Our faces are our most incredible asset. They hold the keys to human life. Emotion, social interaction, sensation, expression, cooperation and acceptance. Our faces define us individually and as a species: they open doors, they forge relationships and they express love. I have been fascinated by faces for 20 years. They are why I became a doctor, then a surgeon and finally a specialist facial surgeon. They are why paralysis of the face and it's physical and psychosocial sequalae are my main research interest. The face is our most complex system, not only does it house the organs of speech, sight, smell, taste, and hearing but with every breath we take and every bite we eat or drink we sip, the face is the portal of our interaction with the world around us. Our faces are why we are alive, literally, socially and metaphorically.
Physically the face is a fantastically complex structure, it is ever changing, statically and dynamically, it ages unlike any other part of the body and others judge us instantly and regularly on our facial appearance ...."you look well!, "what's wrong?", "Are you OK?"
The face should be respected, studied, and cherished - it is always on show. It is for this reason that I only treat the face, my sole focus is on facial aesthetic surgery, as I believe this is the only way it can be mastered. In this one complex feature there is more than a lifetime's work. An outstanding facial aesthetic surgeon needs to have meticulous surgical technique, an artistic eye and must truly understand the science of beauty. I hope on this page to describe with the kind assistance of my patients my thoughts on the latter.
The central facial triangle is the inverted triangle formed by the 2 eyes and the mouth. It is the first area to draw the gaze of an observer. It is the only visible feature a newborn child sees in his or her mother and it has been proven that it is the first part of the face strangers assess before all else. Infact Roger Hargreaves in 1971 created a whole community of "people" based on subtle changes of the central facial triangle!
The Mr Men series were not the first to identify the importance of the central facial triangle, 4 years before the first book in the series, a Pittsburgh pop artist was creating screen prints of an American icon in the same vein. Warhol emphasised the central facial triangle by creating prominence of the eyes and lips. Any feature which could distract from the central facial triangle such as the nose, cheeks and facial structure was minimised. In this way, he emphasised the ‘youth and beauty’ of his subjects. However, Andy Warhol was 17 years late, the Vogue cover voted the most iconic of the 20th century was the January 1950 issue photographed by Erwin Blumenfeld, which distilled the face down to just the eye and mouth and yet we still can perceive it as a face. This illustrates the powerful impact which the features of the central facial triangle have on global facial perception.
1. A face where the central facial triangle is emphasised is perceived as more attractive.
2. Wide bright eyes and proportionate lips without distracting features such as a large nose.
3. Prominent nose to mouth lines or jowls reverse the triangle and are a cardinal feature of ageing.
"My Patients Debbie and Sue illustrate this phenomenon perfectly. Both ladies have petite attractive features, but ageing had reversed the polarity of the central facial triangle. Surgery in both cases restored this balance leaving both looking younger, fresher and beautiful"
There are now far too many facial treatments out there promising the impossible. It is easy to see how this has happened. Relative "demedicalisation" of the procedures, an increasing consumer drive for fast track and minimal downtime results has lead some practitioners to offer "lunchhour and non-surgical facelifts", it would appear that LASER and radiofrequency are now the panacea for everything! This is irresponsible to prospective patients as at times the marketing machine can be pretty compelling. These treatments are certainly effective for the right indications but claims need to be backed by hard evidence.
The non-surgical market is booming however and for good reason. When treatments are used responsibly and for a specific aim the results can be very good. Some of the newer hyaluronic acid dermal fillers can improve the bony structure that previously only implants could do. More superficial dermal fillers in skilled hands give a natural and soft finish for fine wrinkles and skin folds. Appropriate facial subunit volumisation is key as long as proportion is respected.
So with the proliferation of injectable fillers and volumisation as a contemporary buzzword, what is it we are actually treating? As we age, our facial skin becomes thinner, less elastic and sags under gravity and exposure. This sagging leads to panfacial volume shift, with the skin, fat and muscle volume collecting in the lower facial third (jowls and neck). This is at the expense of the middle facial third - the area between the eyebrows and the nostrils - which become sunken, hollow and skeletal. Fillers and impants can "replace" this volume and create an illusion of youthful midfacial fullness, but this does not address where that volume has gone to! When I perform a facelift, I am looking to resite native volume back to where it came from, not just replace it with borrowed (fat) volume and or artificial fillers. Traditional facelift techniques can only tighten the underlying muscles in a backwards 45º vector, necessitating secondary procedures to alter midfacial volume - lower eyelid surgery or fat transfer - but to address midfacial volume shift, a more vertical vector is key (more later).
The Ogee curve is the double soft-S curves that are seen from an oblique angle on the youthful face. There is convex fullness in the tail of the brow that gently curves where the upper and lower eyelids meet, then softly curves outward on the upper cheek to again curve inward just above the mouth. As we age and lose volume, these natural curves collapse with loss of the attractive contours of the Ogee Curve.
"Leila is an excellent example of a young lady (39) who had prematurely lost her Ogee curve. Prior to facelift her oblique profile had no definition, no depth. She had beautiful eyes but they weren't framed properly. Surgery resited her midfacial volume thereby restoring her Ogee Curves, defining her eyes and resiting youthful cheek volume."
