Mirror, mirror on the wall…: self-perception of facial beauty versus judgement by others

Evaluation of facial pleasantness in patients with complete and unilateral cleft lip and palate rehabilitated and submitted to orofacial harmonization

OBJECTIVE

The objective of the present prospective case control study was to evaluate the facial pleasantness of patients with complete and unilateral cleft lip and palate at the end of interdisciplinary rehabilitation, submitted to facial fillers based on hyaluronic acid.

METHODS

The study group consisted of 18 individuals with complete unilateral cleft lip and palate, aged between 18 and 40 years (mean age 29 years) of both sexes. The patients presented a concave profile with mild to moderate maxillary deficiency, with completed orthodontic treatment and conducted by means of dentoalveolar compensations without orthognathic surgery. Participants underwent facial filling procedures with hyaluronic acid (HA) in the midface, inserted by a single operator. Standard photographs in frontal norm at rest, right profile at rest, and left profile at rest were obtained from each patient at the following operative times: (T1) pre-filler and (T2) and one-month post-filler. The photographs in T1 and T2 were randomly placed on a page of a virtual album. A 5-point Likert scale was used to assess facial pleasantness. The photographs were evaluated by two groups of evaluators consisting of 18 individuals with cleft lip and palate (CLPG=18) and 18 orthodontists with experience in the treatment of clefts (OG=18). For comparison between phases T1 and T2, and between evaluators with orofacial clefts and orthodontists, the Wilcoxon test was used (p<0,05).

RESULTS

People with cleft lip and palate rated their face as more pleasant after the midface filling procedure. In the perception of the orthodontists, on the other hand, the facial pleasantness remained similar after the facial filling procedure.

CONCLUSIONS

The filling of the middle third of the face in patients with cleft lip and palate treated without orthognathic surgery increased the pleasantness of the face in the opinion of laypeople with cleft lip and palate.

Facial shape affects self-perceived facial attractiveness

Facial appearance expresses numerous cues about physical qualities as well as psychosocial and personality traits. Attractive faces are recognized clearly when seen and are often viewed advantageously in professional, social and romantic relationships. On the other hand, self-perceived attractiveness is not well understood and has been mainly attributed to psychological and cognitive factors. Here we use 3-dimensional facial surface data of a large young adult population (n = 601) to thoroughly assess the effect of facial shape on self-perceived facial attractiveness. Our results show that facial shape had a measurable effect on self-perception of facial attractiveness in both sexes. In females, self-perceived facial attractiveness was linked to decreased facial width, fuller anterior part of the lower facial third and more pronounced middle forehead and root of the nose. Males favored a well-defined chin, flatter cheeks and zygomas, and more pronounced eyebrow ridges, nose and middle forehead. The findings of this study support the notion that self-perceived facial attractiveness is not only motivated by psychological traits, but objectively measured phenotypic traits also contribute significantly. The role of social stereotypes for facial attractiveness in modern society is also inferred and discussed.

Unattractive people are unaware of their (un)attractiveness

Past research has shown that how people rate their physical attractiveness is only moderately correlated with how they are rated by others, suggesting that at least some people have little insight into their true level of attractiveness. The present research tests the hypothesis that unattractive people are not aware of their unattractiveness. In fact, six studies (overall N = 1,180) showed that unattractive participants considerably overestimated their attractiveness compared to ratings by strangers. In contrast, attractive participants were more accurate. If anything, they underestimated their attractiveness. It was also examined why unattractive people overestimate their attractiveness. As expected, unattractive participants differentiated less between attractive and unattractive stimulus persons than did attractive participants. They were also more likely than attractive participants to select unattractive stimulus persons to compare themselves to. However, these tendencies did not account for why unattractive participants overestimated their attractiveness, nor did affirming participant's self-worth. Limitations and avenues for future research are discussed.

