BrazJOtorhinolaryngol.2017;83(4):373---374
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
EDITORIAL
The
multicultural
evolution
of
beauty
in
facial
surgery
夽
A
evoluc
¸ão
multicultural
da
beleza
na
cirurgia
facial
Theconceptoffacialbeautyhasbeen definedinavariety ofwaysdatingbacktoancienttimes,andwhilethe defini-tioncontinuestodevelop,ithasbecomeclearthatbeauty crossesethnicboundariesandhasasignificantculturaland economic impact. Subconsciously, beauty is perceived by humans as a sign of favorable genes and increased fer-tility, both of which play a role in mate selection. As a result, perceived attractive features that are subcon-sciously selected evolve much more quickly than other naturallyselectedcharacteristics.Additionally,the beauti-fularemorelikelytogetbettergradesinschool,tobehired for ajob,toreceive higher salaries,and tobeviewedas nicer,smarterandhealthier.1Whilebeautywasoncestated
tobe ‘‘inthe eye of thebeholder’’, more recentstudies have suggested that beauty is an objective, quantifiable quality.
The ancient Greeks began the quest for a universal standardofbeautyandbelieveditwasrepresentedbythe ‘‘goldenratio’’alsoknownas‘‘phi,’’whichwasthoughtto representperfectharmony.1---3 Innature,theratioappears
inthespiralofseashells,inthegrowthrateofthehuman mandible,andintheDNAantihelix.Examplesofits appli-cationincludeEgyptianartandarchitecture,theFibonacci sequence,andgeometricshapessuchasthepentagonand decagon.Many stillbelievethat phicorresponds tofacial beautyaswell.3However,othershavefoundittobeinexact.
Forexample,Marquardtcreatedan‘‘ideal’’facialstandard basedoffofphi,andnotonlydiditapplypoorlytopeople ofnon-European/Caucasiandescentbutitalsomasculinized Caucasianwomen.4
Theconceptofbeautyasaformulacontinuedtoevolve withtheartistsoftheRenaissanceperiod.ThroughDaVinci andhiscontemporaries,theneoclassicalidealswerelargely based on phi. The art anatomists of the 17th and 19th
夽 Pleasecitethisarticleas:CerratiEW,ThomasJR.The
multicul-turalevolutionofbeautyinfacialsurgery.BrazJOtorhinolaryngol.
2017;83:373---4.
centuries propagated these new standards into the medical field, which created a ‘‘universal’’ definition of beautyfor theperiod.2 Whiletheseideals continuetoday
tohave a strong influenceon facialanalysisand serve as aguidelinefor surgical planning,researchhasshown that theseidealsstilldonotapplycross-culturally.
Despite the inability to universally quantify beauty, researchershave found that thereis a consensus on rat-ingattractivenessacrosssexualorientations,ethnicgroups, andages.Studieshaveshownthatdiversepopulationsagree onwhoisand isnot attractive.Additionally, eveninfants have an innate preference toward attractive faces.1
Cer-tainconceptionsoffacialbeautyorattractiveness maybe everlasting. In 2006, Bashour researched and challenged each of the four concepts. He concluded that subjective attractiveness comprises only a small percentage of per-sonal preference over a much larger biological objective assessmentofattractiveness.5
The four concepts of facial beauty include symmetry, averageness,youthfulness,andsexualdimorphism.Thefirst conceptofsymmetryisbelievedtorepresentahigh qual-ityof development.A symmetric face reflects a person’s phenotypic and genetic condition giving him or her an advantageinsexualcompetition.Averageness,thesecond concept, is informed by the Darwinian theory that evo-lutionary pressures function against the extremes of the population. As a result, humans innately appreciate that averagenessrepresentsgeneticheterozygosityandagreater resistance to disease. The third concept is youthfulness. Neonatal features, such as large eyes and a small nose, arebelievedtosuggestdesirablequalitiesofyouthful live-liness, open-mindedness and affability. As a person ages and demonstrates soft tissue descent, the face deviates fromthephistandard,resultinginadecreasein attractive-ness.In addition,thehuman braininterpretsthe physical changesof agingasadecreaseinfertility.The fourthand lastconceptofbeautyissexualdimorphism,whichisdefined asaphenotypicdifferencebetweenmalesandfemales.For females, increasedestrogen leads tothe development of
http://dx.doi.org/10.1016/j.bjorl.2017.04.005
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen
374 EDITORIAL
secondarycharacteristics thatsuggesta fertilehostanda reproductive advantage. These include a thin jaw, small chin,largewidelyspacedeyes,smallnose,highcheekbones, andplumplips.Onthecontrary,desirablephysicalfeatures inmenarethosethatsignifyhightestosteronelevels,such asprominent chins,squarejaws, deep-seteyes,thin lips, heavybrowsandabundanthair.1,2
Although attractiveness can be agreed upon cross-culturally, each ethnicity has unique features that are factoredintoitsdefinitionof‘‘averageness.’’Forthefacial plasticsurgeon,these uniquefeatures must be respected andembracedinordertocreateaharmoniousandelegant result that meets the criteria of beauty and attractive-ness.As aresult,theneoclassicalideals maynotserveas accurateguidelinesinnon-Caucasianpatients.Specifically inrhinoplasty,distinctanatomicdifferencesexistbetween the leptorrhine nose seen in Caucasians, the platyrrhine nose seen inAfrican and Asianpopulations,and the mes-orrhinenoseseeninLatinAmericanpopulations.1 Patients
frequentlywanttopreservetheirculturalidentity,soitis paramountthatthesurgeonclearlydistinguishesthesegoals preoperatively.
Today’stypicalfacialplasticsurgerypracticeisbecoming increasingly multicultural. The globalized modern society hasplayed a significant rolein the perception of beauty. Economicmobility coupledwithan increase ininterracial couples has blurred the lines of ethnic identity, and the resultingestheticallyuniqueandbeautifuloutcomesdonot allowpatientstobecharacterizedasfittinganarrowmold withpredictable desires.1 Theclassic principlesofbeauty
including phi, symmetry, averageness, youthfulness, and sexual dimorphism can still be applied asguidelines, but thesurgeon must incorporatea broader outlookon facial analysisandsurgicaltechniques.Theimportanceof identi-fyingpatients’ethnicidentitiescannotbeunderemphasized aspatientsmay wanttoerase, preserve,modify, or even enhancethosespecificinherenttraits.
Furthermore, cosmetic surgery continues to become increasingly desirableand sociallyacceptable. The ampli-fiedattentionandinterestcanbecreditedtoitsexposurein realitytelevision,socialmedia,andsurgicaldocumentaries. The increaseddemand and therising population diversity ensurethateach patientwillpresentwithaunique back-ground andcosmeticobjective. The surgeonshould assist patientstoarriveatagoalthatisharmoniouswiththeirface
givingatimeless,attractiveresultratherthanbeswayedby thedevelopmentofafashiontrend.Theproperguidance, insight,andethicalcontroldistinguishthesurgeonfroma technician.More importantly,thesequalitiespreservethe integrityofthefieldoffacialplasticsurgery.
Whilefacialmodificationscanhaveatremendousimpact onpatients’lives,theplannedresultshouldnotventuretoo far from the concepts of facialbeauty that have defined thefieldsinceitscreation.Digitalphotographyalongwith computerimaginghasaidedwithpreoperativeassessments inanefforttoconfirmthesurgeonandthepatienthavethe same esthetic goals. Technologywill continue to improve tofacilitatethisinitialconversation.Associety evolvesso mustourunderstandingofbeautyalongwithourattemptto surgicallydefineit.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.WeeksDM,ThomasJR.Beautyinamulticulturalworld.Facial PlastSurgClinNAm.2014;22:337---41.
2.ThomasJR,DixonTK.Aglobalperspectiveofbeautyina multi-culturalworld.JAMAFacialPlastSurg.2016;18:7---8.
3.ProkopakisEP,VlastosIM,PicavetVA,NolstTreniteG,Thomas JR,CingiC,etal.Thegoldenratioinfacialsymmetry.Rhinology. 2013;51:18---21.
4.HollandE.Marquardt’s phimask: pitfallsofrelyingonfashion modelsandthegoldenratiotodescribeabeautifulface. Aes-theticPlastSurg.2008;32:200---8.
5.BashourM.Historyandcurrentconceptsintheanalysisoffacial attractiveness.PlastReconstrSurg.2006;118:741---56.
EricW.Cerratia,∗, J.ReganThomasb
aUniversityofIllinoisatChicago,Departmentof
Otolaryngology-HeadandNeckSurgery,DivisionofFacial Plastic&ReconstructiveSurgery,Chicago,USA
bUniversityofIllinoisatChicago,Departmentof
Otolaryngology-HeadandNeckSurgery,Chicago,USA
∗Correspondingauthor.
