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BMA News — Saturday June 12, 2004

Doctors who work in the field of reconstructive surgery tend to have an excellent grasp of anatomy, but when it comes to aesthetics – the shape of, and spatial relationship between, individual features – they can be less confident. This prompted one plastic surgeon to call on the teaching skills of a sculptor. Lisa Pritchard reports on an innovative mix of medicine and art

A dozen surgeons, who think they have a pretty good idea about anatomy, are faced with a lump of clay and a model – and told to sculpt a likeness. Retired London plastic surgeon Brian Morgan, who has led the Royal College of Surgeons of England’s (RCS) reconstructive surgery for plastic surgeons course, recalls one participant who epitomised the value of such an exercise.
`He knew all about bone structure and was only thinking in terms of that. His first attempt at the head was very hollow looking, more like a skull, because he said he did not know how to fill in the soft tissue (around the bone structure). He thought because he knew the anatomy of the face that was all that was going to be necessary,’ says Mr Morgan.

Helping the surgeons get to grips, as it were, with the aesthetics of a person rather than just their anatomy is sculptor Luke Shepherd. He admits he never imagined becoming a tutor to plastic surgeons when he began his career after training at Cardiff College of Art and the Royal College of Art, but he enjoys the added dimension the role brings.
Mr Shepherd, a portraiture sculptor who lives and works in Devon, says: `I find the work challenging. It is nice to know I am helping people through the surgeons.’
He became involved with the RCS course after plastic surgeon Ron Pigott, now retired, attended one of the sculpting courses he runs and spotted the potential of his teaching methods.

Shapes that the mind sees

Mr Shepherd uses a mix of practical work and lectures to teach plastic surgeons how to `see 3-D’ on the RCS’s four-day course, which is run approximately every 12 months. He describes aesthetics as `a visual language’ and the course akin to `brushing up on a foreign language’.
“Some people can speak good French and order things in restaurants; the next level is refining that”, he explains. “The surgeons have got the basics-they have to do their jobs and this is about refining those basics through the visual language. When they see the curve of a nose or the shape of the nose, they need to imprint it in their mind so that they don’t have to study it, they just understand it”.

“Everyone can see the same things, such as recognising someone from a distance and knowing who they are, but the hand cannot always coordinate on paper the shapes that the mind sees. The course is about closing that gap – how the hand understands what the eye sees.”.

When sculpting a clay likeness, Mr Shepherd asks the surgeons to begin by taking accurate measurements from the model’s head. This helps the eye understand the distances between the features.
`Then it should be possible for them to understand those things without the measurements,’ he adds. `It really trains the eye to see well, and the surgeon can trust what they see. Surgeons are fantastic with skin and flesh but there is nothing in their training that teaches them aesthetics.’
Mr Morgan has been very impressed with the outcome of the sculptor’s tuition.
He says: `The surgeons who attend our course, who also include maxillofacial surgeons and ear, nose and throat surgeons, have artistic tendencies and we aim to develop those. We want to show them that the shape of the end of a nose, the shape of an ear or the shape of an eyelid is a lot more complex than one realises from anatomy.
`It is about really absorbing into the brain what one is looking at. I think it is magical that they start off with a lump of clay and end up with something that looks like the model. Luke Shepherd has the knack of knowing what we want on the course.’

“The hand cannot always coordinate the shapes that the mind sees. The course is about closing that gap — how the hand understands what the eye sees”.

Very different materials
Mr Morgan says that compared to clay, flesh and skin are very different materials. However, once surgeons have mastered the aesthetics in one, they can work better in the other.’

Sculpting since the age of six (he became hooked after being presented with a lump of clay to play with at a friend’s house), Mr Shepherd works in clay, which is then cast into bronze.
His commissions have included comedian Billy Connolly, actor Philip Madoc, a six-foot Buddha statue now sitting in Lucknow, India, and politicians such as Conservative peer Lord Crickhowell, former Commons speaker the late Viscount Tonypandy and former Labour MP Leo Abse.
Teaching plastic surgeons has changed how Mr Shepherd works and how he looks at anatomy.
“Surgeons like the measuring and the ‘scientific’ approach, whereas artists prefer to use their eyes alone. I now try to make the artists measure more and the surgeons use their eyes more”, he says. Whichever way you look at it, hundreds of patients will potentially be very grateful for this unique meeting of art and science.

A similar article was printed in the IJS. To avoid copyright the article below is similar to the one printed the IJS in 2005.

