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2. The Artistry of Plastic Surgery
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 13–20
AESTHETICS AND ITS ASSOCIATION
1. Which of the following best explains the evolving social acceptance of aesthetic medicine and surgery in vari-
ous cultures around the world?
A. “Ideal ” beauty is a constant.
B. Caucasian beauty standards have influenced social acceptance of plastic surgery.
C. Clinical studies have failed to show positive outcomes after aesthetic procedures.
D. There is an increasing relationship between the science of aesthetic medicine and the safety of invasive and
noninvasive procedures.
E. Aesthetic surgeons are more skilled today than they were 20 years ago.
BEAUTY AND ITS CONCEPTS
2. Which of the following is an example of documented measures taken by the ancient Egyptians to enhance
appearance?
A. Use of kohl (lead-based mineral) as eye makeup.
B. Creation of Pythagorean theorem.
C. Creation of architecture symbolizing both symmetry and proportion.
D. Development of the “golden ratio.”
E. Living a virtuous lifestyle.
BEAUTY AND ITS CONCEPTS
3. The famous Greek statue “Venus de Milo” (formerly, the logo of PRS and the seal of ASPS) best represents
which form of beauty?
A. Classical beauty.
B. Mankind's ideal.
C. Manufactured beauty.
D. Natural beauty.
E. Mythical beauty.
BEAUTY AND ITS CONCEPTS
4. Vitruvius was quoted, “Just so the parts of Temples should correspond with each other, and with the
whole.” How can this best apply to an aesthetic surgeon's practice?
A. One external aesthetic ideal guiding the surgeon's practice.
B. The golden ratio is critical in plastic surgery and should not be deviated from.
C. Making a compromise between what is desired and what is achievable, individualized to each patient.
D. Strictly follow canons set forth by neoclassical artists and philosophers.
E. Strive for greater variation in surgical technique.
BEAUTY AND ITS CONCEPTS
5. Although objective studies have consistently failed to confirm the applicability of many neoclassical canons to
aesthetic surgery practice, which of the following choices lists three components of facial attractiveness considered to be critical?
A. Uniqueness, symmetry, skin tone.
B. Averageness, interalar width, neoteny.
C. Intercanthal distance, malar projection, defined jawline.
D. Averageness, symmetry, neoteny.
E. Pigmentation, symmetry, bone structure.
Chapter 2&The Artistry of Plastic Surgery 9
BEAUTY AND ITS CONCEPTS
6. Which of the following anatomical features is most concordant with an aesthetic male dimorphic trait?
A. Less prominent cheek bones.
B. Thicker lips.
C. Supraorbital ridges.
D. Smaller noses.
E. Smaller eyes.
BEAUTY AND ITS CONCEPTS
7. In women, sexual dimorphism toward the aesthetic ideal implies which of the following?
A. Lower set eyebrows.
B. Smaller eyes.
C. Thinner lips.
D. Smaller jaw.
E. Longer nose.
10 Part I&Basic Considerations
Answers
AESTHETICS AND ITS ASSOCIATION
1. Which of the following best explains the evolving social acceptance of aesthetic medicine and surgery in vari-
ous cultures around the world?
D. There is an increasing relationship between the science of aesthetic medicine and the safety of inva-
sive and noninvasive procedures.
The rise in social acceptance and popularity of aesthetic medicine and surgery in the sexes and in various
cultures around the world is thought to be intrinsically connected with the increasing relationship
between the science of aesthetic medicine and the safety of invasive and noninvasive procedures. The
standard of care in aesthetic medicine and surgery is founded upon evidence-based practice, born from
clinical and psychological studies, which have shown an overall sense of well-being of patients who seek
aesthetic procedures.
REFERENCES
1. Saariniemi KM, Helle MH, Salmi AM, et al. The effects of aesthetic breast augmentation on quality of life, psy-
chological distress, and eating disorder symptoms: a prospective study. Aesthetic Plast Surg 2012;36:1090
2. Saariniemi KM, Salmi AM, Peltoniemi HH, et al. Does liposuction improve body image and symptoms of eating
disorders? Plast Reconstr Surg Glob Open 2015;3:e461
3. Saariniemi KM, Salmi AM, Peltoniemi HH, et al. Abdominoplasty improves quality of life, psychological distress,
and eating disorder symptoms: a prospective study. Plast Surg Int 2014;2014:197232
1,2,3
BEAUTY AND ITS CONCEPTS
2. Which of the following is an example of documented measures taken by the ancient Egyptians to enhance
appearance?
