Historical Perspectives

Since ancient Egyptian times, the ideals of aesthetic facial surgery have been portrayed in art. Modern facial analysis, however, began in Greece. Greek artists and philosophers analyzed the perceptions of beauty and established standards for ideal facial proportions and harmony. Strongly influenced by the Greeks, artists and anatomists of the Renaissance period continued the study of aesthetic proportions. Leonardo da Vinci’s work is well known for its portrayal of ideal facial proportions. His study of facial anatomy included the concept that facial balance exists when the face can be divided into equal thirds from the frontal hairline to the nasal root, the nasal root to the nasal base, and the nasal base to the bottom of the chin.

Modern Concepts

Whereas some concepts of facial beauty endure across time and culture, others vary. In our culture, television, magazines, internet, and motion pictures appear to have the greatest impact on our perception of beauty. Temporal differences in the aesthetic ideal can be appreciated by observing popular media from recent decades.

Various sociological studies suggest at least some cultural differences in aesthetic tastes. In a classic study by Martin, ¹ photographs of black female magazine models were ranked with respect to facial features considered to be most black and least Caucasian, to those felt to be least black and most Caucasian. These models were then ranked in terms of beauty by 50 college-age white American males, 50 college-age black African American males, and 50 college-age black Nigerian males. The beauty rankings of American whites and African American blacks both showed a positive correlation with models displaying more Caucasian, less black features. The beauty rankings of Nigerian blacks correlated with more black, less Caucasian features. Martin’s study suggests that there is, or was at that time, a single cultural standard of beauty in American society, despite its multiracial composition, different from that of an African society that is predominantly based on the black facial model. Other studies show high interrater reliabilities in crosscultural beauty, suggesting that some features are perceived as attractive regardless of the racial and cultural background of the viewer.

More recent research has sought to define facial beauty in terms that are more objective. It has sought to define preferences that appear to be biologically predetermined and crosscultural. Langlois et al ² showed that infants, whose inclinations presumably do not reflect culture-specific standards of beauty, prefer to look at adult faces that were perceived as more attractive. In a later study with adults, Langlois and Roggman ³ showed that a computergenerated face that was a composite of many faces was favored over any singular face of actual male and female subjects. This study suggests that “average” features (those that deviate least from the norm in terms of size, shape, location, and proportion) are the paragon of facial beauty.

Perrett et al ⁴ found that subjects preferred a computergenerated composite of attractive female faces to a composite of average female faces. Male subjects preferred a caricature in which the differences between the attractive composite and the average composite were increased by 50%. This preference was observed in British subjects judging British faces, Japanese subjects viewing Japanese faces, and British subjects viewing Japanese faces. British and Japanese women preferred an “attractive” male composite to an “average” male composite as well, but had no preference for a caricature over an attractive composite. Qualities found to be more attractive in female faces included large eyes, high cheekbones, narrow jaw, and smaller vertical third of the face.

Effects of Aging Face Surgery

Recent studies have focused on perceived age change after aesthetic facial surgical procedures. Chauhan et al ⁵ evaluated 60 patients who underwent three combinations of aging face surgery: (1) face- and necklift, (2) face- and necklift plus upper and lower blepharoplasty, and (3) face- and necklift plus upper and lower blepharoplasty plus forehead lift. Raters reviewed preoperative and postoperative photographs, and estimated the perceived age change (difference between the chronological and estimated age). They reported that patients overall appeared 8.9 years younger than their actual age after the procedures. Not surprisingly, the patients who underwent all three of the offered aging face procedures had the most dramatic “age reducing” results.

Zimm et al ⁶ also evaluated the degree of perceived age change but additionally assessed the improvement in “attractiveness” following aging face surgery. Preoperative and postoperative photographs of 49 consecutive patients were graded by 50 blinded reviewers. They reported that the mean overall “years saved” (true age minus estimated age) following aesthetic facial surgery was 3.1 years, with a range of −4.0 to 9.4 years. They also reported that there was a small but insignificant increase in attractiveness, perhaps supporting the adage that “beauty is in the eye of the beholder.” One can also speculate that the perception of beauty is not directly correlated to a youthful appearance, but that our expectations of beauty change to coincide with the perceived age of a person.

