https://orcid.org/0009-0008-5118-6964
Figures
Abstract
The aim of this study was to create a facial soft tissue thicknesses database of Azerbaijan adult population and find relation between FSTT and sex, age, body mass index (BMI). The study investigates the FSTT on 300 CT scans of living inviduals of three age groups: I, 18–25 years old; II, 26–45 years old; and III, 46 years and older. The CT images of the patients were divided into two groups according to BMI. The soft tissue thicknesses were measured at 20 landmarks, 10 along the midline and 10 bilateral. The mean, standard deviations, range, median for each anthropometric landmark were determined, and differences related to age, sex, BMI were calculated. This article presents the first database of facial soft tissues thicknesses of Transcaucasia populations.
Citation: Sultanova N, Bayramov R, Maharammova N (2026) Facial soft tissue thicknesses of Azerbaijan adult population: CT study. PLoS One 21(6): e0348124. https://doi.org/10.1371/journal.pone.0348124
Editor: Giulia Pascoletti, University of Perugia: Universita degli Studi di Perugia, ITALY
Received: April 25, 2025; Accepted: April 10, 2026; Published: June 5, 2026
Copyright: © 2026 Sultanova et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Facial soft tissue thickness (FSTT) data are an important component of the facial approximation process and play a pivotal role in the planning of reconstructive and aesthetic surgeries of the craniofacial complex [1–3].
Over the past 140 years, more than 100 FSTT studies have been conducted on adults [4–6], following the same basic principles as established in 1883 by Welcker [7,8]. During the last years, a considerable volume of new data has been added [8], which is explained by the need to study the parameters of the modern population [9,10]. Studies conducted in scientific centers have confirmed that age, sex, ethnicity and body mass index (BMI) are key factors determining FSTT [11–18].
According to the data of Scopus, PubMed, and Google Scholar, study of the FSTT of different populations is described in the scientific literature. The populations showed notable differences in facial tissue thickness, raising the question of whether soft tissue thickness data from one population can be used for facial reconstruction in people of different origins [19–22, 23, 24].
A FSTT database was created for Australian [19], Caucasian [25–27], English [28], Bulgarian [29], Italian [30], German [31], Portuguese [32], Russian [33], Slovak [34, 35, 36], Czech [37], French [38], Egyptian [20], Turk [39–40], Iranian [41], Pakistani [42], Saudi [43], Brazilian [44–46], Colombian [15], Sri Lankan [47], Indian [23,48,49], Chinese [50], Korean [51], Japanese [24,52], Sudanese [53], Zulus [54], South African [55] and Black American [4] populations.
A literature search of the FSTT database of various populations showed no studies investigating the parameters of the Azerbaijan population.
This study aimed to create a facial soft tissue thicknesses database of Azerbaijan adult population and find relation between FSTT and sex, age, body mass index.
Materials and methods
The study was approved by the Ethics Committee of Azerbaijan Medical University in accordance with the Code of Ethics of the World Medical Association and the Declaration of Helsinki. None of the patients was exposed to ionizing radiation for the purpose of this research.
The study of the facial soft tissues thickness of the Azerbaijan population was conducted using computed tomography (CT) images of the head of 300 patients (157 males and 143 females) aged 18–73 years who underwent diagnostic examination at the Department of Radiology of the Azerbaijan Medical University. The exclusion criteria were adentia, injuries, deformities of the craniofacial complex, history of reconstructive and aesthetic surgeries on the face and injection of fillers. The 200 CT-scans of the sample cover the entire face, the 100 CT-scans only the superior and middle part of the patient’s face. Scientific research was conducted between 2021 and 2023. The sample is representative of Azerbaijan population.
Males and females were classified according to their ages and BMI. The 300 subjects were divided into three age groups: I, 18–25 years old; II, 26–45 years old; and III, 46 years and older. During the examination, the 200 patients’ height and weight were measured, and their BMI was calculated (weight to height ratio [kg/m2]). The CT images of the patients were divided into two groups according to the following scale: BMI < 25 (underweight: BMI < 18.5; normal weight: BMI 18.6–24.9) and BMI > 25 (overweight: BMI 25.0–29.9; obesity: BMI ≥ 30.0).