Influence of sexual dimorphism on the attractiveness evaluation of one's own face

The present study aimed to explore the influence of sexual dimorphism on the evaluation of the attractiveness of one's own face. In the experiment, a masculinized and a feminized version of the self-faces of the participants were obtained by transferring the original faces toward the average male or female face. The participants were required to rate the attractiveness of three types (original, masculine, feminine) of their own faces and the other participants' faces in same-sex and opposite-sex contexts. The results revealed that the participants rated their own faces as more attractive than other participants rated them regardless of the sexually dimorphic type (original, masculine, feminine) or the evaluation context. More importantly, the male and female participants showed different preferences for the three types of self-faces. Specifically, in the same-sex context, the female participants rated their own original faces as significantly more attractive than the masculine and feminine faces, and the male participants rated their own masculine faces as significantly more attractive than the feminine faces; while in the opposite-sex context, no significant difference among the attractiveness scores of the three types of self-faces was found in both the male and female participants. The present study provides empirical evidence of the influence of sexual dimorphism on the evaluation of the attractiveness of self-faces.

Evaluation of Personality Perception in Men Before and After Facial Cosmetic Surgery

Importance

Facial cosmetic surgery has previously focused on improvements in perceived physical attractiveness and youthfulness. However, human beings are judged throughout life based on many other characteristics and personal qualities that are conveyed by their faces.

Objective

To examine the association of facial cosmetic surgery in men with perceptions of attractiveness, masculinity, and personality traits.

Design, Setting, and Participants

Cohort study with retrospective evaluation by blinded raters of preoperative and postoperative photographs of 24 male patients who underwent facial cosmetic surgery between January 1, 2009, and January 31, 2016. A total of 6 surveys were constructed with 8 sets of photographs each (4 preoperative and 4 postoperative). Each of these surveys was then sent to at least 36 lay people via the web-based survey tool Survey Monkey. Additional invites were sent for individual surveys until a minimum of 24 responses were received for each survey. Preoperative and postoperative photographs of the same patient were not placed in the same survey to avoid recall bias. Anonymous raters used a 7-point Likert scale to rate their perception of each patient's personality traits (aggressiveness, extroversion, likeability, risk seeking, sociability, and trustworthiness), attractiveness, and masculinity based on photographs in their assigned survey. Raters were blinded to study intent. Data analysis was performed between August 2018 and March 2019.

Main Outcomes and Measures

Ratings of personality, attractiveness, and masculinity.

Results

This survey study included photographs of 24 men who underwent facial cosmetic surgery; the mean (SD) age of the patients was 49.3 (16.4) years. A total of 145 participants completed the survey; the majority of respondents were men (n = 81; 56%) between the ages of 25 and 34 years (n = 116; 80%). Score increases were significant for perceived attractiveness (0.29; 95% CI, 0.13-0.46), likeability (0.41; 95% CI, 0.24-0.57), social skills (0.25; 95% CI, 0.08-0.40), and trustworthiness (0.27, 95% CI, 0.11-0.44) when evaluating all facial cosmetic procedures together (upper blepharoplasty, lower blepharoplasty, face-lift, brow-lift, neck-lift, rhinoplasty, and/or chin implant). Upper blepharoplasty was associated with positive changes in perceived likeability (0.72; 95% CI, 0.06-1.50) and trustworthiness (0.74; 95% CI, 0.22-1.25). Lower blepharoplasty was associated with decreased perception of risk seeking (-0.78; 95% CI, -1.45 to -0.10). Face-lift was associated with increased perception of likeability (0.69; 95% CI, 0.08-1.30) and trustworthiness (0.66; 95% CI, 0.05-1.27). Neck-lift was associated with increased perception of extroversion (0.60; 95% CI, 0.10-1.09) and masculinity (0.70; 95% CI, 0.21-1.19). Patients who underwent rhinoplasty had improvements in perceived attractiveness (0.51; 95% CI, 0.03-1.00) and likeability (0.40; 95% CI, 0.03-1.00). Chin augmentation did not show any significant improvements.

