.8 8–9 0.7 103.1
9–10 0.3 102.0 9–10 0.4 101.6
10–11 0.1 101.0 10–11 0.3 101.5
11–12 0.3 102.4 11–12 0.5 102.0

Table 3 Table 5
From 2 to 12 years the width of the upper lip increases by 12.1 mm, and the From 2 to 12 years the width of one limb of the Cupid’s bow increases by
growth rate is 126.0% 1.2 mm, and the growth rate is 127.0%
Age (years) Mean (SD) (mm2 ) Age (years) Mean (SD) (mm2 )
(A) (A)
2 46.3 (3.8) 2 4.6 (0.8)
3 49.1 (3.6) 3 4.7 (0.9)
4 50.3 (7.8) 4 5.0 (3.4)
5 50.5 (3.7) 5 4.8 (0.6)
6 52.3 (4.0) 6 5.1 (0.6)
7 54.6 (3.8) 7 5.3 (0.8)
8 55.0 (4.3) 8 5.8 (1.0)
9 56.0 (4.1) 9 5.6 (0.7)
10 57.0 (3.9) 10 5.8 (1.0)
11 57.3 (4.4) 11 5.6 (0.8)
12 58.3 (4.5) 12 5.7 (0.8)

Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%) Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%)
(B) (B)
2–3 2.8 106.1 2–3 0.2 104.0
3–4 1.2 102.3 3–4 0.3 106.6
4–5 0.2 100.4 4–5 −0.2 95.8
5–6 1.9 103.7 5–6 0.3 105.6
6–7 2.2 104.3 6–7 0.3 104.9
7–8 0.5 100.7 7–8 0.4 107.7
8–9 1.0 101.9 8–9 −0.1 95.6
9–10 1.1 101.9 9–10 0.2 102.8
10–11 0.3 100.5 10–11 −0.2 97.1
11–12 1.0 101.7 11–12 0.1 100.9
558 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560

Table 6 Table 8
From 2 to 12 years the length from the alar base to the commissure increases From 2 to 12 years the area adjacent to the lip increases by 182.7 mm2 , and
by 4.5 mm, and the growth rate is 122.4% the growth rate is 157.5%
Age (years) Mean (SD) (mm2 ) Age (years) Mean (SD) (mm2 )
(A) (A)
2 20.1 (1.8) 2 318.0 (53.0)
3 21.5 (1.6) 3 360.6 (102.6)
4 21.9 (2.1) 4 375.3 (124.5)
5 22.1 (1.6) 5 379.3 (55.5)
6 22.6 (1.7) 6 411.2 (65.4)
7 23.0 (1.6) 7 417.6 (70.6)
8 22.9 (1.8) 8 411.7 (66.8)
9 24.1 (1.8) 9 423.7 (76.1)
10 23.9 (2.0) 10 450.4 (73.8)
11 24.1 (1.9) 11 470.8 (67.9)
12 24.6 (2.1) 12 500.7 (79.4)

Interval (years) Interclass increase (mm2 ) Link relative odds ratio(%) Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%)
(B) (B)
2–3 1.5 107.2 2–3 42.6 113.4
3–4 0.4 101.9 3–4 14.7 104.1
4–5 0.2 100.8 4–5 3.9 101.1
5–6 0.5 102.3 5–6 32.0 108.4
6–7 0.3 101.5 6–7 6.4 101.6
7–8 0 99.9 7–8 −5.9 98.6
8–9 1.1 104.9 8–9 12.0 102.9
9–10 −0.1 99.3 9–10 26.7 106.3
10–11 0.2 100.7 10–11 20.4 104.5
11–12 0.5 102.1 11–12 29.89 106.4

