Facial Surgery

Aesthetic Surgery Journal

Quantification of the Aesthetically Desirable 2017, 1–10

© 2017 The American Society for
Aesthetic Plastic Surgery, Inc.
Female Midface Position Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjx122
www.aestheticsurgeryjournal.com

Gary Linkov, MD; Pooja Mally, MD; Craig N. Czyz, DO; and

Allan E. Wulc, MD

Abstract
Background:  The purpose of this study was to attempt to determine a reliable method of evaluating midface position. We assessed a novel param-
eter called WIZDOM (Width of the Interzygomatic Distance of the Midface) and its relationship to other facial metrics.
Objectives:  The goal was to evaluate midfacial position quantitatively in women by examining 2-dimensional photographs of a subset of women
with idealized facial proportions.
Methods:  Three examiners analyzed stock photographs of nonsmiling female model faces. Numerous parameters were analyzed for each photo-
graph, including: interpupillary distance, medial canthus (MC) to lip, brow length, WIZDOM, WIZDOM to MC, WIZDOM to hairline, WIZDOM to chin
vertical, and lateral brow to WIZDOM. Meaningful relationships between various parameters were statistically analyzed. Examiner measurements were
assessed for interobserver reliability.
Results:  Fifty-five female model photographs were included in the analysis. The average interpupillary distance was 59.2 mm ± 3.54 (range, 50.5-
67.3 mm). The WIZDOM average was 108 mm ± 5.81 (range, 93-127 mm) and brow length was 107 mm ± 5.87 (range, 96.7-124 mm). The difference
between brow length and WIZDOM was not statistically different (P = 0.834). The interobserver reliability between the 3 examiners was excellent for
all parameters (P < 0.01), ranging from 0.718 (WIZDOM-MC) to 0.993 (interpupillary distance). The WIZDOM measurement was reproducible with an
interobserver coefficient of 0.939.
Conclusions:  WIZDOM can be used to quantify aesthetically desirable midfacial position in patients and can be used as a measurement to aid in
assessment and as an ideal to achieve balanced aesthetic results in midface restorative procedures—lifting or volumization—in females.

Editorial Decision date: June 1, 2017.

