Consensus Opinions on Facial Beauty and Implications for Aesthetic Treatment in Middle Eastern Women : Plastic and Reconstructive Surgery – Global Open

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Original Article

Consensus Opinions on Facial Beauty and Implications for Aesthetic Treatment in Middle Eastern Women

Kashmar, Mohamad MD*,†; Alsufyani, Mohammed A. MD, FAACS‡; Ghalamkarpour, Fariba MD§; Chalouhi, Micheline MD; Alomer, Ghanima MD, FRCPC‖; Ghannam, Sahar MD**,††; El Minawi, Hisham MD‡‡; Saedi, Babek MD§§; Hunter, Nahla MD¶¶; Alkobaisi, Abeer MD‖‖; Rafla, Karim MBBCh, MSc, MRCS***; Zari, Shadi MD, FRCPC†††; Abdel Razzak Elsayed, Mohamed MD, MRCS, MSc‡‡‡; Hamdan, Firas MD§§§; Santangelo, Samantha PhD¶¶¶; Khater, Mohamed MD, MS, MBA‖‖‖; Rogers, John D. MD, MPH‖‖‖

Author Information

From the *Cosmoderm Clinic, Prince Saud Al Faisal, Al Rawdah, Jeddah, Saudi Arabia

†Hazmieh International Medical Center, Beirut, Lebanon

‡Department of Dermatology and Dermatologic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

§Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Sacre Coeur Hospital, Beirut, Lebanon

‖Skin Clinic, Al Kuwayt, Kuwait

**Sahar Polyclinic, Kuwait City, Kuwait

††Department of Dermatology and Venereology, Alexandria University, Alexandria, Egypt

‡‡Kasr El Aini, School of Medicine, Cairo University, Cairo, Egypt

§§Facial Plastic Division, Department of Otolaryngology, Tehran University of Medical Sciences, Tehran, Iran

¶¶Faculty of Medicine, Cairo University, Cairo, Egypt

‖‖CosmPlastic Clinic, Um Al Hassam, Manama, Bahrain

***KR Aesthetics, Cairo Egypt, and Anglo American Hospital, Cairo, Egypt

†††Department of Dermatology, University of Jeddah, Jeddah, Saudi Arabia

‡‡‡Cosmetic Department, Royale Hayat Hospital, Kuwait

§§§Plastic Surgery, Highness Beauty Clinics, Beirut, Lebanon and Dubai, United Arab Emirates

¶¶¶Santangelo Consulting, Singapore, Singapore

‖‖‖Global Medical Affairs, Galderma, QMed AB, Uppsala, Sweden.

Published online 25 April 2019.

Received for publication November 18, 2018; accepted February 19, 2019.

Disclosure: Dr. Kashmar has been a consultant for Galderma, a consultant and trainer for Allergan, a speaker for Cynosure and Sciton, and a consultant and speaker for Viol. Dr. Alsufyani has been a trainer, speaker, and advisory board member for Galderma and a speaker for Merz. Dr. Ghalamkarpour has been a speaker for Ipsen. Dr. Chalouhi is a speaker and a trainer for Ipsen and Galderma. Dr. Alomer has served on advisory boards and as a trainer for Galderma, Allergan, and Sinclair. Dr. Ghannam has been a consultant and trainer for Galderma, Merz, and Allergan. Dr. El Minawi has worked as a trainer, speaker, and consultant for Allergan and Galderma. Dr. Saedi is a trainer and speaker for Galderma. Dr. Hunter is a trainer for Galderma. Dr. Alkobaisi has been a speaker and trainer for Galderma. Dr. Rafla is a trainer and speaker for Galderma. Dr. Zari is a trainer for Allergan and has attended advisory boards for Galderma. Dr. Abdel Razzak Elsayed has been a trainer for Galderma. Dr. Hamdan is a consultant and trainer for Galderma. Dr. Santangelo is a consultant for Galderma and Allergan involved in data gathering, data analysis, development of educational presentations, and manuscript writing. Dr. Khater is an employee of Galderma. Dr. Rogers was an employee of Galderma at the time this manuscript was written. This consensus project was funded by Galderma.

