Abstract
Background
This paper aims to evaluate and standardize measurements of 11 nasal parameters specific to the South Indian population. This is significant because different ethnicities exhibit varying nasal proportions. The findings of this study will serve as a foundation for rhinoplasty procedures performed on the South Indian population as currently there is a lack of literature in this area of study.
Methodology
A total of 136 young individuals of age group 18–30 were taken as a sample; 34 from each state that is Kerala, Karnataka, Tamil Nadu, and Andhra Pradesh were taken up for the study. Standardized photographs of the nose were taken. Eleven nasal parameters were measured using Digimiser software and analyzed.
Results
Eight out of eleven parameters have statistically significant differences among the population of all four South Indian states, while three parameters did not have much of a statistically significant difference.
Conclusion
When compared to the standard values of nasal parameters of the Indian population, only radix height and nasolabial angle were similar. The nasal index of all four South Indian ethnicities was platyrrhine. The nasal parameters did not differ among males and females in all the four South Indian populations.
Keywords: Nasal parameters, Nasal index, Rhinoplasty
Introduction
The nose, being the center of the face, is an individual’s most determining feature of the face [1]. The main factor determining nasal morphology is genetics along with environmental factors. The nasal parameters are correlated to airway dynamics as well [2]. As part of the evolutionary process of adaptation, the structure of the nose is narrower among populations in cold and dry climates, whereas it is broader among populations in relatively humid climates [3].
Anthropometric measurements are widely used for planning rhinoplasty procedures [4]. The nasal parameters are used for pretreatment counseling, virtual surgical planning, and intraoperatively as reference parameters for rhinoplasties. Indian population has distinct features compared to other populations, but only very limited studies exist. According to studies, the nose of the South Indian population falls into the category of mesorhine [5].
The main advantage of photogrammetry is digitalizing the photographs and measurements using software. Lu SM et.al. included in their study that aesthetic rhinoplasty has a significant impact on public perception of a person’s appearance [6]. Various other studies have also concluded that both the observers’ and also patient’s race influences the perception of attractiveness [7].
These differences in each ethnicity have become more important for all aesthetic practitioners as most cities have a cosmopolitan population with people from different ethnicities [8]. The motive of this study is to standardize nasal parameters for the South Indian population which can act as reference values for cosmetic rhinoplasties, forensic science, and even in genetic counseling.
Materials
Canon DSLR camera EOS 1500D with 100 mm Macro Lens Vertical metric scale with calibrations in centimeters, Digimiser image measuring software, and white background were used.
Methodology
Students studying at Yenepoya University, A B Shetty Memorial Institute of Dental Sciences, A J Institute of Dental Sciences and Research Centre, and Manipal College of Dental Sciences, Mangalore, were included for the study. The sample comprised of 136 young individuals.
Inclusion criteria included 34 young individuals from each state in South India (Kerala, Tamil Nadu, Karnataka, and Andhra Pradesh (present-day Telangana and Andhra Pradesh combined), of age between 18 and 30 years. All individuals in the study belonged to the respective states mentioned in terms of their ethnicity. Additionally, all participants were queried about whether their parents also hailed from the same respective state.
Exclusion criteria included participants with a history of previous trauma or surgery/any congenital deformity or gross asymmetry of face or nose and participants of age less than 18 and more than 30.
The sample was collected by stratified sampling method. The sample size was calculated by using G*power software. At a 1% level of significance and 90% power with an effect size of 0.6767 by considering pooled standard deviation of 0.4569, the total sample size was 136. The total sample size was equally distributed for 4 states, and from each state 34 samples were selected based on the gender ratio [1].
After explaining the study and its objectives to the participants, written consent was taken from them. Another specific consent was taken from them concerning photography. Standardized frontal, lateral, and basal photographs of the nose were taken. To increase the accuracy of measurements, each photograph was taken with a vertical reference scale next to the face. Participants were seated comfortably in an anatomically relaxed position. The camera lens was aligned parallel to the frontal view of the patient with a neutral head position which could be easily reproduced. A Digital Canon DSLR camera EOS 1500D with 100 mm Macro Lens mounted on a stand was used. A distance of 1 m between the subject and lens was maintained.