Treatment of the aging midface is increasingly recog-
nized as a key component in aesthetic rejuvenation of
the face and periorbital region. Yet, a paucity of objec-
tive guidelines or methods exist to describe and to assess
midfacial position. Few parameters exist to suggest to
the aesthetic surgeon how much to elevate a midface, or
how much to volumize the midface in order to achieve
a balanced aesthetic result. Since the time of Angle,
orthodontists, maxillofacial, and craniofacial surgeons
have developed determinants of ideal facial propor-
tion defined by bony cephalometric interrelationships.1
These guided the manipulation of facial components to
produce aesthetically desirable outcomes. Many of the
assumptions made to define these interrelationships
were made on “ideal” subpopulations.2-8 Similarly,
rhinoplasty surgeons utilize angles and proportions
that guide evaluation and surgical management in order
Dr Linkov is a Resident, Department of Otolaryngology—Head &
Neck Surgery, Temple University School of Medicine, Philadelphia,
PA. Dr Mally is a Clinical Instructor, Department of Ophthalmology,
Drexel University College of Medicine, Philadelphia, PA. Dr Czyz
is an Attending Physician, Division of Ophthalmology, Section
Oculofacial Plastic and Reconstructive Surgery Ohio University/
OhioHealth Doctors Hospital, Columbus, OH. Dr Wulc is a Clinical
Instructor, Department of Ophthalmology, Scheie Eye Institute,
University of Pennsylvania, Philadelphia, PA.
Corresponding Author:
Dr Allan E. Wulc, WCosmetic Surgery, 610 W. Germantown Pike,
Suite 161, Plymouth Meeting, PA 19462, USA.
E-mail: awulcmd@gmail.com
2
Figure 1.  WIZDOM represents the most anterior point of projection of the malar body, lateral to which the shadow of the
zygomatic arch becomes apparent. Red crosses represent the lateral extent of WIZDOM.
to create aesthetic results.9 Oculoplastic surgeons also
have defined idealized aesthetic measurement of fis-
sures, margin reflex distances, and curves and contours
in the upper and lower eyelids.10
The midface is key to the heart shaped face of youth
and a recent element that is thought to be key in both
volumizing and lifting procedures.11-13
The pathogenesis of midfacial aging includes aesthetic
and anatomic alterations in all layers. Skin, muscle, bone,
fat, and ligaments all are affected, and both gravitational
and volumetric changes work inevitably, and in concert,
on the aging face.14-16 Specifically, lower eyelid fat becomes
prominent due to the absence of the malar fat that covers
it in youth and vertical and horizontal projection of the
midface is lost.17 The lid cheek junction is also a well-de-
scribed entity that, in youth, should blend smoothly from
a single concavity close to the preseptal eyelid into the
convexity of the cheek.
Having defined the midface as one of the key areas to
be addressed in the aging face, the aesthetic ideal remains
elusive and without many objective means of measure-
ment. What constitutes an aesthetically pleasing and
balanced midface? How do we judge our results when
working in this area? What constitutes an overcorrection
or an undercorrection? There are few objective means of
assessment that have been described.11,12,18,19
Aesthetic Surgery Journal
Despite the development of implants created to enhance
the midface, the advent of fillers specifically designed
for volumizing this area (Voluma, Allergan, Irvine, CA;
Restylane Lyft, Galderma, Fort Worth, TX), liposculpture
in the periorbital region enjoying greater acceptance, and
midface lift surgery being performed using a variety of
techniques, it is surprising that there are few quantitative
or qualitative descriptions of what constitutes the desire-
able aesthetic outcome.
Several authors have attempted to classify midface
aesthetics. Little described the ogee, a curvilinear sil-
houette found in art and architecture, and in the youth-
ful human face.18 Swift and Remington have described
the Phi relationships and applied them to the midface.20
Ramirez described the zygomatic point.19 The authors of
the Juvéderm Voluma trial attempted to divide the cheek
into zones,21 as did Binder22 and Terino.23 Jacono cre-
ated a midface classification scheme and based treatment
options on midface class.13 More recently, Marianetti et al
described the “beauty arch,” for the assessment of sagit-
tal projection of the malar region.12 Surek et al outlined 3
target zones and 2 adverse event zones in the midface to
facilitate volumizing procedures.11
We defined a parameter we called the WIZDOM: the
Width of the Interzygomatic Distance of the Midface,
defined as a horizontal line connecting the right and left
Linkov et al 3

zygomaxillary points. In the anteroposterior view and with

almost all types of studio photography and as experienced
in portrait drawing, WIZDOM represents the most anterior
point of projection of the malar body, lateral to which the
shadow of the zygomatic arch becomes apparent (Figure 1).
It highlights the orbit, and conceals any concavity at the
lid cheek junction. It is a light reflection point that widens
the orbital highlight before tapering toward the less well
defined malar body shadow. WIZDOM can be emphasized
applying the artful use of highlighter makeup and blush.
This measurement, and the distance to the eyelid as mea-
sured to the medial canthus (WIZDOM-MC), were assessed
along with multiple other parameters in an idealized female
patient population in 2 dimensions in order to determine
an aesthetic ideal. We attempted to: (A) determine whether
WIZDOM is a reliable and easily reproducible approxima-
tion of midfacial position; (B) evaluate whether ideal spa-
tial relationships exist between WIZDOM and other facial
features that might help in the assessment of aesthetic out-
comes; and (C) show how these parameters can be used to
assess pre- and postprocedural changes in the aging face.

