Professor Bob Khanna shares his key concepts for assessing the patient profile to achieve successful facial rejuvenation.
When I would assess patients for facial aesthetic procedures back in 1996, like my peers of that era, I performed an extensive evaluation of primarily the frontal view. Back then, the most common treatments were botulinum toxin to the upper facial region and dermal filler injections to the lips and nasolabial lines.
In this article, I will show you that it’s in fact the profile (side view) that sets the tone for 3D facial aesthetics, and why it should be your primary consideration in every facial assessment. I will also explore my trademarked BK P-Line system for profile assessment and how you can utilise this to set yourself up for treatment success.
Up until around 2007, I was examining every patient from the frontal facial view to begin with, before incorporating the other views. Based on my experience of training aesthetic practitioners from all over the world, I believe that this is still what the majority of practitioners are doing, especially those new to aesthetics, as it seems to be the natural way to approach an assessment. Of course, the patient assessment should never just include one view but should incorporate the information obtained from a comprehensive three-dimensional approach. In this way, a thorough diagnosis can take place, leading to appropriate treatment options and results for our patients. Based on 27 years of clinical practice, I have noticed that people with aesthetic profiles tend to have the most aesthetically-pleasing faces.
It is important to appreciate the differences between all types of patients and adopt an ‘individualised’ approach. I am often seeing male patients being feminised and females being almost ‘dehumanised’ by treatments. The mid-face and perioral areas are typical regions which are vulnerable to such anomalies in both sexes. Equally, we must consider what is appropriate for different ethnicities; for example, I find it’s generally rare for you to see a male in the Far East to have an angular, European jawline as they typically have more of a heart-shaped face and it may look very odd if you create one.1 A full discussion of the differences between genders and ethnicities, along with appropriate treatment approaches, is beyond the scope of this article, but there are a number of resources that explore these considerations.2,3,4
To help with my initial assessment, I endeavour to take good quality photographs. These provide vital discussion aids with the patient to facilitate a truly co-diagnostic exercise. I will then use my BK P-1 to BK P-3 parameters to identify the relationship of the forehead, nose, lips, chin and jawline to ascertain where the discrepancies lie and which areas need to be considered for treatment (Figure 2). Tying in all of my parameters will give me a good understanding as to whether or not I need to augment the forehead, nose, lips and/ or chin and, importantly, to what extent. My BK Ps are not the only parameters, of course, but are an excellent way to get you thinking about the right way for profile assessment.
The BK P-0 Line is a horizontal straight line that runs from the mid-tragus to the mid-alar and will help set your horizontal determinant for a successful assessment. To ensure you take accurate and standardised before/after photographs, the line needs to be completely straight and parallel to the floor. I use this concept instead of the Frankfort plane, which is a line that intersects both porions and the left orbitale, and is commonly used to orient the head so that the plane is horizontal.5 In my opinion, the Frankfort plane is not as reproducible as using soft tissue landmarks.
The BK P-1 line falls vertically through the most anterior point of the upper lip. Once you have identified this line, observe the soft tissue regions associated with the glabella (the most anterior position on the profile view of the patient’s forehead, which lies between the eyebrows), nasion, (the deepest part of the frontonasal sulcus) and pogonion (the most anterior point of the chin). Taking into account males, females and people from differing ethnic backgrounds I have developed a range in millimetres for each parameter. This will help the practitioner determine the precise amount of augmentation required.
The BK P-2 line runs from the most anterior point on the tip of the nose to the pogonion, allowing us to observe the projection of the lips. This will identify how much room is available for augmentation and subsequent projection. The BK P-2 line is similar to the traditional Ricketts’ line, which is a line drawn from nose tip to chin.6 Ricketts is based on cephalometric assessment, which in my view is limited and outdated when looking at current facial aesthetic procedures. According to Ricketts, the upper lip lies around 4mm behind the line, while the lower lip lies 2mm behind;6 however, this is based on Caucasians and doesn’t take into account racial differences. In fact, most people with an African descent will actually violate that line – this doesn’t make them un-aesthetic, it just means that it is normal for their racial background.7 In certain cases, it is appropriate for the patient’s upper and lower lip to touch the BK P-2 line. If the lips touch BK P-2 pre-treatment, I would be reluctant to augment a patient’s lips and if I were to treat, it would be for a rejuvenation, hydration effect with very little volumisation. This is because volumising will risk causing the infamous ‘trout-pout’ and could easily ‘dehumanise’ your patient. In such cases, it would be appropriate to facilitate this by adjusting BK P-2 by careful chin augmentation, making sure the BK P-1 line is respected.
