Introduction

During every recorded age of history, and undoubtedly even earlier, humankind has sought to define and measure beauty and ultimately re-create it. Indeed, it has been stated that the prime requisites of a civilization are intellectual energy, freedom of the mind, and a sense of beauty. ¹ Aesthetic is derived from the Greek word aisthesis, which means having a sense or love of that which is beautiful. Individuals have unique perspectives on aesthetics that are related to their personalities and environmental milieux. ² Thus, no two people would likely describe their concept of beauty in exactly the same way. Although a universal canon of beauty cannot be established because of differences in time, culture, ethnicity, and age, there are found proportion and harmony among the parts of certain faces, which confer on the whole a timeless beauty. ³

Defining the ideal beauty has historically been an elusive, unattainable goal. In interpreting the definition of ideal beauty from civilizations past, we are limited in the resources available. Often we are left to interpret the most popular artistic creations of the time and assume that this is how society felt beauty should be portrayed. At other times, we are able to read the historical record and writings about the subject from the people of those eras. Ancient Greeks attempted to describe beauty through the perfection of the mind and body in an ordered universe. Their civilization focused on art, literature, and politics while also prizing the value of beauty in society. There were rewards for those of society with beauty, and often people were referred to with names that described specific aspects of their beauty. ⁴ They attempted to define beauty through mathematical equations and geometric formulas (i.e., laws by which much of nature seemed to abide). ⁵ The Athenian philosopher Plato stated that “the qualities of measure and proportion invariably constitute beauty and excellence.” He wrote that there are three wishes of every man: to be healthy, to be rich by honest means, and to be beautiful. Although Plato started defining beauty in terms of mathematics, he also realized that beyond physical proportions, beauty was also the result of good taste and balance.

History of Beauty in Art

Several other Greek figures played important roles in helping to define ideal beauty. Polyclitus developed a canon of proportions in the fifth century BC that he felt produced a figure with a flawless body. He experimented with proportions taken from nature and from those proportions created figures appearing more aesthetically pleasing to onlookers. Even more influential in the development of an ideal beauty was the Greek sculptor Praxiteles. His work in the fourth century BC led to a depiction of ideal beauty that held for the next 100 years. ⁴ He sculpted the figure of Aphrodite, the goddess of love, in what is considered the first completely nude image of the goddess created. In his interpretation he crafted a female figure that appeared much more gentle than previous sculptures, in which females seemed more like males with breasts attached to their chests. ⁶ His Aphrodite showed human expression, and this figure, modeled after a wellknown woman of his society, was imitated and revered for many years.

In the first century BC the Roman architect Marcus Vitruvius Pollio wrote that the proportions of humans should be used when creating sacred buildings. He reasoned that the human body is a model of perfect proportions; thus, architecture would benefit if buildings were modeled on nature. He described the proportions of humans who he felt created the most ideal figure. He also attempted the task of trying to contain the human figure within a circle and square by having the figure with arms and legs extended (later to be referred to as the Vitruvian man). Although his work was not appreciated in his time, he provided a great influence for several of the Italian Renaissance painters.

The late 14th century through the middle of the 16th century in western Europe is referred to as the Renaissance period. During this time there was a renewed interest in ancient Greece, and the ideals of classic beauty reappeared. Women were starting to receive formal education and were attaining some increased degree of independence. People were also regarding female intelligence as compatible with beauty. ⁴ The increased reverence for women was also met with new advances in artistic techniques. Masaccio (1401–1428) developed the artistic technique of perspective, allowing the creation of figures that appeared more realistic and human. ⁶ Artists during this time found that copying beauty was no longer the goal; they wanted to perfect beauty. Female faces would often be created with the combination of various features from different models. ⁴

Leonardo da Vinci (1452–1519) devised a new version of the Vitruvian man and developed an obsession with the infinity of geometric transformation as exhibited by his attempt to square the circle ( Fig. 7.1 ). The image he created, recognizable to most people, was far more aesthetic in appearance than the original created by Vitruvius. ⁷ This figure uses the golden proportion (discussed later) prominently, as do many of da Vinci’s other works.

