A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness

Lip Feminization and Rejuvenation in Patients Assigned Male at Birth With Gender Dysphoria: Our 27-year Experience

Background

Despite the increasing demand, the combination of lip feminization and rejuvenation in patients assigned male at birth with gender dysphoria is rarely reported in the medical literature. We present our 27 years of experience performing these procedures in this patient population.

Methods

All patients assigned male at birth with gender dysphoria from 1997 to 2023 were included and grouped into 4 age categories. Combined surgical procedures were performed to achieve lip rejuvenation and feminization, with detailed descriptions of the techniques used. Results were evaluated three months postsurgery using the Global Aesthetic Improvement Scale and the Global Satisfaction Scale. Complications and outcomes were documented, and statistical analysis was conducted to compare the differences between the results obtained.

Results

During a 27-year period, 988 patients underwent 1789 procedures. Of these, 79.8% were younger than 50 years, with the largest group being between 20 and 35 years (47.6%). However, patients older than 65 had the highest average number of procedures (2.4 per patient). The results showed a high degree of improvement and satisfaction on both evaluated scales. There were only 2 hematomas, both resolved without incident. The main issues were volume loss after fat infiltration (14.3%) and poorly positioned scars in lip lifts (13.2%).

Conclusions

Surgical procedures to feminize and rejuvenate lips can be combined in patients assigned male at birth with gender dysphoria, achieving highly satisfactory results, high patient satisfaction, and few complications.

Ethnic Considerations When Planning Lip Augmentation

Ideal standards of beauty including preferred lip characteristics vary between ethnicities. Although plump, well-defined lips are globally associated with youth, variation exists with regard to the perceived ideal lip volume and proportions between ethnicities. Proportions that may be assessed when planning lip augmentation include the upper-to-lower lip ratio, philtrum length, upper and lower vermilion heights, the ratio between the philtrum height and that of the upper vermilion, and the lip height-to-lip width ratio.It is important that accurate assessments of patients are made pre- and postaugmentation. However, many aesthetic assessment tools are based on Caucasian models with limited use in other ethnicities. We present a review of the ideal lip characteristics and assessment techniques accounting for ethnicity, with a view to providing practitioners an evidence-based approach to lip assessment and treatment planning for patients of all backgrounds.

Profiloplasty and facial contouring with injectables: A holistic, practical, and user-friendly approach

BACKGROUND

Expansion of the aesthetic treatment armamentarium with novel injectable products has greatly improved our ability to reshape and enhance the facial profile. However, full-face "profiloplasty" with injectables remain a nascent concept and is insufficiently considered in daily practice. While techniques have been widely published for treating the individual facial areas that constitute an attractive profile-including the forehead, nose, lips, jawline, and chin-the literature remains fragmented on more universal methods for profile improvement.

AIMS

To collate disparate knowledge on profile optimization with injectables, and define a holistic, practical, and user-friendly approach to profiloplasty and facial contouring.

METHODS

Consideration is given to key anatomical aspects and the changes that occur with age; patient assessment parameters for planning profiloplasty; and the technical specifications, product selection, and essential safety considerations for minimizing the risk of complications and optimizing the effectiveness of treatment.

RESULTS

Relevant case studies are presented.

CONCLUSIONS

Holistic approaches of this type are essential if we are to maximize the potential of full-face treatment with injectables-both now and in the future.

Lip Lifting: The Missing Link in Central Facial Rejuvenation

SUMMARY

The lip lift is a powerful yet finesse operation in the realm of facial rejuvenation. In an era of increased popularity of nonsurgical lip augmentation, the astute plastic surgeon must identify which patients will end up with an unnatural appearance should they receive volume enhancement alone in pursuit of central facial and perioral rejuvenation. In this article, the authors review the ideal youthful lip appearance, characteristics of the aged lip appearance, and indications for lifting. The authors present their preferred surgical technique, the underlying principles that it respects, and adjunct procedures to optimize results in central facial rejuvenation.

Advancements in lip augmentation: A scoping review exploring novel techniques

Lip augmentation is among the most popular cosmetic procedures done today. Advancements in trustworthy techniques have made it feasible to alter the visual characteristics of the lips through the utilization of various injectable substances and surgical procedures. However, there is a lack of standardization in these techniques. The purpose of this review is to focus on novel dermal filler injection and surgical techniques for lip augmentation. We did a scoping review of the literature using PubMed, Embase, and the Google Scholar database to identify all original articles published up to June 2023, assessing new techniques that focus on lip augmentation. In our review, only two studies out of seven included studies were surgical whereas the other five studies were non-surgical. This suggests that injection of dermal fillers is currently the most opted technique performed. This review suggests that incorporating perioral rejuvenation into the plan for lower facial surgery can help to complete the youthful look sought by patients. Injectable fillers provide excellent but short-term benefits and additional options such as Modified upper lip lift and French kiss techniques exist that offer the patient permanent improvements at a low cost.

Artificial Intelligence Versus Human Focus Group Rating of Facial Attractiveness

Background: Many open-access artificial intelligence (AI)-based websites that rate facial attractiveness are available, but none have been compared with human focus group outcomes. Objective: To compare human and AI-based websites scoring of facial attractiveness of adult female white faces. Methods: A 40-photograph database of AI-generated adult, white, female, expressionless, and frontal-view facial images were scored by otolaryngology residents and five AI-based facial rating websites: prettyscale.com, attractivenesstest.com, face-score.com/en, hotchat3000.com, and beautyscoretest.com. Sample t-test and bivariate correlation were performed for statistical analyses. Results: The focus group of 24 otolaryngology residents consisted of 62.5% males and 58.3% white participants. There was a strong positive correlation between average human score and average AI score for each photo (Pearson's correlation 0.84, p < 0.01). The average human raters' scores were significantly lower than the average AI scores (5.0 ± 1.8 vs. 6.9 ± 0.9, p < 0.01). Thirty images (75.0%) had statistically higher scores from the AI websites versus the focus group. On correlation analysis, all AI-based websites individually had scores that positively correlate with the human scores (all p < 0.05). Conclusion: AI-based websites and human focus-group scoring of facial attractiveness of adult white female faces were significantly correlated with the AI ratings biased toward higher values, encouraging their cautious utilization in future research.