The subject was asked to stay stable while taking the photograph (Fig. 1a–d).
Fig. 1a.
Frontal photograph, b lateral photograph, c lateral photograph, d basal photograph
Digital images were transferred, and 11 nasal parameters (both linear and angular) were measured using Digimiser software (Digimiser Image Measurement Software version 5.7.2). The measurements were taken thrice to improve the accuracy, and the mean of all the three values was taken. We considered a permissible error of 1 mm as within the acceptable range. Statistical analysis was performed using SPSS version 22 and Microsoft Excel, and the data were presented as mean values with their corresponding standard deviations.
t test was conducted to see the variation between males and females. ANOVA test was used to see any significant difference in the nasal parameters among the above groups. Type one error was 5% level of significance.
Parameters Assessed
The following 11 parameters were assessed:
nasal length, radix height, dorsal height, nasal tip projection, columellar show, nasal base, intercanthal distance, nasofrontal angle, nasolabial angle, nasofacial angle, and nasomental angle.
Results
Eight out of 11 parameters taken in this study, which are nasal length, dorsal height, nasal tip projection, columellar show, intercanthal distance, nasolabial angle, nasofacial angle, and nasomental angle, have statistically significant differences of p < 0.05 among all four student groups. Radix height, nasal base, and nasofrontal angle—all these three parameters did not have much of a statistically significant difference among all four student groups.
(Table 1).
Table 1.
Regional comparison of each nasal parameters
| Parameters | States | Mean | Std. Deviation | Test Statistic | P value |
|---|---|---|---|---|---|
| Nasal length | Andhra Pradesh | 4.02224 | 0.315518 | 3.541 | 0.016 |
| Karnataka | 3.91626 | 0.164374 | |||
| Kerala | 4.01524 | 0.262563 | |||
| Tamil Nadu | 3.86457 | 0.190762 | |||
| Radix height | Andhra Pradesh | 1.18703 | 0.250574 | 1.308 | 0.275 |
| Karnataka | 1.24338 | 0.153694 | |||
| Kerala | 1.26718 | 0.068096 | |||
| Tamil Nadu | 1.62000 | 1.981503 | |||
| Dorsal height | Andhra Pradesh | 1.75715 | 0.436566 | 10.388 | < 0.0001 |
| Karnataka | 1.51609 | 0.146479 | |||
| Kerala | 1.45765 | 0.116256 | |||
| Tamil Nadu | 1.50914 | 0.106090 | |||
| Nasal tip projection | Andhra Pradesh | 2.20129 | 0.436900 | 4.064 | 0.008 |
| Karnataka | 2.31735 | 0.215567 | |||
| Kerala | 2.29382 | 0.186450 | |||
| Tamil Nadu | 2.43429 | 0.203460 | |||
| Columellar show | Andhra Pradesh | 0.41194 | 0.228935 | 10.778 | < 0.0001 |
| Karnataka | 0.28968 | 0.090735 | |||
| Kerala | 0.24412 | 0.063633 | |||
| Tamil Nadu | 0.44286 | 0.224730 | |||
| Nasal base | Andhra Pradesh | 3.87524 | 0.332102 | 1.218 | 0.306 |
| Karnataka | 4.87294 | 5.128579 | |||
| Kerala | 3.91379 | 0.369195 | |||
| Tamil Nadu | 3.91937 | 0.155536 | |||
| Intercanthal distance | Andhra Pradesh | 3.39785 | 0.258159 | 6.269 | 0.001 |
| Karnataka | 3.39341 | 0.249427 | |||
| Kerala | 3.53647 | 0.216835 | |||
| Tamil Nadu | 3.57829 | 0.150675 | |||
| Nasofrontal angle | Andhra Pradesh | 123.2712 | 10.41234 | 0.826 | 0.482 |
| Karnataka | 122.0356 | 1.10244 | |||
| Kerala | 122.1353 | 0.83273 | |||
| Tamil Nadu | 121.2800 | 1.68397 | |||
| Nasolabial angle | Andhra Pradesh | 105.0406 | 4.35465 | 13.608 | < 0.0001 |
| Karnataka | 102.5365 | 0.88498 | |||
| Kerala | 102.2694 | 0.75390 | |||
| Tamil Nadu | 101.7829 | 1.05927 | |||
| Nasofacial angle | Andhra Pradesh | 36.08247 | 3.143285 | 53.815 | < 0.0001 |
| Karnataka | 25.83824 | 6.677888 | |||
| Kerala | 23.00706 | 0.741430 | |||
| Tamil Nadu | 24.00763 | 6.020381 | |||
| Nasomental angle | Andhra Pradesh | 125.72388 | 3.467921 | 40.395 | < 0.0001 |
| Karnataka | 121.62324 | 2.935059 | |||
| Kerala | 120.66706 | 1.411214 | |||
| Tamil Nadu | 119.57714 | 1.388415 |
South Indian Nasal Angular Parameters (Table 2)
Table 2.