Measurements
The distance between the bone and soft tissue was measured using 20 classical anthropometric landmarks, 10 along the midline and 10 bilaterally, by Rhine and Campbell [4]. The craniometric landmarks, their synonyms and the description of the measurement direction are presented in Table 1.
Midline anthropometric landmarks: 1. supraglabella (sg); 2. glabella (g); 3. nasion (n); 4. rhinion (rhi); 5. mid-philtrum (mp); 6. supradentale (sd); 7. infradentale (id); 8. mentolabial sulcus (mls); 9. pogonion (pg); 10. gnathion (gn).
Bilateral anthropometric landmarks: 1. frontal eminence (fe); 2. supraorbital (so); 3. infraorbital (io); 4. inferior malar (im); 5. zygion (zy); 6. condylion (cdl); 7. gonion (go); 8. supraM2 (sM2); 9. occlusal line (ocl); 10. infraM2 (iM2).
Head scan was performed using a Toshiba Aquilion CXL 128 CT scanner. The imaging protocol of 200 patients had a field of view of 24 cm x 19 cm, which enabled visualisation of all the included anatomical structures and landmarks from the supraglabella to the gnathion along the vertical axis and bilaterally to the condylion. At the same time, the imaging protocol of the other 100 patients allowed the inclusion of all landmarks except: infradentale, mentolabial sulcus, pogonion, gnation, frontal eminence, gonion, infraM2. Axial, sagittal and coronal CT views were collected for all subjects. The obtained images were converted into Digital Imaging and Communication in Medicine files and transferred to a personal portable computer (MDview 232; NEC, Germany). The image’s slice was 0.5 mm thickness. The skull images were positioned with the Frankfurt Horizontal Plane, and measurements were performed on the monitor by a cursor with an accuracy of 0.01 mm.
The following head CT slices were selected to measure the soft tissue thickness at 20 landmarks:
Slice 1 – On the midsagittal slice (Fig.1), FSTT was determined in the area of the following landmarks: supraglabella (sg); glabella (g); nasion (n); rhinion (rhi); mid-philtrum (mp); supradentale (sd); infradentale (id); mentolabial sulcus (mls); pogonion (pg); gnathion (gn).
Slices 2 – On the coronal slice (Fig. 2), FSTT was determined in the area of gonion (go).
Slices 3 – At different levels, 10 axial slices (Fig. 2), FSTT was determined in the area of: frontal eminence (fe); supraorbital (so); infraorbital (io); inferior malar (im); zygion (zy); condylion (cdl); supraM2 (sM2); occlusal line (ocl); infraM2 (iM2).
Statistical analysis
The data were analyzed using the SPSS software version 26.0. (SPSS Inc., Chicago, IL). The intra-observer reliability agreement was achieved by repeat measurements the 30 landmarks of 30 randomly selected subjects with testing the intraclass correlation coefficient (ICC) for each point. The measurements were repeated in an interval of one week by the second author.
Since when testing the normality of the distribution of variation series using the Shapiro-Wilks test, in some series the 0-hypothesis was rejected, therefore nonparametric tests were used. Mann-Whitney U-test was applied to investigate the differences of soft tissue thickness between the sexes and BMI. Descriptive statistics of FSTT, classified by age and sex, age and BMI, sex and BMI was performed also by non-parametric Mann -Whithey U-test. The differences of FSTT between the three age groups were tested by using the Kruskal-Wallis H-test. Basic descriptive statistics, such as mean, standard deviation, range (between minimum and maximum), median and interquartile range (IQ) were calculated for each anthropometric landmark, taking into account BMI, sex and age. For all statistical analysis, differences were considered significant at P < 0.05.
