Lip Augmentation with Soft Tissue Fillers: Social Media, Perceptual Adaptation, and Shifting Beauty Trends beyond Golden Standard Ideals

Abstract

Background:

Unfortunately, current beauty trends greatly advertised by social media are trespassing recognized cannons of beauty. Of particular interest are patients’ expectations of soft tissue volume augmentation of the face, specifically of the lips.

Methods:

An artificial intelligence picture of a White female face was generated. With the fixed standard golden upper-to-lower (U/L) lip ratio, a first set of pictures was generated with varying lip fullness. A second set of pictures was generated with various U/L ratios and lip fullness. In a survey format, the 2 sets of pictures were rated for attractiveness from the most to the least attractive by adult men and women.

Results:

Rating the first set of pictures clearly demonstrates that overinflation of lips with upper lip height in excess of 30% of hemi-lip width is highly regarded as unaesthetic and unattractive, with a net preference of 20%–25%. For the second set, U/L ratios between 0.618:1 and 1:1 are still regarded to be most aesthetic.

Conclusions:

Though social media have an influence on perception of beauty, data provided by the survey confirm that golden standards of aesthetics remain constant and that exaggerated requests of some patients may not be attributed solely to social media influence but probably to social media in combination with additional personal predisposing factors. Patients must be made aware that how they are perceived by others is essential for them to be satisfied with their appearance.

Takeaways

Question: Do social media have an influence on the perception of beauty, and does it cause a shift in beauty trends beyond golden standard ideals?

Findings: Though it is believed that social media have an influence on perception of beauty, data provided by the survey confirm that the golden standards of aesthetics remain constant, and that the exaggerated requests of some patients may not be attributed solely to social media influence and perceptive adaptation, but probably to social media in combination with additional underlying personal predisposing factors.

Meaning: The golden standards of aesthetics remain constant, and the exaggerated requests of some patients may not be attributed solely to social media influence.

INTRODUCTION

As a consequence of the culture of youth and physical health that has characterized the past 2 decades and a general desire to adhere to ideals of attractiveness and beauty, concerns about one’s individual appearance have greatly increased. With the belief that body features can be transformed into any size and shape, plastic surgeons are increasingly faced with a wide range of patient desires and perceptions of beauty.^1–5

The fluid perception of beauty, however, is largely influenced by sociocultural standards that are affected by cultural practices and media exposure of the time.^6–9 Social media platforms with editing applications have significantly shaped patients’ perceptions and have created new sociocultural ideals. They have also shaped the current practice of aesthetic medicine and surgery.^2,10–12 Many patients at present bring with them pictures of celebrities and demonstrate the interest of not only becoming beautiful but also looking similar to the “Hollywood star” prototypes, expecting outcomes that are out of proportion with established standards of beauty.^4,5,13–15 Unfortunately, overtreated patients and overzealous practitioners are becoming very common.¹⁶ Of particular interest are patients’ expectations of face soft tissue volume augmentation, specifically of the lips. Far from overcorrection, the lip augmentation objective is to create smooth lips with a natural appearance. Unfortunately, unattractive, if not disastrous, outcomes are frequent.^17,18 We have also observed that even when the ideal upper-to-lower (U/L) lip ratio is respected, outcomes may still be unaesthetic if upper lip height is disproportionate to width. To the best of our knowledge, ideal lip volume measurements have not yet been practically defined. This study is aimed at determining the most attractive current trend for U/L lip ratio and ideal volume reflected by upper lip height to hemi-width ratio (U/hL). It is also a critical analysis of evolving concepts of beauty that are drifting away from well-described and recognized harmonious features and golden proportions.

MATERIALS AND METHODS

In this study, the U/L lip ratio of 0.618:1 was considered as baseline, and lip height and width are being considered regardless of projection, cupid’s bow variable definition, and other facial features.