Understanding Public Awareness and Practices of Nonsurgical Facial Dermal Fillers: A Cross-Sectional Study in Saudi Arabia

BACKGROUND

Dermal fillers augment soft tissues by replacing lost volume in the skin or subcutaneous fat. Dentists and other professionals utilize or recommend facial fillers for cosmetic and therapeutic purposes.

AIMS

This study aims to investigate public awareness regarding using nonsurgical facial dermal fillers in Saudi Arabia.

METHODS AND MATERIAL

A cross-sectional study was conducted using an online self-administered questionnaire distributed to a total of 400 males and females through social media platforms. The participants reside in Mecca, Saudi Arabia. Descriptive statistics and the Chi-square test were employed for data analysis.

RESULTS

A total of 256 participants completed the survey, including 204 females and 51 males, with a mean age of 33.86 (SD = 10.5) years. Among the participants, 88 (34.4%) reported using facial fillers. Among them, only 46 (18%) were frequent consumers. Knowledge regarding correctly using facial fillers was generally high, especially for the lips (240, 94%), chin augmentation (203, 79.3%), and face lifting (226, 88.3%). However, participants' knowledge needed improvement in other areas. Most participants were aware of the side effects, except for visual impairment (83, 32.4%) and blockage of the vessels (128, 50%).

CONCLUSIONS

The findings highlighted a remarkable level of knowledge among participants regarding the uses of fillers. However, participants demonstrated low awareness of all possible side effects associated with the treatment. Participants had valid reasons for undergoing facial treatments. However, constraints preventing them from pursuing fillers included fear of unexpected results and financial limitations.

Upper lip characteristics and associated excessive gingival display etiologies in adults: Race and sex differences

BACKGROUND

This cross-sectional study aimed to examine upper lip (UL) and smile characteristics and soft tissue excessive gingival display (EGD) etiologies (hypermobile upper lip [HUL], altered passive eruption [APE], and short upper lip [SUL]) in a nondental adult population and to analyze interracial (Black and White) and intersex differences.

METHODS

Community participants, non-Hispanic Blacks (NHB) and non-Hispanic Whites (NHW), were recruited and examined for UL vertical dimensions at rest and maximum smile and for HUL, APE, and SUL. Associations between gingival display (GD) or EGD and UL anatomical characteristics, HUL, APE, and SUL were analyzed.

RESULTS

Participants included 66 NHB and 65 NHW adults. Ergotrid height (greater among NHW; p = 0.019) averaged 14.0 mm. Upper lip vermilion length (ULVL), total UL length, internal lip length, total UL length during smile, and UL mobility averaged 8.6, 22.5, 23.1, 16.6, and 5.9 mm, respectively (all significantly greater in NHB; p ≤ 0.012). SUL prevalence was 4.6%, found only among NHW. Lip length change from rest to smile (LLC) averaged 26.2% (significantly greater in females; p = 0.003). HUL prevalence was 10.7% (NHB 13.1%, NHW 3.5%; p = 0.024). NHB had significantly greater GD (p ≤ 0.017). EGD and APE prevalence (6.9% for both) showed significant interracial and intersex differences (p ≤ 0.014). Multivariate logistic regression analyses indicated that LLC and HUL were the most consistently significant EGD determinants.

CONCLUSIONS

UL anatomical and functional characteristics and soft tissue-related EGD etiologies exhibit significant interracial and intersex differences, with UL mobility/hypermobility being the most consistently significant determinant of GD.

Facial Aesthetic Ideals: A Literature Summary of Supporting Evidence

BACKGROUND

To achieve the goal of enhancing facial beauty it is crucial for aesthetic physicians and plastic surgeons to have a deep understanding of aesthetic ideals. Although numerous aesthetic criteria have been proposed over the years, there is a lack of empirical analysis supporting many of these standards.

OBJECTIVES

This aim of this review was to undertake the first exploration of the empirical evidence concerning the aesthetic ideals of the face in the existing literature.

METHODS

A comprehensive search in MEDLINE, Embase, Scopus and CENTRAL databases was conducted for primary clinical studies reporting on the classification of the facial aesthetic units as per the Gonzales-Ulloa facial aesthetic unit classification from January 1962 to November 2022.

RESULTS

A total of 36 articles were included in the final review: 12 case series, 14 cohort studies, and 10 comparative studies. These described the aesthetic ideals of the following areas: forehead (6 studies; mean level of evidence, 3.33); nose (9 studies; mean level of evidence, 3.6); orbit (6 studies; mean level of evidence, 3); cheek (4 studies; mean level of evidence, 4.07); lips (6 studies; mean level of evidence, 3.33); chin (4 studies; mean level of evidence, 3.75); ear (1 study; level of evidence, 4).

CONCLUSIONS

The units that were most extensively studied were the nose, forehead, and lip, and these studies also appeared in journals with higher impact factors than other subunits. Conversely, the chin and ear subunits had the fewest studies conducted on them and had lower impact factors. To provide a useful resource for readers, it would be prudent to identify and discuss influential papers for each subunit.

LEVEL OF EVIDENCE: 3

Revision Rhytidectomy: Pearls and Pitfalls

While rhytidectomy can yield remarkable results, some patients may subsequently require revision rhytidectomy due to either unsatisfactory outcomes from primary surgery or the natural aging process many years later. Like most other secondary plastic surgical procedures, revision rhytidectomy is a complex undertaking and fraught with potential pitfalls. This can be attributable to natural or postsurgical alterations that can occur with the facial skin, superficial musculoaponeurotic system/platysma muscle, and/or facial nerve landmarks. Additionally, complications such as cobra neck deformity, pixie ear deformity, and synkinesis can add an extra level of complexity to revisional surgery. Furthermore, as more surgeons are performing deep-plane facelifts and more aggressive neck procedures, the risks are further amplified in revisional surgery. In this article, we review the challenges that a facelift surgeon may face when performing revision rhytidectomy and the technical considerations to overcome these obstacles.

