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TheArtofCombiningSurgicaland
NonsurgicalTechniquesinAesthetic
MedicineJuliusW.FewJr.,MD

Director
TheFewInstituteforAestheticPlasticSurgery
ClinicalProfessor
DepartmentofSurgery
DivisionofPlasticSurgery
UniversityofChicagoPritzkerSchoolofMedicine
HealthScienceClinician
DivisionofPlasticSurgery
NorthwesternUniversityFeinbergSchoolofMedicine
Chicago,Illinois

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Title:Theartofblendingsurgicalandnonsurgicaltechniquesin
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Description:NewYork:Thieme,[2017]|Includesbibliographical
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Identifiers:LCCN2017054011(print)|LCCN2017055891(ebook)|
ISBN9781626237698(ebook)|ISBN9781626236820(print:alk.
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Iwouldliketodedicatethisbooktomyfamily—Miles,Maxwell,JuliusSr.,
Gladys,Mark,andKris;TeamTFI—Shay,Charisse,Elizabeth,andCarly;my
pastandpresentfellows—LaNesha,Denis,Sheri,Diane,Diana,MarieK.;
Megan(myfirstemployee);andallthepatientswhobelievedinourvision.


Contents
VideoContents

Preface
Acknowledgments
Contributors
1

ConceptsofBeauty
JuliusW.FewJr.andMichaelP.Ogilvie

2

Nonsurgical Cervicofacial Rejuvenation of a Traditional Surgical
Candidate
SaharNadimiandCoreyS.Maas
CommentarybyJuliusW.FewJr.

3

BackgroundofNoninvasiveTechnology:EvolvingPatientSelection
JuliusW.FewJr.

4

BlendingandSequencingConsiderations
DanielR.ButzandJuliusW.FewJr.

5

Diverse Skin Type Considerations and Applications for Nonsurgical
Combinations
ValerieD.Callender,MoneéThomas,andSusanC.Taylor

CommentarybyJuliusW.FewJr.

6

NoninvasiveDevicesUsedinCombinationwithVolumizing
RachelN.Pritzker,ShraddhaDesai,andBrianS.Biesman
CommentarybyJuliusW.FewJr.

7

MicroneedlingandPlatelet-RichPlasma
JohnsonC.LeeandZ.PaulLorenc
CommentarybyJuliusW.FewJr.andAlecSemersky

8

UseofLight-andEnergy-BasedTherapieswithCosmeticSurgery


MichaelI.KulickandNatashaKulick
CommentarybyJuliusW.FewJr.
9

Blending Nonsurgical Treatments with Surgery for Facial
Rejuvenation
LawrenceS.Bass,JasonN.Pozner,andBarryE.DiBernardo
CommentarybyJuliusW.FewJr.

10

BlendingNonsurgicalTreatmentswithSurgeryforSkinLiftingontheBody

LawrenceS.Bass,BarryE.DiBernardo,andJasonN.Pozner
CommentarybyJuliusW.FewJr.
11

NonsurgicalSalvageandEnhancementofaSurgicalResult

DavidA.Sieber,JohnE.Hoopman,andJeffreyM.Kenkel
CommentarybyJuliusW.FewJr.
12

IntegratingTechnologyinFacialPlasticSurgery

JonathanM.SykesandAmirAllak
CommentarybyJuliusW.FewJr.
13

Cryolipolysis

W.GrantStevens,MichelleManningEagan,CoryFelber,DenizSarhaddi,
andMarcVincentOrlando
CommentarybyJuliusW.FewJr.
14