METHODS
The study was exempt from Institutional Review Board
approval according to Title 45 of the Code of Federal
Regulations (45 CFR 46.101[b][4]). Informed written con-
sent with permission to publish photographs was obtained
from the patient included in the study. The study was con- Figure 2.  Example of model photograph with markings
ducted from November 2015 to November 2016. for all analyzed parameters. A: corneal diameter; B:
interpupillary distance; C: nasal length; D: medial canthus
to lip; E: brow length; F: WIZDOM; G: WIZDOM to medial
Photograph Selection canthus; H: hairline to WIZDOM; I: chin to WIZDOM; J:
chin to WIZDOM diagonal; K: angle to WIZDOM; L: medial
Fifty-five stock photographs of female models were canthus to nasal ala; M: eye length; N: lateral brow to
obtained from Shutterstock (www.shutterstock.com, New WIZDOM.
York, NY) in November 2015. Photographs were selected
by the senior author (A.W.) based on search criteria typed
diameter of 11.5 millimeters, based on normative data.24
into the website’s search tab: “beautiful young woman not
Each resized photograph was independently analyzed and
smiling.” These photographs were often of models that
measured electronically within the Photoshop software by
were heavily made up and retouched to enhance the pho-
three graders. Specifically, WIZDOM was independently
tographic image. We felt that the highly idealized aesthetic
identified by each of the three graders. The graders had
of cosmetics and enhanced with lighting or retouching
varying levels of experience in facial plastic surgery: one
might also be a benefit in defining the beautiful midface.
was an experienced eye and facial plastic surgeon for
Selection criteria included: anteroposterior facial photo-
greater than 20 years (A.W.), the second was a facial plas-
graph from the hairline to the chin, no obscured features,
tic surgeon who recently completed training (P.M.), and
and nonsmiling. Photographs in which both sides of the
the third was a facial plastic surgeon in-training (G.L.).
face were not visible or with obscured facial features were
The following parameters were evaluated on each pho-
excluded from the study. All races were included. The first
tograph, with all measurements recorded in millimeters
55 photos that satisfied the above criteria were selected.
(Figure 2):
a. Right corneal diameter: the horizontal distance across the
Data Acquisition
right cornea, standardized to 11.5 millimeters.
All photographs were resized in Adobe Photoshop 2014 b. Interpupillary distance: the horizontal distance from the
(Adobe Systems, San Jose, CA) to a right horizontal corneal center of one pupil to the center of the other pupil.
4 Aesthetic Surgery Journal

c. Nasal length: the vertical distance from the radix to the tip. Table 1.  Analysis of the Ideal Female Midface (n = 55)
d. Medial canthus to lip: the vertical distance from the right
Variable Average ± SD P value
medial canthus down to the upper border of the lip.
e. Brow length: the horizontal distance from the tail of one eye- Corneal diameter 11.5 ± 0 mm —
brow to the tail of the other eyebrow. Interpupillary distance 59.2 ± 3.54 mm —
f. WIZDOM: the horizontal distance between one zygomaxil-
lary point to the other zygomaxillary point. Of note, identi- Nasal length 43.6 ± 3.29 mm —
fying WIZDOM was aided by using the “invert color” option MC to lip 53.8 ± 3.34 mm —
in Photoshop for an enhanced shadow effect.
g. WIZDOM to medial canthus (MC): the vertical distance Brow length 107 ± 5.87 mm 0.834

from the right medial canthus down to the perpendicular WIZDOM 108 ± 5.81 mm
intersection with the WIZDOM line.
WIZDOM-MC 13.1 ± 1.67 mm 0.075
h. Hairline to WIZDOM: the vertical distance from top of the
hairline at the center of the face down to the perpendicular 1/3*MC to alar border 12.7 ± 0.729 mm
intersection with the WIZDOM line.
WIZDOM-hairline vertical 86.9 ± 6.10 mm 0.003
i. Chin to WIZDOM: the vertical distance from the bottom
of the chin at the center of the face up to the perpendicular WIZDOM-chin vertical 83.5 ± 5.66 mm