A picture of a White female face was generated using artificial intelligence. With the fixed standard golden U/L lip ratio, a first set of pictures was generated with varying lip fullness using the Face Liquify tool of Adobe Photoshop (Fig. 1). A second set of pictures was generated with various U/L lip ratios and fullness (Fig. 2). In a survey format, the 2 sets were rated from the most to the least aesthetic and attractive. Online response was negligible; alternatively, adult men and women were approached individually. Due to the study’s non-interventional nature, no institutional review board approval was necessary. Survey participants did not receive any financial or other compensation.

Fig. 1.

Various upper and lower lip volumes (A-F) with constant U/L golden number ratio: U/L = 0.618.

Fig. 2.

Various U/L ratios with various lip volumes: (A): U/L = 0.618, (B): U/L = 1, (C): U/L > 1, (D): 0.618 > U/L < 1, (E): U/L = 1, and (F): U/L > 1.

A total of 200 responses were recorded. Participants were classified by sex, age, educational level, occupation, and how often they view celebrity pictures or outcomes of aesthetic procedures on social media. Data were recorded on an Excel sheet (Microsoft Excel, Microsoft Inc, Redmond, WA); statistical Student 2-tailed unpaired t test analysis was conducted as well as Friedman, Mann-Whitney U, and Pearson chi-squared test analyses.

RESULTS

Demographic data of participants are summarized in Table 1. Though the Friedman test has failed to demonstrate a specific order of preference, grading by all participants of the first set of pictures clearly demonstrates that overinflation, of lips with upper lip height in excess of 30% of hemi-lip width (U/hL) is regarded as highly unaesthetic with net preference of U/hL = 25% (Fig. 3). (See table, Supplemental Digital Content 1, in which raw data for grading of both sets of pictures by all participants is presented, http://links.lww.com/PRSGO/D553.) (See table, Supplemental Digital Content 2, in which raw data for grading of both sets of pictures by all participants is presented, http://links.lww.com/PRSGO/D554.) Only 12% of participants considered upper lip inflation in excess of 30% U/hL to be the most aesthetic (grade 1). When grading is classified by high (grades 1–2), moderate (grades 3–4), and poor (grades 5–6), most lips with 20% and 25% U/hL are regarded as highly aesthetic, whereas thinner lips and lips with 30% U/hL are mostly moderately appreciated (Table 2). The Pearson chi-squared test performed with these 3 categories for each picture yielded P values significantly greater than 0.05, indicating that distribution of gradings is not uniform, reflecting real aesthetic preferences. Moreover, the percentage of overall positive grading (1-2-3) of thin lips is higher than the similar combined grading of the 2 overinflated lips (55% versus 35%). Furthermore, difference in positive grading (1-2-3) between the most and least favored lips volumes [pictures 1(2)-1(3) and pictures 1(5)-1(6)] is highly significant (P value = 0.002) (Table 3).

Table 1.

Demographic Characteristics of Survey Participants

Gender	Male: 88 (44%)		Female: 112 (56%)
Age, y	<25: 103 (51.5%)	26–35: 64 (32%)		>35: 33 (16.5%)
Education	Elementary: 0	High school: 3 (2.5%)		University: 197 (98.5%)
Occupation	Medical related: 114 (57%) Medical students, interns: 107 Plastic surgery residents: 7		Nonmedical: 86 (43%)
Social media viewing	Frequently. and very frequently: 127 (63.5%) Frequently: 105 Very frequently: 22		None and rare: 73 (36.5%) Not at all: 24 Rarely: 49
Country of residence	Asia: 10	Europe: 18	North America: 10	Middle East: 162

Fig. 3.

Grading of both sets of pictures by all the surveyed participants. Overinflation of lips with upper lip height in excess of 30% of hemi-lip width is regarded as unaesthetic and unattractive with net preference for 20%–25% U/hL.

Table 2.

Classification of Aesthetic Grading of the First Set of Pictures with Constant U/L Golden Number Ratio as High (Grades 1–2), Moderate (Grades 3–4), and Poor (Grades 5–6)

	Picture 1(1), %	Picture 1(2), %	Picture 1(3), %	Picture 1(4), %	Picture 1(5), %	Picture 1(6), %
Grades 1–2	21	63	76	29	11	13
Grades 3–4	54	30	21	63	28	8
Grades 5–6	24	8	9	9	61	79

Table 3.

