A Simple, Reliable, and Validated Method for Measuring

Brow Position
Pieter S. Verduijn, MD,* Ruud W. Selles, PhD,* and Marc A.M. Mureau, MD, PhD*
Purpose: To establish outcome of brow suspension techniques, a reliable and
clinically suitable measurement tool is required. Most of the published meth-
ods lack statistical validation, and in none of the reviewed studies, the stan-
dardized photograph protocols were validated.
Methods and Techniques: Fifteen subjects were independently photographed
by 2 different professional medical photographers. Adobe Photoshop CS5
software (San Jose, Calif) was used to perform the measurements based on
interpupillary distance and medial, midpupil, and lateral reference points on
the brow. To establish intrarater reliability, the photos of both photographers of
the same subject were analyzed by the same researcher. To establish interrater
reliability, the photos of 1 photographer were analyzed by 1 researcher,
whereas the photos of the second photographer were analyzed by a second
researcher. Reliability was assessed using the intraclass correlation coefficients
(ICCs) and the smallest detectable differences.
Results: The ICCs indicated good to excellent interrater and intrarater reli-
ability. The ICCs of the interrater reliability were lower compared with those of
the intrarater reliability, although they could still be categorized as good to
excellent. We found that the lateral measurements had the highest reliability,
and the medial measurements, the lowest reliability.
Conclusions: The current study supports that the en face photographs in
our database are truly standardized. The good to excellent interrater and
intrarater reliability of the present method makes it a valid measuring tool.
Key Words: brow position, measuring method, interclass coefficient
validation, oculoplastic
(Ann Plast Surg 2014;73: 81Y85)
T
he position of the brow has an important function in the dynamic
and aesthetic appearance of the face. Asymmetry of the brows,
after facial paralysis for example, is hard to miss during facial ani-
mation in various social situations. In addition, the aging face may
lead to an unwanted expression of sadness or tiredness because of
a lowered position of the brows.
1
It is a challenging task for a reconstructive surgeon to restore
normal brow position. Several surgical techniques have been devel-
oped to correctly place the brow.
2
Examples are the direct brow lift,
3,4
coronal brow lift,
5,6
frontal hairline brow lift, temporal brow lift,
7
transpalpebral brow lift, endoscopic brow lift,
8
and the use of threads.
9
With so many surgical techniques available, the question remains to
be which technique is most optimal.
To establish outcome of brow suspension techniques, a reli-
able, validated, simple, and clinically suitable measurement tool is re-
quired to measure preoperative and postoperative brow position. Var-
ious methods for brow position assessment have been described in
literature.
4,10Y18
Again, the number of different methods suggests that
an optimal way to measure brow position is not yet available. Most
of the published methods lack statistical validation, and in none of
the previous studies, the standardized photograph protocols were
validated.
To be able to validly analyze our own results after brow-lifting
procedures, we aimed to overcome the shortcomings of previously
published methods by creating a simple, validated, and clinically
applicable method without the need for costly and specialized soft-
ware that can be easily implemented in any clinical setting.
METHODS
Recruitment of Volunteers
Fifteen subjects without a facial disability or disfigurement
visiting our outpatient clinic agreed to participate in our study. After
explaining the goal of the study, 6 men [mean (range) age, 51 (25Y76)
years] and 9 women [mean (range) age, 32 (22Y66) years] agreed to
participate. Informed consent was obtained verbally.
Standardized Digital Photography Protocol
All 15 healthy controls were independently photographed by 2
different professional medical photographers using our standardized
protocol for patients with facial palsy. The standardized photograph
series depicts 7 different facial expressions: in repose, gentle smile,
full smile, lips pucker, gentle eye closure, forceful eye closure, and
elevation of eyebrows. For the present study, we photographed the
healthy controls in repose en face, preferably without the patient
wearing earrings or other jewels. Pictures were taken from a 90-cm
distance using a digital Nikon D100 camera (Nikon Corp, Tokyo,
Japan) with a 60-mm lens and fixed, standardized camera settings.