The Proportional Relationship Among the Aesthetic Units of the Upper Lip: A 3-Dimensional Morphological Analysis of Young Adults

A deep understanding of the proportional relationship among the crucial aesthetic units of the upper lip is essential for lip treatment procedures, yet limited information can be found. The authors used 3-dimensional (D) photogrammetry to analyze the proportional features involving different lip structures. One hundred sixty volunteers (aged 18-35 y) were included, and standardized frontal view 3D images were obtained. A series of anthropometric parameters were measured, including linear, angular, and ratio parameters. The authors took the philtrum as one structure of particular concern. The philtrum was classified into 4 groups according to the shape of philtral columns, and philtrum depth was measured. The authors analyzed the correlations between the philtrum and the vermillion lip. They found significant differences in philtrum depth among different type groups. A significant negative correlation between philtral depth and philtrum length was found, which indicated that a long philtrum was more likely to be accompanied by a flat philtrum with shallow depth. The philtrum width was significantly correlated with the mouth width with a mean ratio of 0.25. The authors also found a significantly negative correlation between philtral depth and angle of Cupid's bow's peak (Achp), and a positive correlation between Achp and mouth width. This study used 3D photography to quantitatively analyze proportional characteristics among labial aesthetic units in young Chinese adults. The results showed that the philtrum and the vermillion lip morphology were closely related, providing helpful references in perioral procedures.

Evaluation of the attractiveness of lips with different volumes after filling with hyaluronic acid

To compare the attractiveness of lips with different volumes after filling in the view of laypersons, dentists, and specialists. The sample comprised close-up frontal and lateral photographs of the lips of 16 women who underwent lip filling procedure with hyaluronic acid and was divided into 2 groups. Group 1: eight women with thinner lips at pretreatment. Group 2: eight female patients with thicker lips at pretreatment. Photographs from before and 10 days after lip filling were used to assess attractiveness randomly displayed in a Google Forms questionnaire and then sent via a messaging app to the evaluators. The evaluators' groups were general dentists, dentists with degrees in facial aesthetics, and laypersons. The attractiveness was evaluated with scores from 0 to 10 (0: least attractive and 10 the greatest). T-tests were used for the statistical comparisons. The group with thinner lips showed significantly improved attractiveness after filling. The group with thicker lips showed a worsening attractiveness after filling. The group with thicker lips had significantly higher attractiveness scores than those with thinner lips. There was no significant difference in the preference between men and women. The group of laypersons was more rigorous, giving significantly lower lip attractiveness scores. Thinner lips showed a significant improvement in attractiveness after filling. Thicker lips showed a worsening of the attractiveness score after filling. Before and after filling, thicker lips had significantly higher attractiveness scores than thinner lips.Clinical relevance: The amount of fillers applied to each patient must be individually evaluated.

Impact of subnasal lip lift on lip aesthetic: a systematic review

This study is to perform a systematic review of the literature on surgical correction of the upper lip in order to assess whether the subnasal lip lift technique improves lip aesthetics and maintains its stability. A systematic search was carried out using the PubMed, Science Direct, Scopus, Cochrane Library and EMBASE databases, based on records published until July 2020. The quality of the included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. In the absence of randomized clinical trials, prospective or retrospective cohort studies, case control and case series were considered eligible. Of the 464 articles initially found by the two reviewers, 4 were selected, with 2 retrospective cohorts and 2 case series. The results of the studies showed that 92.4% of subnasal lip lift cases were performed in women with an age range between 21 and 65 years (mean of 36.6 years). Only one of the 4 studies did not contain information regarding the sex and age of the patients. The bull's horn excision pattern for subnasal lip lift was used to perform the subnasal lip lift in 75% of the included studies. All studies pointed to an improvement in lip aesthetics after the subnasal lip lift, based on anthropometric measures and the degree of patient satisfaction while maintaining results for varying periods of time (from 12 to 59.1 months). The studies included in this review suggest that the subnasal lip lift improves lip aesthetics in adult patients and maintains its stability for a certain period of time.

Introduction of the Lip Classification of Tubercles: A Novel Approach to Minimally Invasive Aesthetic Lip Treatments

Background

Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic treatments. However, current trends are associated with unnatural results and involve increased risks of complications and compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function.

Objectives

To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification of Tubercles (LCT).

Methods

To test the reliability of the LCT, a total of 214 high-definition photographs of patients' lips with no previous histories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions 3 months apart; the second followed a more detailed explanation of the classification.

Results

When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was considered the standard, the average score for the remaining 3 showed some individual variation but improved significantly from 58% to 85%.

Conclusions

The LCT is a reliable way to classify lip types based on the morphology of tubercles.

Level of Evidence 3

[Autologous fat grafting for perioral and lower face rejuvenation]

Objective

To review the research progress of the application of autologous fat grafting in perioral and lower face rejuvenation.

Methods

By extensively reviewing related articles and combining the clinical experiences, the anatomic features (fat compartments and blood supply), aging features of the perioral and lower face, and the application advancement and related complications of autologous fat grafting in this area were generally summarized.

Results

The aesthetic features of perioral and lower face include the lip, chin, and so on, and the anatomic structures relating autologous fat grafting include the mandibular fat compartments, chin fat compartments, and other fat compartments. Meanwhile, the facial artery passes through this area and spreads out several important branches. The aging features of perioral and lower face include the depening of nasolabial fold, the aging lip, perioral wrinkles, "marionette lines", and so on. Autologous fat grafting can improve perioral and lower face rejuvenation by restoring volume loss of facial fat compartments, correcting aging malformation, and improving skin quality. But there are neurovascular injuries, facial aesthetic problems, and other related complications.

Conclusion

Autologous fat grafting can be applied in perioral and lower face rejuvenation, and it can effectively improve related aging features. There are several aspects developing aggressively, including the research of facial asthetics features of Chinese people, combining autologous fat grafting with surgery as well as other methods to comprehensively treat facial aging, and the application of fat tissue related derivatives in perioral and lower face rejuvenation. However, the resorption rate of facial grafted fat tissue is still too high, and the long-term effectiveness can not be assured. In the future, the solutions related to improving the survival rate of grafted fat tissue need to be explored in the future.