MinimallyInvasiveTechniques:PreventingandManagingAdverseEvents

MarkS.Nestor,PaigePaparone,andMitchellManway
CommentarybyJuliusW.FewJr.
15

FutureConsiderations

MichaelP.OgilvieandJuliusW.FewJr.
16

ProductIndex:Fillers

17

ProductIndex:Lasers
Index


VideoContents
1.1 Where are We? My Perspective on Facial Rejuvenation with Soft Tissue
FillersandNeuromodulatorsJuliusW.FewJr.
2.1 Aesthetic Evaluation and Facial Treatment Midface (Restylane Lyft,
RestylaneSilk)JuliusW.FewJr.
2.2 AestheticEvaluationandFacialRejuvenationMidface(Voluma)JuliusW.
FewJr.
2.3 AestheticEvaluationandFacialRejuvenationLowerFace(Voluma)Julius
W.FewJr.
2.4 ChoosingaBotulinumtoxinAProduct
JuliusW.FewJr.
2.5 Aesthetic Evaluationand InjectionsofBotulinumtoxinAinTheFaceand
Neck(BotoxCosmetic)JuliusW.FewJr.
2.6 DemonstrationofSilhouetteInstaLiftintheMidface:EvaluationJulius W.
FewJr.
2.7 Demonstration of Silhouette InstaLift in the Midface: Placing the Sutures

JuliusW.FewJr.
2.8 Demonstration of Silhouette InstaLift in the Midface: Setting the Sutures
JuliusW.FewJr.
2.9 DemonstrationofSilhouetteInstaLiftintheLowerFaceandNeck,Part1
JuliusW.FewJr.
2.10 DemonstrationofSilhouetteInstaLiftintheLowerFaceandNeck,Part2
JuliusW.FewJr.
2.11 CorsetPlatysmaplastyWithFacialUltheraJuliusW.FewJr.
2.12 NonsurgicalDivisionofPlatysmaBands
JuliusW.FewJr.


2.13 Halo 1080 Fractional Laser Animation (Courtesy Sciton, Inc.) Halo
2.14
4.1 FractionalLaser(CourtesySciton,Inc.)SubmentalSkinFlapElevation(In
preparationforcorsetsubmentalplatysmaplastypriortofullfaceandneck
Ultherainthesameclinicalsetting)JuliusW.FewJr.
4.2 SubmentalCorsetPlatysmaplasty
JuliusW.FewJr.
4.3 NonsurgicalChinAugmentionwithJuvedermVoluma(CourtesyAllergan,
5.1 Inc.)AfricanAmericanRhinoplasty
JuliusW.FewJr.
11.1 NonsurgicalSalvage
JuliusW.FewJr.
15.1 Morphshowingtheaverageof116femalefacesfrom20to30yearsofage
animatedwith100femalefacesfrom68yearsofageandup(averageage:
76).
ValLambros
I.1 Cellfina: Clinical Demonstration (Cellfina is a registered trademark of
Ulthera,Inc.)

Preface
Thequote“Weallstandontheshoulderofgiants”wasfirsttoldtomebysome
ofmyearlysurgicalidols,BobBartlett,NormThompson,andLazarGreenfield,
morethan2decadesagowhileIwascompletinggeneralsurgerytrainingatthe
UniversityofMichigan.AlthoughthiswastakenfromthefamousquotebySir
IsaacNewtonin1676,ithitmeasoneofthemostprofoundstatementsandlefta
desiretomakeadifferenceintheworldofmedicinethatstillburnstoday.
Adesiretomakeadifferenceintheworldofmedicineandtogivebacktoa
specialtythathasbeensogoodtomehascomeverynaturallyasaresultofvery
earlyimpressionsonme.Thisbookdiscussestheideaofcombiningnonsurgical
techniquesinasurgicalway—muchlikeatextwoulddescribethetechniquesfor
a patient having a facelift. The surgeon outlines the combination of
blepharoplasty,fatgrafting,laserresurfacing,andofcourseSMASrepositioning
with skin removal. So why would there be initial resistance to the concept?
Therehavebeensomanyinnovationsintheworldofcosmeticmedicine,andnot
all of them have delivered as promised, leaving many surgeons skeptical and
believing that only surgery can deliver for the cosmetic patient. Much of the
skepticism is valid if one looks at single modalities in a less-than-ideal
candidate,butIchallengethereadertoconsiderthisnodifferentthanthinkinga
facelift alone will address the older face with end-stage sun damage. Another
issuehasbeentheoveruseofasinglenonsurgicalmodalitytoachievea“good
correction,”which,inmanycases,onlycreatesunnaturalresults.
Whatdoyoudoforthepatientwhowantsmoreresultsbutabsolutelyrefuses
surgery?Thisquestionbringsaboutthebirthof“TheStackableTreatment,”an
attempt to address the nonsurgical patient by using surgical reasoning to
formulateatreatmentstrategy.TheArtofCombiningSurgicalandNonsurgical
Techniques in Aesthetic Medicine is for all aesthetic specialists, novice and
expert alike, wanting to deliver more for their patients in a thoughtful,

