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Facial Attractiveness in Eastern Paris
Aesthetic Surgery Pr Meningaud
What is an attractive face?
Thanks to work in experimental psychology and advances in the feminization of transsexual faces, we now have a better understanding of what makes a female face attractive in our society. Femininity and attractiveness often go hand in hand.
Facial feminization is increasingly practised in maxillofacial and facial plastic surgery. It concerns gender reassignment, of course, but also a number of syndromes such as acromegaly, the iatrogenic effects of certain hormone treatments, women who find themselves too masculine in the absence of any pathology, and above all the effects of age, which tend to masculinize the face.
Surgical or medical techniques are used. It is often necessary to combine these techniques[1].
Facial attractiveness at Paris Est
Professor Meningaud at Henri-Mondor
A man’s face is shaped like a rectangle, while a young woman’s face is shaped like an upside-down egg, round at the top and oval at the bottom. With age, a woman’s face deepens at the temples and sags at the lower cheeks. It becomes more rectangular.
Diagnosis
Etiological diagnosis is obviously fundamental. We won’t go into detail here, but it can be very complex, particularly in the case of gender dysphoria (transsexualism). In this case, it’s a matter for ultra-specialists, and can only be made by an experienced multidisciplinary team after confirmation of the normality of all the biological tests and long-term psychiatric follow-up.
Apart from this very special case, a systematic clinical examination should be carried out and, depending on the findings, additional tests should be prescribed. It cannot be stressed enough that aesthetic medicine and plastic surgery are first and foremost medical procedures.
Assessing attractiveness
Assessing attractiveness/femininity begins with a morphological diagnosis.
The silhouette of a young woman’s face resembles the outline of an egg laid upside down on a table. It’s round and convex on top, and oval on the bottom. A man’s face, on the other hand, is rectangular (see drawing below). It’s no coincidence that many young men trim their beards to give their jaws angular, more virile contours, especially if they have a receding chin. As a result of certain syndromes or simply ageing, women’s facial contours tend to become “rectangularized”. Temples deepen. The lower cheeks transform the oval into an arc and then into a rectangle.
Mandibular angles tend to protrude due to hypertrophy of the masseter muscles and/or the lower lobe of the parotid glands and the lower jawbone. As a result of the perspective effect, the cheekbones appear less prominent. In profile, the angle defined by the neck and face is more pronounced in women than in men.
Certain syndromes, or simply age, tend to open up this angle, thus masculinizing the face. Finally, wrinkles are generally better accepted in men than in women, although we don’t really know why. Their deepening also helps to masculinize the face. Morphological diagnosis should be detailed on a diagram, layer by layer, frontal, medial and inferior.
Ideally, front and profile photos of the patient should be projected onto a screen, and commented on in the form of an open, constructive dialogue. Finally, it may be useful to perform a morphing (computer simulation) for information and educational purposes, to ensure that the patient’s requests, issues and objectives have been clearly understood.
These images are not contractual, and fortunately the result is almost always more convincing than the simulation. For complete feminization, several consultations are required to assimilate the information. When facial feminization procedures are combined with a facelift, the attractiveness of the face is significantly enhanced.
Professor Jean-Paul Meningaud
Maxillofacial Surgeon Paris Est Créteil
Facelift techniques
On the upper face, the treatment targets are forehead wrinkles, the temples, the frontal sinus region and the superciliary arches. For forehead wrinkles, botulinum toxin should be used sparingly, as it can cause eyebrows to droop and ultimately masculinize the look. With a few exceptions, blanching (a difficult but highly effective technique) and/or lipofilling should be used.
In my department at Henri Mondor Hospital, we use techniques enriched with growth factors. In addition, laser techniques give good results.
Our team has scientifically tested a successful Erbium-Yag treatment[1]. If they are hollowed, the temples can be treated with volumizing hyaluronic acids or lipofilling. Techniques used in reconstructive surgery, such as cement injections under endoscopic control, are not suitable.
With age, the volume of the frontal sinuses increases, while that of the maxillary sinuses decreases. This leads to protrusion of the glabellar region and the superciliary arches. Treatment is necessarily surgical. In most cases, endoscopically controlled grinding through a punctiform approach is sufficient. In complex cases, a surgical approach is required, with retraction of the anterior wall of the frontal sinus.
The position of the eyebrows can be modified at the same time as a temporal lift, or by more sophisticated techniques. My team and I have long used Dr. Daniel Marchac’s endoscopic facelift technique, which uses surgical glue[2], but we now use Dr. Fausto Viterbo’s aforementioned technique, which involves direct eyebrow placement via subcutaneous detachment.
Facelift: Which areas to target
The main targets of the middle stage are the nose and the zygomatic arches (lateral part of the cheekbone). Everyone agrees that some noses are more feminine than others. Experimental psychology studies have shown that a nose that is very slightly sunken (concave) and thin will appear more feminine[3]. With injectables, it is possible to give the impression of a finer tip and erase a slight hump. If not, surgery is required, bearing in mind that feminization involves subtle gestures. As they age, many patients who had a straight nose at 20 are left with a hump and a loss of definition at the tip, which tends to masculinize the nose. This is why feminising rhinoplasty is a procedure that should be discussed during a facelift consultation.
