The demand for aesthetic surgery by Asians in both Asia and other parts of the world is very high [12,20]. For the most part, a strong emphasis is placed on facial features, although in recent years, trunk and body contouring and augmentation procedures are performed with increasing frequency [20,26]. Unlike plastic surgeons practicing in the United States, who are faced constantly with patients of different ethnicities, plastic surgeons in Asian countries deal primarily with a more homogeneous ethnic group specific for the practice site. Plastic surgeons have made a special effort to understand better the specific needs of Asian patients. Plastic surgery symposia and various publications addressing these educational needs reflect this trend [12,20]. It is now generally understood by most plastic surgeons that oriental Asians do not simply want “westernization.” However, many still tend to assume that the general beauty criteria and consequently the expectations from cosmetic surgery are the same for most oriental Asians [4,17,20,26].

Nevertheless, further awareness of the different demographic and cultural makeups that characterize different Asian ethnicities is needed [5,8,21]. This study was undertaken to test the hypothesis that generalizing all oriental Asians into one category of aesthetic preferences is inappropriate [4,8,26]. To demonstrate that there are definite differences in features and aesthetic preferences, even among seemingly similar (to the untrained eye) (Fig. 1) ethnic Asian groups, Korean and Japanese subjects were surveyed with regard to facial beauty criteria and desired cosmetic surgery objectives.

Fig. 1
figure 1

Image a (left) represents a Korean woman, and image b (right) represents a Japanese woman. A significant percentage of Korean women prefer a larger forehead (1), a more defined palpebral crease (3), a longer nose (4), and fuller lips (5). Japanese women favor a more lateral peak of the eyebrow arch (2).

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Methods

For the purpose of this study, oriental Asians were defined as non-Caucasians whose families originated from East Asia [15,20]. The investigation was based on a picture and a structured questionnaire survey without narrative elements regarding facial aesthetics conducted with two selected groups: 50 Korean and 50 Japanese women ages 18 to 50 years residing in southern California [7]. Both groups were of similar age. The mean age was 28 ± 6 years for the Japanese and 30 ± 6 years for the Koreans. Other “matching” and bias-reducing factors for both groups included similar predominant self-reported primary activities (housewife duties) and the fact that none of the subjects had previously been involved in any plastic surgery considerations [10,18,19]. Preferences regarding the periorbital region, nose, lip, and overall facial features were surveyed. A special emphasis was placed on the periorbital region given the frequency of aesthetic surgery to this region by Asians. Whenever pictures were used, only oriental Asian models were shown, and the area of interest was isolated by covering the remainder of the face to eliminate any bias from the appearance of the overall facial qualities [7]. The preferential features included in the survey questionnaire are listed in Tables 1 and 2. Differences between the groups were considered significant if p was less than 0.05 (chi-square test).

Table 1 Features included in the survey
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Table 2 Survey results
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Results

A high positive response rate (>95%) to the investigator’s invitation for inclusion in the survey was reported [11]. The results of the survey are collated in Table 2.

Periorbital Region

The most significant differences were identified in relation to the periorbital region. Almost universally, the survey subjects from both groups found the presence of a supratarsal fold to be desirable. However, half of the Korean women (50%) preferred large creases, as compared with most Japanese women (82%), who preferred medium-sized creases, with very few (6%) preferring a large crease (Fig. 2). In addition, most Korean women (78%) preferred the fold to parallel the lid margin (Fig. 3), whereas most Japanese women found the medial convergence of the fold to be preferable. Furthermore, when questioned about the epicanthal fold, the same percentage of Korean women (78%) favored elimination of the epicanthal fold if cosmetic “double-eyelid” surgery was to be performed. In contrast, the vast majority of the Japanese women preferred retaining the epicanthal fold (100%) (p < 0.05).

Fig. 2
figure 2

Preferred size of the eyelid crease. Whereas 94% Japanese women prefer a small and medium crease, 92% of Korean women favor a medium to large double-lid crease.

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Fig. 3
figure 3

The shape of the double-lid lines: parallel to the lid margin (preferred by 78% of Korean women) versus medially convergent lines (favored by all surveyed Japanese women).

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There also was a difference in the preference for the shape of the eyebrow. Half of the surveyed Korean women (50%) preferred the peak of the eyebrow to be in the midpupillary line during a neutral gaze, whereas all the Japanese women desired the peak to be more lateral, ranging from the lateral limbus to the canthus (Fig. 4) (p < 0.05).

Fig. 4
figure 4

Preferences for the highest point of the eyebrow arch. Japanese women consistently (in 100%) preferred lateral arching, whereas 50% of Korean women favored the highest arch at the midpupil, with the remaining 50% desiring more lateral arching.

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Nose

For the most part, similar aesthetic values regarding the nose were obtained (Table 2). Both groups overwhelmingly found a straight and narrow-based nose (width/length ratio less than 1) to be desirable (p > 0.05). The only significant difference in aesthetic values with regard to this region was the preferred shape of the nostril. Most Japanese women (70%) desired an oval nostril shape, whereas most Korean women (72%) preferred a more triangular (teardrop-like) nostril shape. The subjects in both groups desired medium-sized noses, although of the remaining minority, the Korean women preferred larger noses (22%) to smaller noses (14%) as their second choice, in contrast to the Japanese women (0% and 12%, respectively) (Table 2).

Lips

A significant difference was identified in the desired size of lips. Most of the Korean women (78%) preferred fuller lips, with the remaining women desiring medium-sized lips. In contrast, the Japanese women preferred thinner to medium lips, with a minority (2%) desiring fuller lips (p < 0.05).

Overall Facial Profile and Harmony

Forehead

Most of the Japanese women (86%) preferred the forehead height to be roughly one-third of the overall facial height. In contrast, the Korean women had a wider range of desirability. Half of the Koreans also preferred the forehead height to be one-third of the facial height, but more than one-third (36%) preferred a large forehead (vs 7% of the Japanese women). With regard to the forehead slope, both groups (93%, respectively) preferred a negative slope over straight inclination (0°) of the forehead (Table 2) [1,2].

Malar Prominence (“High” Cheek Bones)

A significant difference in preferences was encountered with regard to the desirability of “high” cheek bones. A majority of the Japanese women (66%) did not find malar prominence to be aesthetically pleasing. In contrast, most of the Korean women (72%) desired “high” cheek bones (p < 0.05) (Table 2).

Overall Shape and Profile

Universally, both the Korean (84%) and Japanese (100%) women found the oval shape of the face to be pleasing (p > 0.05). Although both groups also favored a moderate facial profile, most of the remaining Korean women preferred very prominent features (36%), as compared with the Japanese women (12%) (p < 0.05) (Table 2).

Discussion

This survey-based study was undertaken to determine whether differences exist in aesthetic preferences among various oriental Asian ethnic groups, and how significant such differences are. Two randomly selected groups of women (Japanese vs Korean) chosen for the study demonstrated a high positive response rate to investigators’ request for their inclusion in the survey. This rate of response is considered an achievement in establishing a representative sample and strengthening the validity of the study [11,18].

It was assumed that to the “untrained eye” of a nonoriental Asian, the subtle differences in the facial features of these two groups would not be easily discerned. This in turn could lead to broad generalizations or misconceptions regarding the aesthetic values of seemingly similar oriental Asian candidates for aesthetic surgery [17,29].

Despite the fact that all the surveyed subjects lived in southern California and were exposed to similar cultural and socioeconomic surroundings, their facial aesthetic preferences were different. The most significant, and probably the most clinically pertinent, differences in preference among the Korean and Japanese women surveyed concerned the periorbital region. As demonstrated clearly in the past, the desirability of the supratarsal fold is strong and universal among different Asian groups [26,28]. Approximately half of oriental Asians have natural creases in either one or both eyes [23]. However, unlike the supratarsal folds found in most Caucasians, the folds found in oriental Asians often are smaller, with the presence of concomitant epicanthal folds [5,28,29]. Given the popularity of the “double-eyelid” operation, it is pertinent that the plastic surgeon be familiar with the aesthetic preferences regarding the details of this surgery. It is not adequate to assume that all Asians seeking the “double-eyelid” surgery have the same values and preferences. This is supported by the results of this investigation. Korean women preferred the creases to be made larger and parallel to the lid margin, as compared with Japanese women (Table 2, Figs. 2 and 3) [9,23].

A rather delicate, narrow-sized (medium in this study) eyelid crease line with double-eyelid lines starting medially under the epicanthus seemed to be popular among Japanese women in the 1970s, and remains popular currently [9]. Furthermore, there are differences in attitudes toward the epicanthal fold, which should be discussed preoperatively. Clearly, women of Japanese heritage favor epicanthal fold preservation, whereas most Korean women favor its elimination. Social changes after the dismantling of the feudal system in Japan in the second half of the 19th century led not only to an interest in western culture by the emancipation of Japanese women, but also to the beginnings of Japanese cosmetic surgery [16,27].

