A deep understanding of beauty and aesthetics is implicit when forging a career in aesthetic medicine and yet perhaps this is not given the attention it should receive when in training.
There is quite rightly a focus on patient assessment, anatomy, technical skills, product knowledge, safety and avoidance of complications, but the study of aesthetics and artistic appreciation is generally considered to be an area of expertise developed over time. In this article we will explore some of the historical and contemporary concepts of beauty, the psychology of beauty in the modern world and the importance of artistic appreciation within a successful aesthetic practice.
Why is artistic appreciation important?
Understanding and learning about artistic appreciation is a fundamental concept within aesthetic practice. However, we recognise it is considered a relatively nebulous concept and usually only grasped and embraced after years in practice.
The concepts behind beauty, including its representation, articulation and modification are part of a complex sociological dynamic spanning thousands of years. However, regardless of fads and fashions, we wish to present a few ideas and inspirations that practitioners may find useful and incorporate into their own thought processes when assessing and treating patients.
It is also important to constantly examine what we are trying to achieve for any one patient and to listen carefully to their aspirations and wishes – are we improving beauty, treating their insecurities and psychology, are we contouring, improving proportions, minimising asymmetry or making patients look younger? Or indeed all of the above? Whilst we need to be sensitive to what the patient wants and not necessarily what the aesthetic practitioner wants, an understanding of beauty and artistic appreciation will help evolve the best treatment programme for that patient.
Historical concepts of beauty
The notion that beauty is ever changing is certainly true but to understand where we are today, we must first understand where our concepts of beauty are derived. Western standards of beauty were generally considered to be set 2,400 years ago in Greece and Rome.
The ancient Greeks believed that a beautiful woman’s face was defined by perfect, harmonious proportions and symmetry. Maths played a significant role in this, with early mathematicians such as Euclid formulating a pattern known as the ‘Golden Ratio’ (also termed the Fibonacci Ratio, Phi Ratio and, sometimes, the Divine Proportion), which has a constant value of Phi=1.618.1
This ratio was later used by artists, such as Leonardo Da Vinci when drawing the human body, as a way of creating perfect symmetry and form. The width of the mouth is ‘Phi’ times the width of the nose. The distance between the lateral canthi is ‘Phi’ times the width of the mouth. The height of the face from the pupils to the chin is ‘Phi’ times the height from the hairline to the pupils (Figure 1).
“The secret to beauty, by Greek standards, was in the harmonious proportions of facial features,” confirmed art historian and painter Carol Ravenal in a Washington Post article, who added, “There was both a rationale as well as mystical appeal. Mathematics was the key to form.”2 In a similar vein the Greek philosopher Plato viewed the structure of the human body and face as a system of triads; for Greek mathematicians, the number three had special significance. The perfect face was divided into three sections: from hairline to eyes, from eyes to upper lip, and from upper lip to chin. The ideal face was two thirds as wide as it was high. Even today, plastic surgeons divide the face into thirds during their routine examinations and we would encourage all aesthetic practitioners to do likewise.3
Concepts of feminine beauty then definitely entered a new era and changed subtly with advent of the 15th-century Italian Renaissance. Famous artists like Botticelli, Raphael and Leonardo Da Vinci painted a procession of exquisitely varied faces and yet all were united by a certain aesthetic. Ravenal explained, “Botticelli’s Madonnas are lovely… because they appear delicate and destructible. Leonardo’s paintings of the Virgin show a woman who is beautiful not because her features are perfect in the Greek sense but because her face conveys a sense of tenderness and mystery,” – i.e. is less objective and more subjective.2
However, many commentators believe it is Raphael’s standard of beauty that shaped the work of artists for centuries after. “His image of beauty is exquisite,” said Ravenal, “It’s not threatening. While less monumental than the Greeks, it’s still harmonic. Raphael understood the feminine psyche.”2
These comments start to give us a flavour of the different approaches to beauty and aesthetics – they give credence to the importance of both the complexities of mathematical ratios, symmetry and facial harmony from the Greeks, but also the more erudite and nebulous subjective concepts of beauty developed during the Renaissance. Both these concepts are very much evident today in our aesthetic practices. In essence, history suggests that whilst a beautiful face is one with harmonious proportions and symmetry, other factors come into play too.
