Facial Rejuvenation Surgery
Original Investigation Research
Not all patients experienced a positive change in the perception of their personality traits, femininity, and attractiveness postoperatively. While there was no identifiable variable that was shown to convey worse outcomes in this small patient sample, clearly more research is needed in this area. There are several limitations to this study. All patients were white women in order to eliminate sex and racial biases, but this demographic restriction limits the applicability of the data. In addition, most patients underwent more than one procedure, making it difficult to draw conclusions from procedurespecific data. The patients in this study group also agreed to have their photographs used for research purposes, which may create a selection bias. While there was strong statistical significance to the data, a larger patient population would be desirable for more conclusive findings. Last, there may have been personality differences among the raters, which could have influenced their perception of the photographs.23
ARTICLE INFORMATION Accepted for Publication: January 19, 2015. Published Online: April 9, 2015. doi:10.1001/jamafacial.2015.0158. Author Contributions: Dr Reilly had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Reilly, Tomsic. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Reilly, Tomsic. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Reilly, Tomsic, Fernandez. Administrative, technical, or material support: Davison. Study supervision: Reilly, Davison. Conflict of Interest Disclosures: None reported. Previous Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery International Symposium; May 29, 2014; New York, NY.
Conclusions The comprehensive evaluation and treatment of the patient who undergoes facial rejuvenation requires a broader understanding of the many changes in perception that are likely to occur with surgical intervention. The face is not defined by youth alone. There are many more nuanced and personal elements that must be considered, such as the changes in femininity, attractiveness, likeability, and social skills seen in this patient cohort. While this study demonstrates that there are clearly changes to an individual’s perception that occur beyond perceived youth, more studies are needed to discern the specifics of how each surgical procedure may affect the perception of these traits. As we gain more specific knowledge about these changes in perception, we will be able to improve outcomes for our patients.
4. Said CP, Sebe N, Todorov A. Structural resemblance to emotional expressions predicts evaluation of emotionally neutral faces. Emotion. 2009;9(2):260-264.
14. Walker M, Vetter T. Portraits made to measure: manipulating social judgments about individuals with a statistical face model. J Vis. 2009;9(11): 12.1-12.13.
5. Etcoff NL, Stock S, Haley LE, Vickery SA, House DM. Cosmetics as a feature of the extended human phenotype: modulation of the perception of biologically important facial signals [published online October 3, 2011]. PLoS One. 2011;6(10): e25656.
15. Todorov A, Dotsch R, Porter JM, Oosterhof NN, Falvello VB. Validation of data-driven computational models of social perception of faces. Emotion. 2013;13(4):724-738.
6. Knutson B. Facial expressions of emotion influence interpersonal trait inferences. J Nonverbal Behav. 1996;20(3):165-182. doi:10.1007 /BF02281954. 7. Sutherland CA, Oldmeadow JA, Santos IM, Towler J, Michael Burt D, Young AW. Social inferences from faces: ambient images generate a three-dimensional model. Cognition. 2013;127(1): 105-118. 8. Oosterhof NN, Todorov A. The functional basis of face evaluation. Proc Natl Acad Sci U S A. 2008; 105(32):11087-11092.
REFERENCES
9. Todorov A, Engell AD. The role of the amygdala in implicit evaluation of emotionally neutral faces. Soc Cogn Affect Neurosci. 2008;3(4):303-312.
1. Springer IN, Wiltfang J, Kowalski JT, et al. Mirror, mirror on the wall…: self-perception of facial beauty versus judgement by others. J Craniomaxillofac Surg. 2012;40(8):773-776.
10. Calder AJ, Ewbank M, Passamonti L. Personality influences the neural responses to viewing facial expressions of emotion. Philos Trans R Soc Lond B Biol Sci. 2011;366(1571):1684-1701.
2. Zebrowtiz LA, McDonald SM. The impact of litigants’ baby-facedness and attractiveness on adjudications in small claims courts. Law Hum Behav. 1991;15(6):603-623. doi:10.1007 /BF01065855.