Results
The study included 300 participants, of whom 52.3% were males (N = 157) and 47.7% were females (N = 143). Their average age was 59 years with a standard deviation of 16.76. The youngest was 18 years old (females), and the oldest was 73 years old (males). The reliability and reproducibility of the method was determined using intra-class correlation coefficient (ICC). ICC showed significant consistency between the main and repeated records (Table 2). All raw data of FSTT required to replicate the results of this study are presented in S1Table.
Descriptive statistics of FSTT, classified by sex, are presented in Table 3. When the FSTT of males and females in the Azerbaijan population were compared, sexual dysmorphism was statistically confirmed (P < 0.05). The average values of FSTT in males exceeded those in females for all landmarks, with the exception of infraorbitale (r, l). Statistically significant differences were observed in 16 of the 20 landmarks, except for sg, g, sor (r), and zy (r,l). Differences of more than 2 mm between the average values of both sexes were observed in the mid-philtrum (+3.15 mm), supradentale (+2.65 mm) and gnathion (+2.21 mm).
Descriptive statistics of FSTT, classified by age, are presented in Table 4. A comparison between the three age groups showed a statistically significant difference in FSTT in 14 of the 20 landmarks. Thickening of the facial soft tissues with age was observed in all the studied landmarks, except of the mid-philtrum and supradentale. In the area of these anthropometric landmarks, a gradual thinning of FSTT was observed. When age groups 1 and 2 were compared, an increase in soft tissue thickness of more than 2 mm was observed in the area of the zygion,l (+ 2.13 мм), gonion,r (+2.12мм), gonion,l (+2.52 мм). When age groups 1 and 3 were compared, an increase in soft tissue thickness by more than 2 mm was noted in the area of mid-philtrum (+ 2.27мм), zygion,r (+ 2.71мм), zygion,l (+ 2.99мм), condilion,r (+2.28 мм), condilion,l (+2.39 мм), gonion,r (+3.63 мм), gonion,l (+3.71мм), supra M2,r (+2.56 мм), supraM2,l (+2.4 мм).
Descriptive statistics of FSTT, classified by age and sex, are presented in Tables 5–7. Reliable differences were found in the middle and lower region of the face in 8 out of 20 anthropometric landmarks (P < 0.05) between the FSTT of males and females aged 18–25 years (Table 5). The tissue thickness of males at these landmarks was greater than that of females. Despite the absence of statistically significant differences in the remaining measured landmarks, the average values in males were higher than those in females, except for the infraorbital (r, l).
Reliable differences were found in the upper, middle, and lower parts of the face in 19 out of 20 landmarks (P < 0.05) when comparing the FSTT values of males and females aged 26–45 years (Table 6). The values in males were considerably higher at these landmarks. Notably, tissue thickness in the infraorbital (r, l) landmarks was almost the same in both sexes.
Significant differences were observed in the middle and lower part of the face in the area of 8 of the 20 landmarks in males and females aged 46 years and above (P < 0.05) (Table 7). The FSTT at these landmarks in males of this age group was greater than those in females. Concurrently, the tissue thickness in the infraorbital, glabella, supraorbital, zygion and occlusal line landmarks were higher in females than in males.
Descriptive statistics of FSTT, classified by BMI, are presented in Tables 8. Since the division into several subgroups by BMI reduces the number of elements in the subgroups, the confidence intervals expand and thus the obtained statistical results become unreliable, based on this, it was decided to distribute the subjects into two categories with a BMI greater than and less than 25. Statistically significant differences in the FSTT between the two groups were observed in 17 of the 20 anthropometric landmarks, whereas no difference was observed in the area of some mid-line parameters (mid-philtrum, supradentale, infradentale). In individuals with overweight and obesity, FSTT greater than 3 mm was determined in the following areas: zygion,r (+ 3.57мм), zygion,l (+ 3.83мм), gonion,r (+ 5.05мм), gonion,l (+ 5.49мм), supraM2,r (+ 4.13мм), supraM2,l (+ 4.36мм), occlusial line,r (+ 3.37мм), occlusial line,l (+ 3.50мм), infra M2,l (+ 3.03мм).
