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About Face

C H A P T E R O N E

The Facial Assessment

Chapter One The Facial Assessment Balance and Proportion The Possibilities

THE FIRST ORDER OF BUSINESS, once I've established that a patient is a good candidate for facial cosmetic surgery, is to find out what the chief complaint is. We get to this easily enough: I simply say, "What's bothering you?" The answer is not always so straightforward. A patient might tell me that she doesn't like the bump on the end of her nose, but her idea of where the end of her nose is could be different from mine. I'll make the patient point with a finger directly at the area of concern, and sometimes, it's a surprise to me.

One reason I can be surprised is that, naturally, I take a more objective view of a patient's face than the patient is able to. It's not as simple as "A nose is a nose" (with apologies to Gertrude Stein).

Balance and Proportion

In a facial assessment, I start by looking for balance, or lack of balance, as the case may be. To do this, I mentally draw lines that would divide the face roughly into three parts: the top third extends from the forehead hairline to the middle of your eyebrows; the middle third is from your eyebrows to the base of your nose; and the bottom third is from the base of your nose to the lower edge of the chin. If the three parts are essentially equal in height, you've got a nicely proportioned face, no matter what your individual features might look like to you.

But let's just say that the bottom third of your face is noticeably shorter than the top two-thirds. Perhaps you have a slightly receding chin. While all you can see is the bump on your nose, I can see that once I've reduced the overall size of your nose, perhaps as a result of minimizing the bump, I'll have to add a small chin augmentation, a "chin implant" as it is called, in order to balance the effect.

Or my assessment of your chief concern might have less to do with overall balance than with a slight deviation that you haven't been able to properly identify. To continue with the example of the bump on your nose, it could be that the natural Aging process or upper-teeth dental surgery has caused the nose to drop its tip a bit, and as a result, a bump on the dorsum (the central ridge of the nose), has begun to appear. The solution might have more to do with tilting the tip up than smoothing out a bump. I have a three-way mirror in my office, and I have my patient to stand in front of it so we can consider balance and profile, letting his or her illustrate our discussion.

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