Contribution of lip proportions to facial aesthetics in

different ethnicities: A three-dimensional analysis

Wendy W. Wong*, Drew G. Davis, Matthew C. Camp, Subhas C. Gupta
Loma Linda University Department of Plastic Surgery, 11175 Campus Street, Suite CP-21126, Loma Linda, California, USA
Received 16 September 2009; accepted 19 December 2009
KEYWORDS
Lip proportions;
Lip volume;
Lip aesthetics;
Three-dimensional
imaging;
Chinese;
Korean
Summary Background: Lip augmentations are commonly performed procedures in the
United States, with annual numbers surpassing 100 000. While lips contribute to facial
beauty, the relative inuence of this feature to whole facial appeal has not yet been
established. What is also of increasing interest is the consideration of ethnic differences
in the evaluation of beauty. However, most current anthropometric measurements refer
to Caucasians, and their use in the treatment of Asian American patients would be
inappropriate.
Methods: Three-dimensional models of 197 male and female Caucasian, Chinese and
Korean subjects were created using surface-imaging technology. The lips and correspond-
ing faces from these models were ranked according to subjective aesthetic appeal by 20
male and female raters of various ages, occupations and ethnicities. The raters results
were subsequently compared with individually measured lip parameters.
Results: Rankings between lips and their corresponding whole faces differed greatly. Lips
that were rated as the most attractive were smaller than average in midline upper lip
surface heights, bilateral paramedian lip surface heights, upper lip angles and volume in
the lower lip. Both Asian groups exhibited signicantly different lip parameters and lip-
projection volumes from that of Caucasians.
Conclusions: The results from this study suggest that there are indeed measurable differ-
ences in the baseline Asian lip morphology as compared with Caucasians. Tailoring lip
enhancement treatment to each individuals anatomy, ethnic background and personal
goals can optimise outcomes. What is also of interest is that lips did not contribute as much
to facial attractiveness as previously thought.
Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and
Aesthetic Surgeons.
* Corresponding author. Tel.: 1 909 558 8085; fax: 1 909 558 4175.
E-mail address: wewong@llu.edu (W.W. Wong).
1748-6815/$ - see front matter Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
doi:10.1016/j.bjps.2009.12.015
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 2032e2039
Introduction
Lip augmentation procedures, both surgical and inject-
able in nature, are performed annually in the United
States with the numbers surpassing 20, 000 and 100, 000,
respectively.
1
With the current popularity of pouty,
sensual-appearing lips on many Hollywood actresses, the
rate of these procedures will undoubtedly continue to
climb. The innovation of new injectable products, surgical
techniques and the popularity of currently available llers
creates a necessity for a clear understanding of lip volu-
metrics and parameters for optimal results. In addition to
having a role in facial aesthetics, lips are fundamental in
social communication, oral function and speech
articulation.
2
When questioned as to what features contribute to an
attractive face, a common response is lips. This facial
feature is comprised of a single-unit lower lip and a triple-
unit upper lip.
3
Some believe that components contributing
to attractive lips include fullness and the appearance of
a diamond-shaped unit.
3e5
Others have identied charac-
teristics of perioral rhytids and decreased lip projection as
signs of ageing and unattractiveness.
6
While it is commonly
known that certain elements of lips exemplify beauty, to
what degree lips are responsible for the perceived appeal
of ones face has yet to be answered.
Of increasing interest over the past two decades is the
consideration of ethnic differences in the evaluation of
beauty. In recent years, increasing immigration to the
United States and a surge in ethnic populations has created
a challenge for American plastic surgeons in distinguishing
facial characteristics specic to a certain ethnicity. Most
available anthropometric measurements have been estab-
lished from Caucasian faces.
7,8
However, applying these
parameters for the treatment of Asian American patients
would be inappropriate, as treatment regimens that typi-
cally result in aesthetic success in one ethnicity could yield
unpleasing results in others. Of note, caution must be taken
