Changing Perceptions of Beauty: A Surgeon’s Perspective

Peter A. Adamson, M.D., F.R.C.S.C., F.A.C.S.,1,2 and Matthew B. Zavod, M.D.1

Abstract

Beauty is a mystery that has been with us for ages. Scholars and scientists have investigated its roots and effects, and its presence is ubiquitous. Has the construct of beauty changed over time? Is our sense of beauty learned or innate? What is beauty, and can we quantify it? A substantial amount of work supports a Darwinian theory of selection, which predicts a survival advantage based on physical attractiveness. However, there is evidence that certain perceptions of beauty change with time. Indeed, the recent globalization of modern society has wrought changes in our perceptions of beauty. Are patients electing cosmetic surgery procuring a survival advantage, or are they bypassing genetics and setting a new standard for beauty? As facial plastic surgeons, we must be poised to respond to this metamorphosis and understand its roots. Although there is some equivocation and debate about this elusive subject, it is our duty to stay abreast of the current dynamic to make sound judgments that are in the best interests of our patients.

KEYWORDS: Beauty, facial plastic surgery, evolution, perceptions

Beauty is a controversial subject and has been throughout the known history of humankind. Regardless of one’s knowledge or lack of knowledge about the maze of beauty, each person has his or her own opinion and is confirmed in its rectitude. This may be particularly true regarding surgeons, who are sometimes said to be ‘‘wrong but never in doubt.’’ But beauty is a much more ethereal subject, not to mention emotive, and therefore demands a flexibility of thought if one is to imbibe its complexities.

PERCEPTIONS OF BEAUTY THROUGH THE AGES
Ancient philosophers grappled with the true definition and meaning of beauty. Sappho stated that, ‘‘What is beautiful is good,’’ and Aristotle noted that, ‘‘Beauty is a greater recommendation than any letter of introduction.’’ Plato described Beauty, Truth, and Goodness as the three most significant values in his philosophical system. He further stated that the Good and True are always beautiful, but what appears to be beautiful is not always good or true. Would many of us today, even with only a cursory thought, disagree with this reflection? So what is it that creates this ambivalence in us about beauty? Today we know much more about the anthropology, psychology, biology, mathematics, and sociology of beauty, yet even its definition can be confounding. The Oxford dictionary¹ defines beauty as ‘‘Excelling in grace or form, charm of coloring, qualities which delight the eye and call forth that admiration of the human face in figure or other objects.’’ Aaron Spelling, the Hollywood producer, was somewhat less erudite, but perhaps just as telling, when he said, ‘‘I can’t define it, but when it walks in the room, I know it.’’ So, has beauty changed, or not? Marquardt² has studied the mathematics of beauty and created the Golden Decagon Mask (Fig. 1).

Figure 1 Golden Decagon Mask. (Available at: http://www.beautyanalysis.com/index2_mba.htm. Accessed May 23, 2006.)

This two-dimensional visual perception of the face is based upon the phi ratio, which is 1:1.618. It is also been called the Divine or Golden Ratio because it is found throughout nature and is thought to represent perfect harmony. As Sir Francis Bacon noted, ‘‘Beauty is harmony.’’ This ratio and our innate ability to appreciate its expression in the attractive human form have been with us forever but only more recently explicitly understood.

Symons³ has postulated a biological basis for beauty, utilizing the term koinophilia to describe the human attraction to others of average appearance. This is based partially on Darwinian theory, which explains that evolutionary pressures operate against the extremes of the population.⁴ Therefore, averageness is attractive to potential mates as we inherently appreciate that such mates have a greater probability of passing along our genes. It is strongly suggested that this is not a cultural construct but rather is innate and hard-wired into our genes.⁵

Thornhill and Gangestad⁴ in 1999 stated that the face is really a health certificate indicating an individual’s value as a mate. The value increases with increasing symmetry, koinophilia, and the size of sexually dimorphic traits. Symmetry is important as it is thought to be an indicator of developmental stability.⁶ Only 15% of human faces are essentially symmetric, and these individuals have a biological advantage over the rest of us.

Averageness is important as it is thought that we constantly collect the images of all of the faces we see⁷—it takes only 0.15 second to scan and recognize another face. We create a composite image of the ideal face that for each of us forms an individual standard of attractiveness. Penton-Voak has shown that males prefer females with features that are expressed by their higher estrogen levels and presumed fertility. These hyperfeminine features include a thin jaw and small chin, large widely spaced eyes, small nose, high cheekbones, and a short upper lip. Is it a coincidence that contemporary dolls that are popular with young girls highlight this premise in exaggerating these features (Fig. 2)? Similarly, women generally prefer males with features that express higher testosterone levels. These include prominent chins, deep-set eyes, heavy brows, and abundant hair. These traits, too, have been reproduced in the merchandising of heroic masculinity (Fig. 3). The truly beautiful, it can be shown, are those who are symmetrical with prominent secondary sexual characteristics and who have one or two features that are outside the average range. Because they are different from the average, one can presuppose that they have a strong reproductive capability to overcome the inferiority of their lack of more ‘‘averageness.’’ Thus, the explanation of why ‘‘Gentlemen prefer blondes.’’