Conclusions and Relevance

The results of this study suggest that men undergoing facial cosmetic surgery may experience changes in perceived attractiveness, masculinity, and a variety of personality traits. These findings complement those from a previous study on female patients, which together broaden the understanding of the association of cosmetic surgery with societal perceptions of persona.

Level of Evidence

NA.

Development and Application of a Novel Patient-Reported Outcome Measure on QoL and Facial Aesthetics-A Study on South Indian Population

BACKGROUND

The goal of cleft therapy has progressed from simply correcting the deformity to uplifting the patient's quality of life (QoL). At the end of comprehensive treatment, a patient with cleft lip and palate (CLP) should report with satisfactory QoL scores in all domains such as aesthetics, speech, function, and psychology.

OBJECTIVE

To develop and validate a novel, disease-specific questionnaire designed in 2 regional languages to assess the QoL in young adult patients with CLP of South India following comprehensive treatment.

METHODS

A preliminary questionnaire was created from the literature review and patient interviews, considering regional sociodemographic conditions. The questionnaire was then validated by subject experts and pilot tested. The resultant tool was implemented on patients at treatment completion. Data collected were assimilated for statistical evaluation.

RESULTS

The questionnaire was deemed reliable (Cronbach α = .854 and test-retest reliability, κ = 0.8) and was administered to 100 young adult patients with CLP (mean age: 22 years). A large majority (83%) of the population felt more confident about themselves, with positive responses to familial relations, social interaction, and self-image. About 25% of the patients faced problems with speech regularly, while a majority of patients did not face problems with chewing and swallowing. Nearly 60% of patients were fully satisfied with their facial appearance, while others had concerns about their lip and nose aesthetics. The results were descriptive of the local population.

CONCLUSIONS

Most patients achieved satisfactory QoL in all domains following comprehensive multispeciality therapy. The novel tool is simple, reliable, and can be adapted to homogenous population groups.

The Effect of Romantic Relationships on the Evaluation of the Attractiveness of One's Own Face

The present study sought to explore the effect of romantic relationships on the attractiveness evaluation of one's own face using two experiments with the probability evaluation and the subjective rating method. Experiment 1 and Experiment 2 enrolled couples and single individuals as participants, respectively. The results of the two experiments indicated that the participants evaluated their own face as significantly more attractive than did others of the same sex. More importantly, the romantic relationship enhanced the positive bias in the evaluation of self-face attractiveness, that is, couple participants showed a stronger positive bias than did single individuals. It was also found that a person in a romantic relationship was prone to overestimating the attractiveness of his or her lover's face, from the perspective of both probability evaluation and rating score. However, the abovementioned overestimation did not surpass the evaluations of the exaggeratedly attractive face. The present results supported the observer hypothesis, demonstrating the romantic relationship to be an important influential factor of facial attractiveness. Our findings have important implications for the research of self-face evaluation.

Self-esteem, Self-efficacy, and Appearance Assessment of Young Female Patients Undergoing Facial Cosmetic Surgery: A Comparative Study of the Chinese Population

IMPORTANCE

The psychological traits of cosmetic surgery patients (CSP) are important for selecting patients and postoperative patient satisfaction. A patient's self-esteem, self-efficacy, and self-assessment affect his or her motivation for cosmetic surgery, but the association among these traits remains unclear, especially in the Asian population.

OBJECTIVE

To clarify the association of a patient's psychological traits, decision to undergo cosmetic surgery, and the effectiveness of facial cosmetic surgery on the psychological conditions of young, female Chinese patients.

DESIGN, SETTING, AND PARTICIPANTS

Three different groups of young women (aged 18-30 years) from the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and 7 universities were enrolled from January 1, 2012, through December 31, 2014: CSPs (n = 161), general population controls (GPCs) (n = 355), and facial appearance raters (FARs) (n = 268). The last date of follow-up was January 20, 2015. Patient data from questionnaires were obtained preoperatively and 6 months postoperatively, and the data from the control groups were obtained immediately after enrollment. Front-view facial images of the study participants were taken and then shown to independent raters to assess the participants' facial appearances on a rating scale.

MAIN OUTCOMES AND MEASURES

Evaluation of self-esteem and self-efficacy, subjective and objective assessment of facial appearance, and structural equation models.

RESULTS

A total of 163 CSPs and 387 GPCs were recruited for the study, and complete and valid data were obtained from 161 CSPs and 355 GPCs. All responses from the 268 FARs met the criteria for subsequent analysis. Of the questionnaires issued to the CSPs 6 months postoperatively, 126 valid responses were returned (response rate, 78.3%). Self-esteem and self-efficacy decreased significantly in preoperative patients compared with controls (P < .001) (mean [SD] scores, 22.60 [1.80] for CSPs and 27.39 [2.11] for GPCs for self-esteem and 21.50 [2.40] for CSPs and 28.59 [4.23] for GPCs for self-efficacy) and were found to be at nearly normal levels 6 months postoperatively (mean [SD] scores, 25.88 [3.65] and 26.38 [2.45] for self-esteem and self-efficacy, respectively). The patients' objective assessments of facial appearance did not differ significantly from those of the control group participants (mean [SD] scores, 4.51 [0.77] and 4.55 [0.74] for CSPs and GPCs, respectively; P = .86); however, a significant decrease in patient self-assessment was noted (mean [SD scores], 6.45 [1.15] and 7.31 [1.42] for CSPs and GPCs, respectively; P = .01). Moreover, the structural equation models revealed a path from low self-esteem and self-efficacy after decreased self-assessment to decision for cosmetic surgery.

CONCLUSIONS AND RELEVANCE

Self-esteem and self-efficacy mediate the negative effects of self-assessment on the decision of young women to undergo facial cosmetic surgery. The impairment of self-esteem and self-efficacy may indicate the need for preoperative psychological intervention. Facial cosmetic surgery can have positive effects on self-esteem and self-efficacy.

LEVEL OF EVIDENCE

2.

Effect of facial rejuvenation surgery on perceived attractiveness, femininity, and personality

IMPORTANCE

To date, the conversation about facial rejuvenation surgery has focused on one goal: youthfulness. However, human beings are judged throughout life based on many other characteristics and personal qualities conveyed by their faces. The term facial profiling has been used to describe this act of determining personality attributes through visual observation.

OBJECTIVES

To introduce the concept of facial profiling to the surgical literature and to evaluate and quantify the changes in personality perception that occur with facial rejuvenation surgery.

DESIGN, SETTING, AND PARTICIPANTS

This study was a retrospective evaluation of preoperative and postoperative photographs of 30 white female patients who underwent facial rejuvenation surgery between January 1, 2009, and December 31, 2013. Procedures included rhytidectomy (face-lift), upper blepharoplasty, lower blepharoplasty, eyebrow-lift, neck-lift, and/or chin implant. The 60 photographs (30 preoperative and 30 postoperative) of these patients were split into 6 groups, each with 5 preoperative and 5 postoperative photographs. The same patient's preoperative and postoperative photographs were not included in any single group to avoid any recall bias. At least 24 individuals rated each photograph for 6 personality traits (aggressiveness, extroversion, likeability, trustworthiness, risk seeking, and social skills), as well as for attractiveness and femininity. The raters were blinded as to the intent of the study.

MAIN OUTCOMES AND MEASURES

Ratings of personality traits, attractiveness, and femininity.

RESULTS

Of the 8 traits that were evaluated, analysis revealed 4 traits with statistically significant improvements when comparing preoperative and postoperative scores: likeability (+0.36, P < .01), social skills (+0.38, P = .01), attractiveness (+0.36, P = .01), and femininity (+0.39, P = .02). Improvement in scores for perceived trustworthiness (+0.22, P = .06), aggressiveness (-0.14, P = .32), extroversion (+0.19, P = .14), and risk seeking (+0.10, P = .27) did not demonstrate statistically significant changes.