Difference in Positive Grading (1-2-3) between the Most and Least Favored Lip Volumes [Pictures 1(2)–1(3) and Pictures 1(5)–1(6)]

t Test: 2-sample Assuming Unequal Variances
	Variable 1 Pics 1(2)–1(3)	Variable 2 Pics 1(5)–1(6)
Mean	55.8333333	14
Variance	367.766667	38.4
Observations	6	6
Hypothesized mean difference	0
df	6
t Stat	5.08447313
P(T ≤ t) one-tail	0.00112779
t Critical one-tail	1.94318028
P(T ≤ t) 2-tail	0.00225558
t Critical 2-tail	2.44691185

On the other hand, chi-square tests conducted for each picture of the second set indicated that observed distribution of grades is highly unlikely to have occurred by chance. It can be concluded with high confidence that grades for these pictures are due to a defined order of preference and are statistically significant. In fact, U/L lip ratios between 0.618:1 and 1:1 seem to be the most appreciated, with the highest grading of moderately full lips at U/L = 1, which reflects a shifting trend from the golden proportions recently reported by other investigators,^17,19,20 though this shift is not statistically significant. Furthermore, the difference in positive grading between the moderately full U/L = 1 and U/L > 1 lips and the same proportions in overinflated lips is significant (P = 0.017) (Table 4). When grading is classified by high, moderate and poor, U/L = 1 lips are the most favored, followed by lips in golden proportion, whereas U/L > 1 lips are only moderately appreciated and 0.618 > U/L < 1 lips are appreciated highly and moderately equally. Interestingly, U > L lips, though not receiving high 1 and 2 grading, may not be highly unaesthetic provided that the upper lip is not overinflated. Furthermore, even the preferred U/L = 1 ratio becomes less aesthetic with overinflation (Table 5). It must be noted, however, that aesthetic perception is relative and is influenced by the group with which an object is viewed. In this survey, a picture is graded differently depending on whether it is viewed within the first or the second set of pictures; however, this difference is not statistically significant.

Table 4.

Significance of Observed Difference in Positive Grading (1-2-3) between the Moderately Full U/L + 1 and U/L > 1 Lips and the Same Proportions in Overinflated Lips

t Test: 2-sample Assuming Unequal Variances
	Variable 1 Full	Variable 2 Overfull
Mean	31.1666667	8.5
Variance	262.166667	33.5
Observations	6	6
Hypothesized mean difference	0
df	6
t Stat	3.2289558
P(T ≤ t) one-tail	0.00896701
t Critical one-tail	1.94318028
P(T ≤t ) 2-tail	0.01793402
t Critical 2-tail	2.44691185

Table 5.

Classification of Aesthetic Grading of the Second Set of Pictures with Variable U/L Ratios as High (Grades 1–2), Moderate (Grades 3–4), and Poor (Grades 5–6)

	Picture 2(1), %	Picture 2(2), %	Picture 2(3), %	Picture 2(4), %	Picture 2(5), %	Picture 2(6), %
Grades 1–2	49	73	23	44	15	12
Grades 3–4	37	18	63	48	24	8
Grades 5–6	15	10	14	8	62	81