11. Fiske ST, Cuddy AJ, Glick P. Universal dimensions of social cognition: warmth and competence. Trends Cogn Sci. 2007;11(2):77-83.
3. Claes P, Liberton DK, Daniels K, et al. Modeling 3D facial shape from DNA [published online November 6, 2014]. PLoS Genet. 2014;10(3): e1004224.
jamafacialplasticsurgery.com
12. Todorov A, Said CP, Engell AD, Oosterhof NN. Understanding evaluation of faces on social dimensions. Trends Cogn Sci. 2008;12(12):455-460. 13. Todorov A, Duchaine B. Reading trustworthiness in faces without recognizing faces. Cogn Neuropsychol. 2008;25(3):395-410.
16. Rojas M, Masip D, Todorov A, Vitria J. Automatic prediction of facial trait judgments: appearance vs. structural models [published online August 17, 2011]. PLoS One. 2011;6(8):e23323. 17. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Hum Relat. 2008;61(8):1139-1160. doi:10.1177 /0018726708094863. 18. Kleisner K, Chvátalová V, Flegr J. Perceived intelligence is associated with measured intelligence in men but not women. PLoS One. 2014;9(3):e81237. 19. Byrne D, Griffitt W. Interpersonal attraction. Annu Rev Psychol. 1973;24:317-336. doi:10.1146 /annurev.ps.24.020173.001533. 20. Zimm AJ, Modabber M, Fernandes V, Karimi K, Adamson PA. Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery. JAMA Facial Plast Surg. 2013;15(6):405-410. 21. Etcoff NL, Magee JJ. Categorical perception of facial expressions. Cognition. 1992;44(3):227-240. 22. Smith ML, Cottrell GW, Gosselin F, Schyns PG. Transmitting and decoding facial expressions. Psychol Sci. 2005;16(3):184-189. 23. Perlman SB, Morris JP, Vander Wyk BC, Green SR, Doyle JL, Pelphrey KA. Individual differences in personality predict how people look at faces. PLoS One. 2009;4(6):e5952.
(Reprinted) JAMA Facial Plastic Surgery May/June 2015 Volume 17, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a Monash University Library User on 06/04/2015
207
Research Original Investigation
Facial Rejuvenation Surgery
Invited Commentary
The Perception of Beauty After Facial Plastic Surgery Samuel M. Lam, MD
This Invited Commentary addresses the psychosocial effects that facial plastic surgical procedures have on the perception of observers. A guiding force behind what I do as a facial plastic surgeon is to achieve a better “blink,” as espoused by Gladwell1; that is, to help make an individual be perceived instantaneously as more attractive to an onlooker. These perceptual cues, triggered in the right brain of the viewer, render an immediate judgment Related article page 202 about the person being observed before the cues enter the observer’s conscious awareness. I judge my work the moment I walk through the door to greet my patient to see if I think the person looks better to me. If not, I try to figure out why I have failed to achieve an improved countenance by enlisting my analytical left brain to decipher the puzzle at hand. I emphasize to my patients that my goal for them is to look better because quality facial work should favorably affect their social and professional standing. This goal stands in contrast to the requests that many patients make for me to change aspects of their faces that I do not believe would have merit in improving their “blink,” such as fine lip lines that are unobservable to a bystander at a casual distance. Accordingly, I believe it is important to be artistic and to help patients try to look better not only to themselves but also, even more important (in my opinion), to others. This goal is why I commend the article in this issue by Reilly et al2 that squarely addresses these broader psychosocial perceptual renderings that truly should underscore the reason why ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliation: Lam Facial Plastics, Plano, Texas.
[published online April 9, 2015]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2015.0158.
REFERENCES
3. Zimm AJ, Modabber M, Fernandes V, Karimi K, Adamson PA. Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery. JAMA Facial Plast Surg. 2013;15(6):405-410.
