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Our Dermatol Online.  2014; 5(3): 301-303
DOI:.  10.7241/ourd.20143.78
Date of submission:  16.05.2014 / acceptance: 03.06.2014
Conflicts of interest: None


Neerja Puri

Department of Dermatology and Venereology, Punjab Health Systems Corporation, Ferozepur, Punjab, India

Corresponding author:  Dr Neerja Puri    e-mail:

How to cite this article: Puri N. Is beauty skin deep – an approach to a beautiful face. Our Dermatol Online. 2014; 5(3): 301-303.


Everyone dreams of a beautiful and flawless face but true beauty is God given gift. Plastic surgery and various filler techniques can just highlight certain features and are just the temporary procedures. Features that further enhance the attractiveness of a beautiful face are the hair, skin, and teeth. These areas are the easiest to routinely enhance. There are many methods of facial sculpting including botulinum toxin, fillers and various other invasive plastic surgery techniques. Whatever the techniques followed by the cosmetic surgeon, certain ethical guidelines should be strictly adhered to. Loss of volume in the face can lead to deepening of the nasolabial folds. Hyaluronic fillers can be used to lift up the fold and restore a natural, youthful contour.
The true difference in an individual’s face is the positioning, volume, shape and angles of facial fat, skin, skeletal landmarks, and external features such as eyebrows, eyes, cheeks, the nose, etc [1,2]. In evaluating a beautiful face, the features that command the most attention, in order of importance, are:
– Eyes
– Brow
– Cheeks
– Lips
– Nose
– Chin and Jawline
Although covering only approximately 15% of the facial surface area, the brows, eyes and cheeks seem to command over 90% of one’s attention. For an artist, this area is the most difficult to capture and recreate since these features differ subtly with each individual, thus creating a “fingerprint” of individuality [3]. These also happen to be the most difficult areas for plastic surgeons to correctly modify. So, how does one determine what the ideal facial structure is. One of the most important, instinctively perceived attributes of beauty is facial symmetry [4]. Along with averageness and youthfulness, this influences the perception of a person as physically attractive or beautiful. All of us are slightly asymmetrical (fluctuating asymmetry) in that one side of the face is slightly different than the other. If a mirror reflection of one side of the face is used to make a whole face, that face will not look like the person him/herself. So if there is an obvious asymmetry to the two halves of the face, that can be corrected to bring them closer in shape to each other.
Plastic surgeons have long had the tools and techniques to provide patients with an attractive nose, chin and neckline [5]. The ideal female face is shaped as an inverted egg (Fig. 1) or a heart with the widest area approximately between the eyes and cheekbones. A beautiful nose represents one of the most prominent features of the face that ranges in shape, size, and angle. A beautiful nose must reflect overall harmony and proportion in relation to the other features and the face as a whole (Fig. 2). An attractive nasal contour is represented by a slightly sloped dorsum which blends into a moderate nasal frontal angle located at the supra-pupillary line. The beautiful cheek is one of the most important and attractive facial features. For centuries, this beautiful eminence has been highlighted with make-up and festive painting. The beautiful cheek should be well defined, full, and ovoid, like a definite highlighted “egg”. The peak of the highlighted cheekbone, or malar eminence, should be high and full. The full egg volume should be sitting at an angled position, marked from the upper lip to the upper ear with its pointed end toward the ear. The egg apex should lie on the vertical line splitting the lateral canthus and brow, and the horizontal line, from the division of the middle and lower thirds of the nose to the superior auricular tragus or cartilage bump in front of the ear. The fullest portion of the cheek should be centered high over the cheekbone and not down towards the nasolabial fold, as what occurs with aging. The appearance of the nasolabial fold should be minimal, and the jowl area should be flat or slightly concave. A prominent nasolabial fold occurs due to genetics, aging, the loss of fat and bone volume, or the slipping of the fat pad and skin down against the contracted nasolabial fold. This creates the aged and unattractive cheek folds and jowls. The lower eyelid should be shaped like a tapered scroll, much like the subtle edge of an English rosebud. The lower lid positioning should be at the level of the iris or slightly below. It should have a slight concavity, but blend smoothly with the cheekbone. The lid margin curves are slightly asymmetric, with slight medial elevation on the upper lid and light depression on the lower lid. The eyelashes, arched and somewhat “full”, should be longer and thicker on the upper lid and begin more medially than on the lower lid. A white sclera, with a distinctive color to the iris, is most attractive; hence the popularity of colored contact lenses. It is possible to change one’s facial structure. How difficult or easy it is to do depends on what you want changed. For example, longer, thinner faces can be made fuller with dermal fillers, fat augmentation or implants [6]. Fuller, more round faces are more difficult to change to a thinner, longer one without plastic surgery. It is absolutely essential that whatever cosmetic procedure you decide on, you choose a board-certified physician in the core cosmetic surgery specialties, like dermatology, plastic surgery or facial plastic surgery, with proper training and experience in that particular procedure. Ask for recommendations, consult with several specialists, make sure you learn as much as you can about the procedure before and after the consultation, look at before and after photos and talk to your doctor about recovery times, risks and possible complications. Of course, in the ideal world, the physicians are ethical, fully trained and are doing what is best for the patient. And in the great majority of cases that is true. However, sometimes that is not the case, and choosing the wrong person to perform the procedure can have tragic consequences. Non-surgical treatments to rejuvenate and beautify the face and body have come a long way in the last decade, making it possible for patients to achieve a more youthful and attractive appearance with simple walk in procedures and no downtime. Botulinum toxin is a purified protein that is used to eliminate the frown lines between the brows, flatten deep forehead wrinkles, and soften the ‘crow’s feet’ wrinkles next to the eyes. It blocks nerve transmission to the muscles that cause wrinkles of the face [7,8]. After treatment, the muscles relax, and the overlying skin becomes smooth and unwrinkled. Botulinum toxin can be used to decrease the size of hypertrophied or thickened masseter muscles to slim the lower third of the face [9]. More recently a new generation of cosmetic products called dermal fillers have come onto the market that are especially effective in restoring the volume of the face and have rendered many minor plastic surgery procedures unnecessary [10,11]. As we age, we start losing our youthful facial volume, which contributes to the formation of folds and wrinkles. Dermal fillers contain hyaluronic acid, which is a natural substance that binds tightly to water [12,13]. These fillers replace lost volume and restore youthful contours to the skin by smoothing facial wrinkles and folds. They can also help change the shape of the nose or add structure to the jawline or a small/receding chin. The fillers provide natural, immediate results. Common areas include the nasolabial folds (the creases that run from the bottom of your nose to the corners of your mouth), the tear tough (dark shadows under the eyes), and the marionette lines. Full, plump lips are considered feminine and sexy. The ‘ideal’ lips, according to a survey of Australian women are full, natural-looking and well-defined, with a strong Cupid’s bow (the v-shaped area of the upper lip). Facial implants, a more permanent solution, can be used to do the same for the cheekbones, although if a person loses weight drastically, these implants may become visible. Facial plastic surgery to change the shape of the nose and chin is also an option. More invasive plastic surgery can be done to shape the bony structure of the face, either increasing (adding implants or bone grafts) or decreasing (shaving down) the size and proportions of cheekbones, chin, etc. Platelet rich plasma is also used for facial rejuvenation. Also known as “The Vampire Treatment”, the use of Platelet Rich Plasma (PRP) is not new [14]. It has long been recognized for its accelerated wound healing properties in such applications as surgery and sports injuries. This technology is now being used for cosmetic enhancement with outstanding results. A small collection of blood (20ml) is taken and processed to give us the PRP required for your treatment. Placing your blood in a centrifuge for 8 minutes separating the plasma and platelets from your red blood cells does this. The concentrated source of autologous platelets within the plasma contains numerous growth factors that stimulate tissue regeneration and remodeling. After application of a topical anaesthetic, the PRP is then injected into your skin, much like having other cosmetic injections [15]. The entire process takes about an hour. Results take around 2-3 weeks to see and a series of up to 3 treatments is recommended 4 weeks apart.
Figure 1. Oval shaped face of a 23 years old female.
Figure 2. Nose in harmony with other features in a 19 years old girl.
The most important judge of facial attribute is you and your sense of what is attractive. Society’s ideas of what is beautiful change [16]. It was not so long ago that women used to remove their lower ribs to make their waists smaller. In my opinion, that’s pretty drastic. In addition to that, standards of beauty and attractiveness vary by geography and ethnicity as well. There is no true ideal face. With so many choices of fillers and toxins available, choosing the one that will produce best results is a difficult question to be answered. Answering this question is the key to achieving a result that pleases both the physician and patient. With so many inexperienced injectors currently treating patients, many of them have only been trained to use one or two different filling agents. This usually leads to many dissatisfied patients, as many of the agents are best suited to certain areas of the face. Clinicians are beginning to understand that the ultimate goal of nonsurgical cosmetic dermatology procedures is patient satisfaction, which generally can be defined as the delivery of a natural, relaxed look for most patients.
1. Fitzgerald R, Graivier MH, Kane M. Update on facial aging. Aesthetic Surg J. 2010;30-1:11S-24S.
2. Carruthers J, Carruthers A. Volumizing the glabella and forehead. Dermatol Surg. 2010;36:1905-9.
3. Fitzgerald R, Graivier MH, Kane M. Surgical versus nonsurgical rejuvenation. Aesthetic Surg J. 2010;30:28S-30S.
4. Vleggaar D, Fitzgerald R. Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol. 2008;7:209-20.
5. Finn JC, Cox SE, Earl ML. Social implications of hyperfunctional facial lines. Dermatol Surg. 2003;29:450–5.
6. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg. 2003;29:588–95.
7. Binder WJ. Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins. Arch Facial Plast Surg. 2006;8:426–31.
8. Carruthers J, Carruthers A. Botulinum toxin type A treatment of multiple upper facial sites: patient-reported outcomes. Dermatol Surg. 2007;33:S10–7.
9. Moy R, Maas C, Monheit G. Long term safety and efficacy of a new botulinum toxin type A in treating glabellar lines. Arch Facial Plast Surg. 2009;11:77-83.
10. Arlett JP, Trotter MJ. Anatomoic location of hyalurionic acid filler material injected into nasolabial fold: a histologic study. Dermatol Surg. 2008;34:S56-S63.
11. Fitzgerald R, Graivier MH, Kane M. Appropriate selection and application of nonsurgical facial rejuvenation agents and procedures: panel consensus recommendations. Aesthetic Surg J. 2010;30:36S-45S.
12. Lowe N, Grover R. Injectable hyaluronic acid implant for malar and mental enhancement. Dermatol Surg. 2006;32:881-5.
13. Hedelund L, Bjerring P, Egekvist H, Haedersdal M. Ablative versus non-ablative treatment of perioral rhytides. A randomized controlled trial with long-term blinded clinical evaluations and non-invasive measurements. Lasers Surg Med. 2006;38:129–36.
14. Sclafani AP. Safety, efficacy, and utility of platelet-rich fibrin matrix in facial plastic surgery. Arch Facial Plast Surg. 2011;13:247-51.
15. Baek RM. Effect of platelet-rich plasma on ultraviolet b-induced skin wrinkles in nude mice. J Plast Reconstr Aesthet Surg. 2011;64:E31-E9.
16. Etcoff N. Survival of the prettiest: the science of beauty. New York: Anchor Books; 1999.

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