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Congratulations are in order to Sisti et al. for their tremendous effort in assembling a comprehensive multitude of documents, articles and references pertaining to beauty and attempting to make some sense of what it is [1]. We feel that the final product is a delightful, scholarly article that should be read not only by all doctors involved in the business of beauty, but by lay persons too. There is a wealth of information in this article that makes for highly stimulating and interesting reading and no one will come away without having learnt something useful from it.

However, the article does not actually answer the question ‘what is beauty?’ which is its metaphorical title, because simply put, this is truly unanswerable. Beauty we feel, is too multidimensional to be adequately captured in one single article, no matter how extensive the references may be. In this commentary, we do not attempt to answer the question either, only to humbly offer our views and clinical perspectives on this mysterious subject which we have an imperfect understanding of and which continues to defy definition [2,3,4].

We can all agree that true beauty (not just something or someone that is ‘good looking’ or ‘pretty’) is something that takes our breath away. It makes us gasp in awe and appreciation because it is so rare, so unusual, so other worldly. A beautiful person, man or woman is a delight to behold and contemplate. At its essence, it is a study in angles, sensual curves, measurements and proportions. But can beauty really be reduced to such simple mathematical theories? Probably not. There are other inexplicable dimensions within that beauty that embody it, giving it life and personality. Like the spark of life that makes our human bodies warm, pink and vibrant or when that spark itself is snuffed out, leaving behind a cold, empty, inanimate shell that bears no resemblance to the person it used to be. This is the soul of divine beauty.

Beauty means different things to different people. Whether a philosopher, mathematician, artist or a plastic surgeon, we all perceive beauty in our own way, imposing our own values and ideals relative to our individual instinct, what we have learnt and understand about it, what we feel about it and more importantly our perception of what it means to those who covet it.

Humanity’s search for beauty and ways to enhance physical beauty is as old as mankind itself. This article discusses human beauty from historical, philosophical, biological and social perspectives. To effectively discuss beauty though, it is important to have a clear definition of what it is. Sisti et al. have, however, stated that it is impossible to agree on a singular definition of beauty and showed us how famous philosophers have argued about the myriad concepts of beauty as something that so profoundly touches us but yet remains so difficult to exactly define.

However, while specific definitions may differ, beauty universally induces a common emotion in the observer. From the Socratic dialogues, despite their nuanced disagreement on the exact definition of beauty, both Hippias’ and Socrates’ conceptualization of beauty is something that ultimately brings delight to the senses. Plato’s concept of beauty, be it of nature, art, human forms or spiritual, is that which provokes our delight and devotion. Beauty may therefore be defined as a quality that pleases the senses, which explains why beauty relates to the mind and emotions, ‘beauty is in the eye of the beholder’. By definition then, beauty touches all senses, not just visual, and includes taste, touch, smell and hearing. That is why a wonderful meal, a poignant piece of music, a captivating performance or even a passage of prose can be considered exquisitely beautiful, giving us great pleasure and joy. It is something you feel and instinctively know when you are in the presence of beauty. It is also important to understand the distinction between being beautiful and being pretty. When someone is pretty, the person has a good appearance and is attractive, but when someone is beautiful, the person shines from the inside and out, profoundly touching our senses. Created beauty to a formula of the social ideals tends to lack the emotions that induce a deeper connection with the observer. For example, seeing an image of an attractive girl on social media, one will readily agree that she may be pretty but without a true emotional connection that touches our other senses, one can never call her beautiful.

The Ancient Greeks and Europeans studied beauty intensely, extolling and philosophizing its many virtues. In the Classical era, artists created statues to immortalize beauty with an idealized portrayal of the most desirable physical features. One main emphasis then, which is still an enduring canon in modern aesthetic surgery today, concerns symmetry and proportions. Although highly valued in the pursuit of perfect physical beauty, complete symmetry is exceedingly rare in nature. That said, while people with gross asymmetry are considered less attractive, beauty lies perhaps, in subtle asymmetry. Such subtle asymmetry gives ‘character’ to the face. People that are considered most attractive, such as Brad Pitt and Angelina Jolie as the authors have selected, are in fact very subtly asymmetric. This with their charisma and personality gives them the X factor that so attracts people to them. In the pursuit of ideal proportions, the ratio 1.1618:1, called Phi, has been found to be recurring in all things beautiful in nature and the human body and face are no exception. The Renaissance Artists called this ratio the ‘The Golden Ratio’ or ‘The Divine Proportion’. This ratio has been extensively used in studying the idealized proportions of the human face. However, as noted by the authors, this classic Renaissance analysis is mostly applicable to Caucasian patients. There are profound differences in what would be considered beautiful between Caucasian, African, Asian and Middle Eastern facial features. Furthermore, cultural differences and preferences for what is considered beautiful and desirable will mean that while these proportions and ratios remain a helpful guide, minor controlled deviations from these ‘ideals’ would be prudent to achieve an ethnically appropriate2-4 and culturally sensitive outcome.