The BK P-3 line allows you to reference the mid-face in relation to the eyes. It is a vertical line that is perpendicular to BK P-0, and crosses the anterior part of the cornea of the eye. This will help determine to what extent we can project the anterior section of the mid-face. The mid-face is actually really important for the profile view because by correcting mid-facial projection, particularly the antero-medial portion of the cheek, you can make the nose look less projected.
As discussed, the profile should not be assessed in isolation and the other views are also very important, such as the three quarter profile view, revealing both eyes and to some extent the characteristics of the profile,8 and frontal facial view. From these views, I can determine key measurements (angles, lengths and widths) to ascertain to what extent I need to augment in terms of facial proportions – facial thirds and facial fifths.9
There is nothing worse than a bad before and after image. I understand that as medical professionals we are not photographers, however I believe that it’s something that is seriously lacking in our field and all practitioners need to have more of a focus on improving this. Exceptional before and after photographs not only allow for great marketing resources (with the correct consent of course), but it also provides clear proof of how the patient was before treatment, should you ever find yourself in the instance of an unhappy patient.10
My best advice for taking photographs is consistency and reproducibility. The head and body position, lighting, camera settings such as angles and zoom, and device are all factors to consider, among others.10 Patient expression should also be kept as consistent as possible; however, I understand that this is difficult to replicate especially as many patients are much happier following their treatment. I use a DSLR camera in my clinic rather than a phone or tablet as I find it takes better quality images, and I also have several staff members trained in its use. We also take the images at one designated location in clinic, which always has the same background and lighting.10 When taking images, ensure to follow General Data Protection Regulation (GDPR) and know the legal and regulatory issues surrounding their use.10,11
I usually conduct most of my treatments over at least two sessions. Should the patient require it, I will firstly craft the forehead convexity, then I’ll look at the nasal frontal sulcus, the nose, the mid-face – including the tear troughs and the cheeks – and then I will move down to the chin and the jawline, and finally the lips. When treating patients, my general rule is that the lips are ‘the icing on the cake’, so I will always do these last as they will complement all the other features.
By assessing the patient’s profile first, followed by a three-dimensional analysis of the full face from all angles, you will be well positioned to understand the areas that require treatment and tailor your approach to each patient, regardless of age, gender and racial background.
1. Future Lear, Identifying the ethnicity of a skull, Forensic Facial Reconstruction, The University of Sheffield. <https://www.futurelearn.com/courses/forensic-facial-reconstruction/0/steps/25658>
2. Zhuang Z,Landsittel D,Benson S,Roberge R,Shaffer R, Facial Anthropometric Differences among Gender, Ethnicity, and Age Groups, Ann Occup Hyg.2010 Jun;54(4):391-402.
3. de Maio, M. Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients. Plastic and Reconstructive Surgery. November Supplement, Volume 136, Number 5S 2015.
4. Andrew F. Alexis, and Jasmine O. Obioha, Ethnicity and Aging Skin, Journal of Drugs in Dermatology, 2017.
5. Santos RMGD, De Martino JM, ‘Influence of different setups of the Frankfort horizontal plane on 3-dimensional cephalometric measurements.’ Am J Orthod Dentofacial Orthop. 2017 Aug;152(2):242-249.
6. Robert MurrayRickett, A foundation of cephalometric communication, American Journal of Orthodontics, 1960, 46(5):330-357.
7. Vinay V Umale, Kamlesh Singh, et al., Evaluation of Horizontal Lip Position in Adults with Different Skeletal Patterns: A Cephalometric Study, Journal of Oral Health and Craniofacial Science, 2017.
8. J. Powell, & R.K. Rayson,‘The Profile in Facial Aesthetics’, British Journal of Orthodontics,Vol 3,No 4, pp.207-215.
9. Jovana Milutinovic, Ksenija Zelic, & Nenad Nedeljkovic,Evaluation of Facial Beauty Using Anthropometric Proportions, The Scientific World Journal, 2014.
10. Chloé Gronow, Special Feature: Managing Patient Photography, Aesthetics journal, <https:// aestheticsjournal.com/feature/special-feature-managing-patient-photography>
11. Martin Swann, Patient Photography and Data, 2018. <https://aestheticsjournal.com/feature/patient-photography-and-data>