Contemporary concepts of beauty
The modern idea of beauty draws richly from these past influences, with one commentator summarising four emerging concepts that are now widely acknowledged as being the major determinants of attractiveness.3,4 These are:
- Averageness (prototypicality) – this draws on the concept that humans are actually attracted to ‘average’ faces as they are easier on the eye and on the mind
- Sexual dimorphism – femininity is considered more desirable as it is a signal of fertility in human female faces because it is associated with oestrogens which in turn is a sign of reproductive health
- Youthfulness – a young face that doesn’t show the signs of ageing is generally considered most attractive
- Symmetry – facial features in proportion with one another are often regarded as a signal of beauty5
Inspired by the concepts of symmetry and patterns from the Greeks, in 2001 board-certified plastic surgeon Dr Stephen Marquardt adapted these ideas and created a template called the Marquardt Beauty Mask, which is made up of a primary and secondary ‘Decagon Golden Matrix’ (geometrically and mathematically all multiples of Phi).6 He believes this concept identifies facial characteristics that are universally perceived as beautiful. This ‘mask’ has often been applied to various actresses and individuals considered to represent the pinnacle of a beautiful face.
Whilst beauty is subjective and in the eye of the beholder as well as determined by culture, fashion and many other influences, the Marquardt Beauty Mask was formulated on the concept that certain aspects of beauty remain consistent throughout history.
However, not all commentators subscribe to the importance of symmetry and one London author, Alexander Walker, considered further definitions of beauty in his 1836 book Beauty: An Analysis and Classification. He countered the importance of the idea of symmetry and instead identified the need for asymmetry, saying that it is, “The first character of beauty in thinking beings. An occasional irregularity makes us better appreciate symmetry.”2 This is perhaps something to bear in mind in every day aesthetic practice as it is not always wise or correct to chase the quest for symmetry.
The psychology of beauty
Like it or not, there is a beauty bias. Scientists discovered long ago that people for better or worse show favour to those with a pretty face.7 Attractive people are also more likely to get jobs and we even unconsciously think attractive people are smarter and friendlier than less attractive people. This so-called ‘Beauty Premium’ is a theory that people who are more attractive are more successful in life, in work and earn more money than those with below average looks.7
This idea is also supported by Daniel Hamermesh, a US economist, and a professor of Economics at Royal Holloway, University of London. He contests that beauty is connected to financial success and has written a book called Beauty Pays, Why Attractive People Are More Successful looking at this correlation. The book also suggests that attractive people earn an average of 3-4% more than people with below-average looks.8
Even more well-known is Nancy Etcoff, a faculty member at Harvard Medical School and a practising psychologist, who has promoted similar concepts in her book – a must-read for all aesthetic practitioners – Survival of the Prettiest. She examines notions such as how beauty cannot be precisely defined, but how people recognise it instinctually (many parallels with our discussion on classical concepts of beauty above). Crucially, Etcoff supports the concept that it is an evolutionary and biological development of our species.9 In other words, our desire for beauty is hardwired in our brains.
Social media and modern influences on beauty idealism
Social media, influencers, celebrities, selfies, filters, Zoom and Snapchat dysmorphia are now all instantly recognisable terms highlighting how modern technology dominates and drives perceptions of beauty. However, clinical psychologists Mavis Henriques and Debasis Patnaik point out that, “Images on social media sites are idealised and unreal, due to digital alteration thereby setting high expectations from individuals in society.”10 The impact of social media has been further explored by author Autumn Whitefield-Madrano in her book Face Value: The Hidden Ways Beauty Shapes Women’s Lives.11 This diary of beauty examines in detail the relationship between appearance, beauty, science, social media, sex, friendship and more.
