TITLE: Preoperative Evaluation of the Aesthetic Patient
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: April 21, 2004
RESIDENT PHYSICIAN: Glen T. Porter, MD
FACULTY PHYSICIAN: Francis B. Quinn Jr., MD
Contributions from Rusty Stevens, MD and Michael E. Prater, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD
"This material was prepared by resident physicians
in partial fulfillment of educational requirements established for the
Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and
Neck Surgery and was not intended for clinical use in its present form. It was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect to its
accuracy, completeness, or timeliness. The material does not necessarily
reflect the current or past opinions of members of the UTMB faculty and should
not be used for purposes of diagnosis or treatment without consulting
appropriate literature sources and informed professional opinion."
INTRODUCTION
From the 1940's to the 1960's, most patients
seeking cosmetic surgery were referred for psychiatric evaluation, as it was
felt that essentially every patient seeking cosmetic surgery had a psychiatric
problem. Psychiatric illness was
considered an absolute contraindication to cosmetic surgery. By the
1990’s Stanbaugh and others asserted that “there [were] no poor candidates for
facial aesthetic surgery.” The 2000’s
have been marked by a heightened cultural awareness and acceptance of cosmetic
surgery for both females and males.
Television programs such as “Extreme Makeover” reflect an unprecedented
celebration of aesthetic surgery. It is
not surprising that the current level of demand for cosmetic surgery is greater
than ever before.
As the demand for aesthetic surgery continues to grow,
a reliable means of assessing the patient is desired. This paper will
discuss the preoperative evaluation of the surgical patient, including patient
selection and facial analysis.
THE SURGEON'S ROLE /PATIENT SELECTION
The surgeon plays the roles of physician, therapist,
psychiatrist and artist. Successful cosmetic surgeons tend to have three
characteristics. First, they recognize their role is no longer sacrosanct
yet they are able to maintain the principle role of leader. Second, they
approach problems affirmatively and assertively. Third, and most
importantly, they have a clear understanding of the patient's motivation before
the operation proceeds.
First and foremost the surgeon must understand the
motivation of the patient. This is not always easy, as patients may mask
their true desires. They may even request one surgery, when truly
desiring another. Occasionally, the patient suffers from a psychiatric
illness. Such circumstances demand the surgeon understand what is not
said. This means the surgeon know the patient, including a complete
history and physical exam with emphasis on social and family
history.
The selection of a patient for cosmetic surgery begins
with the initial interview. It is the surgeon's responsibility to screen
all patients. A poor outcome is likely
due to either poor patient selection or technical error. Once the
patient’s medical history and physical exam indicate that the patient is able
to undergo surgery, the physician should attempt to uncover the patient's fears
and wishes and to assess whether these issues will lead to future
problems. Rohrich felt that a surgeon
must understand the patient’s personality traits, likes and dislikes, as well
as their goals for surgery, their reason for pursuing surgery at that time, and
their expectations for surgical outcomes.
If the surgeon does not feel comfortable with the information obtained
from the patient he or she should either continue with more in-depth evaluation
of the patient, or refer the patient to someone else. Goldwyn and Gorney (see below) proposed
additional series of questions that might be used to preoperatively evaluate
the aesthetic patient. The accepted
consensus emphasizes that the surgeon spend whatever time is necessary to
effectively evaluate the patient such that he or she is able to offer the best
treatment option for each patient. When
couched in the context of the surgeon’s aesthetic standards and surgical
abilities the offered treatment options may range from referral to surgical
correction, but should be based on a thorough understanding of the patient and
their desires.
The patient interview requires a subtle leadership
which relies on communication. The
physician should not voice any opinion until the patient has fully explained
their desires. This avoids projection of the surgeon's wishes onto the
patient. The surgeon should explain what
can and cannot be accomplished with all interventions. The most frequently expressed patient
dissatisfaction is the physician's lack of communication prior to
treatment. Thus, the definition of an
acceptable outcome should be jointly established by the surgeon and the patient
prior to any surgical procedure. Failure to do so may result
in misunderstandings and dissatisfied parties.
PSYCHOLOGIC CONDITIONS
Early studies on patients seeking cosmetic surgery
showed a large percentage of patients with identifiable psychological
problems. These studies employed an
interview format of psychoanalysis, and suffered from the lack of
standardization and bias. More recent
standardized studies employing survey formats have identified a much smaller
percentage of psychopathology in cosmetic patients. Moreover, studies have shown that many
patients suffering from depression, neurosis, and even psychosis report a
significant improvement of their symptoms after cosmetic surgery. There are, however, a group of patients who
have consistently been shown to fair poorly after cosmetic surgery. The aesthetic surgeon should be able to
recognize psychological conditions and then use that knowledge to make informed
patient recommendations in regards to surgery and/or psychiatric
evaluation. If the patient is already
under psychiatric care, the decision to pursue surgery should include the
psychiatrist, as well.