intersection with the WIZDOM line. WIZDOM-chin diagonal 98.9 ± 5.68 mm —

j. Chin to WIZDOM diagonal: the distance from the bottom of
the chin at the center of the face up to the right zygomaxillary
point.
k. Angle to WIZDOM: angle between the WIZDOM line
and the chin to WIZDOM diagonal (j) line. Of note, this
measurement was obtained by the first author only, on all
photographs.
l. Medial canthus to nasal ala: the vertical distance from the
medial canthus to the base of the ipsilateral ala.
m. Eye length: horizontal distance from the medial to lateral
canthus.
n. Lateral brow to WIZDOM: vertical distance from the lateral
brow down to WIZDOM.
Data Analysis
The collected data were compiled in an Excel (Microsoft,
Seattle, WA) spreadsheet and analyzed utilizing SPSS
version 22.0 (SPSS, Chicago, IL). Average values were
obtained by averaging each parameter across all examin-
ers, followed by averaging across all subjects. Independent-
sample t tests were used to compare brow length to
WIZDOM, WIZDOM-hairline vertical to WIZDOM-chin
vertical, WIZDOM-MC to 1/3 distance of MC to nasal ala,
and WIZDOM-lateral brow to eye length. Intraclass cor-
relation, 2-way mixed model (consistency, average meas-
ures), was used to calculate interobserver reliability for all
raters (>0.6 = substantial agreement). Significance was
defined a priori as P < 0.05.
RESULTS
Fifty-five female model photographs were included in
the analysis. The average interpupillary distance was
59.2 mm ± 3.54 (range, 50.5-67.3 mm), nasal length was
WIZDOM-lateral brow 28.7 ± 2.06 mm 0.385
Eye length 29.0 ± 1.56 mm
Angle to WIZDOM 56.4 ± 2.45 degrees —
MC, medial canthus; WIZDOM, width of interzygomatic distance of midface.
43.6 mm ± 3.29 (range, 37.3-50.8 mm), medial canthus to
lip was 53.8 mm ± 3.34 (range, 49.1-64.6 mm). WIZDOM
average was 108 mm ± 5.81 (range, 93-127 mm) and brow
length was 107 mm ± 5.87 (range, 96.7-124 mm). The
difference between brow length and WIZDOM was not sta-
tistically different (P = 0.834). The average WIZDOM-MC
was 13.1 mm ± 1.67 (range, 7.5-16.6 mm) and WIZDOM
to chin diagonal was 98.9 mm ± 5.68 (range, 86.2-
114 mm). The difference between WIZDOM-MC to 1/3 of
MC to nasal ala was not statistically different (P = 0.075).
In addition, the WIZDOM-lateral brow to eye length dif-
ference was not statistically different (P = 0.385). The
average of WIZDOM to hairline vertical (86.9 mm ± 6.10,
range 69.8-97.7) was compared to WIZDOM to chin verti-
cal (83.5 mm ± 5.66, range 70.5-95.9) and was found to be
statistically different (P = 0.003). The angle between the
WIZDOM line and the chin to WIZDOM diagonal line was
found to be 56.4 ± 2.45 degrees (range, 50.5-61 degrees).
A summary of results can be found in Table 1. Figures 3
and 4 serve to display the statistical comparisons that were
stated above and to display their relationships on a sample
model photograph.
The interobserver reliability between the 3 examiners
was excellent for all parameters (P < 0.01), ranging from
0.718 (WIZDOM-MC) to 0.993 (interpupillary distance).
The WIZDOM measurement, in particular, was highly
reproducible with an interobserver coefficient of 0.939.
See Table 2 for the complete interobserver reliability
analysis.
Linkov et al 5

A B

C D

Figure 3.  Graphical representation of parameter comparisons with error bars and P-values listed. (A) Brow length vs
WIZDOM. (B) WIZDOM-lateral brow vs eye length. (C) WIZDOM-MC vs 1/3 of MC to alar border. (D) WIZDOM-hairline
vertical vs WIZDOM-chin vertical.

DISCUSSION In their attempts to develop a clinically practical

The notion of “mathematical beauty” implies the exist-
ence of ideal facial contours, dimensions, and ratios that,
when present, create a harmonious, balanced, and attract-
ive face. The scientific and artistic communities have yet
to describe the ideal aesthetic proportions or relationships
in the midface.
method of evaluating facial aesthetics, in regards to the
midface, Bartlett and Whitaker described the bizygomatic
distance as the widest portion of the face, with the bitem-
poral and bigonial distances being approximately equal
and 10% less than the widest portion of the face.26 The
ogee curve is another valuable and powerful tool to qual-
itatively appraise midfacial contour.18 When seen in the
6 Aesthetic Surgery Journal

Table 2.  Interobserver Reliability of the Ideal Midface (n = 3 Evaluators)

Variable Interobserver reliability P value

Interpupillary distance 0.993 <0.01

Nasal length 0.776 <0.01

MC to lip 0.954 <0.01

Brow length 0.987 <0.01

Eye length 0.889 <0.01

WIZDOM 0.939 <0.01

WIZDOM-MC 0.718 <0.01

WIZDOM-hairline 0.951 <0.01

vertical

WIZDOM-chin vertical 0.954 <0.01

WIZDOM-chin diagonal 0.944 <0.01

WIZDOM-lateral brow 0.809 <0.01

1/3*MC to alar border 0.964 <0.01

MC, medial canthus; WIZDOM, width of interzygomatic distance of midface. Reliability