Processing and Analysis of Photographs
After uploading the photographs in Adobe Photoshop CS5
software (Adobe Systems, Inc, San Jose, Calif ), the measurement
tool was chosen and set on custom. The ruler was then used to
pinpoint the center of the pupils and to connect them with a line.
Subsequently, the interpupillary distance (IPD) was computed by the
program using the number of pixels because we did not measure the
exact IPD in each subject. In all subjects, the IPD was scaled to 6 cm to
obtain numbers that could more easily be interpreted than pixels. This
6 cm is close to the mean pupil distance in adult males and females but
is used here only for the purpose of converting pixels to approximate
distance.
19
After drawing the line from pupil to pupil, we straight-
ened the photo by making the interpupillary line horizontal using
the straighten button in the ruler tool menu. Then, still using the
ruler tool, a horizontal reference guideline was drawn from the ruler
frame of the picture through both pupils. Vertical guidelines could
subsequently be drawn in the same manner and were placed on 3
locations on each eye: on the lateral border of the sclera (LS), the
medial border of the sclera (MS), and through the midpupil (P). The
upper border of the brow at LS and P was defined as the most cranial
RESEARCH
Annals of Plastic Surgery & Volume 73, Number 1, July 2014 www.annalsplasticsurgery.com 81
Received July 5, 2012, and accepted for publication, after revision, August 2, 2012.
From the Departments of *Plastic and Reconstructive Surgery and Rehabilitation
Medicine and Physical Therapy, Erasmus MC, University Medical Centre
Rotterdam, Rotterdam, the Netherlands.
Conflicts of interest and sources of funding: none declared.
Reprints: Marc A.M. Mureau, MD, PhD, Department of Plastic and Reconstructive
Surgery, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040,
3000 CA Rotterdam, the Netherlands. E-mail: m.mureau@erasmusmc.nl.
Copyright * 2014 by Lippincott Williams & Wilkins
ISSN: 0148-7043/14/7301-0081
DOI: 10.1097/SAP.0b013e31826d298e
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
root of eyebrow hair that is still part of the brow, considering the
medial and lateral neighboring hairs. For the MS measurement, it was
not always possible to visualize the superior hair root because the
eyebrow hairs often grow vertically in cranial direction. Therefore,
we relied on the neighboring hair roots to estimate the height on this
part of the brow. As a last step, we measured the position of the brow
as the distance from the horizontal pupil line along each vertical line
to the upper brow border (see Fig. 1). The procedure, from uploading
the photo to the last measurement, took on average approximately 2.5
minutes to perform.
Interrater and Intrarater Variability
Two photographers independently took pictures of all 15 sub-
jects to determine test-retest reliability. To establish intrarater reli-
ability, the photos of both photographers of the same subject were
analyzed by the same researcher (P.V.). To establish interrater reli-
ability, the photos of 1 photographer were analyzed by 1 researcher
(P.V.), whereas the photos of the second photographer were analyzed
by a second researcher (S.V.).
Statistical Analyses
The data of the brow height of each photograph were exported
from Photoshop to PSAW 17 (previously SPSS, SPSS Inc, Chicago,
Ill). In PSAW, we calculated means and SDs of the total group for the
left and the right eye. In addition, we calculated a ratio of the right eye
divided by the left eye, expressed as a percentage.
Reliability was assessed using 2 parameters: the intraclass
correlation coefficient (ICC) and the smallest detectable difference
(SDD). The ICC is a measure of agreement between test and retest
values measured in the same subject. An ICC of 0 means no agree-
ment between test and retest, whereas an ICC of 1 means perfect test-
retest reliability.
20
The SDD expresses the difference between test and
retest in the original measurement units (centimeters) and was cal-
culated with the estimated variance components.
