The appearance and architecture of the human face is a product of the skin underlying bone and muscle and the amount and distribution of subcutaneous fat. Visible signs of aging include the formation of facial lines and folds, a decline in skin quality, an increase in skin pigmentation, and loss or redistribution of soft tissue volume and bone.1–4 The signs of facial aging have been reported to first manifest in women by the age of 35 years with the appearance of lines in the periorbital area.2
Self-esteem may erode in women in parallel with a decline in self-perceived attractiveness and self-confidence in appearance.5–7 Younger women may seek aesthetic treatments to retain a youthful appearance, particularly once they notice the first signs of aging, whereas older women may seek treatment with the aim of reversing some of the negative effects of aging such as facial lines, folds, and loss of volume. Although individual physicians may have general perceptions of patient treatment preferences in their practices, there are no systematic data available that describe either the specific concerns that prompt women to seek treatments or their preferences for facial areas requiring treatment.
The aims of this cross-sectional research survey were to determine the facial areas that were most likely to be treated first among women who are considering facial treatment, to understand whether there is a correlation between areas of most concern and the areas that respondents planned to treat first, and to identify whether there were differences in treatment preference between younger and older women in a distinct subpopulation of women who were most likely to present at an aesthetic physician's office.
The facial treatment preferences of aesthetically aware women were assessed in an online research survey in which they were questioned about demographic factors, the facial areas of most concern to them, and how they would prioritize treatment of their areas of concern. Women qualified to participate in the research survey if they were aged 30 to 65 years, had a household income of at least $50,000 per year, had discretionary income (answered affirmatively to either of the following questions: “I have some discretionary income, but I really have to prioritize how I use it” or “I have enough discretionary income to meet most of my personal needs”), and were “aesthetically orientated” as defined by a self-rating of 5 or 6 on a scale of 1 to 6 for one or both of the following statements: “I care about improving my facial appearance” and “I want my face to look good for my age.” Respondents were further eligible if they were naive to neuromodulator and dermal filler treatments but were aware of onabotulinumtoxinA and were considering at least 1 medical facial treatment in a physician's office in the next 2 years, such as neuromodulator treatment, dermal fillers, laser skin resurfacing, physician strength chemical peels, or facial plastic surgery.
The research survey was conducted between July and August 2013 in the United States. Invitations to participate were sent electronically to members of a large web-based research panel. Invitations were distributed in proportion with the regional population distribution of the United States, based on census data, and quotas were established to ensure adequate representation across the required age range and household income distribution. The survey assessed women's opinions on 14 distinct facial areas, specifically forehead, glabella, temporal region, lateral canthal area, infraorbital, cheeks, nasolabial folds, lips, perioral area including perioral lines, oral commissures and marionette lines, jawline, chin, and eye lashes (Figure 1). For each facial area, women were asked to rate the degree to which they were bothered by the appearance of the area on a scale of 1 to 6, where 1 represented “not bothered at all” and 6 represented “very bothered.”
To determine which facial areas were most likely to be treated first, women were presented with 14 different combinations of 3 of the facial areas described above, and using the Maximum Difference (MaxDiff) scaling system (Sawtooth Software, Inc., Orem, UT),8,9 they were asked to select the 1 area “most likely to treat first” and the 1 area “least likely to treat first” for each combination presented.
Correlation analyses for the most bothersome facial areas and areas most likely to be treated first were conducted as part of the MaxDiff analysis using a logit transformed function with 95% confidence bands (Sawtooth Software, Inc.).8 Descriptive statistics were reported for demographic data.
Six hundred and three women with mean age of 52 years and mean income of $106,600 per year participated in the research survey. Eighty-two percent of women were married or living as a couple, 52% were in full-time employment, and 59% had completed some college or had graduated from college (Table 1).
When asked to determine, using the MaxDiff scaling system, the facial areas that they would most likely treat first, women believed that crow's feet lines (CFLs) were the highest priority facial area to treat, being selected as the most likely option 82% of the time. This was followed by oral commissures (74% of the first preferences), tear troughs (72%), forehead lines (66%), glabellar lines (65%), and nasolabial folds (56%). Cheeks (22%), chin (24%), and temples (27%) were the least likely facial areas to be prioritized for treatment (Figure 2).