International Journal of Surgery

Practical Sculptural Training for the Plastic Surgeon

Abstract
For the past 25 years I have been working as a portrait sculptor and educator, developing a scientific approach and protocol to train the eye to see accurately and fully understand the complexity of 3-D form. The methods developed over this period, aim to unravel the visual complexity of the human head and to close the gap between the forms that are seen and that which the hand can re-create.
The method has been put to the test in teaching programmes with surgeons, artists and non-artists.

Intro
An article in the BMA News states that ‘Doctors who work in the field of reconstructive surgery tend to have an excellent grasp of anatomy, but when it comes to aesthetics, the shape of and spatial relationship between, individual features, they can be less confident’. 1 While possibly an over exaggeration, it is true to say that the training received by plastic surgeons favours surgical protocol over the development of spatial awareness.

Following on from this, when teaching visual aesthetics and perception to plastic and maxillofacial surgeons, it is apparent that an intricate knowledge of anatomy, while being of paramount importance to the surgeon, plays little significance in visual awareness of form.

It is also apparent from teaching art students the same artistic protocol, that excellent visual results can be achieved exclusively through perception of form, with minimal anatomical knowledge or understanding.

Arnheim in Tolleth states ‘We see not only with our eyes but with our brain. Our knowledge of a subject. past experience and preconceived notions may seriously alter perception.’ 2

Beyond an appreciation of aesthetics and anatomy arises the question what visual training is appropriate and relevant for the plastic and maxillofacial surgeon?

Text
6 years ago I was first invited to teach a ‘Sculpture for Surgeons’ course held in collaboration with the Royal College of Surgeons of England. This is popularly referred to as ‘The Heads Course’ and was held in London at the Raven Institute at the College of Surgeons. The course comprised 4 days of intense clay portrait life modelling combined with 3 daily lectures.
The visual content of the course being designed to train and refine each surgeon’s perception of form to complement his or her surgical skills. The success of the methodology is measured by the surgeon’s ability to model a likeness in clay.
The hand cannot always coordinate the shapes that the mind sees. The course is about closing that gap how the hand understands what the eye sees. 3

Subsidiary lectures by visiting surgeons accompany the life modelling and can include subjects such as basic principles of proportions and relationships, orthodontic measurement, and measurement in orthognathic surgery, aesthetics, craniofacial and face lift surgery psychology of facial surgical procedures, the relationship between art and surgery, sculpting flesh and bone:, surgical misconceptions and facial movement to name but a few., etc.

Throughout the course it is shown that the ability to create a likeness in clay, and hence understand 3-D form, is not dependent upon an intricate knowledge of anatomy, but more an understanding of what is seen and perceived. In fact, anatomy plays little significance in the visual awareness of 3-D form. In practical terms, neither is memory, nor intellect shown to contribute significantly towards success. In fact the experience can be quite sobering as surgeons with over 15 years clinical experience realize how much their visual understanding can be developed in just 4 days training.

An example of this is clearly given by one participant on the Heads Course whose speciality is craniofacial manipulation. His clay sculpture had the appearance of a skull, particularly around the orbit, showing his knowledge of anatomy inhibiting his ability to fully understand the complexity of the soft tissues of the eye and eyelid.

As such the teaching protocol recognizes the need to interpret perceived data in a way that does not analyse or recognise such data linguistically or symbolically, but does so wholly visually

This refined “visual language” trains the eye to see well and subsequently the surgeons are able to more fully trust what they see. This new understanding can subsequently inform their clinical work.

As stated by Tolleth “Not only can many of us not draw a symmetrical circle or oval, some even seem not to recognize a markedly asymmetric one. The obvious application to surgery requires, again, awareness of our biases in order that they may be compensated for and eliminated, best accomplished with practice.” 4

Artist Frederick Frank recognises that “The act of seeing / drawing is essentially a reflex arc. The image falls onto my eye. From the retina it travels directly to my hand, of which the pencil is the extension. I let it travel through what I happen to be, but without interference: I don’t allow the interpretive machinery of the brain to take hold of it, to label it quickly: a ‘beautiful tree’ or a poplar. While drawing, the hand precipitates onto the paper only what the eye perceives and the traces and dots form the mosaic on which all pieces fit together to form an image, which then I may recognize as being that of a ‘beautiful tree’ or a poplar. The pencil in my hand becomes like a seismographic needle which in these dots and strokes registers the inner tremors of my seeing. Progress in drawing is the ever finer sensitization of this reflex arc that comes with years of practice.” 5

“Recent research on human brain-hemisphere functions and on the information-processing aspects of vision indicates that ability to draw may depend on whether you have access to the capabilities of the subdominant right hemisphere, whether you are able to turn off the dominant verbal left brain and ‘turn on’ the right.” 6

Scientist Jerre Levy has said, only partly humorously, that “American scientific training through graduate school may entirely destroy the right hemisphere.” 7 The hemisphere responsible for processing visual, spatial, non-verbal information.