Descriptive statistics of FSTT, classified by sex and BMI, are presented in Tables 9,10. In males with BMI less and more than 25, the thickness of the tissues differed significantly at all landmarks (P < 0.05), except for mp, sd, and id. The thickness of the tissues in these facial landmarks increased as the BMI values increased. The same pattern was observed in females at all reference landmarks except for mp, sd, id and iM2 (r,l) (P < 0.05).
Descriptive statistics of FSTT, classified by age and BMI, are presented in Tables 11–13. When the FSTT data of the first age group were analysed, statistically significant differences were observed between the categories of underweight, normal (BMI less than 25), and overweight, obesity (BMI more than 25) for all landmarks. In individuals with a BMI greater than 25, the facial soft tissues were thicker in all landmarks, except for sg, g, mf, id, cld (l), and iM2 (r,l), which was statistically confirmed. A difference of more than 4 mm in the thickness of the facial soft tissues was determined in the area of gnathion (+ 4.25 мм), zygion,l (+ 4.29 мм), condylion,r (+ 5.41 мм), condylion,l (+ 5.41 мм), gonion,r (+ 4.56 мм), gonion,l (+ 4.70 мм).
In the second age group, the FSTT in the area of 14 anthropometric landmarks was greater in individuals with overweight and obesity. At the same time, in the area of id landmark did not reveal statistically significant differences between the groups with BMI less and more than 25. A difference of more than 4 mm in FSTT was determined in the area of gonion,r (+ 5.10 мм), gonion,l (+ 5.82 мм), supraM2,r (+ 4.33 мм), supraM2,l (+ 4.39 мм), infra M2,l (+ 4.27 мм).
In the third age group, in individuals with overweight and obesity, the thickness of the facial soft tissues was greater in the area of 14 anthropometric landmarks, which was statistically confirmed. A difference of more than 4 mm in thickness of facial soft tissues was determined in the area of zygion,r (+ 4.01мм), zygion,l (+ 4.29 мм), gonion,r (+ 4.39 мм), gonion,l (+ 4.87 мм), supraM2,r (+ 4.16 мм), supraM2,l (+ 4.70 мм), occlusial line,l (+ 4.22 мм).
Discussion and conclusion
Studies on the thickness of facial soft tissues have been conducted since the end of the 19th century. Measurement of FSTT is performed by forensic scientists, maxillofacial and plastic surgeons, orthodontists, and anthropologists.
Numerous studies have confirmed the presence of FSTT variations among populations, indicating the importance of using specific values for each population [27,32,40,55–57]. Thieman, by comparing databases, came to the conclusion that population specificity influences on FSTT [31]. However, scientific papers have been published that contradict or do not confirm this hypothesis [31,38,58]. This could be explained by the fact that the data of the average FSTT values obtained using different measurement protocols were compared [59].
The development of non-invasive diagnostic methods, such as cephalometric radiography [21,28,30,42,43,45,48,49,53], ultra-sound examination [7,20,26,28,33,35,36,54], magnetic resonance imaging [23,28,39,41,49], and computed tomography [13–15,27,29,31,34,37,38,40,55,57,60], has made it possible to conduct studies on the thickness of facial soft tissues in vivo. However, invasive studies of FSTT ex vivo using the puncture method are still ongoing [3,19,24,25,32,44,54,55].
The method of collecting soft tissue thickness data from CT images is considered to be one of the most accurate; however, it has a high output radiation power, which is harmful to biological tissues. CT of the paranasal sinuses is often performed for diagnostic purposes, which contributes to the collection of head CT-scans. Concurrently, the CT data stored in the archives of radiological departments of clinics can be utilised to study and create a large FSTT database.
Thus, Connie L. Parks conducted a study of the thickness of the facial soft tissues of Americans on CT images of 388 patients aged from 18 to 62 years, taking into account their BMI. Furthermore, Panenkova carried out a study of FSTT on CT images of 160 adult patients of the Slovak population aged 18–60 years, without consideration of the BMI. In addition, Pierre Guyomarc’h conducted a study on the thickness of facial soft tissues in representatives of the French population also on CT images. The study included 500 people aged 18–96 years, taking into account their BMI. Moreover, Anna Drga´ cˇova´ performed a study of FSTT on 102 CT images of representatives of the Czech population aged 21–83 years, without consideration of the BMI. Thiemann N analysed data on the modern adult population of Germany, on the material of 320 people according to CT, taking into account sex, age and BMI. Based on the CT images of 320 individuals, Bulut O. conducted a study of the FSTT of the Turkish population, taking into account sex and age; patients only with normal weight were included in the study. A study of the FSTT of representatives of the Chinese population was performed by Ya Dong using CT images of 200 patients aged 18–32 years, taking into account sex and BMI. Furthermore, Cavanagh D. employed CT scanning to determine the average FSTT values in 154 South African black females. FSTT of the 100 representatives of the Korean population aged 20–36 years was studied on CT images, by H. Hwang. Furthermore, Moritsugui D.S., investigated the soft tissues thickness of 101 representatives of the Brazilian population of three age groups, from 18 and above, taking into account age and gender. The study of FSTT on CT scans of 75 the Bulgarian adults aged 20–74 years was carried out by Toneva D, representatives were divided into groups according to sex, age and BMI. Based on these studies, a data bank of FSTT was created for these populations [13,31,34,37,38,40,46,55,60].
A literature review revealed the absence of a database of FSTT in the Azerbaijan population. In this study, FSTT was investigated on CT scans of 300 individuals, taking into account sex, age and BMI, on the basis of which a database was created and a number of conclusions were made.
This study demonstrated a statistically significant difference in FSTT between the sexes, and sexual dysmorphism in the Azerbaijan population was confirmed. The greatest difference was observed in the upper lip and chin. The thickness of the facial soft tissues in males was greater than that in females. Similar results were obtained in numerous studies [3,13,19,31].
A study of the relationship between FSTT and age revealed thickening of the facial soft tissues with age at all the anthropometric landmarks. Gradual thickening of the FSTT was observed in the area of studied landmarks. The exception was the upper lip, the thickness of the soft tissues of which decreases with age.
Comparison of the thickness of facial soft tissues in males and females of different age groups showed that at the age of 18–25 years and 46 years and above, differences were observed only in the middle and lower part of the face, whereas at the age of 26–45 years, differences were found in the upper, middle, and lower part of the face. However, Guyomarc’h P. in his work revealed an insignificant difference between age groups [38].
During the analysis of the obtained information, a correlation was revealed between the thickness of the facial soft tissues and the BMI for all reference landmarks. The thickness of the tissues in the area of the facial anthropometric landmarks increased as the BMI increased, with the exception of the projection of the upper and lower lips [13,23,26,31,38].
Our study also showed that with age, the effect of BMI on the thickness of facial soft tissues persists, which was observed in all three age groups.
The creation of data banks that use facial tissue thickness data classified according to race, sex, age, BMI will provide forensic scientists, plastic and maxillofacial surgeons, and anthropologists with more accurate information.
This article presents the first database of the thickness of facial soft tissues of Transcaucasia populations. The data from this study can be used to update pooled means and create a new version of the Global T-Table.
Limits of the study and further recommendations
CT examination of the FSTT in our study were done with patients in the supine position. The gravity is the limitation of this method of measuring of FSTT. In differ from this scientific work, the future studies of azerbaijan population could benefit from examination of the relationship between age, sex, BMI and the measurement of FSTT with upright position of the head.
Measurements of FSTT in gonion landmark, taken in the coronal plane may occasionally result in a non-perpendicular orientation to the bone surface, due to the bone’s angular orientation.
Supporting information
S1 Table. All raw data required to replicate the results of this study.
https://doi.org/10.1371/journal.pone.0348124.s001
(XLSX)
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