Key points
• Facial contour and highlighting makeup (CHM) creates the illusion of light and shadow to produce the effects of projection and recession, respectively, changing perceived facial anatomy.
• The majority of vertical disproportions of the face occur in the middle zone. CHM can decrease perceived excess length by enhancing cheek convexity and buccal concavity.
• CHM of the chin can appreciably improve the appearance of macrogenia, whereas CHM effects on improving retrognathia and microgenia are very limited.
• CHM of the jaw improves mandibular angle definition, and a perceived increase of the angle to feminize the face is achieved with contour application bordering the desired angle edges.
• If a revision is necessary, CHM may create an illusion of the desired result to allay patient anxiety before the optimal time for surgical revision.
• The effects of CHM serve as a guide for filler and fat grafting locations to create aesthetic highlights.
• CHM effects are largely restricted to the frontal view.
Introduction
The concepts of attractiveness and perceived physical beauty have been topics of philosophic fascination for centuries. The reiteration of mathematics and geometry in existence with symmetry appear time and time again throughout history. The awe-inspiring advancements in science and art made by the Egyptians, the Greeks, and our Renaissance ancestors instigated the revivification of the Canons of Beauty. Although countless artistic renditions of human aesthetic ideals have existed for centuries, the establishment of a universal systematic assessment of the pulchritude of the human face has remained a perplexing endeavor.
Patients often seek the guidance of aesthetic surgeons to apply expert knowledge toward envisioning the most realistic ideal form. Thus it is of utmost importance for the aesthetic surgeon to possess a comprehensive understanding of current concepts in beauty. Technologic advances provide the modern-day surgeon with a wide array of tools, which, in addition to patient input, allow optimization of surgical and/or nonsurgical outcomes. Clinical photography combined with digital superimposition of ideal facial blueprints, such as the Golden Mask (Marquardt), or digital enhancement of facial features via software applications, such as Facetune (Lightricks), enables patients to visualize or effectively express their desired outcomes ( Figs. 44.1 and 44.2 ). No single application produces a verified universal ideal, but a combination of these tools will serve modern plastic surgeons and their patients well. In this chapter, we will discuss contouring makeup techniques that may be utilized in conjunction with surgical and minimally invasive procedures to enhance surgical outcomes, such as accentuating nasal definition after rhinoplasty, altering the perceived shape of the face after facial feminization, or optimizing facial contours after rejuvenation. We will also discuss the possibility of utilizing and understanding the patient’s preferential makeup techniques as a guide for the patient’s desired outcome with fillers. For example, a patient who consistently applies highlighting makeup to the chin and Cupid’s bow would likely benefit from chin and lip augmentation with fillers. Finally, we will discuss the use of makeup to correct distressing postsurgical changes, such as ecchymoses and edema, to improve patients’ quality of life during the postoperative period.
Sexual dimorphism
Sexualization of the facial skeleton has been hypothesized to confer fascinating anthropomorphic implications. An elevated testosterone-to-estrogen ratio facilitates the lateral growth of the zygoma and the mandible, lengthens the lower third of the face, and promotes the anterior growth of the supraorbital processes. These physical characteristics are innately associated with masculinity or, at the very least, decreased femininity. Interestingly, testosterone confers downstream immunocompetence; thus high concentrations have been postulated to provide evolutionary advantages by signaling immunologic competence to the opposite sex. ,
A high estrogen-to-testosterone ratio elicits the feminizing processes of the facial skeleton. Estrogen promotes a smoother glabella, thus creating a widened nasofrontal angle. A smooth zygomatic eminence without lateral protrusion is associated with high estrogen, whereas a high zygomatic eminence with lateral extension is associated with high testosterone levels. Interestingly, recent studies have shown that hyperfeminized faces are viewed as the most attractive, whereas slightly feminized male faces are preferred over masculine and hypermasculinized faces.
In females, a convex forehead with mildly increased vertical height, increased palpebral fissure (larger eyes), minimal lateral extension of the zygoma, fullness of the midface, and decreased intergonial width, along with decreased proportions of the middle and lower thirds, as opposed to elongated middle and lower thirds of the face, are considered desirable. In contrast, a flat, wide face has a disproportionately short and narrow forehead along with a wide, low-set, square jaw.
The power of makeup
Contour and highlighting makeup
CHM is a softened representation of the “drag queen” and advanced theater makeup artistry. An example of CHM of the face by the makeup artist Samer Khouzami is shown in Fig. 44.3 . Pigmented opaque powder or cream formulations a few shades darker or a few shades lighter than the natural skin tone is used to modify the perceived facial anatomy. Contour shades are formulated with cool undertones to simulate shadows on the face. This results in an overall receding effect of the contoured structures. In contrast, highlights simulate reflective points of light on the desired regions and create a subtle projecting effect. Highlights may also refer to translucent shimmer shades that consist of high concentrations of shimmer particles that enhance the highlighting effect. These techniques are combined with seamless blending for an amplified illusion of ridges and valleys to enhance the perceived facial form. Using only makeup, the artist has created the illusion of increased cheek fullness, increased nasal definition, and a more tapered, well-defined mandible and chin.
