A possible definition of cosmetic treatment is the operative or non-operative change of a “normal” individual to another form that improves their quality of life, wellbeing and self-esteem. It does in fact raise the fundamental question of what we regard as normal?
The pictorial representation of normality, especially of the face, underwent several revolutions since the dawn of civilization. The renaissance was an intense period of re-discovery of the classical ideals of ancient Greek culture and sculpture. Genius artists such as Leonardo Da Vinci explored the rules of facial proportions. He understood the range of ratios between the width of the eyes and the width of the nose or the distance the eyes are apart. On a two-dimensional plane, he divided the face into horizontal thirds and vertical fifths, which helped him to draw a “normal” Western face (Fig 1).
These basic concepts developed into modern sophisticated photographic and X Ray-based guidelines known as cephalometric analysis. Angles and lines are drawn to mathematically describe apparent proportions. These studies can certainly guide reconstructive and cosmetic surgeons towards the goals and boundaries of how much change would be aesthetically acceptable. However although much is known about the ideal proportions of the Western face, these techniques do not really tell us if someone is unattractive or beautiful. Indeed these subjective concepts are complex, personal, psychological and cultural.
I find it fascinating that Leonardo’s painting of the Duke of Milan’s mistress, Lady with an Ermine drawn 500 years ago, still resonates to European minds as a young woman of beauty (fig.2). We are conditioned, taught, educated or maybe genetically wired to appreciate her. In the twenty first century, the yardstick by which we judge aesthetic results are based upon our pre-conceptions, education, genes and exposure to mass media!
When African art influenced Picasso, the artistic frame of reference was thrown out. This was partly because of the huge conceptual differences between the depiction of the African face and Western art, and also the known proportional studies of the Western face were invalid for the African one. Picasso (initially representing Western aesthetic appreciation) tried to explore this during his African phase of paintings. He eventually produced outrageous images partly based upon African art. I suspect, at the time, its primitive and alien nature must have inspired him (Fig.3)
For the major facial reconstructions for severe abnormalities I help to carry out in Ethiopia for Facing Africa charity missions, I will never achieve the classical ideals with which I have been trained. The yardstick by which I judge aesthetic results is based upon our pre-conceptions and exposure to a world that is distinctly not Ethiopian. I am very curious about the dissimilarities in cultural aesthetic and in the future intend to study whether my concept (which is Western) of a normal or a beautiful African face will be the same as that of an indigenous person. I hope that you will all help with this in due course with a photo questionnaire.
I am sure there also are a myriad of other factors that I have yet to understand. However, all this in relationship to cosmetic surgery, has made me appreciate that really understanding the patient’s aims and goals and the personal benchmarks that drive the wish for change are the most critical elements to enable the surgeon to understand whether cosmetic surgery is in their best interests. I believe that in many cases, unhappy outcomes arise because this critical part of the assessment was misunderstood or misinterpreted. We each carry around our own personal concepts of what is normal and beautiful. To appreciate this is part of the art of cosmetic surgery.