Aesth Plast Surg (2016) 40:331–333 DOI 10.1007/s00266-016-0616-y

LETTER TO THE EDITOR

EXPERIMENTAL/SPECIAL TOPICS

Art and Plastic Surgery Julio Wilson Fernandes1 · Susanne Metka2,3

Received: 13 September 2015 / Accepted: 21 January 2016 / Published online: 16 February 2016 © Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2016

Abstract The roots of science and art of plastic surgery are very antique. Anatomy, drawing, painting, and sculpting have been very important to the surgery and medicine development over the centuries. Artistic skills besides shape, volume, and lines perception can be a practical aid to the plastic surgeons’ daily work. An overview about the interactions between art and plastic surgery is presented, with a few applications to rhinoplasty, cleft lip, and other reconstructive plastic surgeries. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Plastic surgery · Aesthetics · Plastic surgery history · Surgery art

The roots of science and the art of plastic surgery reach back far beyond the Common Era. Ancient Egyptian papyrus scrolls show the treatment of nasal fractures as early as 2200 BCE, and nasal reconstruction was performed in 1500 BCE by the Koomas, a caste devoted to sculpture and astrology [1, 2]. The origins of the Golden & Julio Wilson Fernandes [email protected] 1

Plastic Surgery Division, Universidade Positivo Medical School, FBCS, FBSPS, AMISAPS, Av. Getulio Vargas 2079, Curitiba, PR 80250-180, Brazil

2

Kunsthistorisches Museum, Vienna, Austria

3

Department of Applied Anatomy, Center of Anatomy and Cell Biology, Vienna, Austria

Proportions can be traced back from the Greek sculptor, painter, and architect Phidias (480 BCE–430 BCE) and Roman architect Marcus Vitruvius Pollio in the first century before Christ, up through the Renaissance-era “Vitruvian Man” by Leonardo da Vinci in 1490 [3]. Aesthetics, as the study and creation of beauty in art and nature, derives from the Greek word “αἰσθάνομαι,” meaning “I perceive” or “I feel.” Plastic surgeons need a particular view of the human body, to be able to identify beauty, and especially its absence. The French plastic surgeon Pierre Fournier, in his lecture, “What is Human Beauty?,” brings attention to our deeply rooted impulses to associate beauty with very early facial characteristics [4], which we might reasonably relate to a possible unconscious inclination towards the opposite of the signs of chronologic aging, which signal the inexorable progression towards death. Dr. Mario Gonza´lezUlloa from Mexico strongly emphasized in his “Manifesto” the importance of beauty, esthetics, and art as a vital counterpart of technical skills for aesthetic surgeons to truly understand the beauty of the human body as a whole [5]. The late Viennese plastic surgeon Dr. Wolfgang Metka strongly believed that performing aesthetic surgery that yields considerable improvement in the results demands both an excellent technique and an artistic perspective [6]. An artist is trained to observe the formal aspects of the world and objects, extracting form, body, shape, and texture from nature into a concrete visualization and implementation of perception. These observational skills are especially important for a plastic surgeon, to be able to clarify the individual desire and ideal of beauty of a patient. Like an obstetrician, the plastic surgeon has to be able to “draw out” the image, which exists only in the patient´s mind, in order to determine the technical feasibility and the

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aesthetic appropriacy of that patient’s desire and vision, before an aesthetic procedure. Knowledge of proportions and measurements, shape and form, is essential for an aesthetic surgeon, who must rely on both objective and subjective measurements to fit the part to the whole in a way that will achieve harmony. The perfect nose, for example, should have many objectively determined desirable features, including the tip higher than dorsum, making it a specific and independent structure instead of a single continuity of the dorsum lines. The nasal root should be delineated by two harmonic divergent lines, from the superior orbital rim to the lateral crura dome of the alar cartilages; and many other objective rules [7]. However, much more important than achieving a perfect canonic nose through rhinoplasty is achieving a beautiful face where the nose has a proper contour and prominence. In other words, our goal is harmony, rather than canonic perfection. Even the best technical training can lead the most skillful surgeon to an undesirable result if aesthetic, ethnic, and psychological aspects are not taken into consideration and if the surgeon is unable to predict the outcome of his/her efforts. Artists face the same challenge when making the sketch, before the first drop of pigment touches the canvas or the first hammer strikes the marble, but the artist’s limits are broader—the plastic surgeon’s limits end where they meet the patient’s wishes. As artists, plastic surgeons can develop their sensibility, aiding in their ability to foresee what their work ideally should look like as the result of an aesthetic surgery. Studying light and shadow in still life and in the body itself, the pencil becomes a useful two-dimensional tool to summarize the actions one will take in the three-dimensional world of surgery and sculpture. Photography can also be a great help in seeing light and shadow in the human form, but it is only the understanding of what lies beneath the skin that gives us a true understanding of that light and shadow. Both Da Vinci and Michelangelo inspired their artistically beautiful and anatomically correct drawings and sculptures with their extensive studies and drawings of the precious cadavers they managed to obtain [8]. Through the practice of sketching and clay modelling, “the eyes start to feel and hands learn to see,” as stated by Neuffer-Hoffmann in 2009. Some of the practical contributions of clay modelling to plastic surgery are as follows: ●

