Another title for aesthetic facial plastic surgery may be the “science of looking better”.
A main reason why mastering the field is that this means different things to different people. Sometimes this means younger, sometimes better rested. Sometimes it means resetting things to how they were. But before we promise a patient we can make them look better, we have to spend years studying the question: what is the ideal result? What do we and our patients consider beautiful?
The answer to this question, like the question itself, is quite layered. It straddles the worlds of surgery and psychology - even art and philosophy. When we look at someone’s face for the first time, which features are we drawn to? What is pleasing to the eye? Which areas would that person want to appear differently – and why? These discussions can make for a long clinic visit.
Facial plastic surgeons need to produce reliable, consistent results that our patients love.
To that end we can’t operate on wildly different definitions of what is attractive or youthful. However we also can’t apply a cookie-cutter approach for each patient assuming we all prefer the same result. So we must provide a reliably successful - but customized - approach.
Luckily we’re armed with reams of data to help tailor our approaches. For centuries scientists and artists have studied what we define as beautiful. A difficult task, because the answer is obviously a moving target. If da Vinci painted a face he considered “ideal” in the Italian Renaissance it would likely look much different than what see on social media today. Also what is “ideal” in East Asia is likely different than in Alabama. Also, can any face be “ideal”, no matter whom we’re asking?
This leads to a host of philosophical questions. What is beauty? How much of the definition do we as a people share vs. differ? Is it something that we appreciate but can’t define? We’ll get into how researchers have cleverly tried to find these answers. But first, let’s discuss the rules of thumb that facial plastic surgeons have developed in the clinic and operating room to ensure we get our patients the desired result.
The building blocks of facial aesthetic surgery are found in facial analysis.
Facial analysis is the practice of evaluating each patient and their photos in a standardized, methodical way – measuring angles, defining the space between facial features, and targeting the areas the patient hopes to have addressed. It’s this primary step where the science meets the abstract. Intuitively, we think of attractiveness as an obvious subjective quality. But the researchers that study these angles and spaces argue otherwise. They tell us that if you show pictures of people’s faces to groups of strangers most of the time they’ll agree on what’s attractive. Even infants can agree on which features they prefer. The angles and spatial relationships found in these studies were recorded, averaged, and then used as a guidebook for the facial plastic surgeons to memorize and apply in the operating room.
First, a disclaimer: referencing scientific studies and guidebooks to define what makes a beautiful face beautiful is to make cerebral what is normally a pleasant experience. It’s like putting a grid atop the Mona Lisa and analyzing each square. But we must endeavor to know the “why” and the “how” behind that smile. As surgeons, if we’re gently redefining (or reconstructing) one’s facial features, without the science there’s no reproducibility – which is essential to getting great results.
Now the “how” of facial analysis: it begins during the first meeting with a patient and continues with photographs taken from standardized angles and distances.
These photos allow for direct comparisons between patients and across surgeons. From the photos we can divide the face into segments to find if specific proportions may be improved. There are many, many ways to analyze a face and assess the various relationships – it depends on what specifically you’re trying to improve. A few examples: if I’m looking at a picture of my face straight on, I can draw vertical lines across the photo it to segment it into parts. I can draw two vertical lines from top to bottom on either sides of my ears, two more running through the outside corners of my eyes and another two down through the inside corners. These vertical segments of the face “ideally” create five equal running strips. If a patient feels as though their face is too wide, too narrow, or out of balance somehow – we can start with a simple analysis like this to see if one strip if wider than another.
Another example: in that same photo I can draw a horizontal line through my pupils, through the point at the bottom of my nose, and another just below the bottom of my chin. These three lines roughly create two balanced horizontal segments. If I look at my photo from the side I can draw one vertical line from the top of my nose to its lowest point where it meets my cheek (line A), another line perpendicular to that from the same point to the tip of the nose (line B), and a final, oblique, line that runs from the top of the nose to the tip of the nose at an angle (line C). Dr. Goode writes that the ratio of line B to the oblique line, line C, is ideally 0.55 to 0.6. Dr. Crumley takes the vertical line, line A, all the way down to the upper lip and says this line should be 3.53 times the length of line B. Dr. Simons just writes that the upper lip should be as tall as line B is long. You can see how specific these analyses can be.
Even more specificity – the ideal ratio of the thickness of my lower lip to my upper lip is said to be 1.618. This is a number to remember - 1.618. The ideal ratio of the height of my head from top to bottom to the width of my head should be the same number. A line between the corners of my eyes to a line between the corners of my mouth – also “ideally” found to be 1.618.