21,22
The SDD is
specifically valuable for clinical use in individual patients because
with this index, an examiner can distinguish between a measurement
error and a real (treatment) change. Only a difference that exceeds
the SDD can be considered a real (nonerror) change in an individual
patient.
22,23
For example, an SDD of 0.2 mm indicates that a follow-
up measurement should differ by at least 0.2 mm from a baseline
measurement to be sure that a real (nonerror) change in distance has
occurred in an individual subject.
RESULTS
Table 1 shows the mean values and the reliability of the mea-
surements. The measured distances ranged from 1.89 to 2.15 cm. In
this population, the left brow was, on average, slightly higher than the
right brow. This was also expressed in the left-right ratio, showing
values smaller than 100% (95%Y99%).
The ICCs indicated good to excellent interrater and intrarater
reliability. The ICCs of the interrater reliability were lower compared
with the intrarater reliability, although they could still be categorized
as good to excellent. The intrarater SDDs ranged from 0.16 to 0.29 cm,
and the interrater ICC, from 0.19 to 0.31 cm. As also explained in the
Methods section, these absolute differences are based on the as-
sumption that all patients have an IPD of 6 cm. The results should
therefore be interpreted as an approximation. The SDDs for the right-
left ratios ranged from 4.7% to 10.5%. When comparing the lateral,
midpupil, and medial measurements, we found that the lateral mea-
surements had the highest reliability, and the medial measurements,
the lowest reliability.
DISCUSSION
If you cannot measure it, you cannot improve it. There are
several challenging obstacles to overcome before a bias-free mea-
surement of brow position is possible. Electronic patient files will
increasingly contain digital photographs in the near future. They are
used to compare postoperative results with the preoperative situation
and can be used for follow-up, scientific research, education, medi-
colegal issues, or reimbursement judgments by insurance companies.
Comparison of photographs is possible only if they are taken in a
standardized reproducible manner. A good example is published by
Coombes et al,
24
who developed a standardized digital photography
system with computerized eyelid measurement analysis. Other inves-
tigators took standardized photographs but did not give any details
about the exact procedures.
10Y12
Table 2 provides an overview of rel-
evant articles. Although in more recent studies the photo protocols
FIGURE 1. The horizontal reference line and the vertical
guidelines. The yellow arrows correspond with the measured
distance from the reference line to the upper brow.
TABLE 1. Intrarater and Interrater Reliability Per Measurement Method Expressed as the ICC and the SDD
Measurement Mean (SD) Intrarater ICC Interrater ICC Intrarater SDD Interrater SDD
Right LS, cm* 2.08 (0.32) 0.96 0.94 0.16 0.19
Right P, cm* 2.04 (0.31) 0.92 0.88 0.21 0.22
Right MS, cm* 1.89 (0.34) 0.91 0.83 0.25 0.28
Left LS, cm* 2.15 (0.33) 0.96 0.91 0.17 0.20
Left P, cm* 2.07 (0.33) 0.94 0.94 0.22 0.20
Left MS, cm* 1.90 (0.33) 0.87 0.80 0.29 0.31
LS right-left ratio, % 95.7 (7.0) 0.82 0.74 7.9 10.5
P right-left ratio, % 98.6 (7.0) 0.83 0.83 7.5 7.4
MS right-left ratio, % 99.5 (8.7) 0.90 0.82 4.7 9.6
*Measurements are based on the assumption that each patient has an IPD of 60 m.
Verduijn et al Annals of Plastic Surgery & Volume 73, Number 1, July 2014
82 www.annalsplasticsurgery.com * 2014 Lippincott Williams & Wilkins
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T
A
B
L
E
2
.
O
v
e
r
v
i
e
w
o
f
R
e
l
e
v
a
n
t
A
r
t
i
c
l
e
s
A
u
t
h
o
r
R
e
f
e
r
e
n
c
e
P
o
i
n
t
o
n
B
r
o
w
N
o
.