The neurotic patient: The neurotic
patient is characterized by excessive worry, anxiety and somatic
complaints. These neuroses serve as a defense mechanism, and attempting
to address these characteristics in a flippant manner results in a defensive,
unhappy patient. These patients usually ask numerous, often repetitive,
questions which often require detailed and technical explanations. They
often obsess about possible postoperative complications, which they usually are
aware of in detail. Their questions are often a "cover" for the
need for reassurance.
Properly counseled, neurotic patients often make
excellent surgical candidates. Their preoperative concerns are usually
unfounded, and they are often happy with results. The important part in
this patient selection is to identify the problem preoperatively and properly
address all issues, including possible psychological evaluation.
The psychotic patient: The most commonly
seen psychotic disorder is schizophrenia. These patients have
disorganized thoughts, flight of ideas and are incapable of
introspection. They are usually emotionless and humorless.
The paranoid schizophrenic also incorporates thoughts of persecution and
selfish behavior. Several cases of paranoid schizophrenics turning
violent after their cosmetic surgeon attempted to terminate care have been
reported. Thus, if a patient appears
paranoid, a psychiatric evaluation should be pursued. If one
chooses to operate on the paranoid patient, meticulous postoperative care
should be anticipated.
Personality Disorders: Personality
disorders manifest as behavior problems, rather than psychotic or neurotic
problems. Unfortunately, these patients are often able to
disguise their personalities, making diagnoses difficult.
The narcissistic patient is usually regal and elegant
in appearance, and often obsessed with subtle- even imperceptible - physical
flaws. Their opinions of themselves are often grandiose, and they are
sometimes "name droppers." They suffer from poor ego formation
and self esteem, and are prone to postoperative depression and
dissatisfaction. Psychiatric evaluation is warranted.
Several other personality disorders have
"splitting" as a personality trait. "Splitting"
refers to lumping people into "us versus them" categories. They
may idealize their current physician while denigrating former physicians.
The same is often true for feelings about family members and friends.
Manipulation is usually prevalent in this population, and these patients may
occasionally dress inappropriately and be excessively flirtatious.
Likewise, these patients benefit from preoperative psychiatric evaluation.
The malingerer: The malingerer
fakes symptoms and illnesses. The motive is usually monetary, either from a
presumed injury or through malpractice insurance from the physician. Like
the personality disorder, this condition may cause the physician to feel
uneasy. Usual findings during examination include complaints that are
grossly out of character with physical findings.
The depressed/manic patient: The
depressed patient complains of minimal joy in things they formerly found
pleasing (anhedonia). They either have difficulty sleeping despite
being tired, or sleep excessively with little sensation of rest. They
complain of poor energy and motivation. Depression may be part of a
grief reaction and therefore transient, or part of an underlying pathologic
process. An adequate social and family history may discern between the
two. The manic patient usually has flight of ideas, pressured
speech and is disheveled in appearance. They rarely present for aesthetic
surgery. Psychiatric evaluation may be helpful for both depressed and
manic patients. Once treated, these
patients are excellent candidates for surgery and may even show further
improvement of symptoms after surgery.
Body Dysmorphic Disorder: More than half of Americans (43-56%) are
unsatisfied with their appearance. Thus,
body dissatisfaction is common. Body
dysmorphic disorder (BDD), however, describes a group of patients with an
inordinate concern for slight or imagined aesthetic defects. These patient’s lives are significantly
disrupted by their obsession with their perceived physical flaws. The most common focus of the patient’s
dissatisfaction is the skin, face, and nose.
The incidence of the disorder has been estimated at 0.2% of the general
population. This number is significantly
higher (2-7%) in the population of patients presenting for cosmetic
surgery. Sarwer described several
disorders that often accompany BDD.
These include obsessive-compulsive disorder, social phobia, eating
disorders (anorexia/bulimia), gender identity disorder, and major depression. Identification of these problems should
prompt a thorough search for symptoms of BDD.
Multiple authors have indicated that patients with body dysmorphic
disorder are not good candidates for aesthetic surgery as they are seldom, if
ever, satisfied with the results. In
fact, their symptoms may actually be exacerbated by surgery. These patients should not be considered for
surgery and should be referred for a psychiatric care.