in some young individuals who have thin lips as this may be
a result of hereditary or racial factors rather than be
explained by ageing.
4
As with any delicate facial surgery,
dramatic adjustments of labial shape can result in
a suboptimal outcome.
In the past, two-dimensional images have posed limi-
tations in anthropometric studies, many of which corre-
spond to the inability to accurately appreciate surface
and volume concavities and convexities. The advent of
three-dimensional imaging now adds the element of
depth to photographic analysis, improving the ease and
clarity of geometric measurements and permitting volu-
metric evaluation of facial structures. In this study,
aesthetics and anthropometric measurements of the lips
were determined in Caucasian, Chinese and Korean male
and female subjects with three-dimensional imaging
technology. First, aesthetic ratings of isolated lips and
faces were compared to assess whether a correlation
existed between lips and their corresponding face. Next,
three-dimensional anthropometric parameters were
measured in all lips. Lastly, the lips deemed most
attractive were compared for similarities in measured
parameters.
Subjects and methods
Subjects
For subject recruitment, yers and e-mail invitations were
distributed to nearby university students, hospital
employees and congregational members, asking for the
participation of any males and females under the age of 45.
This study enrolled 197 subjects: 46 Chinese-Americans (23
females and 23 males), 70 Korean-Americans (35 females
and 35 males) and 81 North American Caucasians (51
females and 30 males). In female subjects, the average age
for Chinese was 24.9 years (ranging from 23 to 28 years),
Koreans was 25.9 years (ranging from 15 to 40 years), and
Caucasians was 24.8 years (ranging from 15 to 44 years). For
the male subjects, the average age for Chinese was 26
years (ranging from 23 to 33 years), Koreans was 27
years(ranging from 22 to 36 years) and Caucasians was 25
years (ranging from 22 to 37 years). All Asian subjects were
either born or had resided in the United States for more
than 20 years. None of the subjects had neither a history of
facial rejuvenation nor were edentulous. One Korean male
had orthognathic surgery and one Caucasian male had
a history of broken nose, both more than 5 years ago. This is
an Institutional Review Board-approved study and informed
consent was obtained from each subject.
Three-dimensional imaging and software
The 3dMD digital camera system and accompanying patient
software (both 3dMD, Atlanta, GA, USA) is comprised of 12
cameras positioned in a three-dimensional array centred on
the subject to be imaged. The cameras re simultaneously,
acquiring an image data set that is then sent for processing
by the 3dMD desktop software. A three-dimensional facial
model is then generated in the computer work environ-
ment, and can be analysed by a number of powerful soft-
ware utilities.
Rating of lip aesthetics
All sets of lips were isolated from their corresponding faces
in the same manner to exclude any distracting facial hair in
preparation for rating. It is important to note that isolation
was used for visual evaluation only, not anthropometric
measurements. Isolation was carried out using the 3dMD
software plane function in six pairs of cuts perpendicular
to the anterior facial surface. First, planes were cut away
to isolate the lips in a rectangle with its edges approxi-
mately 3 mm from the vermillion border, followed by
diagonal pairs of cuts in a diamond shape and lastly with
pairs of cuts to taper at the lateral commissures (Figure 2).
Once isolated, these were used to create a compilation of
randomised lips. To avoid impartiality bias, this set of lips
and their corresponding whole faces were organised as two
separate self-administered slideshows. Twenty male and
female raters (average age 29.5 years, ranging from 17 to
61 years) of various occupations and ethnicities (nine
Caucasian, four Chinese, two Korean, two Vietnamese, one
Asian-Indian, one Hispanic and one African) were directed
Contribution of lip proportions to facial aesthetics in different ethnicities 2033
to rate each lip and face on a scale from 1 to 5, with 1
representing very unattractive and 5 as very attractive.
A difference of 1.0 between lip and face ratings were
considered clinically signicant. The sets of lips that were
rated as the most attractive were later evaluated for
similar anthropometric values.
Measurement of lip parameters
To evaluate facial parameters with focus on the lips,
precise calliper and surface distance measurements were