CONCLUSIONS AND RELEVANCE

Facial plastic surgery changes the perception of patients by those around them. Traditionally, these interventions have focused on improvements in youthful appearance, but this study illuminates the other dimensions of a patient's facial profile that are influenced by facial rejuvenation surgery. The data in this sample population demonstrate an increase in the perception of likeability, social skills, attractiveness, and femininity. To our knowledge, this is the first study in the surgical literature to evaluate these broader outcome measures after facial rejuvenation surgery.

LEVEL OF EVIDENCE

NA.

Nasofacial angle and nasal prominence: A quantitative investigation of idealized and normative values

PURPOSE

A quantitative evaluation of the influence of the nasofacial angle on perceived attractiveness and threshold values of desire for rhinoplasty.

MATERIAL AND METHODS

The nasofacial angle of an idealized silhouette male Caucasian/white profile image was altered incrementally between 21° and 48°. Images were rated on a Likert scale by pretreatment patients (n = 75), laypersons (n = 75), and clinicians (n = 35).

RESULTS

A nasofacial angle of approximately 30° was deemed to be ideal, with a range of 27°-36° deemed acceptable. Angles above or below this range were perceived as unattractive. Angles outside the range of 21°-42° were deemed very unattractive. Excessive nasal prominence (nasofrontal angle of 48°) was deemed the least attractive. In terms of threshold values of desire for surgery, for all groups a threshold value of ≥39° and ≤24° indicated a preference for surgery, with clinicians least likely to suggest surgery. The patient group assessments demonstrated the greatest variability, stressing the importance of using patients as observers, as well as laypersons and clinicians, in facial attractiveness research.

CONCLUSIONS

It is recommended that in rhinoplasty planning, the range of normal variability of the nasofrontal angle, in terms of observer acceptance, is taken into account, as well as threshold values of desire for surgery.

The impact of education on the perception of facial profile aesthetics and treatment need

BACKGROUND

The purpose of this study was to evaluate the influence of education on the perception of various male and female Caucasian profiles with respect to attractiveness and treatment need.

METHODS

Four hundred questionnaires were distributed among six groups of raters (nonacademic laymen, academic laymen, preclinical students, clinical students, orthodontists, and maxillofacial surgeons). Male and female profile images were altered digitally in the sagittal and vertical dimensions resulting in nine different male and female profiles. The raters had to assess the images according to attractiveness and treatment needs.

RESULTS

Three hundred four questionnaires were completed in this study. Age and gender of the rater had no significant influence on the perception of profile attractiveness. The different groups of raters perceived the Class I normodivergent profiles as most attractive. Significant differences in the perception of attractiveness were seen between laymen, orthodontists, and maxillofacial surgeons. The orthodontists and maxillofacial surgeons reported treatment needs the most. The orthodontists were most sensitive in discerning profiles.

CONCLUSION

Attractive male and female profiles are recognizable by any rater. Education seemed to have a significant influence on facial profile perception and recommendation for treatment need of unattractive profiles. Professionals should be aware of their judgment discrepancy to laymen.

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 .

Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile

OBJECTIVE

Harmony is one of the main objectives in surgical and orthodontic treatment and this harmony must be present in the smile, as well as in the face. The aim of the present study was to assess the perceptions of professionals and laypersons in relation to the harmony of the smile of patients with or without vertical maxillary alterations.

MATERIALS AND METHODS

Sixty observers (oral and maxillofacial surgeons, orthodontists and laypersons) reported the degree of harmony of six smiles using an objective questionnaire and the participants indicated if there was a need for corrective surgery or not. The classification of observers was recorded on a Likert scale from 1 to 5. Mixed regression was used to determine differences between the three groups.

RESULTS

Statistically significant differences were found only for the harmony of the smile between the oral and maxillofacial surgeons and laypersons, with laypersons being more critical when assessing the smile. There was no statistical difference between the other groups for the harmony of the smile or the indication of corrective surgery. The patterns of greater or lesser harmony determined by observers during the smile were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning.