Three-Dimensional Perioral Assessment Following Subnasal Lip Lift

BACKGROUND

The subnasal lip lift is a surgical technique that elevates the "lip line" (interface between vertical maxillary incisor height and upper lip) to achieve a more youthful aesthetic.

OBJECTIVES

The authors sought to offer the first ever definition, to their knowledge, of 3-dimensional (3D) changes to the upper lip due to subnasal lip lift.

METHODS

A lip lift procedure was performed (on cadaveric samples) in a sequential manner from 2.5- to 5.0-mm intervals (n = 13). 3D photographs were taken with the VECTRA H1 system (Canfield Scientific, Fairfield, NJ), and 3D analysis was performed including vermillion height and width, philtral height, sagittal lip projection, vermillion surface area, and incisor show. A subset of samples (n = 9) underwent a modification of the technique by undermining the upper lip subcutaneous tissue off the underlying muscular fascia.

RESULTS

Vermillion surface area (baseline range, 1.45-5.52 cm2) increased by an average of 20.5% and 43.1% with 2.5-mm and 5.0-mm lip lift, respectively. Anterior projection of the vermillion increased in all cases by an average of 2.13 and 4.07 mm at 2.5 and 5.0 mm, respectively. Philtral height decreased in all cases by an average of 3.37 and 7.23 mm at 2.5 and 5.0 mm, whereas incisal show increased on average of 1.9 and 4.09 mm, respectively.

CONCLUSIONS

This study is the first to our knowledge to define the 3D morphometric changes to the upper lip following subnasal lip lift. Quantifying these changes aids the surgeon in preoperative planning and guiding patient expectations.

In Search of the Most Attractive Lip-Proportions and Lip-Volume -An Eye Tracking- and Survey-based Investigation

BACKGROUND

Despite various aesthetic trends, the ideal lip proportion and lip volume still remains elusive. Thus, the aim of this study was to investigate the aesthetic perception of various lip shapes to identify the most attractive lips.

METHODS

59 Caucasian study participants with a mean age of 32.73 (9.4) years were asked to assess lips of various proportions and of various volumes. Gaze assessment and aesthetic rating of the same set of modified lip images were performed.

RESULTS

The results revealed that the lip proportion which was rated to be most attractive was the 1:1.6 ratio (upper:lower lip, 4.21 out of a possible 5). This lip proportion, however, was not the first one to be viewed upon initial image display (1.20 sec) and had the shortest duration of a stable eye fixation within the 6 sec image display interval (2.18 out of 6 sec). The lip volume which received the highest aesthetic rating was the 100% volume (original lip size) with 4.56 out of a possible 5. This lip volume however, had the third longest interval between initial image exposure and the first stable eye fixation (0.81 sec) and had the shortest duration of stable eye fixations during the 6 sec of image display (2.22 out of 6 sec).

CONCLUSION

The results presented could be potentially reflective of the internal cognitive processes during the involuntary and voluntary assessment of lip attractiveness.

CAPSULE SUMMARY

The results revealed that the lip proportion and lip volume which was rated to be most attractive was the 1:1.6 ratio and the non-augmented, natural volume. Eye tracking showed that attractive lips captured the observer's attention less quickly and were viewed for a shorter time.

The Role of the Ventromedial Prefrontal Cortex in Preferential Decisions for Own- and Other-Age Faces

Own-age bias is a well-known bias reflecting the effects of age, and its role has been demonstrated, particularly, in face recognition. However, it remains unclear whether an own-age bias exists in facial impression formation. In the present study, we used three datasets from two published and one unpublished functional magnetic resonance imaging (fMRI) study that employed the same pleasantness rating task with fMRI scanning and preferential choice task after the fMRI to investigate whether healthy young and older participants showed own-age effects in face preference. Specifically, we employed a drift-diffusion model to elaborate the existence of own-age bias in the processes of preferential choice. The behavioral results showed higher rating scores and higher drift rate for young faces than for older faces, regardless of the ages of participants. We identified a young-age effect, but not an own-age effect. Neuroimaging results from aggregation analysis of the three datasets suggest a possibility that the ventromedial prefrontal cortex (vmPFC) was associated with evidence accumulation of own-age faces; however, no clear evidence was provided. Importantly, we found no age-related decline in the responsiveness of the vmPFC to subjective pleasantness of faces, and both young and older participants showed a contribution of the vmPFC to the parametric representation of the subjective value of face and functional coupling between the vmPFC and ventral visual area, which reflects face preference. These results suggest that the preferential choice of face is less susceptible to the own-age bias across the lifespan of individuals.

What is Beauty?

PURPOSE

In the current study, the authors attempt to thoroughly investigate the concept of beauty from different perspectives in different historical periods and offer their personal thoughts about it.

METHODS

The authors performed a comprehensive and across-the-board literature review about 'beauty', including beauty from a philosophical perspective, beauty perception by human mind, beauty from a biopsychological perspective, beauty of the face, body and breast, models of beauty and beauty in cosmetic surgery.

RESULTS

From Plato to modern neuro-psychological studies, the concept of beauty has always been a theme for adamant debates and passionate thoughts. Different aspects of beauty, from intellectual to pure physical, have received a tremendous amount of attention. The true definition of the concept of beauty is still ambiguous, and there is not a unanimous explanation for it. It seems that the definition of beauty differs in every individual's mind and over the history of humankind.

CONCLUSION

Although beauty is a very important concept and the seek for achieving it is a very natural behavior, one must remember that the importance of beauty should not overshadow the fact that every human being is made up of similar internal organs. We strongly encourage the reader to look beyond the hedge, to be aware that each of us is made up of internal organs, beyond the external appearance. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Injectable platelet-rich fibrin for perioral rejuvenation as assessed by 3D lip volume imaging

BACKGROUND

Various injectable autologous platelet aggregate preparations have been developed and used for facial rejuvenation. Limited evidence exists for the use of these for augmentation of the lip.