made by placing points directly on the three-dimensional
model (Figure 1B). Each landmark was placed on the loca-
tion described by Farkas.
7,8
The following landmarks were
placed on each subject for analysis: endocanthion (en),
zygoma (zy), right and left alare (alR and alL), subnasale
(sn), labiale superioris (ls), right and left labiale superioris
(lsR and lsL), right and left cheilion (chR and chL), stomion
(sto), labiale inferioris (li), sublabiale (sl) and gnathion
(gn). A reference line was drawn between the cheilion
points along the labial ssure (lf). A point was placed along
this line directly inferior to the left and right labiale
superioris to gauge the paramedian heights of the upper lip.
Along this reference line, ve points were placed at equi-
distant intervals for surface distance calculation of the
labial ssure. Seven points at equidistant intervals were
placed along the upper and lower lip vermillion borders to
calculate the surface length of each.
Relative measurements of upper and lower lip volume
were calculated using the lasso function of the 3dMD
software. This capability yields a volume and surface
area within the region of manually placed points. Eight
points were positioned along the parameter of the
region of interest (upper lip, lower lip or total lip),
yielding the corresponding volume and surface area
measurement. Five angles (upper lip, lower lip, right and
left cupidss bow and central cupids bow) using the
3dMD three-point angle tool (Figure 1A) were calcu-
lated. With this function, manual placement of three
consecutive points yields a numerical value representa-
tive of the angle size.
Three previously described
2
lip curves were evaluated:
two M-shaped curves along the upper vermillion border
and the intralabial line and one lower lip W shaped curve.
A score of 1 was given for each curve present. The pres-
ence of all three curves yielded a score of 3, while 0
represented the lack of these curves. The combined three
scores represented the total curvature score for each
individual. Then, an average value for each of the three
curves was calculated per ethnicity and sex.
Figure 1 A) Lip angles measured: a, upper lip angle; b, lower lip angle; c, right cupids bow angle; d, left cupids bow angle;
e, central bow angle B) Facial and lip landmarks used for measurements.
2034 W.W. Wong et al.
Parameters of attractive lips
The parameters of sets of the most attractive lips, as deter-
mined by raters, were evaluated for shared similarities. For
eachset of attractivelips, measurements that weregreater or
smaller than average were recorded and compared.
Statistical analysis
Means and standard deviations were calculated for the
differences between ethnicities. Measurements differing
more than 1 mm were considered valid. For each sex,
differences were compared between ethnic groups.
Numerical differences between groups were analysed by
analysis of variance (ANOVA). All variables were analysed
for normal distribution using the skew and kurtosis statis-
tics. Homoscedasticity was evaluated using Levenes test.
Variables that did not pass this test were not included due
to the unequal sample size of the groups under study.
Differences between ethnicities were evaluated using the
Bonferroni post hoc analysis with a p value of 0.05 consid-
ered as signicant.
Results
Lip aesthetic ratings
Comparisons between the rating score of lips and the
corresponding faces were made for each individual and
group (Table 1). Of the three ethnic groups, Korean
females received the highest average lip rating and
lowest average whole face rating; however, both their lip
and face scores were the same. By contrast, Caucasian
females received the lowest average lip rating and the
highest whole face rating. The male subjects followed the
same pattern with the Koreans scoring the highest on the
lips and lowest on the whole face rating, the opposite
being true for Caucasian males. In the three top-rated
faces, the average ranking difference between the face
and lip was 1.4, which is a substantial discrepancy when
considered on a 5-point scale (Figure 3). The discrepancy
in relative lip and face scores suggests that lips do not
have a strong determining role in overall facial
aesthetics.
Normative data of facial parameter measurements
In the evaluation of female lips, numerous differences exis-
ted between the Asian subjects in comparison to the
Caucasians. Fewer differences were found between Chinese
and Koreans (Table 2). When compared with Asian lips, the
Caucasian lips were found to be generally thinner as evi-