P
o
i
n
t
s
P
h
o
t
o
P
r
o
t
o
c
o
l
*
V
a
l
i
d
a
t
i
o
n
P
h
o
t
o
C
a
l
i
b
r
a
t
i
o
n
S
o
f
t
w
a
r
e
S
t
a
t
i
s
t
i
c
s
V
a
l
i
d
a
t
i
o
n
M
e
t
h
o
d
C
l
i
n
i
c
a
l
S
u
i
t
a
b
i
l
i
t
y
T
i
m
e
t
o
P
e
r
f
o
r
m
K
i
m
e
t
a
l
(
2
0
0
9
)
L
i
n
e
t
h
r
o
u
g
h
m
e
d
i
a
l
c
a
n
t
h
i
S
u
p
e
r
i
o
r
b
o
r
d
e
r
e
y
e
b
r
o
w
a
t
l
e
v
e
l
o
f
l
a
t
e
r
a
l
l
i
m
b
u
s
1
Y
e
s
N
o
D
i
s
t
a
n
c
e
o
f
m
e
d
i
a
l
c
a
n
t
h
i
t
o
l
a
t
e
r
a
l
l
i
m
b
u
s
/
r
a
t
i
o
U
n
i
t
e
d
I
m
a
g
i
n
g
M
a
r
k
e
t
w
i
s
e
p
r
o
g
r
a
m

P
a
i
r
e
d
t
t
e
s
t
N
o
S
i
m
p
l
e
a
n
d
e
l
e
g
a
n
t
N
o
t
m
e
n
t
i
o
n
e
d
M
a
t
r
o
s
e
t
a
l
(
2
0
0
9
)
L
i
n
e
t
r
o
u
g
h
m
e
d
i
a
l
c
a
n
t
h
i
U
p
p
e
r
b
r
o
w
m
a
r
g
i
n
a
t
m
e
d
i
a
l
l
a
t
e
r
a
l
a
n
d
p
u
p
i
l
l
e
v
e
l
3
Y
e
s
N
o
M
e
t
r
i
c
r
u
l
e
r
t
a
p
e
d
t
o
f
o
r
e
h
e
a
d
A
d
o
b
e
i
m
a
g
i
n
g
s
o
f
t
w
a
r
e
P
a
i
r
e
d
t
t
e
s
t
a
n
d
i
n
d
e
p
e
n
d
e
n
t
t
t
e
s
t

N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
N
a
h
m
e
t
a
l
(
2
0
0
4
)
L
i
n
e
t
h
r
o
u
g
h
m
e
d
i
a
l
a
n
d
l
a
t
e
r
a
l
c
a
n
t
h
u
s
o
f
1
e
y
e
C
e
n
t
e
r
o
f
t
h
e
b
r
o
w
,
a
t
m
i
d
p
u
p
i
l
a
n
d
l
a
t
e
r
a
l
c
a
n
t
h
u
s
l
e
v
e
l
2
N
o
N
o
I
P
D
M
i
r
r
o
r
s
o
f
t
w
a
r
e

M
e
a
n
a
n
d
S
t
u
d
e
n
t
t
t
e
s
t
N
o
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
P
r
i
c
e
e
t
a
l
(
2
0
0
9
)
M
i
d
d
l
e
u
p
p
e
r
l
i
d
m
a
r
g
i
n
I
n
f
e
r
i
o
r
m
o
s
t
b
r
o
w
c
i
l
i
a
1
Y
e
s
N
o
H
o
r
i
z
o
n
t
a
l
c
o
r
n
e
a
l
w
h
i
t
e
t
o
w
h
i
t
e
d
i
s
t
a
n
c
e
I
m
a
g
e
J
1
.