OBJECTIVES

This prospective, uncontrolled, single-center study evaluated the qualitative and quantitative effects of an injectable platelet-rich fibrin preparation (known as i-PRF+) for lip augmentation.

PATIENTS/METHODS

PRF^® PROCESS system technology was used to prepare i-PRF+ supernatant. Ten healthy females were included in the study and received a single intradermal injection of i-PRF+ in the upper and lower lips (5 ml in each quadrant, total ~2 ml). Participants were followed for 3 months post-procedure. The efficacy of the procedure was assessed qualitatively by a subjective patient-reported outcome (FACE-Q) assessment and quantitatively by objective 3D skin surface volume analysis (ProFace^® ) at baseline and after 3 months.

RESULTS

FACE-Q scales that measure satisfaction with skin and lip showed a statistically significant improvement from baseline (p = 0.04 and p = 0.02, respectively). Satisfaction with lip lines showed a numerical improvement with mean total scores for adverse effect scales related to the skin and lips reduced at 2 weeks post-procedure (p = 0.03 and p = 0.13, respectively). Overall lip volume at 3-month follow-up was unchanged (p = 0.11). The treatment was well tolerated with only minor adverse effects.

CONCLUSIONS

A single session of i-PRF+ injections resulted in significant lip rejuvenation at 3-month follow-up, shown by improved patient-reported outcome measure. No significant change in lip volume was observed.

The Ideal Lips: Lessons Learnt from the Literature

Defining the ideal dimensions and proportions of the human face has been attempted for centuries, popularised in the Renaissance period by artists including Leonardo Da Vinci. The lips are part of the lower third of the face and are central to lower face aesthetics and the overall symmetry of the face. They also place an important part in conveying facial emotions and expressions. Full lips with well-defined Cupid's bow have always been associated with youth and beauty. The approval of hyaluronic acid use for tissue augmentation and the prevalence of social media have caused an exponential increase in lip augmentation procedures (Linkov et al. in Arch Plast Surg 46(3):248-254, 2019), as such researchers and aestheticians have focused on characterising the ideal lips mathematically to help guide clinicians. This narrative review will summarise the available evidence in the literature pertaining to the ideal lips, taking into account age, ethnicity and gender differences. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of the Philtrum on Facial Attractiveness, Perioral Proportions, and Perceptions of Facial Aging

BACKGROUND

Lip enhancement continues to be one of the most popular facial procedures. State-of-the-art lip enhancement involves sculpting of perilabial soft tissue, in particular, the philtrum, but it is unclear how patients perceive their philtral contours.

OBJECTIVES

The aim of this study was to test the impact of the philtrum on attractiveness, and on the perception of facial proportions and age.

METHODS

Respondents (1100, including 50 aesthetic specialists) were presented with 2 sets of identical portraits, 1 set of a young Caucasian female and 1 set of an aged Caucasian female, with 1 portrait in each set having an upper lip lacking any philtral contours. The respondents were asked to choose which upper lip was more attractive, appeared longer, and looked older. Rankings were analyzed according to population demographics.

RESULTS

Overall, most respondents considered the young face (84%) and the aged face (68%) with philtral contours to be more attractive. Moreover, the majority of respondents (81%) considered the upper lip of the young face without a philtrum to appear longer in a craniocaudal orientation (67% for the aged image), and 67% of respondents described the image of the young woman with no philtral definition as appearing older (55% for the aged face with no philtrum).

CONCLUSIONS

This study confirms the authors' hypothesis that the existence of philtral contours exerts a significant impact on perioral attractiveness, and that its absence can be related to a longer appearance of the upper lip as well as an older facial appearance.

Assessing Gaze Patterns in Common Cosmetic Procedures With Eye-Tracking Technology

BACKGROUND

Understanding the salient features that draw focus when assessing aesthetics is important for maximizing perceived outcomes. Eye-tracking technology provides an unbiased method for determining the features that draw attention when evaluating aesthetic plastic surgery. This study aimed to characterize viewing patterns of plastic surgery patients and laypeople when assessing facial cosmetic procedure images.

METHODS

Twenty women who previously underwent cosmetic procedures and twenty women without a history of cosmetic procedures were shown sixteen pairs of preprocedure and postprocedure images of patients who underwent laser resurfacing or lip augmentation. Image pairs were randomized to whether preprocedural or postprocedural images came first. Participants viewed each image until they decided upon an aesthetic rating (scored 1-10), while an eye-tracking device recorded participants' gaze.

RESULTS

The patient group's average ratings were 8.2% higher for preprocedural images and 13.3% higher for postprocedural images (P < 0.05 for both). The patient group spent 20.4% less time viewing images but spent proportionally more time evaluating the relevant features of each procedure (41.7% vs 23.3%, P < 0.01), such as the vermillion border of the upper lip, labial commissure, or periorbital region (P < 0.05 for each). For both groups, the most common site of first fixation was the nose for laser resurfacing images (26.6%) and the labial commissure for lip augmentation images (37.7%). Both groups spent more time fixated on nasolabial folds, marionette lines, and the periorbital region when viewing pre-laser resurfacing images than postprocedural images. Overall, each group had similar viewing patterns for time to first fixation on and frequency of fixations for a particular feature.

CONCLUSIONS

Women who previously underwent cosmetic procedures view postprocedural images more favorably and require less time to assess images, likely related to familiarity with aesthetic procedures. These women spend more time fixated on relevant features, such as the vermillion border of the upper lip, the labial commissure, and the periorbital region, than the control group. Notably, each group spent less time focused on regions associated with wrinkles, such as the marionette and periorbital areas in post-laser resurfacing images, suggesting that the procedure reduces attention-drawing features in these areas.