A. Use of kohl (lead-based mineral) as eye makeup.
Ancient Egyptians left behind vast evidence suggesting that both sexes went to great lengths to improve
their appearance. Based upon ubiquitous beauty products left by ancient Egyptians in burial settings,
much of what is perceived as symbolic of beauty is influenced by what we think was considered
beautiful in ancient Egypt. For example, kohl, a mineral base composed of lead, was used as eye makeup
in ancient Egypt, which may have given rise to the smoky eye makeup worn today. Also, it is thought
that kohl may have antibacterial properties and was utilized as a protectant from the glare of the sun,
thus providing not only enhanced beauty, but also function.
1
REFERENCE
1. Al-Kaff A, Al-Rajhi A, Tabbara K, El-Yazigi A. Kohl—the traditional eyeliner: use and analysis. Ann Saudi Med
1993;13(1):26–30
BEAUTY AND ITS CONCEPTS
3. The famous Greek statue “Venus de Milo” (formerly, the logo of PRS and the seal of ASPS) best represents
which form of beauty?
A. Classical beauty.
The idea of “classical beauty” arose from the Renaissance referring to re-adoption of ancient Greek
idealism and the study of nature. This is symbolized by a woman who conforms to the standard Greek
classical ideal, with proportion and symmetry as it relates to nature's ideal, and not necessarily
“mankind's ideal.”
1
REFERENCE
1. Brent B. The reconstruction of Venus: following our legacy. Plast Reconstr Surg 2008;121:2170
Chapter 2&The Artistry of Plastic Surgery 11
BEAUTY AND ITS CONCEPTS
4. Vitruvius was quoted, “Just so the parts of Temples should correspond with each other, and with the
whole.” How can this best apply to an aesthetic surgeon's practice?
C. Making a compromise between what is desired and what is achievable, individualized to each patient.
As aesthetic surgeons, we hardly ever work with the anatomy that we would like, but rather the anatomy
that we have been given. To that end, in practice, the surgeon is guided by the principles described by
Vitruvius’ quotation of aligning internal aesthetic goals with external aesthetic ideals but must also reach
a compromise between what is desired and what is achievable.
1,2
REFERENCES
1. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg
2006;118:741
2. Bashour M. An objective system for measuring facial attractiveness. Plast Reconstr Surg 2006;118:757
BEAUTY AND ITS CONCEPTS
5. Although objective studies have consistently failed to confirm the applicability of many neoclassical canons
to aesthetic surgery practice, which of the following choices lists three components of facial attractiveness
considered to be critical?
D. Averageness, symmetr y, neoteny.
Averageness indicates similarity to a typical phenotype for a group and therefore signals genetic
diversity, which has presumable links to greater health and disease resistance.
Symmetry seems obvious as a characteristic of attract iveness; in fact, studies across a number of species
have shown that greater symmetry is associated with both fitness and fertility.
Neoteny (juvenile features in an adult) is not simply youthfulness in the aging adult face. A baby's
features (large eyes, small nose, round cheeks, smooth skin, glossy hair, and lighter skin tones) correlate
with greater perceived attractiveness, more paternal attention, and even a lower incidence of childhood
abuse. The preference for childlike facial features appears consistently across ethnic populations,
regardless of sexual orientation.
1,2
REFERENCES
1. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg
2006;118:741
2. Bashour M. An objective system for measuring facial attractiveness. Plast Reconstr Surg 2006;118:757
BEAUTY AND ITS CONCEPTS
6. Which of the following anatomical features is most concordant with an aesthetic male dimorphic trait?
C. Supraorbital ridges.
Attractiveness is also related to sexual dimorphism—that is, the degree to which a particular face
resembles the prototype of his or her sex. In men, this means larger jaws and supraorbital ridges; more
prominent cheekbones; smaller eyes; thinner lips; and wider, larger noses. Although facial attractiveness
may not always conform to algorithmic or mathematical proportions, it still derives from species-specific
psychological adaptations.
1
REFERENCE
1. Constantian MB. Rhinoplasty: Craft and Magic. New York: Thieme Publishers; 2009
BEAUTY AND ITS CONCEPTS
7. In women, sexual dimorphism toward the aesthetic ideal implies which of the following?
D. Smaller jaw.
The prototype of the female sex portrays facial features including prominent cheekbones; smooth,
hairless skin; wider eyes; higher, thinner eyebrows; smaller jaws; fuller lips; and shorter, smaller noses.
The other answer choices depict the aesthetic ideal for males.
1,2,3
12 Part I&Basic Considerations
REFERENCES
1. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg
2006;118:741
2. Bashour M. An objective system for measuring facial attractiveness. Plast Reconstr Surg 2006;118:757
3. Constantian MB. Rhinoplasty: Craft and Magic. New York: Thieme Publishers; 2009
3. Photography for the Aesthetic Surgeon
Ara A. Salibian, Anmol Chattha
See Essentials of Aesthetic Surgery, pp. 21–42
ELEMENTS OF STANDARDIZED CLINICAL PATIENT PHOTOGRAPHY
1. What does the focal length of a lens determine?
A. How the lens brings an object into focus.
B. The distance from the camera to the subject.
C. The width of the image plane.
D. The sensor type.
E. The type of flash utilized.
VARIABLES TO CONSIDER IN FACE OR NECK SERIES
2. Which of the following areas can be distorted when photographing a patient's face in the lateral view using
the Frankfort plane as a reference instead of the natural horizontal plane?
A. Nasal tip.
B. Malar eminence.
C. Cerviocomental angle.
D. Upper lip height.
E. Brow position.
VARIABLES TO CONSIDER IN FACE OR NECK SERIES
3. A patient is at her preoperative visit for a facelift and necklift. When taking preoperative photos for this pro-
cedure, which of the following pairs of landmarks should be aligned for the most appropriate oblique view of
the patient's face?
A. Dorsal nose and medial canthus.
B. Lateral commissure and mandibular angle.
C. Helix and lateral canthus.
D. Menton and gonial angle.
E. Ala and lateral canthus.
STANDARD BROW AND EYELID SERIES
4. When taking postoperative photographs of a blepharoplasty patient, a lens with which of the following focal
lengths is the most appropriate?
A. 20 mm.
B. 40 mm.
C. 60 mm.
D. 80 mm.
E. 200 mm.
STANDARD RHINOPLASTY SERIES
5. When taking a worm's eye or basal view photograph of the nose, what reference points should be used to
ensure an appropriate angle?
A. Nasal tip and hairline.
B. Lower lip and nasal base.
C. Nasal dorsum and forehead.
D. Nasal tip and glabella.
E. Chin and lower lip.
14 Part I&Basic Considerations
STANDARD BODY SERIES
6. A patient presents for preoperative consultation for abdominoplasty and truncal lipocontouring. Standard
body series photographs are taken for evaluation. What additional view will further help evaluate abdominal
soft tissue laxity?
A. Swimmer's view.
B. Diver's view.
C. Worm's eye view.
D. Lateral view.
E. Posterior view.
STANDARD MASSIVE-WEIGHT-LOSS BRACHIOPLASTY AND LATERAL CHEST EXCISION SERIES
7. In a massive-weight-loss patient planned to undergo brachioplasty and chest wall skin excision, which of the
following arm positions is best for evaluating soft tissue excess of the upper arm?
A. Arms at the sides.
B. Arms straight out with palms up.
C. Arms straight vertical with palms inward.
D. Arms straight out with elbows bent at 90 degrees and hands forwards.
E. Arms on patient's hip.
INFORMED CONSENT
8. Which of the following methods is the most appropriate way of ensuring that a photograph of a patient's
face used for educational purposes is compliant with Health Insurance Portability and Accountability Act
(HIPAA) regulations?
A. Blur out the patient's eyes.
B. Place a black bar over the patient's eyes.
C. Hide any distinctive birthmarks or lesions.
D. Obtain full written authorization from the patient.
E. Only show the upper half of the face.
Chapter 3&Photography for the Aesthetic Surgeon 15
Answers
ELEMENTS OF STANDARDIZED CLINICAL PATIENT PHOTOGRAPHY
1. What does the focal length of a lens determine?
A. How the lens brings an object into focus.
The focal length of a lens is the distance between the lens and the image sensor of the camera when the
subject being photographed is in focus. This length is typically measured in millimeters. Using a lens
with the appropriate focal length for a particular subject is important to prevent unwanted distortion of
the image. With a shorter focal length, the angle of view will be wider and a larger area will be captured.
A longer focal length, on the other hand, will have a smaller angle of view, and will make the subject
appear larger. The Cardiff Scales of Reproduction recommend using a lens with a focal length equal to at
least twice the diagonal of the image plane to avoid distortion.
REFERENCE
1. Roos O, Cederblom S. A standardized system for patient documentation. J Audiov Media Med 1991;14:135
VARIABLES TO CONSIDER IN FACE OR NECK SERIES
2. Which of the following areas can be distorted when photographing a patient's face in the lateral view using
the Frankfort plane as a reference instead of the natural horizontal plane?
