Psychology of facial aesthetics

Introduction

Over the past several decades, a now sizable body of research on the psychology of physical appearance has developed. This research has suggested that individuals who are more physically attractive are judged by others more favorably and also receive preferential treatment across a wide range of social interactions. Aesthetic surgeons have had a long-standing interest in the psychologic characteristics of individuals who choose to use medical treatment to improve their physical appearance. They also have had great interest in the psychologic benefits that patients may experience following treatment.

This chapter provides an overview of the psychology of facial aesthetics. The chapter begins with a review of the psychology of physical appearance. After considering the issue from the societal perspective, the chapter turns its focus on the psychologic characteristics of individuals who present for aesthetic treatments. The psychologic construct of body image is used as a framework to understand an individual’s motivation for an aesthetic procedure as well as the desired benefits from it. The chapter provides an overview of body dysmorphic disorder (BDD), the psychiatric condition of greatest relevance to the aesthetic surgeon. The chapter concludes with recommendations on the psychologic assessment and management of the patient who presents for aesthetic treatment.

Physical appearance and society

The discussion of the role in physical appearance in the human experience has to begin with the work of Darwin. His description of the theory of natural selection is one of the earliest scientific acknowledgments of the importance of physical appearance. According to the theory, the goal of all species is survival through reproduction. Identification of a mate who can facilitate successful reproduction is a central part of the process. To that end, specific physical characteristics have evolved to signal reproductive capability to others. These characteristics, particularly those that suggest the potential for healthy reproduction, serve as the foundation for what is considered attractive in another member of the species.

When applied to facial appearance, the characteristics of youthfulness, symmetry, and averageness have been most commonly associated with facial attractiveness. The development of adult facial features at puberty for both females and males signal reproductive potential to others. They also may suggest reproductive health as expressions of normal levels of testosterone and estrogen. Clear skin, bright eyes, and lustrous hair also draw attention to the youthful face. While a youthful facial appearance is considered attractive, an aging appearance typically is not. Ratings of attractiveness of males and females decline with age; the relationship is stronger for women than for men.

Symmetry of features across the midline of the face is associated with increased ratings of attractiveness. Evolutionary theorists believe that the ability to develop symmetrical features in a world full of environmental pathogens is conferred on only the healthiest of a population. Similarly, averageness, with respect to the size of individual facial characteristics, is also associated with ratings of attractiveness. Composite faces made up of hundreds or thousands of individual faces via computer technology (and therefore believed to represent “average” facial features) are judged as more attractive than individual faces. The most beautiful of the combined faces, however, are far from average. The highest rated composite faces for females, for example, reflect a petite face with a smaller than average mouth and jawline, full lips, and pronounced eyes and cheekbones.

With these elements of evolutionary theory in mind, the exploding popularity of minimally invasive aesthetic treatments over the past 15 years is not surprising. Add to those procedures the countless number of topical products marketed to minimize the effects of facial aging and it is quite clear that women and men around the world have some sense of the importance of a youthful facial appearance.

While some may question the use of evolutionary theory to explain the popularity of aesthetic facial procedures, there is little doubt about the role that sociocultural influences play in physical appearance. Some of these factors, such as the influence of parents and peers, begin early in life and sustain themselves into adulthood. Exposure to mass media depictions of physical beauty begin in childhood, but their emphasis appears to be greatest in adolescence and early adulthood. Similarly, early experiences in romantic relationships throughout this same period of time provide feedback to an individual on how his or her appearance is perceived, and responded to, by others.

Social psychologic research confirms these intuitive beliefs. Over the past 50 years, the role of physical appearance in daily life has been one of the most developed areas of research in the field of psychology. This research, while detailed and thorough, can be summarized with two general statements: (1) individuals who are judged to be more physically attractive are assumed to have more positive and desirable personality characteristics; and (2) individuals who are seen as more attractive receive preferential treatment in a wide range of interpersonal interactions across the lifespan.

Finally, it is important to note the role of the mass media and the entertainment industry impacting our thoughts and behaviors related to physical appearance. From print magazines to websites, television shows, and movies, consumers are bombarded by images of physical beauty continuously. While some of the images are of persons who have been blessed with youthful and symmetrical features that naturally signal attractiveness, others have been computer enhanced and photoshopped to the limits of physical reality. Studies have repeatedly shown that exposure to these images increases body image dissatisfaction which, as argued below, is believed to be the motivational catalyst to seeking aesthetic treatments. ^, Furthermore, discussion of aesthetic procedures are popular topics for mass media outlets. Thus mass media both contribute to the development of the “problem” (that the consumer does not look as good as the model) and offers the pathway to the “solution” (aesthetic treatment).

What this means and what it says about us at the societal or individual level is open to debate. Some would argue that the impact of mass media on the pursuit of aesthetic treatments is merely an example of consumer culture, perhaps no different from buying a luxury automobile—no one “needs” to buy an expensive car, but if doing so makes someone happy or improves his or her quality of life, is there a problem with it? Decades ago, mental health professionals believed that persons who underwent cosmetic procedures were suffering from significant psychopathology. From their perspective, a psychologically healthy individual would not be focused on trivial vanity. In contrast, both evolutionary theory and findings from social psychologic research could lead to the conclusion that improving one’s appearance with an aesthetic treatment is an adaptive strategy. In this regard, improving one’s appearance with an aesthetic procedure could be seen as an appropriate investment in one’s self-esteem and quality of life, perhaps not all that different from eating a healthy diet and exercising regularly.

Psychologic characteristics of aesthetic surgery patients

Patients typically present for aesthetic procedures with a number of motivations and expectations. Some of these may be expressed to the surgeon or the treatment team during the initial consultation; others may remain unspoken. Dissatisfaction with one’s facial appearance and body image is believed to be the primary motivator for facial aesthetic procedures, other cosmetic procedures, and other appearance-enhancing behaviors. ^,

Body image has been defined in several ways. A commonly used definition suggests that body image consists of perceptions, thoughts, and feelings associated with the body and bodily experience. While this definition describes the multidimensional nature of the construct, it does not highlight body image behaviors, such as changing one’s appearance through aesthetic procedures. Body image also has been defined as “the psychologic experience of embodiment.” This description conveys a sense of importance of the role of body image in larger psychologic constructs like quality of life and self-esteem.

The relationship between body image dissatisfaction and aesthetic treatments has been the focus of much of the research on the psychosocial considerations of aesthetic surgery. ^{, ,} Individuals who seek cosmetic procedures, both surgical and nonsurgical, typically report heightened body image dissatisfaction preoperatively. This dissatisfaction is typically centered on concerns about the specific feature to be improved with an aesthetic treatment. Thus some degree of body image dissatisfaction is believed to be a prerequisite to cosmetic surgery.

A number of studies have looked at a range of personality characteristics, symptoms of psychopathology, and life experiences in persons who present for aesthetic treatments. Some of these investigations have been of conceptually relevant characteristics and symptoms (i.e., history of abuse, symptoms of depression, or low self-esteem). Others have investigated constructs, such as parent–child relationships, that may be of inherent interest to some but of little clinical relevance to the treating surgeon. These studies have yet to identify consistent characteristics of aesthetic surgery patient beyond heightened body image dissatisfaction. However, several studies have suggested that the use of psychiatric medications, particularly antidepressants, is higher among patients who present for aesthetic treatments and compared with the general population. With this finding in mind and as discussed next, aesthetic surgeons are encouraged to evaluate the psychiatric status and treatment history of all new patients.