Surgeons Compare Notes in Quest for Beauty : Specialists Describe in Detail an Array of Techniques for Altering Anatomy

Sometimes beauty is not a pretty sight:

The face of an African girl, deeply furrowed with the “beautifying” scars of a tribal ritual appeared on a screen. A second screen displayed a slide of three Burmese women who had stretched their necks to ostrich-like lengths with tight gold collars.

Every culture has its own concept of aesthetics, Dr. George Brennan told about 150 of his colleagues from across the country last week, launching the Foundation for Facial Plastic Surgery’s conference at the Four Seasons Hotel in Newport Beach. For the next five days, 17 specialists described, in sometimes grisly detail, the array of techniques to which Americans are currently subjecting themselves in hopes of approaching their culture’s ideal of flawless beauty. Titled “The Latest Advances in Cosmetic Surgery of the Face,” the conference covered the “state of the art” of chin implants, scalp reductions, and techniques for altering every square inch of anatomy in between.

The first thing presenters at the conference made clear is that a surgeon should have some concept of good looks before he puts scalpel to skin.

Basic aesthetic principles dating back to da Vinci are helpful, speakers said, pointing with red lasers at slides of faces onto which graphs and lines had been superimposed like blueprints to beauty.

The “rule of thirds,” for instance, holds that the length of a person’s nose should be equal to the length of the forehead and to the distance from the bottom of the nose to the chin. The “rule of fifths” dictates that the width of a person’s eye be exactly one fifth of the distance from ear to ear.

But such guidelines ignore the more subjective aspects of beauty.

Film stars have some influence on a culture’s sense of facial aesthetics, Brennan said. But Barbara Streisand is “a surgeon’s dream,” and even Marilyn Monroe had “an extremely bulbous nose” and thin lips. Since actors are often considered beautiful despite such “defects,” cosmetic surgeons generally don’t use them as primary examples in deciding how to sculpt a nose or shape an ear.

Magazines as a Resource

“The most important” resources for determining current aesthetic values are photography models and “the ladies’ interest magazines,” in which they appear, Dr. Norman J. Pastorek, an associate professor at New York Hospital, Cornell University Medical School, told the group. “It’s not us with our lines and protractors, but the top photographers, modeling agencies and the editorial staffs of these magazines--these are the people who determine who are the most beautiful people in America.

” . . . These are the people we’re trying to duplicate or emulate with our surgery,” Pastorek continued, showing slides of Christie Brinkley and other models as they appear on the current issues of Seventeen, Glamour, Redbook and Mademoiselle.

Such “increased aesthetic awareness” is one of the most important developments in elective, or non-essential, facial surgery, according to Brennan, a Newport Beach “facial surgery specialist” and the organizer of the event, which was presented in cooperation with the American Academy of Cosmetic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery. “We’re really in tune with what constitutes beauty now,” Brennan said.

(Plastic surgeons, who are certified by the American Board of Plastic Surgery, make a distinction between themselves and Cosmetic Surgeons, who are certified by the American Board of Cosmetic Surgery. Certified plastic surgeons point out that their board is acknowledged by the American Board of Medical Specialties, while the American Board of Cosmetic Surgery is not. Both plastic surgeons and cosmetic surgeons argue that they are best qualified to do “aesthetic” surgery.)

As speakers demonstrated, once someone decides he wants his appearance improved, the possibilities are almost endless. Program topics included “levator fixation and shortening” (a method of correcting a condition called “drooping eyelid” or “bedroom eyes”), “standard blepharoplasty” (the conventional method of doing upper eyelid surgery) and “cannula dissection with lipsuction” (an increasingly popular and controversial technique in which fat deposits are literally sucked up).

Extended Face Lift

Dr. Pierre F. Giammanco, a Michigan surgeon and assistant professor at Wayne State University, Detroit, detailed a technique called an “extended face lift” which he and a handful of doctors have been using for more than three years to remove the oro-labio folds--semicircles that run from the nose to the mouth--commonly known as “smile lines.” In this “technically difficult” operation, surgeons completely detach facial skin from the underlying muscle, stretch it back, reattach the tissue without the fold, then trim the skin and suture it behind the ear.

That technique gets rid of the fold, but leaves the faint line etched by the fold into the skin, Giammanco said. “A perfectionist will want to erase that line,” he added.

Speakers also gave an update on “filling agents,” the stuff doctors inject under the skin to fill the tiny spaces behind wrinkles or scars. A breaking development in this area is called “injectable dermis,” explained Dr. Dennis Everton, a Phoenix, Ariz., cosmetic surgeon who developed the procedure at Tripler Army Medical Center in Honolulu.

Doctors currently attempt to fill scars and wrinkles with silicone or various collagens, all of which have drawbacks. Silicone can, if improperly used, trigger dangerous reactions, Everton said. Collagens, including those synthesized from cowhide, such as Zyderm and Zyplast, tend to be absorbed fairly quickly by the tissue--and so the wrinkles may reappear, he added.

Using Everton’s technique, however, doctors use the patient’s own dermis--or deep layer of skin--which is usually discarded after a face lift or other operation. As Everton explained the procedure, the surgeon takes the tissue he has removed, “chops it down with scissors, and puts it into a machine that ‘morselizes’ it.” The tissue is then dried and pressed into “the consistency of toothpaste.”

Only five doctors in the country are now injecting patients with this substance, but Everton claimed it promises to have two advantages: It may last longer than other collagens, and patients who might reject silicone or other collagens will not reject their own dermis.

