Commentary

Otolaryngology–
Head and Neck Surgery

Reframing Our Approach to Facial 1–2

Ó American Academy of
Otolaryngology–Head and Neck
Analysis Surgery Foundation 2020
Reprints and permission:
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DOI: 10.1177/0194599820912031
http://otojournal.org
Lauren E. Miller, MD MBA1,2, Elliott D. Kozin, MD1,2,
and Linda N. Lee, MD1,2,3

Abstract
Facial analysis is a foundational aspect of facial plastic and
reconstructive surgery. Unfortunately, ideal proportions of
beauty are commonly discussed without much thought
regarding their historical derivation and associated cultural
implications. Facial analysis often is limited to narrow ethnic
and gender-normative aesthetics. As we evolve as a specialty
that treats disparate patient populations and embraces a
diverse community of surgical trainees, it may be time to
reframe our approach to facial analysis education.

Keywords
facial analysis, otolaryngology, facial plastic surgery, plastic
surgery

Received November 22, 2019; accepted December 10, 2019.

The ear is exactly as long as the nose, the parting of the

mouth in profile slopes to the angle of the jaw. The ear
should be as high as from the bottom of the nose to the top
of the eyelid. The space between eyes is equal to the width
of one eye. The ear is over the middle of the neck when
seen in profile.
Figure 1. Renaissance era facial proportions. The proportions of
the head and a standing nude. Leonardo da Vinci c1490. Royal
Collection Trust.

At first glance, the opening quotation could derive from a

contemporary otolaryngology–head and neck surgery text-
book chapter on facial analysis. In fact, it was written over
5 centuries ago by Leonardo da Vinci.1 Da Vinci and his
Renaissance period contemporaries employed mathematical
formulas, such as the golden ratio, to study and illustrate the
human form (Figure 1). The pursuit of quantifying ideal
facial proportions continues today. Countless research arti-
cles describe measurements and surgical techniques to
achieve an aesthetically appealing face. Some of this research
trickles down to surgical textbooks and is studied as facial
aesthetic canon. Mantras such as ‘‘Vertical fifths and horizon-
tal thirds’’ and ‘‘3-4-5 triangle’’ roll off the tongues of medi-
cal students, residents, and fellows.
Unfortunately, ideal proportions of beauty are commonly
discussed without much thought regarding their historical
derivation and associated cultural implications. Indeed,
facial analysis is often limited to narrow ethnic and gender-
normative aesthetics.2,3 Contemporary research has begun to
address these issues.4-6 For example, with nasal analysis,
studies have explored whether augmenting the nasal dorsum
‘‘Westernizes’’ its appearance and is preferred in the Caucasian
population, while improving tip projection may be preferred
in the Asian population.7 Analogous research has been per-
formed in diverse patient populations and other areas of
facial analysis, such as the eyelid.8,9 Moreover, transgender
studies point to facial analysis as being inherently based on
traditional gender-normative assumptions of beauty.10 In
brief, ideal proportions and concepts of beauty are, at a min-
imum, highly variable.
1
Department of Otolaryngology, Massachusetts Eye and Ear Infirmary,
Boston, Massachusetts, USA
2
Department of Otolaryngology, Harvard Medical School, Boston,
Massachusetts, USA
3
Division of Facial Plastic & Reconstructive Surgery, Massachusetts Eye and
Ear Infirmary, Boston, Massachusetts, USA
Corresponding Author:
Linda N. Lee, Department of Otolaryngology, Massachusetts Eye and Ear
Infirmary, 243 Charles Street, Boston, MA 02114, USA.
Email: Linda_lee@meei.harvard.edu
2 Otolaryngology–Head and Neck Surgery

While emerging research and associated surgical approaches analysis, and interpretation of the data; and writing of the manu-
are expanding our approach to facial analysis, this work does script; Linda N. Lee, collection, analysis, and interpretation of the
not appear to have landed meaningfully in our mainstream data; and writing of the manuscript.
textbooks or board examinations. In many respects, contem-
porary education on facial analysis appears as dated as that Disclosures
during the Renaissance, emphasizing the rote memorization Competing interests: None.
of facial proportions. Unfortunately, by recanting and testing Sponsorships: None.
‘‘correct’’ facial proportions, we are overtly and tacitly pro- Funding source: None.
mulgating narrow notions of beauty. As we evolve as a spe-
cialty that treats disparate patient populations and embraces References
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