Facial Anthropometric Norms of the Young Black South African Woman : Plastic and Reconstructive Surgery – Global Open

Journal Logo

Global Health: Original Article

Facial Anthropometric Norms of the Young Black South African Woman

Wilson, Stephen P. MBChB, MMED, FC Plast Surg (SA); Medapati, Vengal MBChB, MMED, FC Plast Surg (SA); Segwapa, Kenneth MBChB, MMED, FC Plast Surg (SA)

Author Information
Plastic & Reconstructive Surgery-Global Open 11(4):p e4942, April 2023. | DOI: 10.1097/GOX.0000000000004942
  • Open



Question: What are the facial anthropometric norms of the young, Black, South African women? How do they compare to those of ethnically and regionally different populations, as well as commonly known neoclassical canons?

Findings: Photogrammetric facial analysis of the study population identified significant differences in the general facial, nasal, lip, and chin measurements when compared with ethnically and regionally different populations and also varied greatly from the neoclassical canons.

Meaning: There is a need for regionally specific anthropometric norms for international populations with less reliance on neoclassical canons when planning and performing interventions of the face.


In the postmodern age, an eagerness to embrace the uniqueness of each individual culture has sparked a nationalistic pride in one’s heritage and background.1 Nowhere is that more apparent than in the recognition of beauty—specifically that of the face.

Anthropometry and Neoclassical Canons

The study of anthropometric norms is vital in the planning of facial reconstruction for craniofacial, orthodontic, and orthognathic interventions. Increasing popularity in cosmetic surgery and medical aesthetics has made this knowledge even more important in the planning of procedures. The idea of an innate set of geometric norms to govern the make-up of a “normal face” is one that can be traced back to Ancient Egypt and Greece in many forms of art.2 The “neoclassical canons” described by Renaissance artists further refined this concept, firstly with the use of Phi as the “divine” ratio to describe the relationship between many key anatomical measurements, and the splitting of the face into equal “horizontal thirds and vertical fifths”3 (Fig. 1).

Fig. 1.:
Illustration of the human face divided up into the “neoclassical canons” of vertical fifths and horizontal thirds of the face. Examples of the golden ratio as it relates to various measurements of the face represented by coloured blocks.

The classical descriptions of anthropometry are not without their limitations, especially when observing differing ethnic groups. Farkas et al compared the interethnic, sexual, and age-related variabilities to these neoclassical canons and found many variations between these “ideals” and international populations.4 Interestingly, Farkas found that the neoclassical canons did not even conform to the norms of North American White people, and were even more lacking when describing those of other ethnicities.4,5

The African Face

The study of the African face was first found in the realm of anthropology.6 Sushner was one of the first clinicians to research the differences in Black faces, in particular, those of the African American population.7 He concluded that the soft tissue norms previously identified by Rickets, Steiner and Holdaway were not applicable to African American subjects who had facial profiles that were more protrusive.7

The African Nose

The African nose has long been studied to understand the key differences that contribute to its overall shape. The terms “African,” “Negroid,” and “Platyrrhine” nose have come to be synonymous with a shortened columellar, decreased tip projection, wider alar, and broader nasal dorsum.8 This definition is problematic because it generalizes a vast population of nonhomogeneous people with origins spanning an entire continent and beyond. This problem was not lost on Ofodile et al, who sought to further define the heterogeneous population of African Americans into “Afro-Indian,” “Afro-White,” and “African.”9 Building on this work, Porter et al went on to study the African American female nose in 2003.10 When comparing with White subjects, they found, in particular, a decreased columellar height to lobule ratio, a high variability in nasal base shape and axis, a wider nasal width in comparison with intercanthal distance, a more acute nasolabial angle, and an increased nasofrontal angle.10 Three main nasal base/axis relationships were also identified in this study, namely the triangular base/vertical axis, oval base/horizontal axis, and the trapezoidal base/inverted axis combinations corresponding to Farkas classification 3, 4, and 7 (Fig. 2).10,11 Rohrich and Muzaffar went on to describe the “classic” differences between African American noses and White noses as a practical guide to the rhinoplasty surgeon to preserve ethnicity and natural aesthetics.12 Their findings were that while the African nose is in no way homogeneous, it generally has a wider depressed dorsum with a low radix, a poorly defined and under-projected tip, and a decreased nasal length and height.11 They also describe an increased interalar width and/or an excess in alar flaring.12

Fig. 2.:
Nostril base/alar axis relationship as adapted from the original work of Farkas et al in 1983.10 A, Triangular base/vertical axis. B, Oval base/horizontal axis. C, Trapezoidal base/inverted axis.