Method
The human head is far too complex to be visually understood immediately. In modelling the head in clay over approx. 5000 observations need to be captured and cross referenced before the form is accurately understood. It is only after this long and tenacious enquiry during which every possible facet and every possible profile is studied and then reassembled, that the subject can be fully understood.

In order to visually investigate the complexity of form, it is necessary to break the form into easily understood sections which simplify it. This demands a rigorous methodology that isn’t compromised regardless of the complexity of what is seen.
Often with methods for visual training, smaller sections of the whole are focussed upon based on linguistic or anatomical divisions. Hence the head can be separated into ear, nose, eye etc or bones, muscles, skin etc. Whilst each segment divides the whole, it still retains its original visual complexity. When the form is broken down into easily understood simple ‘perceptual layers’ these can be perceived, understood and gradually refined to construct the final complex form.

As stated by Edwards in Tolleth “We must recognise that it is not enough to know in our left brain what an ear looks like with its concha, helix,and tragus; there must be a sense of the whole and a synthesis before an adequate ear can be modelled either in clay or flesh.” 8

In this way refinement of observation can be developed, building a successive layered understanding of the complexity of the form. Modelling is performed sequentially so that each layer is clarified before refinement commences in subsequent layers.
The eye is trained to seek the simple within the complex and the interrelationship between shapes, forms and volumes becomes systematically understood. With experience of viewing in this manner, the process becomes naturalised and far quicker than could be imagined as the visual cortex is trained to fully understand the 3-D make up of what is perceived.

Indeed modelling can be very quick when you know exactly how to interpret what is seen, yet experience shows that to ìknow what to look forî can take considerable focus and deliberation.
As stated by Maurice Grosser “the painter draws with his eyes, not with his hands. Whatever he sees, if he sees it clear, he can put it down. The putting of it down requires, perhaps, much care and labour, but no more muscular agility than it takes for him to write his name. Seeing clear is the important thing.” 9

Shortcuts such as simple moulds and a plaster casts can be quickly manufactured without the need to visually understand the form. But these casts, like anatomy, are one step removed from perceived visual knowledge and understanding of the plastic interrelationships of form. While they have certain value in the surgical field, they can not replace the surgeon’s visual understanding of form.

Working Procedure
Starting with clay, a wooden armature, newspaper, callipers and a life model, work proceeds. The first step is to measure the distance between the model’s left and right Temporomandibular Joint (TMJ), and then cut a dowel that size and locate this in the centre of a ball of clay on the armature. (fig 2)

per1Both tips of the dowel are now 100% accurate. The next point in space to locate is the nose tip. The model is measured with callipers from left and right TMJ to nose tip. The accurate location of the nose tip is the intersection of the callipers at these measurements along a projected angle from the TMJ on the clay. A triangle is now established in space, giving accurate width, direction and angle of inclination of the head. This represents the basic underlying physical structure. If any aspect of this triangle is inaccurate, the head can never truly resemble the model.
This protocol continues until 8 points on the head are located, giving an accurate framework of points in space. The callipers are now dispensed with and focus turns towards observation without measurement, other than as a means to qualify that which is perceived.
A thin fin of clay is made in along the midsagittal plane to give the profile of the head. It can be read like a Victorian paper cut out and fully represents the accuracy of model’s profile. (fig 3)

per2From this accurate underlying structure, further profiles and curved lines are found and angles recognised prior to the leap to establish more complex 3-D surfaces and planes. Each modelling session focuses upon one perceptual layer, so that over the course of 4 days the understanding progressively develops, building complexity of form upon each underlying layer. Each new addition of clay is cross referenced to ensure that it is accurately placed. (fig 4)

The work develops evenly over the entire head (fig 4), with care taken to remain focussed upon each layer before progressing to the next stage. Clarity of intent in following this protocol helps to establish a visual recognition of form and a framework for training the development of keen perception.

per3Don’t you see that, for my work of modeling, I have not only to possess a complete knowledge of the human form, but also a deep feeling for every aspect of it? I have, as it were, to incorporate the lines of the human body, and they must become part of myself, deeply seated in my instincts. I must feel them at the end of my fingers. All this must flow naturally from my eye to my hand. Only then can I be certain that I understand.” 10

Conclusion
With relatively short yet intensive visual training, the surgeon can refine his visual perception. The experiential nature of the training method offers a practical tool and challenging training for professional development.