Mohamed Khater, MD, MS, MBA, Galderma Qmed AB, Seminariegatan 21 SE-75228 Uppsala, Sweden, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Plastic and Reconstructive Surgery - Global Open 7(4):p e2220, April 2019. | DOI: 10.1097/GOX.0000000000002220
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Abstract

INTRODUCTION

Aesthetic facial treatment to enhance beauty has become more normalized in traditionally conservative Middle Eastern societies following the emergence of internet-based social media. Rising standards of living and growing independence also enable increasing numbers of Middle Eastern women worldwide to seek treatment from aesthetic practitioners who may have been trained in the Middle East or elsewhere. The Egyptian queen Nefertiti has long symbolized and influenced perceptions of beauty worldwide and in the Middle East, but influential Middle Eastern beauty icons are otherwise scarce in contemporary media and consciousness. An analysis of more than 5,000 female models in fashion magazines from 12 countries suggested that the image of beauty was more the result of editorial decisions than objective principles, with North American and European magazines dominating these beauty standards.1

A survey of Saudi women revealed that improving self-esteem was their most common motive for undergoing a cosmetic procedure, and that wearing a veil is no barrier in seeking cosmetic treatment.2 A desire to boost self-confidence is now as important as improving the aesthetics of sagging skin, according to a commercial survey of nearly 8,000 women to assess the evolving beauty needs of women around the world.3

Literature describing standards of beauty across the Middle East is relatively scarce, compared with those for white, Asian, and African populations.4–10 The region is characterized by a wide range of ethnic and racial diversity, even within individual countries. What has been published rarely covers more than one Middle Eastern country or ethnic group. Thus, a lack of knowledge and insight into the aesthetic preferences and facial anthropometry of Middle Eastern women might lead practitioners inadvertently to impose Western beauty ideals or create aesthetic results without regard to culturally recognized or identified facial characteristics.

This consensus paper was developed to inform and educate practitioners worldwide who treat Middle Eastern women. It is aimed at those who may be unfamiliar with aesthetic preferences among women from different parts of the Middle East, or ignorant of their facial anthropometry. Based on the expertise of aesthetic experts from the Gulf, Iran, Lebanon, and Egypt, its objective is to describe subregional preferences regarding facial beauty among Middle Eastern women, their facial characteristics and aesthetic deficiencies, and the solutions that can be provided by facial injectable treatments.

METHODS

Female Middle Eastern beauty from the Gulf (comprising Bahrain, Kuwait, Saudi Arabia, and the United Arab Emirates), Iran, Lebanon, and Egypt (Fig. 1A) was evaluated. On the basis of their expertise and clinical practice location, 17 Middle Eastern dermatologists and plastic surgeons who had 7.5–25 (mean 13.5) years of experience in aesthetic medicine were invited to participate in this consensus project. The goal was to develop consensus opinions regarding facial beauty among Middle Eastern women. Following an initial advisory board in 2016, each member of the consensus group completed a detailed “workbook” structured to identify historical and contemporary influential icons of beauty, and descriptions of characteristic beauty in his or her own country/subregion. Using the findings from these workbooks, a more detailed multiple-choice SurveyMonkey (Galderma, Q-Med AB, Uppsala, Sweden) questionnaire was developed in 2017 to capture country-specific patient treatment preferences and standards of beauty for each facial feature.

F1
Fig. 1.:
Maps showing (A) countries and geographic subregions represented by the Consensus Group on Middle Eastern Beauty and (B) an overview of selected migration patterns that contributed to the ethnic origins of people in the Middle East.11–17

In September 2017, the available literature on Middle Eastern facial anthropometry, cephalometry, and perceptions of beauty was reviewed in preparation for a consensus meeting. PubMed was searched for English-language papers using the terms “facial,” “attractiveness,” “beauty,” “anthropometry,” “anatomy,” and “cephalometry” combined with each of the following: “Middle East/Middle Eastern,” “Bahrain,” “Dubai,” “Egypt,” “Iran,” “Jordan,” “Kuwait,” “Lebanon,” “Levant,” “North Africa,” “Palestine,” “Persia,” “Qatar,” “Saudi Arabia,” and “United Arab Emirates.” All detected abstracts were reviewed, and the data from relevant papers were presented at the meeting. The consensus group members (9 dermatologists and 5 plastic surgeons) completed the questionnaire, and 11 subsequently attended a one-day consensus meeting in Dubai, United Arab Emirates, in December 2017. The consensus opinions presented here are derived from the experts’ workbook and survey responses, their clinical experience, and peer-reviewed literature, and reflect the proceedings of the consensus meeting.