When asked to identify the facial areas that bothered them the most, respondents were most concerned with their CFLs and tear troughs, as determined by a ranking of those areas scoring 5 or 6 on the “bothersomeness” question for these areas (tear troughs, 32% of women, CFLs, 30% of women). These were followed by forehead lines and glabellar lines (25% of women for each), nasolabial folds and oral commissures (24% of women for each), and eye lashes (22% of women) (Table 2).
To establish whether there was a relationship between the degree of concern with a particular facial area and the likelihood that it received a high treatment preference, the authors performed a correlation analysis. A strong correlation was observed between the 2 variables (r2 = 0.77), suggesting that in the overall survey population, there was a high degree of consistency between facial areas of concern and those that women would desire to treat (Figure 3). There were some notable exceptions, including the eye lashes, which although of significant concern to respondents, were not prioritized for treatment compared with other facial areas of similar concern.
To understand whether there were differences in treatment preferences between younger and older women, the authors contrasted the treatment preferences and areas of concern for the 30- to 34-year age group (n = 63) with those of the 60- to 65-year age group (n = 113). Based on the responses, it was clear that the younger group believed that features of the upper face were most important to prioritize for treatment, specifically CFLs (89%), tear troughs (81%), glabellar lines (73%), and forehead lines (71%). In contrast, although these facial areas were still relevant in older women, treatment priority was shifted toward the features of the lower face, in particular, the perioral area, with oral commissures selected as “most likely to treat” 80% of the time, nasolabial folds (62%), marionette lines (59%), perioral lines (54%), and the jawline (50%) (Figure 4A).
The relative difference in preferences for different facial areas is presented in Figure 4A,B. The largest numerical increase in preference in the 60- to 65-year age group over the 30- to 35-year age group was seen in marionette lines (+24%), then jawline (+22%), followed by nasolabial folds (+17%). In contrast, the facial areas with the largest decreases in preference in the oldest cohort were forehead lines (−19%), glabellar lines (−17%), and CFLs (−14%) (Figure 4B). These findings suggest a clear shift in women's aesthetic preferences toward the lower face in the 60- to 65-year age group.
The facial areas of concern for the 2 age cohorts are generally aligned with the differences observed in preference, with the younger age group most concerned with lines in the upper face. Fifty-one percent of women in the 30- to 34-year age group rated CFLs as 5 or 6 on the 6-point bothersomeness scale (Table 3). This was followed by forehead lines (46%) and glabellar lines (38%). Women in the older age group were most bothered by their marionette lines (30%), followed by jawline (29%), oral commissures (28%), and nasolabial folds (27%). Both the younger and older groups were equally bothered by their nasolabial folds (Table 3).
The findings from this cross-sectional research survey suggest that aesthetically oriented women are most bothered by and prefer to prioritize the treatment of upper facial lines, tear trough area, and eye lashes. The perioral area is also important, including nasolabial folds, oral commissures, perioral lines, and marionette lines. Furthermore, the authors observed age-related differences in treatment preferences, with younger women being most concerned by features of the upper face, whereas older women were increasingly concerned by features of the lower face and less concerned with the appearance of their upper face. In this population, CFLs were identified as the facial area that was most commonly prioritized for treatment in women aged 30 to 65 years. Tear troughs, forehead lines, and glabellar lines were also considered high priorities and reflect the importance of the appearance of the periorbital area (Figure 2).
This research survey was not designed to be reflective of the entire female population rather by way of the inclusion/exclusion criteria it sought to study the aesthetic treatment preferences of women selected for their likelihood to present at an aesthetic physician's office. The majority of participants were in full-time employment and had completed some college or graduated from college (Table 1). Moreover, they defined their income (mean $106,600 per year) as sufficient to meet most of their discretionary needs. It is noteworthy that a high proportion of women were married or living as a couple (82%), perhaps suggesting that women did not undergo treatment to attract a partner but rather to achieve their personal beauty goals or to retain their current partner.