4
0

I
C
C
Y
e
s
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
S
c
l
a
f
a
n
i
e
t
a
l
(
2
0
1
0
)
O
r
b
i
t
a
l
r
i
m
a
n
d
h
o
r
i
z
o
n
t
a
l
l
i
n
e
t
h
r
o
u
g
h
m
e
d
i
a
l
c
a
n
t
h
i
L
o
w
e
r
a
n
d
u
p
p
e
r
b
o
r
d
e
r
5
Y
e
s
*
*
N
o
1
0
0
m
m
r
u
l
e
r
t
a
p
e
d
t
o
n
a
s
a
l
t
i
p
M
i
r
r
o
r
s
o
f
t
w
a
r
e

M
e
a
n
a
n
d
S
D
N
o
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
S
i
d
l
e
e
t
a
l
(
2
0
0
5
)
M
i
d
p
u
p
i
l
a
n
d
l
a
t
e
r
a
l
c
a
n
t
h
u
s
L
o
w
e
s
t
r
o
w
o
f
e
y
e
b
r
o
w
h
a
i
r
s
2
Y
e
s
N
o
I
P
D
M
i
r
r
o
r
s
o
f
t
w
a
r
e

P
a
i
r
e
d
t
t
e
s
t
N
o
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
T
a
k
u
s
h
i
m
a
e
t
a
l
(
2
0
0
3
)
M
i
d
p
u
p
i
l
l
a
r
y
l
i
n
e
M
e
d
i
a
l
b
r
o
w
a
n
d
a
p
e
x
2
N
o
N
o
S
c
a
l
e
o
n
p
h
o
t
o
o
r
I
P
D
N
I
H
-
I
m
a
g
e
s
o
f
t
w
a
r
e
S
p
e
a
r
m
a
n
r
a
n
k
-
c
o
r
r
e
l
a
t
i
o
n
c
o
e
f
f
i
c
i
e
n
t
N
o
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
T
r
o
i
l
i
u
s
,
C
.
(
1
9
9
9
)
M
i
d
p
u
p
i
l
,
l
a
t
e
r
a
l
a
n
d
m
e
d
i
a
l
c
a
n
t
h
u
s
T
o
p
o
f
b
r
o
w
3
N
o
N
o
I
P
D
M
i
r
r
o
r
s
o
f
t
w
a
r
e

M
e
a
n
a
n
d
r
a
n
g
e
N
o
N
o
t
m
e
n
t
i
o
n
e
d
N
o
t
m
e
n
t
i
o
n
e
d
V
e
r
d
u
i
j
n
e
t
a
l
(
2
0
1
1
)
L
a
t
e
r
a
l
a
n
d
m
e
d
i
a
l
s
c
l
e
r
a
l
b
o
r
d
e
r
,
m
i
d
p
u
p
i
l
S
u
p
e
r
i
o
r
b
o
r
d
e
r
b
r
o
w
(
h
a
i
r
r
o
o
t
)
3
Y
e
s
Y
e
s
I
P
D
A
d
o
b
e
P
h
o
t
o
s
h
o
p
C
S
5
I
C
C
,
S
D
D
Y
e
s
S
i
m
p
l
e
a
n
d
r
e
l
i
a
b
l
e
2
.
5
m
i
n
u
t
e
s
*
I
s
t
h
e
p
r
o
t
o
c
o
l
r
e
p
r
o
d
u
c
i
b
l
e
?

U
n
i
t
e
d
I
m
a
g
i
n
g
,
I
n
c
,
W
i
n
s
t
o
n
-
S
a
l
e
m
,
N
C
.

A
l
l
m
e
a
s
u
r
e
m
e
n
t
s
w
e
r
e
p
e
r
f
o
r
m
e
d
t
w
i
c
e
:
o
n
c
e
b
y
2
a
u
t
h
o
r
s
,
t
o
e
n
s
u
r
e
i
n
t
e
r
r
a
t
e
r
r
e
l
i
a
b
i
l
i
t
y
.