The Knowledge Gap

A “cookie-cutter” approach when treating individuals of different cultures, geographical groups, and races is no longer an acceptable practice. Data for the young Black South African female face have yet to be studied in sufficient detail and with large enough numbers to grant significantly powered results. Practitioners treating this population have come to rely on population data from alternative regions such as those of central Africa and African American populations, thus ignoring the regional uniqueness of the Black South African woman at the expense of the ultimate outcome.

The key objectives of the study are to:

  1. Gather a database of soft tissue facial anthropometric values of young Black South African women to aid in describing the “norms” of this population.
  2. Compare these data with international population groups.

These data will assist in the achievement of regionally sensitive and individualized treatment of the women in the region, and also highlight the need for locally-specific data for other populations internationally.


Ethical approval was obtained from the Sefako Makgatho Health Sciences University Ethical Committee (ref: SMUREC/M/282/2020). Sample size was calculated using the mean nasolabial angle of 84.4 ± 13.3 degrees from a previous study conducted in Cape Town, South Africa by Miles and Naidoo, 80% power, alpha of 5% and effect size of 2.13 A sample size of 156 was obtained using the G-power statistical software, version

An observational study design was used to investigate the population of young Black South African women, of traditional South African descent.

Inclusion criteria include:

  1. Women aged 18–25 years;
  2. Normal body mass index (BMI) (18.5–24.9);
  3. Normal dental occlusion;
  4. No previous facial or orthodontic treatments, including neurotoxin and fillers, as well as previous facial trauma;
  5. No facial congenital abnormalities.

These criteria served to identify the norms of the “ideal” youthful Black face in those who have reached skeletal and dental maturity. A convenience sampling technique was used to gather 156 female student participants from Sefako Makgatho Health Sciences University in Tswane, South Africa, between January 2021 and June 2021.

Materials, Apparatus, and Equipment

  • Students were approached by one examiner and an assistant at Sefako Makgatho Health Sciences University (SMU), and informed consent was obtained.
  • Participants were assessed observationally for gross facial symmetry (obvious facial asymmetries were excluded from the study) and normal dental occlusion.
  • Anterior, lateral, and basal view photographs were taken of the participants’ faces. Within the strict conditions of the SMU audiovisual photography studio, a Nikon D700 camera (12.1 megapixel) with an AF-S Micro Nikkor 105 mm 1:2.8G ED lens, mounted on an adjustable tripod stand with spirit level was used with triangulated soft-box lighting. The camera was placed 1.5 m away from the participants. Anterior and lateral photographs were taken with the head in the natural position and lips in repose. Basal photographs were taken, with the neck extended until the columellar and alar rims were perpendicular to the camera lens. A matte white backdrop was used as well as a standardized linear ruler mounted above the participants head placed in the vertical plane of the glabellar, malar eminence and columellar for anterior, lateral, and basal photographs, respectively. The ruler and other physically measured linear measurements were used to establish a magnification scale for the subsequent photogrammetric analysis

Digital photographs were analyzed, and measurements were performed using IC Measure version and Rhinobase (2000–2001), both with a track-record of clinical reliability.15–17 Linear and angular measurements as well as ratios were performed on anterior (Figure 3, Table 1), lateral (Figure 4, Table 2) and basal views (Figure 5, Table 3).

