Aesthetics, Beauty & Cosmetic Surgery
Cosmetic Surgery, i.e. operating on normal human beings to a super-normal level, is not a name to be stamped on the pad of a plastic surgeon, who has no practical training in it,- it is not a quick means for earning some cheap money, spreading a myth and misconception of its role to the lay common public. It is an evolving scientific art, an art which is only learnt, like any other thing, with the sweat of your brow and the tears of your eyes. It needs years of structured training.
Today’s cosmetic surgery has evolved considerably from when it took its birth in 1920’s from the prisons of San Quentin. It is a multidisciplinary approach between a plastic surgeon, cranio-maxillofacial surgeon, orthodontist, clinical psychologist, qualified beautician and dietician.
To understand cosmetic surgery one has to be familiar with the concepts of normality related to a particular age at a particular time depending on the ethnic characteristics of the individual.
The first and foremost is a definition of normality. Leonardo da Vinci has been the pillar stone of this definition, when he described the proportions of human face and the body. As building of a house is dependant on its structural framework, so the definition of this normality, has been the ground framework on which individual, ethnic, socio-cultural variations are embalmed. Obviously the concept is a dynamic process, changing its colours and parameters with time, but the basic ground framework always remains the same.
Figure 1 : Renoir's Irene 1800
Figure 2 Toulouse-Lautrec's The Modeste 1900
Maybe art would point to the aesthetic and cephalometric variations. Renoir’s perception may have had a different touch than Toulouse-Lautrec - it is obviously the artist’s perception. Similarly, though certain basic parameters have been laid down in the aesthetic framework of cosmetic surgery, yet it is the surgeon’s own perception of the patient. Sometimes the patient may desire, something which ‘she’ feels might look good, but the surgeon may perceive it otherwise. Unless the surgeon and the patient can meet on a common platform, it is best not to operate on the patient.
It is not whether a cosmetic surgery can be done, it is not how much the money a patient will pay, the key issue is whether you can achieve what she has come in for, - or in other words, whether she will be happy.
Aesthetic craniofacial surgery has progressed significantly in the form of carrying out 3-D NMR scans of the patient and superimposing them on the proposed aesthetic profile and carrying out a digital subtraction to exactly delineate the amount of change that is essential. In other words, perfection to the nearest millimeter is the goal of the exercise. Cephalometric analysis is of prime importance in putting a scientific basis to a conceivable aesthetics.
Aesthetics is not of an organ itself, - it is the overall appearance. There is no point in jumping on a nose to do augmentation rhinoplasty, when the patient has a mid-face deficiency, which will require a Lefort II advancement. Or carrying out a face-lift on a twenty eight year old. These surgical crimes committed by lot of our fellow colleagues, is an abuse of cosmetic surgery and the profession itself. It is onus of the whole plastic surgery community in Kolkata to see that the profession is not abused. It is sad to see advertisements of penis enlargement, when it is an well-accepted fact that the results are not satisfactory. Liposuction, does not correct obesity and liposuction more than two litres at one go can cause disastrous problems. Anyone preaching to take out more, is just abusing the profession and putting the lay people at risk. People are laymen, they are not conversant with the after results or the possible complications. Cosmetic surgeon should always inform the patient of the recognised complications and possible disasters. If patient agrees on the operation, she is fully aware of this and is prepared to go ahead with the procedure. In this age of medical litigation, most of the litigations stem from misrepresentation or misunderstanding to the disclosure of the truth in the ‘informed consent’.
This is just a brief introduction to the cosmetic surgery practice that is acceptable to the world. I have talked a lot on Bengali beauty, in my previous article. This time it is my professional colleague Dr.R.D.Rekhade MDS, Consultant Orthodontist, Kothari Medical Centre who is going to highlight his perception of beauty in Kolkata.
Kothari Medical Centre
The human face and its beauty have always enticed mankind. From the times of Greek and Egyptian art, the quest for understanding beauty has evolved down to the modern times. The lower face in humans influences to a large extent the social acceptance and physiological well being of an individual. W.J.B.Houston in his textbook of Orthodontics writes “Facial appearance can be very important to an individual self-image, well being and success in society.”
Orthodontics and aesthetics are closely related. Correction of malocclusion leads to a change in facial profile. Orthodontic treatment by alteration of the dento-skeletal framework produces changes in the external or soft tissue contours of the face. Relatively nominal investigations of the soft tissue profile are reported in the medical and dental literature. Proper diagnosis is essential for success in any form of treatment. With overwhelming demands on the aesthetics, soft tissue analysis of the face has become essential. There is a wide ranging diversity on the definition and perception of beauty among diverse racial groups. Normals and standard used for analysis mainly have a Caucasian heredity. Keeping this in perspective, a study was conducted on adult Bengali females. Angular measurements were done on facial profile photographs of this sample. The observations were compared with those available for other groups.
