On Beauty: Title and subTitle BreakEvolution, Psychosocial Considerations, and Surgical Enhancement FREE

Beauty, according to the Oxford English Dictionary, is "a combination of qualities, including grace of form and charm of coloring that delights the sight or other senses."¹ (p8) In practice, beauty may be easier to recognize than to define. We may each know it when we see it, hear it, or smell it, but to accurately describe beauty or the features that impart it to a face, song, or scent can be daunting. Aaron Spelling, the Hollywood producer, explains that he "can't define it, but [he] know[s] it when it walks into the room."² (p8) Physiological reactions may be triggered by the sudden apprehension of the beautiful object, as one modeling agent has noted: "It's when someone opens the door and you almost can't breathe."² (p8) In narrow usage, as applied to persons, beauty may be characterized as an individual or societal assessment of attractiveness influenced by cultural standards (Figure 1).

The power of beauty in human affairs has been expounded since the advent of writing. Plato understood that to be beautiful was 1 of the 3 wishes of every man, the other 2 being good health and riches acquired by honest means. Aristotle concurred, conceding that "beauty is a greater recommendation than any letter of introduction."² (p31) Female beauty, in particular, has inspired poets and philosophers and has been seen as a gift that provides entrée into secret domains. Jean de la Bruyere wished in 1688 "to be a girl and a beautiful girl from the age of 13 to the age of 22 and then after that to be a man."² (p9) Dire conditions have not deterred people from practicing culturally mandated beautification activities. Even during famines, the Kalahari bushmen of southern Africa apply animal fats as skin moisturizers.³ Similarly, the insistence of the 18th century French nobility to use flour to powder ornamental wigs precipitated food shortages and rioting.⁴ While in contemporary Western society beauty may be exploited for socioeconomic gain, beauty itself is not a new cultural construct.

Formally measuring beauty is a human enterprise, and one that also has historical antecedents. The early Greeks were among the first to appreciate aesthetic perfection in terms of numeric symmetries and proportions. Phidias the sculptor based his creations on golden sections or rectangles; he used divisions of a line to create ratios of proportion in which the smaller was to the larger segment as the larger was to the whole (1:1.618).⁵ Later Europeans accepted the relations between limb size, torso, and facial features seen in classical sculptures as the 3-dimensional representation of the ideal human form. Durer,⁶ during the Renaissance, developed a new system of physical proportions that used as a benchmark the length of his finger. Other criteria for beauty required dividing the face into quadrants or thirds, and then mandating that the height of the ear and the nose be equal, the distance between the eyes be the width of the nose, the mouth be 1½ times the width of the nose, and the inclination of the nasal bridge parallel the main axis of the ear. Although these various systems were not necessarily compatible with each other, in each, beauty was equated with symmetry and defined in terms of immutable ratios.

Provided that his or her measurements were as prescribed, it was believed, a person would of necessity be perceived as beautiful. Modern attempts to verify the validity of these schemes by analysis of photographs of attractive people have not been successful. Apparently, fixed proportions are not essential for beauty, and the proposed ratios are even less likely to occur in the facial features of nonwhite beautiful individuals (Figure 2).^{7 - 8}

While beauty may not be reducible to a few simple ratios, it is also not an accident of nature. The existence of beauty is at least on 1 level an evolutionary adaptation for ensuring the survival of the species. Darwin,⁹ in the Descent of Man and Selection With Relation to Sex, agreed that the plumage of peacocks conferred to the best-endowed a reproductive advantage rather than a survival advantage.

The situation is the same for humans. Beautiful people may be more likely to be relatively healthy and able to reproduce because beauty is a physiologic burden that only a strong body can support.^{10 - 11} According to the pathogen-resistance theory of beauty, beauty is a marker for pathogen-free status in a potential mate.¹² Indeed, in cultures with numerous pathogens and high disease prevalence, physical attractiveness is rated as more vital in mate selection than in cultures without so many pathogens.¹³ Average size and shape,^{14 - 15} bilateral symmetry,^{16 - 17} and skin free of blemishes suggest the absence of acquired or inherited health disorders. Hourglass figures are more consistent with reproductive and general health in women than are body shapes with relatively larger waists. ^{18 - 19}

Differences in standards of beauty for men and women can also be seen in terms of an evolutionary argument. Size and muscle power is valued among men as they were once needed to obtain and defend resources. Now there are financial and political proxies for physical strength, but in the words of Henry Kissinger, "power [remains] the ultimate aphrodisiac."²⁰ (p78) Young, fair, curvaceous women are perceived as beautiful because they are more likely to be nulliparous and hence fertile.^{21 - 23} Women's hair and skin is permanently darkened following pregnancy,^{24 - 25} and waist-to-hip ratios in excess of 0.8 are associated with a diminished chance of pregnancy.^{26 - 27} That "beauty is not so much in the eye of the beholder as on the brain circuitry of the beholder" is demonstrated by the behavior of infants.²⁸ Three- to 6-month-olds stare longer at photographs of attractive, unfamiliar faces than at unattractive unfamiliar faces and play for relatively longer durations with attractive dolls and attractive strangers than with less attractive dolls and strangers.^{29 - 31} The features most attractive in young women, as Konrad Lorenz³² has noticed, may be those that remind us of babies' soft, clear skin and hair, big eyes and cheeks, and small noses. In short, beauty may be in the eye of the beholder, but those eyes and the minds behind the eyes have been shaped by millions of years of human evolution.³³ Nancy Etcoff, in Survival of the Prettiest, explains that beauty is a universal part of human experience that promotes pleasure, rivets attention, and impels action that helps ensure survival of our genes.² (p233) People value beauty in a mate because other qualities essential for parenting, such as fidelity, reliability, kindness, and intelligence have no physical markers.