The ratio mentioned: 1.6180339887 (when rounding), is especially interesting – it’s an irrational number called the “golden ratio” and is represented as phi (φ). I first learned of it while studying architecture in college. And then again studying DaVinci’s “The Last Supper” in art history.
To illustrate the golden ratio, picture a straight, finite line with a point in the middle. The length of the line before the point we’ll call “a”, the length after we’ll call “b”. I can divide the line carefully so that the whole of the line, “a+b”, carries the same relationship to segment “a” as segment “a”, by itself, carries to segment “b”. This gives me the golden ratio: if the length of the “a” segment is said to be equal to 1, then “a+b” is = 1.618. And then if “b” = 1, then “a” = 1.618.
This number, in essence, represents a relationship between two things: two lengths, two areas, two frequencies - two quantities of any type. It carries a simplicity and elegance that we innately find pleasing and balanced. For example, we can draw a rectangle that is divided by applying φ. This creates two areas within the rectangle, one larger and one smaller, that have been applied in countless paintings by the masters because the viewer finds this to be natural and harmonious.
We can draw an arc within each rectangle so that the arc decreases by φ as it spirals infinitely smaller and smaller. This spiral can illustrate how the golden ratio can also represent a rate of change, whether getting smaller or bigger. This rate of change occurs in nature, such as with an animal’s growth rate when compared to its size, or within a spiral of our DNA.
In facial plastic surgery we apply it just as Leonardo DaVinci would apply it to paint a face – to encourage a natural, well balanced result. When I am filling a lip, I know that I need to provide a natural relationship between the two to avoid looking artificial. It’s similar with performing a rhinoplasty – the final result needs to have the width, height, length, projection, and rotation all in an ideal relation to each other. And the nose as a whole needs to be balanced with the entirety of the face. We have to follow the rules of nature to get the most natural result.
These tricks of facial analysis are invaluable when deciding which changes to make (and which not to make). They help to answer the how regarding the perception of beauty, but not the why. Why does “beauty” matter? Why were 1.7 million cosmetic surgeries performed last year? Why do we all hold cross-cultural, deeply embedded beliefs about what is beautiful?
The answer seems to stretch from one discipline to another: from genes to magazines.
Something in our DNA wires us to hold a general collective view as to what we perceive as beautiful.
But obviously, this is only part of the answer – our perceptions clearly vary from one person to another, one age group to the next, one country to its neighbor. Cultural predispositions, societal trends, the opinions of friends and family and countless other factors all play a role in our preferences.
Researchers have spent a great deal of time looking into this. We know now that our perceptive preferences are ingrained from day one. In one study, researchers displayed pictures of various adult faces to infants, one after the other. They analyzed how long the babies studied each one – if one picture held the baby’s attention longer than another it was assumed the baby preferred that picture to the other. The faces they were shown were a mix - both genders and more than a single ethnicity. The study authors were trying to find if certain faces were preferred across the population even at an age before cultural influences (e.g. the E! channel) would take effect. The results could have turned out in multiple ways.
The infants may have paid the most attention to what they’re used to – the ethnicity and/or ages of the family at home. Or they may have paid more attention to an age group or ethnicity completely foreign to them out of curiosity. Or they may have not preferred one photo or another at all and just looked around the room as babies do. None were true – the babies consistently picked the face identified at the outset by the researchers as “attractive”. This was irrespective of ethnicity or gender.
Why do we have this ingrained sensibility?
Prior study tells us that when defining attractiveness at least three characteristics float to the top: averageness, symmetry, and ‘sexual dimorphism’. Averageness means that attractive faces possess the features that are found most commonly among that group of people. For example the most Icelandic features when chosen by Icelanders, or the most Ugandan features to Ugandans. Symmetry is an intuitive one.
Researchers have performed studies where they find if people prefer photos of faces that are unaltered – their true, asymmetric appearance – or photos that are really one half of a face and its mirror image, so it appears as a perfectly symmetric face. Unsurprisingly subjects thought the symmetric, digitally altered photo was the winner. Finally - sexual dimorphism. This science-y term refers to the features that make a man a man and a woman a woman. Men have noses with the tip pointed more downward than women. Women have eyebrows that sit higher above their eyes than men. A man’s attractiveness depends on the degree to which they possess attractive masculine features, and the same for women.
But nailing down the attractive features that even babies agree on helps to answer the question “What is beauty?” not “Why is beauty?” I could describe with great specificity what Kiera Knightley’s face possesses that makes me perceive her as more attractive than Danny Devito, but I’d have trouble telling you why this is the case. It just is.