CONCLUSIONS

Laypersons had a tendency to be more critical in relation to facial harmony than surgeons, although no statistical differences were found in the other groups in relation to the harmony of the smile or indication for the corrective surgery. In addition, the patterns of greater or lesser harmony of the smile determined by the participants were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning. Overall, the present study demonstrates that adequate interaction between surgeons, orthodontists and laypersons is essential in order to achieve facial harmony with orthodontic and/or surgical treatment.

CLINICAL RELEVANCE

Opinion of specialists and laypersons about the smile in relation to the vertical positioning of the maxilla.

Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: evaluation by patients versus health professionals

OBJECTIVE

To explore how improvement in facial appearance is related to patients' perception and satisfaction following cleft rhinoplasty.

DESIGN

A cross-sectional survey.

PARTICIPANTS

35 cleft rhinoplasty patients treated between 2005 and 2010. 45 observers comprised of healthcare professionals.

MAIN OUTCOME MEASURES

Evaluation of patient satisfaction including Rhinoplasty Outcome Evaluation (ROE) questionnaire, Preoperative and Postoperative Semi-quantitative Ordinal Scale Rating (PPSOSR) and a specifically designed semi-structured questionnaire. Evaluation by panel of observers using Asher-McDade Aesthetic Index (AMAI) Rating and PPSOSR.

RESULTS

Patient satisfaction was high, based on the ROE questionnaire (score 76.1). 91% of patients rated their appearance as improved, 3% remained 'uncertain' and 6% felt 'different but not improved.' Teenage females (score 94.1) showed statistically higher satisfaction, when compared to older females (score 75.5), or their male counterparts (score 69.8). The preoperative appearance ratings were not statistically different between patients and panel members but postoperatively, patients' rating of their appearance was statistically higher. All components of the AMAI were scored between 'good' to 'fair' (score 9.3). Seventy percent of the panel rated the postoperative appearance as improved. Interestingly, 10% rated the postoperative appearance as 'unchanged', while 3% reported a 'worsened' appearance. There was no correlation between panel assessment of aesthetic outcome and patient satisfaction.

CONCLUSIONS

Cleft rhinoplasty contributes to subjective patient satisfaction as a result of their perceived improvement in appearance and function, even though this was not correlated to objective aesthetic rating by panel members.

Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public

The aesthetic outcome of cleft treatment is of great importance due to its complex management and the psychosocial consequences of this defect. The aim of the study was to assess the aesthetic evaluations of patients following cleft surgery by various groups and investigate potential associations of the assessments with life quality parameters. Head photos of 12 adult patients with treated unilateral cleft lip and palate were evaluated by laypeople and professionals. A questionnaire was distributed and answered by the patients and their parents. Intra-panel agreement was high (α > 0.8) for laypeople and professionals. Between-groups agreement was high for both laypeople and professionals, but not when patients and/or parents were tested. Professionals, parents, and patients were more satisfied with patients' appearance than laypeople, although in general all groups were not highly satisfied. Low satisfaction with aesthetics correlated with increased self-reported influence of the cleft in the patients' social activity and professional life (0.56 < rho < 0.74, p < 0.05). These findings highlight the observed negative influence of the cleft on the patient's social activity and professional life and underline the need for the highest quality of surgical outcome for this group of patients.

Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience

PURPOSE

Rhinophyma is characterized by slowly progressive tumour-like enlargement of the nasal skin that will not resolve spontaneously. Though its treatment consists of surgical removal of the hyperplastic alterations, in the literature there is not general agreement about the best method. We presented our experience with two different treatment modalities such as decortication by scalpel and CO2 laser treatment.

METHODS

The authors reviewed the long-term results of 67 patients affected by rhinophyma treated with two different methods between 1996 and 2011. Outcomes were determined by case notes, clinical review and patient satisfaction questionnaire.

RESULTS

Forty-five cases were treated with tangential excision and 22 with a CO2 laser. Minor complications, including scarring and hypopigmentation, were seen in 6 patients. All patients were satisfied with their outcomes at the follow-up visit, and no major complications were detected during follow-up.

CONCLUSION

Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs.