Key points

Introduction

The purpose of facial aesthetic surgery is to improve the patient’s psychological well-being. The primary responsibility of the facial aesthetic surgeon therefore is to determine whether they can meet the expectations of their patient. Specifically, this means determining whether it is possible to achieve the physical change the patient wants. If it is possible, the surgeon must be confident that he or she has the personal experience to achieve such possible changes. Of equal importance is determining whether achieving the aesthetic changes expected will lead to fulfillment of the patient’s psychological expectations. Having carefully determined the patient’s physical and psychological expectations, the surgeon must be sure the patient has understood the risks and accepted that their expectations, although achievable, may not be met, or that an adverse event may occur, making their appearance worse.

In determining psychological motivations and expectations, it is increasingly recognized that body image is the critical factor to consider when assessing patients seeking aesthetic surgery, rather than looking for traditional diagnoses of psychopathology. That is not, however, to say that disorders such as depression or personality disorders should be dismissed because they may be co-conditions predicting a poor outcome. Body image is the mental picture individuals have of how they appear to others. This image is judged in relation to what the individual considers is normal. Although most patients are not asking to look beautiful, they do want to achieve what they perceive is an aesthetic standard, which they consider to be normal and therefore not abnormal, unattractive, or deformed. The patient’s set standard against which they judge themselves and perceive others are judging them will be influenced by culture. The cultures contributing to this aesthetic standard may be that of the patient’s own background and in the era of global communication that of other societies too. The surgeon must understand which cultural influences the patient is subject to and what they are.

Introduction

The purpose of facial aesthetic surgery is to improve the patient’s psychological well-being. The primary responsibility of the facial aesthetic surgeon therefore is to determine whether they can meet the expectations of their patient. Specifically, this means determining whether it is possible to achieve the physical change the patient wants. If it is possible, the surgeon must be confident that he or she has the personal experience to achieve such possible changes. Of equal importance is determining whether achieving the aesthetic changes expected will lead to fulfillment of the patient’s psychological expectations. Having carefully determined the patient’s physical and psychological expectations, the surgeon must be sure the patient has understood the risks and accepted that their expectations, although achievable, may not be met, or that an adverse event may occur, making their appearance worse.

In determining psychological motivations and expectations, it is increasingly recognized that body image is the critical factor to consider when assessing patients seeking aesthetic surgery, rather than looking for traditional diagnoses of psychopathology. That is not, however, to say that disorders such as depression or personality disorders should be dismissed because they may be co-conditions predicting a poor outcome. Body image is the mental picture individuals have of how they appear to others. This image is judged in relation to what the individual considers is normal. Although most patients are not asking to look beautiful, they do want to achieve what they perceive is an aesthetic standard, which they consider to be normal and therefore not abnormal, unattractive, or deformed. The patient’s set standard against which they judge themselves and perceive others are judging them will be influenced by culture. The cultures contributing to this aesthetic standard may be that of the patient’s own background and in the era of global communication that of other societies too. The surgeon must understand which cultural influences the patient is subject to and what they are.

Motivations for surgery

There may be differences in the motivations of those seeking restorative aesthetic surgery as opposed to transformative surgery such as rhinoplasty. The restorative patient may be seeking rejuvenation or correction of changes caused by trauma but may have been satisfied with their appearance previously. However, their acquired change in body image through injury or age will still have led them to think they no longer meet their perception of society’s standard aesthetic and so are judged adversely; this will have resulted in low social confidence and loss of self-esteem. Different cultures and different social classes within the same culture may attach different values to facial appearance. The degree of a patient’s lack of social confidence will be proportional to the culture they reference. Duelling scars were popular among upper-class Austrians and Germans involved in academic fencing at the start of the 20th century. Deviated noses are accepted as badges of masculine bravery among rugby players today—a sport traditionally associated with higher socioeconomic groups. In lower socioeconomic groups, such an appearance may be interpreted as a sign of nefarious, pugilistic activity.

The surgeon must further distinguish between internally motivated patients looking to improve confidence and esteem and who have a better chance of a positive outcome and externally motivated patients. The latter are expecting not only to change their bodies but also the success of their lives, often in the hope of pleasing others. The Asian or Middle Eastern patient may expect to achieve greater career success or to increase their chance of marriage if they westernize their appearance with blepharoplasty or rhinoplasty. Although their close cultural peers may hold this to be likely, in the context of their broader society, this outcome is unlikely to be true. The cultural frame referenced by the surgeon must therefore not be too narrow.

Aesthetics and beauty

The facial aesthetic surgeon must also understand the patient’s interpretation of normal to be able to assess whether the degree of their body image concerns matches their perception of normal. It is equally important to appreciate also what the patient’s community and peer group consider standard. The patient will not only be judging themselves against a standard but will also be perceiving society’s judgment of them. The perceived standards will be very significantly influenced by culture and further by varying social groups’ tastes within a culture. The facial aesthetic surgeon must understand the value a society or social group attributes to appearance, also influenced by culture. It seems that beauty and youth are the apparent new indicators of social worth. This view contrasts with cultures wherein age may be revered and elders are deferred to with respect. Such cultural values will influence a patient’s body image and provide a context for their decision to consider aesthetic facial surgery. In cultures where beauty and youth are attributed a high social worth value, the definition of this social worth may be different. One culture’s perceived wisdom may be that a certain appearance may lead to a greater chance of marriage, another to increased corporate career success. As a surgeon, therefore, one must understand that what might be a false expectation in one’s own culture might not be in our patient’s culture. However, it is important to explain to the patient that the perceived wisdom of a culture, often influenced by powerful marketing, may be wrong.

The facial aesthetic surgeon must also appreciate that a culture or society will judge an individual’s desire to undergo aesthetic surgery differently. What may be considered a positive action to increase one’s psychological well-being by one culture might be considered vanity or a lack of psychological strength and conviction by another. This concept will help us understand the patient and their body image and expectations in the context of their cultural norms. The facial aesthetic surgeon can then better advise on the validity of their judgments and better determine whether their psychosocial expectations can be met.

It is interesting in this context, however, to consider whether there are any universal normals that the facial aesthetic surgeon can refer to that are independent of cultural influence. Is there a universal concept of physical facial beauty with an associated normal range of attractive appearance around a universal standard? If there is, across races and culture, then it makes it easier for us to determine whether our patients’ requests are based on expectation of achieving a normal or not. Research does suggest that appreciation of facial attractiveness is innate and present in infancy. Furthermore, cross-cultural investigations reveal similar standards of beauty across diverse cultures. Measuring beauty has been performed for centuries and all facial aesthetic surgeons understand the importance of analysis, which implies comparison with a normal value. Normal values relate to averageness, and averageness and symmetry are associated with attraction. Jefferson proposes that there are universal standards for facial beauty in both frontal and lateral profile views and that racially and ethnically diverse faces possess similar facial features that are deemed desirable and attractive. He refers to Marquardt’s beauty mask used for facial soft tissue analysis that describes beauty and is independent of race.

Outstanding beauty may necessitate multiple facial features being average or magnification or diminution of at least one feature. Fashion will determine what is magnified or diminished and will change the context and relationship of facial features with age and race. The fashion and entertainment industry with the increasing power, presence, and influence of modern media and marketing, used to create demand, will manipulate facial features to create new representations of beauty. These representations may not be attainable. Different cultures may be exposed to the same media images but have different levels of public scrutiny, comment, and perspective. Some of our patients therefore will not understand that what is portrayed as an aspirational, aesthetic appearance is unattainable. The associated lifestyles and relationships, that is, the social worth portrayed with these appearances, may erroneously be interpreted as highly likely sequelae of aesthetic surgery too. The facial aesthetic surgeon must explain to the patient that these expectations cannot be met.