PATIENT REJECTION
During the preoperative evaluation the surgeon should
pay special attention to their “gut feeling” about the patient. A sense of unease should trigger a more
in-depth evaluation and perhaps rejection of the patient. Authors Gorney and Goldman have delineated
findings which, in their experience, should cause the surgeon to think twice
about operating. These include patients
who are single, immature, male, overly expectant, and narcissistic. They also warn against operating on the
patient whom you don’t like, who is rude to your or your staff, who lies to you
or refuses to be photographed, and patients who want you to do something you
can’t deliver or feel is outside your aesthetic sense of what should be
done.
Physicians do not commonly reject patients
outright. They are usually referred to another physician or a repeat
consultation session is scheduled. The patient may find another
surgeon whom they prefer, or they may become tired of the apparent indecision
by the surgeon and seek treatment elsewhere. Another common method is to
schedule an initial consultation which is free of charge, but charge for
additional consultations.
THE DISSATISFIED/LITIGINOUS PATIENT
Despite a
seemingly meticulous preoperative evaluation and successful surgical
intervention, there will always be
dissatisfied patients. When faced with an unhappy patient, the first
impulse of the surgeon is often a defensive one. This should be avoided. Defensive
posturing on the surgeon's part leads the patient to feel abandoned and
unappreciated. The unappreciated and abandoned patient is more likely to
be litigious. Thus, the physician must
listen to these patients patiently. Listening is often therapeutic and
does not imply agreement. Restating the patient’s concern will help the
surgeon to understand their complaint, and will reassure the patient that he or
she is being listened to. If the surgeon
feels the patient is correct in their concern, the surgeon should be forthright, and if necessary, offer revision
surgery. If the surgeon does not feel revision is warranted, return visits
at regular intervals may be scheduled. Concerns and dissatisfaction often
resolve with time.
CONCLUSION
Preventing patient dissatisfaction depends upon proper
patient selection. The selection process begins with the initial
interview. Any patient that makes the surgeon uncomfortable should at the
minimum have surgery delayed, and perhaps referred for psychiatric
evaluation. The most commonly diagnosed psychological conditions which
should make the surgeon concerned include: neurotic disorders, personality
disorders, psychotic disorders, depression/mania and body dysmorphic
disorder.
FACIAL ANALYSIS
INTRODUCTION
Although facial beauty may be difficult to define, it
is important for the Otolaryngologist to adopt an objective and systematic
method of preoperative evaluation of patients seeking aesthetic surgery. This
will not only enhance the surgeon's ability to identify flaws within the facial
subunit in question, but will also ensure that equally important abnormalities
in other subunits do not go undetected.
The currently accepted norms of facial analysis have a long
history. The Greek Polycleitus (450-420
B.C.) was the first to quantify symmetries and proportions and describe the
canon of facial analysis. His sculpture
of Doryphorus was intended to represent these ideal relationships. Leonardo Da Vinci (1452-1519) reported
extensively on the proportions of the human body. He was the first to describe the three vertical
divisions of the face. His canon of
facial and body proportions were also reflected in his art. Durer (1471-1528) also created a canon of
facial proportions. He felt his
measurements should be used by artists to guide their compositions. He was the first to report that the
intercanthal distance is equal to the width of an eye, and divide the lower
face in to equal fourths. Jacques Joseph
(1865-1934), also known as the father of rhinoplasty, reported extensively on
the measurements of the nose. B. Holly
Broadbent (1894-1977) introduced the use of radiographic cephalometrics to
evaluate facial proportion. R.M.
Ricketts popularized the golden proportion (1:1.618). L.G. Farkas was responsible for revising the
classic canon based on multiple soft tissue studies. He also described how ethnic faces differed
from the accepted canon.
Farkas and others showed that few people, Caucasian or
ethnic, fit the neoclassical canon of fixed proportions and ratios. Yet, beauty has been shown to be consistent
even across cultural groups. Studies
have shown that symmetry and “averageness” is associated with beauty by
infants, children and adults in multiple cultures. Interestingly, extreme beauty is associated
with magnification or diminution of at least one feature. Multiple studies have shown that those who
are deemed “beautiful” by their societies are given deferential treatment, rise
to the top of their work fields earlier, are less likely to be reported or
convicted of crime, and even wait shorter amounts of time for services.