scientificallysupportedmanner.
Thisbookpresentsthetechniquesandistheresultoftheworkofsomeofthe
brightest minds in the world of cosmetic plastic surgery, dermatology, and
oculofacial and facial plastic surgery. These are authors who are not afraid to
look at disruptors in their world of expertise and cosmetic medicine. My
colleagues who have contributed to this book are true visionaries who have


looked at a very challenging, dynamic subject and developed approaches that
willrevolutionizethefield—Iamforevergrateful!
The Art of Combining Surgical and Nonsurgical Techniques in Aesthetic
Medicine presents practical, real-life case studies, and is supported by science
and practical strategy. There are more than 200 vivid photos and colorful
illustrations,technicalvideo,andacomprehensiveproductindexwithfull-color
productimagesandcasestudies.
Althoughtherearemanybooksthatlookatcosmeticmedicine,thisisthefirst
booktolookspecificallyattechniquesandtostrategicallycombinethemwithor
withoutsurgery.Wehopeourreadersfinditbeneficial.
JuliusW.FewJr.,MD


Acknowledgments
As I continue to be a part of educating future plastic surgeons, I realize how
muchtheseamazingmenandwomenareeducatingme.Theirinquisitivenature
andspiritisinfectious.Andwhilethistextbookiscosmeticinnature,Imustpay
respecttomyreconstructiveandrestorativeroots.
First,“donoharm”andthepursuitofaclinicalsolutionoriginateintheartof
reconstructionandrestorativemedicine.Ihavebeenblessedtobesurroundedby
truly incredible minds, starting with the faculty and staff at the University of
Chicago Department of Surgery, led by the late George Block, and then at the

UniversityofMichiganundertheleadershipofLazarGreenfield.Thepastand
currentfacultyofNorthwesternUniversityandtheUniversityofChicagoplastic
surgery divisions continue to be a source of pride for me as a faculty member
today.
I appreciate Thomas Mustoe for giving me my first job, as both Plastic
Surgery Resident and then Assistant Professor. Laurie Casas, Neil Fine, and
Gregory Dumanian were major sources of inspiration and guidance during the
earlyyearsofmycareerinplasticsurgery—ThankYou.
David Song, one of the most powerful minds in our specialty, brought me
back to the University of Chicago and supported me during very challenging
times,forwhichIwillalwaysbegrateful;Icouldnotaskforabetterfriendor
colleague. I thank Dan Baker and Sherrell Aston for allowing me to see their
magicatwork.
ShayMoinuddin,mysenioraestheticnurseandclinicalmanagerinChicago,
has been a respected voice of reason for my clinical pursuits, and I am most
appreciative for her valuable contribution to the practices’ innovation. Thank
you,CarlyBruno,forhelpingtosecurevaluablematerialforthistext.
I am forever grateful to Robert Flowers, Glenn and Elizabeth Jelks, Clinton
McCord, Mark Codner, and Foad Nahai, who showed me the true art of
ophthalmicplasticsurgery.Theyarelikefamilytomenow.
Finally,Imustacknowledgesomeofmydearestfriendsandconfidantswho
have been there for me: Morris Velilla, DDS; Sanjay Gupta, MD; Thomas
Sarakatsannis, JD; Jeff Marcus, MD; Michael Lee, MD; Al Lin, DDS; Matt
Murphy; David Greenwald, JD; James Chandler, MD; Robert Gramins, DDS;
James Platis, Lainchen Friese, and Sean O'Connor, the senior authors of this


textbook, and Emilio Salvi. Thank you, Genevieve Bulev, for being the best
administrativeassistantthatanyonecouldhopetohave.Thisbookwouldhave
notcometogetherwithoutyoursupport.