Whether beauty is preprogrammed or truly only exists in the eye of the beholder, the most important goal for the facial plastic surgeon is to create a result that portrays beauty and contributes to a positive selfimage in the mind of the patient. Certainly, one can accept that a face that is beautiful beyond a certain level is likely to be universally accepted as beautiful, transcending racial, cultural, and temporal preferences. In addition, in the present world with well-developed communications, frequent travel, and globalized media, beauty does not exist in a culture- or race-specific vacuum.

History and Physical Examination

A complete and systematic medical history and physical are as important in facial plastic surgery as any other surgical discipline. History taking should include information about medical problems, prior surgeries, medications, and allergies as well as smoking, illicit drug use, and drinking habits. As hematoma is among the most common complications of facial aesthetic surgery, risk factors for postoperative bleeding, such as hypertension and use of nonsteroidal anti-inflammatory drugs, should be elicited. Smoking history is pertinent to concerns for skin slough and flap necrosis.

Questions regarding dryness or irritation of the eyes should be posed to patients undergoing surgery in the periorbital region. Vision in each eye is assessed, and tests for adequate tear production are performed if the history is suggestive of decreased lacrimation.

Patients with rare skin disorders may present to the facial surgeon with premature aging or skin laxity. These conditions include Ehlers-Danlos syndrome, progeria, Werner’s syndrome, cutis laxa, and pseudoxanthoma elasticum. The underlying pathological process must be taken into account in determining whether such patients are candidates for aesthetic surgery. Ehlers-Danlos is a genetic disease of connective tissue associated with thin, hyperextensible skin, hypermobile joints, and subcutaneous hemorrhages. Rhytidectomy is contraindicated due to high risk of postsurgical bleeding and poor wound healing. Plastic surgery is contraindicated in progeria, a disorder characterized by growth retardation, craniofacial disproportion, baldness, prominent ears, pinched nose, micrognathia, and shortened life span. Due to associated microangiopathy, cosmetic surgery is also contraindicated in Werner’s syndrome, or adult progeria, a condition that also presents with sclerodermalike skin changes, including baldness, aged facies, pigmentation defects, short stature, muscle atrophy, osteoporosis, premature atherosclerosis, and diabetes. Cutis laxa, in which there is a degeneration of dermal elastic fibers, is associated with chronic obstructive pulmonary disease, cor pulmonale, hernias, as well as urologic and intestinal diverticula. Facial rejuvenation is generally safe in these patients as long as their overall health status is satisfactory. Finally, pseudoxanthoma elasticum is a degenerative disorder of elastic fibers resulting in premature skin laxity for which facial rejuvenation surgery is beneficial.

Preoperative Photography

Preoperatively, the surgeon should photograph the patient in standard views specific to each operative procedure. These photographs should include, at the minimum, a frontal view, left and right lateral views, and left and right oblique views, as well as close-up views of the regions to be addressed surgically. The photographs should be taken with the head in the Frankfort horizontal position. In the Frankfort horizontal, the supratragal notch is level with the infraorbital rim. Photographs assist in preoperative planning and intraoperative decision making, and postoperatively as a way of assessing results. They assist preoperatively in discussion with the patient as well as postoperatively during the counseling of patients who may not remember their exact preoperative appearance. Photographs are necessary for medicolegal documentation. Standardized photographs can also be used to take objective measurements of surgical and nonsurgical procedure results, and allows comparisons between different techniques. ⁷ The reader is referred to Chapter 9, Photography in Facial Plastic Surgery.

Computers in Facial Analysis

There is no doubt that the use of preoperative computer imaging is an excellent tool to increase communication with patients. It allows the surgeon to visualize what the patient desires as a final result. The patient can articulate any desired modifications. It allows the surgeon and patient to compare their own aesthetic interpretations.