" this photo is one of my favourites! it shows the upward direction of my lifts. Traditionally, facelifting pulls the SMAS muscle layer backwards towards the ear (at 45º) which may result in a pulled or windswept look. Marie has some Melasma (sun spots - circled) and their movement post surgery are a perfect demonstration of the SMAS lift direction / vector which is key to a subtle and natural result."
This is a really important concept and has revolutionised my approach to facelifting. Literally all the traditional techniques I had been taught, seen, performed or read about resulted in a 45º (backwards) tightening of the Superfical Musculo-Aponeurotic System (SMAS). This to me was an anathema. Our faces don't age forwards towards the lips so why are we being taught to lift back towards the ear? Looking at Marie's pre op photo below, we can see mid and lower facial descent occurs downwards towards the jowl and jawline. So the correction needs to be at 70º upwards to reverse this descent.
As described above in Michael's slide on midfacial volumisation, this downward descent of the facial soft tissue curtain to the lower facial third, is at the expense of the middle facial third - the area between the eyebrows and the nostrils - which become sunken, hollow and skeletal. Traditional facelift techniques can only tighten the underlying muscles in a backwards 45º vector, necessitating secondary procedures to alter midfacial volume - lower eyelid surgery, implants or fat transfer - but to address midfacial volume shift, a more vertical vector is key. By lifting at 70º the infraorbital midfacial volume is restored more often than not obviating the need for contingent lower eyelid surgery. Have a look at Michael, Sue, Lesley and Janes' before photos again above and below, all had been told before seeing me that lower eyelid surgery may be necessary. With a 70º vector of lift, I suggest this is not the case. Further photos can be enlarged in the Gallery for closer scrutiny!
The golden ratio (Phi) has fascinated western intellectuals of diverse interests for at least 2,400 years.
Some of the greatest mathematical minds of all ages, from Pythagoras and Euclid in ancient Greece, through the medieval Italian mathematician Leonardo of Pisa and the Renaissance astronomer Johannes Kepler, to present-day scientific figures such as Oxford physicist Roger Penrose, have spent endless hours over this simple ratio and its properties. But the fascination with the Golden Ratio is not confined just to mathematicians. Biologists, artists, musicians, historians, architects, economists, astronomers, psychologists, and even mystics have debated the basis of its ubiquity and appeal. In fact, it is probably fair to say that the Golden Ratio has inspired thinkers of all disciplines like no other number in the history of mathematics.
Phi, named after Phidias the greek sculptor who made the Parthenon statues conforming to the ratio, is the simple mathematical ratio 1.618, it is the code of beauty and is present throughout a living things.
Centre of pupil : Base of nose : Bottom of chin
Outer & inner edge of eye: Centre of nose
Outer edges of lips : Cupid's bow
Width of centre tooth : Width of second tooth
Width of eye : Width of iris
"I have been fascinated by the golden ratio since I first read about it as a teenager. goldennumber.net is a brilliant website with more information on this phenomenon.
I use Phi proportion as another tool when analysing a face. In the slide below Lesley's proportions are restored after surgery - note specifically the horizontal elevation of her mouth corners and the relative proportions in her midface vertical section."
“It is the key to facial aesthetics”
The face is built on Phi. The head forms a golden rectangle with the eyes at its midpoint. The mouth and nose are each placed at golden sections of the distance between the eyes and the bottom of the chin. in the slide opposite I have illustrated further features which relate to the golden ratio.
Dr Steven Marquardt is quoted as saying:
"All life is biology, all biology is physiology, all physiology is chemistry, all chemistry is physcis, all Physics is Math"
With this in mind he developed a series of masks based on the golden ratio to template facial aesthetic perfection. Below, I have applied the masks to iconic beautiful faces from past eras and current times. The results are fascinating. Styles may change, but structural facial beauty is quantifiable it seems.
How important are eyebrows? Well here is a picture of the beautiful Anne Hathaway - with brows and without.... Are eyebrows important? You decide!
Just like hairstyles, makeup shades, and clothing fashions, different shapes and textures of eyebrows go in and out of style over time. In the the '20s and '30s, it was all about thin, dramatic brows with lots of curves. In the '80s, it was all about a bigger-the-better attitude. And then there were the '90s, when brows were so thin, tweezers worked overtime before the browline was pencilled back in!
What we do know, is that a defined eyebrow brings balance to the face. It frames our eyes and provides a foundation for the central facial triangle. A huge body of work exists that describes in detail the eyebrow and eyelid aesthetic ideal. Simply put, both Males and Female have an ideal range in which the lateral brow should sit relative to the orbital bony rim, any variation from this ideal is unattractively perceived.
" These slides show Jo's brow position the morning after facelift and browlift. Prior to surgery her brow peak was lowered and offset from the aesthetic ideal (blue line). After surgery, the brow is elevated and gently peaks in the perfect position. The slide below illustrates the significant brow elevation achieved relative to the supraorbital bony rim. Secondarily this opens up the distance between the lid margin and eyelid crease, refreshing and rejuvenating the eye."
Thank you for reading this article. I hope it demystifies the compelling science behind beauty. A facial cosmetic surgeon, more than any other, not only needs to have an innate artistic eye and meticulous surgical technique, but also a thorough understanding of the scientific quantification of beauty. Only then should we consider letting him or her operate on our face.
© Dominic Bray FRCS(ORL-HNS) August 2013
This article is a guide for my patients and colleagues, please do not copy, reproduce or publish without prior consent or referencing. Thank you.