Another artist who was inspired by the Vitruvian notion of perfect proportions was the German painter and printmaker Albrecht Dürer (1471–1528). He tested the human proportions devised by Vitruvius that would create the perfect body. By applying these principles, he created drawings of the female figure as described by Vitruvius. Unfortunately, the image that resulted was a round-bellied, drooping-breasted, large-hipped woman with gigantic feet. Without becoming discouraged, Dürer continued in his pursuit to define beauty by writing four books on human proportions. The Italian monk Agnolo Firenzuolo (1493–1543), also interested in defining ideal beauty, wrote a catalog of desirable female traits. Basically analyzing every feature of the female body, Firenzuolo described the size, shape, and proportions of what he considered the ideal woman. ⁴

Perhaps the artist most renowned for defining the Renaissance ideal of beauty was the Florentine painter Sandro Botticelli (1445–1510). In his art he was able to combine the social preferences of his time with the classic ideals of antiquity. His images of women show classical bodies, but they also have the Renaissance style of high foreheads and high coloring. ⁴ The women appear voluptuous but not cumbersome. In his most famous work, The Birth of Venus (c. 1480), the image of Venus appears to be floating, despite having her feet touching the shell beneath her. ⁶ Her face is long and angular rather than oval, as had been common. Although ideals change from generation to generation, this image of the female figure exhibits many of the traits still deemed ideal.

After the Renaissance period, the beauty ideal changed to the long-fingered, long-necked, graceful female figures of the Mannerist period. Artists of this time tried to convey an unearthly beauty by greatly extending and distorting the natural proportions. ⁴ After this period, which lasted 75 years, the Baroque period, a counterreformation response of the Catholic Church to Protestantism, inspired many splendorous works of art. Peter Paul Rubens (1577–1640) was one of the great artists of this period. His figures, recognized throughout the world, depict females as robust, round, pink nudes who were cheerful and playful in appearance. For a brief period of time Rubens’ nudes were seen as the ideal beauty of women, perhaps due to the energy portrayed by the subjects rather than the appearance of the figures themselves. ⁶

From the middle of the 18th century until early in the 19th century, the definition of beauty switched back and forth between the classical images of the Greeks to the Romantic images of the time. In the 19th century, doll-like females began to emerge as the epitome of beauty. These women, with pale, rounded faces, portrayed purity in addition to beauty. No longer did the ideal female possess certain physical traits, but the role of fashion in the determination of beauty came to the forefront.

The 20th century saw the concept of beauty change with each successive decade. The advent of motion pictures and later television facilitated the widespread dissemination of images of models and actresses who represented the beauty of their generation. The ideal beauty at the turn of the century was personified by the Gibson girl, and later in the 1920s by the flapper. The pin-up girl of the 1940s gave way to the new look of the 1950s. The flower child of the 1960s made the natural look, with long, flowing hair, no makeup, and simple clothing, popular. The 1970s brought excess in hair styles, makeup, and clothing, followed by an emphasis on a healthy, fit appearance at the end of the century. Undoubtedly, the look of beauty will continue to change at an even more rapid pace in the 21st century.

The perception of beauty is an emotional experience. The regard for beauty is perhaps one of the most precious of human qualities, and in its most basic form is intuitive or instinctive. ⁸ Recognizing and appreciating beauty in different forms and analyzing proportion and harmony can be learned. Even though tastes, fashions, and standards of beauty change from age to age, there appear to be certain facial proportions and relationships that provide a basis for diagnosis and planning in facial surgery.

Considerations in Facial Analysis

To form a basis for analysis of the facial components, several general considerations should be taken into account. These factors help shape our concept of beauty and therefore should be noted first. Performing a generalized analysis of the whole before considering the individual parts will create some general impressions on which a more detailed analysis can be constructed.

Age

Consideration of the patient’s age is of primary importance in facial analysis. The effect of the aging process is often the main factor involved in the patient’s desire for surgery. Although senescence of the facial structures is a normal physiological process, there may be a discrepancy between chronological age and perceived age because of either an acceleration of these processes, or a slow onset of these processes. Many patients present with complaints that there is dissonance between their external appearance and how they feel internally.