RESULTS

Origins of Modern Middle Eastern Populations

Egypt and the Arabian Peninsula have seen waves of migrations over the past 50,000 years, including the earliest human migrations from Africa to eastern Asia and back along ancient civilization trading routes, and more recent colonization by European and Asian peoples (Fig. 1B).11–14,18,19 Genotyping studies of Arabian Peninsula populations reveal 3 distinct racial “clusters” that reflect their primary ancestry: (1) Bedouin (genetically closest to Europeans); (2) Persian-South Asian (genetically between Bedouins and Asians, and from which many Iranians are descended); and (3) African (less closely related to the Middle East cluster).19 In Iran, Persian populations are descended from Aryan tribes who arrived from central Asia in the second millennium BC; mitochondrial DNA analyses reveal close affinities between Persians and European whites.20 Iranians’ Arabian genetic patterns are derived from people who migrated from Africa to Eurasia and settled on the Arabian Peninsula and southwest Asia.15,16 Modern Egyptian peoples’ physical characteristics are derived from the originally indigenous African populations, Arab ancestry, and Europeans (Crusaders, Greeks, and Romans).15,17 The Lebanese are descended from the Phoenicians, who had their origins in the eastern Mediterranean,21 and are also genetically influenced by the Islamic expansion from the Arabian Peninsula, and the European Crusaders, and Ottomans.14,17

Defining Beauty in the Middle East

Historical, Cultural, and Popular Influences on Middle Eastern Beauty

To gain an overview of Middle Eastern female beauty, the consensus group collected images of women that represented both historical and contemporary ideals of beauty in their respective countries. Nefertiti is identified as a historically influential icon of beauty in many Middle Eastern countries; influences in Iran included paintings and the actress Soraya Esfandiari. Other 20th century beauty icons identified by members from several subregions included Princess Fawzia, and actresses Soad Hosni, Mariam Fakhr, and Mervat Amin, all originally from Egypt, where visual representation of women has traditionally been more commonplace.

Contemporary icons of beauty look more traditionally Middle Eastern. They include Saudi princess Ameera Al-Taweel, Lebanese actors Haifa Wehbe and Nadine Njeim, Iranian actors Golshifteh Farahani, Niki Karimi, and Leila Hatami, and Queen Rania of Jordan, who is of Palestinian origin. Nevertheless, the contemporary icons chosen by the group showed that Western beauty standards and media strongly influence contemporary Middle Eastern perceptions of beauty. For example, Angelina Jolie was selected as a modern beauty icon by several consensus group members because their patients frequently ask to look like her.

In summary, the Middle Eastern beauty icons’ faces are oval, full and symmetrical, with elevated, thick, arched eyebrows; almond-shaped eyes; straight noses; well-defined, laterally full cheeks; full lips; well-defined jawlines; and prominent, pointed chins.

Middle Eastern Facial Anthropometry

In addition to understanding the factors that affect perceptions of facial attractiveness,6,7,22 knowledge of facial anthropometry is important in aesthetics, because the facial skeleton and its soft tissue coverage differ by race and ethnic group. Table 1 shows comparisons of anthropometric and cephalometric measurements of different Middle Eastern populations (broadly described as Arabian, Persian, Levantine, and Egyptian) with those of whites (usually North Americans, as measured by Farkas et al30). These cited features in Table 1 are well represented within the framework developed by Cunningham et al38 who have studied female physical attractiveness from a cross-cultural perspective. Their model of how female beauty is perceived is based on physical features and characteristics that relate to 3 categories: innate features of a newborn infant which suggest desirable qualities of vivaciousness, openness, and agreeableness (conveyed by the physical dimensions of the eye and nose); facial features relating to sexual (developmental) maturity that may convey status, competence, and confidence (conveyed by facial width and the shape and projection of the midface and chin); and expressive features that support nonverbal expression (conveyed by the width and shape of the mouth and lips).38

T1
Table 1.:
Comparative Facial Anthropometry between Middle Eastern Women and North American Whites

The literature search showed that, although several anthropometric studies of Iranians are found, very few articles relevant to the populations in the Levant or Egypt have been published. Data from the Gulf region are represented mainly by studies on Saudi populations and are incomplete.

When facial anthropometric measurements of attractive young Iranian and average white women were compared, lip projection was greater in the Iranians, the nasofrontal angle was larger (ie, the nose was less projected), and their faces were more convex.31 In another study of attractive versus unattractive Iranians, the attractive women had straighter profiles, less prominent noses with higher nose tips, slightly more protruded maxillae, longer lower faces (or shorter middle faces), more protruded upper than lower lips, and lips positioned closer to the middle of the vertical chin–nose distance.39 A third study of Iranian women showed that the more attractive the subjects’ profiles were judged to be, the closer their facial ratios are to phi, the Divine Proportion.40

In a United Arab Emirates study on facial profile attractiveness, a straight profile was the most frequently perceived to be highly attractive, and the least attractive profiles had mandibular retrusion.29 A straight profile was also the most favored in a cross-sectional survey of facial profile preferences in Lebanon.33 The anthropometric measurements of aesthetically pleasing young Saudi adults’ faces were compared with those in other Arab populations and races, and with the neoclassical canons.23 Compared with the canons, the attractive Saudi women generally had a wider intercanthal distance than eye fissure length, and a wider nasal width than intercanthal distance. They also had longer upper and middle facial thirds, a shorter lower third, a greater eye fissure length, a shorter intercanthal distance, and greater nasal width than white women.