The Rhino-Lip-Lifting: A Novel Proposal for Midface Profileplasty Performed as a Single Surgical Procedure

As facial aging occurs, aesthetic changes of the nasal tip and the senile upper lip include tip ptosis, increase in skin length, loss of vermillion height and Cupid's bow, and vertical wrinkles.Regardless of the rejuvenation procedure, the lips are not to be considered as a single anatomical entity, instead they should be placed in a strong correlation with the nose. The aim of this study is therefore to demonstrate the effectiveness of the association of primary closed rhinoplasty together with indirect subnasal lip-lifting technique.A total of 45 patients were enrolled in this study and underwent primary closed rhinoplasty with indirect subnasal lip-lifting. The result showed an overall average nasolabial angle width reduction of 10.9% and lip length shortening of 23.5%, as assessed 1 year after the surgical procedure. When comparing before and after photographs and using the Subjective Global Aesthetic Improvement Scale (sGAIS), the overall satisfaction was rated 4.4 on 5, as "much improved."The authors show that lips should not be considered as a single anatomical entity but that they indeed must be placed in a strong correlation with the nose since a droopy nasal tip is likely to be considered unattractive and is often associated with the appearance of a long nose with covered philtrum and upper lip.Tip rotation to a normal nasolabial angle width could grant a beneficial impact on overall nose aesthetics; however, it may not fully balance the midface profile as it is the "lip position-to-incisal show" ratio that defines beauty, whereas the balance among forehead, nasal tip, upper lip, and chin is what defines the contour of harmonious profiles.This is the first patient series to show that the combination of closed rhinoplasty and indirect lip-lifting is a highly effective, safe, and reliable procedure to address profile rejuvenation.

Analysis of upper lip appearance after surgical lip augmentation procedure "VY in VY": Progress of results

INTRODUCTION

Many materials and techniques were used for lip augmentation, whereas in the last years all attention is paid for filling material, and long-lasting surgical techniques were ignored.

MATERIALS AND METHODS

This study includes 12 candidate patients for upper lip augmentation; all are females, their age range 21-24 years. Standardized anterior and lateral photographs of each subject were taken at: preoperative, 2, 4, and 12 months later, and were analysed using digital imaging software to quantify postoperative changes. We used t-test of correlated samples to detect any statistical significance and Interclass correlation coefficient test (ICC) for reliability that proved the reliability and reproducibility of our method.

RESULTS

there were statistically significant improvements in al parameters that characterize the fullness of the upper lip. These changes was observed from the 2^nd month (P<0.05) and continued improving until the 4^th month (P<0.05), after that they appeared to be stable (P>0.05). These changes were at the 12^th month postoperative in: upper white lip (-9%), upper red lip (53%), upper red lip area (63%), protrusion (41%) and nasolabial angle (-7%). There was no statistical significance in the change of Cupid's bow curvature (P-value = 0.104 > 0.05).

CONCLUSIONS

VY in VY for upper lip augmentation improves the parameters that define the youthful and fully appearance of the upper lip and the progress of results may be predictable. These improvements appear to be stable from the 4th month. Also, it doesn't change the Cupid's bow curvature.

Lip Shapes Over the Last Century (1948-2012)

The aim of this study was to analyze lip shapes as represented in the British edition of Vogue over the last century (1916-2015). Photographs containing distinguishable lips were selected from a book entitled Vogue 100: A Century of Style. A total of 98 frontal pictures (20 males, 78 females) in which the lips and mouth were identifiable were included and analyzed in terms of 4 lip-related ratios (lip thickness-to-width ratio [LTW]; upper-to-lower vermillion ratio [ULR]; upper vermillion thickness-to-upper lip height ratio [VUL]; and lip-to-nose width ratio [LNW]). The LTW was 0.39 ± 0.07, and did not vary significantly over time (P = 0.261 [linear regression analysis]). The LTW of women (0.41 ± 0.07) was significantly greater than that of men (0.34 ± 0.05) (P < 0.001 [independent 2-samples t-test]). The ULR was 0.74 ± 0.16, and did not vary significantly over time (P = 0.647). There was no significant difference in the ULR between men (0.75 ± 0.10) and women (0.74 ± 0.17) (P = 0.769). The VUL was 0.43 ± 0.09, and did not vary significantly over time (P = 0.550). The VUL of women (0.44 ± 0.09) was significantly greater than that of men (0.37 ± 0.06) (P = 0.001). The LNW was 1.49 ± 0.19, and did not vary significantly over time (P = 0.619). There was no significant difference in the LNW between men (1.43 ± 0.16) and women (1.51 ± 0.19) (P = 0.082). The results of this study may be useful for planning facial rejuvenation operations, as well as for clinical practitioners dealing with brow esthetics or lip tattooing.

A Safe and Effective Lip Augmentation Method: The Step-by-Step Φ (Phi) Technique

The shape and fullness of the lips are essential in facial aesthetics. We describe a safe injection technique of hyaluronic acid (HA), based on the well-known golden number Φ (phi), for lip augmentation.

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness

BACKGROUND

Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment.

METHODS

An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness).

RESULTS

In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both].

CONCLUSION

The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Beauty is in the eye of the follower: Facial aesthetics in the age of social media

BACKGROUND

The advent of social media has influenced the relationship between aesthetic surgeons and their patients, as well as the motivations of such patients to seek cosmetic surgery.

AIMS & OBJECTIVES

To determine how the cephalometric proportions of modern social media models fit with historical canons of beauty.

MATERIALS & METHODS

Frontal and lateral photographs of 20 high-influence female Instagram models were obtained and evaluated for cephalometric measures. The means of these measures were compared with previous reports in the literature.

RESULTS

Cephalometric measurements of social media models were in agreement with historical ideals of beauty for Nostril axis (120.7°), Goode's ratio (0.6), Nasofacial angle (35.7°), Nasofrontal angle (130.9°), and the horizontal thirds. Results were discrepant from historical ideals for the Nasolabial angle (82.6°) and the vertical facial fifths.

CONCLUSION

Cephalometric measurements of social media models in the digital age closely resemble the ideal values proposed by previous authors. Due to a preference for larger or altered lip profiles, nostril axis is a more reliable measure of nasal tip rotation than nasolabial angle.