Table 1. - Anterior View Linear and Angular Measurements
Upper facial height Trichion to glabella
Midfacial height Glabella to subnasale
Lower facial height Subnasale to menton
Interalar width Left to right alar
Intercanthal width Left to right endocanthus
Upper vermilion height Labrale superius to stomion
Lower vermilion height Stomion to labrale inferius
Upper lip length Subnasale to stomion
Lower lip length Stomion to mental crease
Canthal tilt Angle between the line from medial and lateral canthus to a line perpendicular to the midline

Table 2. - Lateral View Linear and Angular Measurements
Nasofrontal angle Glabella to nasion to nasal tip
Nasofacial angle Angle between: 1. glabella to pogonion and 2. nasion to nasal tip
Nasolabial angle Angle between: 1. columellar break to subnasale & 2. subnasale to labrale superius
Nasomental angle Angle between: 1. nasion to nasal tip and 2. nasal tip to pogonion
Mentocervical angle Angle between: 1. glabella to pogonion and 2. menton to cervical point
Nasal length Nasion to nasal tip
Tip projection Alar crease to nasal tip
Radix projection Corneal plane to nasion
Chin protrusion Distance from pogonion to vertical facial plane (a line perpendicular to frankfort horizontal starting at the nasion)
Angle of facial convexity Angle between lines: 1. glabella to subnasale and 2. subnasale to pogonion
Mentolabial sulcus The distance from the depth of the sulcus perpendicular to a line from labrale inferius to pogonion

Table 3. - Basal View Linear and Angular Measurements
Columella height Subnasale to columellar break point
Alar Base Alar crease right to left
Alar Flare (AL to AL) – (AC to AC)
Nostril Type According to Porter et al (2003) 9 : vertical, horizontal, inverted axis. See Figure 4
Lobule Width Lobule dome left to right

Fig. 3.:
Anterior facial anthropometric landmarks.
Fig. 4.:
Lateral facial anthropometric landmarks.
Fig. 5.:
Basal soft tissue anthropometric landmarks.

Statistical Analysis

Statistical analysis of data was performed to determine the mean and standard deviation (SD) values of each measurement. The data were compared with the results of similar studies found in a literature review of Black African faces from Central and Northern Africa, African American populations, and North American White populations using individual Student t tests. Studies were included based on geographical location, participant demographics, and study methodology where similar and comparable to the index study (Table 4). Statistical significance was determined at P less than 0.05. The statistics software used for analysis was Statistical Package for Social Sciences, version 23 (SPSS Statistics for Windows. Release 14; IBM Corp, Armonk, N.Y.).

Table 4. - Demographic and Methodological Data of International Studies
Study Country Sample Size Age BMI Method of Measurement
Miles and Naidoo 12 South Africa 15 23.4 ± SD 3.8 y Not specified Photogrammetric + cephalometric
Olusanya 25 Nigeria 51 16–31 y 22.3 ± SD 3.72 Direct caliper
Virdi 18 Kenya 36 >18 y students Not specified Direct + photogrammetric
Salah 26 Sudan 100 17–23 y Not specified Photogrammetric
Esabish 27 Congo 71 18–30 y Not specified Photogrammetric
Farkas 4,28 USA:
African Americans
18–30 y Not specified Direct + photogrammetric


Intra-examiner reliability was tested by the remeasuring of all anthropometric indices (both linear and angular) in 10 randomly selected participant photographs. The error of method was then calculated by comparing the first and second measurements with the use of the Dahlberg formula.18

Differences in general facial (morphological) measurements less than 2 mm, angular measurements less than 2.5 degrees, and remaining aesthetic linear measurements less than 0.5 mm were considered to be within an acceptable range of error.19


Population Demographics

Population demographics are detailed in Tables 5 and 6. The demographic analysis showed a mean age of 21 years and a BMI of 21.8 in the study group. Tribal variation within the index population showed a predominance of Pedi, Tsonga, Tswana and Venda participants, which was to be expected with the geographical location of this study.

Table 5. - Sample Population Demographics
Total (n = 156) Mean Median Max Min SD
Age 21 21 25 18 2.12
Height (m) 1.6 1.6 1.8 1.4 0.063025
Weight 56.8 57.1 73.0 41.2 6.847209
BMI 21.8 21.9 25.0 18.5 2.179092

Table 6. - Tribal Variation Amongst Sample Population
Tribal Affiliation Ndebele Pedi Sotho Swati Tsonga Tswana Venda Xhosa Zulu
Number 3 53 3 9 28 24 19 3 14
Percentage 1.9 40 1.9 5.8 17.9 15.4 12.2 1.9 9


Dahlberg formula analysis of the intra-examiner reliability is detailed in Table 7. All general facial, angular and aesthetic linear measurements fell within the acceptable range of error prescribed in our methods.