Morgan says that “compared to clay, flesh and skin are very different materials. However, once surgeons have mastered the aesthetics in one, they can work better in the other.” 11

Luke Shepherd is an international sculptor based in Devon, England, whose portrait commissions include comedian Billy Connolly, Lord Crickhowell, the Late Viscount Tonypandy and many other leading statesmen. He has bronze portrait sculpture in the collections of the National Museum of Wales and the National Portrait Collection of Wales, Aberystwyth as well as many private collections. He has exhibited at the Royal Academy of Arts Summer Exhibition, London and at the Academie des Beaux Arts, Paris.

Reflective Account by Per Hall

When one embarks upon a career as a surgeon who reconstructs peoples faces there is no entry criteria based on aesthetic appreciation, artistry or 3 dimensional appreciations. Perhaps Plastic Surgeons gravitate towards the area of reconstruction that they feel most comfortable in.

It was with trepidation that I enrolled upon the Sculpture for Surgeons Course. Why? Because I knew I would be mixed in with other colleagues, some of which had well known talents as artists in their own rights, yet I had no idea myself of whether I would be able to sculpt. Would anatomical knowledge and surgical experience be sufficient background to make this possible?

Over 4 days periods of intense concentration can only be compared to 4 all day operating lists each with a complex reconstruction. Every step is new and has to be learned and understood from the basic form, relying on measurement, to the reproduction of the sitters features based upon observation and mathematical checking where possible to finally trying to capture expression within the limitations of the medium.

The method of instruction suits surgeons down to the ground. Watch, discuss then do it alone. Understand the principles and then the foundations are set. Break the rules when starting ñ inaccuracy in measurement is a recipe for a result which will never resemble the sitter. Observation and re-observation highlights the inaccuracies and practice helps solve the differences. Surgeons who can only measure will get to a certain level then fail to progress. The methodology takes one into the realms of observation and reproduction of what is seen with the ability to check the reconstructed form against the original from many vantage points.

The sense of achievement in producing ones first head sufficient to begin to see a likeness in the sitter is proof that the approach for replicating 3 dimensional forms is transferable to those who have no previous artistic experience. Furthermore one returns to ones reconstructive cases with a new way of thinking and observing that culminates in an undoubtedly superior approach and outcome for the patient.

This methodology should be considered at an early stage in the training of reconstructive surgeons.

Acknowledgements
Many thanks to Brian Morgan and Per Hall for their support in the writing of this article and to Per Hall for his reflective account and the use of his photographs of his sculpture at the Royal College of Surgeons of England.

References

  1. Hand Eye Coordination:BMA News:2004: BMJ vol 328 no.7453:13
  2. Arnheim R: Art and Visual Perception: Berkley University of California Press:1974 quoted in Tolleth H Concepts for the Plastic Surgeon from Art and Sculpture: Clinics in Plalstic Surgery:1987:vol 4:58
  3. Shepherd L: Hand Eye Coordination:BMA News:2004: BMJ vol 328no.7453:13
  4. Tolleth H Concepts for the Plastic Surgeon from Art and Sculpture: Clinic in Plastic Surgery:1987:vol 4:586
  5. Frank F: Art as a Way: Crossroad Publishing Co:1981:99
  6. Edwards B: Drawing on the right Side of the Brain: Fontana 1990:32
  7. Edwards B: Drawing on the right Side of the Brain: Fontana 1990:37
  8. Edwards B. quoted in Tolleth H: Concepts for the Plastic Surgeon from Art and Sculpture: Clinics in Plastic Surgery:1987:vol 4:585
  9. Grosser M in Edwards B: Drawing on the right Side of the Brain: Fontana 1990:4
  10. Rodin A: Rodin’s Drawings: Roding Rediscovered: NGA, Washington 1983:
  11. Morgan B:Hand Eye Coordination: BMA News:2004: BMJ vol 328 no.7453:13