C
a
n
f
i
e
l
d
I
m
a
g
i
n
g
S
y
s
t
e
m
s
,
F
a
i
r
f
i
e
l
d
,
N
J
.

N
a
t
i
o
n
a
l
I
n
s
t
i
t
u
t
e
s
o
f
H
e
a
l
t
h
,
B
e
t
h
e
s
d
a
,
M
d
.
*
*
T
w
e
n
t
y
-
f
i
v
e
p
e
r
c
e
n
t
o
f
p
a
t
i
e
n
t
s
w
e
r
e
e
x
c
l
u
d
e
d
b
e
c
a
u
s
e
o
f
m
i
s
f
r
a
m
e
d
o
r
o
u
t
-
o
f
-
f
o
c
u
s
p
h
o
t
o
s
.
Annals of Plastic Surgery & Volume 73, Number 1, July 2014 Method for Measuring Brow Position
* 2014 Lippincott Williams & Wilkins www.annalsplasticsurgery.com 83
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
were more or less explained, they were not validated. In the present
study, we showed that our photo protocol leads to reproducible stan-
dardized photographs and measurements.
The measuring method is just as important as having stan-
dardized and validated images. Many photo-editing software packa-
ges allow performing 2-dimensional measurements.
Three groups of software programs have been used in the lit-
erature: (1) free noncommercial software such as Image J
15
and its
predecessor NIH Image
11
; (2) software that was specially devel-
oped for aesthetic facial surgery such as Mirror imaging
10,12,14,18
and United Imaging Marketwise program,
17
which are very ex-
pensive; and (3) less expensive commercially available photo-editing
software such as Adobe Photoshop
16
and CorelDRAW 7 (Corel Corp,
Ottawa, Ontario, Canada).
24
It is unlikely that the software used in the
present study is a major source of bias. More important are the re-
producibility of the procedure and the definitions of the measuring
points.
Troilius
10
and Sidle et al
14
used individual measuring points
such as midpupil and lateral and medial canthi from which vertical
lines were drawn to measure brow height. However, it is difficult to
reproduce the same straight line between 2 points in preoperative and
postoperative pictures without some sort of reference line, making
this method not very reliable.
To overcome this problem, during brow height measurements,
a horizontal reference line is generally placed either through the
medial canthi
16Y18
or through the midpupils.
11
Nahm et al
12
used a
horizontal line through the canthi. If this means that a line is drawn
through both lateral and medial canthi, it is hard to believe that this
line would be horizontal because the lateral canthi are generally po-
sitioned a few millimeters cranial to the medial canthi.
The medial canthus is a preferred reference point in the face
because it is a very discrete anatomical landmark in which position
is unaffected by time. The same is true for the pupil. In addition, the
IPD can be used for calibration purposes.
11,14
Therefore, we decided
to draw our reference line through the midpupils.
The brow is a less discrete measuring point in the face. There
are many different brow types among race, sex, and age. Even the
color of the brow hairs can make accurate assessment more difficult.
The hairs in the upper half of the lateral two thirds of the brow grow
in an inferolateral direction. In the lower half of the lateral two thirds
of the brow the hairs grow in a superolateral direction. This growth
pattern cause thickening of the brow in the central part as the hairs
are forming layers. Hairs in the medial third grow predominantly in
a vertical direction, from caudal to cranial, and because of the over-
lapping of hairs, it is difficult to find the follicles determining the
cranial border of the brow. Interpretation of the medial brow height
therefore seems to be the most difficult. This was confirmed by the
present study in which the results of the medial brow measurements
had the highest intrarater and interrater variability.
We agree with others
10,16
that the lower brow border is not
suitable as a reference point because women tend to pluck their brow
hairs on this side to accomplish a more appealing shape. Nahm et al
12
use the center of the brow as a reference point. Plucking of the brow
would influence the position of this point with 50% less compared
with the lower border of the brow, but it remains unreliable as a ref-
erence point. This leaves the cranial border as the most stable and
reliable part of the brow.
