Sculpting the Face: A Novel, Dynamic andArtistic Technique for Structural Analytic Assessment of the Aesthetic Patient
Dr. Benjamin P. Caughlin, MD
It is well accepted that photographic documentation is essential in reconstructive and cosmetic surgery. Similarly, artists that sculpt human faces have utilized age-old techniques, such as projection of lights and shadows, to delineate nature skin folds and asymmetries prior to sculpting. Utilizing pre-sculpting images from sculptors allows for comparison which exemplifies the similarities between artistic sculpting and facial plastic surgery. This article is an artistic application of photographic adaptation into the world of facial plastics. Lights and shadows are pivotal to assessing the aesthetic face. The exact architecture of shadowing is crucial to success. Shadowing delineates the topographical appearance of the face. Pre and post-operative assessment of the aesthetic patient is one of the most objective aspects of the field. Objective documentation is important both clinically as well as scientifically, as reproducibility is essential to scientific studies. Persichetti and colleagues have published on standardization of such documentation. In their article they appreciate the the importance of consistency and reproducibility. They also focus on the importance of cost effective use of digital equipment to obtain such data. The photographic aspect of the plastic surgery field has become advanced and this encourages practitioners to even develop photographic studios. Similar techniques have been utilized by sculptors for over a century now (Figures 1- 3). One aspect of facial plastic photography that has been underdeveloped is intraoperative assessment of the facial topography. Acutely, during the operation, the surgeon is forced to subjectively assess the progress of alterations. This is due to the fact that taking and producing photos, even computer generated ones, is time consuming intraoperatively. Assessing lights and shadow realtime during operations or clinic injections would be ideal. To be able to dynamically assess augmentation while utilizing more objective tools than solely the naked eye would be advantageous.
It is ideal for the surgeon to demonstrate to patients the asymmetries and other imperfections that are amenable to the armamentaruim of the facial plastic surgeon. In this article we propose an objective, expeditious and dynamic process for documentation of real time facial augmentation. The goals of this article are twofold. The first goal is to create a method for dynamic feedback during procedures in the office and in the operating room. It will allow the surgeon to directly and accurately appreciate how facial architecture changes during facial injection or during other augmentation procedures. Intra-operatively the technique could be useful to help delineate precise geometries of the face.
The second objective is to create a technique that could be used for assessment of pre and post-operative aesthetic patients. This is accomplished by harnessing the artistic quality of sculptors. It will allow for immediate and objective information for the patient and the surgeon. This could be used as a tool for the descriptive process of pre-operative assessment while the surgeon explains his role in obtaining the patient’s goals. The same photos and positions could then be taken post operatively for comparison and documentation for scientific studies.
This information is confidential and is property of Dr. Benjamin P. Caughlin, MD. 2
Figure 1: Pre-sculpture Photo of a Woman Utilizing Grid Projection by
Beltran. The soft tissue structures of the face and their inter-relationships
are well appreciated with this view.
Figure 2: Pre-sculpture Photo of a Man with vertically projected lines to
appreciate the true topography of the face by Beltran.
Figure 3: Profile preparation for pre-wax molding depicting facial topography
Artistic Topographical Assessment
With one technique the artist would take profile images projecting straight
lines in a vertical fashion. This would create multiple sequential true profile
shadows as pictured above. Then, plywood is used to cut out each sequential
profile view. Measurements are taken from the photo and used to properly
prepare the wooden profile selections. These are then aligned and secured
together. Next a wax mold is made of the head. A knife, or scalpel, is used to
dissect off all of the wax until wood is reached. This creates a topographical
model of the face with exact subsite relationships.
Figure 4: Profile preparation for pre-wax molding 2
Figure 5: Sculpture of the Face by Beltran
• Utilize laser projected grids to dynamically illustrate and portray the
affects of injectable materials and other facial augmentation techniques
immediately and throughout the procedure
• Harness ancient sculpting techniques to illustrate an artistic and novel
aspect to the pre and post-operative assessment process
• Create a time conscious and cost effective technique for pre and post-
operative assessment of the aesthetic patient
• Develop an objective assessment tool that is standardized and easily
replicated pre and post-operatively
• Allow patients to conceptualize the process of facial aesthetic assess-
ment and to allow them to immediately visualize and appreciate their
This novel technique involves projected laser light to delineate precise facial
topography. In this article we use a green light laser with 530nm wavelengths,
a projected grid, a tripod to secure the laser, and a camera for assessment
of the aesthetic patient (Eric will insert photographic specifics such as light-
ing and camera angles and camera type). The projected light falls on the
patient’s face delineating natural angles, folds and asymmetries. The grids
are built with the appropriate shapes, angles and dimensions for standard-
ized analysis of the face. Utilizing the previously published criteria stated
by Persichetti, a standardized criteria for each specific anatomic area is de-
fined. Placing the grid on a sliding platform with measurements will allow
for documentation of distance of the laser to patient. The lens of the camera
and the lens of the laser source is secured directly tangental to the patient.