C. Cerviocomental angle.
The Frankfort horizontal plane is formed by a line connecting the porion, or the upper margin of the
external auditory meatus, and the orbitale, or infraorbital rim. This plane is a commonly utilized landmark
in cephalometric measurements. It can be utilized to orient lateral photographs and the face and neck;
however, it can distort the submental tissue and change the jawline contour in certain patients. An
alternative reference for facial photography is the natural horizon facial plane, which is based on the
patient gazing straight as if looking at himself or herself in a mirror at eye level (Fig. 3.1a,b).
1
1,2
Fig. 3.1 Head positioning. (a) Patient shown in the Frankfort plane. Neck retraction can overemphasize the
degree of submental soft tissue. (b) Patient shown in the natural horizontal facial plane. (Source: Head
Positioning. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
16 Part I&Basic Considerations
REFERENCES
1. Sommer D. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg
2004;114:10
2. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg 2002;109:1421
VARIABLES TO CONSIDER IN FACE OR NECK SERIES
3. A patient is at her preoperative visit for a facelift and necklift. When taking preoperative photos for this pro-
cedure, which of the following pairs of landmarks should be aligned for the most appropriate oblique view of
the patient's face?
A. Dorsal nose and medial canthus.
Different standards are accepted for oblique photographs of the head and neck. The patient should be positioned to have the same degree of neck flexion or head retraction, as well as the same posture as the anterior
and lateral photographs. A preferred angle for the oblique photograph is when the dorsum of the nose is
touching the medial aspect of the eye. The other accepted angle is taken when the nasal tip touches the opposite side of the cheek (particularly for rhinoplasty series). Whichever angle the surgeon prefers, effort should
made to keep these standards consistent in the photography (Fig. 3.2a,b).
Fig. 3.2 Options for oblique views. (a) Tip of the nose touching the side of the far cheek for a rhinoplasty series.
(b) Dorsum touching the medial eye. (Source: Focal Lengths and Distances. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Sommer D. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg
2004;114:10
STANDARD BROW AND EYELID SERIES
4. When taking postoperative photographs of a blepharoplasty patient, a lens with which of the following focal
lengths is the most appropriate?
D. 80 mm.
Post-blepharoplasty patients will have close-up photographs of the eye and periorbit. In these cases, a
lens with a longer focal length is more appropriate to prevent distortion and narrowing of the image.
These focal lengths typically can be around 80 to 105 mm and are designed for close-up or macro
photography.
1
Chapter 3&Photography for the Aesthetic Surgeon 17
REFERENCE
1. DiBernadino BE, Adams RL, Krause J, et al. Photographic standards in plastic surgery. Plast Reconstr Surg
1998;102:559
STANDARD RHINOPLASTY SERIES
5. When taking a worm's eye or basal view photograph of the nose, what reference points should be used to
ensure an appropriate angle?
D. Nasal tip and glabella.
The basal view of the nose is a critical view in rhinoplasty to assess nasal projection, nostril length, columellar
proportions, width of the alar base, and flaring of the crura. The angle of this photograph should be
standardized for accurate preoperative assessment and analysis of postoperative results. A standard referenc e
point inv ol v e s aligning the nasal tip between the eyebrows, or at the glabella, to determine appropriate
cephalo-caudal angle for the photograph. However, the surgeon must note that this angle may vary in patients
with extremes in tip underprojection or upper lip projection that can obstruct the view of the alar base.
1
REFERENCE
1. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg 2002;109:1421
STANDARD BODY SERIES
6. A patient presents for preoperative consultation for abdominoplasty and truncal lipocontouring. Standard
body series photographs are taken for evaluation. What additional view will further help evaluate abdominal
soft tissue laxity?
B. Diver's view.
Standard photographs for truncal procedures should have the patient standing with the midpoint of the
body centered in the frame. The lens axis should be parallel to the patient at all times and positioning of the
patient's feet should be consistent. The diver's view that can additionally assist in evaluation of abdominal
skin laxity involves oblique views of the patient bending forward at the hip while relaxing the abdomen
(Fig. 3.3a– c).
1
Fig. 3.3 Supplemental views for body contouring. (a,b) A diver's view is an oblique view with the patient bending over while relaxing the abdomen. (c) Back view. (Source: Supplemental Views for the Body Contouring Series.
In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Gherardini G. Standardization in photography for body contour surgery and suction-assisted lipectomy. Plast
Reconstr Surg 1997;100:227