A new review of the literature delves into diversifying beauty standards and suggests that the ‘golden ratio’ is no longer valid in a changing ethnocultural landscape.
There is increasing demand for cosmetic surgery across the world, spanning different cultures and ethnicities. Diverse beauty ideals are emerging and there are significant variations in beauty perceptions depending on the country, ethnic background and culture. A recent review paper* examines how long-held Western beauty standards no longer apply to all and may not yield satisfactory cosmetic surgical outcomes for non-Western ethnicities. It strongly suggests that better understanding of cultural and ethnic variances in aspirations, aesthetic standards and attitudes towards cosmetic surgery are needed for more acceptable cosmetic outcomes.
The 2023 review, published in Clinical, Cosmetic and Investigational Dermatology, summarises findings in the literature regarding cosmetic surgery and the diversity of cultural and ethnic perceptions of aesthetics in women. This comprehensive analysis of 66 peer-reviewed studies unravels the diverse preferences that have emerged in different societies and how they are shaping contemporary cosmetic surgery practices.
‘As cosmetic surgery has become increasingly popular, and patients from diverse ethnic backgrounds seek interventions to maintain the balance and harmony of their natural features, beauty standards have become more diverse and vary according to cultural and ethnic norms,’ the authors write.
‘Traditional aesthetic criteria such as symmetry, averageness, youth and sexual dimorphism may not be applicable to different ethnic groups. Despite this, aesthetic surgeons still rely heavily on Western beauty standards to assess aesthetics.’
The authors emphasise the importance of understanding the cultural and ethnic context in the patient’s perception of beauty and their expectations from cosmetic surgery. ‘
To provide personalised and culturally appropriate interventions, surgeons must understand the changing trends and preferences of the growing patient population and appreciate the diverse ethnic facial morphology and physical attributes that appeal to patients… it is crucial to consider cultural and ethnic diversity when assessing aesthetics and performing cosmetic surgery,’ they note.
Diversifing beauty standards and the golden ratio
The Golden Ratio (1:1.618), rooted in geometry, has long been considered a marker of beauty and used as a reference point in various artistic and architectural designs throughout history.
In cosmetic surgery, the Golden Ratio, or phi, has served as a guide for achieving aesthetically ‘ideal’ and harmonious facial proportions, the most prominent example being Dr Stephen Marquardt’s mask, which is based on the Golden Ratio and reflects the “perfect” facial typology.
The authors note that multiple studies have pointed out the inadequacies of the Golden Ratio or the Marquardt mask in capturing perceived attractiveness standards among different ethnicities:
‘Although the Marquardt phi mask was supposed to reflect the global facial beauty archetype, it has been deemed inadequate in several cases.
‘A recent study found that the existence of a formula for beauty in mathematics does not automatically suggest that this formula represents beauty.
‘In another study, beautiful contemporary faces from reputed magazines were ranked by 20 prospective ortho-facial surgery patients and compared with classical sculptures representing gods. Harmonious modern female features were discovered to have a much lower classical facial index, suggesting major changes in perceived facial attractiveness over time. In this respect, it is acknowledged that demographic differences and cross-cultural exchanges that define 21st-century globalisation are important phenomena guiding individual perceptions of facial attractiveness.’
Facial aesthetics
The authors emphasise that beauty ideals amongst cultural and ethnic backgrounds vary for facial features such as the eyes, nose and lips. ‘Beauty standards have also shifted over time and across cultures. For example, contemporary faces with more harmonious features are now preferred to the classical facial index,’ they write.
‘Lip projection and relative size are essential for lip aesthetics. The optimal ratio of the vertical height of the upper lip to that of the lower lip in young Caucasians was 1:1.6, whereas Black individuals were genetically predisposed to a larger lip volume. Full lips with a well-defined cupid’s bow are preferred in Han Chinese culture, while Middle Eastern beauty is characterised by full lips.
The review cited a study carried out by Heidekrueger et al, which gathered more than 1,000 responses from 35 different nations, on lip preference. The results showed that most people thought the 1.0:1.0 lip ratio to be the most appealing.
‘Nose-shape preferences also vary across cultures and ethnicities,’ the authors continue. ‘Latin American and Caribbean populations favour smaller, narrower noses with tips that project more, whereas South Indians and Middle Easterners prefer straight and small noses.’ Chin and eyebrow aesthetics also vary among ethnic groups. A study that compared 50 nations across regions and ethnicities found that optimal chin projection was correlated with the country of residence and ethnicity. Han Chinese favour round and pointy chins; South India prefers thin chins; and in the Middle East, pointed chins are regarded as signs of beauty.