If we take up the egg analogy cited above, the arches must appear more prominent than the temples or the oval of the face. This appearance can easily be treated with volumizing hyaluronic acids or lipofilling. In men, however, injection of the arch is feminising and should be avoided. In men, only the anterior region, known as the valley of tears, should be injected. To minimise risks, I strongly recommend the use of cannulas, backtracking injections, the absolute avoidance of boluses (large clumps, sources of biofilm and infection) and the routine use of transillumination, which makes it easy to locate veins and limit bruising.
Orthognathic surgery
In exceptional cases, orthognathic surgery (surgery to advance or retract the jaws) may be performed. Transfacial profiles (maxilla forward) are considered more feminising.
The targets for the lower face are the length of the upper lip, the mandibular angles, the chin and the cervico-facial angle. Feminization of the lips is easily achieved with a combined upper lip lift (a simple technique updated by Dr. Cornette de Saint Cyr[4], performed under local anaesthetic). In addition to the effect on lip length and the uncovering of the upper incisors at the smile, this technique enables the vermilion, cupid’s bow and philtrum to be redesigned. In most cases, it is combined with bleaching (or laser or peeling) techniques for the “bar code” and vermilion injections for volume.
Treatment of mandibular angles is spectacular, but unfortunately difficult and often surgical. It involves an endobuccal ostectomy. The bone is filed with a rotary motor fitted with a burr, or its modern equivalent, the Piezotome®.) A mistake often made is to cut the angles, but a woman’s mandibular angles contribute to her attractiveness. They should be feminised, but not amputated. In the Middle East, there is a growing demand for so-called “Texas” surgery, which tends to make the mandibular rim, including the angle, more visible. However, this modelling is often inadequate, and the result is achieved by relaxing the masseter muscles. Treatment with botulinum toxin is possible, but highly technical and demanding.
In exceptional cases, partial surgery of the lower lobe of the parotid gland may be indicated. There is also a plication technique that makes this procedure simpler.
Treatment of lower jowls
The treatment of the lower cheeks is fundamental to the treatment of the oval of the face. Filling in on either side tends to make the face heavier, and no longer corresponds to today’s philosophy, which aims to fill in the upper regions and refine the lower ones. What remains is the centrofacial lift (in my department, we perform a solid transosseous docking) and/or the deep lift. The male chin has two paramedian protuberances, while the female chin has only one central one. The best technique is transverse genioplasty, which aims to reduce the width of the chin and restore or accentuate the oval. Remodelling of the chin tuft, which completely disrupts the complex kinetics of the chin muscles, should always be avoided. Ultimately, a face is best appreciated dynamically, not in a photograph. Depending on the case, this gesture may be isolated or accompanied by an advancement to clarify the cervico-facial angle, a vertical reduction to accentuate feminization, or a retraction, but the soft tissues must be reorganised to avoid the classic “witch’s chin”.
Although my technique differs from his, it is to Dr Claude Le Louarn that I owe the greatest contribution to my understanding of the physiology of facial ageing, with his theory of Face Recurve®[5]. For me, in difficult cases, for a lasting result, the solution is to transect the muscle. Fortunately, these cases are not that frequent.
Professor Meningaud
As always in medicine, the key to success lies in good diagnosis, good information, good follow-up and perfect mastery of the sequence of programmed procedures. The etiological diagnosis must be unambiguous, and the morphological analysis as precise as possible.
Patient compliance is crucial. This requires repeated consultations to allow the decision to mature and the information to be assimilated. This essential time unquestionably contributes to patient satisfaction and the pleasure we derive from our work. Modern teaching tools are important: high-quality photographic documents, morphing, information sheets, commented diagrams, 3D resin models, examples of similar cases, etc.
Finally, in my opinion, techniques should be taught in university hospitals, to guarantee independence. Treatment plans should combine medical techniques as a minimum, and often both medical and surgical techniques.
Publications
[1] Hersant B, SidAhmed-Mezi M, Chossat A, Meningaud JP. Multifractional microablative laser combined with spacially modulated ablative (SMA) technology for facial skin rejuvenation. Lasers Surg Med. 2017;49(1):78-83.
[2] Marchac D et al. Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases. Plast Reconstr Surg. 1997;100(3):704-714.
[3] Berli JU et al. Gender-confirming Rhinoplasty. Facial Plast Surg Clin North Am. 2019;27(2):251-260.
[4] Cornette de Saint Cyr B, Prevot H. Lifting de la lèvre supérieure [Upper lip lift]. Ann Chir Plast Esthet. 2017;62(5):482-487.
[5] Le Louarn C et al. Structural aging: the facial recurve concept. Aesthetic Plast Surg. 2007;31(3):213-218.
[1] La Padula S, Hersant B, Chatel H, Paola Aguilar , Romain Bosc , Giovanni Roccaro, Robin Ruiz, Jean Paul Meningaud. One-step facial feminization surgery: The importance of a custom-made preoperative planning and patient satisfaction assessment. J Plast Reconstr Aesthet Surg. 2019;72(10):1694-1699.
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