Art & Surgery

Introduction
The interaction of art and surgical aesthetics is essential to achieving a natural and pleasing result following cosmetic surgery. This crucial interaction was the subject of the Guggenheim lecture delivered at the Louvre in Paris by Rajiv Grover in 2009. He is the first surgeon to have been given this honour and has also lectured on the importance of an artistic element to surgical technique in order to improve the outcome of cosmetic surgery at The Royal College of Art in London as well as the University of the Arts (Central Saint Martins). The following is a short summary of the lecture delivered at the Louvre in Paris.

Rajiv Grover delivering the Guggenheim Lecture at the Louvre in Paris 2009

Why are certain facial features so important?
What features make a face beautiful?
How does the face age and how does this affect the Central Facial Triangle?
How does all this help us rejuvenate and enhance the face in the 21st Century?
Conclusion

Why are certain facial features so important?

The central facial triangle

Following research conducted at New York’s Metropolitan museum of art where a camera was used to see where a person’s eyes look when they first see a face it became clear that people look initially at the subject’s eyes, then down to the mouth and then back to the eyes before looking around the outline of the face. The central facial triangle, consisting of the two eyes and the mouth, is therefore a key feature of the face. Even very young children look at faces this way long before they have learnt about facial beauty or perception.

Artistic perception and the central facial triangle

The central facial triangle is the first area to draw the gaze of an observer. Andy Warhol used this to his advantage when creating flattering silk screen prints of his subjects. He emphasized 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 was minimised. This way he emphasized the youth and beauty of his subjects.

Silk screen prints by Andy Warhol

In the world of Photography the Vogue cover which was voted the most iconic of the 20th century was the January 1950 cover photographed by Erwin Blumenfeld which has 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 perception

1950 Vogue cover by Erwin Blumenfeld

What features make a face beautiful?

The role of the central facial triangle

Understanding the central facial triangle allows us to look at beauty in an analytical way. A face where the central facial triangle is emphasized may be perceived as more attractive. Wide bright eyes and proportionate lips without features that could distract attention away such as a large nose, prominent nose to mouth lines or jowls mean that one can focus on the key features of the central triangle. The example of Brigitte Bardot illustrates this well. Particularly around the eyes the smooth junction between eyelid and cheek mean that the eyes stand clear as does the mouth so attention focuses on the central facial triangle. The fact that her central facial triangle is so clear makes her very beautiful.

Brigitte Bardot age 25

Can anatomical features enhance the central facial triangle?

Although the eyes and lips themselves are the key areas of facial perception, they can be enhanced by certain anatomical features. Both the eyebrows and the cheeks “frame” the eyes and the cheeks in particular act as a pedestal for the eyes. Enhancement of the cheek within the normal anatomical range therefore acts to enhance the appearance of the eyes which in turn improves our perception of the face. This interaction of the cheek with the central facial triangle was clearly understood by the great artists of the Italian Renaissance such as Sandro Boticelli. The majority of his works are housed at the Uffizi gallery in Florence including “Primivera” which announces the arrival of spring. Although the painting is famous for the inclusion of the three graces the depiction of Primavera herself is a good example of how the cheek (i.e. midface) can act as a pedestal and enhance the eye.

Primivera by Sandro Botticelli emphasizing how the cheek can enhance the eye

The shape of the midface and cheek relative to the lower face is a double curve referred to by architects as an “ogee”. This double curve which is convex over the cheek and then slightly concave towards the jawline enhances the appearance of the central facial triangle by providing a pedestal for the eyes and further defining the triangular shape of the face as a whole.

Mathematical illustration of
“Ogee curve – convex above with concave below
Illustration of face with ogee curve which enhances the central facial triangle by the cheek acting as a pedestal to emphasize the eye

How does the face age and how does this affect the Central Facial Triangle?

How does Ageing happen – Is it Volume Loss or Gravity?

In 2006 to investigate what happens to facial anatomy as we age Rajiv Grover in collaboration with the Qmed Institute studied facial scans taken at different ages to see what happened as they aged. Interestingly about 7 years before there is evidence of gravity causing tissues to descend there is a gradual LOSS of volume from the face particularly over the cheek which changes the form of the face from heart shaped to more square (Published in the American Journal of Aesthetic Surgery march 2006). By reducing cheek volume the “pedestal for the eyes” is diminished which reduces their prominence in the central facial triangle which we know to be important for youth and beauty. What this indicates is that overall change in shape is a key factor in ageing. The age at which this volume loss from the cheek begins is between 38 and 40 with gravity having an effect about 7 years later.

Volume loss occurring 7 years before effects of gravity in facial ageing

Is the concept of change in shape being the central factor of ageing something new?

Absolutely not! Although the world of science may have thought this was a new discovery the world of art had known this for nearly 500 years. In his teachings on how to draw the features of an older face Leonardo da Vinci commented that the most important determinant of age was face shape and second was facial features like the nose to mouth lines and last of all was skin wrinkles.

Leonardo da Vinci talked about the shape being more important than features and wrinkles as signs of ageing nearly 500 years before its value was appreciated by science – His teachings on face shape are housed in The Louvre.

What are the signs of ageing?

The characteristics of ageing can best be described by dividing the face into thirds:

Upper Third The forehead and brow tends to drop due to gravity and gives a tired appearance around the eyes. The muscles of the forehead cause horizontal creases and similar creases are seen vertically between the eyebrows as the frown muscles fold the skin over time. The eyelids age first by developing crepey skin which later develops into bags as the underlying fat of the eye socket protrudes forward.