A novel facial attractiveness evaluation system based on face shape, facial structure features and skin

Facial attractiveness is an important research direction of genetic psychology and cognitive psychology, and its results are significant for the study of face evolution and human evolution. However, previous studies have not put forward a comprehensive evaluation system of facial attractiveness. Traditionally, the establishment of facial attractiveness evaluation system was based on facial geometric features, without facial skin features. In this paper, combined with big data analysis, evaluation of face in real society and literature research, we found that skin also have a significant impact on facial attractiveness, because skin could reflect age, wrinkles and healthful qualities, thus affected the human perception of facial attractiveness. Therefore, we propose a comprehensive and novel facial attractiveness evaluation system based on face shape structural features, facial structure features and skin texture feature. In order to apply face shape structural features to the evaluation of facial attractiveness, the classification of face shape is the first step. Face image dataset is divided according to face shape, and then facial structure features and skin texture features that represent facial attractiveness are extracted and fused. The machine learning algorithm with the best prediction performance is selected in the face shape structural subsets to predict facial attractiveness. Experimental results show that the facial attractiveness evaluation performance can be improved by the method based on classification of face shape and multi-features fusion, the facial attractiveness scores obtained by the proposed system correlates better with human ratings. Our evaluation system can help people project their cognition of facial attractiveness into artificial agents they interact with.

Facial Plastic Surgery Journals: Understanding Their Relevance and Getting Published

This article seeks to inform facial plastic surgeons about the evolving issues that affect contemporary medical literature and the publishing landscape. We hope to shed light on the key metrics that influence a journal's decision to accept a particular submission and how these metrics are predicated on a rapidly changing landscape within the academic and public community. The key metrics are: citations, number of views, and social media or public attention. These metrics produce what we call "high impact" articles. This article introduces bibliometric terms and further defines the metrics that are most important to a journal.

Comprehensive histological investigation of age-related changes in dermal extracellular matrix and muscle fibers in the upper lip vermilion

OBJECTIVE

Few histological studies have directly examined age-related changes within the lips, although non-invasive investigations of such changes are increasing. Therefore, this study aimed to provide histological and molecular data on age-dependent alterations in the vermilion.

METHODS

Upper vermilion specimens from 15 female Caucasian cadavers (age range, 27-78 years) were investigated histologically or immunohistochemically.

RESULTS

Histologically, age-dependent decreases in areas occupied by hyaluronan and collagenous fibres in the dermis of upper vermilion were demonstrated. Elastic fibre content varied widely between individuals. The area occupied by muscle fibres in the orbicularis oris muscle region within the vermilion also correlated negatively with age. Immunohistochemically, signals of four proteins were attenuated in vermilion from older individuals compared with young individuals: procollagen type I, hyaluronan synthase (HAS)1, myosin heavy chain (MYH)2 (a component of fast-twitch oxidative muscle fibres) and MYH7 (a component of slow-twitch muscle fibres). In contrast, signals of cell migration inducing hyaluronidase 1 (CEMIP) were intensified in vermilion from older individuals. No marked differences between young and older individuals were seen in procollagen type III, HAS2, HAS3, hyaluronidase (HYAL)1, HYAL2, MYH1 or MYH4.

CONCLUSION

Age-dependent decreases of hyaluronan in the dermis of vermilion were prominent, possibly due to both the decrease in synthesis (HAS1) and the increase in degradation (CEMIP). Furthermore, age-dependent decreases in collagenous fibres and two types of muscle fibre in the vermilion were also identified histologically. Type I collagen, MYH2 and MYH7 appear to represent the molecules responsible for these respective decrements.

Influence of different techniques of secondary cleft lip revision surgery on upper lip projection

Patient dissatisfaction with labial appearance in the adult cleft lip is frequently linked to poor upper lip projection. Other areas of concern include asymmetry and impaired upper lip height. Different surgical techniques are available to address volumetric deficiencies, according to extent and localization. However, data comparing outcomes in these different areas are limited. The main aim of this study was to assess the relative gains in upper lip projection. An evaluation of upper vermilion height and symmetry was also performed. Thirty-seven consecutive patients treated by a single surgeon had their pre- and postoperative results measured using standardized photographs; these were analysed using subjective and objective outcome measures. Seven examiners evaluated anonymized pre- and postoperative side and front views for subjective evaluation. The objective analysis was performed using Adobe Photoshop. Fifteen lip revisions, four Abbe flaps, 12 dermal grafts, and six PermaLip implants were performed. In bilateral cleft lip and palate patients, Abbe flaps showed the most significant improvement in labial projection, followed by PermaLip implants and dermal grafts. In unilateral cleft lip and palate patients, PermaLip implants best addressed impaired lip projection, followed by dermal grafts. Overall, functional lip revisions showed excellent outcomes for upper lip symmetry; however, only minor changes in labial projection were found.

Anatomical Basis and Surgical Techniques Employed in Facial Feminization and Masculinization

Increasingly, facial feminization and masculinization techniques are being employed in the treatment of gender dysphoria. For the facial surgeon, knowledge of the anatomical differences between masculine and feminine facial skeletal structures is of utmost importance. Combining this knowledge with the various surgical and non-techniques that may be employed in order to achieve each patient's goals will allow the facial surgeon to greatly impact the lives of persons of transgender and gender diverse experience. Below, this article discusses these anatomical differences as well as current surgical practices employed in order to masculinize or feminize the face.

A variety of processes that affect the perception of skin aging

The purpose of this paper is to discuss the most important factors affecting perceived age. Aging is an unavoidable and irreversible process, but perceived age is a modifiable psychosocial factor. Our exterior has become one of the determinants of our social position, the key to success in our professional and personal lives. Today, we see people through their appearance, we judge after the first impression. With the help of aesthetic medicine, we can change the perceived age, but we cannot stop aging. This article discusses factors affecting the perceived age, such as hair color, skin color, general appearance and environmental factors. Many cannot be avoided, but we can make changes in life to look younger and more well-groomed. Indeed, we can change our habits for the benefit of the whole body, not only for the skin.