The quest for beauty, harmony, and symmetry in the face extrapolates to the use of many dimensional references for the clay bust, as well as the use of external measurements and sizers during surgical procedures.



A refined and accurate perception of concavities and convexities in the clay is a great contribution to more

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refined reconstruction of the ear, the eyelids, and to a more conscious approach to increasing malar projection via facial fat injections, SOOF surgery, and malar fat pad repositioning. ●

Developing a tactile understanding of the amount of fullness needed to give the lips a perfect backwards convexity while retaining their anterior projection can be very useful when harvesting all the tissue we need to repair a cleft lip.



Using surgical instruments as periosteal elevators during sculpturing to make, for example, the clay eyelids over the eyes, increases the fine control of the tip of the tool, which can be very welcome in an orbital or cleft palate surgery.

Besides the aforementioned possible contributions of modelling and sketching to the performance of plastic surgery, art can be an outstanding creative joy, providing relief to the surgeon from the rigid, strenuous discipline that surgery demands. The Danish plastic surgeon Michael Pers, in his article “Some General Principles as Applied to Aesthetic Surgery” [9], mentioned Henry Matisse, who showed his painting of a woman to a friend who said, “A woman does not look like that” and Matisse replied, “This is not a woman, it is a picture.” We know for certain that our patients are much more complex than sculptures, but art has contributed to making them as beautiful as art for many centuries. Acknowledgments The authors thank plastic surgeon Dr. med. Wolfgang Metka, Prim.IR. for his pioneering contributions to our studies. We thank Mag. Illona Neuffer-Hoffmann, Univ. Prof. Dr. Michael Pretterklieber and Prim. Univ.-Prof. DDr. Kurt Vinzenz for their lectures and ongoing support of our professional development. Compliance with Ethical Standards Disclosure Julio Wilson Fernandes, MD is a former student (2014/ 2015) and guest lecturer (2015) at Kunsthistorisches Museum Sketch Course & Anatomic Modelling for Surgeons, Vienna, Austria. Assistant Professor of Plastic Surgery (Plastic Surgery) at Universidade Positivo, Brazil with side activities as nonprofessional sculptor and Art History student (2015/2016) at Claretiano University Center, Brazil. Suzanne Metka, MD has profits as Course Director, Sketch Course & Anatomic Modelling for Surgeons, Vienna, Austria.

References 1. Converse JM (1977) General principles. In: Converse JM (ed) Reconstructive plastic surgery. W.B. Sauders Company, Philadelphia, p 4 2. Farina R (1966) Histo´ria da cirurgia pla´stica do nariz. In: Farina R (ed) Pla´stica de Nariz. O Calva´rio, Sa˜o Paulo, pp 4–8 3. Hemenway P (2005) Divine proportions: phi in art, nature and science. Sterling, New York, pp 20–21

Aesth Plast Surg (2016) 40:331–333 4. Fournier PF (2012) What is Human Beauty? In: Erian A, Shiffman MA (eds) Advanced surgical facial rejuvenation. Springer, Heidelberg, pp 117–122 5. Hage JJ (2002) Gonza´lez-Ulloa’s manifesto on aesthetic surgery. Plast Reconstr Surg 110:1167–1171 6. Metka W, Metka S, Neuffer-Hoffmann I (2012) Beauty, esthetics and art: acquiring soft skills in esthetic surgery. Menopause Congress Lecture, Vienna

333 7. Scheen JH (1998) Fundamentals. In: Sheen JH (ed) Aesthetic rhinoplasty: aesthetic Rhinoplasty, 2nd edn. Quality Medical Publishing, Missouri, pp 20–98 8. Simblet S (2001) The art of anatomy. Anatomy for the artist. Dorling Kindersley, London, pp 12–14 9. Pers M (1983) Some general principles as applied to aesthetic surgery. Scand J Plast Reconstr Surg 17:187–190

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Art and Plastic Surgery.

The roots of science and art of plastic surgery are very antique. Anatomy, drawing, painting, and sculpting have been very important to the surgery an...
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