Table 7. - Intra-examiner Reliability: Dahlberg Formula
General Measurements Dahlberg Coefficient
Upper facial height 0.648
Midfacial height 0.819
Lower facial height 0.154
Facial width 0.661
Angle of facial convexity 1.3
Intercanthal width 0.329
Canthal slant 0.035
Interalar width 0.329
Nasal measurements
Nasal length 0.953
Alar flare 0.03109
Radix projection 0.209
Tip projection 0.067
Alar base 0.26682
Lobule width 0.22
Columella length 0.113
Nasofrontal angle 2
Nasofacial angle 0.712
Nasolabial angle 2.456
Nasomental angle 0.8
Lip measurements
Upper lip height 0.066
Lower lip height 0.127
Upper vermilion height 0.102
Lower vermilion height 0.093
Upper lip projection 0.025
Lower lip projection 0.0196
Chin measurement
Mandibular height 0.103
Chin projection 0.375
Depth of mentolabial sulcus 0.07
Mentocervical angle 0.613
All results showed an acceptable level of error with general facial (morphological) measurements less than 2 mm, angular measurements less than 2.5degrees, and aesthetic linear measurements less than 0.5 mm.

General Facial Measurements

A comparison of general facial dimensions demonstrates many statistically significant differences between ethnic groups when compared with the index South African study (Tables 8–9). Many of these differences hold relatively small margins, with some being in the region of 5 mm or less in difference, with overlapping standard deviations. An example of this is the comparison of the upper, mid, and lower facial height of the Kenyan population in relation to the index population. Of more interest are the relative and ratio-based measurements of each measurement within the entire face. The midface and lower face of South African women tends to be similar in height, with means of 69.3 ± 5.1 mm and 67.8 ± 5.44 mm, respectively, whereas the upper facial height tends to be shorter (60.2 ± 6.96 mm). Although in conflict with the neoclassical canon of “equal horizontal thirds,” this finding is mirrored in studies in both Black and White female populations from Kenya and the United States of America and comes in contrast to the Sudanese and Nigerian populations where upper facial height approaches that of the mid and lower face. Due to the variable nature of the upper facial height due to trichion position, this difference may be due to variation in local hairstyle trends rather than an absolute anatomical discrepancy.

Table 8. - Results of General Facial Measurement: Index Study
Facial Measurement (mm) Mean Median Max Min SD
Upper facial height 60.2 60.1 80.7 46.0 6.96
Midfacial height 69.3 69.0 84.7 58.0 5.134
Lower facial height 67.8 68.1 81.7 56.0 5.44
Facial width 139.2 139.7 153.7 122.0 6.83
Angle of facial convexity 7.9 7.0 19.0 0.0 4.80
Facial width: height 0.71 0.70 0.80 0.59 0.04

Table 9. - Comparison of General Facial Dimensions of Index Study versus Local and International Studies
Present Study Miles and Naidoo Olusanyo Virdi Salah Farkas
Country South Africa South Africa Nigeria Kenya Sudan USA
Race group Black Black Black Black Black White African American
No. participants 156 15 51 36 100 200 50
Mean (SD) Mean (SD) P Mean (SD) P Mean (SD) P Mean (SD) P Mean (SD) P Mean (SD) P
Upper facial height 60.2 (6.9) 62.5 (6.1) 0.0349 55.4 (3.3) <0.0001 74.2 (11.9) <0.0001 52.3 (6) <0.0001 55.7 (0.7) <0.0001
Midfacial height 69.3 (5,1) 67.36 (4.8) 0.2171 58.8 (6.7) <0.0001 63.3 (4.8) <0.0001 77.9 (11.1) <0.0001 63.1 (4.4) <0.0001 62.0 (0.4) <0.0001
Lower facial height 67.8 (5.4) 77.8 (5.5) <0.0001 63.6 (5.0) <0.0001 65 (4.8) 0.0047 78.1 (10.1) <0.0001 64.3 (4) <0.0001 67 (0.5) 0.2975
Facial width 139.2 (6.8) 122.5 (6.37) <0.0001 130.1 (3.5) <0.0001 103.4 (6.1) <0.0001 120 (4.6) <0.0001 135 (0.5) 0.2147
Comparative studies by Miles & Naidoo, Olusanya et al, Virdi et al, Farkas et al and Salah et al.4,13,19,2629 Individual student t test performed with P provided. Significant at P less than 0.05.

