Dimitrije E. Panfilov
Many anthropometric rules have been related to the face since ancient times. There is a relation between the whole body and the head, or the face. The head should have an eighth of the body length and the face a tenth of it. Leonardo da Vinci in his Trattato della Pittura gives the relations of the nose, ear, and thumb - they should have the same length. Also Leonardo's quadrangle incorporates the nose and ear in profile and should have edges of the same length. The Frankfurt line goes through the tragus and osteocartilaginous junction of the nose and divides the face into the upper and lower half. Stephen Marquardt, a maxillo-facial surgeon from the USA, considers the golden cut of 1:1.618 to be essential for geometric perfection of facial harmony. Steven Hoefflin, a plastic surgeon also from the USA, measures the beauty through oval forms and angles (as one can read in his chapter, Chap. 11). These are useful planimetric and stereometric measurements. It is, however, more difficult to measure the grade of glittering eyes or the warmth of a human smile. And there is another rule: a smiling face cannot be ugly.
In profile there are three points relevant for the facial analysis: the root of the nose (nasion), the dimple below the nasal columella (gnathion), and the dimple between the lower lip and the chin (mention). In a beautiful face, the line connecting these three points is convex-curved outwards. In a less pleasing facial profile, its course is straight, and in an ugly face it is concave-curved inwards. This is referred to as a "dish face" or a "witch face". This can be corrected either by protruding the maxilla forwards or by augmentative rhinoplasty and reductive mentoplasty. The opposite extreme of "bird face" can be corrected either by pro truding operation of the mandibulla or by reductive rhinoplasty and augmentative mentoplasty.
The young nice face incorporates a triangular apex which is turned down. When we grow old, this apex turns upwards and the cheeks sag down and build the base of this triangle. It is always useful to encourage patients to bring us their photographs of when they were young. By doing so, we will be able to make the right plan for operative procedures to reestablish their youthful appearance. This triangle can be turned upside down to restore juvenile harmony.
In frontal two-dimensional photographs of people - persona is the Latin word for "mask" - we sometimes discover some imperfections like "heavy cheeks", disproportions of a broad jaw compared with a narrow forehead, descendent lip commissures, and nose-eye-irregularities even in young patients. Before starting to analyse the feature composition of the patients, it is advisable to make either digital or Polaroid photographs in professional manner. Sometimes the patients are astonished at how they look in those pictures taken straight ahead. Our aim is not only to rejuvenate, but also to harmonize and beautify faces. And each face is unique, so we have to discuss many details with our patients to find an individualized op timal prescription for each facial surgery. We also have to respect the fact that mimic expressions reflect our emotions. Facial dynamics has to be saved.
Some prominent plastic surgeons have proposed special projections should be analysed, which help our patient to be able to realize what we are able to improve today. Bill Little from the USA has analysed the contour of the semiprofile and has found that this line should not be angular, but from above to the bottom it should be convex-concave. He borrowed an architectural term to describe it: ogee line. He achieves this by his imbrication procedure. Analogously, I have called the angular contour of the semiprofile (not edgy but) edgee line.
Bruce Connell has suggested analysing the neck region when the head is in a prone position. In this position the skin and subcutaneous tissue laxity produce multiple wrinkling or rippling called "accordion phenomenon" which could and should be corrected after facelift surgery.
Sam Hamra has invented "split-faces". This is a photograph divided in the middle (by scissors or by computer) of the preoperative face and the postoperative face. Both photographs have to be taken under the same conditions. Then, for instance, the right pre-operative half-face should be added to the left postoperative half (or the opposite combination). In this way we are able to demonstrate on a single picture what has been done or what we are able to change.
Patrick Tonnard also had an excellent idea: he made a physically fit male patient stand on his hands, then a photograph was taken in this upside-down po sition and was compared with a photograph of the same man in a normal standing position. These photographs were useful to demonstrate that cheek area benefits mostly from a vertical vector of traction. In contrast, the neck skin was wrinkled. Obviously, the vector of traction in the neck should be directed obliquely backwards.
We have added another projection which could be considered when analysing faces: a half profile from the back view. The signs of getting old appear first around the eyes and the lips and they cannot be seen from this projection, but a postoperatively accentuated malar region with concavity below suggests a postoperative pleasing youthful appearance as an ogee line, instead of the preoperative edgee line which would be characteristic for an elderly face.
In order to demonstrate postoperative changes which could be achieved operatively, computer imag
The preoperative facial analysis includes also examination of the skin by inspection and palpation. In front of a mirror, we pull the proposed skin vectors to show the patient in which way we intend to refresh and harmonize her/his face. Some of our patients worry about redundant, wrinkled skin above our pulling fingers. We have to assure them that this will disappear after we have resected the skin. For more about skin conditioning, see Chap. 62 by Desmond Fernandes.
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