Infants and children have a large amount of subcutaneous fat in their faces. Combined with highly elastic skin and a facial skeleton that is not yet fully developed, this imbues them with a round-faced, cherubic appearance. Growth of the facial skeleton during puberty and adolescence results in the characteristic curves and angles of the adult face.

The effects of senescence on the face have been described by Gonzales-Ulloa and Flores ( Fig. 7.2 ). ⁹ The effects of aging begin to appear at about age 30. Skin laxity is first noted when the upper eyelids begin to overhang the palpebral lines. The inferior palpebral sulci and nasolabial folds become noticeable.

At about age 40, forehead wrinkles and glabellar furrows begin to appear. Laxity of eyelid skin develops into noticeable excess, and crow’s feet begin to appear at the lateral canthi. Sagging of the mandibular line also becomes detectable.

By 50 years of age the forehead and glabellar wrinkles have become permanent and may unite to form continuous lines. Upper lid sagging may reach the level of the lashes. The outer canthi begin to tilt downward, and the nasal tip begins to droop. Fine wrinkles develop around the mouth and along the neck. Sagging of the cheek skin indicates early loss of subcutaneous facial fat.

At age 60 all skin wrinkles deepen and begin to coalesce. There is a perceived diminution in the size of the eyes resulting from progressive encroachment of the surrounding lid skin. Skin thickness begins to decrease, and the loss of subcutaneous adipose tissue accelerates, producing noticeable deficits in the temporal, orbital, and buccal areas.

By age 70 the nasal tip has descended even farther, and the excess skin of the lower eyelids may have developed baglike deformities. Continued loss of subcutaneous fat makes the malar complexes appear prominent and the orbits more hollow.

At 80 years of age minute wrinkles coalesce about the face to produce the typical appearance of advanced senescence. Loss of skin thickness, absence of subcutaneous fat, and diminution in the size of the cranial vault combine to make the facial skeleton more conspicuous than at any other time in life.

Sex

Sex differences in facial appearance are the result of hormonal and cultural influences. In general, men tend to have stronger, more angular facial features. Women tend to have rounder, more curved lines defining the face. The gonial angle of the mandible is more defined and prominent in men, and the chin is more prominent. Consequently, a receding chin in a man may cause him to be perceived as weak and ineffective. The forehead and zygomatic bones are more apparent in men. The eyebrows are thicker, straighter, and positioned at the supraorbital rim in men. Women’s brows are usually thinner, more arched, and positioned above the level of the supraorbital rim. Facial skin is usually thicker and more textured in men.

Numerous differences are noticeable regarding the ideal noses of men and women. Men usually have larger, broader noses with a dorsum that is straight to slightly convex. Women tend toward smaller noses with a slightly concave dorsum. Their nasolabial angle is preferably obtuse, whereas most men prefer a nasolabial angle of no more than 90 degrees. Overall nasal contour is strongly associated with sex identity. Individuals may wish to masculinize or feminize their facial features to better harmonize with their selfimage ( Fig. 7.3 ). ¹⁰

Facial Proportions

For facial harmony to exist there must be some degree of relative proportion of the various parts through which an overall balance is achieved. No individual component of the face exists or functions in isolation from the other integral parts. Any change in one part of the face will have a real or perceived effect on the other facial parts and on the whole.

The most basic facial proportions are those that are learned by beginning art students drawing the face. The ancient Greeks taught that the ideal human stature must equal eight times the height of the head. ¹⁷ The length of the neck is approximately onehalf the length of the head. This distance is measured from the suprasternal notch to the chin and from the chin to the vertex of the skull.

Relative proportions of the hand to the face play an important role for the portrait artist in establishing facial proportions. ¹ The length of the hand is three fourths the length of the head or the length of the face as measured from the chin to the hairline. The width of the hand is one half the width of the face. Placed transversely, the hand will cover one fourth the length of the head or one third the length of the face. Leonardo da Vinci described the relationship of the forehead, nose, and chin on the lateral view as lying along an arc produced by a radius based at the external auditory canal. ¹⁷

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