ANATOMICAL LANDMARKS
Prior to any discussion of facial analysis, a basic
understanding of the important landmarks is required. The superior boundary of
the forehead is the trichion which is located at the frontal hairline.
Inferiorly the forehead slopes anteriorly to the glabella. The nose has several
important landmarks including the often-referenced nasion, which is the
depression at the root of the nose corresponding to the nasofrontal suture. The
rhinion corresponds to the bony-cartilaginous junction and the tip-defining
point is the most anterior point of the nasal tip. The subnasale is another
frequently used reference point that is located at the junction of the
columella and the upper lip. The primary landmarks of the lips are the
vermilion borders (mucocutaneous junctions) and the stomion where the upper and
lower lips come together. Moving inferiorly, the lower lip transitions into the
chin at the mentolabial sulcus and the most anterior point on the chin is
termed the pogonion. The menton is the lowest point on the chin curvature. The
gnathion is located where a line tangent to the pogonion intersects a line
tangent to the menton. The cervical point is located where a line tangent to
the menton intersects another tangent drawn along the anterior border of the
neck. Finally, the tragion is located at the supratragal notch and is an
important landmark for determining the standard horizontal position of the
face. There are also multiple lines and angles used to objectively evaluate
facial structures and these will be defined as they are presented.
METHODOLOGY
There is a large body of literature discussing various
techniques to analyze the face as a whole as well as its individual subunits.
Perhaps more important than the specific technique used is the constant use of
the same technique. Ideally, the technique will allow thorough evaluation of
each subunit as well as how the subunits relate to each other to determine
overall facial harmony. While more experienced surgeons may not require a
rigid, systematic approach, the younger facial plastic surgeon may fail to
recognize subtle abnormalities or disproportions if such a step-by-step
approach is not utilized. With this in mind, Hom and Marentette developed an
eight step approach to facial analysis with the goals of providing a basic
conceptual framework that reinforces the established facial proportional
relationships. Initially the facial
height, width and symmetry are evaluated on frontal view. Subsequent steps
utilize the lateral view to determine facial height, projection (lateral view
width), and the nose-lip-chin relationship. Finally, the individual subunits
are carefully evaluated.
Frontal view
evaluation
Step 1. Vertical height -
From the time of Michelangelo, observers have noted
that the face can be divided into equal thirds. The boundaries of the upper
third are the trichion and the glabella, with the mid third extending from the
glabella to the subnasale. The lower
third extends from the subnasale to the menton.
The lower third can be further subdivided into thirds with the stomion
marking the inferior boundary of the upper third, and the lower lip and chin
forming the lower two-thirds. While some have advocated evaluating only the mid
and lower face in men with receding hairlines, others have stated that the
appropriate superior border for the upper third can be determined in these
cases by locating the most superior movement of the frontalis muscle.
Step 2. Width -
The easiest way to evaluate the relative width of
facial structures is to divide the face into vertical fifths with each fifth
being equal to one eye width. This technique is also helpful at determining the
appropriate width of several individual subunits and will be discussed further.
Step 3. Symmetry -
A midsagittal line is drawn and the symmetry of the
various subunits (ears, eyes, eyebrows, nose, and mouth) is compared. This is
also a good time to assess the overall facial shape which should be roughly
oval.
Lateral View evaluation:
Prior to evaluating the patient's profile, it is
important to assure appropriate head position. This has traditionally been
accomplished by placing the Frankfort horizontal line parallel to the floor.
The Frankfort horizontal line is drawn between the superior aspect of the
external auditory canal (or through the tragion) and the infraorbital rim. A
second technique to obtain the patient's natural horizontal head position is to
have them fix their eyes on a point at eye level.
Step 4.
Vertical height -
Again, facial height is divided into thirds as in step
1, and the equality of the thirds reassessed. The vertical placement of
landmarks is also determined in this step. As stated above, the lower third can
be further divided into thirds with the stomion separating the upper and mid
thirds and the pogonion lying in the center of the lower subdivision.
Step 5. Midface projection –
To assess the midface position relative to the upper
face, a second line is drawn from the nasion to the subnasale. This line should
form an angle of 85 to 92 degrees when compared to the Frankfort horizontal
line and is termed the zero meridian. If
this line is excessively anterior, the
midface is described as anteface, and if posteriorly, a retroface profile is
present.
Step 6. Lower face position -
The position of the lower third of the face compared
to the upper third is then established, again with the zero meridian providing
the reference. A line is drawn from the subnasale to the pogonion. This line
should lie at a ten degree posterior angle from the zero meridian. If the
pogonion is placed significantly anteriorly, it is said to be protruding and if
posteriorly, retruding.