The mean facial width (bizygonal) in the index study was significantly larger than that of the participants from Nigeria, Kenya, and Sudan as well as North American White participants (P < 0.0001), whereas there was no significant difference in African American participants (P = 0.2147). The facial width-to-height ratio shows a value of 0.71 ± 0.04 (the width is roughly 70% of the height).

Eye Measurements

The mean intercanthal distance was found to be 34.7 ± 3.3 mm in length. The mean intercanthal distance to facial width ratio of 0.25 ± 0.02 or 25% of the facial width. This indicates the deviation of the young South African female face away from the neoclassical canons of “vertical fifths,” where intercanthal distance is 20% of the facial width.

The mean canthal tilt in participants showed a superolateral inclination of the lateral canthus in comparison to the medial canthus of 6.9 ± 2.7 degrees. These findings are summarized in Table 10.

Table 10. - Eye Measurements
Mean Median Max Min SD
Intercanthal distance (ID) 34.7 34.4 46.9 27.3 3.298482
Canthal tilt (degrees) 6.8 6.7 14.0 -2.3 2.687014
ID to facial width 0.25 0.25 0.36 0.20 0.02
Index study: eye measurements (linear measurements in mm; angular measurements in degrees).

Nasal Measurements

Tables 11 and 12 summarize the linear and angular nasal measurements from the index and international studies. Nasal length was found to have a mean of 38.8 ± 3.78 mm. The projection of the radix from the corneal plane was 7.8 ± 3.18 mm, which may guide the rhinoplasty surgeon on the need for dorsal augmentation. The tip projection with a mean of 21.5 ± 2.9 mm, together with a significantly larger nasofrontal angle, shows a less-projected nasal tip compared with ethnicities examined in other studies. This finding is consistent with a nasofacial angle of 31.3 ± 3 degrees and columellar length of 8.2 ± 1.69 mm. The nasolabial angle approximates that of Kenyan participants but is unsurprisingly less than that of North American White participants, indicating an inferiorly rotated, flatter nasal tip in comparison. This measurement however, is significantly greater than that of African American and Congolese populations.

Table 11. - Nasal Measurements
Linear Measurements (mm) Mean Median Max Min SD
Nasal length 38.8 38.6 48.9 29.6 3.778
Radix projection 7.8 7.6 15.6 0.0 3.177
Tip projection 21.5 21.5 31.0 10.3 2.929
Interalar width 42.9 43.0 51.8 34.2 3.061
Base width 39.5 39.5 51.8 31.6 3.241
Alar flare 1.7 1.7 5.0 0.0 0.916
Lobule width 25.0 24.9 33.8 17.4 2.490
Lobule width to nasal width 0.637 0.635 0.837 0.43 0.071
Columella length 8.2 8.3 12.5 4.4 1.693
Interalar/intercanthal distance (%) 124.5 123.5 157.6 91.7 12.2
Angular measurements
Nasofrontal angle 141.0 141.0 180.0 129.0 5.764
Nasofacial angle 31.3 31.3 38.4 22.7 3.028
Nasolabial angle 85.6 85.6 110.0 58.0 10.818
Nasomental angle 134.8 134.5 150.0 125.0 4.412
Nostril subtype Total %
Triangular base/vertical axis 29 18.6
Oval base/horizontal axis 86 55.1
Trapezoidal base/inverted axis 41 26.3

Table 12. - Comparison of Nasal Angular Measurements of Index Study versus Local and International Studies
Present Study Miles and Naidoo Esabish Virdi Farkas
Country South Africa South Africa Congo Kenya USA
Race group Black Black Black Black White African American
No. participants 156 15 71 36 200 50
Mean (SD) Mean (SD) P Mean (SD) P Mean (SD) P Mean (SD) P Mean (SD) P
Nasofrontal Angle 141(5.8) 131.3 (5.6) <0.0001 127.9 (3.0) <0.0001 134.3 (7) <0.0001 127.6 (8.1) <0.0001
Nasolabial Angle 85.6 (10.8) 82.6 (10.9) 0.306 79.3(0.7) <0.0001 85.2 (13.8) 0.8499) 104.2 (9.8 <0.0001 73.9 (14.5) <0.0001
Comparative studies by Miles and Naidoo, Esabish et al, Virdi et al, Farkas et al 4,5,13,19,28 Individual Student t test performed with P provided. Significant P less than 0.05.