In our field, the term ‘Aesthetic Surgery’ is used inter-changeably with the term ‘Cosmetic Surgery’. The subtle difference between these terms is similar to the difference between beauty and pretty. Something that is ‘Aesthetic’ touches the emotions whereas something that is ‘Cosmetic’ implies a mere superficial enhancement. The authors’ preference for the term Aesthetic surgery is hence quite evident. When patients are burdened by an aspect of their appearance that diminishes their enjoyment of life, correcting or eliminating the deformity will improve the patient’s sense of well-being and bring them joy and a measure of peace. Instead of the procedure being merely ‘cosmetic’, it is able to also uplift their emotions and hence the deeper benefit of Aesthetic Surgery. One can appreciate then for many patients, aesthetic surgery at a spiritual level, is surgery for the soul.

Beauty is inextricably linked to youth. From an evolutionary perspective, humans are genetically programmed to be seduced by the fresh allure of youth. This freshness is something we are irresistibly drawn to; flawless wrinkle-free skin, a sharp and clean jawline, high cheeks with full but soft facial soft tissues and a bright and captivating gaze. The breasts are full, firm and perky and the hips and buttocks wide and full. This, no doubt, is intended to maximally harness the limited period of optimal human fertility.

The other intangible but essential component of beauty is innocence, a quality so pure and simple, that displays no conscious desire to impress or to attract. Innocence is the essence of beauty that we subconsciously find so compelling and attractive. It cannot be manufactured. Naturally beautiful people do not wear their beauty on their sleeve nor do they flaunt or abuse it. True beauty is natural and effortless, unlike the imagery we see on social media, which is largely contrived and whose intent is to manipulate the mind of the observer. One can see and feel the conscious desire to be noticed and for others to be impressed, maybe even a need in the subject to be envied.

The painful fact is beauty of a person’s appearance fades with age, 'Her last fading flush of beauty’. To restore this youthfulness is the reason why patients come to see us. It should be realized however that is not possible, nor is it desirable, to completely reverse the signs of ageing. The purpose of Aesthetic Surgery is to make patients beautiful for their age, in the true sense of the word. The surgery eliminates those aspects of facial ageing that burden the patient. This will have a positive physical as well as psychological impact on the patients well-being, bringing the inner person into better harmony with her outer appearance. This renewed sense of confidence will in turn allow the inner person and personality to shine through. This is the best gift plastic surgeons can give to their patients, to restore the inner confidence of their patients, in order to live happier and more satisfactory lives.

On the impact of beauty on social standing, the authors noted that beautiful people have better access to education, better jobs and earn more money. This directly or indirectly provides them with greater satisfaction, a happier life and even better marriages. People tend to judge beautiful people more favourably and be more forgiving towards them. The effects of Aesthetic surgery, by rejuvenating the faces of both men and women, have also been shown to improve the person’s perceived attractiveness, likeability, social skills and trustworthiness. The positive psychological impact of this on a person’s sense of well-being is very profound and translates into a positive impact on the person’s competitive advantage in society. These benefits of Aesthetic Surgery will encourage more patients to come for quality aesthetic surgery as more people understand the direct and indirect benefits of these procedures.

So after reading this article, what should the plastic surgeon take home in our pursuit to create / enhance beauty or to restore beauty? Beauty is youth. Understanding this is key as it serves to create an idealized mental image of beauty that we should work towards. Examining photos of our patients in their youth is helpful for this purpose. Our approach should of course be to select those techniques that deliver the most natural rejuvenation and eliminate those that result in the ‘operated look’ or give recognizable stigmata of surgery. Most cultures value authentic natural beauty. If there are any overt signs of cosmetic surgery, the person is perceived as a ‘fake’. A contrivance. Superficially attractive, but not beautiful in its truest sense. Symmetry is highly valued, but complete symmetry is not necessary to achieve beauty. Patients with obvious asymmetry can be made more beautiful by bringing them closer to symmetry. Analysing proportions is important but these must be ethnically and culturally appropriate. The aim of aesthetic surgery is to bring inner joy to our patients, and therefore, whatever we do for them should enhance their natural beauty and not make them look different from their ethnicity or inappropriate for their culture. This is the reason why it is important that as we become more globalized in our outlook and thinking, we should remain sensitive to the culture and preference of the specific patients that we care for.

We would like to end with a contemplative verse from a British poet, Philip James Bailey, extracted from his poem ‘Festus’ written in 1857, that aptly captures our feelings about this fascinating subject:

Ask not of me, love, what is love?

Ask what is good of God above;

Ask of the great sun what is light;

Ask what is darkness of the night;

Ask sin of what may be forgiven;

Ask what is happiness of heaven;

Ask what is folly of the crowd;

Ask what is fashion of the shroud;

Ask what is sweetness of thy kiss;

Ask of thyself what beauty is.