Magic of Beauty, Beauty of The Face
“Beauty is in the eyes of the beholder” (William Wordsworth) or “I looked at the rose and said it is beautiful, it became beautiful” (Rabindranath Tagore).
No matter what the poets may say, the concept of beauty in the end lies with the beholden. What the particular individual being perceives to be appropriate in her eyes. This concept is based on the socio-cultural interaction of the individual and her perception of what is beautiful. Beauty in itself is a relative term, with wide variations in its concept.
Its perception varies from age to age, from civilization to civilisation, from culture to culture and from individual to individual. What is beautiful in Japan might not be beautiful in India and a beauty of the fifteenth century maybe may be entirely different from the one of twenty-first century.
The concept of beauty is a dynamic process and its assessment pertains to a particular race over a particular period of time.
Though there may be variations with age and civilization, as well as individual perception, yet when a cosmetic surgeon is confronted with converting a human face from normal to super-normal, he is at a loss as to where to start off with. Variations can be handled, provided the base-line is known.
So first and foremost he has to learn the baseline. This means he has to have conceptions of art.
So while performing this art it is important to consider the profile in respect to her ethnic origin (eg.Bengali) and also understand the modern concept of a Bengali beauty. 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. And it was Michelangelo who carved it in form. But that remained as a masterpiece over centuries until in 1857 when the authorities of the prison at San Quentin ordered first cosmetic surgery of the prisoners to improve their mental health. This put forward a new concept by Aldus Adler “Concept of Body Image”. To understand beauty and the patient’s requirements, one has to be familiar with her conception of body image.
As building of a house is dependent 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. 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 have cosmetic surgery.
Once equipped with the grammar and aesthetics of art, and the concept of body image, the cosmetic surgeon endeavours to carve the aesthetics of human face. In other words, he makes it beautiful and attractive. But having done all these, does she still look beautiful? Cosmetic dentistry and proper orthodontics forms an integral part to complete the story.
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 influence 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.”
Some articles about facial aesthetics have already been cited to clarify the validity of the above statement, and cosmetic surgery with aesthetic orthodontics can ultimately achieve the desired goal.
A. Wilson 1957
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 far cry 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.
Some cephalometric and aesthetic studies have been done also on our Bengali population. The results have been calibrated below
1. 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
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.
This is all about art and orthodontics. So what can be done to improve our facial profile?
Kolkata has a culture of its own and indeed stands uniquely as being the cultural capital of India. Indeed lots of beauties have emerged from this historic soil. To figure, where cosmetic surgery stands in Kolkata, one has to understand, what is beautiful in Kolkata?
In considering the facial profile as a whole, - we all know nasion, nasal base and chin must be in a straight line in the side view. This is the western concept. The grannies in Kolkata would hug a newlywed bride by her chin. So mild chin protrusion may be the concept of a Bengali beauty. “Beauty is in the eyes of the ‘beholden’”- if one organ is most important in a face, it is the eyes. Many a poets have written volumes on its beauty, many an artists have flown with its dream - even sculptors at Koomortooli will say this forms the mainstay of sculpting of Goddess Durga. Its disposition varies with the ethnic trait of the individual. The distance between two eyes is broad in an eastern Asian (Japanese, Chinese etc.), whereas it is narrow in European face. Bengali face is somewhere in-between. This can be cosmetically shaped to right aesthetic appearance by movement of the orbit bilaterally. Large ocular opening with a slight upward slant of the lateral canthus is probably the most attractive Bengali eye. Shaping it to this form is easily possible by cosmetic surgery.
After eyes, most people would view the nose. Where does the root of the nose originate? In a Greek it will probably be at the nasion. In an Anglo-Saxon, it is slightly lower down. In Bengalis it is usually further down. An even dorsal line would be the most aesthetic nose on the lateral profile. But did it ever occur to you, whether Barbara Streisand’s nose is beautiful or not? So a standard reduction rhinoplasty, as is practised by most Europeans, would not be the right solution for a Bengali nose. I would agree with George Peck, here reduction has to be combined with augmentation. But that is where the difficulty starts. To strut a nasal dorsum and merge it with nasion is so damn easy, but where this strut extends only to mid-nose, securing it without creating ripples in the dorsum, is not an easy job. We all know African or Arabic Nose (especially males) have a broad nasal tip, British nasal tip is relatively thin - Bengali nose has a softer hue with significant equidistant separation of the three point reflex. Will supra-tip projection enhance beauty? In my opinion, it would. This means, addition of the supra-tip projection. What about the nasal base? Type II alar reduction would reduce the ethnic characteristics of a Bengali female. What would be the tip to nasal aperture ratio and what would be its proportion to the nasal base? In my opinion, the height to the base has to be 1:1.5 and tip to aperture ratio 1:2. Now talking of the columello-labial angle in a Bengali face this would be 1050. One must be careful in over-reducing the lower laterals - it would definitely spoil the ethnic characteristics.