Contributors
AmirAllak,MD,MBA
FellowSurgeon
FacialPlasticandReconstructiveSurgery
UniversityofCaliforniaDavisMedicalCenter
Sacramento,CaliforniaLawrenceS.Bass,MD,FACS
ClinicalAssistantProfessorofPlasticSurgery
HofstraNorthwellSchoolofMedicine
DepartmentofPlasticSurgery
LenoxHill/ManhattanEye,EarandThroatHospital
NewYork,NewYorkBrianS.Biesman,MD,FACS
AssistantClinicalProfessorofOphthalmology,
Dermatology,Otolaryngology
VanderbiltUniversityMedicalCenter
PastPresident
AmericanSocietyforLaserMedicineandSurgery
Nashville,TennesseeDanielR.Butz,MD
PlasticandReconstructiveSurgeon
PrivatePractice
Milwaukee,Wisconsin
ValerieD.Callender,MD
ProfessorofDermatology
HowardUniversityCollegeofMedicine
Washington,DC
MedicalDirector
CallenderDermatologyandCosmeticCenter
GlennDale,MarylandShraddhaDesai,MD
Physician

PrivatePractice
TheDermatologyInstitute
Naperville,Illinois
BarryE.DiBernardo,MD,FACS
Director


NewJerseyPlasticSurgery
Montclair,NewJerseyUSA
ClinicalAssociateProfessor
DivisionofPlasticSurgery
RutgersNewJerseyMedicalSchool
Newark,NewJerseyCoryFelber,PA-C
ClinicalResearchCoordinator
MarinaPlasticSurgeryAssociates
MarinadelRey,California
JuliusW.FewJr.,MD
Director
TheFewInstituteforAestheticPlasticSurgery
ClinicalProfessor
DepartmentofSurgery
DivisionofPlasticSurgery
UniversityofChicagoPritzkerSchoolofMedicine
HealthScienceClinician
DivisionofPlasticSurgery
NorthwesternUniversityFeinbergSchoolofMedicine
Chicago,IllinoisJohnE.Hoopman,CLMSO
LaserSafetyOfficer
UniversityofTexasSouthwesternMedicalCenter
Dallas,Texas

JeffreyM.Kenkel,MD
ProfessorandChairman
DepartmentofPlasticSurgery
UniversityofTexasSouthwesternMedicalCenter
Dallas,TexasMichaelI.Kulick,MD
Director
BayAreaPlasticSurgeryMedicalCenter
SanFrancisco,California
NatashaKulick,EMT
Student
DepartmentofNeuroscience
ResearchAssistant
CenterforCatalysisandSurfaceScience


President
NorthwesternEmergencyMedicineOrganization
NorthwesternUniversity
Evanston,IllinoisValLambros,MD,FACS
PlasticSurgeon
PrivatePractice
CosmeticandReconstructiveSurgery
CoronaDelMar,CaliforniaJohnsonC.Lee,MD
PrivatePractice
JohnsonC.Lee,MDPlasticSurgery
BeverlyHills,California
Z.PaulLorenc,MD,FACS
Director
LorencAestheticPlasticSurgeryCenter
NewYork,NewYork