A. Wilson 1957
Figure 3 ; Apollo Belvedere
The statue of Apollo of Belvedere was considered typical of Greek sculpture from 3rd to 1st Century BC . Greek impressions were that bodies were cut into squares or cubes. Several fundamental errors were found in the head sculptures of the Greeks. History of Greek sculpture aims at producing the head of God Apollo. Among the more famous being the 6th Century BC Strangford Apollo, Marble Apollo of The Temple of Zeus 460 BC This sculpture has full mouth and lips. Apollo Belvedere of the 2nd Century BC was farcry from the Marble Apollo. The lower third of the face is retruded. The Apollo Belvedere is considered by many to have an ideal facial profile.
Henry Fields formerly curator of Physical Anthropology Museum of Natural History talks of seventy-six types of faces. None of these qualify by Apollo Belvedere standard. Or by the standard we are asked to accept. The possible exception being Kashmiri from North-West India.
B. Rudee 1964
The motivating factor for patients desiring orthodontic treatment was a desire for improved facial harmony and aesthetics. Proper diagnosis was essential for predicting post treatment results. However the face could not be evaluated without taking into consideration the nose and the chin.
The study of an aesthetically well-balanced profile is difficult because the subjective point of view of the person who prosecutes it can bias his opinion. A soft tissue profile which most people feel well-balanced exists. The difference in the well balanced and the otherwise is observed in the depth of the face than the height. The lower part of the face is more important than the middle. The shape of the nose, upper lip and the lower lip which makes up the soft tissue profile is of significance.
D. Kjury-Epker 1991
In modern society people’s attitude reflects a growing infatuation with the youth. Facial appearance is perhaps the most perceived manifestation of individual youthfulness. The peri-orbital area has a well-developed, shaped and positional eyebrow., well defined upper eyelid platform and supra-crestal crease. A well-developed cheek prominence is located approximately 10mm lateral and 15mm inferior to the lateral canthus of the eye. The nose varies in appearance in different ethnic groups and between men and women. It has a straight dorsum, a well-deformed tip with a good projection and rotation. The nostrils are almond shaped. The interlabial line is above the incisal line. The lower lip vermillion display was 1.5 to 2 lines that of the upper lip.
To properly analyse the soft tissue profile, a good quality standardised photographic technique is required. According to the Kodak Book of Photography a profile portrait reduce the risk of awkward distortion. A moderate 105mm telephoto lens is best suited for portrait photography. To avoid crowding of the subject within the frame and to obtain natural proportions the distance between subject and the camera should be 4ft. For diagnostic purpose the distance best suited is 5ft.
Using this photographic technique a study was done on the adult Bengali female population. The sample selection was random. Persons from different fields of life were requested to suggest a sample they considered good, aesthetically well-balanced profile. Tracings were done on the photographs using tracing paper. The angles analysed were the naso-maxillary angle and total facial contour.
1. Nasomaxillary Angle
Figure 4: Nasomaxillary Angle
This angle relates the upper lip to the tip of the nose. The angle changes correspondingly with the projection of the nose and also with the position of the incisors. The mean value for this angle was 104.880 with a SD of 2.250. . The difference between the Bengali mean and the Caucasian norm was insignificant. However the nasal tip projection for the Bengali can be said to be less than the Caucasian.
2.Total Facial Contour
Figure 5: Total Facial Contour
This is a measure of facial convexity. The angle is formed by the intersection of the upper and lower facial components. The mean Bengali value is 16.080 with a SD of 4.010. The Caucasian norm according to the study is 11.30 with a standard deviation of 4.10. This proved the Bengali population sample had a fuller lower facial component when compared to the Caucasian norm.
In conclusion it can be said that the overall dimension of this Bengali sample are smaller than the Caucasian norm. The lower part of this Bengali face is longer and fuller when compared to the Caucasian standard. The nasal prominence of this sample is lesser than the Caucasian norm.
It is evident from this study that the use of Caucasian standards for diagnostic purpose in the Indian population can be erroneous. I will also stress that before contemplating change in facial proportion for a patient, a detailed soft-tissue analysis should be done. This is frequently and commonly done by orthodontists. It is also now necessary for us to conduct such studies on a much larger scale to increase our data bank on the Indian population for giving better treatment to our clients.