General considerations on cosmetic surgery and medicine

Professor Meningaud - Maxillofacial Surgery at Paris Est Créteil

In the course of my teaching in medicine and cosmetic surgery, I am asked many questions about appearance. They are always pertinent. Here are a few that come to mind.

What is the relationship between rejuvenation and beautification?

In aesthetic surgery, a distinction is made between figure surgery, face surgery, beautification surgery and rejuvenation surgery. This distinction serves to highlight the aim, but in practice these four categories overlap.

Body contouring surgery largely comprises ‘reduction’ surgery, such as the treatment of the after-effects of weight loss, the treatment of saddlebags, breast ptosis and hypertrophy, and the after-effects of pregnancy. Excess tissue must be removed and the remaining tissue reshaped to recreate the desired shape. Most patients are overweight or have been overweight.

As a general rule, the subjects concerned tend to be bon vivants. The aim is to beautify the body either directly or through clothing, but in practice a slim figure always looks younger. There may also be requests for ‘augmentation’, such as breast implants or, more rarely, buttock or calf implants. Facial surgery poses very different problems, because it concerns the identity that the person wishes to display. Obviously, human beings recognise each other by their faces. A person seeking facial cosmetic surgery is pursuing a desire to display increased attractiveness or a younger age. Attractiveness can be enhanced by improving the proportions of the face.

In practice, the key to attractiveness lies in the middle third of the face. The most classic facial cosmetic surgery procedures are rhinoplasty, eyelid surgery (blepharoplasty) and facelifts. But there are also more sophisticated procedures involving cheekbones, the chin, the shape of the eyes, the shape of the jaws and, in particular, the angles.

Do beauty criteria change over time?

It seems clear that certain criteria evolve over time and across cultures, such as plumpness, tanning and the absence of teeth in classical painting. The Flemish painter Rubens (1577-1640), in his work The Three Graces, which takes up a mythological theme in which the daughters of Jupiter symbolise different aspects of beauty, presents women who are rather slim, whereas today’s fashions glorify slimness.

Are there any criteria that don't change?

There are general criteria of beauty that don’t seem to have changed since ancient times. Aristotle (385-323 BC) already referred to symmetry, precision and harmony of proportions (in various passages of the Metaphysics, but also of the Poetics). Numerous studies in experimental psychology have confirmed the relevance of these criteria1. For example, if a sample of 100 people chosen at random were shown two photos, one with a roughly symmetrical face and the other with the same face ostensibly asymmetrical, the vast majority would consider the symmetrical face to be more beautiful.

How can beauty be quantified?

There have been temptations in the past, historically with the golden ratio(2) and more recently with so-called cephalometric studies(3). In fact, when these criteria are applied systematically, they lead to aberrations (see below). Aristotle, in his great wisdom, did not consider the question of proportions in rigid terms, but simply as the fact that beauty could not be found at extremes.

What is the golden ratio?

Towards the end of the 15th century, Lucas Pacioli, an Italian mathematician and monk, put forward the idea of an ideal proportion based on a very specific number that would later be known as the golden section. In fact, this number had been known since Antiquity, but only for some of its mathematical properties (described by Euclid). It has been argued that artists such as Leonardo da Vinci based their canons of beauty on the golden section. However, contrary to what has been written here and there, the famous Vitruvian Man is inspired by the proportions described by Vitruvius himself, the Roman architect who lived in the 1st century BC, but does not use the golden ratio.

Vitruvius described the ideal proportions of a temple, which should be close to human proportions(4). Vinci went in the opposite direction to draw a man. The confusion over the golden ratio stems from the fact that Vinci and Pacioli were friends and that Vinci had illustrated a book by Pacioli entitled De la divine proportion. In fact, for his works, Vinci relied much more on his own anatomical observations than on a mathematical system.

Can statistics be used to define ideal proportions?

What is beautiful lies within a more or less wide zone around average measurements. It is in the study of the face that this biometric method, cephalometry, has found its greatest field of application. It requires the use of a special X-ray called teleradiography. Precise anatomical points are identified and angles measured. Although underpinned by a high degree of scientific rigour, cephalometric analysis suffers from a number of limitations. The most important relates to calibration. Each type of analysis calculates its averages on a reference population which, over time, may become questionable. For example, Tweed’s analysis is based on a population of young Americans from the 1950s, most of whom were white. Can the results be extrapolated to a study of the face of an African patient in her fifties today(5)?