CoreyS.Maas,MD,FACS
AssociateClinicalProfessor
FacialPlasticandReconstructiveSurgery
UniversityofCalifornia,SanFrancisco
AestheticandFacialPlasticSurgery
TheMaasClinic
SanFrancisco,CaliforniaMichelleManningEagan,MD
AestheticPlasticSurgeryFellowship
UniversityofSouthernCalifornia
LosAngeles,CaliforniaMitchellManway,DO
Fellow
CenterforCosmeticEnhancement
CenterforClinicalandCosmeticResearch
Aventura,FloridaSaharNadimi,MD
AssistantClinicalProfessor
FacialPlasticandReconstructiveSurgery
LoyolaUniversityMedicalCenter
AestheticandFacialPlasticSurgery
OakbrookAesthetic,PC
OakbrookTerrace,IllinoisMarkS.Nestor,MD,PhD
CenterforCosmeticEnhancement
CenterforClinicalandCosmeticResearch


Aventura,FloridaUSA
DepartmentofDermatologyandCutaneousSurgery
DepartmentofSurgery
DivisionofPlasticandReconstructiveSurgery
UniversityofMiamiMillerSchoolofMedicine
Miami,FloridaMichaelP.Ogilvie,MD,MBA

AestheticSurgeryFellow
TheFewInstituteforAestheticPlasticSurgery
Chicago,IllinoisMarcVincentOrlando,MD
MarinaPlasticSurgeryAssociates
MarinadelRey,California
PaigePaparone,DO,MSBS
CenterforCosmeticEnhancement
CenterforClinicalandCosmeticResearch
Aventura,FloridaJasonN.Pozner,MD,FACS
Director
SanctuaryPlasticSurgery
BocaRaton,Florida
AdjunctClinicalFaculty
DepartmentofPlasticSurgery
ClevelandClinicFlorida
Weston,FloridaRachelN.Pritzker,MD
Dermatologist
ChicagoCosmeticSurgeryandDermatology
Chicago,Illinois
DenizSarhaddi,MD
ResidentPhysician
DepartmentofPlasticandReconstructiveSurgery
SaintLouisUniversityHospital
SaintLouis,MissouriAlecSemersky
UndergraduateStudent
UniversityofNorthCarolinaatChapelHill
ChapelHill,NorthCarolina
DavidA.Sieber,MD
PlasticSurgeon
SieberPlasticSurgery

SanFrancisco,California
W.GrantStevens,MD,FACS
ClinicalProfessorofSurgery
UniversityofSouthernCalifornia
KeckSchoolofMedicine
DivisionofPlasticSurgery
DirectorUSCAestheticSurgeryFellowship
Chairman,MarinaPlasticSurgery
MarinadelRey,CaliforniaJonathanM.Sykes,MD
Professor
UniversityofCaliforniaDavisMedicalCenter
Sacramento,California
SusanC.Taylor,MD
AssociateProfessorofMedicine
DepartmentofDermatology
PerelmanSchoolofMedicine
UniversityofPennsylvania
Philadelphia,PennsylvaniaMoneéThomas,MD
DermatologyResident
HowardUniversityHospital
Washington,DC


1ConceptsofBeauty
JuliusW.FewJr.andMichaelP.Ogilvie
Summary
Thischapterprovidestheunderstandingthatbeautyisthecentralconceptbehind
aestheticsurgery,butthatbeautyisverydifficulttodefine.Withtoday'smodern

technologyandmedicaladvancements,creatinggreaterbeautycanbeachieved.
Today, aesthetic surgeons possess the same passion to redefine beauty by
improving a patient's aesthetic qualities with a finesse few others can produce.
Ultimately,naturalbeautyisbest(VideoI.1).
Keywords:beauty,historyofaestheticsurgery,symmetry,proportion,harmony,
GoldenRatio,DivineProportion

KeyPoints
ConceptsofBeauty
•Understandingbeautyisacentralconceptbehindaestheticsurgery.
• Attempted explanations that describe beauty include creating symmetrical
images, proportions (Golden Ratio), harmony, and an individual's own
intrinsicbeliefs.
•Therearesignificantsocialeffectsthatsurroundbeauty.
• Aesthetic surgery has transformed into the new generation of art that
combinesascientificapproachandakeeneyetocreatebeauty.