The authors note that the criterion of an aesthetically pleasing eyebrow has been the subject of much debate over the years. ‘It has been reported that significant cultural differences exist concerning ideal eyebrow shape and position,’ they write.
‘A German study found that although there is no standard for brow height, there is a preference for lower-positioned brows with a maximum height in the lateral third. However, in a notable development, a study examined complete facial photographs on the Frankfort plane of Korean women ranging in age from young childhood to their 50s and calculated the height-to-width ratio (HWR) and take-off angle (TOA). The preferred HWR was 1:1.0, and the preferred TOA was 10.’
The review also analysed several Chinese studies on perceptions of beauty, reporting that the Chinese population aims to be beautiful by retaining its ethnicity and not following Western beauty standards.
In one study, Asians were compared to Caucasians of the same age, with a focus on injectable procedures for facial aesthetics. The study revealed that facial aesthetic treatments in Asians are not directed at Westernisation, but rather at achieving optimal Asian ethnic characteristics (which includes an oval-shaped face with a smooth jaw angle.
‘Injectable procedures to restore facial form and three-dimensionality are becoming popular among younger Asians, reflecting an increasing trend towards repairing facial imperfections or minimising deviations from ethnic and cultural standards of facial beauty,’ the authors write. ‘In this way, general facial beauty is improved, but the aesthetic features of Asian ethnicity are preserved.
‘As the aesthetic aspirations of Asian patients are different from those of Western patients, they require distinct management and treatment tactics. It is natural to expect that with globalisation, many women will seek cosmetic surgery interventions from surgeons of different ethnicities, who might have different personal preferences for aesthetic standards. Therefore, to obtain the best outcomes, it is critical to understand the ethnic diversity in beauty standards.’
Breast aesthetics
The ‘ideal breasts’ are still up for debate and the authors say significant ethnic differences in preferences for upper- and lower- pole breast proportions have been reported.
‘Different cultures and ethnicities have varying opinions regarding breast size, shape and nipple placement,’ they write. ‘For example, Asian females generally prefer non- ptotic, adequately proportioned breasts with nipple frontal projection over enormous, ptotic breasts. A notch-to-nipple distance of 21cm is often considered an important indicator of breast attractiveness. ‘However, recent studies have found no association between distance and aesthetic appeal. Other factors, such as the pole ratio, upper and lower pole forms and breast height, also contribute to breast attractiveness. Women of different demographics prefer an upper pole-to-lower-pole ratio of 45:55. Nipple-areola complex (NAC) placement is also essential, with the optimal position being the centre of the breast gland, vertically and somewhat horizontally to the side of the centre.’
The review examined Colombia’s most extensive breast aesthetics study, in which software-modified photographs of breasts with varied areolar nipple complex positions, pole ratios and sizes were used. The results showed that the preferred ratio of upper-to-lower- pole breast proportions varied significantly across demographics.
In a study from the UK, 1,315 respondents were asked to rank the attractiveness of images of women with upper pole-to-lower-pole proportions of 35:65, 45:55, 50:50, and 55:45. The pole ratio of 45:55 had the highest score and was preferred by 87% of women, 90% of men, 94% of plastic surgeons, 95% of South Americans, 92% of North Americans, 86% of Europeans, 87% of Caucasians, and 87% of Asians. It was concluded that the 45:55 ratio has a universal appeal for defining the ideal breast.
In a study conducted in Sweden, breast attractiveness was also shown to correlate highly with both lower and upper pole forms and breast height.
In the United States, the authors reviewed an online survey that used morphed, life-like 3D female models to examine preferences for breast attractiveness. Various attributes such as the breast pole ratio,
areola size, direction of the breast and projection were assessed. Consistent with previous findings, the results showed that participants favored a 55:45 upper pole-to-lower pole ratio and the smallest depicted areola (3 cm).
The review elucidates that breast size preference can differ substantially among societies and that these cultural influences not only affect women’s decisions to undergo breast augmentation or reduction procedures, but also influence the choice of implant materials and techniques used.
Buttock aesthetics
The review also highlights the ethnic perceptions of gluteal aesthetics in women. While in some cultures, a smaller, more slender buttock area is considered attractive, other societies appreciate larger, more curvaceous buttocks. This has led to an increase in buttock augmentation procedures, such as fat transfer and the use of implants, in countries where larger buttocks are admired.
