The multicultural evolution of beauty in facial surgery Braz J Otorhinolaryngol. 2017;83(4):373---374 www.bjorl.org Brazilian Journal of OTORHINOLARYNGOLOGY EDITORIAL The multicultural evolution of beauty in facial surgery� c c m b t a t r i a o h t e e a s a a c i p a c l p a r N a l a f n changes of aging as a decrease in fertility. The fourth and A evolução multicultural da beleza na The concept of facial beauty has been defined in a variety of ways dating back to ancient times, and while the defini- tion continues to develop, it has become clear that beauty crosses ethnic boundaries and has a significant cultural and 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 naturally selected characteristics. Additionally, the beauti- ful are more likely to get better grades in school, to be hired for a job, to receive higher salaries, and to be viewed as nicer, smarter and healthier.1 While beauty was once stated to be ‘‘in the eye of the beholder’’, more recent studies have suggested that beauty is an objective, quantifiable quality. The ancient Greeks began the quest for a universal standard of beauty and believed it was represented by the ‘‘golden ratio’’ also known as ‘‘phi,’’ which was thought to represent perfect harmony.1---3 In nature, the ratio appears in the spiral of seashells, in the growth rate of the human mandible, and in the DNA antihelix. Examples of its appli- cation include Egyptian art and architecture, the Fibonacci sequence, and geometric shapes such as the pentagon and decagon. Many still believe that phi corresponds to facial beauty as well.3 However, others have found it to be inexact. For example, Marquardt created an ‘‘ideal’’ facial standard based off of phi, and not only did it apply poorly to people of non-European/Caucasian descent but it also masculinized Caucasian women.4 The concept of beauty as a formula continued to evolve with the artists of the Renaissance period. Through Da Vinci and his contemporaries, the neoclassical ideals were largely based on phi. The art anatomists of the 17th and 19th � Please cite this article as: Cerrati EW, Thomas JR. The multicul- tural evolution of beauty in facial surgery. Braz J Otorhinolaryngol. 2017;83:373---4. l a f http://dx.doi.org/10.1016/j.bjorl.2017.04.005 1808-8694/© 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia access article under the CC BY license (http://creativecommons.org/lic irurgia facial enturies propagated these new standards into the edical field, which created a ‘‘universal’’ definition of eauty for the period.2 While these ideals continue today o have a strong influence on facial analysis and serve as guideline for surgical planning, research has shown that hese ideals still do not apply cross-culturally. Despite the inability to universally quantify beauty, esearchers have found that there is a consensus on rat- ng attractiveness across sexual orientations, ethnic groups, nd ages. Studies have shown that diverse populations agree n who is and is not attractive. Additionally, even infants ave an innate preference toward attractive faces.1 Cer- ain conceptions of facial beauty or attractiveness may be verlasting. In 2006, Bashour researched and challenged ach of the four concepts. He concluded that subjective ttractiveness comprises only a small percentage of per- onal preference over a much larger biological objective ssessment of attractiveness.5 The four concepts of facial beauty include symmetry, verageness, youthfulness, and sexual dimorphism. The first oncept of symmetry is believed to represent a high qual- ty of development. A symmetric face reflects a person’s henotypic and genetic condition giving him or her an dvantage in sexual competition. Averageness, the second oncept, is informed by the Darwinian theory that evo- utionary pressures function against the extremes of the opulation. As a result, humans innately appreciate that verageness represents genetic heterozygosity and a greater esistance to disease. The third concept is youthfulness. eonatal features, such as large eyes and a small nose, re believed to suggest desirable qualities of youthful live- iness, open-mindedness and affability. As a person ages nd demonstrates soft tissue descent, the face deviates rom the phi standard, resulting in a decrease in attractive- ess. In addition, the human brain interprets the physical ast concept of beauty is sexual dimorphism, which is defined s a phenotypic difference between males and females. For emales, increased estrogen leads to the development of Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open enses/by/4.0/). dx.doi.org/10.1016/j.bjorl.2017.04.005 http://www.bjorl.org http://crossmark.crossref.org/dialog/?doi=10.1016/j.bjorl.2017.04.005&domain=pdf