denced by shorter median and paramedian upper lip heights
and an overall smaller upper lip size (p values <0.002). The
ratio of upper to lower lip was highest in Koreans (p <0.005),
enhancing a diamond-shaped lip unit. Several unique
features characterised Chinese female lips, including the
overall thickest lower lip (p <0.03), widest cupids bow, the
most acute cupids bow angles and shorter philtral columns
when compared with Caucasian females (p <0.02). No
differences in total mouth width, upper vermillion surface
distance and total vermillion surface distance were observed
between the three female groups. The lower lip vermillion
surface distances did not pass Levenes test and were
excluded in data analysis. The upper lip volume was the
greatest in Chinese females (p <0.001), but no differences
were observed in lower lip or total lip volumes amongst the
three groups.
Figure 2 The three most highly rated lips.
Table 1 Average lip and whole face aesthetic scores of Chinese, Koreans, and Caucasians
Average Rating Scores: Female Average Rating Scores: Male
Ethnicity Lip Rating Whole Face
Rating
(Face Score) e
(Lip Score)
Ethnicity Lip Rating Whole Face
Rating
(Face Score) e
(Lip Score)
Chinese 2.43 2.58 0.14 Chinese 2.22 2.47 0.25
Korean 2.56 2.56 0.00 Korean 2.27 2.40 0.13
Caucasian 2.29 2.88 0.60 Caucasian 2.13 2.73 0.61
Contribution of lip proportions to facial aesthetics in different ethnicities 2035
The male lips showed fewer differences when
compared among ethnic groups (Table 3). Caucasian male
lips demonstrated the smallest cupids bow width, short
halves of the cupids bow (p <0.04) and overall thinner
lips due to a shorter paramedian red lip height and total
lip height (p <0.008). Furthermore, Caucasian males had
a more acute upper lip angle than Chinese males
(p <0.007) and a more acute lower lip angle than Korean
males (p <0.03). A larger total lip volume was observed in
Chinese males than in Caucasians (p <0.03), but no
differences in the lower lip volume were appreciated
between groups. Although the upper lip volume of Chinese
males was signicantly larger than Caucasian males, this
parameter did not pass Levenes test and is therefore
suspect. Between the three male groups, no differences
were observed in the ratios of upper to lower lips, upper
white lip height or philtral columns.
In evaluating the natural lip curvatures, Chinese females
had the highest total average number of curvatures (1.83)
while Caucasian females had the lowest (1.65). Conversely,
Caucasian males exhibited the highest total curvature
average (1.77) and Chinese males showed the least (1.39).
Korean averages remained in between that of the Chinese
and Caucasian in both female (1.74) and male (1.65)
groups. Interestingly, the Korean male and female groups
each had one subject without a visible cupids bow,
creating an oval-appearing total lip unit.
Parameters of attractive lips
The three sets of lips that were rated as the most attractive
shared ve similar parameters that were smaller than
average for their sex-based ethnic group including: upper
lip surface midline height, bilateral paramedian lip surface
height, upper lip angle and lower lip volume (Figure 2). Of
these, four parameters translated into a relatively thinner
upper lip, a stark contrast to the current trend of enhancing
upper lip volume for increasing youth fulness and beauty.
Discussion
Lips alone do not carry as inuential a role as previously
assumed in the evaluation of an attractive face. An inverse
relationship between the rating of whole facial appeal and
isolated lips within groups implied a weak correlation
between the two. This nding is inconsistent with previ-
ously reported conclusions that the upper lip, lower lip and
chin carry the most emphasis when Caucasian examiners
ranked Chinese faces.
9
These results support previous
hypotheses that the appearance of lips within the context
of the face as a whole is of critical importance.
3,10
Traditionally, full and luscious lips appear more youthful
and striking, fuelling the ever-present desire that some
women possess to emulate young models and lm starlets.
There is a high demand for lip augmentation procedures,
but the actual improvement in facial aesthetics resulting
from these interventions may be questioned. Of the large
population in this study, it was consistently found that the
lips that were deemed most attractive exhibited features
consistent with a thinner upper lip. This contradicts the
prevailing popular belief that labial fullness is exclusively
synonymous with beauty. Two explanations for this nding
are possible. First, the subjects were asked to not smile for
accurate measurements of lip fullness and height. Rating
pleasant, smiling lips may have resulted in higher aesthetic
scores; however, this would have come with a price of
decreased accuracy in lip measurements with the intro-
duction of teeth and altered labial proportions. Another
reason is that perhaps other facial features, such as the
eyes or nose, have a greater inuence on overall facial
aesthetics. Future studies evaluating other facial compo-
nents may elucidate the relationships of these features
with the whole face. It is reasonable to conclude that the
results from this study support Tessiers belief that the
status of harmony arises from proportion as opposed to
individual measurements such as angles, distances,
surfaces or volume measurements.
10
Figure 3 The female and male faces rated as most attractive out of 197 faces rated. All values listed are averages. Two females
had the same aesthetic average and were therefore both included in analysis for whole face and lip score difference.
2036 W.W. Wong et al.
In addition to understanding this relationship between
lips and facial harmony, extra effort should be made in
planning lip enhancement treatments for patients of
different ethnic backgrounds. Before the recent progress in
studies of different ethnicities, it was not uncommon to
refer to a template of parameters derived from one
Table 2 Comparison of Anthropometric Facial Measurements in Chinese-American, Korean-American, and North American
Caucasian Women
Parameter Mean (SD)
Chinese
Mean (SD)
Korean
Mean (SD)
Caucasian
P-value
(Ch vs. Ko)
P-value
(Ch vs. Ca)
P-value
(Ko vs. Ca)
Upper Lip Volume (cc) 1.5 (0.3) 1.2 (0.3) 1.1 (0.3) < 0.001 < 0.001 ns
Lower Lip Volume (cc) 1.3 (0.4) 1.3 (0.5) 1.4 (0.6) ns ns ns
Total Lip Volume (cc) 2.8 (0.6) 2.5 (0.6) 2.4 (0.7) ns ns ns
ls e sto CAL (mm) 8.5 (1.1) 8.1( 1.1) 6.7 (1.2) ns < 0.001 ns
ls e sto SUR (mm) 9.0 (1.4) 8.5 (1.4) 7.1 (1.4) < 0.001 < 0.001 < 0.001
lsL e lfL CAL (mm) 10.2 (1.0) 9.4 (1.2) 8.0 (1.1) 0.011 < 0.001 < 0.002
lsL e lfL SUR (mm) 10.9 (1.2) 9.4 (1.2) 8.3 (1.1) ns < 0.001 < 0.001
lsR e lfL CAL (mm) 10.0 (1.1) 9.3 (1.0) 8.1 (1.2) ns < 0.001 < 0.001
lsR e lfL SUR (mm) 10.6 (1.3) 9.7 (1.1) 8.5 (1.5) 0.037 < 0.001 < 0.001
sto e lfL CAL (mm) 10.8 (1.7) 9.6 (1.6) 9.3 (1.8) 0.030 0.004 ns
sto e lfL SUR (mm) 12.1 (2.3) 10.4 (2.1) 10.5 (2.5) 0.021 0.016 ns
ls e sto CAL / sto e li CAL 0.8 (0.1) 0.9 (0.1) 0.7 (0.1) ns ns < 0.001
ls e sto SUR / sto e li SUR 0.8 (0.1) 0.8 (0.1) 0.7 (0.1) 0.090 ns < 0.001
lsL e lfL CAL / sto e li CAL 1.0 (0.1) 0.9 (0.1) 1.0 (0.1) ns 0.030 < 0.001
lsL e lfL SUR / sto e li SUR 0.9 (0.2) 1.0 (0.1) 0.8 (0.2) ns ns 0.001
lsR e lfR CAL / sto e li CAL 0.9 (0.2) 1.0 (0.1) 0.9 (0.1) ns ns 0.001
lsR e lfR SUR / sto e li SUR 0.9 (0.2) 1.0 (0.1) 0.8 (0.2) ns ns 0.005
ls e li CAL (mm) 19.3 (2.5) 17.6 (2.5) 16.0 (2.8) ns < 0.001 0.024
sbalL e lsL CAL (mm) 13.1 (1.5) 14.1 (1.5) 14.2 (1.9) ns 0.027 ns
sbalLe lsL SUR (mm) 14.0 (1.7) 14.7 (1.6) 15.3 (2.0) ns 0.020 ns
sbalR e lsR CAL (mm) 13.3 (1.6) 14.7 (1.6) 14.2 ( 1.8) ns ns ns
sbalR e lsR SUR (mm) 13.9 (1.7) 14.7 (1.7) 15.2 (1.9) ns 0.017 ns
sn e ls CAL (mm) 14.6 (1.5) 15.2 (1.7) 15.1 (1.9) ns ns ns
sn e ls SUR (mm) 16.0 (1.8) 16.2 (1.8) 16.8 (2.1) ns ns ns
li e sl CAL (mm) 7.1 (2.4) 8.9 (2.5) 9.7 (2.3) 0.024 < 0.001 ns
li e sl SUR (mm) 7.4 (2.6) 9.2 (2.7) 10.1 (2.4) 0.026 < 0.001 ns
sl e gn CAL (mm) 27.2 (4.5) 25.9 (3.3) 25.3 (3.7) ns ns ns
sl e gn SUR (mm) 28.8 (4.7) 27.4 (3.8) 27.5 (4.1) ns ns ns
ch e ch SUR (mm) 54.3 (6.1) 52.8 (4.1) 55.2 (3.7) ns ns 0.043
ch e ch CAL (mm) 47.1 (4.9) 45.6 (3.1) 46.9 (3.3) ns ns ns
Upper Vermilion SUR (mm) 63.4 (4.2) 61.7 (4.5) 62.6 (3.8) ns ns ns
Lower Vermilion SUR (mm) 61.7 (6.7) 58.9 (4.3) 60.4 (4.5) ns ns ns
Total Vermilion SUR (mm) 125.0 (9.9) 120.6 (8.1) 123.0 (7.6) ns ns ns
Upper / Lower Vermilion 1.0 (0.1) 1.0 (0.1) 1.0 (0.1) ns ns ns
en e en CAL (mm) 34.3 (2.8) 35.1 (2.7) 30.6 (2.8) ns < 0.001 < 0.001
al e al CAL (mm) 37.3 (2.4) 36.0 (2.2) 31.8 (2.1) ns < 0.001 < 0.001
zy e zy CAL (mm) 136.5 (5.8) 127.5 (6.2) 128.8 (5.6) ns < 0.001 < 0.001
lsL e lsR CAL (mm) 9.4 (2.5) 10.8 (1.7) 11.4 (1.8) 0.022 < 0.001 ns
lsL e lsR SUR (mm) 9.5 (2.6) 11.5 (1.8) 11.0 (1.7) 0.022 < 0.001 ns
lsR e ls CAL (mm) 6.2 (1.0) 5.6 (0.9) 6.0 (1.1) ns ns ns
lsR e ls SUR (mm) 6.2 (1.0) 5.6 (0.9) 6.0 (1.1) ns ns ns
lsL e ls CAL (mm) 6.2 (1.0) 65.9 (1.0) 6.0 (1.0) ns ns ns
lsL e ls SUR (mm) 6.2 (1.0) 5.9 (1.0) 6.0 (1.0) 0.817 1.000 1.000
Upper Lip Angle (