>0.6 = substantial agreement.

numerous surface landmarks as well as bony anatomy,

Figure 4.  Schematic representation of data in Figure 3.
Dashed lines indicate brow length and WIZDOM. Yellow
lines are for WIZDOM-lateral brow and eye length. Blue lines
are for WIZDOM-MC and MC-nasal ala. Green line depicts
WIZDOM-chin diagonal.
three-quarter view, the soft tissues of the ideal youthful
midface form an architectural ogee or “S”-shaped curve.
The youthful face as a whole approximates a double ogee
curve, described by Ramirez,19 with the convexity of the
upper ogee at the lateral brow and of the lower ogee at
the upper midface. Recreating this curve is an important
aspect of midfacial rejuvenation, but placement of the mid-
facial convexity remains arbitrary and inconsistent. Where
should the apex of the curve be? This is not defined, nor is
its point of maximum curvature or its point of maximum
projection.
Swift and Remington20 described the ideal midface posi-
tion as an ovoid, angular cheek mound with an eccen-
tric apex that is measured at 1.618x from the ipsilateral
medial canthus, where “x” is the distance from medial
canthus to medial canthus. Furthermore, the malar apex
was defined by the intersection of a line drawn from the
nasal alar groove to the upper tragus with a line drawn ver-
tically down from the midpoint of the lateral orbital rim.
This description is obtuse, not validated, and is a difficult
estimation that may not be reproducible as it depends on
particularly the vertical line—to where and in relationship
to what?
The midface apex, or “zygomaxillary point,” described
by Ramirez,19 is the point of maximum anterior projec-
tion of the cheek convexity. This is most easily seen on
a three-quarter pose, but may also be readily and reli-
ably identified on a direct anterior view. Ramirez further
described the location of the zygomaxillary point at the
intersection of a vertical line at the external lateral orbital
rim and a horizontal line extending from the upper lat-
eral cartilage of the nose to the tragus. This description
is similar to that of Swift and Remington.20 We feel that
this definition may be useful while assessing a patient, but
not in assessing pre- or postoperative photographs and/or
results. The landmarks Ramirez refers to are bony and car-
tilaginous landmarks defined only by palpation, not visu-
ally. The upper lateral cartilage varies in size, as does the
tragus. It is difficult to pinpoint the upper lateral cartilage
precisely without palpation.9 In addition, these measure-
ments are invalid in the operated patient, as landmarks
may have been surgically altered.
Carruthers et al introduced midface scales for assessment
of age-related midface changes. One problem with their
metrics is that the 3-dimensional aspect of fullness may not
be sufficiently captured in 2-dimensional photographs, par-
ticularly with only a frontal view. Even with the three-view
updated scales, the measures are qualitative and highly sub-
jective. In their studies, intrarater reliability of ratings was
inconsistent and low for certain aesthetic units.27
Linkov et al 7

A B

Figure 5.  Representative 56-year-old female patient (A) preoperative and (B) 7 years postoperative following an endoscopic
midface lift. WIZDOM is marked in both photographs by a red line and the WIZDOM-MC by a blue line. Notice how WIZDOM
grossly enlongates and WIZDOM-MC shortens after surgery. Of note, in addition to the endoscopic midface lift, the patient also
underwent fat transfer, upper and lower blepharoplasty, and ptosis repair.