Brow hairs may be lost in the period between 2 measuring
points because of the telogen phase. This is unlikely to affect the
measurement outcome because of the existing balance between the
amount of hairs in the anagen and telogen phase, thus maintaining a
constant brow density.
Tilting of the head will increase or decrease the distance be-
tween the reference line and the brow.
10
This seems not to be an issue
when using our protocol. Our goal was to develop a method for
measuring preoperative and postoperative brow position in patients
treated for facial nerve palsy. Preoperatively, the lateral canthus on
the affected side in these patients can be hidden behind upper eyelid
skin because of severe ptosis of the brow. To minimize interrater
variability, we choose to use the medial-sclera-to-brow (MS) distance,
the midpupil-to-brow (P) distance, and the lateral-sclera-to-brow (LS)
distance. The white of the sclera is most of the times well distin-
guishable from the color of the skin.
A limitation of this study was that we did not measure ab-
solute distances. The measurements in the images were expressed in
pixels. To express the distances in cm, we then scaled them using
a standardized IPD of 6 cm. Nevertheless, absolute distances may
not always be needed. For example, the left-right ratio that we cal-
culated is independent of absolute distances. In future studies,
to establish changes in individual patients over time, a reference
measure not influenced by intervention, such as the IPD, can be
used as a reference or calibration to allow comparing images.
Based on the current study, we can state that the en face pho-
tographs in our database are truly standardized and reproducible. This
is, to our knowledge, the first description of a standardized photo
protocol for brow height assessment that is validated using statistical
analyses. The method introduced for measuring brow position had
a good to excellent interrater and intrarater reliability, making it a
valid tool in research projects. Based on the description of the method
in this article, most of the readers should be able to obtain similar
results. The photo-editing software that was used is readily available
and relatively cheap compared with the medical imaging software
that was developed for the aesthetic facial surgery practice. Others
already emphasized the importance of standardization in digital
photography.
25Y28
We strongly recommend to anyone who wants to
perform measurements on digital photographs to not only standardize
but also validate the photograph protocol. Neglecting this step will
make all the effort and time spent in measuring to no avail.
ACKNOWLEDGMENTS
The authors kindly thank Sarah Versnel, MD, PhD, for analyzing
the photos of the second photographer.
REFERENCES
1. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg.
2009;124:2118Y2126.
2. Arneja JS, Larson DL, Gosain AK. Aesthetic and reconstructive brow lift:
current techniques, indications, and applications. Ophthal Plast Reconstr Surg.
2005;21:405Y411.
3. Booth AJ, Murray A, Tyers AG. The direct brow lift: efficacy, complications,
and patient satisfaction. Br J Ophthalmol. 2004;88:688Y691.
4. Ueda K, Harii K, Yamada A. Long-term follow-up study of browlift for
treatment of facial paralysis. Ann Plast Surg. 1994;32:166Y170.
5. Ortiz-Monasterio F, Barrera G, Olmedo A. The coronal incision in rhyti-
dectomyVthe brow lift. Clin Plast Surg. 1978;5:167Y179.
6. Friedland JA, Jacobsen WM, TerKonda S. Safety and efficacy of combined
upper blepharoplasties and open coronal browlift: a consecutive series of 600
patients. Aesthetic Plast Surg. 1996;20:453Y462.
7. Fogli AL. Temporal lift by galeapexy: a review of 270 cases. Aesthetic Plast
Surg. 2003;27:159Y165; discussion 166.
8. Core GB, Vasconez LO, Graham HD 3rd. Endoscopic browlift. Clin Plast Surg.
1995;22:619Y631.
9. Citarella ER, Sterodimas A, Green AC, et al. Use of triple-convergence poly-
propylene thread for the aesthetic correction of partial facial paralysis. Aes-
thetic Plast Surg. 2008;32:688Y691.