NASAL angles: anthropometric measurements
| Nasal parameters | Measurement in cm and SD | Measurement in cm and SD | Test statistic | P value |
|---|---|---|---|---|
| Female | Male | |||
| Nasofrontal angle | 122.862(5.895) | 121.455 (4.508) | 1.564 | 0.120 |
| Nasolabial angle | 103.003 (2.602) | 102.790 (2.632) | 0.476 | 0.635 |
| Nasofacial angle | 26.423(6.956) | 28.033(7.093) | − 1.341 | 0.182 |
| Nasomental angle | 121.616(3.145) | 122.158(3.610) | − 0.938 | 0.35 |
Nasofrontal angle was 122.8 degrees in females when compared to males at 121.5 degrees. The nasolabial angle was 103.003 degrees in females and 102.79 degrees in males. The nasofacial angle was slightly more in males (28 degrees) when compared to females, while the nasomental angle was slightly more in males (122.16 degrees).
South Indian Nasal Linear Parameters (Table 3)
Table 3.
Nasal anthropometric measurements
| Nasal parameters | Measurements in cms with SD | Measurements in cms with SD | Test statistic | P value |
|---|---|---|---|---|
| Female | Male | |||
| Nasal length | 3.979 (.287) | 3.927 (0.195) | 1.228 | 0.222 |
| Radix height | 1.398(1.414) | 1.262 (0.168159) | 0.781 | 0.436 |
| Dorsal height | 1.55947(.282) | 1.56(0.2512) | − 0.007 | 0.994 |
| Nasal tip projection | 2.307(0.28) | 2.319(0.3) | − 0.245 | 0.807 |
| Columellar show | 0.336 (0.166) | 0.36(0.208) | − 0.730 | 0.466 |
| Nasal base | 4.329 (3.6) | 3.950 (0.172) | 0.859 | 0.392 |
| Intercanthal distance | 3.4719(0.231718) | 3.48284(0.239848) | − 0.271 | 0.786 |
Independent sample t test was performed, and we observe that there is no significant difference in the nasal parameters between those of males and females
The study found that nasal lengths were 3.979 cm for females and 3.927 cm for males, while radix height was 1.3 cm for females and 1.26 cm for males, and dorsal height was 1.56 cm for both sexes, with an average nasal tip projection of 2.3 cm. The columellar show was slightly lower in females at 0.33 cm compared to males at 0.36 cm, and the nasal base was 4.3 cm for females and 4 cm for males. The intercanthal distance was slightly greater in males at 3.482 cm compared to females at 3.47 cm. An independent sample t test revealed no significant difference in nasal parameters between males and females.
Discussion
Rhinometry is used in preoperative as well as postoperative evaluation [9]. Anthropometric studies include the measurement of any part of the human body which includes rhinometry [10]. Manual measurement has become cumbersome; hence, nowadays software is available like Digimiser [11]. Recent studies have even used CT scans for anthropometric studies in rhinoplasty as well as for preoperative evaluation [12].
A surgeon should keep in mind that the ‘new nose’ will blend in with the features of the particular ethnicity that the patient belongs to [13, 14]. The shape and size of the nose are dependent on many factors like ethnicity, genetics, geographical areas, and sex [15, 16]. The evolution of the nose in humans has been closely related to climatic factors [17].