Comparing preferences of individuals viewing social media frequently and extremely frequently to preferences of those viewing social media rarely or not at all, it appears that both groups view U/L = 0.618 and U/L = 1 lips as more attractive than U/L > 1, and both regard overfilled U = L or U > L lips as less aesthetic, suggesting that preferences of some patients requesting lip augmentation beyond the standard norms may not be attributed solely to social media influence even though the group that views social media rarely or not at all seems to appreciate more picture 1(1) thin lips (grade 1-2-3: 74% versus 51%). Interestingly, expressed preference of exaggerated full lips by few participants who view social media frequently was more for U/L = 1 than U > L lips (24% versus 15%). As for choosing from the second set of pictures, the most aesthetic (grade 1) lip proportions and fullness, those who do not view social media regularly appreciated better moderately full lips in golden proportion (30% versus 18%) and U/L = 1 exaggerated fuller lips (18% versus 5%), whereas U > L exaggerated lips were selected more by the frequent social media viewing group (8% versus 1%). Nevertheless, most striking is the generally low grade 1 of U > L lips by both social media groups whether with moderate or excessive fullness (Fig. 4). (See table, Supplemental Digital Content 3, in which raw data for grading of both sets of pictures by frequency of social media viewing are presented, http://links.lww.com/PRSGO/D555.) (See table, Supplemental Digital Content 4, in which raw data for grading of both sets of pictures by frequency of social media viewing are presented, http://links.lww.com/PRSGO/D558.)

Fig. 4.

Grading of both sets of pictures by frequency of social media viewing. Social media viewing has no significant influence on aesthetic preferences of lip proportions and fullness.

Despite some possible bias regarding age distribution of respondents, it appears that age and occupation do not have a significant influence on aesthetic preferences of lips contrary to sex. Though net preference remains predominantly for U/hL within 20%–30%, some men seem to appreciate fuller lips more than women. This preference is reflected by a higher percentage of men favorably grading exaggerated full lips (P value: 0.059) (Table 6). In fact, chi-square statistics demonstrated that pictures 2(1), 2(4), 2(5), and 2(6) graded by men were statistically significantly different from the uniform distribution, indicating that grading by men is not random but due to a significant order of preference. As for the most aesthetic proportions and fullness by sex, U/L = 1 with moderate fullness not exceeding U/hL 30% is the most preferred by both but more by women, whereas U > L with exaggerated fullness is more preferred than exaggerated U/L = 1 by both but with more male preference (Fig. 5). (See table, Supplemental Digital Content 5, in which raw data for sex-based preferences of lip proportions and fullness are presented, http://links.lww.com/PRSGO/D556.) (See table, Supplemental Digital Content 6, in which raw data for sex-based preferences of lip proportions and fullness are presented, http://links.lww.com/PRSGO/D557.)

Table 6.

Significance of Observed Difference in Aesthetic Preference (Grade 1-2-3) of Exaggerated Lip Fullness [Pictures 1(5), 1(6), 2(5), 2(6)] by Sex

t Test: 2-sample Assuming Unequal Variances
	Variable 1 (M)	Variable 2 (F)
Mean	7.91666667	4.25
Variance	32.0833333	7.29545455
Observations	12	12
Hypothesized mean difference	0
df	16
t Stat	2.02409495
P(T ≤ t) one-tail	0.02999464
t Critical one-tail	1.74588368
P(T ≤ t) 2-tail	0.05998928
t Critical 2-tail	2.1199053

Fig. 5.

Percentage of favorable grading (1-2-3) of pictures of exaggerated lip fullness and percentage of highly aesthetic grade 1 lip proportions and fullness by sex.

DISCUSSION

The term “aesthetics” is derived from the ancient Greek “aisthesis,” which can be translated as “sensual perception.”⁶ Whether beauty is subjective or predefined by specific “standards” built into biased affinity for beauty and innate behavioral sensory attraction is still debated.^8,21 Of particular interest is the study confirming that, similar to how blind individuals can recognize danger, they can detect beauty without physical contact or any form of communication.⁶ Furthermore, from neuroaesthetic perspective, aesthetic experiences trigger special effects in well identified brain regions that are differentially activated by visual stimuli.^6,22,23

Preferred beauty ideals have changed over time and differed across and within cultures, countries, and even periods. Anecdotally, during the Renaissance period of hardship, women with significant body fat were considered beautiful.^21,24–27 However, although seeking to achieve beauty is a very natural behavior,^28,29 and although there may not be an absolute ideal of beauty, certain stable attributes have stood the test of time and cross-cultural variances and are universally accepted as ideal characteristics, supporting the notion of biologically based preferences of beauty.^{9,17,24,30,31}