What Do We Find Attractive about the Face?: Survey Study with Application to Aesthetic Surgery

The appearance of the face is one of the most important factors influencing our perception of beauty. However, few studies have attempted to quantitate what one perceives as beauty. Therefore, this study was conducted with the goal of providing physicians with anatomical data that demonstrate which facial traits most influence our perception of one's attractiveness. In the first phase of the study, faces of 60 participants (30 males and 30 females) were photographed. Next, the photographs were shown to another group of 120 study members (60 males and 60 females), who evaluated the facial features using a Visual Analogue Scale. The highest rated facial parts were then measured using the ImageJ program. In men, the most attractive parts of the face were Type 1:2 lips, a Type IV nose of medium width, blue eyes, brown hair, and a very narrow face. Among females, the most attractive parts of the face were Type 2:1 lips, Type III and V noses of medium width, dark brown eyes, blonde hair, and a narrow face. This is the first study in which the most aesthetically important facial parts have been comprehensively examined. The results obtained in our study show a higher degree of representativeness compared to other studies due to a different methodological approach and can be used as an aesthetic guide and can help in the planning of aesthetic surgery such as lip augmentation and rhinoplasty. Clin. Anat. 33:214-222, 2020. © 2019 Wiley Periodicals, Inc.

Perceptions of Attractive and Healthy-Looking Lips

The aim of this study was to characterize Koreans' perceptions of attractive and healthy-looking lips.A survey was conducted among 258 women and 72 men who were asked to view illustrations of various examples of the 4 lip-related ratios (lip thickness-to-width ratio [LTW]; upper-to-lower vermillion ratio [ULR]; upper vermillion thickness-to-upper lip height ratio [VUL]; and lip-to-nose width ratio [LNW]) and to choose which they thought were attractive or healthy-looking.The LTW ratios most often identified as attractive were LTW-1/3 (lip thickness is 1/3 of lip width, 40.0%) and LTW-2/5 (47.3%). The LTW value most often identified as healthy-looking was LTW-2/5 (54.3%). The most attractive ULR ratio was ULR-4/5 (upper vermillion thickness is 4/5 of the lower vermillion, 49.4%). The most healthy-looking ULR ratio was ULR-4/5 (47.0%). The most attractive VUL ratio was VUL-1/2 (thickness of the upper vermillion is 1/2 of upper lip height, 60.3%). The most healthy-looking VUL ratio was VUL-1/2 (61.0%). The most attractive LNW ratio was LNW-3/2 (lip width is 3/2 of nose width, 42.1%). LNW-3/2 was also the most preferred in all age groups below 50 years, while those over 50 preferred LNW-4/3 (55.0%). The most healthy-looking LNW ratios were LNW-3/2 (35.2%) and LNW-4/3 (32.1%). LNW-3/2 was the most preferred in all age groups below 50, while those over 50 preferred LNW-4/3 (40.0%). It therefore seems that older people preferred a narrower lip width than younger people.The results of this study can be applied in lip augmentations or aesthetic lip surgery.

Perception of upper lip augmentation utilizing simulated photography

BACKGROUND

No head to head comparison is available between surgical lip lifting and upper lip filler injections to decide which technique yields the best results in patients. Despite the growing popularity of upper lip augmentation, its effect on societal perceptions of attractiveness, successfulness and overall health in woman is unknown.

METHODS

Blinded casual observers viewed three versions of independent images of 15 unique patient lower faces for a total of 45 images. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses.

RESULTS

Two hundred and seventeen random observers with an average age of 47 years (standard deviation, 15.9) rated the images. The majority of observers were females (n=183, 84%) of white race (n=174, 80%) and had at least some college education (n=202, 93%). The marginal mean score for perceived attractiveness from the natural condition was 1.5 points (95% confidence interval [CI], 0.9-2.18) higher than perceived attractiveness from the simulated upper lip filler injection condition, and 2.6 points higher (95% CI, 1.95-3.24) than the simulated upper lip lift condition. There was a moderate to strong correlation between the scores of the same observer.

CONCLUSIONS

Simulated upper lip augmentation is amenable to social perception analysis. Scores of the same observer for attractiveness, successfulness, and overall health are strongly correlated. Overall, the natural condition had the highest scores in all categories, followed by simulated upper lip filler, and lastly simulated upper lip lift.

Nonsurgical Management of Facial Masculinization and Feminization

BACKGROUND

Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures.

OBJECTIVES

The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization.

METHODS

A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review.

CONCLUSIONS

Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

LEVEL OF EVIDENCE: 4

Lip Augmentation

This article examines 6 questions about lip augmentation answered by 3 experts in their field of facial plastic surgery. The topics covered include high-yield areas such as injection, surgical enhancement, rhytid resurfacing, implants, complications, and technique changes over the years. All the authors answered these questions in a "How I do it" manner to provide the reader with a true understanding of their thoughts and techniques. This article provides a practical resource to all physicians and practitioners performing lip augmentation on some of the most common questions and issues.

Art or Science? An Evidence-Based Approach to Human Facial Beauty a Quantitative Analysis Towards an Informed Clinical Aesthetic Practice

BACKGROUND

Patients often seek guidance from the aesthetic practitioners regarding treatments to enhance their 'beauty'. Is there a science behind the art of assessment and if so is it measurable? Through the centuries, this question has challenged scholars, artists and surgeons.

AIMS AND OBJECTIVES

This study aims to undertake a review of the evidence behind quantitative facial measurements in assessing beauty to help the practitioner in everyday aesthetic practice.

METHODS

A Medline, Embase search for beauty, facial features and quantitative analysis was undertaken.

SELECTION CRITERIA

Inclusion criteria were studies on adults, and exclusions included studies undertaken for dental, cleft lip, oncology, burns or reconstructive surgeries. The abstracts and papers were appraised, and further studies excluded that were considered inappropriate. The data were extracted using a standardised table. The final dataset was appraised in accordance with the PRISMA checklist and Holland and Rees' critique tools.

RESULTS

Of the 1253 studies screened, 1139 were excluded from abstracts and a further 70 excluded from full text articles. The remaining 44 were assessed qualitatively and quantitatively. It became evident that the datasets were not comparable. Nevertheless, common themes were obvious, and these were summarised.

CONCLUSION

Despite measures of the beauty of individual components to the sum of all the parts, such as symmetry and the golden ratio, we are yet far from establishing what truly constitutes quantitative beauty. Perhaps beauty is truly in the 'eyes of the beholder' (and perhaps in the eyes of the subject too).

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .