QUESTIONS ABOUT APPEARANCE:
General considerations on surgery and aesthetic medicine.
Jean-Paul Meningaud, MD, PhD
Professor, head of the department of plastic and maxillofacial surgery. Director of the ambulatory surgery department at Henri Mondor Hospital (Paris Hospitals).
During my teaching in medicine or cosmetic surgery, 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 :
body contouring surgery,
surgery of the face,
This distinction helps to highlight the purpose, but in practice these four categories overlap.
Body contouring surgery:
It includes for a very large part a "decreasing" surgery as :
Treatment of the after-effects of weight loss
The treatment of saddlebags,
Breast ptosis and hypertrophy,
It will be necessary to remove excess tissue and to adjust the remaining tissue to recreate the desired shape. Most of the time, these patients are overweight or have been overweight. As a general rule, the subjects concerned are rather healthy people. The goal is to beautify, either directly or through clothing, but in practice a slim figure always looks younger.
There may also be "increasing" demands:
Such as breast implants
or more rarely, buttock or calf prostheses.
It poses very different problems, because it concerns the identity that the person wishes to display. Obviously, human beings recognize each other by their faces. A person requesting facial cosmetic surgery is pursuing a 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 classic procedures of facial plastic surgery are :
Eyelid surgery or blepharoplasty,
But there are also more sophisticated interventions concerning :Cheekbones,
The shape of the eyes,
The shape of the jaws and especially the angles.
Are there any criteria that do not change?
There are general criteria of beauty that do not seem to have changed since antiquity. Aristotle (385-323 B.C.) already mentioned symmetry, precision and harmony in proportions (in various passages of the Metaphysics, but also of the 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 photos, one with a roughly symmetrical face and the other with the same ostensibly asymmetrical face, the vast majority will consider the symmetrical face more beautiful.
Can beauty be quantified?
There have been temptations in history, historically with the golden ratio.  Prokopakis EP, Vlastos IM, Picavet VA, et al. The golden ratio in facial symmetry. Rhinology. 2013;51(1):18-21.
More recently with the 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 beauty could not be located at the extremes.
What is the golden ratio?
Towards the end of the 15th century, Lucas Pacioli, an Italian mathematician monk, supported the thesis of an ideal proportion based on a very particular number which was later given the name of golden number or golden section. In fact, this number was 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 had based their canons of beauty on the golden section.
However, contrary to what has 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 involve the golden ratio. Vitruvius describes the ideal proportions of a temple that should be close to human proportions.  Vitruvius, De architectura, book 3, chapter 1.
Vinci goes the other way around 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 De la divine proportion. In fact, for his works, Vinci relied much more on his own anatomical observations than on a mathematical system.
Do the statistics allow
to define ideal proportions?
The beautiful would be located in a more or less wide area around average measurements. This biometric method, cephalometry, has found its greatest field of application in the study of the face. It requires the realization of a particular radiography called teleradiography.
Precise anatomical points are identified and angles are measured. Although underpinned by a high degree of scientific rigor, cephalometric analysis suffers from some limitations. The most important one is related to calibration.
Each type of analysis calculates its averages on a reference population which, over time, may become questionable. For example, Tweed's analysis is based on a population of young Americans from the 1950s, the majority of whom were white. Can the results be extrapolated to the study of the face of an African patient in her fifties 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 " Harmony of the face " published in 1967, described function as an intrinsic criterion of beauty.
A beautiful face implies correct tooth meshing, good breathing, properly functioning eyelids, non-paralyzed smile muscles, etc.
- It is certain that a group of people with a significant prognathism to the point of having no contact between their incisors will appear statistically less beautiful than a group with functional contacts between the dental arches. However, the absence of contact between the arches singularly decreases the stimulation of the bone that supports the dental roots and results in long-term loosening.
- Similarly, 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 a blepharoplasty (eyelid surgery).
The clinical examination of this request must eliminate a respiratory problem. A retromandibulia (backward mandible), can favor snoring or worse an obstructive sleep apnea syndrome. This syndrome results in a significantly higher rate of myocardial infarction and daytime sleepiness, which is the cause of certain road accidents. However, aesthetically, what will appear in the foreground will be an open cervico-facial angle with an impression of sagging 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 endlessly, but to summarize, function and aesthetics are much more linked than one might think. The function does not only create the organ, it favors 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, patient with significant retromandibulia with an appearance of open cervico-facial angle, therefore older and especially a predisposition to 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 a reduced medical risk (case of Prof. Jean-Paul Meningaud).
- Example of a patient with palpebral bags at an early age, less than 30 years old, which is not normal and indicates a respiratory problem (case of Prof. Jean-Paul Meningaud).
IN CONCLUSION: What is charm?
We have considered more or less precise criteria, all static, except for some functional criteria, but never from the point of view of emotion. However, a smiling and loving face is worth many face lifts. On the other hand, an angry face will never appear beautiful.
A tense or sad face may appear beautiful, but will quickly become boring. When we look at ourselves in the mirror, we do so on a still face. In social life, we never analyze others from a strict and immobile profile, but rather from three quarters and in an emotional situation.
A surgeon can never operate on your emotions.
Excerpt from Pr Meningaud's Anti-Aging Program
Available on www.amazon.fr
Who is Professor 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 Paris Hospitals, Former Chief 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 Court of Appeal of Paris, approved by the Court of Cassation.
- A face specialist, 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 referenced scientific articles per year.
- In 2011, he received one of the highest honors in plastic surgery, the James Barret Brown Award in the United States for his work on face transplantation.
- 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 caring for patients on a daily basis.