Facial Aesthetics for Dummies

I once asked my boss and my mentor Frederick J. McCoy, how he measured something on the face. His answer was ‘scientifically by eye.’ Fred was a master of Kansan one-liners. When asked, whilst sitting with him on the terrace at the Mission Hills Country Club, drinking a wild Turkey Mint Julip, whether he played golf often, he said “regularly, once a year.”.

Plastic surgeons talk endlessly about divine proportions and the golden number (see below) otherwise known as ‘Phi’ (approximately 1.618) as well as the Fibonacci Sequence. The rule of thirds and fifths divides the face vertically into thirds and horizontally into fifths. Every artist from Giotto to Gauguin knows these proportions.

We know that the angles of your mouth are supposed to line up with the inside edge of your iris and the alar (nostril) edges with the inner angle (medial canthus) of the eye. The distance between the medial canthus and outer (lateral) canthus should equal the distance between the two eyes. Too close together and you look like Prince Charles.

I am not saying that these observations are irrelevant. Every resident and every plastic surgeon should know and understand them. Although, I am not too sure about remembering the ‘nasal length to nasal projection ratio’. But these facts and observations fall short of an understanding of facial aesthetics. 

The face is not symmetric. It cannot be summarized and analyzed by measurement alone. Hence the phrase to ‘measure scientifically by eye.’

The golden ratio is one where the ratio of the smaller segment to the larger segment is the same as the larger segment to the sum of both segments. This is more easily seen in a simple diagram.

The golden ratio or divine proportion is a visual representation of the golden number Phi (Φ) which is approximately 1.618.
The Fibonacci Sequence

The mathematics behind the golden ratio is heavily connected to the Fibonacci Sequence. If you’re unfamiliar with the Fibonacci sequence, it begins by definition with the numbers 0, 1 and then each successive number in the sequence is the sum of the previous two numbers.

It would behoove every practitioner dealing with facial aesthetics to take a global approach to the face. It’s not about lines or depressions, although these play a part. When fillers first came out, we were all taught to fill nasolabial lines so that everyone looked like a Cro-Magnon or a Neanderthal. Now we understand that recreating the volume in the cheeks will correct the sagging of the cheek fat pads and improve a deep nasolabial line and that filling in nasolabial lines alone does not result in an aesthetic outcome.

The aesthetics of the face consists of one-dimensional and three-dimensional aspects. The one-dimensional elements are the skin color, skin texture and the rhytids. There is an intermediate dimension (call it 2.5 dimensional) which consists of the folds formed by skin ptosis (sagging) and laxity. The 3D aspects of the face are the underlying bone and cartilage skeleton and their ‘interrelationship’.

Put simply, in the female face the overall shape is an oval, in the male a square. The cheeks or malar bones are wider than the mandibular angles in the female and equal or reversed in the male.  Malar prominence is more anterior in the male and more to the side (lateral) in the female. The chin is smaller in a vertical and a horizontal dimension in the female. The glabella (the depression in the nose between the eyes) and the sub-labial crease (depression / crease below the lower lip and above the chin prominence) are more or less on the same vertical profile line in the male whereas in the female the front of the chin or the pogonion is behind this vertical plane. 

You don’t need a cephalometric analysis to determine this, but it may be helpful if you want to calculate the ideal size of an implant. However, for most of us, like life and choosing a yacht to sail the Mediterranean, it really comes down to small, medium or large and as Graham Chapman said: ‘you either have one or you don’t’.

Dr Edward Terino in the Los Angeles area and Dr Harry Mittelman in San Francisco have both set the stage for understanding and correcting the ‘third dimension’. Dr. Mittelman’s pre-jowl implant addresses the 2.5 D aspects of skin ptosis and the pre-jowl depression as well.

Cro-Magnon: How the Ice Age Gave Birth to the First Modern Humans

By Brian M. Fagan, Bloomsbury Press

Published March 2nd, 2010 by Bloomsbury Press (first published 2010)

All of this is very interesting, but it still does not get to the core. Imagine you are an astronaut looking at the earth for the first time or even the first person to stand on top of the Eiffel tower (a steelworker). Neither would be trying to find his-semi-detached house in the suburbs. They would be looking at the big picture and ignoring the details

Plastic Surgeons should be Astronauts not town planners. To understand this a little better let’s, look at a Bernini and Brancusi. Gian Lorenzo Bernini lived from 1598 to 1680 and Constantin Brâncuși from 1876 to1957. Despite a three-hundred-year difference between the two artists they both lived into their eighties.  Bernini actually lived a year longer. The similarities between their representations of the female face created three hundred years apart, are more obvious than the differences.

Both artists represented the female head and facial proportions as an oval upside-down triangle with a small chin and wide cheek bones. Brancusi reduces the aesthetic proportions to the essentials, focusing on the oval triangular format not just in the front view but from almost every angle.

This is not an Art History lesson. The simple message is that when you look at a face, look at the proportions in relation to one another. When I say this, I am mostly talking about the mid-face versus the lower face. Maxilla versus mandible or cheeks versus jaw. The forehead is not really part of this equation. It is not to say it is unimportant, but other than fat loss in the temporal fossa and hair styling there is not a great deal one can do about it, especially in the non-surgical sense. You either have a high forehead or you don’t.

Is the mandible too strong or too weak? Does the mandible overpower the cheeks or leave the cheeks looking too prominent? Is the chin retrusive or prognathic? Above all, fix the fixable (excluding craniofacial surgery). It is difficult to make a wide mouth (the Joker, Julia Roberts, Anne Hathaway) smaller (Kendall Jenner, Kate Moss) or make small eyes (Cara Delevingne) larger (Twiggy) any more than you can make a tall person shorter, long arms shorter, big feet or big hands smaller or vice versa. It is also unnecessary. Beautiful faces break all the aesthetic rules with large and small mouths, big and little eyes, strong and weak chins etc. 

However, altering the malar/mandibular relationship is relatively easy and can makes a dull face beautiful. It is the easy solution and Rule One for Dummies. It is also Rule Two and Three.

Rule One: fix the mid-face/lower face disproportion.

Rule Two: when in doubt, look at the relationship between the cheeks and the mandible.

Rule Three: re-read Rules One and Two.

The four F’s
Facelift, Filler, Fat, Facial implants (cheek, mandibular angle and chin)

Face-lifts, Filler and Fat and Facial implants can correct a flat malar projection or a weak chin and jawline. 

But is it not just about facial interrelationships and proportions but it is also about how the light strikes the face. Often times the face presents as flat planes without shadows. Like a cube or a pyramid. To create a beautiful face, you need highlights. Make-up artists know this instinctively. 

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