The review authors write that cosmetic surgery to improve the buttock region is often troublesome because perceptions of the ideal buttock differ substantially.
‘Patient satisfaction has been reported to vary substantially by ethnicity in gluteal lifts, fat grafting and gluteal implants, and ethnic disparities in the buttocks form are notable among Caucasian, Latino and African American women,’ they write.
‘In recent years, Brazilian butt lift has become a common cosmetic surgical procedure. A survey of more than 400 patients for preferred buttock size and shape revealed that African Americans favoured larger buttocks than Caucasians, whereas Hispanics favoured larger buttocks solely in the lateral view.
‘Asian population favours curvy buttocks that range in size from small to moderate and lack lateral thigh or buttocks bulges.’
The authors reference the waist- to-hip ratio (WHR) as a typical criterion for buttock aesthetics: ‘The WHR of the most attractive buttocks is 0.75 from the back and 0.70 from the side in women.
‘Pérez et al showed survey participants four photoshopped versions of the same model, one with the golden ratio (1.61) and three with other proportions. The picture in which WHR equalled the golden ratio was commonly voted as “the most attractive.” Another demographic analysis of ideal buttocks metrics to help surgery planning revealed the WHR of the most desirable buttocks from the posterior aspect to be 0.65, with 0.60 being the second-most attractive ratio.’
THERE IS A CLEAR PREFERENCE FOR ATTRACTIVENESS BASED ON ETHNIC ORIGIN AND CULTURE… WHEN DEFINING NOVEL AESTHETIC TREATMENTS AND TREATING PATIENTS, IT IS ESSENTIAL TO CONSIDER CULTURAL VARIATIONS AND INTERNATIONAL DIVERSITY.
Contemporary attitudes to cosmetic surgery
The authors note that fascination with physical beauty is becoming increasingly common in modern society and that culture and body dysmorphism are predictive factors in the decision to undergo cosmetic surgery. It should be noted, however, that one study included in the review revealed that while most respondents stated that being attractive impacts everyday life and improves quality of life, they were unwilling to undergo cosmetic surgery.
Moreover, when given the choice of surgical or non-surgical cosmetic procedures, most participants preferred non-surgical procedures.
Another study examined cosmetic surgery preferences among Dutch women and Chinese women in the Netherlands and in China, finding that materialistic beliefs and considerations of face attractiveness were important predictors of positive views about cosmetic surgery across these cultures.
‘Notably, among Chinese women, body acceptance was a substantial positive factor in both the Netherlands and China, but age and acceptance of beauty standards were the only significant factors in China. It is evident that the Chinese population seeks to be beautiful by retaining its ethnicity rather than following Western beauty standards,’ the authors write.
Cosmetic surgery rates in South Korea have grown dramatically over the last decade, following similar growth trajectories in other East Asian countries. According to studies analysed in the literature review, women gave higher overall ratings than males, indicating that they were more receptive to cosmetic surgery. One study in Singapore found that the younger population is becoming more receptive to cosmetic surgery; nonetheless, there is a widespread lack of knowledge regarding the associated risks and complications.
In today’s interconnected global society, beauty ‘standards’ are shifting and becoming more diverse. As aesthetic ideals continue to evolve and vary widely among different ethnic and cultural groups, the significance of ethnocultural awareness in cosmetic surgery only increases.
The authors conclude that a better understanding of cultural and ethnic variances in aspirations, aesthetic standards, and attitudes toward cosmetic surgery can help expedite the development of effective cosmetic procedures and enhance the acceptability of cosmetic surgery in broader sections of society.
‘There is a clear preference for attractiveness based on ethnic origin and culture. Therefore, cosmetic surgeons should consider the ethnicity of patients when offering cosmetic treatments… When defining novel aesthetic treatments, treating patients and reporting results in today’s increasingly global world, it is essential to consider cultural variations and international diversity. Further studies should be conducted to accommodate ethnic and cultural variations in cosmetic surgery planning.’ AMP
* Arian H, Alroudan D, Alkandari Q, Shuaib A. Cosmetic Surgery and the Diversity of Cultural and Ethnic Perceptions of Facial, Breast, and Gluteal Aesthetics in Women: A Comprehensive Review. Clin Cosmet Investig Dermatol. 2023;16:1443-1456