1.1Introduction
Elena Dmitrievna Diakonova met Salvador Dalí in 1929 in Paris, France.1
Knownas“Gala”byherclosefriends,Diakonovawasaprominentfigureinthe
Paris art scene and known to be a muse for many artists. However, Dalí saw
moreinher( Fig.1.1).Inhisautobiography,1Dalíwrites,“‘Itismostlywith
yourblood,Gala,thatIpaintmypictures,’Isaidtoheroneday,andsincethenI
have always used her name with mine in signing my work.” Gala helped Dalí
refine his artistic skills and push boundaries that others were incapable of
reaching. Specifically, Dalí was fascinated by the idea of depicting any image,


idea, or concept in his imagination and illustrating it as unaltered and
realisticallyaspossible.Dalítookthistoheartwhenpaintinghiswife.

Gala makes numerous appearances in Dalí’s art. From Gala Contemplating
the Mediterranean Sea to Dalí from the Back Painting Gala ( Fig. 1.1),
SalvadorDalítranscribesGala'sbeautyasnaturalandraw.1Dalídidnothaveto
imagine Gala's beauty—he saw it. Concluding his memoire, Dalí1 profoundly
declares,“Gala,youarereality.”Withthatsimpleline,onefinallycomprehends
themainpursuitofDalí’slife.ForDalí,likemanyotherartists,theobsessionto
translateanideaorimagetoanartisticrepresentationdominateswhotheyareas
a person. Artists are never satisfied until the image they see with their eyes
matches the image found in their innermost self. Dalí was consumed by this
ideology,especiallywhendrawingGala—theartist'strueembodimentofbeauty.


Fig.1.1DalíSeenfromtheBackPaintingGalafromtheBackEternalizedbySixVirtualCorneas
ProvisionallyReflectedbySixRealMirrors.(ReproducedwithpermissionfromDalideespaldas
pintandoaGala–DalipaintsGalainfrontofamirror,1972-1973.MuseoDali,Figueras,Spain.Erich
Lessing/ArtResource,NY.SalvadorDalí,FundacióGala-SalvadorDalí,ArtistsRightsSociety[ARS],
NewYork2017.)

Dalíwasofcourseaproductofhistimeperiodanditsrespectivetechnology.
Imagine what vivid cinematography Dalí could have generated with computergeneratedimageryathisfingertips.CouldDalíhavecreatedadivine,unearthly
representationofbeauty?
Withtoday'smoderntechnologyandmedicaladvancements,creatinggreater
beauty can be achieved. Today, aesthetic surgeons possess the same passion to
redefine beauty by improving a patient's aesthetic qualities with a finesse few
others can produce. Perceived as a new generation of art, aesthetic surgery


carriesthefirethatDalíandhisfellowinnovativeartistsignited.
Today's new aesthetic of art utilizes a needle laser, and energy-firming
technologytosubstituteforabrush,oilpastels,andpalate.Withacalm,careful

demeanor, aesthetic surgeons create an artistic work located one layer beneath
theskin'sepidermis.Ratherthancreatingasingledimensionthatremainslifeless
onapainting,aestheticsurgeonscreatemasterpieceswithbloodflowingthrough
the individual's veins. This cannot be accomplished, however, without many
unusualyeteffectivemethods.Forinstance,skilledprofessionalscarefullyinject
micro-dosesofClostridiumbotulinumtoxin(Botox)aroundtheorbicularisoculi
(musclessurroundingtheeye).
The toxin, the same neuromodulator that causes flaccid paralysis in other
situations,relaxesthemuscles,thusdiminishingwrinklingandaccentuatingthe
eye's beauty. Similarly, hyaluronic acid, a substance that is found naturally
outsideacell,canbeappliedundertheskintosmoothenalmostanyagingsigns.
A frequent concern for patients includes nasolabial lines or smile lines.
Strategicallyinsertedatanangle,thebluntedcannulatipspreadsouthyaluronic
acidwhilecausinglittletonosideeffects.Anyofthesenonsurgicalprocedures
revealthemoderneraofaesthetictoolsthathavelimiteddownsides.
Thebeginningdaysofplasticsurgerywerecoarse.Aestheticsurgeonswould
primarilyfocusonsurgicallyalteringandnotenhancinganindividual'snatural
beauty. A common procedure, the traditional facelift alone, resulted in a
homogeneouspopulation.Insomecases,incorrectly,aphysicianwouldpullthe
skin removing not only wrinkles but also the patient's basic individuality. A
doctorcertifiedinaestheticsmustbeintunetorapidlychangingtrendsandbe
able to cater to patient's desires. Also, a true professional understands that not
everypatientisacandidateforaspecificprocedureorsurgery,evenifapatient
is adamant about it. A genuine physician will be honest with the patient and
advocateforproceduresthatfollowhisorherbestinterests.Inordertoavoidthe
stigmanegativelyassociatedwithaestheticmedicine,onehastounderstandthe
goal of natural-appearing alteration and enhancement. The primary reason for
this divide between the aesthetic physician and the public is rooted in the
perplexingquestion:whatisbeauty?