There were five items in which there were significant dif-

ferences among the groups: the length from the alar base to
the commissure; the length from the tip of the Cupid’s bow to
the commissure; the width of the upper lip; the area adjacent
Table 7
From 2 to 12 years the area of philtrum increases by 13.9 mm2 , and the
to the lip; and the area of the upper lip. The development of
growth rate is 120.0% the width of the upper lip peaked after the age of 6. The width
Age (years) Mean (SD) (mm2 )
of one limb of the Cupid’s bow developed slowly, while the
length from the tip of the Cupid’s bow to the commissure
(A)
2 69.7 (7.8)
grew noticeably after the age of 5. This showed that the wide
3 79.3 (57.0) increase of the upper lip was mainly attributable to the growth
4 77.8 (9.4) of the latter. The area of the upper lip increased fast after the
5 77.4 (8.7) age of 6, and particularly after the age of 10. The area of
6 79.7 (10.1) the philtrum increased slowly and did not peak. From the
7 79. 2 (9.2)
8 79.9 (11.2)
9 79.7 (11.7) Table 9
10 81.1 (11.1) The relation between the length from the alar base to the commissure (from
11 81.8 (9.7) A to B), and the length from the tip of the Cupid’s bow to the commissure
12 83.6 (11.3) (from A to F) from 2 to 12 years
Age (years) Length from A to B Length from A to F (mm) t test
Interval (years) Interclass increase (mm2 ) Link relative odds ratio (%) (mm)
(B) 2 20.1 19.0 0.4
2–3 9.6 113.8 3 21.5 19.8 0.5
3–4 −1.5 98.1 4 21.9 20.1 0.4
4–5 −0.6 99.5 5 22.1 20.4 0.5
5–6 2.3 103.0 6 22.6 21.1 0.4
6–7 −0.5 99.4 7 23.0 21.9 0.3
7–8 0.7 100.8 8 22.9 22.0 0.3
8–9 −0.2 99.8 9 24.1 22.4 0.5
9–10 1.4 101.8 10 23.9 22.7 0.3
10–11 0.6 100.8 11 24.1 23.1 0.3
11–12 1.8 102.3 12 24.6 23.5 0.3
 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560
Fig. 5. The growth of the upper lip was mainly in the lateral direction.
Fig. 6. Diagram of the development of the upper lip.
ages of 2 to 12, the increase in the philtrum was 13.92 mm2 ,
the growth rate was 120%, and the mean 1.8% (SD = 14.33)
each year. The increase in the area adjacent to the lip was
182.7 mm2 , the growth rate was 157.5%, and the mean 4.6%
(SD = 75.97) each year. It showed that the increase of the
area of the upper lip was mainly attributable to the growth of
the area adjacent to the lip. In conclusion, the growth of the
upper lip was mainly in a lateral direction (Fig. 5). Based on
the present results, we drew a diagram of the development of
the upper lip (Fig. 6).
The traditional accepted age for the treatment of cleft lip is
6 months, and many research workers have recently reported
repair during the neonatal period.4–6 Our results show a ten-
dency for the development of the upper lip during the 2 to
3 year-old age group. Because of the non-continuity of the
Fig. 7. The development of a “whistle-like” deformity.
559
orbicularis oris in patients with cleft lip, the functional abil-
ity of their lips is not as normal.7–9 The development of the
cleft side and the normal side will not be balanced. As the
patients grow up, the difference in the area of the two sides
will be increased.10 The results of operation at this time will
not be good, so the time of operation should be before devel-
opment of the upper lip peaks. Based on these results, we
think that cleft lip should be repaired within a year of birth.
To avoid interfering with the growth of the upper lip, the
time of secondary repair should be after it peaks. The second
peak of upper lip development was after the age of 5. The
secondary repair should therefore be between 3 and 5 years
old.
We found that the growth rate of the height of the upper
lip was less than that of its width. From 2 to 12, the height
increased by about 2 mm, while the width increased by about
12 mm. All methods of repair of a cleft lip will leave a vertical
scar, which can affect the height of the upper lip, whereas
the effect on the width of the upper lip is much less. The
vertical scar often contracts postoperatively which makes the
height of the upper lip on the cleft side shorter. To make the
two sides of the upper lip symmetrical postoperatively, we
suggest that when the height of the upper lip is measured
before the operation; 1 mm should be added to the normal
side to balance the cleft side. One objective of the correction
of a cleft lip is symmetry, particularly the length from the tip
of the Cupid’s bow to the commissure on the two sides. If
the vertical scar results in a “whistle-like” deformity (Fig. 7),
a secondary prosthesis is needed, which is important for the
morphology of the lip in the long term.
Kernahan and Bauer,11 Randall et al,12 and Park and Ha13
have all emphasised the functional reconstruction of cleft
lip. Kernahan and Bauer recognised the advantages of the
procedure, which in addition to the functional reconstruction
of the orbicularis oris, were its applicability to clefts of all
widths, and its superior scar formation.11 They suggested that
to balance the growth of the upper lip, the reconstruction of
the orbicularis oris was important.
We found that the mean width of one limb of the Cupid’s
bow was 5 mm, with no significant differences among the
groups. The difference between the distance from the alar
base to the columella central base, and the length from the
560 L.-y. Zhu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 554–560
columella lateral base to the tip of the Cupid’s bow was within
1 mm, and there were no significant differences among the
groups. It was so small that it might be neglected, but it would
be helpful in reconstruction of the labial arch.
In conclusion, all these data identify criteria for the mor-
phological development of the normal lip at different ages.
They are the criteria for development of the upper lip in
healthy children in Western China, and are also necessary for
preoperative and postoperative observations of patients with
cleft lip. Static anthropometric measurements as the refer-
ence data for the repair of cleft lip would be more direct and
simple for the surgeons who decide the method and design
of the operation, and are also the most direct way of judging
the symmetry of the lip after the operation. This study may
therefore provide useful clinical references for the repair of
cleft lips.
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