On a similar note, Dr. Norman Pastorek, who practices in Manhattan, and “just passed the 2,400 mark” on nose jobs, explained a new method he has developed for repairing what he refers to as “the ravaged nose”--often a nose that has been bungled by another surgeon or has sagged years after a seemingly successful rhinoplasty (nose job).

“As far as I know, I’m the only one doing this now,” Pastorek said of the operation. Pastorek first removes cartilage from a patient’s ear and shaves it into thin, razor-edged pieces. He then opens the tissue on the nose and begins rebuilding. “It’s a shingle effect. I put the grafts one on top of another like Spanish tiles. . . . I can totally restore the basic contours of a nose.”

Computer Imaging

For patients who want some idea before surgery how the contours of their new noses will look, Dr. Ron Shippert, an assistant clinical professor of surgery at University of Colorado School of Medicine and a cosmetic surgeon, discussed computer imaging.

With this system, a patient in search of a new visage is seated in front of a low-light video camera and his image appears on a high resolution video monitor. Using a light pencil and graphics pad the doctor redesigns the face on the screen, offering several possible “goals”--a few new noses for instance, and different shapes for the brow. A machine attached to the computer then produces photographs of each version of the remodeled face, which the patient can take home for approval by family or friends.

“Beauty is only skin deep, but I’m here to tell you, ugly goes straight to the bone,” Brennan said. “Weak jaws, weak chins, flat cheekbones, sloping foreheads. . . . None of these features are considered attractive. . . . We know that the prerequisite for facial beauty is the underlying skeletal structure. . . .”

For 20 years or so, doctors have inserted pieces of pre-shaped silicone into the chin and breast. For 10 years they’ve opened up the chin and whittled away excess bone.

Forging New Terrain

Within the past few years, though, a relative few surgeons have used refinements of those techniques to forge new facial terrain. After deciding the ideal shape of the patient’s face, the doctors create customized implants made of a substance called Silastic. Cutting and peeling back the slabs of skin covering a patient’s temple or forehead, they create a small pocket in the tissue into which they insert their “designer implants,” Brennan explained. Tissue grows into holes within the insert, anchoring it to the face. A small but growing number of surgeons also remove bone in areas previously avoided--such as the orbital rim above the eye, he added.

A stereotype links women and vanity. That fell apart in a presentation on what men go through to correct baldness.

One of the oldest methods is the simple graft--hair plugs are plucked from one area of the scalp and poked into bald spots. The result, however, often looks more like rows of corn than a head of hair, panelists said.

Using another technique, long or short flaps of scalp are transplanted from the hairy areas over the ears to the top of the head. As illustrated in a series of graphic slides, the surgeon cuts a strip of skin and rotates it, leaving a small segment attached to the head to maintain the blood supply. The piece is then sutured where a matching section of scalp has been removed. When properly done, the thin scar is invisible beneath the new and

Reducing Scalp Area

A surgeon can also make a patient’s head of hair appear fuller simply by reducing the amount of bald area. To do this, the doctor slices through the scalp in the desired pattern, removes the bloody swatch of hairless skin, and sutures shut the wound. The hairline has been lowered.

A problem arises, however, because the skin on the heads of about 50% of the men who would like to have scalp reductions is too tight to be stretched over the excised area, explained Dr. Sheldon S. Kabaker, an Oakland facial plastic surgeon, and associate clinical professor at U.C. San Francisco.

For a long time, these guys were out of luck. Since 1982, however, a few surgeons, including Kabaker, have been slicing open the scalps of select patients and inserting a balloon-like device called a “tissue expander” into the cavity.

For eight weeks, the patient pumps fluid into the expander until it grows to “the size of a baseball . . . slowly and safely stretching the scalp in the process,” Kabaker said. Then the doctor removes the device, cuts the expanded skin and stretches it over the gap.

The balding Dr. Kabaker obviously doesn’t practice what he preaches. “I’ve never had to rely on my looks,” he said. “My hair-bearing appearance just isn’t that important to me.”

Asked about the future of cosmetic surgery, Kabaker expressed an opinion his colleagues might find discomfiting. “I think there will be greater acceptance (of people’s natural appearance) in our society. . . ,” he said. “I think many of our idols will be viewed positively for being bald.”

However, he said, people have been judgmental of appearances since ancient times.

If anything, the trend is towards greater acceptance of cosmetic surgery, doctors at the conference claimed. And it’s no longer just actors and models and the idle rich who are willing to pay from $150 for simple collagen injections to $8,500 or more for a major overhaul.

A more likely future is the one Dr. Shippert is working on.

“Within the next couple of years you’ll be able to sit in front of a video camera, and we’ll be able to match your features with those of (people who have) more perfect features,” he said. “ . . . We’ll be able to say, this is where you fit relative to what we consider perfect in this culture.”

It has yet to be decided who will pick the range of perfect features to be programmed into the computer, Shippert said. “It will probably be done on the basis of a panel,” he said, “We might include a New York surgeon, a country surgeon,” and others who would reflect the range of America’s aesthetic tastes. “But surgeons will have to remember, this is not a cookbook that you follow. It will just give you some guidelines.”

The cookbook approach probably wouldn’t sit well with cosmetic surgeons anyway, since many see themselves as artists as well as doctors, said Shippert, who, like many of the surgeons at the conference, said he has had his own features touched up a bit. “I’m 50, and I’ve had a nose job, a face lift and my eyelids done.”

As Brennan said: “This is the only specialty in medicine I can think of that combines true art and science. . . . It’s living art--sculpting the living face.”