However, even when the interest in occidental ideals was strong, the original Mikamo’s double-eyelid blepharoplasty, frequently perceived as the symbolic standard of westernization, was aimed toward achieving objectives determined by the oriental culture rather than plain occidentalization. Mikamo’s double-eyelid blepharoplasty was performed to eliminate the impassive, nonenergetic look of a traditionally subservient woman, and to allow emanation of newly emancipated Japanese women’s beauty rather than simply to westernize [16,27]. The epicanthal fold was not a central consideration of Mikamo’s technique, nor that of subsequent techniques for upper lid blepharoplasty. These procedures were aimed primarily toward creating larger, more expressive eyes with a more or less delicate lid sulcus definition [26,27].

These attitudes, rooted deeply in Japanese tradition and aesthetic preferences, persist. Even currently, a fashionable procedure by means of a gadget “Samacool” promises a larger eye, a lid sulcus definition, and a nicely appearing epicanthal fold [14,15]. However, for the plastic surgeon to assume one way or the other (to preserve or eliminate) could be a mistake that could jeopardize an all-ensuing patient–physician relationship [23].

It becomes apparent that there is an increasing demand for cosmetic brow-lifts in the Orient [13]. Once again, the aesthetic preference of the patient needs to be considered. It is recognized that Caucasian patients place a strong emphasis on the lateral lift, whereas for Orientals more of a horizontal lifting vector may be advisable because an enhanced Mongoloid slant of the palpebral fissure resulting from a more vertical lifting vector may not be welcomed [5,13,29]. Personal preference regarding the aesthetics of eyebrow arching seems to be particularly important for Korean women, 50% of whom described the ideal eyebrow as having the highest point of its arch over the midpupil. The remaining 50% preferred the arch to overlie the lateral limbus or canthus. Notably, Japanese women demonstrated more uniform preferences favoring the latter configuration (Table 2) [25].

Another surgery frequently performed among oriental Asians is rhinoplasty, usually a variant of the augmentation rhinoplasty [6,8]. This is attributable to the fact that most oriental Asians have a dorsal deficiency (“natural saddling”) of the nose, accentuated by malar prominences [8,29]. The commonality of this feature plus the preferred aesthetic value of a modestly bigger and straighter dorsal profile causes augmentative procedures and width reduction to be widely sought. A variability of preferences with regard to nasal tip and glabellar configuration necessitates recognition of individual patient preferences for optimal design of other than straight dorsal augmentation components of rhinoplasty (Table 2) [8,9].

It is important in consideration of facial aesthetic surgery to predict how a facial feature change will affect and match the rest of the face [2,3,5,8,22,29]. The overall facial harmony and profile must be considered in planning for the operation. This appears to be especially true for oriental Asian patients. Most Japanese prefer mild to moderate (smaller) facial qualities, with delicate, “soft” definition of facial lines, planes, and prominences. They do not favor a large palpebral crease, “high cheek” bones, or fuller lips (Table 2).

This viewpoint, as discovered during the interviews, stems from cultural ideals that oppose artificial intervention to a point of obvious noticeability resulting in surgery stigma. Japanese women are not opposed to cosmetic surgery, but want to maintain a natural appearance [26,27]. Interestingly, the traditional Japanese makeup “guidelines” favor lip enhancement that appears more fleshy and round (“ochoboguchi” lips). However, modern Japanese women favor more discrete, thin, or medium-bodied lip definition (Table 2) [24]. In contrast, Koreans desire an increased malar prominence and fuller “natural” lips, all leading to a more extreme facial contour with less concern for the “operated” image, contradicting the popular assumption that all oriental Asians prefer to maintain delicate features [2,5,8,20].

As stated earlier, this investigation was restricted to subjects residing in southern California. Perhaps Asian Americans living in different regions of the country, and certainly oriental Asians residing in the Orient, may have different values and preferences. The method of obtaining information was simple. It was not based on cephalometric or exact photometric studies, but rather on isolated photographic images and a selection of appearance features described in layman’s language. This investigation was aimed at determining general differences and preferences, and more importantly, at demonstrating that oriental Asians expect not only preservation of ethnic identity by plastic surgeons, but also recognition of national diversity and individual desires [15].