) 36.3 (8.6) 39.8 (10.0) 27.8 (8.4) ns 0.001 < 0.001

Lower Lip Angle (

) 37.8 (10.1) 41.1 (7.1) 40.1 (12.1) ns ns ns

Left Cupids Bow Angle (

) 132.3 (8.8) 140.3 (8.5) 138.9 (8.5) 0.002 0.008 ns

Right Cupids Bow Angle (

) 134.4 (7.3) 141.3 (9.1) 140.4 (7.9) 0.006 0.013 ns

Central Bow Angle (

) 125.7 (13.2) 138.6 (8.3) 140.3 (10.2) < 0.001 < 0.001 ns
Abbreviations: SD, standard deviation; Ch, Chinese; Ko, Korean; Ca, Caucasian; sbalL, left subalare; sbalR, right subalare; lsR, right
labiale superioris; lsL, left labial superioris; lf, labial ssure; sto, stomion; li, labiale inferioris; ch, cheilion; sn, subnasale; sl, sublabiale;
gn, gnathion; en, endocanthion; zy, zygoma; alR, right alar; alL, left alar; C, calliper distance; SUR, surface distance.
Contribution of lip proportions to facial aesthetics in different ethnicities 2037
ethnicity. Now, an emphasis on appreciating the anatomic
and aesthetic features specic to each ethnic standard has
become a focus in optimisation of desired outcomes. The
results from this study have reiterated as much. As expec-
ted, large differences were found between Caucasian and
Asian lips, especially in the female groups. Of note, the
Table 3 Comparison of Anthropometric Facial Measurements in Chinese-American, Korean-American, and North American
Caucasian Men
Parameter Mean (SD)
Chinese
Mean (SD)
Korean
Mean (SD)
Caucasian
P-value
(Ch vs. Ko)
P-value
(Ch vs. Ca)
P-value
(Ko vs. Ca)
Upper Lip Volume (cc) 1.2 (0.4) 1.1 (0.3) 0.9 (0.3) 0.399 0.006 0.176
Lower Lip Volume (cc) 1.6 (0.6) 1.4 (0.5) 1.3 (0.5) 0.796 0.141 0.910
Total Lip Volume (cc) 2.8 (1.0) 2.5 (0.7) 2.2 (0.6) 0.476 0.022 0.385
ls e sto CAL (mm) 7.9 (1.5) 7.7 (1.2) 6.7 (1.6) ns 0.015 ns
ls e sto SUR (mm) 8.3 (1.7) 7.4 (1.4) 6.9 (1.7) ns 0.011 ns
lsL e lfL CAL (mm) 9.8 (1.2) 9.2 (1.2) 8.1 (1.4) ns < 0.001 0.002
lsL e lfL SUR (mm) 10.3 (1.4) 9.6 (1.3) 8.3 (1.5) ns < 0.001 0.001
lsR e lfL CAL (mm) 9.7 (1.3) 9.2 (1.1) 8.1 (1.5) ns < 0.001 0.002
lsR e lfL SUR (mm) 10.2 (1.6) 9.7 (1.3) 8.3 (1.5) ns < 0.001 0.001
sto e lfL CAL (mm) 10.1 (1.8) 9.4 (1.6) 8.1 (1.3) ns < 0.001 0.005
sto e lfL SUR (mm) 10.8 (1.8) 10.2 (2.1) 8.5 (1.5) ns < 0.001 0.002
ls e sto CAL / sto e li CAL 0.8 (0.1) 0.8 (0.2) 0.8 (0.2) ns ns ns
ls e sto SUR / sto e li SUR 0.8 (0.2) 0.8 (0.2) 0.8 (0.2) ns ns ns
lsL e lfL CAL / sto e li CAL 1.0 (0.1) 1.0 (0.2) 1.0 (0.2) ns ns ns
lsL e lfL SUR / sto e li SUR 1.0 (0.1) 1.0 (0.2) 1.0 (0.2) ns ns ns
lsR e lfR CAL / sto e li CAL 1.0 (0.1) 1.0 (0.2) 1.0 (0.2) ns ns ns
lsR e lfR SUR / sto e li SUR 1.0 (0.1) 1.0 (0.2) 1.0 (0.2) ns ns ns
ls e li CAL (mm) 18.0 (2.8) 16.8 (2.3) 14.8 (2.4) ns ns ns
sbalL e lsL CAL (mm) 15.2 (2.0) 15.6 (1.7) 16.2 (2.2) ns ns ns
sbalL e lsL SUR (mm) 15.6 (2.1) 16.1 (1.8) 16.7 (2.2) ns ns ns
sbalR e lsR CAL (mm) 15.4 (2.0) 15.6 (1.9) 16.2 (2.1) ns ns ns
sbalR e lsR SUR (mm) 15.8 (2.0) 16.2 (1.9) 16.7 (2.0) ns ns ns
sn e ls CAL (mm) 16.8 (2.3) 17.3 (1.7) 17.4 (2.3) ns ns ns
sn e ls SUR (mm) 17.7 (2.4) 18.3 (1.7) 18.6 (2.2) 0.835 ns ns
li e sl CAL (mm) 12.3 (3.6) 12.7 (3.3) 13.4 (2.3) ns ns ns
li e sl SUR (mm) 12.0 (3.6) 13.1 (3.4) 14.0 (2.2) ns ns ns
sl e gn CAL (mm) 26.1 (2.9) 24.8 (3.5) 26.9 (3.2) ns ns 0.043
sl e gn SUR (mm) 27.8 (3.6) 25.8 (3.6) 28.5 (3.5) ns ns 0.014
ch e ch SUR (mm) 59.1 (6.4) 56.2 (4.6) 58.0 (4.9) ns ns ns
ch e ch CAL (mm) 50.5 (4.2) 47.8 (3.4) 49.2 (3.4) 0.022 ns ns
Upper Vermilion SUR (mm) 68.1 (6.6) 66.7 (5.3) 65.8 (4.4) ns ns ns
Lower Vermilion SUR (mm) 66.8 (6.4) 63.0 (5.8) 61.9 (5.3) ns 0.009 ns
Total Vermilion SUR (mm) 134.8 (12.3) 129.7 (10.2) 128.7 (10.4) ns ns ns
Upper / Lower Vermilion 1.0 (0.1) 1.1 (0.1) 1.1 (0.1) ns ns ns
en e en CAL (mm) 35.2 (2.3) 35.4 (2.1) 32.0 (2.9) ns < 0.001 < 0.001
al e al CAL (mm) 41.2 (3.4) 40.7 (2.5) 36.0 (2.8) ns < 0.001 < 0.001
zy e zy CAL (mm) 140.8 (8.2) 144.1 (5.3) 138.7 (9.9) ns ns 0.024
lsL e lsR CAL (mm) 12.9 (1.5) 12.8 (2.1) 11.6 (2.1) ns ns ns
lsL e lsR SUR (mm) 13.1 (1.6) 12.9 (2.2) 11.5 (2.8) ns 0.037 0.034
lsR e ls CAL (mm) 6.9 (1.0) 6.7 (1.1) 6.2 (1.2) ns 0.047 ns
lsR e ls SUR (mm) 7.0 (1.0) 6.7 (1.1) 6.2 (1.2) ns ns ns
lsL e ls CAL (mm) 7.0 (0.8) 6.7 (1.2) 6.2 (1.2) ns 0.036 ns
lsL e ls SUR (mm) 7.0 (0.8) 6.7 (1.2) 6.4 (1.3) ns ns ns
Upper Lip Angle (

