THE ARTS AND MEDICINE

The Art of Plastic Surgery

Steven Neal, MD

N
euroscience assigns mental tasks to specific areas
of the brain. Speech, language, math computation,
time, and logic reside in the left hemisphere of the
brain in right-handed individuals. The right side of the brain
is the neural home for intuition, the recognition of faces, a
sense of direction, and the appreciation of beauty of form.
I was an artist before I became a physician and lan-
guished in the right side of my brain, unconscious of the pas-
sage of time as I worked. I took this tendency with me when
I trained in facial plastic surgery, thinking all other surgeons
might feel the same. It took a few years to realize most
did not. Plastic surgery is surgery of form, and synthesis of
form is purely right-brained. Acceptance to medical school
and training programs is based on left-brain skills, so when
residents in training first attempt plastic surgery, many have
an obvious lack of natural ability because they have never
been required or trained to demonstrate proficiency in judg-
ing form.
In house construction, contractors use plans designed
by architects to build spaces and forms. When patients pre-
sent to facial plastic surgeons for cosmetic or reconstructive
surgery, the physician is both architect and carpenter. Resi-
dency training concentrates almost exclusively on surgical
or “carpentry” skills, with the assumption that five or six
years of surgical training also qualifies the graduate as facial
or body architects with a highly developed sense of beauty
and direction. This assumption is as valid as the expectation
that art students, presented with a block of clay and instruc-
tion in the rudiments of shaving and cutting, might produce
Top, Shaping the nose in clay. Bottom, Dorsal hump resection
a mature and finished masterpiece. Clay is 100% compliant
during rhinoplasty.
to any maneuver to shape it, and the techniques to mold it
can be learned in minutes. But the maturation of an artist’s
aesthetics and judgment, which direct the clay’s shape into a
masterpiece, may take a lifetime. knew of such uncertainty. We only have to look around us to
Facial plastic surgeons’ medium is most unideal; it often see the results of poor judgment: through injudicious use of
behaves unexpectedly and changes as it heals. And of course, laser treatments, fillers, various tucks, and rhinoplasties.
some things are impossible to achieve. Training courses and It is for these reasons that I have run a week-long “Aes-
conventions continue after residency. Facial plastic surgeons thetics Boot Camp for Surgeons,” during which I have taught
are always eager to learn new techniques, but those who al- sculpture courses or developed clay exercises for surgeons and
ways get superior results possess something that cannot be encouraged them to take up sculpture, or figure drawing, or
learned in conventional technique training: judgment. painting—but especially sculpture—because it is an effective
I have taught hundreds of surgeons over the past 25 way to improve a sense of aesthetics and judgment without
years and have seen vast differences in surgeons’ abilities to inflicting harm on patients by performing the wrong opera-
judge with their eye. Is a modification too big, too small, tion or technique.
Photographs: Steven Neal, MD

or just right? What form is correct, what is desirable, what
is not, how should a variation in appearance be fixed, or
should one even attempt to fix it? These judgments—and the
ability to judge—vary so radically between physicians that I
think patients would be frightened at the prospect of under-
going surgery destined to change their appearance if they
In one exercise, I provide attendees a clay life-sized
face that has no nose, and the student-surgeon is assigned
to sculpt a nose for that face. The exercise teaches attend-
ees that no one really knows the nose in three dimensions
unless he or she can sculpt it from memory. With that
memory, and the ability to translate it through one’s hands

2072 JAMA November 22/29, 2016 Volume 316, Number 20 (Reprinted) jama.com

Copyright 2016 American Medical Association. All rights reserved.

 The Arts and Medicine

into plastic form, the surgeon will possess a better ability to

refine each of its components to make an aesthetic match to
the patient’s face.
In another clay exercise, I distribute little clay faces that
I have deliberately altered. The student-surgeon has to fig-
ure out what is wrong with the face and resculpt it to make
it “normal.”
These exercises are very difficult for some and much
easier for others. It has been especially gratifying to hear
from senior surgeons, well versed in facial plastic surgery,
that sculpting a face in clay from a live model has given
them new insights for their own surgery. They have told me
that they “saw the human face different from how they ever
had before” I think because they were filling in the three-
dimensional form of the face that they carry in the right
hemisphere of the brain. Even young children can tell a face
is distorted or ugly, but it takes a special eye to know why, Bronze sculpture depicts the correction of congenital defects, traumatic
connected to hands that can alter it to become beautiful. defects, and rejuvenation of the aging face.
Also, some surgeons have said the exercises made them a
better injector of fillers through an improved understanding the time what will be noticed is what is wrong. If so, fix it
of the aesthetic three-dimensional contours of the cheeks accordingly.”
and lips.
I wish I could convince newer, younger surgeons to show
Author Affiliation: Oregon Health & Science University, Portland.
the same interest. It makes me wonder: Would our patients and
Corresponding Author: Steven Neal, MD (nealmd9@gmail.com).
our profession benefit more if we recruited plastic surgeons
Section Editor: Roxanne K. Young, Associate Senior Editor.
out of sculpture school instead of medical school?
Conflict of Interest Disclosures: The author has completed and submitted
It does teach me as a surgeon, however, that mastery of
the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none
plastic surgery is best done with humility; it is a life-long were reported.
pursuit. As the German Renaissance artist Albrecht Durer Submissions: The Arts and Medicine editors welcome proposals for features
said, “In putting a finished work before the public, most of in the section. Submit yours at artsandmedicine@jamanetwork.com.

jama.com (Reprinted) JAMA November 22/29, 2016 Volume 316, Number 20 2073

Copyright 2016 American Medical Association. All rights reserved.

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