Recent studies suggest that although attractiveness is thought to be based on individual taste, culture, popular trends, and sex, what each person perceives as beautiful stems from a complicated process influenced by peers, parents, and media as well as by perceptual adaptation.^{3,4,11,24,26,32} Much of what is currently considered ideal stems from a complex socialization process.²⁴ In today’s digital era, social media is one of the most relevant socialization agents. By playing a key role in fostering objectification and internalization of media beauty standards and increasing body surveillance, social media has transformed how we perceive ourselves and others.³³ Nevertheless, as much as it can perpetuate standards, social media holds great responsibility in cultural shifts, and in formulating societal norms and evolving ideals over time. By providing a platform to contribute content that challenges appearance ideals, it may also disrupt the visual environment of beauty and impose standards that fuel unattainable expectations.^3,32,34–37 Because advertising models are highly idealized comparison standards, upward contrastive comparisons are generally unavoidably made. This generates negative body image perceptions with explicit moral judgements of culpability and responsibility.^{24,29,35,36,38–40} But why can very different feelings be experienced by 2 different individuals of the same social group, with similar body shape and identical social influences?²⁴

Both psychological and emotional factors play a significant role in the motivation to modify one’s appearance. Compared with the general population, higher physical dissatisfaction scores and symptoms of psychiatric disorders are observed in 21%–59% of patients undergoing aesthetic procedures.^3,4 Furthermore, individuals’ unique personality determines in large part the “perceptual” awareness about body shape, size, or form. It influences also the “attitudinal” emotional component of body image that determines whether view of the body is pleasing or displeasing. Furthermore, one’s personality can focus attention in a way that may distort reality. It can lead also to biased judgments and determines the impact of these judgments on self-esteem. On the other hand, neuroticism associated with elevated levels of body dissatisfaction is of particular interest. Besides exhibitionism and vanity, the maladaptive conceptualization of narcissism reflects anger, resentment, interpersonal friction, and an unyielding demand for attention. Furthermore, by modifying perceptions of aspired-to ideal body and perfectionism, it adds another dimension to cultivation of body dissatisfaction.²⁴ Though it is clearly a socially desirable and admired attribute, this trait can be gravely maladaptive. It may be associated with various behavioral, emotional, and psychological problems, including depression, anxiety, fear of nonacceptability, eating disorders, and several personality and body dissatisfaction disorders.^24,41 However, influence of external factors that shape perception of beauty such as context and experience must not be overlooked. Perception of beauty in abstract artwork, for example, is altered after exposure to beautiful or nonbeautiful images. Likewise, averaging and contrastive effects determine how an individual’s beauty is perceived due to crowd biasing toward the group’s average.^7,9,22,41,42

There currently are genuine concerns regarding how beauty ideals are being promoted.^3,35,37,43 Most important is perceptual adaptation that has acquired special importance due to the currently wide infiltration of people’s lives by mass- and social media and the proliferation of altered images.^8,11,29,44 Perceptual adaptation can be triggered by irrelevant, unrealistic, and even absurd visual information. Not only overexposure, but even minimal exposure to manipulated and exaggerated features can lead to significant changes in one’s perception of beauty.^8,16,24 Shifting users’ perception toward the unrealistic ideal certainly needs to be seriously reconsidered.^8,29