10. Troilius C. A comparison between subgaleal and subperiosteal brow lifts. Plast
Reconstr Surg. 1999;104:1079Y1090; discussion 1091Y1072.
11. Takushima A, Harii K, Sugawara Y, et al. Anthropometric measurements of the
endoscopic eyebrow lift in the treatment of facial paralysis. Plast Reconstr
Surg. 2003;111:2157Y2165.
12. Nahm WK, Su TT, Rotunda AM, et al. Objective changes in brow position,
superior palpebral crease, peak angle of the eyebrow, and jowl surface area
after volumetric radiofrequency treatments to half of the face. Dermatol Surg.
2004;30:922Y928.
Verduijn et al Annals of Plastic Surgery & Volume 73, Number 1, July 2014
84 www.annalsplasticsurgery.com * 2014 Lippincott Williams & Wilkins
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
13. Goldstein SM, Katowitz JA. The male eyebrow: a topographic anatomic
analysis. Ophthal Plast Reconstr Surg. 2005;21:285Y291.
14. Sidle DM, Loos BM, Ramirez AL, et al. Use of BioGlue surgical adhesive
for brow fixation in endoscopic browplasty. Arch Facial Plast Surg. 2005;
7:393Y397.
15. Price KM, Gupta PK, Woodward JA, et al. Eyebrow and eyelid dimensions: an
anthropometric analysis of African Americans and Caucasians. Plast Reconstr
Surg. 2009;124:615Y623.
16. Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow position and shape
with aging. Plast Reconstr Surg. 2009;124:1296Y1301.
17. Kim BP, Goode RL, Newman JP. Brow elevation ratio: a new method of brow
analysis. Arch Facial Plast Surg. 2009;11:34Y39.
18. Sclafani AP, Jung M. Desired position, shape, and dynamic range of the normal
adult eyebrow. Arch Facial Plast Surg. 2010;12:123Y127.
19. Pointer JS. The far interpupillary distance. A gender-specific variation with
advancing age. Ophthalmic Physiol Opt. 1999;19:317Y326.
20. Bland JM, Altman DG. Statistical methods for assessing agreement between
two methods of clinical measurement. Lancet. 1986;1:307Y310.
21. Rousson V, Gasser T, Seifert B. Assessing intrarater, interrater and test-retest
reliability of continuous measurements. Stat Med. 2002;21:3431Y3446.
22. Roebroeck ME, Harlaar J, Lankhorst GJ. The application of generalizability
theory to reliability assessment: an illustration using isometric force mea-
surements. Phys Ther. 1993;73:386Y395; discussion 396Y401.
23. de Kraker M, Selles RW, Molenaar TM, et al. Palmar abduction measurements:
reliability and introduction of normative data in healthy children. J Hand Surg
[Am]. 2009;34:1704Y1708.
24. Coombes AG, Sethi CS, Kirkpatrick WN, et al. A standardized digital pho-
tography systemwith computerized eyelid measurement analysis. Plast Reconstr
Surg. 2007;120:647Y656.
25. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photog-
raphy: its not all in the eye of the beholder. Plast Reconstr Surg. 2001;108:
1334Y1344.
26. Parker WL, Czerwinski M, Sinno H, et al. Objective interpretation of surgical
outcomes: is there a need for standardizing digital images in the plastic surgery
literature? Plast Reconstr Surg. 2007;120:1419Y1423.
27. Riml S, Piontke A, Larcher L, et al. Quantification of faults resulting from
disregard of standardised facial photography. J Plast Reconstr Aesthet Surg.
2011;64:898Y901.
28. Sommer DD, Mendelsohn M. Pitfalls of nonstandardized photography in facial
plastic surgery patients. Plast Reconstr Surg. 2004;114:10Y14.
Annals of Plastic Surgery & Volume 73, Number 1, July 2014 Method for Measuring Brow Position
* 2014 Lippincott Williams & Wilkins www.annalsplasticsurgery.com 85
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.