1.2“BeautyIsintheEyeoftheBeholder”
Thissimpleyeteffectivestatementdemonstrateshowone'sperceptionofbeauty
is a personal choice. A man may find a woman appealing, although his friend
does not feel the same way. What factors determine this? Is it the appeal of


Hollywood actresses in extravagant wedding dresses shown on tabloid
magazines? Or is it the athletic build of a football player that makes him
handsome? Whether it is from the simplicity apparent in the DNA's helical
structure to the complexity apparent in a rosebud, beauty's presence permeates
every corner of the universe. One cannot argue that Michelangelo's grandiose,
dramatic representation shown in La Pietà or his sculpture David outdoes the
eleganttimelessnessthatAlexandrosofAntiochcapturesintheVenusdeMilo.
Clearly,itisimpossibletodefinebeautyinanabsolutemanner.However,there
are a number of algorithms that have been developed to attempt to define an
answer.
Aninfinitenumberofexamplesillustratebeauty,sotheremustbeatleastone
unifyingaspectthathelpsproduceit.Inactuality,somehavetheorizedthatthere
isareproducibleelementthatattemptstodefinebeauty'spresence—symmetry.
Symmetryreferstoexactmirrorimagebetweentwopartsseparatedbyanaxisor
line. The linkage between symmetry and beauty is quite logical. Since its
creation, humanity has an intrinsic predisposition toward symmetrical images.
Peopleareinclinedtofavorequality,becauseithaslessdichotomyanddisorder.
As visualized in nature, countless examples of symmetry are seen in various
animals, insects, or even the sun's shape. Consequently, it appears rational to
make human features similar when comparing contralateral sides. By
understanding that a genetic code for perceived attractiveness may exist, could
oneunlockthemapforcreatingnatural,humanisticmasterpieces?
However,symmetricalproportionsarenotthemainfoundationforachieving
beauty. A study conducted in Italy explored the three-dimensional (3D) facial

asymmetryinsubjectsdeemed“attractive”and“normal.”2Withdigitalcomputer
technology, researchers demonstrated how asymmetrical features undermine an
individual'sbeauty.Mostimportantly,though,theysawageneraltrendshowing
noexactcorrelationwithhighersymmetrywith“attractive”people( Fig.1.2).
Althoughthisisconvoluted,theirdata2expressedthat“asymmetricfacesdeviate
fromattractivenessbecausetheydeviatefromaverageness[definedassimilarity
tothebasicappearanceofrespectivegenders]…Insynthesis,humans’symmetry
may be a good sign of health, but not necessarily for attractiveness, also
consideringintrinsicasymmetryofourbrain,and,therefore,ofourperception.”
Furthermore,symmetry,althoughsignificant,unfortunatelydoesnotequateto
real-life applications of beauty. Theoretically, even if a patient were a 100%
symmetrical, they may not be identified as beautiful by a lay observer. Artist
AlexJohnBeck3revealsthisinhisphotographicseriesentitled“BothSidesOf,”
a photography project that juxtaposes side-by-side portraits of models whose