he prevalence of photo-editing technology has also altered our perceptions of beauty and means the level of physical ‘perfection’ previously seen only in celebrity or beauty magazines is now commonplace on social media. Researchers from Boston in the US argue that as these images become the norm, people’s perceptions of beauty worldwide are changing and being distorted, which can inevitably take a toll on a person’s self-esteem and can trigger body dysmorphic disorder.12 Research published in 2018, consisting of 26 in-depth interviews with women aged 18-32, indicated that although female millennials do look up to celebrities to define their ideal body, they also experience equally intense negative feelings after the comparison of their selfies to those of attractive friends. It was also demonstrated that the number of likes and comments are as important to female millennials as the aesthetics of the selfie. Likes and comments therefore play a significant role in the construction of body image perception of beauty.13
Artistic appreciation and facial aesthetics
Whilst practitioners definitely need to be aware of classical and modern influences on beauty idealism as well as consideration of patient psychology, a focus and understanding of their application to artistic appreciation is clinically more relevant. No matter what stage you are at in your career, artistic appreciation encompasses a consideration and understanding of beauty, geometry, harmony and proportions. Whilst we have seen that concepts of beauty have changed over the years, there are constants that still remain and our contemporary understanding of the ageing process to include bony, soft tissue, fat compartments and skin changes has reinforced our thoughts immensely in this regard.14,15
However, a systematic (and critical) full facial physical evaluation still remains a pre-requisite regardless of whether you are at foundation level or an advanced injector – the assessment should always remain constant, but the treatment response/ technique/product choice may vary depending upon experience.
Splitting the face into thirds, as per the Greeks, still remains at the core of artistic appreciation (Figure 3). We recommend careful observation of the upper third (forehead, temples and eyes), middle third (nose, fat pads and cheeks) and lower third (mouth, chin and jaw) to visualise symmetries and asymmetries, before looking at the side profile with particular reference to the profile balance (relationship of the nose and chin). The age of the patient and their ‘skin age’ will also then influence choice of product and therapeutic approach. A younger patient in general will be looking for balance and harmony with refinements in structure and contour, in contrast to an older patient, where addressing volume loss is usually the key.
As part of our teaching programme at Banwell.Prisk School of Medicine we have formalised these steps into the following acronym to help focus thoughts of artistic appreciation:
- Full facial assessment
- Contour and curves
- Artistic considerations
- Treatment plan/Therapeutic approach
Thinking about the full face in a holistic manner, focusing on asymmetry, contours and curves leads to a complete evaluation; however, make a point of thinking about your patients as a canvas in an artistic way and then re-evaluate your plan before commencing treatment. Another simplistic observation which is often overlooked is not to be afraid to move around the patient – get yourself in the most comfortable position to perform your work, even if it means moving when injecting one side. Artists move around their work all the time and it is the same when thinking about artistic appreciation in aesthetics.
Focused anatomical approaches and artistic appreciation
Treatment of the ageing mid-face is increasingly recognised as a key component in aesthetic rejuvenation and is arguably one of the two main areas where artistic appreciation is particularly pertinent. Board-certified plastic surgeon Dr Oscar Ramirez described the so-called zygomatic point,16 otherwise known as the malar eminence, while board-certified plastic surgeon Dr Arthur Swift and board-certified dermatologist Dr Kent Remington have argued that clinicians should use the Phi relationships to apply to the mid-face.17 And, of course, boardcertified plastic surgeon Dr John Little described the ‘ogee’ curve – a curvilinear silhouette found in art and architecture and in the youthful human face (Figure 4).18
The authors of a Juvéderm trial using Voluma also attempted to sub-classify the cheeks into zones,19 while Marianetti and colleagues described the so-called ‘beauty arch’ for the assessment of sagittal projection of the malar region.20
Linkov and colleagues also reported that having cheekbones that are as wide as the eyebrows is apparently the most desirable type of face and described as ‘mathematically beautiful’. Their conclusion was derived after analysing the average facial measurements from photographs of 55 female models using the WIZDOM (Width of the Interzygomatic Distance of the Midface) research tool. They revealed that the ‘average inter-pupillary distance’ was a strict 59.2mm and the vertical distance between the eyes and the cheekbones should be 13.1mm to be classed as attractive. They believe these measurements add up to create a ‘heart-shaped’ attractive face, which can act as a guide to help plastic surgeons and aesthetic practitioners design their filler treatments.21
The second pertinent focused area for artistic appreciation are the lips, which also represent the most common anatomical area to be treated with dermal filler globally. The Fibonacci sequence/Golden Ratio/Phi proportions (1:1.6) greatly appertain to the appearance of ‘perfect lips’, where the lower lip should be 1.6 times thicker than the upper lip in Caucasian patients.22 Note that this will differ in other ethnicities. The lower lip should also be longer than the upper lip and the modiolus (corners of the mouth) should be straight and preferentially elevated. In keeping with the Golden Ratio, the distance between the nose and upper lip should represent 1 to the 1.6 of the distance from the lower lip to the chin – over recent years, surgical lip lifts have become increasingly popular which also help to adhere to this tenet.