Middle Third Changes in midface volume lead to loss of cheek prominence and the combined effect of this volume loss and gravity then leads to deepening of the nose to mouth lines (nasolabial fold).

Lower Third Here the effects of gravity rather than volume loss are most noticeable with development of jowls due to loss of skin tone and eventually loose skin in the jaw line and neck.

The “Virtual Face”. A computerised research tool developed to study the science of ageing by Rajiv Grover in collaboration with the Qmed Institute.

What happens to the Central Facial Triangle with age?

In the youthful face the prominence of the eyes is enhanced by the cheek and midface volume whilst the appearance of the mouth is clear as it has not yet developed any nose to mouth lines which can distract attention from it. As the face ages the loss of midface volume detracts from the eyes and the presence of nose to mouth lines distracts from the mouth as do the development of jowls. The appearance of the central facial triangle therefore seems to reverse.

The signs of ageing seen in the “real face” of Brigitte Bardot age 25 and 62. Loss of midface volume and jowl formation reverses the perception of the central facial triangle.

How does all this help us rejuvenate and enhance the face in the 21st Century?

The foregoing discussion has emphasized that beauty is to some extent dependent on the appearance of the central facial triangle. This can be enhanced by features like cheek prominence which add emphasis to the eyes. Certain features like a large nose, prominent nose to mouth lines or jowls take emphasis away from the central facial triangle and so distract from beauty. As we age the most important and first change is volume loss from the cheek which reduces eye prominence and through reduction in facial support deepens the nose to mouth lines. Modern rejuvenation should therefore address these changes in order to rejuvenate in a natural way and one which respects what is known from the work of the great artists.

What was wrong with previous methods of Facial Surgery?

The previous approach to facial surgery focussed on the fact that ageing lead to loose skin and therefore tightening of the face and neck was the main aim. The effects of tightening the skin alone rather than the underlying soft tissues lead to surgery which caused pulling of the cheek and flattening. The tension in the skin distorted facial appearance including the ear which was often pulled forward. The world’s first ever billionaire and richest man was John Paul Getty. A biography of him shows a youthful face in his 40’s and later in life after an “alleged” facelift we see distortion around the mouth, flattening of the cheek due to pulling and because of the tension in the skin, there is an opposite reaction around the ear where it gets pulled forward (the so called “pixie ear deformity”).

John Paul Getty in middle age and in his late 60’s after facial surgery that tightened the face by pulling only skin and paying no attention to volume. This did nothing to enhance the central facial triangle and so did not rejuvenate in a natural way

The Modern Approach

Surgery has changed a lot in the last two decades and appreciation that the soft tissues also require support rather than just pulling the skin has lead to the so called “deep plane” lifts where the underlying muscle of the face (SMAS) is pulled in addition to the skin. The true appreciation that cheek volume is the key to beauty and also the key to a natural, artistic rejuvenation has only reached prominence in the last few years. Its recognition in the popular press lead to the cover of New York Magazine having a picture of Madonna emphasizing her beauty through the heart shaped face where volume in the cheek emphasizes the central facial triangle.

Madonna at age 50 on the cover of New York magazine which had an article on how new beauty was about volume (500 years after Leonardo da Vinci had said the same!!)

Volumetric enhancement to face shape and beauty

We can learn from this scientific work and the lessons of the great artists by using volume to enhance the cheek and so make the eyes a greater focus within the central facial triangle. In a woman of her 30’s although she will not really have aged, adding some modest cheek volume can enhance the appearance of the eyes and improve face shape.

Split face photograph of a patient (mid 30’s) treated by Rajiv Grover to enhance the cheek which therefore gives more emphasis to the eye and central facial triangle.

Before and after photographs of patient (mid 30’s) treated by Rajiv Grover to enhance the cheek in order to give emphasis to the eye and central facial triangle as well as more definition to face shape.

Volumetric rejuvenation: the key to achieving a natural look

Understanding that the face ages first by volume loss and then by gravity means that both these parameters must be addressed. The fact that volume in the cheek also creates beauty which is typical of youth gives it a double significance in trying to rejuvenate and give some artistic beauty to the face. How does one do this in a natural way? The key to all good surgery is thorough planning at the consultation. Here the study of photographs taken about 10 years before and also from the patient’s youth allows the character and shape of their face to be studied so that a bespoke and natural surgical plan can be made. These photographs (usually just family snaps) act as the surgical “Roadmap” for the planning. Of course the surgery must be carried out meticulously and by an experienced surgeon but one who has at his disposal the many tools which can aid in making a facelift not an “off the shelf” procedure but a truly individual operation for each patient. A “bespoke” procedure guided by the “roadmap” of the patient’s photographs and artistically enhancing the central facial triangle.

Before and after photographs of patient operated by Rajiv Grover using a technique to emphasize cheek volume whilst lifting the face and neck

Before and after photographs of patient operated by Rajiv Grover using a volumetric approach to facelifting with volume added to cheek

Before and after photographs of patient operated by Rajiv Grover using a volumetric approach to facelifting

Conclusion

Science has helped us understand the mechanism of ageing and that volume loss is the precursor of gravitational change. Focussing attention on adding volume to the cheek and midface enhances the perception of the central facial triangle which creates a beautiful and youthful face. The amount of volume and extent of the change can be guided by a “roadmap” of the patients own photographs.

It should be humbling to all surgeons that this knowledge is actually over 500 years old and first documented by Leonardo da Vinci. However it is in fact intuitive in the minds’ of all great artists who have known this for centuries!

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