Thus, important anthropometric differences exist in comparison to western populations, but also within the Middle East. Conflicts with ethnic identity or facial disharmony may be created if western-derived neoclassical canons of beauty6,30,41,42 are used as the only guide when planning facial treatment for Middle Eastern women.

Consensus on Facial Beauty in Middle Eastern Women: Universal Similarities and Subregional Differences

The perception of facial beauty is highly individual. It is influenced by social status, race, cultural factors, and familial background. It was therefore agreed to develop consensus opinions about beauty preferences, rather than defining “standards” of beauty among Middle Eastern women.

Asked to define which facial features are the most important in defining the unique beauty of women in their country, the eyes, followed by the lips and cheeks, were the features most commonly selected by the consensus group (Fig. 2). The consensus opinions on Middle Eastern female beauty and local/subregional preferences summarized in Table 2 are derived from the members’ workbook and questionnaire responses, their discussions, and existing literature, and were agreed during the consensus meeting and by all members during the manuscript writing process. Examples of women who exemplify female beauty for each Middle Eastern subregion are shown in Figures 3–6.

T2
Table 2.:
Summary of Consensus Opinions on Preferences Regarding Ideal Female Facial Beauty in the Middle East and Its Subregions
F2
Fig. 2.:
Opinions regarding the facial features that define Middle Eastern beauty. Consensus group members’ responses to the survey question: “Which 3 facial features are the most important in defining the unique beauty specific to women in your country of practice (choose only 3 features and rank them in order).”
F3
Fig. 3.:
Examples of Middle Eastern beauty among women from the Gulf.
F4
Fig. 4.:
Examples of Middle Eastern beauty among women from Iran.
F5
Fig. 5.:
Examples of Middle Eastern beauty among women from Lebanon.
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Fig. 6.:
Examples of Middle Eastern beauty among women from Egypt.

The complexion should be clear, with minimal pore visibility. Skin tones vary throughout the Middle East, but a tone that is lighter than the natural skin color of each ethnic group is preferred.

Throughout the Middle East, the desired facial shape is generally oval, although ethnic and cultural differences may impact this preference. The type of head covering or veil worn may influence the facial shape preference and the strong preferences regarding the appearance of the eye and periorbital area. For example, in the North and South of Kuwait, rounder faces with fuller cheeks are preferred among women who wear a full hijab, because it looks more attractive than a thinner, more narrow face enveloped by the scarf. The foreheads of beautiful Middle Eastern women may be convex or flat, high or short, but temple fullness is preferred, because if it is worn, a head covering reduces visibility of the upper and middle third of the face. Much emphasis is placed on the distinctiveness and beauty of the eyes and periorbital area. The eyes are the most prominent and important facial feature in a woman who wears a niqab. Large, wide, striking, almond-shaped eyes are considered the most beautiful. A wide upper lid margin area that further emphasizes the eye is desirable. The preferred shape for eyebrows is arched and elevated, and lateral eyebrow flare may be preferred over arched eyebrows in Egypt and Iran. Thicker eyebrows are preferred by most Middle Eastern women, although preferences regarding thickness may differ between regions.

In the midface, the general preference is for cheek fullness, with prominence laterally, defined cheekbones, and slight medial fullness. A subregional preference in the northern and southern Gulf is for full cheeks and a round face, due to the Bedouin influence. By contrast, the urban preference is generally for submalar hollowness. In Kuwait, urban beauty preferences are for prominent cheeks with a defined submalar area and jawline; prominent nasolabial folds are very undesirable. A small, short, narrow, straight nose is most commonly desired, but preferences for tip shape vary.

The lips are generally full and defined, but preferences for the ratio of upper-to-lower lip fullness and height differ subregionally (Table 2). In beautiful Middle Eastern women, the jawline is well defined, ending in a pointed, moderately anteriorly projected chin.

