Downloaded from http://journals.lww.com/jcraniofacialsurgery by BhDMf5ePHKbH4TTImqenVKgR5BWYxyIr/hBY5nm99/IZrFj9HqI2JMNY1emcngkq on 12/19/2018 Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Anthropometric Evaluation of Periorbital Region and Facial Projection Using Three-Dimensional Photogrammetry Diana S. Jodeh, MD,  Heather Curtis, MD, y James J. Cray, PhD, z Jonathan Ford, PhD, § Summer Decker, PhD, § and S. Alex Rottgers, MD  Introduction: Direct anthropometric and three-dimensional (3D) photogrammetry measurements have been used extensively in cleft/ craniofacial surgery to assess morphological changes and surgical outcomes. Craniofacial procedures alter the sagittal projection of periorbital bony prominences. Mulliken described a method of measuring their projection relative to the corneal plane but is impractical in clinical practice. Three-dimensional photogramme- try may offer a solution; however, the cornea is not visualized on this. The authors propose to develop new normative measurements of facial projection relative to the pupil. Methods: Five 3D photographs were taken of 5 individuals using Vectra M5 camera. Facial projection measurements were taken of the sagittal projection of the bilateral periorbital landmarks and nasal radix relative to the pupil using Mirror 3D analysis. Standard deviations (SD) were determined for each subject and laterality. Chi-square tests confirmed all SD <1 mm. Intra and inter-rater reliability were confirmed with an intraclass correlation coefficient assessment. Results: Three male and 2 female subjects were photographed with 5 unique images. Standard deviations of repeat measures of all landmarks were <0.5 mm. Chi-square tests confirmed with statistical significance that SD for all values except for the radix was <1 mm (P<0.05). Intrarater reliability was high for all landmarks (intraclass correlation coefficient coefficients 0.93– 0.99). Inter-rater reliability was good for the lateral canthi and excellent for all others. Conclusion: This technique demonstrates repeatability with high reliability on serial photographs and is applicable to measuring surgery effects and growth on facial projection. Establishment of age-specific normative values for landmark projection will refine usage applicability in operative planning. Key Words: 3D photogrammetry, craniofacial surgery, facial projection, sagittal projection (J Craniofac Surg 2018;29: 2017–2020) D irect anthropometric analyses and measurements with three- dimensional (3D) photogrammetry have been used extensively in cleft and craniofacial surgery to assess facial morphology differences and surgical outcomes. 1–4 These methods often use linear measurements, but more sophisticated measures such as volumetric analyses have been employed. 5–8 Frontofacial advance- ment procedures such as fronto-orbital advancement (FOA), Le Fort 3, and monobloc advancement alter the sagittal projection of periorbital bony prominences. 9,10 The treatment goal in these procedures is to increase intracranial volume, to improve upper airway volume, and to increase bony protection of the eye. 11 The clinical endpoints used to judge outcomes are the periorbital aesthetics and sagittal projection of the surrounding bony promi- nences. 12 These are more difficult to quantify. In an attempt to quantify the outcomes of fronto-facial surgery and to make relevant clinical measures preoperatively on which to base clinical decisions, Kohout et al 13 introduced the os-acor relationship as a measurement of sagittal projection of the brow relative to the anterior corneal plane. This concept is valuable in planning the degree of advancement needed in a particular proce- dure and in assessing surgical results as well as their durability, but the stumbling block is clinical execution. A device has been described which utilizes a calibrated arm to measure the difference in the sagittal projection of the closed eye and various periorbital landmarks while the patient rests in a chin-cup. This device is unique and cumbersome in a busy clinical setting. 14 This is also not feasible for small children. Since surgical correction of craniosyn- ostosis is usually undertaken when a child is less than 12 months of age, these measurements lose clinically utility. 15 Procedures are therefore planned based on radiographic measurements to achieve bone symmetry or a clinical estimate of brow projection. 4 Three- dimensional photography allows a solution to these problems as patient’s photographs can be taken and archived for future photo- grammetric evaluation. 5,16–18 This alleviates the clinic work-flow and eliminated the need for patient compliance other than comple- tion of a single photograph. 1,2,8 Images can be stored and then analyzed with highly reproducible measurements comparable to direct anthropometry of the patient. 19 This will allow for clinically useful measurements of young children and use of this information in planning surgical correction of their deformities. 5,19–22 The os-acor anthropometric relationship must be altered to apply it to 3D photogrammetry. The point of maximal projection of the eye is the apex of the cornea, but the cornea is clear and is not captured as part of the 3D model created with 3D photogra- phy. 11,14,23 For this reason, measurements must be made from the plane of the iris, which is included in a 3D photograph. Before utilizing this technology, it must be confirmed that optical distortion does not result in significant variation between shape and projection From the  Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, St. Petersburg; y Department of Plastic Surgery, University of South Florida, Morsani College of Medicine, Tampa, FL; z Departments of Oral Health Sciences and Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC; and § Department of Radiology, University of South Florida, Morsani Col- lege of Medicine, Tampa, FL. Received February 1, 2018. Accepted for publication May 23, 2018. Address correspondence and reprint requests to S. Alex Rottgers, MD, Assistant Professor of Plastic Reconstructive Surgery, Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, 601 Fifth Street South, Suite 306, St. Petersburg, FL; E-mail: srottge1@jhmi.edu The authors report no conflicts of interest. Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004761 ORIGINAL ARTICLE The Journal of Craniofacial Surgery  Volume 29, Number 8, November 2018 2017