Corresponding Author: Samuel M. Lam, MD, Lam Facial Plastics, 6101 Chapel Hill Blvd, Ste 101, Plano, TX 75093 ([email protected]). Published Online: April 9, 2015. doi:10.1001/jamafacial.2015.0168.
208
we as surgeons do what we do. By unpairing preoperative and postoperative photographs and by segregating them into different observer groups, the authors helped to control unwitting bias. In addition, too often we see postoperative photographs of a smiling or semi-smiling patient that subconsciously conveys a positive emotion, but the authors have controlled for this bias and used strictly standardized photography, which I applaud. My only criticism would be that pairing words describing physical traits, such as attractiveness and femininity, with words describing emotional traits, such as trustworthiness and aggressiveness, might have created an unconscious bias in the respondent. The respondent may see attractiveness and trustworthiness and pair the 2 traits in his or her mind and thereby link a more attractive person with being trustworthy. As a suggestion for future refinements in this study, I would have the authors consider evaluating only terms describing emotional traits without reference to physical descriptions to determine truly how a more youthful face affects the way we emotionally envisage it. In a similar yet different study, Zimm et al3 evaluated in a prospective fashion only the perceived age change and improvement in attractiveness following facial rejuvenation surgery but did not evaluate any emotional perceptions that the intervention had on the viewer. As we continue to strive for more evidence-based medicine in our field, I contend that we should still be able to achieve this rigorous standard even when investigating matters that would otherwise seem elusive, such as perception and emotion.
1. Gladwell M. Blink: The Power of Thinking Without Thinking. New York, NY: Back Bay Books; 2007. 2. Reilly MJ, Tomsic JA, Fernandez SJ, Davison SP. Effect of facial rejuvenation surgery on perceived attractiveness, femininity, and personality
JAMA Facial Plastic Surgery May/June 2015 Volume 17, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a Monash University Library User on 06/04/2015
jamafacialplasticsurgery.com
Original Investigation Research
Not all patients experienced a positive change in the perception of their personality traits, femininity, and attractiveness postoperatively. While there was no identifiable variable that was shown to convey worse outcomes in this small patient sample, clearly more research is needed in this area. There are several limitations to this study. All patients were white women in order to eliminate sex and racial biases, but this demographic restriction limits the applicability of the data. In addition, most patients underwent more than one procedure, making it difficult to draw conclusions from procedurespecific data. The patients in this study group also agreed to have their photographs used for research purposes, which may create a selection bias. While there was strong statistical significance to the data, a larger patient population would be desirable for more conclusive findings. Last, there may have been personality differences among the raters, which could have influenced their perception of the photographs.23
ARTICLE INFORMATION Accepted for Publication: January 19, 2015. Published Online: April 9, 2015. doi:10.1001/jamafacial.2015.0158. Author Contributions: Dr Reilly had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Reilly, Tomsic. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Reilly, Tomsic. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Reilly, Tomsic, Fernandez. Administrative, technical, or material support: Davison. Study supervision: Reilly, Davison. Conflict of Interest Disclosures: None reported. Previous Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery International Symposium; May 29, 2014; New York, NY.
Conclusions The comprehensive evaluation and treatment of the patient who undergoes facial rejuvenation requires a broader understanding of the many changes in perception that are likely to occur with surgical intervention. The face is not defined by youth alone. There are many more nuanced and personal elements that must be considered, such as the changes in femininity, attractiveness, likeability, and social skills seen in this patient cohort. While this study demonstrates that there are clearly changes to an individual’s perception that occur beyond perceived youth, more studies are needed to discern the specifics of how each surgical procedure may affect the perception of these traits. As we gain more specific knowledge about these changes in perception, we will be able to improve outcomes for our patients.
4. Said CP, Sebe N, Todorov A. Structural resemblance to emotional expressions predicts evaluation of emotionally neutral faces. Emotion. 2009;9(2):260-264.