Can beauty be perfect?

However, experience shows us that academic criteria are not enough to define beauty. For example, a strictly symmetrical face does not appear beautiful to us. Digital photography makes it possible to recompose completely left- or right-handed faces by inverting and reattaching half the image. Experimental psychology studies have significantly established that the human eye prefers faces with a left side and a right side, i.e. slightly asymmetrical(6). Comparison is not a reason, but the towers of Notre Dame cathedral in Paris are not symmetrical, and despite its recent fire, this cathedral is considered to be one of the most beautiful in the world. Perfect symmetry is unconsciously perceived as artificial, strange, unhuman and ultimately not beautiful.

What is the best criterion of beauty?

 Charles Auguste Baud, a Swiss surgeon, in his book Harmonie du visage published in 1967, described function as an intrinsic criterion of beauty. A beautiful face implies correct meshing of the teeth, good breathing, properly functioning eyelids, non-paralysed muscles in the smile, etc. It is certain that a group of people who are so undershot as to have no contact between their incisors will appear statistically less beautiful than a group with functional contact between the dental arches.

The absence of contact between the arches significantly reduces stimulation to the bone that supports the dental roots, leading to loosening over the long term. Similarly, it’s easy to imagine that a respiratory problem linked to a deviated nasal septum could result in a deformed nose. In fact, the most common aesthetic consequence of this type of respiratory disorder is the early appearance of bags under the eyes. These patients most often consult us for blepharoplasty (eyelid surgery). The clinical examination must rule out a respiratory problem.

 

Retromandibulia (backward mandible) can lead to snoring or, worse still, obstructive sleep apnoea syndrome. This syndrome results in a significantly higher rate of myocardial infarction and daytime sleepiness, which can be the cause of certain road accidents. However, from an aesthetic point of view, the most obvious feature is an open cervico-facial angle, with an impression of sagging at an earlier age. Many of these patients do not consult us for this functional reason, of which they are not even aware, but for a neck lift! The examples could be multiplied ad infinitum, but to sum up, function and aesthetics are much more closely linked than we think. Function not only creates the organ, it also promotes the aesthetic impression. The functional criterion is by definition an advantage in an evolutionary approach. Functional criteria are perceived as advantages, and are therefore favoured in terms of reproduction, whatever the species, and are therefore assimilated to aesthetic criteria. Whatever the case, in my surgical practice, function is my preferred criterion.

On the left, a patient with significant retromandibulia and the appearance of an open cervico-facial angle, who is therefore older and, above all, predisposed to sleep apnoea syndrome, and therefore at greater risk of cardiovascular disease. On the right, the same patient after surgery with a more closed cervico-facial angle, younger and with a reduced medical risk (case of Prof. Jean-Paul Meningaud).

Example of a patient with palpebral bags at an early age, under 30, which is not normal and indicates a respiratory problem (case study by Prof. Jean-Paul Meningaud).

What is the charm?

In this chapter we have considered criteria of varying degrees of precision, all static apart from a few functional criteria, but never from the point of view of emotion. A smiling, loving face is worth many face-lifts. On the other hand, an angry face will never appear beautiful. A tense or sad face may appear beautiful, but will quickly become boring. When we look at ourselves in the mirror, we do so on a still face. But in social life, we never analyse others in strict profile and motionless, but rather from three quarters and in an emotional situation. A surgeon can never operate on your emotions.

References

1. Grammer K et al. Human (Homo sapiens) facial attractiveness and sexual selection: the role of symmetry and averageness. J Comp Psychol. 1994;108(3):233-242.

2. Prokopakis EP, Vlastos IM, Picavet VA, et al. The golden ratio in facial symmetry. Rhinology. 2013;51(1):18-21.

3. Ghorbanyjavadpour F, Rakhshan V. Factors associated with the beauty of soft-tissue profile. Am J Orthod Dentofacial Orthop. 2019;155(6):832-843. 

4. Vitruve, De architectura, livre 3, chap. 1.

5. Ouédraogo Y et al. Cephalometric norms of a Burkina Faso population. Int Orthod. 2019;17(1):136-142. 

6. David I. Perrett et al. Symmetry and Human Facial Attractiveness. Evolution and Human Behavior 20:295-307 (1999).