In this sample population, CFLs were the most desirable facial area to treat. In addition, tear troughs, forehead lines, and glabellar lines were high priorities and reflect the importance of the periorbital area (Figure 2). The authors' clinical experience supports these treatment preferences, as women dislike dark under eye shadows and aim for a contoured facial look.
The authors observed a strong correlation between the facial area that concerned women the most and the area that women felt the greatest need to treat (Figure 3). However, there were some notable exceptions to this pattern. Specifically, although the tear trough was identified as being of a similar degree of concern as CFLs, it was less likely to be prioritized for treatment. Similarly, eye lashes were identified as being of a similar degree of concern to forehead lines, yet they were less likely to be prioritized for aesthetic treatment (Figure 3). It is possible that differences in the likelihood of a facial area being prioritized may be due to a woman's awareness of the availability of aesthetic procedures to address specific facial areas.
The most pronounced differences in treatment preferences between younger and older women were demonstrated by examination of the percent point differences between features of the upper and lower face. Specifically, older women had a ≥15% lower preference for treating glabellar lines and forehead lines but had a ≥20% increase in treatment preference for marionette lines and the jawline (Figure 4B). These differences are also reflected in the relative degree to which the 2 groups were concerned with the appearance of the upper and lower facial regions (Table 3). These findings are supported by the authors' clinical experience, specifically in women younger than 45 years, features of the upper face are more likely to be treated first, whereas women aged 50 years and older have an increased preference for treating features of the lower face.
These data lend support to the concept of the “facial triangle” or the “triangle of youth,” which is frequently discussed.1,10–13 This refers to the facial shape commonly associated with youth or beauty, with the base of the triangle at the level of the eyes or zygomatic region and the apex located at the chin.1,10–13 In younger women, the majority of facial volume is contained within this triangle.10–13 With age, the facial triangle has been described to invert, with the descent of the midface and consequent redistribution of mass to the lower face. In support of this concept, the data illustrate the clearly differing areas of concern and treatment preferences in older and younger women: younger women are most likely to prioritize treatment of lines in the upper face, whereas older women show an increased preference for prioritizing treatment of the oral commissures, nasolabial folds, marionette lines, and other lower facial areas.
In general, the authors observed that treatment prioritization was given primarily to areas in which lines or folds are the most common complaint. The authors found that areas requiring reshaping, such as chin and jawline, cheeks, or temples, were of lower priority for treatment. Structural changes to the face are more commonly observed with older age groups, as significant fat redistribution or skeletal remodeling is not typically a feature of the younger face. The findings may therefore reflect the broad age range of the survey and the fact that while older age groups were included, the mean respondent age was 51 years.
Overall, the results show that aesthetically oriented women, on average, are more concerned by facial areas susceptible to the appearance of lines and folds rather than areas of structural change affecting facial shape such as cheeks, chin, and temples. It is possible that this is because in younger individuals, the appearance of lines and folds represents the first signs of aging, and this may disrupt for the first time their perception of facial balance or harmony. The data also show that as women age, they are less concerned by and are less likely to prioritize treatment of upper facial lines. This may be because these lines have become consistent with their self-image and that of their peers and therefore do not affect their perception of facial balance. Instead, older women are more likely to be concerned with changes in soft tissue such as alterations in subcutaneous fat volume and distribution, which may result in sagging skin and heaviness of the jawline, marionette lines, and perioral lines.
It may be argued that the population of respondents may not be representative of the female population in general; however, this was not the intent of the research survey. Rather, it was intended to sample a distinct subpopulation of women who were most likely to present at an aesthetic physician's office. The strengths of the research survey include the cross-sectional design and use of the MaxDiff scaling system to assess the relative importance of items by forcing respondents to pick facial areas “most” and “least” likely to be treated, thereby eliminating scale bias while providing robust individual-level preference estimates.8
In summary, this is the first research survey examining the treatment preferences of aesthetically aware women with the means to avail themselves of treatment. The results suggest that these women are most concerned with the appearance of their upper face and will prioritize treatment of this area. Furthermore, facial treatment preferences may change with age, with women becoming less concerned by features of the upper face as they age, while becoming increasingly concerned by features of the lower face.