Questions about appearance.
General considerations on surgery and aesthetic medicine.
Pr Jean-Paul Meningaud, MD, PhD
Professor, Head of the Department of Plastic and Maxillofacial Surgery. Director of the outpatient surgery department of Henri Mondor Hospital (Paris Hospitals).
During the course of my medical and cosmetic surgery teaching, I am asked many questions about appearance.
They are always relevant.
Here are the ones that come to mind.
What is the relationship between the demand
for rejuvenation and beautification?
In cosmetic surgery, we distinguish schematically:
surgery of the face,
This distinction highlights the goal pursued, but in practice these four categories overlap.
Silhouette surgery :
It includes for a very large part a surgery « in decrease »:
The treatment of the after-effects of weight loss
The treatment of horse breeches,
Ptosis and breast hypertrophy,
Sequelae of pregnancy.
Excess tissue will have to be removed and the remaining tissue will have to be fitted to recreate the desired shape. These are most often patients who are overweight or have been overweight. As a rule, the subjects concerned are generally “good life’s lovers”. The goal is beautification, directly or through clothing, but in practice a slim silhouette always appears younger.
There may also be « increasing » demands:
Such as breast prostheses,
or, more rarely, buttock or calf prostheses.
Surgery of the face :
It poses very different problems because it concerns the identity that the person wishes to display.
Obviously, human beings recognize themselves by their face.
A person requesting facial cosmetic surgery pursues the desire to display increased attractiveness or a younger age.
Attractiveness can be increased by improving the proportions of the face.
In practice, the key point of attractiveness lies in the middle third of the face.
– The most classical interventions of facial cosmetic surgery are:
Eyelid surgery or blepharoplasty,
– But there are also more sophisticated interventions concerning:
The shape of the eyes,
The shape of the jaws and especially the angles.
Are there criteria that do not evolve?
– There are general criteria of beauty that do not seem to have changed since antiquity. Aristotle (385-323 B.C.) already evoked symmetry, precision and harmony in proportions (in various passages of Metaphysics, but also of Poetics).
– Numerous studies in experimental psychology have confirmed the relevance of these criteria. . Grammer K et al Human (Homo sapiens) facial attractiveness and sexual selection: the role of symmetry and averageness. J Comp Psychol. 1994;108(3):233-242.
– Thus, if a sample of 100 randomly selected people are presented with two photographs, one with a roughly symmetrical face and the other with the same face ostensibly asymmetrical, the vast majority will consider the symmetrical face to be more beautiful
Can we put a price on beauty?
There have been temptations in history, historically with the golden section.  Prokopakis EP, Vlastos IM, Picavet VA, et al. The golden ratio in facial symmetry. Rhinology. 2013;51(1):18-21.
More recently with so-called cephalometric studies.  Gorbanyjavadpour F, Rakhshan V. Factors associated with the beauty of soft-tissue profile. Am J Orthod Dentofacial Orthop. 2019;155(6):832-843.
In fact, these criteria when applied systematically lead to aberrations (see below).
Aristotle in his great wisdom did not consider the question of proportions in rigid terms, but simply as the fact that the beautiful could not be situated at the extremes.
What is the golden ratio?
– Towards the end of the 15th century, Lucas Pacioli, an Italian mathematical monk, defended the thesis of an ideal proportion based on a very particular number that would later be called the golden section or golden section.
In fact, this number had been known since antiquity, but only for some of its mathematical properties (described by Euclid). It has been argued that artists such as Leonardo da Vinci based their canons of beauty on the golden section.
– Yet contrary to what may have been written here and there, the famous Vitruvian Man is inspired by the proportions explained by Vitruvius himself, the Roman architect who lived in the 1st century BC, but does not use the golden ratio.
Vitruvius describes the ideal proportions of a temple, which had to be close to human proportions.  Vitruvius, De architectura, book 3, chap. 1.
– Vinci goes the opposite way to draw a man. The confusion about the golden ratio comes from the fact that Vinci and Pacioli were friends and that Vinci had illustrated a book by Pacioli entitled On Divine Proportion. In fact, for his works, Vinci relied much more on his own anatomical observations than on a mathematical system.
Do statistics allow us to define ideal proportions?
– Beauty would lie in a more or less wide area around average measurements.
It is in the field of the study of the face that this biometric method, cephalometry, found its greatest field of application.
It requires the realization of a particular radiography called teleradiography.
Precise anatomical points are identified, thanks to which angles are measured.
Although underpinned by a very high level of scientific rigor, cephalometric analysis suffers from a few limitations.
The most important is related to calibration.
– Each type of analysis calculates its averages over a reference population which over time can become questionable.
For example, Tweed’s analysis is based on a population of young Americans in the 1950s, the vast majority of whom are white.
Can the results be extrapolated to the study of the face of a 50-year-old African patient today?  Ouédraogo Y et al. Cephalometric norms of a Burkina Faso population. Int Orthod. 2019;17(1):136-142.
What is the best criterion of beauty?
– Charles Auguste Baud, a Swiss surgeon, in his book « Harmonie du visage » published in 1967, described function as an intrinsic criterion of beauty.
A beautiful face implies a correct meshing of the teeth, good breathing, properly functioning eyelids, non-paralyzed smile muscles, etc.
It is certain that a group of people with significant prognathism to the point of not having contact between their incisors will appear statistically less beautiful than a group with functional contact between the dental arches.
The lack of contact between the dental arches, however, significantly reduces the stimulation of the bone supporting the dental roots and results in long-term loosening of the teeth.
In the same way, it is easy to imagine that a respiratory disorder linked to a deviation of the nasal septum could result in a deformation of the nose.
In fact, the most frequent aesthetic consequence of this type of respiratory disorder is the early presence of bags under the eyes. These patients most often consult us for blepharoplasty (eyelid surgery).
The clinical examination of this request must eliminate a respiratory problem.
Retromandibula (mandible backwards), can promote snoring or worse an obstructive sleep apnea syndrome.
This syndrome results in a significantly higher rate of myocardial infarction and daytime drowsiness, which is the cause of some road accidents.
Aesthetically, what will appear in the foreground will be an open cervico-facial angle with an impression of relaxation at an earlier age.
Many of these patients do not consult for this functional reason of which they are not even aware, but for a neck lift!
The examples could be multiplied ad infinitum, but to sum up, function and aesthetics are much more related than one might think.
Function does not only create the organ; it promotes the aesthetic impression.
The functional criterion is by definition an advantage in an evolutionary approach.
Functional criteria are perceived as advantages, and therefore privileged in terms of reproduction whatever the species, they are then assimilated to aesthetic criteria.
In any case, in my surgical practice, function is my preferred criterion.
On the left, a patient with significant retromandibula with an open cervico-facial angle appearance, therefore older and especially a predisposition to the sleep apnea syndrome, and therefore a higher risk of cardiovascular disease.
On the right, the same patient after surgery with a more closed cervico-facial angle, younger and with a decreased medical risk (case of Pr Jean-Paul Meningaud).
Example of a patient with palpebral pockets at an early age, less than 30 years old, which is not normal and indicates a respiratory problem (case of Pr Jean-Paul Meningaud).
In conclusion: What is charm?
We have considered more or less precise criteria, all static, except for a few functional criteria, but never from the angle of emotion.
However, a smiling and loving face is worth a facelift. On the other hand, an angry face will never appear beautiful.
A tense or sad face may appear beautiful, but will quickly become tired. When we detail ourselves in the mirror, we do it on a motionless face.
However, in social life, we never analyze others from a strict and motionless profile, but rather from a three-quarter and emotional situation.
A surgeon will never be able to operate on your emotions.
Excerpt from Pr Meningaud’s Anti-Aging Program
Available at www.amazon.fr
Who is Pr Jean-Paul Meningaud?
Professor at the University of Paris 12, since 2009.
Head of the Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery since 2012.
Former intern at the Hospitals of Paris, Former Head of Clinic at the Salpêtrière Hospital.
Former National Coordinator of the DES in Oral Surgery.
Member of the National Academy of Dental Surgery.
Judicial expert at the Paris Court of Appeal, Approved by the Court of Cassation.
Specialist of the face, he has participated in 7 face transplants since 2007.
Doctor of Science, he devotes a significant part of his time to research and publishes about twenty scientific articles referenced per year.
In 2011, he received one of the highest distinctions in plastic surgery, the James Barret Brown Award in the United States for his work on face grafting.
In 2014, he was elected President of the European association of his discipline (EACMFS in 2018-2020).
He has created six University Diplomas that are references in the field of aesthetic medicine.
He remains passionate about patient care on a daily basis.