A heart-shaped midface is the quintessential symbol
of youth and remains the overarching goal of midfacial
rejuvenation.17 However, few objective criteria exist to
describe midfacial position, whether in the ideal or aged
state. In addition, in performing aesthetic midface lifting or
in volumizing the midface, few criteria exist for measuring
changes and improvements beyond saying “yes, that looks
improved.”11-13
In this pilot study, we introduce a method to assess the
midface: the width of the interzygomatic distance of the
midface (WIZDOM), defined as the horizontal line con-
necting the zygomaxillary points (Figure 1). Our results
demonstrate that WIZDOM is a reliable and easily repro-
ducible measurement on 2-dimensional (2D) photographs,
with an interobserver coefficient of 0.939. The interpupil-
lary distance (PD), which is a ubiquitous and easily repro-
ducible measurement, served as a control and also showed
high interobserver correlation of 0.993. The remaining
parameters were selected based upon our clinical obser-
vations of the aging changes that occur in the midface and
periocular region. We felt that these parameters might be
useful to clinicians looking to find means of quantifiying
aging changes, as well as postoperative improvements. It is
also a means of addressing ideal midfacial proportions and
rendering them for the surgeon and patient that wish to
improve this region, whether with volumizing therapy or
with midface lifting. All included parameters were highly
reproducible among our graders.
Interestingly, brow length and WIZDOM measurements
were found to be nearly identical, without a statistically
significant difference. Therefore, the zygomaxillary points
should ideally lie vertically below the tail of the correspond-
ing eyebrow. This implies that the goal of midfacial eleva-
tion or volumization should be to create a WIZDOM point
below the tail of each brow. This can be an extremely valu-
able aesthetic and attainable endpoint in many patients,
and can serve as a guideline to the aesthetic surgeon. In
addition, the WIZDOM-lateral brow vertical distance was
found not to be statistically different from the eye length,
another useful parameter.
Also of interest is the WIZDOM-MC measurement since
it is an important indicator of midface ptosis and can serve
as a marker of how much lift is obtained. In this study, the
WIZDOM-MC ideal distance was 13.1 mm. WIZDOM-MC
8 Aesthetic Surgery Journal

A B

Figure 6.  Representative 52-year-old female patient (A) preoperative and (B) 1 year postoperative following an endoscopic
midface lift. WIZDOM is marked in both photographs by a red line and the WIZDOM-MC by a blue line. In addition to the
endoscopic midface lift, the patient also underwent brow lift, fat transfer, upper and lower blepharoplasty, full face laser, and
filler.