Figure 2 Bratz™ dolls. (Available at: http://www.bratz.com. Accessed May 23, 2006.)

Figure 3 Sketches of G.I. Joe®. (Available at: http://www.newsarama.com/forums/showthread.php?s=&threadid=6291. Accessed May 23, 2006.)

It can be said with some degree of confidence that these hard-wired concepts of human attractiveness and beauty have been functional in determining the choice of mates and thus evolution of our species for hundreds of generations. But it is only in recent decades, as we have come to study and understand beauty better, that they have had a more substantial influence on our thinking.

CHANGING PERCEPTIONS OF BEAUTY: CONTEMPORARY CAUSES
In Nancy Etcoff’s book,⁸ she cites the evolution of changes in plastic surgery in North America from the 1950s to the 1990s. Changes included a gradual narrowing of the eyelid from extremely high lidded in the 1950s to smaller eyelids. The 1950s nose was more upturned, or rotated, with a very sculpted or narrow tip. By the 1990s, noses with a wider tip and fuller bridge were preferred. Plump lips were always preferred, but lips are getting plumper. Presentations at the Ninth International Symposium of Facial Plastic Surgery⁹ stressed the importance of augmentation of the cheek and minimal elevation of the medial eyebrow. The importance of creating a youthful look by maximally improving the jowls to create a narrow chin was emphasized. It is noted that as a female ages, the squared-off jaw makes her look not only older but also more masculine. Rejuvenation reverses both of these aging characteristics. It is noted by some that facial ‘‘deflation’’ or loss of tissue volume is a significant culprit in aging. This has increased interest in the use of fat transplantation and other fillers to plump the face, making it appear more youthful.

Why are our perceptions of beauty changing, as expressed by surveys completed by the American Academy of Facial Plastic and Reconstructive Surgery or presentations heard at meetings and our own practice experience?

There are obviously multiple factors, some more apparent than others. First, as we learn more about the science of beauty, we learn that symmetry and hyperfeminine features create more attractiveness, even beauty, in our female patients. That is the essence of what our patients seek, as they compare themselves with others in the biological sweepstakes. For men, appearance is also important to attract a mate, although in the vastmajorities of culturesmen place a greater emphasis on their potential mate’s appearance than do women.^10–12 Women tend to place a higher value on financial prospects and ambition in a mate. By understanding better what each of the sexes finds attractive in the other, we can better create a new look that strives for these ideals.

Another factor is Marshall McLuhan’s¹³ ‘‘Global Village,’’ which is upon us. Through electronic and print media and the Internet, we live in a ‘‘connected’’ world. We are each bombarded daily with visual images of faces that remind us of the multiracial aspect of our world. The majority of women are exposed to an average of 2000 images in advertisements each week.¹⁴ No one lives only in their own neighborhood anymore. Each time we see an ‘‘international’’ face, we alter our inner beauty template to accept a new norm, one different from the neighborhood in which we grew up.

For many urban North Americans and Europeans, immigration in the last half century has opened our doors to every race in the world and affected our perceptions. As we constantly scan the multiracial faces all around us, we recognize differences in facial shapes as small as 1 mm and through our ‘‘face-averaging device’’ create composites that become our new standard of attractiveness. Over time it is expected that our internal averaging will ultimately become more homogeneous, creating what Etcoff⁸ calls the ‘‘universal face, a composite of the futures of all races.’’ These standards are obviously translated to our professional analysis of the face we see and our goals related to the new aesthetic ideal.

In addition, for many of us our practices are multiracial. Long gone is the time when Caucasian surgeons were so presumptively ignorant as to believe all Asian, Hispanic, or African American patients wanted a ‘‘white nose.’’ Listening to patients of all races, we hear of their desire to create an appearance that is more normal, that is more average, and that allows them to fit into the average-looking group; or we hear from older patients seeking an appearance that reflects their sense of youthfulness but that they do not want to look ‘‘different.’’

Other influences that are likely to play a role in the facial plastic surgeon’s perception of beauty include the increasing number of international surgeons who educate North Americans about their perceptions of attractiveness and their treatment of their patients. More women than ever are practicing facial plastic surgery, bringing invaluable insight from their perspectives. A variety of specialists now engage in cosmetic surgery, including cosmetic dermatologists, oculoplastic surgeons, cosmetic dentists, oral surgeons, and even tattoo artists. They all affect our thought processes. The results of their work affect our own beauty template, and we all stimulate each other to reassess our ideals and produce better aesthetic results.

It may also be that the media influence our perceptions of beauty. However, Buss’ study¹¹ challenged the notion that the pursuit of beauty is essentially the product of modern North American advertising and mass marketing. It is far more innate. Jones and Hill’s¹⁵ cultural studies revealed similar concepts of beauty that were unrelated to any media influence. They found three separate Western cultures and two isolated native tribes that generally came up with the same beauty ratings when shown sets of multiracial, multicultural pictures. They were all attracted to features who could be described as ‘‘exaggerated markers of youthfulness.’’ However, most of us believe, if only intuitively, that media play some role in shaping our thoughts.