Like the rest of the face, it is especially important to remember that lips are beautiful three-dimensional structures and, as mentioned above, aesthetic practitioners must assess the profile of patients before treatment. Consider the Steiner line – the line from the mid-nares to the chin – and ensure the lips just barely touch it. When they cross this line, the lips have been over projected. This is often ignored to the detriment of natural-looking lips.23
Another important point to check when augmenting the lips is the nasolabial angle. Armijo and colleagues found this should be 93.4 to 98.5 degrees for men and 95.5 to 100.1 degrees for women.24 The angle/slope/concavity of the upper lip skin above the vermilion border should also be assessed. Conventionally there should be a ‘ski-jump’ appearance, with a slight elevation at the vermilion border of the upper lip along the whole length (the Glogau-Klein point – area of inflection as the lip turns from glabrous skin to mucosa).23 In accordance with these findings aesthetic practitioners should therefore be careful to avoid ‘shelving’, ‘trout pout’ or a ‘duck-lips’ look associated with over correction, poor technique or lack of artistic appreciation.
Style and artistic approaches
Not everyone can be a master artist, but it is expected that an aesthetic practitioner should be able to obtain excellent, reproducible results by following certain rules and structured approaches. Using the elements discussed in this paper, thinking about a sense of proportion should help injectors elevate their skills beyond a simplistic formulaic approach. However, the highest quality products, on-going training and mentorship should not be forgotten in this quest.
Beyond foundation techniques, one particular and successful structured approach to artistic appreciation (albeit by another name) in contemporary aesthetic practice is the work of Dr Mauricio de Maio, who invented and popularised the ‘MD codes’. This is a systematic method to approach facial assessment and treatment and is derived from his earlier concepts of injecting eight specific anatomical areas to produce a non-surgical facelift.25
However, the highest elite level of technique, injectors will often abandon such structure and be seen to adopt a more ‘freestyle’ approach, which creates more of a mystique but is essentially a culmination of years of practice and a heightened awareness of artistic appreciation. A classic example of this is observing the markings and approach of Dr Raj Acquilla. Consider the following quote by Picasso to describe this approach which is relevant to both surgical and non-surgical aesthetic practice alike, “Learn the rules like a pro, so you can break them like an artist.”
The last component that warrants discussion is the concept of style in aesthetics. Every practitioner will have their own style and some will have more flair than others. Many practitioners will follow well-accepted approaches but others, as we have discussed, will go beyond these frameworks and freestyle within their treatment plans with patients. The analogy is that we may start teaching with a painting by numbers approach but over time we expect practitioners to develop their own style, just like great artists with their own individualistic approaches.
Understanding the origins of beauty and how mathematicians, historical artists and modern perceptions perceive this, leads us to the idea of ‘artistic appreciation’. It is a simple yet complex subject but we believe it is a mandatory prerequisite for aesthetic practice at the highest level. We believe it needs to be integrated into training programmes at foundation level and explored more deeply throughout one’s career so that clinicians may truly practise as an artist. In conclusion, always view your patient as a work of art: take time to step back, pause, appraise and appreciate – just like going to a museum to look at art.