This assures proper photographic assessment. Below is a description of the
standardized face view with appropriate description of projected lights and
grids used for pre and post-operative assessment in this study.
The Face View
• Straight on Frontal View: A straight on frontal view with a single
straight line that is projected to orient the patient relative to the Frank-
furt plane at the horizontal. A grid with six vertical lines and another
with three lines in the horizontal direction for the assessment of vertical
fifths and horizontal thirds respectively .
• Oblique View: Again with proper orientation utilizing the Frankfurt
plane at the horizontal. This view aligns the tip of the nose with
the cheek outline. A graph paper like grid will be utilized in this
view as well as vertically oriented lines and horizontally oriented lines
separately to assess skin folds and shadows.
• Lateral View: 90 degrees from the Straight-on frontal view. Vertically
projected lines help to delineate natural relaxed skin tension lines.
• Base View: The head is bent backwards to align the nasal tip with the
medial canthi on a horizontal plane. A grid with an equilateral triangle
is then projected to assess symmetry of the ala and vestibule.
In clinical practice angles and grids will be adjusted to assess male versus
female patients, which is ideal for quick preoperative assessment. Grids and
lines, such as those utilized by scuptors, will be projected onto the patient.
These grids are ideal for real time assessment of injection of fillers and other
facial augmentation techniques. By simply contorting ones face the change
in topography is appreciable by laser assessment. Figures 6-8 depict how
changing ones facial expression can be depicted with laser projection.
It is well accepted that photographic documentation is essential in recon-
structive and cosmetic surgery. Similarly, artists that sculpt human faces
have utilized age-old techniques, such as projection of lights and shadows, to
delineate nature skin folds and asymmetries prior to sculpting. Utilizing pre-
scultping images from sculptors allows for comparison which exemplies the
similarities between artistic sculpting and facial plastic surgery. This article
is an artistic application of photographic adaptation into the world of facial
plastics. Lights and shadows are pivotal to assessing the aesthetic face. The
exact architecture of shadowing is crucial to success. Shadowing delineates
the topographical appearance of the face. Pre and post-operative assessment
of the aesthetic patient is one of the most objective aspects of the eld. Ob-
jective documentation is important both clinically as well as scientically,
as reproducibility is essential to scientic studies. Persichetti and colleagues
have published on standardization of such documentation. In their article
they appreciate the the importance of consistency and reproducibility. They
also focus on the importance of cost eective use of digital equipment to
obtain such data. The photographic aspect of the plastic surgery eld has
become advanced and this encourages practitioners to even develop photo-
graphic studios. Similar techniques have been utilized by sculptors for over a
century now (Figures 1- 3). One aspect of facial plastic photography that has
been underdeveloped is intraoperative assessment of the facial topography.
This new assessment process will allow the surgeon to eciently analyze and
demonstrate to the patient the mutual goals of aesthetic surgery. The utility
of acute documentation during the injection or augmentation process is a
novel technique. The laser will allow for concurrent geometric assessment
during facial augmentation. The dynamic aspect of the laser gird could be
utilized intra-operatively to add a more objective aspect to the acute as-
sessment while the patient is still anesthetized and the surgeon is assuring
symmetry and proper augmentation. With precise grids one would be able
to appreciate small asymmetries or dierences in soft tissue geometries that
would otherwise go uncorrected. The realtime intra-procedure feed back will
allow he surgeon to immediately adapt to soft tissue topographic changes.
It oers a dynamic and immediate tool to assist the surgeon with objective
intraoperative assessment. The geometrically projected laser grid will allow
the surgeon to more precisely select areas for augmentation in the oce as
well as the operating room. The signicance of this technique pre and post-
operatively is that it is immediate, standardize and reproducible. The images
will be artistically appreciated by patients and colleagues and will enhance
the eciency of oce visits. The photos will emphasize the patients’ asym-
metries and other imperfections that are amenable to the armamentaruim of
the facial plastic surgeon. The patients will be able to immediately appreci-
ate the results. The more standardized grids used for pre and post-operative
assessment will be cost eective and could be used as a screening tool before
more expensive analytic techniques are pursued. One could assure the pa-
tient is a candidate and that they are interested in what the surgeon has to
oer before moving onto more time and money