Science has sought to give us a better answer.
Most explanations incorporate the principle of natural selection in some way. Remember the aforementioned averageness component of what we find attractive. Averageness here doesn’t imply not attractive but but not unattractive – somewhere in the middle. But rather another way to write this may be that popular features are more attractive. The ”average” faces employed in some studies as attractive by the researchers are composites – constructions of the most common features of the population. The nose isn’t too small, isn’t too big, but right in the average-y middle. The chin isn’t set too forward, isn’t sitting too far back, but rests right in between.
So are these features perceived as attractive because they’re common – right in the middle of the bell curve? Studies tell us that maybe they’re common today because they’re attractive. Your genes are at work trying to gain an advantage, to continue to be naturally selected and passed on.
For example, say one feature has a functional advantage – a long and narrow shaped nostril designed to maximally humidify cold air. As natural selection will tell you, if somebody lives in Iceland and possesses that nostril that person holds a selective advantage - his or her chances of having babies are slightly better than someone with short, flat nostrils because they can breathe more easily in the cold. So as the generations pass the long and narrow nostrils pop up more and more. Fast-forward to today, if you’re single and living in Iceland, swiping through candidates on a dating app, which nostril is going to seem the most attractive? The nostril with a shape that would provide your future kids those same advantageous odds.
Natural selection may explain why we find certain features attractive by other mechanisms, too.
One theory describes the effect of testosterone on our beauty preferences. Testosterone is a hormone that both stresses the immune system and results in those masculine features (strong chins, prominent cheekbones) that people tend to notice in attractive men. So the theory goes that only those men that are healthy enough to tolerate that stress on their immune systems during development have the chins and cheekbones that go with it. This means that Ben Affleck and his ancestors with strong chins must have been resilient enough to tolerate the higher testosterone levels that are required to mold that chin. This may be why we generally describe strong chins as masculine and attractive – it signifies a person that may be a healthy potential gene sharer with the best odds to reproduce. So those features, while otherwise unrelated, are propagated together in the population.
Our skillful genes, whose goal in life is to propagate themselves, now tell us that certain shapes of nostril, prominent chins, and plenty of others are all attractive features.
And so these winning, attractive features have won – they’ve been passed along at a higher rate than other features and become more and more common. One population’s facial traits become more narrowly dispersed around the mean. It’s true that we as individuals are all snowflakes – there is no one on the planet that is exactly like us and never has been and never will be. But we individuals have all been “designed” by the same process. It’s a process that encourages all ages and ethnicities to generally agree on what is attractive and what is not.
Does natural selection entirely explain why we find certain features beautiful? Or why there is such variety in preferences from person to person? Definitely not. It’s universal that you and your friends will disagree on what is most beautiful. Other studies have backed this up. One study presented viewers with a picture of a face with those common, genetically gifted features that we mentioned. Then they added a few touch-ups that were not common and didn’t provide any obvious advantage. They shrunk down the nose, enlarged the eyes, raised the forehead. They found that the viewers usually preferred the less average, more touched-up face to a face with the popular, averaged features. There is no clear answer as to why this might be.
So these evolutionary theories explain the similarities we share when perceiving and describing beauty, but not the differences. The similarities are generally clear – it’s why facial plastic surgeons are able to master certain aesthetic procedures and offer them again and again to satisfied patients. But the variety of preferences among us is easy to see.
When appreciating a beautiful face there are conscious and unconscious forces at place, there is natural and unnatural selection.
You may say that basic, deeply ingrained processes via our genes are there to act as the engine while our higher cognition, influenced by fashion trends, diet and overall health changes, memories of friends and lovers, celebrities of the day, etc. drive the car. We’re all different but on some things we can agree.
It is essential to recognize both the similarities and differences as a facial plastic surgeon. Clients will rightfully expect an ideal, beautiful result after aesthetic surgery. To provide these results a surgeon must use the beauty grid – facial analysis, understanding what we generally appreciate as beauty and why – as well as a customized approach and flexibility for each person. The ideal result for you is different than the ideal result for me. Both the commonality and the diversity have to be appreciated.
Asking ‘why?’ and ‘how?’ we as a diverse group perceive beauty have rendered this abstract science a fascinating field. Still, carefully adjusting the angles in the operating room won’t replace a laugh or a sigh, some of the very things that make us who we are.
But any question whose answer helps to tell us more about ourselves is a good one.