Because full lips have historically been a major component of overall attractiveness and a youthful appearance, lip augmentation with soft tissue fillers has become one of the most popular and commonly performed minimally invasive procedures.^15,45,46 Despite variable lip shape preferences based on ethnicity, country of residence, and profession, and regardless of the influence of other facial features, an “ideal lip” is characterized by lower and upper lip balance of subtle proportion bringing out the best frame for smile.^{12,45,47–49} Ideally, the objective of lip augmentation is to create smooth lips with adequate volume and natural appearance and not to overaugment.¹⁷ However, despite the fact that modern facial beauty ideals have remained overall similar to historical cephalometric canons, a pouty, fuller lip appearance, or what is being referred to as “Russian lips,” has changed aesthetic perceptions and become a growing trend.^{12,17,18,20,31} Though some patients may intentionally seek an artificial look, most consider themselves to be achieving a natural look, admitting nevertheless a shift in their perception. Most describe social media impacting their perceived norms and that their expectations of attractive facial anatomy have adapted over time, losing track of what a normal lip shape would be. In fact, a study designed to investigate the impact of viewing faces with extreme versions of lips on evaluation of facial attractiveness and naturalness demonstrated that adaptation toward faces with extremely modified lips had a clear effect on assessment of attractiveness but not on naturalness,^15,16 challenging the widely accepted principle that composite-averaged faces are perceived as most attractive.^50,51 Unfortunately, misjudgment of what are acceptable anatomical norms may be addictive.¹⁵

Although social media have an undeniable influence on perception of beauty and a profound influence on how aesthetic interventions are being currently practiced,⁴¹ data provided by this survey confirm that standards of aesthetics have remained constant and that exaggerated requests of some patients may not be attributed solely to social media influence and perceptive adaptation but probably to social media in combination with additional underlying personal predisposing factors. It may be argued that the ultimate goal of aesthetic surgery is to harmonize body with spirit¹⁴ and that the outcome must fulfill patients’ requirements. As providers of aesthetic procedures, we should seriously question how rightful is the adaptation of our practice to social media’s ever-changing, unrealistic trends of beauty.^13,14,52,53 Our responsibility is to council patients that outcomes must enhance their natural beauty and must match the internal standard of beauty of those around them to be perceived as beautiful with less cognitive effort.^5,54,55 No matter how difficult it is, patients need to be educated by more open discussions to differentiate between temporary beauty trends and the universal standards almost always judged to be most attractive.^13,14,52,53 Furthermore, aesthetic providers have bioethical and professional obligations to educate themselves on new and relevant trends while ensuring adequate patient safety. They must also strive to generate transcendental beauty to reconcile classical ideals with patient desires, cultural nuances, ethnic considerations, and unavoidable neuropsychological factors. Nevertheless, in view of some discrepancies between classical rules and the current public’s beauty perception, and in view of current arguments that these rules and historically described ideals have become invalid in modern perception of beauty, classical golden standards apparently may need to be reconsidered.^25,30,56 It must be acknowledged, however, that beauty can only be achieved through the concept of harmony, consisting of appropriate proportions and symmetry and that elements of golden ideal proportions are still fundamental in perceived beauty, aesthetic emotions, and judgment.^6,21,57

There are some limitations to this study. Perception of aesthetics was evaluated in relation to 1 lip morphology and mouth width; it may not be representative of perceived attractiveness with different morphologies and facial proportions. Furthermore, survey participants represented a nonrandom subset of the general population that may have been biased; thus, findings may not be true representation of general aesthetic preferences. Nevertheless, the study allowed identification of general trends. Statistical analysis of data with significant observed differences, however, was limited; a larger number of survey participants may have allowed a more meaningful analysis.

CONCLUSIONS

Criteria of order, symmetry, and harmonious proportions that characterize what is viewed as beautiful remain largely unchanged. Though social media have some influence on perception of beauty and patients’ choices, and have definitely influenced how aesthetic interventions are being currently practiced, data provided by the present survey confirms that exaggerated requests of some patients may not be attributed solely to social media influence and perceptive adaptation but probably to some additional underlying personal predisposing factors. Patients must be made aware that as much as it is essential for them to be satisfied with their appearance, how they are judged by and match the internal standard of beauty perceived by others is just as important, if not more important. This does not mean, however, that an individual must indulge in aesthetic treatments and procedures only to please others. On the contrary, patients must pursue their own beauty ideals without being overly influenced by the opinions of others and society, including those on social networking sites, provided that these ideals remain within the unchanged boundaries of aesthetics; otherwise, their exaggerated requests, far from making them more beautiful, would make them a subject of ridicule in the eyes of others. We as physicians and providers of aesthetic treatments must be aware of this fact and counsel our patients accordingly.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.