Step 7. Nose-Lips-Chin Position -
At this point the relationship of the nose, lips and
chin to each other is evaluated using Rickett's E (esthetic) line. This line is drawn from the nasal tip to the
pogonion. The lips should lie just posterior to this line with the upper lip
approximately twice as far from the line as the lower lip. If this is the case,
no further evaluation of these structures is indicated at this time. If not,
one of the three structures is malpositioned. Since the pogonion was evaluated
in step 4 and 6, only the lips and nasal projection are further evaluated at
this time. A quick assessment of nasal projection is provided using Goode's
ratio which compares a line from the alar groove to the tip with a second line
from the nasion to the tip. The ratio of the former to the later should be
approximately 0.55 to 0.62. The
anterior-posterior position of the lips is quickly evaluated by the Holdaway H
(harmony) line. This line starts at the ideal pogonion and is drawn ten degrees
anterior to a line from the pogonion to the glabella. The lips are
appropriately positioned if they approximate this line.
Step 8. Evaluation of individual subunits -
Forehead
Although the forehead is rarely altered surgically, it
is important to evaluate because of its relationship to other parts of the
face. Additionally, certain aspects of the forehead may dictate the surgical
approach as in the case of a receding hair line or the presence or absence of
deep forehead creases. In regards to the normal contour of the forehead, men
tend to have more prominent glabellar and supraorbital rim regions with women
having a smoother transition into the midface.
Eyes and eyebrows
Again the eyebrows differ between sexes with the ideal
male brow placed at the supraorbital rim and fairly flat. The female brow rest
slightly superior to the rim and has a more prominent arch located at the level
of the lateral limbus. The brow should start medially at a vertical line that
passes through the alar groove and medial canthus, and continue laterally to
end along an oblique line from the nasal ala through the lateral canthus at
roughly the same height as the medial brow.
Careful exam to rule out brow ptosis is extremely important if
blepharoplasty is being considered. The intercanthal distance is usually 30 to
35 mm and can readily be evaluated when the frontal view is divided into
vertical fifths with this distance equal to one eye width. Both upper and lower lids should be carefully
examined both visually and manually to determine their shape and elasticity.
The upper lid margin should have its highest point at the junction of its
middle and medial thirds and the lower lids lowest point should be between the
middle and lateral thirds. The upper lid should cover 2 to 3 millimeters of
superior iris and the lower lid margin usually approximates the inferior
iris. Lagophthalmos may be identified by
having the patient look down while tilting the head backward. The superior palpebral lid crease identifies
the attachment of the levator aponeurosis into the orbicularis muscle and
should be located approximately 9 mm from the eyelash line. The presence and location of fat
pseudoherniation should be determined and an inferiorly displaced lacrimal
gland noted if present. Horizontal laxity of the lower lid can be tested by
pulling the lid away from the globe and then releasing it. In the normal lid,
it should snap back. If it returns slowly or not at all, significant laxity
exists. Also the strength of the orbicularis muscle should be checked by having
the patient close their eyes tightly while the examiner attempts to open them
manually.
Nose
In addition to the initial evaluation presented above,
the nose should be evaluated for dorsal deformities and appropriate width on
frontal view. Again, dividing the face into vertical fifths helps quickly
determine whether an acceptable lower nasal width is present. The alar width
should be equal to one eye width (one fifth the facial width) in Caucasians. Wider noses are acceptable in Asian and
African-American faces. This distance may also be evaluated by determining the
length of the nose from nasion to tip, with the width being approximately 70%
of the length. On profile view nasal projection, rotation and length as well as
the nasofrontal, nasofacial and nasolabial angles are more closely evaluated.
The nasofrontal angle is formed at the nasion by lines that extend from this
point to the glabella and to the nasal tip. This angle should ideally be 120 to
135 degrees. The position of the vertex of this angle (nasion) is also
important because moving it up or down will lengthen or shorten the nose,
respectively. Its usual position is at the level of the superior limbus of the
eye. Nasal tip projection is often difficult to determine and many techniques
have been advanced. Goode's ratio of 0.55-0.6:1 when comparing projection to
nasal length has been presented above. Another method involves the nasofacial
angle which is formed by a line along the nasal dorsum intersecting a line from
the glabella to the pogonion. The ideal nasofacial angle is 36 degrees. Nasal
length, height and projection may also be examined simultaneously by creating a
right triangle between the alar groove, the tip defining point and the nasion.