The mean interalar width is 42.9 ± 3.1 mm, which was significantly wider than those of other studies, and the interalar to intercanthal width ratio shows the width of the nose to be (24.5 ± 12.2)% larger than the intercanthal distance. This correlates to a medial canthus that lies more medial to a vertical line from the alar-facial groove of the young Black South African woman and therefore deviates from the neoclassical canon of equal vertical fifths.

Other key factors include an alar flare of 1.7 ± 0.9 mm, and a wide, rounded lobule measuring 25.0 ± 2.5 mm or rather, (63.7 ± 7.1)% of the nasal width. Nostril subtypes in this sample were found to be predominantly “oval base/horizontal axis,” with the second most common being that of the “trapezoidal base/inverted axis.”

Lip Measurements

Lip measurements of the index (Table 13) as well as international studies (Table 14) are detailed below. The analysis of the upper to lower vermilion ratio is more than the classical 1:1.618 described by the golden ratio, with the upper exceeding the height of the lower vermilion in many cases (mean upper to lower ratio of 1.2:1).

Table 13. - Lip Measurements for Index Study
Linear Measurments (mm) Mean Median Max Min SD
Upper lip height 23.9 23.7 30.9 17.9 2.510
Lower lip height 19.5 19.7 26.6 12.9 2.495
Upper vermillion height 11.0 11.0 16.4 6.0 2.043
Lower vermillion height 13.2 13.4 19.5 8.1 1.852
Upper lip projection (E-line) 2.4 2.3 7.7 − 3.2 2.145
Lower lip projection (E-line) 5.2 5.3 10.1 − 1.8 2.160
Upper: lower vermilion 0.838 0.827 1.423 0.510 0.151
Upper vermilion: lip 0.458 0.460 0.726 0.276 0.077
Lower vermilion: lip 0.685 0.677 0.985 0.380 0.120
Lower vermilion: lip 0.685 0.677 0.985 0.380 0.120

Table 14. - Comparison of Lip Measurements of Index Study versus Local and International Studies
Present Study Miles and Naidoo Esabish Virdi
Country South Africa South Africa Congo Kenya
Race Group Black Black Black Black
No. participants 156 15 71 36
Mean (SD) Mean (SD) P Mean (SD) P Mean (SD) P
Upper vermilion height 11 (2.0) 13.4 (0.9) <0.0001
Lower vermilion height 13.2 (1.9) 13.6 (1) 0.229
Upper lip length 23.9 (2.5) 25.5 (3.1) 0.0217 24 (2.5) 0.7802 25 (2.5) 0.8290
Lower lip length 19.5 (2.5) 20.7 (1.1) <0.0001 20.7 (1.1) <0.0001
Comparative studies by Miles and Naidoo, Esabish et al, Virdi et al.13,19,28 Individual Student t test performed with P provided. Significant at P < 0.05.

Ethnic comparison of the lips of the current study population with those from other populations reveals decreased upper vermilion height but no significant difference in lower vermillion height when compared with Kenyan counterparts. The upper and lower lip lengths are comparable to those in other studies where despite a statistically significant difference in lower lip height, this difference was only 1.2 mm.

Lip projection in relation to the Ricketts E-line is classically described as the upper lip falling 4 mm behind and the lower lip falling 2 mm behind the E-line.20 The index population, however, has significantly more protrusive lips with a mean of 2.4 ± 2.1 mm and 5.2 ± 2.2 mm protrusion beyond the E-line for the upper and lower lip, respectively. In summary, the young Black South African woman has full lips with increased protrusion beyond the Ricketts E-line and an upper to lower vermilion thickness, which approximates a 1:1 ratio.

