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A FACIAL PLASTIC SURGERY DISCUSSION

Do You Resemble Your Relatives?

To choose or construct beautiful forms requires good taste and that in its turn requires cultivation, which comes from the observation of beautiful forms. Those who are not accustomed to seeing beautiful things are, in consequence, often uncertain whether they think a thing is beautiful or not. Some or perhaps all of us - have an intuition for what is beautiful; but most of us have to achieve beauty by taking pains.

– The Whiting Lettering and Watermarking by
Edward Johnson
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Family members share certain characteristics, a pattern that can be seen through the generations and among siblings. Genes allow us to share these characteristics. In any family photo there will be features that are common to the family, yet some of the family members will be more physically attractive than others. Why do some features match up better and produce a certain appearance? Each person has a different mixture of the same group of genes, creating resemblances and fitting together in different patterns. Some patterns are balanced and others are not.

A Natural Look

Patients come into the Georgia Plastic Surgery office with many varied descriptions of what they don't like about their face. Others come in with pictures from magazines of features that they do like. In the consultation, my goal is to hear what the patient wants, examine the person to decide what changes are possible, and discuss this with the patient. At this time, I refer to the analogy about the family features. It is possible to visualize the best combination of the family features. I like to explain that a change in the face with surgery can be done to preserve both familial and ethnic features. Balancing the features, enhancing the pleasing areas and softening the asymmetric areas are achievable goals. The result of this kind of surgical plan will give a very natural look, a look without the telltale signs of surgery.

Facial asymmetry is universal. All faces have some differences between the right half and the left half. Studies confirm the finding that some asymmetry is normal and attractive. However, too much asymmetry is viewed as less attractive.

A surgeon should not try to eliminate all asymmetry. Balance of facial features not only allows for some asymmetry but it also embraces it. A face can be too imbalanced (too thin, too fat, jaw too big or too small, nose too broad or crooked, cheeks too flat, teeth crooked). The surgeon can get a good idea of what form the "too much or too little" takes for each individual. He will note that the imbalance is due to genes or due to age. He will note whether the imbalance is from the bones or from the softer tissues. Only then can he give you a picture of what changes can be made.

Facial cosmetic surgery is able to make dramatic changes in the appearance of the face. Plastic surgeons are continually fixing faces that are abnormal. These faces may be that way due to birth deformities, injuries, or cancer surgery. From these experiences, we gain an understanding of how to improve the appearance of a normal face.

What Studies Tell Us

Earlier this year, an elegant research study showed that with age, facial volume decreases. This means that the fullness of the face goes away as we get older. Picture a baby! The round plump features are signs of youth. The features seem to be balanced. Aging robs us of this fullness. Most (90-92 percent) of the volume loss is due to soft tissue shrinkage. Only 8-10 percent is due to wearing down of the bones. When the bones are balanced and pleasingly shaped, the framework for a handsome or beautiful face is there for a lifetime.

We all know that beauty does not go hand-in-hand with brains, wit, or any other trait. And lack of beauty does not indicate lack of the same traits. Yet there is study after study that shows that the more attractive person will be chosen first, will have more opportunities open up, will receive more recognition and will be paid more for accomplishments.

Let me tell you about some of the ways that the foundation of the face can be shaped.

Crooked noses, large noses, unusual noses

The shape of the nose is formed with seven parts - two bones and five pieces of cartilage. When all of the parts are the right size and shape and they fit together well, the nose will be straight, not too big, not too small, and will look good. Different ethnic groups show consistent variations in this pattern. Even within a family there are variations that can be determined as more or less attractive. Nose surgery or rhinoplasty will reshape the parts of the nose and put them back together so that the nose fits the face better. All work is done from the inside so there are no visible scars. The patient wears a bandage for one week but it really takes about six weeks for the parts to heal. Expect some pain and facial stuffiness. This is an outpatient surgery procedure.

No cheekbones (a.k.a. Malar hypoplasia)

With flat cheekbones, the face looks older than it is because advancing age is also associated with shrinking of the cheekbones and sagging of the cheek skin. The cheekbones are also hollow and contain sinuses inside. Although the cheeks can be made larger by moving and shaping the bones, this is a long and complex operation that is usually reserved for treating children with birth deformities. For most people, the cheeks are usually enlarged by laying plastic pads onto the bones. This job is done from within the mouth or together with a facelift, therefore there are no visible scars. Healing is rapid and the amount of pain is low. This is an outpatient surgery procedure and you will be back to work right away.

Small chin (a.k.a. Microgenia)

It may occur by itself or it may be part of a small lower jaw. By itself, it is similar to small cheekbones and can be corrected with an onlay plastic pad. However, it is also an easy operation to correct the small chin by cutting the lower jaw and moving the chin forward and/or down. Sometimes one method is as good as the other, but for some people, one method may be better than the other. A small or weak chin can make the nose look larger than it really is. A small chin can make jowls droop further than with a normal size chin. This operation can be done from within the mouth or from under the chin. Expect bandage for one week, swelling of the chin and lip and some pain. This is an outpatient surgery procedure and you will be back to work in one week.

Jaw Surgery for Overbite and Underbite

Maxillary or mandibular retrognathia/prognathia refers to a large overbite or underbite that occurs because the upper and lower jaws are not of equal size. If the difference is small, orthodontic braces can usually correct the bite. When there is a larger imbalance, the jaws are cut and moved into a better position to create a perfect bite. I work with several fine oral surgeons who do this work. These movements also change the shape of the face and will usually help to balance the facial features. This group of operations can correct a toothless look, a gummy smile, or a weak chin. Incisions are made within the mouth, so there are no visible scars. Expect to stay in the hospital one to two days. There will be a lot of swelling which will last ten days, but not as much pain as you might expect. You can be back to school or work in one week, though it takes six weeks for the bones to heal. Therefore, no athletics should be undertaken for six to eight weeks.

Prominent ears

Ears are made of curled cartilage. "Big ears" do not have too much cartilage but rather the cartilage is curved outward. The shape is easily corrected by changing the curl of the cartilage. The scar is left behind the ear so that it is very hard to see it. Expect an earmuff bandage for one week and mild aching pain. Best to wait until six years of age or more. Back to school in one week.

These are the main procedures that I use to alter the bones and cartilage of the face. In a future issue of the Fountainhead, I will describe some of the techniques that are used to alter the softer tissues of the face.

Until then…Here's lookin' at you.

Sheldon M. Lincenberg, MD, FACS, is a Mayo Clinic trained, board certified Plastic and Reconstructive Surgeon practicing in Atlanta, Georgia.