The projection, height and length should create sides with a ratio of 3:4:5
respectively. Finally, an easy but often
inaccurate method of determining projection compares it to the length of the
upper lip from subnasale to vermilion border with the two being roughly equal.
The fault with this technique lies in the variability of the upper lip length.
Tip rotation is assessed by evaluation of the nasolabial angle which is formed
by lines along the columella and upper lip that intersect at the subnasale. The
ideal nasolabial angle for women is 100 to 120 degrees and men between 90 and
105 degrees. Also on lateral view, the alar and lobular lengths should be equal
and there should be between 2 and 4 mm of columellar show. On basal view, the nose
should have the shape of an equilateral triangle and the columella should be
approximately twice as long as the lobule.
The lobule should be 75% as wide as the alar base and the nostrils
should be roughly pear shaped.
Lips
The relative position of the lips as compared to the
nose and chin have been discussed. It must be remembered that these structures
as well as the patient's dentition will affect the appearance of the lips.
Other considerations include the width of the lips, the interlabial gap and the
degree of incisor show with smiling. The
oral commissures should be located along vertical lines drawn from the medial
limbus of the iris. Also, the lower lip should be slightly more full than the
upper lip. When relaxed and with teeth in occlusion, the lips should
approximate one another with an interlabial gap of 3 mm being the upper limit
of acceptable. When smiling, there should be no gingival show and no more than
two thirds of the maxillary incisors exposed.
Chin and neck
The relative position of the chin has been determined
in the initial evaluation and further evaluation is aimed mainly at the shape
of the chin and its relation to the neck. The mentolabial sulcus depth is
assessed by creating a line from the lower vermilion border to the pogonion.
The sulcus should lie approximately 4 mm behind this line. In regards to the
neck, Dedo developed a classification system based on the depth of the
abnormality proceeding from superficial, skin and fat, to deep, muscle
(platysma) and bone (chin or hyoid). Class I is the youthful, normal neck.
Class II and III represent early abnormalities of skin and fat accumulation,
respectively. When platysmal abnormalities such as banding are identified,
Class IV is defined, and the loss of an appropriate mentocervical angle because
of a posteriorly positioned chin is labeled Class V. Finally Class VI results
from an inferiorly placed hyoid bone. Class VI is particularly important to
identify because very little can be done surgically to correct this
abnormality. Lastly, the appropriateness
of the neck length can be determined by comparing the distance from menton to
suprasternal notch, to the head height measured from menton to vertex, with the
head being approximately twice as tall as the neck.
Ear
The auricular length should be slightly less than
twice its width and the long axis should be inclined approximately 20 degrees
posteriorly. The external auditory canal should be located at a level roughly
halfway between the lateral canthus and the nasal base. The superior aspect of
the ear should be at the level of the lateral brow and the inferior aspect at
the level of the nasal base. The auriculocephalic angle should measure
approximately 20 to 30 degrees. Specific
landmarks of the ear including the helix, antihelix, scaphoid fossa, tragus,
and lobule should be evaluated for obvious deformity. The thickness and
flexibility of the cartilage should also be estimated.
Dental occlusion
As mentioned above, the patient's dentition may play a
significant role in overall cosmesis. Although an in depth discussion is beyond
the scope of this discussion, the dentition should be evaluated and correction
considered if abnormalities are present that could cause aesthetic problems.
Briefly, normal occlusion is present when the mesiobuccal cusp of the maxillary
first molar occludes the buccal groove of the mandibular first molar. This is
termed Type I occlusion. Type II occlusion occurs when the mandibular teeth
occlude in a more posterior position and Type III occlusion is when they are
more anteriorly located.
CONCLUSION
While there are many ways to approach facial analysis, it is important that the technique used be easily remembered and applied. In this way, a routine, systematic approach may be developed that should help maximize the evaluation of the subunit in question while minimizing the risk of overlooking other important abnormalities. The technique described here initially evaluates several general facial parameters on both frontal and profile views, and then looks at specific subunits in more detail.
From the moment the physician walks into the
examination room he or she is acting in several roles. As a physician he or she must evaluate the
patient’s general health and physical ability to undergo surgery. As a therapist, the surgeon must be able to
listen to patient concerns and respond in a way that is helpful to the
patient. Communication skills are
paramount. As a psychiatrist he or she
requires an in-depth understanding of patient motivation with an ability to identify
psychiatric disorders. As an artist, a
surgeon must maintain a clear picture of outcome limitation and be able to
perform objective facial analysis with an artist’s flair.
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