For procedures such as profile changes in rhinoplasty, it allows patients to view themselves from a different perspective, one that they normally do not see. Many times their selfimage is not congruent with what others see. Also, the computer imager shows how different manipulations can yield very different results. This is important with procedures such as rhinoplasty where subtle or dramatic changes can be achieved by single maneuvers. It also shows the illusionary or secondary effects of a singular change. For example, apparent nasal tip rotation can be increased by removing a dorsal hump or augmenting the premaxilla. Such secondary effects can be visualized on the imager and are valuable in the planning of that procedure. The reader is referred to Chapter 8, Computer Simulation in Facial Plastic Surgery.

Skin Type

Due to the key role of skin in the facial appearance, evaluation of the skin deserves special mention. The texture, thickness, elasticity, and degree of sun damage to the skin of various facial regions should be evaluated by inspection and palpation. A gentle touch during this stage of the examination communicates to the patient the surgeon’s technical delicacy. Skin lesions, scars, rhytids, and pigmentation should be noted and pointed out to the patient.

Fine, light skin with minimal subcutaneous tissue will tend to show even minor subcutaneous soft and bony tissue irregularities. Facial implants in such skin may prove problematic or unacceptable. Even minor abnormalities in contour require careful attention during surgery. On the opposite end of the spectrum, thick, oily skin tends to heal with scars that are more obvious. It also may conceal underlying structural changes. Somewhere between these two skin types lies the ideal skin for facial aesthetic surgery. Men tend to have thicker skin in the region of the beard, with an increased blood supply due to a richer subdermal plexus.

Soft tissue fillers are used to fill defects within the skin and subcutaneous tissue, and are effective in treating depressed scars, wrinkles, folds, and volume loss. The depth of the defect should determine the filler chosen for the appropriate procedure. For example, hyaluronic acid–based products, which have secured a prominent role as fillers, may be appropriate for superficial defects while deeper ones may require autologous fat or synthetic products, including implants.

Textural imperfections, such as deep acne and chicken pox scars, may subtract from the desired result. Ice-pick acne scars penetrate through the dermal layer and fixate in the subcutaneous tissues, thus tethering the skin surface. Correction with injectable fillers or punch excision of depressed scars and sequential laser resurfacing may be required.

Skin aging is variable and depends on multiple intrinsic and extrinsic factors. Genetics, sun exposure, smoking history, radiation exposure, and amount of use of the facial mimetic musculature all play major roles in the development of facial rhytids. It is important to differentiate dynamic facial lines from true wrinkles. Dynamic lines or furrows are caused by the repeated pull on the skin of underlying facial mimetic muscles and require that the underlying muscle(s) be addressed. Neuromodulators have secured a prominent role in temporarily paralyzing underlying facial mimetic muscles. True wrinkles that manifest as sagging skin are caused by age-related laxity of the skin. Aging is also associated with a progressive decrease in the elasticity and thickness of the skin.

With age, the development of benign, malignant, and premalignant skin lesions may occur. It is important to biopsy any suspicious lesions. Keratoses and other hyperpigmented lesions may appear on the face. Environmental damage from both ultraviolet radiation and trauma may take a toll on facial skin. Actinic damage and regions of pigmentary change may occur. The presence of facial hypertrophic scars and keloids should be noted, as they may be a relative contraindication to certain types of surgery.

While our foundational surgical armamentarium for performing facial cosmetic procedures has not changed dramatically over recent years, our ability to approach specific skin and soft tissue issues has. This is because of lasers and other noninvasive devices to treat pigment, vascular lesions, tattoos, unwanted hair, excess subcutaneous fat, benign skin lesions, and skin with poor elasticity ( Fig. 13.1 ). Fractional skin resurfacing lasers are an example of such a device that allows controlled peeling of the skin’s surface to improve texture, skin tightening due to thermal effects on collagen, and a reduced recovery period compared to earlier technologies ( Fig. 13.2 ).

When planning skin treatments, it is important to ascertain the patient’s sun reactive skin type (Fitzpatrick) ( Table 13.1 ). Depending on the device being used, those with type IV or type V skin (e.g., persons of Asian or Hispanic descent, respectively) or in anticipation of a hyperpigmentation problem may be pretreated with hydroquinone topically.