Facial Aesthetics – A Primer

When I was a resident in training, I once asked my boss and my mentor Frederick J. McCoy, how he measured a facial proportion. His answer was ‘scientifically by eye.’ Fred was a master of Kansan one-liners.

Plastic surgeons talk about facial aesthetics in terms of 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 into thirds vertically and horizontally into fifths. Every artist from Giotto to Gauguin knows these proportions.

From an ideal aesthetic point of view, the angles of your mouth should align with the inner edge of the iris and the alar (nostril) edges should align 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 inner canthi. Too close together and you may 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. 

However, the face is not symmetric. It cannot be summarized and analyzed by measurement alone. There is a certain beauty in the asymmetry. Most models do not have symmetrical faces. Hence the reason 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. The golden ratio also known as the 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.

Every practitioner dealing with facial aesthetics should take a global approach to the face. It’s not about individual facial proportions such as the width of the mouth or the height of the forehead or about specific lines or hollows, although all of these play a part.

When fillers first came out, we were all taught to fill deep nasolabial lines so that the result looked like a Cro-Magnon or a Neanderthal. Now we understand that restoring volume in the cheeks will lift 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 challenge is to inject enough volume to compensate for the loss of fat and muscle with age and to replace it in the correct deep fat compartments.

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 wrinkles. There is an intermediate dimension (call it 2.5 dimensional) which consists of the folds formed by skin ptosis (sagging) and laxity. The three-dimensional aspects of the face are the underlying bone and cartilage skeleton, with their investing muscle, deep fat and superficial fat compartments 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 to the front (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. In the male profile, nasion (the depression in the nose between the eyes), the sub-labial crease (crease below the lower lip and above the chin prominence) and the pogonion or front of the chin are all, more or less, on the same vertical profile line.  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, like most things in life, such as choosing a yacht to sail the Mediterranean, it really comes down to small, medium or large

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.

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 her-semi-detached house in the suburbs. They would be looking at the ‘big picture’ and ignoring the details. Plastic Surgeons should be Astronauts not interior designers. To understand this a better, 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 in relation to the lower face i.e. maxilla versus mandible or cheeks versus jaw. The forehead is not part of this analysis. It is not to say it is unimportant, but other than fat loss in the temporal fossa and the hair line, there is not a great deal that one can do about it. 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 because it too small? Is the chin retrusive or too strong? 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.

Treatment options are the four F’s
1. Filler
2. Fat
3. Facial Implants (cheek, mandibular angle and chin)
3. Facelifts (surgery) including brow lift and rhinoplasty.

Face-lifts, Fillers, Fat and Facial implants can all correct a flat cheek projection or a weak chin and jawline. 

It is not just about facial interrelationships and proportions, but 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. Restoring volume and repositioning facial skin and fat compartments allows the light to reflect off prominences with the accompanying highlights and shadows.

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