CHANGING PERCEPTIONS OF BEAUTY: IMPLICATIONS FOR OUR PATIENTS
Valéry¹⁶ has shown that we have a spiritual longing to have an outer representation that matches our dreams, visions, and moral aspirations. It is also known that our sense of social ease, or self-image, is related to how others judge our beauty. But our sense of self-esteem is more closely linked to how we see our own beauty. Garner’s¹⁷ survey revealed a growing dissatisfaction with body image, that is, the internal view of the outer self. It was felt that this could be worsened by outside influences, notably peer criticism and the stereotypes of beauty in the media. Another survey showed that the proportion of women dissatisfied with their bodies rose from 23% to 56% from 1972 to 1996. For men the rise was 15% to 43%.18 Our world today is more comparative and competitive than ever, thus compelling everyone to look their best. And the standards of what is beautiful are ever increasing, abetted even by the results of our own cosmetic surgery work. Are we making the lives of many more stressful just as we resolve bodyconcern issues for others?

Berscheid and Walster¹⁹ studied the impact of facial attractiveness on individuals. They found that physical attractiveness affected social acceptance and that enhanced social status is conferred on the beautiful.²⁰

Perhaps beauty should not be important, but in reality our society places value and prestige upon it. Our patients all recognize this, implicitly or explicitly, and are faced daily with changing perceptions of beauty and their impact on their lives. It should be no wonder that increasing numbers of women and men are seeking improvement in their appearance.

CHANGING PERCEPTIONS OF BEAUTY: IMPLICATIONS FOR THE FACIAL PLASTIC SURGEON
Today’s cosmetic surgeon must be learned in the science of beauty and also aware of the multifactorial influences affecting his or her patient’s changing perception.

Our patients today are better informed than ever, often employing diagnostic or treatment terms previously only known by physicians. This surge in patients’ autonomy has accompanied the decline of paternalism in medicine. Contemporary patients are on the Internet – a Google search turned up 40,700,000 sites for ‘‘internet plastic surgery.’’ There are millions of patient Web sites related to rhinoplasty alone, not to mention chat rooms. Patients morph their own digital photos, watch reality plastic surgical shows, and learn which celebrities are considered the most attractive in magazines. Many medical and surgical companies market their beauty products and treatments directly to these consumers, our patients, who promptly advise us what is best for them. Much of this is done without the investigative rigor usually associated with the scientific method. We live in a Western age of self-realization or selfactualization for each individual, and for many that includes looking one’s best. Facial plastic surgery procedures increased 34% from 2000 to 2004,²¹ and cosmetic procedures in North America are said to number almost 10,000,000 annually. Most of us feel our standards must constantly be raised to match our patients’ everincreasing expectations. Although ‘‘improvement, not perfection’’ is our mantra, the subtext is often that perfection must be sought and, with good work, can be achieved. This mandates that patient selection and education be of the highest order to achieve high rates of patient satisfaction.

There are more specialties and more physicians and surgeons practicing cosmetic facial surgery. Patients have better access than ever to locating a physician of their choice. They can more easily ‘‘comparison shop’’ and have easy access to lines of credit to have procedures now and pay later. There is a much larger number of surgical and nonsurgical options available, many with so-called lunchtime results. There is literally something for everybody, making cosmetic enhancement a mainstream activity. With advances in surgical techniques, from endoscopy to lasers to fillers to Botox and beyond, a more subtle, natural, refreshed, and youthful appearance can be achieved by almost anyone so motivated. Accessibility to facial rejuvenation has never been easier.

CONCLUSION
Where does all of this leave the facial plastic surgeon today? We know that we are all hard-wired to seek beauty as a biological imperative. We also know that our rapidly evolving world is changing our perception of beauty and that this is affecting our patients as well as ourselves. Controversy abounds—some would say that cosmetic surgery objectifies women (and men), feeds on realistic images of beauty, and perpetuates our cultural obsession with youth. Others would say that it is one of the best investments that one can make and that many benefits accrue from it. It is arguable that cosmetic surgery is an extension of nutrition, fitness, makeup, and fashion—all of which enhance one’s attractiveness to the opposite sex. If so, are we creating an unnaturally high standard that cannot be met by those not having cosmetic enhancement? Although cosmetic enhancement may improve our chances of having a more attractive mate, what of the offspring who will not be blessed with the altered phenotype?

All cultures throughout history have revered the power of beauty. It is sought after relentlessly, yet we are filled with ambivalence about it. It is said by some to be superficial, yet it is at the core of our survival as a species.

No wonder our perceptions of beauty and attitudes about cosmetic surgery are so conflicted.

Without doubt, we will continue to seek a greater understanding of beauty and the role it plays in our daily lives. To date, we have as many unanswered questions as answers. Our goal as facial plastic surgeons must always be to enhance the lives of our patients within their best interest. To do so we must seek to better understand the changing perceptions of beauty that surround us. We can all look forward to exciting and challenging years ahead as the myths and realities of beauty unfold.

ACKNOWLEDGMENTS
The authors would like to thank Michael Lavoie for his expertise in helping to research the subject matter.

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