Chin and Mandibular Measurements

The mean mandibular height measured from mentolabial crease to menton was 43.6 ± 4.4 mm in this study population (Table 15). The classical principle of Gonzalez-Ulloa is that the chin should lie 0–2 mm behind the vertical facial plane.21 In this sample, the mean chin projection indicated the chin fell 10.2 mm behind this line. This legitimizes the need for ethnic-specific norms for this measurement or the need for alternative measurement techniques when considering other ethnicities.

Table 15. - Chin and Mandibular Measurements for Index Study
(mm) Mean Median Max Min SD
Mandibular height 43.6 43.6 54.5 33.8 4.364
Chin projection 11.2 10.9 22.5 3.0 2.960
Depth of Mentolabial Sulcus 4.6 4.5 8.2 0.8 1.299
Mentocervical angle 82.3 83.1 96.5 66.2 6.216

The mean depth of the mentolabial sulcus was 4.5 ± 1.3 mm. This measurement was not performed by the international studies included; however, a previous study of African American subjects by Flynn in 1989 showed a mean mentolabial sulcus depth of 5.5 ± 1.3 mm.22 Despite this showing statistical significance using a Student t test (P = 0.006), the difference in means is only 1 mm with “normal” ranges overlapping.22

The mean mentocervical angle in this study population was 82.3 ± 6.2 degrees, which is within the “normal” range of 80–95 degrees initially described by Humphries and Powell in 1984, when describing White women.23


There are significant differences in facial anthropometric measurements between Black South African women and those from other ethnic and geographical backgrounds. The general facial proportions of young Black South African women are similar to those of Kenyan and Nigerian populations with upper facial heights being less than that of the lower and midface, thus deviating from the neoclassical canon of equal horizontal thirds. The intercanthal distance makes up approximately 25% of the facial width and, together with the nasal width that is larger than the intercanthal distance, deviates from the neoclassical canons of equal fifths. There is a gentle superolateral canthal tilt of 6.9 degrees on average. The nose is generally flatter in comparison with other populations, indicated by a wider nasofrontal angle and decreased tip projection. The nasal base is generally wider than that of the other populations examined. The nasolabial angle is also more acute than that of White people, indicating a more inferiorly rotated tip, and flatter nose. The nostril base/axis of inclination subtype is generally that of a horizontal or inverted axis. The lips are full, with an upper to lower vermillion ratio approximating 1:1. The lips are also more protrusive than the classical teaching of Ricketts, with the upper and lower lips sitting in front of the E-line rather than behind it.20 The mandible and chin, as well as their relationship to the face and neck closely approximate the findings of Flynn as well as Humphries and Powell when describing African American and White populations.22,23


This study highlights the nuance and sensitivity required to treat patients from varying ethnicities such as that of the Black South African woman. Furthermore, there may also be a degree of tribal variation within the South African population that was not fully elucidated in this study due to lack of sufficient representation from all tribal groups. This is an area for further research and may prove to show additional subtle differences.

The “aesthetic ideal” of this population is to be found within the “normal” ranges detailed in this study. Although these ranges may be relatively wide in some cases, the work of Symons as well Baudouin et al in their description of “facial averageness” showed substantial evidence that the aesthetic ideals of any given population tends toward the average.24,25 It is therefore hypothesized that the mean values from this study could be used as a guide to this ideal value, bearing in mind the need for further research in this area.

Clinicians treating patients of varying or mixed ethnic backgrounds may find themselves needing to use multiple data sets from different populations. Any clinical decision in this scenario would need to be individualized according to the predominant ethnic features and based on multiple points of reference, including the patient’s ethnic identity, aesthetic desires, and the clinician’s discretion and artistic intuition.

This study has shed light on the need for a new data set for the Black South African woman and, indeed, those of all ethnic backgrounds to guide the modern healthcare professional in facial reconstruction and cosmetic and dental interventions. It also serves to highlight the shortcomings of the “classical norms” that are most often quoted in medical literature and the need to scrutinize all medical data that may be confounded by ethnic and geographical variables.


The authors have no financial interest to declare in relation to the content of this article.


The patient provided written consent for the use of her image.