CHM is often strategically applied to regions of the forehead and the supraorbital margin to define the brow, radix and nose, infraorbital region and zygoma, buccal regions, philtrum, lips, mandible, and genu to create the illusion of mild anatomic modifications. It is important to note, CHM of the forehead, nose, chin, and infraorbital region are most appreciable in the frontal view. CHM in these regions is largely restricted by its visibility in the lateral view. Thus it is of utmost importance to avoid overdramatizing CHM and to blend the different shades seamlessly to avoid unrealistic harsh transition points. The nose is likely the most unforgiving of all regions of the face. The natural shadows within the lateral ridges, paired sidewalls, and areas of declivity medial to the alar lobules become substantially diminished in the lateral view. Thus persistence of these artificial CHM shadows on lateral view prohibits the use of harsh lines and drastic CHM maneuvers ( Fig. 44.3 ).
Color correction
Color corrective concealers are typically cream formulations that utilize color theory to neutralize discolorations. Neutralization is achieved by applying the complementary color of the discolored area; the complementary color is located 180 degrees from the color requiring correction on the color wheel ( Fig. 44.4 ). For example, the blue-violet shade of a region of postsurgical ecchymosis can be neutralized with a mustard shade. The application of color-corrective concealers provides a neutral-colored base for further application of skin tone or highlighting concealers, followed by skin-toned foundation. With the application of appropriate techniques, the highly pigmented concealers created by medical makeup brands are capable of effectively concealing significant discolorations; these brands include Kevyn Aucoin (Kevyn Aucoin Cosmetics, New York, NY; Dermablend [a division of L’Oréal USA, New York, NY]) and Cover FX (Toronto, Ontario, Canada). Understandably, many patients cannot afford to recover while confined to their residence for the duration of postsurgical ecchymosis resolution lasting a week or more. By utilizing appropriate color corrective techniques, patients may go about their daily lives without the worry of attracting unwanted attention. It may be necessary for plastic surgeons to associate themselves with makeup artists who are knowledgeable in the application of medical makeup so that patients who desire expert guidance can be referred appropriately ( Fig. 44.5 ).
Patient evaluation and technique
Facial zones
The ideal face consists of well-balanced harmonious features. The face is often divided into three zones of horizontal thirds. Facial analysis should begin with division of the face into upper, middle, and lower thirds. The most superior line is placed horizontally over the hairline; the middle third consists of the zone bordered superiorly by a line drawn across the brows and inferiorly along a line over the subnasale. The lower third is bordered by a horizontal line drawn across the inferior border of the chin ( Fig. 44.6 ).
Upper third
The upper third consists of the forehead. As described previously, a person may still be considered attractive if the upper third mildly exceeds 33% of the vertical height of the entire face. However, vertical height of this zone less than 33% results in facial disharmony. The degree of decreased attractiveness positively correlates with the extent of decreased vertical height. This is likely associated with the characteristic shortened vertical height of the upper third in early hominids. Minor nonsurgical extension of the vertical height and width of the forehead may be achieved with modification of the hairline through permanent hair removal systems (Nd:YAG [neodymium-doped yttrium aluminum garnet], alexandrite, diode, ruby, IPL [intense pulsed light], and electrolysis). Nonsurgical reduction of the upper third may be achieved with microblading, a form of cosmetic tattoo artistry that typically utilizes colorants of iron oxide pigments, which are inserted into the dermal layer with a thin blade to create strokes simulating strands of hair.
In the lateral view, the forehead should be smooth, display subtle convexity, and be void of harsh transition points. The seamless and subtle anterior projection of the supraorbital bar contributes to the superior limb of the nasofrontal angle. A subtle projecting effect (limited to the frontal view) can be achieved with highlight application, most concentrated in the region overlying the upper two thirds of the procerus, along with superolateral extension of the highlight through blending, as a gradient of highlight that decreases radially. A slightly convex forehead with the supraorbital bar as the anterior-most plane aligned with the superior third of the procerus is considered attractive. Decreased glabellar projection, along with pronounced supraorbital ridges, is undesirable and can be corrected with filler injections to the forehead and to the radix and glabellar regions. The injector must always be cautious about devastating complications, such as retrograde flow of the filler through the supratrochlear artery to the ophthalmic artery, resulting in distal occlusion and blindness. Intraarterial filler injection can be avoided with appropriate injection technique and an in-depth understanding of facial anatomy (see Chapter 36 ).
A flat forehead can be made to appear more convex with contour shades blended at the perimeter of the forehead along the hairline. The convex appearance may be augmented by extending the contour anteriorly from the hairline. Mild irregularities of the forehead can be masked with contouring ( Fig. 44.7 ).