) 35.5 (9.6) 32.5 (7.7) 28.0 (8.8) 0.618 0.007 0.109

Lower Lip Angle (

) 39.9 (7.8) 40.7 (7.9) 35.4 (7.8) 1.000 0.127 0.025

Left Cupids Bow Angle (

) 139.9 (8.8) 136.6 (6.7) 137.0 (7.3) 0.319 0.536 1.000

Right Cupids Bow Angle (

) 140.5 (10.0) 138.3 (7.1) 136.0 (8.8) 1.000 0.718 0.834

Central Bow Angle (

) 135.3 (9.3) 135.0 (9.0) 136.8 (8.6) 1.000 1.000 1.000

Abbreviations: SD, standard deviation; Ch, Chinese; Ko, Korean; Ca, Caucasian; sbalL, left subalare; sbalR, right subalare; lsR, right
labiale superioris; lsL, left labial superioris; lf, labial ssure; sto, stomion; li, labiale inferioris; ch, cheilion; sn, subnasale; sl, sublabiale;
gn, gnathion; en, endocanthion; zy, zygoma; alR, right alar; alL, left alar; C, calliper distance; SUR, surface distance.
2038 W.W. Wong et al.
lower lip thickness in Chinese females was greater than in
both Koreans and Caucasians, comprising a key factor in
ethnic identication by affecting the proportionality
between upper and lower lips. Volumetric analysis of the
relative lip volumes between ethnicities revealed a larger
upper lip volume in Chinese women, suggesting that this
group would likely request lip augmentations less
frequently than Caucasians.
While lip enhancement is common for many patients of
European descent, Asian male patients tend to seek lip
reduction instead, citing an undesirably extreme ethnic
appearance and the feminine appearance of their full
lips.
11
Similarly, the highest-rated Korean male face in our
data had lips of smaller volumes and parameters. Current
augmentation procedures of the lips attempt to enhance
the features that are frequently observed in the natural
Chinese lip, including a tall vermillion height, a more
accentuated cupids bow curvature and larger upper-lip
volume.
12
However, current practises of enhancing the
upper lip alone may not necessarily increase aesthetic
appeal. Furthermore, in contrast with recently published
ndings, we found no evidence of sexual dimorphism in our
subjects.
13
On an important note, many patients in ethnically
diverse countries tend to seek treatment based on their
own racial norms rather than aiming for a completely
westernised appearance.
14
This extensive study, consist-
ing of a large sample size of different ethnicities, demon-
strated a contradiction between presumed and objectively
rated lip appeal. In future studies, we hope to recruit
subjects of other ethnicities for a study focussed on a large-
scale multi-cultural comparison. While lip enhancement
services are largely performed according to the clinical
gestalt of the practitioner, it is reasonable to conclude that
these procedures should be tailored to each individual
patient while considering their personal aesthetic goals and
the limitations of their anatomy.
Conict of interest statement
None.
Role of funding source statement
There was no study sponsor in any part of the study design
or the collection, analysis and interpretation of data.
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Contribution of lip proportions to facial aesthetics in different ethnicities 2039