1. Thomas JR, Dixon TK. A global perspective of beauty in a multicultural world. JAMA Facial Plast Surg. 2016;18:7–8.
2. Milutinovic J, Zelic K, Nedeljkovic N. Evaluation of facial beauty using anthropometric proportions. Sci World J. 2014;2014:1–8.
3. Gottlieb E, Marquardt S Dr, Stephen R. Marquardt on the golden decagon and human facial beauty. J Clin Orthod. 2002;XXXVI:339–347.
4. Farkas LG, Katic MJ, Forrest CR, et al. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2015;16:615–646.
5. Farkas L, Forrest C, Litsas L. Revision of neoclassical facial canons in young adult Afro-Americans. Aesth. Plast. Surg. 2000;24:179–184.
6. Hrdlicka A. The full-blooded American negro. Am J Phys Anthropol. 1928;XII(1903).
7. Sushner I. A photographic study of the soft-tissue profile of the Negro population. Am J Orthod. 1977;72:372–385.
8. Bernstein L. Rhinoplasty of the negroid nose. Otolaryngol Clin North Am. 1975;8:783–793
9. Ofodile FA, Bokhari FJ, Ellis C. The Black American nose. Ann Plast Surg. 1993;34:123.
10. Porter JP, Olson KL. Analysis of the African American female nose. Plast Reconstr Surg. 2003;111:620–626; discussion 627.
11. Farkas LG, Hreczko TA, Deutsch CK. Objective assessment of standard nostril types – a morphometric study. Ann Plast Surg. 1983;11:381–389.
12. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg. 2003;111:1322–39; discussion 1340.
13. Naidoo L, Miles L. An evaluation of mean cephalometric values for orthognathic surgery for Black South African adults. Part II: soft tissue. J Dent Assoc South Africa. 1997;52:545–550.
14. Sullivan GM, Feinn R. Using effect size-or why the P value is not enough. J Grad Med Educ. 2012;4:279–282.
15. Kulkarni N, Dave B. Correlation of cervical vertebral bone age and Demirjian’s stages of dental maturation for lower left permanent canine and second molar. J Contemp Dent Pract. 2019;20:471–475.
16. Raina P, Kulkarni N, Shah R. A comparative study of sagittal dental relationship using digital method of bite mark evaluation. J Forensic Dent Sci. 2019;11:125–132.
17. Meruane M, Ayala MF, García-Huidobro MA, et al. Reliability of nasofacial analysis using Rhinobase software. Aesthetic Plast Surg. 2016;40:149–156.
18. Houston W. The analysis of error in orthodontic measurements. Am J Orthod. 1983;83:382–390.
19. Virdi SS, Wertheim D, Naini FB. Normative anthropometry and proportions of the Kenyan-African face and comparative anthropometry in relation to African Americans and North American Whites. Maxillofac Plast Reconstr Surg. 2019;41:9.
20. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod. 1968;54:272–289.
21. Gonzales-Ulloa M. Quantitative principles in cosmetic surgery of the face (profileplasty). Plast an Reconstr Surg Transplant Bull. 1962;29:186–198.
22. Flynn TR, Ambrogio RI, Zeichner SJ. Cephalometric norms for orthognathic surgery in black american adults. J Oral Maxillofac Surg. 1989;47:30–39.
23. Powell N, Humphries B. Proportions of the Aesthetic Face. New York: Thieme-Stratton Inc; 1984.
24. Symons D. The Evolution of Human Sexuality. Oxford Univ Press. 1979.
25. Baudouin J, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women. Acta Psychol (Amst). 2004;Symmetry:313–332.
26. Olusanya AA, Aladelusi TO, Adedokun B. Anthropometric analysis of the Nigerian face: any conformity to the neoclassical canons? J Craniofac Surg. 2018;29:1978–1982.
27. Salah M, Higzi MAI, Ali RW, et al. The Sudanese female face: normative craniofacial measurements and comparison with African-American and North American White females. J Cranio-Maxillofacial Surg. 2014;42:1704–1709.
28. Esabish PL, Beugre-Kouassi LMA, Baukaka FS, et al. Facial photogrammetric profile measurements and sagittal dental occlusion in the young Congolese Bantu adult (DRC). Int Orthod. 2019;17:342–353.
Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.