dx.doi.org/10.1016/j.bjorl.2017.04.005 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ 3 s r c a i a h c f p a r n a i t n o f p p i h E c r a w i s t a f a e i fi r T e g p g t i t i o f t c i s t m s C T R 1 2 3 4 5 Otolaryngology-Head and Neck Surgery, Chicago, USA 74 econdary characteristics that suggest a fertile host and a eproductive advantage. These include a thin jaw, small hin, large widely spaced eyes, small nose, high cheekbones, nd plump lips. On the contrary, desirable physical features n men are those that signify high testosterone levels, such s prominent chins, square jaws, deep-set eyes, thin lips, eavy brows and abundant hair.1,2 Although attractiveness can be agreed upon cross- ulturally, each ethnicity has unique features that are actored into its definition of ‘‘averageness.’’ For the facial lastic surgeon, these unique features must be respected nd embraced in order to create a harmonious and elegant esult that meets the criteria of beauty and attractive- ess. As a result, the neoclassical ideals may not serve as ccurate guidelines in non-Caucasian patients. Specifically n rhinoplasty, distinct anatomic differences exist between he leptorrhine nose seen in Caucasians, the platyrrhine ose seen in African and Asian populations, and the mes- rrhine nose seen in Latin American populations.1 Patients requently want to preserve their cultural identity, so it is aramount that the surgeon clearly distinguishes these goals reoperatively. Today’s typical facial plastic surgery practice is becoming ncreasingly multicultural. The globalized modern society as played a significant role in the perception of beauty. conomic mobility coupled with an increase in interracial ouples has blurred the lines of ethnic identity, and the esulting esthetically unique and beautiful outcomes do not llow patients to be characterized as fitting a narrow mold ith predictable desires.1 The classic principles of beauty ncluding phi, symmetry, averageness, youthfulness, and exual dimorphism can still be applied as guidelines, but he surgeon must incorporate a broader outlook on facial nalysis and surgical techniques. The importance of identi- ying patients’ ethnic identities cannot be underemphasized s patients may want to erase, preserve, modify, or even nhance those specific inherent traits. Furthermore, cosmetic surgery continues to become ncreasingly desirable and socially acceptable. The ampli- ed attention and interest can be credited to its exposure in eality television, social media, and surgical documentaries. he increased demand and the rising population diversity nsure that each patient will present with a unique back- round and cosmetic objective. The surgeon should assist atients to arrive at a goal that is harmonious with their face EDITORIAL iving a timeless, attractive result rather than be swayed by he development of a fashion trend. The proper guidance, nsight, and ethical control distinguish the surgeon from a echnician. More importantly, these qualities preserve the ntegrity of the field of facial plastic surgery. While facial modifications can have a tremendous impact n patients’ lives, the planned result should not venture too ar from the concepts of facial beauty that have defined he field since its creation. Digital photography along with omputer imaging has aided with preoperative assessments n an effort to confirm the surgeon and the patient have the ame esthetic goals. Technology will continue to improve o facilitate this initial conversation. As society evolves so ust our understanding of beauty along with our attempt to urgically define it. onflicts of interest he authors declare no conflicts of interest. eferences . Weeks DM, Thomas JR. Beauty in a multicultural world. Facial Plast Surg Clin N Am. 2014;22:337---41. . Thomas JR, Dixon TK. A global perspective of beauty in a multi- cultural world. JAMA Facial Plast Surg. 2016;18:7---8. . Prokopakis EP, Vlastos IM, Picavet VA, Nolst Trenite G, Thomas JR, Cingi C, et al. The golden ratio in facial symmetry. Rhinology. 2013;51:18---21. . Holland E. Marquardt’s phi mask: pitfalls of relying on fashion models and the golden ratio to describe a beautiful face. Aes- thetic Plast Surg. 2008;32:200---8. . Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg. 2006;118:741---56. Eric W. Cerrati a,∗, J. Regan Thomas b a University of Illinois at Chicago, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic & Reconstructive Surgery, Chicago, USA b University of Illinois at Chicago, Department of ∗ Corresponding author. E-mail: ecerrati@gmail.com (E.W. 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http://refhub.elsevier.com/S1808-8694(17)30069-1/sbref0050 mailto:ecerrati@gmail.com