is useful in defining the idealized lid/cheek junction,
where the concavity of the lower eyelid meets the full con-
vexity of the cheek. Of note, the WIZDOM-MC distance
was statistically similar to one third of the MC to nasal
ala border distance. Fezza and Massry28 documented that
the lower lid does lengthen every decade of life and they
obtained average numerical values of lower lid length at
each decade. Though the methodology of measuring was
different than WIZDOM-MC, the results of our average dis-
tance of 13.1 mm fit between two decades in their study
30s and 40s, supporting the notion that WIZDOM-MC in
our study describes a more youthful appearance.
Initially, it was hypothesized that WIZDOM would be
positioned exactly in the middle of the face, therefore
WIZDOM-hairline and WIZDOM-chin were measured.
However, it was found that these 2 measurements were
statistically different and thus WIZDOM does not fall
on the true y-axis midline in all cases. However, 1.6 ×
WIZDOM was found to be nearly identical to facial length
(WIZDOM-hairline plus WIZDOM-chin measurments),
and thus WIZDOM obeys the golden ratio, and may clue
the clinician into creating the ideal midface width based
on vertical facial length.
WIZDOM and WIZDOM-MC have the potential to be
a powerful tool in the hands of the plastic surgeon. The
clinical utility of WIZDOM may be applied to the assess-
ment and surgical planning of midfacial rejuvenation,
objectively measuring the success of midfacial rejuvena-
tion, and/or evaluating the longevity of midfacial reju-
venation techniques. Using an objective, reproducible
method to define midfacial position allows clinicians and
researchers to communicate more accurately, resulting in
more reliable comparisons among various methods of mid-
facial rejuvenative techniques such as facelifts and fillers.
In aesthetically successful midface surgery, it appears that
midface volume shifts occur accentuating the WIZDOM
point and bringing WIZDOM-MC closer to the ideal,
though additional studies are needed to validate the use of
WIZDOM for aesthetic surgery (Figures 5-6). Additionally,
in order to accurately measure WIZDOM on postoperative
patients, a standardized head tilt angle would be necees-
sary, as this would have impact on a linear measurement
such as WIZDOM.
WIZDOM also appears to be a conceptually straight-
forward determination, as our three graders with varying
levels of expertise in facial plastic surgery had excellent
interobserver correlation. We elected to study WIZDOM,
WIZDOM-MC, and related facial interrelationships in 2D
due to the ease of obtaining stock photographs of youth-
ful and beautiful models. These facial relationships can be
Linkov et al
assessed in clinical practice either from 2D photographs or
simply in 3 dimensions: the subject’s makeup is removed,
and, with overhead lighting that creates the necessary
shadows to define the WIZDOM points, these measure-
ments are accomplished and recorded.
In clinical practice, its measurement is facilitated by ini-
tially viewing the cheeks in the three-quarters view. The
ogee described by the orbital concavity and the apex of the
sinusoidal cheek convexity in the ogee’s secondary curve
represents the WIZDOM point. The face is rotated into
the contralateral three-quarters view and the same point
marked. The distance between points is then measured
in the anteroposterior position, as well as the distance
between the WIZDOM and the inner canthus.
Study limitations include the sample size (n = 55 ideal
images) and number of graders (n = 3). However, the
purpose of this preliminary study was to introduce the
concept of WIZDOM and WIZDOM-MC, and certainly a
larger data set would be necessary to validate the find-
ings. Future goals include assessing a large cohort of cos-
metic patients, who are photographed in the office, to
evaluate how surgery and volumizing procedures affect
WIZDOM. The study sample was also skewed towards
Caucasian models (52 out of 55), based upon the availa-
bility of stock photos. This study did not attempt to define
the ideal midface position in males, and further studies
should be directed towards corroborating whether these
relationships hold. Also, the lack of standardized facial
expressions in the stock photographs may have added an
element of variability.
A theoretical limitation of this study relates to the larger
concept of defining “beauty.” Our selection of youthful
model faces will not be every individual’s ideal, but relate
more generally to the notion of facial attractiveness in our
society. In our discussions of WIZDOM and ideal facial
aesthetics, we do not intend to imply that beauty cannot
exist outside these parameters, but simply strive to provide
a framework for reference. Interestingly, a recent study
showed that beauty is not just about technically achieving
a symmetrical result. In fact, facial asymmetry detection
thresholds allow minor asymmetries, which are key to a
patient’s appearance, to be left untouched or potentially
optimized within acceptable limits.29
The models in these photographs were often heavily
made up to accentuate each model’s facial appearance
and to increase the likelihood that the photograph would
be appealing to the consumer on a photographic website.
We also assume that various facial features, curves, and
lines had been retouched using conventional photoediting
techniques. These “artificial” enhancements further con-
firm that facial proportions in 2 dimensions are created to
conform to a visual ideal and that WIZDOM is a reliable
measurement of the visual ideal in 2 dimensions. The fact
that WIZDOM can be extrapolated to the third dimension
9
is appealing because it has clinical relevance and can be
used to define ideal facial endpoints for injection and for
surgical elevation to define midface projection.
CONCLUSION
The study results suggest that WIZDOM and WIZDOM-MC
are clinically relevant parameters which may be utilized to
define the spatial characteristics of the ideal youthful mid-
face. It may also find utility in the assessment of patients
and as an ideal to achieve balanced aesthetic results in
midface restorative procedures—lifting or volumization—
in females.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1. Angle E. Treatment of Malocclusion of the Teeth. Angle’s
System. Philadelphia, PA: SS White Dental Manufacturing
Co.; 1907.
2. Spradley FL, Jacobs JD, Crowe DP. Assessment of the
anteroposterior soft-tissue contour of the lower facial
third in the ideal young adult. Am J Orthod. 1981;79(3):
316-325.
3. Perrett DI, May KA, Yoshikawa S. Facial shape
and judgements of female attractiveness. Nature.
1994;368(6468):239-242.
4. Borman H, Ozgür F, Gürsu G. Evaluation of soft-tissue
morphology of the face in 1050 young adults. Ann Plast
Surg. 1999;42(3):280-288.
5. Matoula S, Pancherz H. Skeletofacial morphology
of attractive and nonattractive faces. Angle Orthod.
2006;76(2):204-210.
6. Kiekens RM, Kuijpers-Jagtman AM, van’t Hof MA, van’t
Hof BE, Maltha JC. Putative golden proportions as pre-
dictors of facial esthetics in adolescents. Am J Orthod
Dentofacial Orthop. 2008;134(4):480-483.
7. Husein OF, Sepehr A, Garg R, et al. Anthropometric and
aesthetic analysis of the Indian American woman’s face. J
Plast Reconstr Aesthet Surg. 2010;63(11):1825-1831.
8. Mommaerts MY, Moerenhout BA. Ideal proportions in
full face front view, contemporary versus antique. J
Craniomaxillofac Surg. 2011;39(2):107-110.
9. Setabutr D, Sohrabi S, Kalaria S, Gordon K, Fedok FG.
The relationship of external and internal sidewall
dimensions in the adult Caucasian nose. Laryngoscope.
2013;123(4):875-878.
10. Frueh BR. The mechanistic classification of ptosis.
Ophthalmology. 1980;87(10):1019-1021.
10
11. Surek CC, Beut J, Stephens R, Jelks G, Lamb J. Pertinent
anatomy and analysis for midface volumizing procedures.
Plast Reconstr Surg. 2015;135(5):818e-829e.
12. Marianetti TM, Cozzolino S, Torroni A, Gasparini G, Pelo S.
The “beauty arch:” a new aesthetic analysis for malar aug-
mentation planning. J Craniofac Surg. 2015;26(3):625-630.
13. Jacono AA, Ransom ER. Anatomic predictors of unsatis-
factory outcomes in surgical rejuvenation of the midface.
JAMA Facial Plast Surg. 2013;15(2):101-109.
14. Coleman SR, Grover R. The anatomy of the aging face:
volume loss and changes in 3-dimensional topography.
Aesthet Surg J. 2006;26(1S):S4-S9.
15. Richard MJ, Morris C, Deen BF, Gray L, Woodward JA.
Analysis of the anatomic changes of the aging facial skel-
eton using computer-assisted tomography. Ophthal Plast
Reconstr Surg. 2009;25(5):382-386.
16. Zadoo VP, Pessa JE. Biological arches and changes to the
curvilinear form of the aging maxilla. Plast Reconstr Surg.
2000;106(2):460-466; discussion 467.
17. Buchanan DR, Wulc AE. Contemporary thoughts on lower
eyelid/midface aging. Clin Plast Surg. 2015;42(1):1-15.
18. Little JW. Volumetric perceptions in midfacial aging with
altered priorities for rejuvenation. Plast Reconstr Surg.
2000;105(1):252-266; discussion 286-289.
19. Ramirez OM. Three-dimensional endoscopic midface
enhancement: a personal quest for the ideal cheek rejuve-
nation. Plast Reconstr Surg. 2002;109(1):329-340; discus-
sion 341-349.
20. Swift A, Remington K. BeautiPHIcation™: a global approach
to facial beauty. Clin Plast Surg. 2011;38(3):347-377, v.
Aesthetic Surgery Journal
21. Philipp-Dormston WG, Eccleston D, De Boulle K, Hilton S,
van den Elzen H, Nathan M. A prospective, observational
study of the volumizing effect of open-label aesthetic use
of Juvéderm® VOLUMA® with Lidocaine in mid-face area.
J Cosmet Laser Ther. 2014;16(4):171-179.
22. Binder WJ, Azizzadeh B. Malar and submalar augmen-
tation. Facial Plast Surg Clin North Am. 2008;16(1):
11-32, v.
23. Terino EO, Edward M. The magic of mid-face three-di-
mensional contour alterations combining alloplastic
and soft tissue suspension technologies. Clin Plast Surg.
2008;35(3):419-450; discussion 417.
24. Rüfer F, Schröder A, Erb C. White-to-white corneal
diameter: normal values in healthy humans obtained
with the Orbscan II topography system. Cornea.
2005;24(3):259-261.
25. Ricketts RM. The biologic significance of the divine
proportion and Fibonacci series. Am J Orthod.
1982;81(5):351-370.
26. Bartlett SP, Wornom I 3rd, Whitaker LA. Evaluation of
facial skeletal aesthetics and surgical planning. Clin Plast
Surg. 1991;18(1):1-9.
27. Carruthers J, Rzany B, Sattler G, Carruthers A. Anatomic
guidelines for augmentation of the cheek and infraorbital
hollow. Dermatol Surg. 2012;38(7 Pt 2):1223-1233.
28. Fezza JP, Massry G. Lower eyelid length. Plast Reconstr
Surg. 2015;136(2):152e-159e.
29. Wang TT, Wessels L, Hussain G, Merten S. Discriminative
thresholds in facial asymmetry: a review of the literature.
Aesthet Surg J. 2017;37(4):375-385.