When treating the nose to maintain the lateral profile, adequate proportion of the lips is important in relation to nasion and mentum. This may require an augmentation with adequate lip lining.
‘Double Chin’, one of the most common problems in a Bengali past thirty - spoils the whole appearance by obliterating the mandibulo-cervicval angle. Submental lipectomy can leave scars, liposuction is always incomplete and looks dreadful if it is not combined with a lower partial face lift. What happens to a young girl? Face-lift is contra-indicated in normal circumstances. I believe mental adjustment can mask the submental lipectomy scars. In the middle-aged, the situation is somewhat different. Doing a lower face lift without correcting the upper face can cause serious facial disharmony. Since most Bengalis have a ‘sinthi’, bicoronal brow lift has very limited role. Only endoscopic brow lift or contour thread lift can fulfil this problem. Face lift can rejuvenate a face, but in a Bengali face, skin lift has but very little role. Extended SMAS to Hamara lift might correct the naso-labial jowl correctly - as this is a common problem in an ageing Bengali face.
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.
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 Lefort II advancement.
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 millimetre is the goal of the exercise. Cephalometric analysis is of prime importance in putting a scientific basis to a conceivable aesthetics.
In the last one year, new techniques of cosmetic surgery have emerged. Three years back, we introduced Botox to Kolkata in a seminar held at Apollo Clinic (Theatre Road). Since then Botox has been immensely popular to the extent, anyone in Kolkata started doing Botox treatment at a much cheaper price than qualified plastic surgeons. The competition became so intense at reducing the prices that the treatment price fell below the cost price of a Botox vial!!! Botox works well, but the only disadvantage was it lasts for 4 months.
In the last year, a new method of permanent treatment of forehead wrinkles and lifting chin has come up in western world and now available in Kolkata. This is by process of introducing special threads called CONTOUR THREADS or APTOS THREADS. It can be done under local anaesthesia and probably slightly more expensive than Botox. Though, thread lift can be done as an alternative to face lift, I still feel its role in facial rejuvenation is limited to those who are not trained to carry a SMAS or a composite lift, whose results have been proved to have long lasting value.
We were using collagen fillers as Restylane in the past, but this also like Botox lasts for 4 to 6 months. We had tried fat injections, but they dissolve in one years’ time. As a permanent solution, I was not using neither of these techniques. I was injecting Artecol, as I had been trained by Lemperle, who is the inventor of Artecol. This needs special training, otherwise results can be disastrous. Recent reports have revealed they form granulomas in the long run. A more recent solution to this is use of Reviderm which lasts for 5 years or Aquamid, which lasts for 10 yerars, which again needs training but have not been reported to have adverse effects.
Lip enhancement techniques have emerged for those who want to make it prominent and permanent.
With Contour or Aptos threads, a depressed look in the eyes can get a brighter appearance.
Practice of medicine is a process of evolution. Fashions change and with that, new techniques evolve to replace the old. Some stay, others, which cannot pass the test of time and clinical consistency, wither away. Only what is genuine, authentic and proven lingers on.
When considering the beauty in Bengal, because of its unique dress which seems to cover most parts of the body elegantly- only exposed areas like face form the main realms of cosmetic surgery. But the word ‘beauty’ is a variable entity. To understand it one must be familiar with what is normal. Normality is a human conception over time. It may so be that Rene Margaritte’s concept of ‘The Rape’, will emerge as the epitome of normality and challenge our present concept. If that is so, whole definition of normality and cosmetic surgery has to be re-written with a new philosophy.
But until that time, let us define cosmetic surgery parameters in Bengal and ways of its improvement. Brazilian socio-cultural issues are different from the Middle-East - more so different from Bengal. So it is obvious, concepts of beauty and cosmetic surgery parameters will be different. Once when these parameters are rightly defined, cosmetic surgery can start to fly on the required goal, - a goal that is our very own, that is unique.
This uniqueness is characteristic of Kolkata. In sphere of cosmetic surgery, I have tried to give a scientific shape of this uniqueness - in defining the parameters of performing this art. They say no art grows without a vision, no discoveries are made without a dream - this treatise will give some idea of how fashion of cosmetic surgery will develop in Kolkata over years to come.