Although the use of the golden proportion of the face has been used for facial aesthetics, there have been studies that prove that there is variation in certain facial parameters and standard proportions considering the Indian population [18].
Standardizing the parameters according to ethnicity is important as these will serve as reference values in cosmetic rhinoplasties [19, 20]. These values can be used in forensic science and even studies relating to genetics [21, 22].
Many times the standard values and parameters measured will not be according to the aesthetic concern of the patient [23, 24]. Hence, the surgeon should keep in mind the psychological aspect of the patient and the patient’s expected outcome to obtain an optimum outcome [25]. Parab SR et al. in 2019 conducted a study in which 221 young Indian males and females were considered from all the four zones—north, south, east, and west. They had arrived at average values for 11 nasal parameters for Indian males and females which were compared to many other populations of other countries. These Indian reference values varied significantly from other populations [1].
We compared the nasal parameters of the South Indian population to the general Indian population as given by Parab SR et al. and found that the nasal length was smaller, dorsal height was smaller, nasal tip projection was more prominent, the columellar show was lesser, the nasal base was larger, the intercanthal distance was wider, the nasofrontal angle was more acute, the nasofacial angle was more obtuse, and the nasomental angle was more acute in the South Indian population[1]. Eight parameters out of eleven parameters which are nasal length, dorsal height, nasal tip projection, columellar show, intercanthal distance, nasolabial angle, nasofacial angle, and nasomental angle have statistically significant differences of p < 0.05. Radix height, nasal base, and nasofrontal angle—all these three parameters did not have much of a statistically significant difference.
There are significant differences among certain nasal parameters among four South Indian populations with p value < 0.001. The nasal length varied among all four South Indian states with the maximum nasal length in Kerala and Andhra Pradesh population. Dorsal height had significant differences among the four populations (p < 0.0001) with the smallest dorsal height in the Kerala population and the largest in the Andhra Pradesh population. The columellar show also shows significant differences among all four South Indian states (p < 0.0001). Intercanthal distance also varies significantly (p value-0.001) with the largest intercanthal distance in Kerala and Tamil Nadu population. Nasofacial, nasomental, and nasolabial angles also vary (p < 0.0001) among all four South Indian states.
The nasal index has been a reference parameter in anthropometry for decades. The nasal index is calculated by nasal breadth /nasal length × 100 [18]. Based on the values, the nose is classified as—leptorrhine (if the nasal index is < 70), mesorhine (if the nasal index is 70–84.9), and platyrrhine (if the nasal index is > 85) [26]. We calculated the nasal Index for Andhra Pradesh 96.345, Karnataka 124.42, Kerala 97.47, and Tamil Nadu 101.41. All four populations come under the platyrrhine nose. The nasal index difference between this study and Patil et al., who identified the Indian nasal index as mesorhine, likely stems from varying sample compositions, methodological variations and regional focuses [5]. In our study, all the 11 nasal parameters were compared between males and females and not much of statistical difference was seen.
While ethnicity may impact nasal parameter variations within the South Indian population, our study reveals distinct regional variations. However, results could be influenced by interracial mixing, migration patterns, and other factors.
Currently, there is a dearth of literature that considers all the 11 nasal parameters as we have done in our study. Hence, each population should be considered separately and parameters about each should be assessed to get better aesthetic outcomes in cosmetic rhinoplasties.
Conclusion
This study had shown statistically significant difference in nasal parameters in South Indian population as compared to the Indian population. Notably, South Indian nasal characteristics exhibit a distinctive pattern, with the exception of radix height and nasolabial angle, which showed no significant variation. We conclude from our study that South Indian noses are platyrrhine in nature. There is a dearth of knowledge regarding nasal parameters specific to the South Indian population in the existing literature. Therefore, our findings contribute to a better understanding of ethnicity/regional-based rhinoplasties, particularly among the South Indian population, including individuals who have settled abroad. Similar studies with larger sample size and multicentric are necessary for achieving good results for ethnic-based rhinoplasties.
Declarations
Conflict of interests
Authors declare there are no conflicts of interest.
Footnotes
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