14. Walker M, Vetter T. Portraits made to measure: manipulating social judgments about individuals with a statistical face model. J Vis. 2009;9(11): 12.1-12.13.
5. Etcoff NL, Stock S, Haley LE, Vickery SA, House DM. Cosmetics as a feature of the extended human phenotype: modulation of the perception of biologically important facial signals [published online October 3, 2011]. PLoS One. 2011;6(10): e25656.
15. Todorov A, Dotsch R, Porter JM, Oosterhof NN, Falvello VB. Validation of data-driven computational models of social perception of faces. Emotion. 2013;13(4):724-738.
6. Knutson B. Facial expressions of emotion influence interpersonal trait inferences. J Nonverbal Behav. 1996;20(3):165-182. doi:10.1007 /BF02281954. 7. Sutherland CA, Oldmeadow JA, Santos IM, Towler J, Michael Burt D, Young AW. Social inferences from faces: ambient images generate a three-dimensional model. Cognition. 2013;127(1): 105-118. 8. Oosterhof NN, Todorov A. The functional basis of face evaluation. Proc Natl Acad Sci U S A. 2008; 105(32):11087-11092.
REFERENCES
9. Todorov A, Engell AD. The role of the amygdala in implicit evaluation of emotionally neutral faces. Soc Cogn Affect Neurosci. 2008;3(4):303-312.
1. Springer IN, Wiltfang J, Kowalski JT, et al. Mirror, mirror on the wall…: self-perception of facial beauty versus judgement by others. J Craniomaxillofac Surg. 2012;40(8):773-776.
10. Calder AJ, Ewbank M, Passamonti L. Personality influences the neural responses to viewing facial expressions of emotion. Philos Trans R Soc Lond B Biol Sci. 2011;366(1571):1684-1701.
2. Zebrowtiz LA, McDonald SM. The impact of litigants’ baby-facedness and attractiveness on adjudications in small claims courts. Law Hum Behav. 1991;15(6):603-623. doi:10.1007 /BF01065855.
11. Fiske ST, Cuddy AJ, Glick P. Universal dimensions of social cognition: warmth and competence. Trends Cogn Sci. 2007;11(2):77-83.
3. Claes P, Liberton DK, Daniels K, et al. Modeling 3D facial shape from DNA [published online November 6, 2014]. PLoS Genet. 2014;10(3): e1004224.
jamafacialplasticsurgery.com
12. Todorov A, Said CP, Engell AD, Oosterhof NN. Understanding evaluation of faces on social dimensions. Trends Cogn Sci. 2008;12(12):455-460. 13. Todorov A, Duchaine B. Reading trustworthiness in faces without recognizing faces. Cogn Neuropsychol. 2008;25(3):395-410.
16. Rojas M, Masip D, Todorov A, Vitria J. Automatic prediction of facial trait judgments: appearance vs. structural models [published online August 17, 2011]. PLoS One. 2011;6(8):e23323. 17. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Hum Relat. 2008;61(8):1139-1160. doi:10.1177 /0018726708094863. 18. Kleisner K, Chvátalová V, Flegr J. Perceived intelligence is associated with measured intelligence in men but not women. PLoS One. 2014;9(3):e81237. 19. Byrne D, Griffitt W. Interpersonal attraction. Annu Rev Psychol. 1973;24:317-336. doi:10.1146 /annurev.ps.24.020173.001533. 20. Zimm AJ, Modabber M, Fernandes V, Karimi K, Adamson PA. Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery. JAMA Facial Plast Surg. 2013;15(6):405-410. 21. Etcoff NL, Magee JJ. Categorical perception of facial expressions. Cognition. 1992;44(3):227-240. 22. Smith ML, Cottrell GW, Gosselin F, Schyns PG. Transmitting and decoding facial expressions. Psychol Sci. 2005;16(3):184-189. 23. Perlman SB, Morris JP, Vander Wyk BC, Green SR, Doyle JL, Pelphrey KA. Individual differences in personality predict how people look at faces. PLoS One. 2009;4(6):e5952.