1. Vince Tabora, The Mathematics of Beauty and the Golden Ratio (US: Medium, 2019)
2. Sharom Romm, Beauty through History (US: Washington Post, 1987)
3. Bashour M., ‘History and current concepts in the analysis of facial attractiveness’, Plast Reconstr Surg., 2006 Sep;118(3):741-56.
4. P Winkielman, J Halberstadt, T Fazendeiro, S Catty., ‘Prototypes Are Attractive Because They Are Easy on the Mind’, Psychol Science, 2006; 17(9): 799-806.
5. G Rhodes, S Yoshikawa, A Clark, K Lee., ‘Attractiveness of facial averageness and symmetry in non-Western cultures: In search of biologically based standards of beauty’, Perception, 2001; 30(5):611-25.
6. Defining Facial Beauty (US: Marquardt Beauty Analysis, 2021)
7. Allana Akhtar and Drak Baer, 11 scientific reasons why attractive people are more successful in life (US: Business Insider, 2019)
8. D Hamermesh, ‘Beauty Pays: Why Attractive People Are More Successful’, Princeton University Press, (2011).
9. N Etcoff, ‘Survival of the Prettiest’, The Science of Beauty, (2000) Anchor Books.
10. Mavis Henriques and Debasis Patnaik, Social Media and its Effects on Beauty (US: Intecheopen, 202) Read more
11. A Whitefield-Madrano, ‘Face Value: The Hidden Ways Beauty Shapes Women’s Lives’, Simon & Schuster (2016).
12. S Rajanala, M Maymone, N Vashi., ‘Selfies—Living in the Era of Filtered Photographs’, JAMA Facial Plastic Surgery (2018).
13. D Bagautdinova, ‘The Influence of Instagram Selfies on Female Millennials’, Appearance Satisfaction Graduate Theses and Dissertations, (2018).
14. Wan D, Amirlak B, Rohrich R, Davis K., ‘The Clinical Importance of the Fat Compartments in Midfacial Aging’, Plast Reconstr Surgery (2013); 1(9): e92.
15. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ., ‘The Science and Theory behind Facial Aging’, (2013); 1(1): e8-e15.
16. Ramirez OM, ‘Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation’, Plast Reconstr Surg., (2002) ;109(1):329-340; discussion 341-349.
17. Swift A & Remington K., ‘BeautiPHIcation: A global approach to facial beauty’, Clin Plast Surg (2011); 38(3): 347-377.
18. JW Little., ‘Volumetric perceptions in the midfacial aging with altered priorities for rejuvenation’, Plast Reconstr Surg, (2000); 105(1): 286-289.
19. Philipp-Dormston WG, Eccleston D, De Boulle K, Hilton S, van den Elzen H, Nathan M., ‘A prospective, observational study of the volumizing effect of open-label aesthetic use of Juve?derm VOLUMA with Lidocaine in mid-face area’, J Cosmet Laser Ther., (2014);16(4):171-179.
20. Marianetti TM, Cozzolino S, Torroni A, Gasparini G, Pelo S., ‘The “beauty arch:” a new aesthetic analysis for malar augmentation planning’, J Craniofac Surg. (2015);26(3):625-630.
21. G Linkov, P Mally, CN Czyz, AE Wulc., ‘Quantification of the aesthetically desirable female midface position’, Aesth Surg Journal, (2018); 38(3): 231-240.
22. Baudouin JY, Tiberghien G., ‘Symmetry, averageness, and feature size in the facial attractiveness of women’, Acta Psychol [Amst] (2004); 117: 313-32.
23. Michiels G, Sather AH., ‘Validity and reliability of facial profile evaluation in vertical and horizontal dimensions from lateral cephalograms and lateral photographs’, Int J Adult Orthodon Orthognath Surg, (1994); 9: 43-54.
24. Armijo BS, Brown M, Guyuron B., ‘Defining the ideal nasolabial angle’, Plast Reconstr Surg (2012);129(3):759-64.
25. de Maio M., ‘MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers’, Aesthetic Plast Surg. (2020).