Patient Preferences and Implications for Treatment

According to this consensus group, the most important influences that prompt younger Middle Eastern women to seek aesthetic treatment are social media and their friends (Fig. 7). Among women aged 40 years or older, their own opinions, friends, and husbands are the strongest influencing factors. In general, Middle Eastern women, particularly those younger than 40 years, wish to retain a natural appearance without exaggeration of facial features. However, some young women, influenced by social media, want to resemble their beauty icons even if this conflicts with their native anthropometry. In contrast, the priorities for middle-aged women relate mainly to facial aging and the need for a lift effect in the mid and lower face.

F7
Fig. 7.:
Factors that influence Middle Eastern women’s perception of their appearance and decision to seek cosmetic treatment. Consensus group members’ responses to the survey questions: “What are the most important influences on a woman’s appearance and decision-making regarding getting aesthetic treatments for women younger than 40 years/aged 40 years or older?”

Common facial aesthetic issues in Middle Eastern women and the solutions that can be delivered by facial injectable treatment are summarized in Table 3. The consensus group also agreed on the following general points regarding facial aesthetic treatment of Middle Eastern women. In the Gulf, foreheads are seldom volumized to create convexity. Treating the temples is key to maintaining the “inverted triangle of youth” and they should be treated first. Filling the temples and the area above the zygomatic arch can create an upward vector to provide slight lifting of the cheeks and even the lip corners. Lifting the lateral eyes and brow can also be achieved by temporal correction. Tear troughs are corrected after treatment of the mid-cheek. The focus on the periorbital area and midface reflects the importance of youthful eyes and angular cheeks.

T3
Table 3.:
Consensus Opinions on Common Facial Aesthetic Concerns among Middle Eastern Women and Solutions that Can Be Provided by Injectable Treatment

Middle Eastern women have heavier faces that show age via sagging and jowling. Thus, it is important to lift, rather than augment, the midface when it is usually already full. Older women may request cheek volumization to achieve the desired appearance of a lift, but a more laterally placed treatment vector with a high-lifting-capacity hyaluronic acid will improve the appearance of the jawline and reduce jowling.

In the Middle East, a large or misshapen nose is a common complaint that usually requires rhinoplasty, but injectable treatments may address certain issues (Table 3). In Iran, patients often request removal of a nasal hump or to address a nose that is too large. In Egypt, nasal dorsal depression, a depressed nasal bridge, thick nasal covering, or wide nostrils are common aesthetic issues.

The consensus group cautioned against treatments to narrow the lower face of Middle Eastern women in contrast to the trend in Asia,5 where a large bizygomatic width and prominent mandibular angle are deemed undesirable. Treating the angles of the mouth first can increase lip width and create an upward angle, which are signs of youth. Defining and augmenting the chin can help to improve the overall appearance of the lower third of the face, including the oral commissures and pre-jowl sulcus.

CONCLUSIONS

This is the first consensus paper to describe the facial anthropometry, beauty ideals, and treatment implications for Middle Eastern women across 4 ethnically distinct subregions. The size and collective experience of this consensus group are similar to those of groups that have published consensus opinions on beauty and recommendations for facial aesthetic injectable treatments in other regions.5,10,43,44

Middle Eastern facial beauty is defined mostly by the eyes, followed by the lips and cheeks. Despite subregional differences in preference, female beauty in the Middle East is generally characterized by an oval or round face; large almond-shaped eyes; prominent, elevated, arched eyebrows; a small, straight nose; well-defined, laterally full cheeks; full lips; a well-defined jawline; and a prominent, pointed chin.

The most common and challenging aesthetic issues among Middle Eastern women are heavy faces (particularly in the Gulf, Egypt, and some Lebanese); a flat midface (generally cited by women younger than 40 years, although rarely in Iran); noses that are too large and prominent or alternately, too flat and wide; thin lips; jowling and/or an ill-defined jawline; and a small or underprojected chin.

Narrowing of the lower facial third is deemed undesirable by Middle Eastern women who seek aesthetic treatment. In some subregions (eg, Jeddah and western Saudi Arabia), a convex forehead, retroussé nasal tip, and an upper lip thinner than the lower lip are undesirable.

The majority of Middle Eastern women seek to enhance their beauty either by restoring aspects that have changed with aging, or by correcting or enhancing facial features associated with their ethnic beauty. Knowledge of Middle Eastern ethnic anthropometry and subregional beauty preferences and aesthetic deficiencies or weaknesses are key to developing an effective facial enhancement strategy that will optimize and beautify the Middle Eastern woman’s features without sacrificing facial harmony or her ethnic identity.

ACKNOWLEDGMENTS

Dr. Hassan Galadari, MD (United Arab Emirates), and Dr. Ahmad Ibrahim, MD (Qatar), also made valuable contributions to the Consensus Group for Middle Eastern Beauty.

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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.