(Reprinted) JAMA Facial Plastic Surgery May/June 2015 Volume 17, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a Monash University Library User on 06/04/2015
207
Research Original Investigation
Facial Rejuvenation Surgery
Invited Commentary
The Perception of Beauty After Facial Plastic Surgery Samuel M. Lam, MD
This Invited Commentary addresses the psychosocial effects that facial plastic surgical procedures have on the perception of observers. A guiding force behind what I do as a facial plastic surgeon is to achieve a better “blink,” as espoused by Gladwell1; that is, to help make an individual be perceived instantaneously as more attractive to an onlooker. These perceptual cues, triggered in the right brain of the viewer, render an immediate judgment Related article page 202 about the person being observed before the cues enter the observer’s conscious awareness. I judge my work the moment I walk through the door to greet my patient to see if I think the person looks better to me. If not, I try to figure out why I have failed to achieve an improved countenance by enlisting my analytical left brain to decipher the puzzle at hand. I emphasize to my patients that my goal for them is to look better because quality facial work should favorably affect their social and professional standing. This goal stands in contrast to the requests that many patients make for me to change aspects of their faces that I do not believe would have merit in improving their “blink,” such as fine lip lines that are unobservable to a bystander at a casual distance. Accordingly, I believe it is important to be artistic and to help patients try to look better not only to themselves but also, even more important (in my opinion), to others. This goal is why I commend the article in this issue by Reilly et al2 that squarely addresses these broader psychosocial perceptual renderings that truly should underscore the reason why ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliation: Lam Facial Plastics, Plano, Texas.
[published online April 9, 2015]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2015.0158.
REFERENCES
3. Zimm AJ, Modabber M, Fernandes V, Karimi K, Adamson PA. Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery. JAMA Facial Plast Surg. 2013;15(6):405-410.
Corresponding Author: Samuel M. Lam, MD, Lam Facial Plastics, 6101 Chapel Hill Blvd, Ste 101, Plano, TX 75093 ([email protected]). Published Online: April 9, 2015. doi:10.1001/jamafacial.2015.0168.
208
we as surgeons do what we do. By unpairing preoperative and postoperative photographs and by segregating them into different observer groups, the authors helped to control unwitting bias. In addition, too often we see postoperative photographs of a smiling or semi-smiling patient that subconsciously conveys a positive emotion, but the authors have controlled for this bias and used strictly standardized photography, which I applaud. My only criticism would be that pairing words describing physical traits, such as attractiveness and femininity, with words describing emotional traits, such as trustworthiness and aggressiveness, might have created an unconscious bias in the respondent. The respondent may see attractiveness and trustworthiness and pair the 2 traits in his or her mind and thereby link a more attractive person with being trustworthy. As a suggestion for future refinements in this study, I would have the authors consider evaluating only terms describing emotional traits without reference to physical descriptions to determine truly how a more youthful face affects the way we emotionally envisage it. In a similar yet different study, Zimm et al3 evaluated in a prospective fashion only the perceived age change and improvement in attractiveness following facial rejuvenation surgery but did not evaluate any emotional perceptions that the intervention had on the viewer. As we continue to strive for more evidence-based medicine in our field, I contend that we should still be able to achieve this rigorous standard even when investigating matters that would otherwise seem elusive, such as perception and emotion.
1. Gladwell M. Blink: The Power of Thinking Without Thinking. New York, NY: Back Bay Books; 2007. 2. Reilly MJ, Tomsic JA, Fernandez SJ, Davison SP. Effect of facial rejuvenation surgery on perceived attractiveness, femininity, and personality
JAMA Facial Plastic Surgery May/June 2015 Volume 17, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a Monash University Library User on 06/04/2015
jamafacialplasticsurgery.com