The importance of beauty in social discourse is thus not accidental or a cultural construct. Rather, the survival of the species depends on individuals making accurate assessments regarding the suitability of a potential mate. To this end, beauty is interpreted as implying health, and health as ensuring reproductive capacity. At a deep biological level, we prefer beautiful mates because we want viable offspring.

The evolutionary bases of beauty are confirmed by cross-cultural investigations that reveal similar standards of beauty in diverse cultures.^{34 - 36} One oft-cited study entailed interviews of more than 10 000 individuals from 37 cultures indigenous to 6 continents.^{37 - 38} In each case, physical attributes suggestive of youth and health such as smooth, unscarred skin and muscular physique were associated with physical attractiveness. Although skeptics have suggested that obsession with physical attractiveness is a product of popular culture in the West, in this study one third of the non-Western cultures examined actually emphasized physical attractiveness more than a subset of US college students. Other work has yielded consistent results, with beauty more highly regarded than personality traits such as dependability, emotional stability, and maturity.^{39 - 41} Specific features associated with beauty vary slightly, and agreement is greatest among cultures that are racially matched.^{42 - 44}

Indeed, notwithstanding the evolutionary foundations of beauty, its expression is modified by cultural factors. Facial features associated with a dominant or socially successful group may be deemed more attractive.^{45 - 46} One study suggests that the criteria for beauty may possibly be subtly altered by prevailing economic conditions. Prosperous times may breed increased attraction to baby-faced, dependent-looking individuals; lean years, to mature faces more associated with security (Figure 3).⁴⁷

Certain body shapes are universally accepted as beautiful. Female faces are judged most attractive when they have small chins, delicate jaws, full lips, small noses, high cheekbones, and large and widely spaced eyes.⁴⁸ Relative facial proportions among beautiful women in their late teens and early 20s have been assessed by computers to be very close to those typically observed at a chronological age of 6 to 7 years.⁴¹ Waist-to-hip ratios approximating 0.7, the extreme gynoid shape seen in supermodels, are considered most desirable.^{49 - 53} For men, the ideal face is a dominant, rectangular one, replete with prominent chin, deep-set eyes, and a heavy brow. Taller, muscular men with a V-shaped torso (with waist-to-hip ratio of approximately 0.9) are preferred,^{54 - 61} but hypermasculine facies can appear threatening.^{62 - 63} Lustrous, abundant hair and clear skin are signs of beauty in both men and women.⁶⁴

Averageness of features is, paradoxically, consistent with above-average attractiveness.^{65 - 67} Sir Francis Galton,⁶⁸ a cousin of Darwin and inventor of fingerprinting, accidentally discovered this while creating composite photographs of criminals in an attempt to elucidate any commonalities. The composite images were invariably better looking than the original portraits from which they had been derived. Much later, in 1979, Don Symons¹⁵ pursued this finding, and asserted that average faces are relatively more beautiful. The conclusion is intuitive, to the extent that the average face or facial feature is by definition less likely to be too large or small to meet criteria for beauty. Symmetry, especially with regard to the left and right sides of the face, is associated with beauty for the same reasons. Bilateral symmetry additionally seems to be inherently pleasing to the human eye. Still, averageness and symmetry are insufficient to produce outstanding beauty. One-of-a-kind beauty is not average, but rather entails a constructive magnification or diminution of at least 1 feature (Figure 4).⁷⁵

Among faces that have equivalent features at rest, those with more positive expressions are judged more attractive than those with less positive expressions.^{76 - 80} Welcoming and open appearance, however, influences perceptions of attractiveness only to a limited degree. Smilers are regarded as only slightly more attractive than non-smilers.⁷⁹

Considerable research demonstrates that people prefer familiar faces.^{81 - 82} We like our own images better when we view them in a mirror rather than in a photograph. Close friends, conversely, prefer our photographic images, the likenesses that are most familiar to them.⁸³ Manipulations that render faces more familiar increase attractiveness.⁸⁴

Despite the existence of universal, cross-cultural standards for beauty, there is no precise recipe. Moreover, standards have changed subtly over time. Western cultures are now less likely to associate facial hair and large wigs with beauty than were the Romans or the "big wig" European aristocrats of the 17th and 18th centuries.^{85 - 87} Recent decades have witnessed a gradual yet inexorable decline in the ideal female hip-to-waist ratio, and a concomitant increase in the thinness and height of female models.^{88 - 91} These trends seem to be plateauing because the recommended ratios have collided with the bounds of the physically possible (Figure 5).^{53 ,92}

The evolutionary foundations of the features that constitute beauty are important, but they only begin to explain the startlingly pervasive role of beauty in human society. Simply put, we do not perceive beauty as merely a pleasant form, or a beautiful person as merely an eligible mate. Beauty is, instead, unconsciously widely accepted as a marker for other positive attributes. Sappho's observation that "what is beautiful is good"⁹³ may be philosophically debatable, but in practice the beautiful is routinely judged to be qualitatively superior. Mental acuity, interpersonal skills, employability, and moral goodness are all associated with physically beautiful individuals.^{94 - 95} The magnitude of the effect is, in most cases, small to moderate. Teachers presented with report cards and photographs of students expect the better looking to be more intelligent, sociable, and popular when academic performance is objectively equivalent.⁹⁶ Actual classroom grades are higher for more attractive students, and this difference disappears on standardized tests.⁹⁷ Beautiful people are believed by others to have better lives, including happier marriages and more rewarding jobs. They are, all else being equal, more often judged to be kind, decent, and honest.

In general, the positive attributes ascribed to beautiful people result in their obtaining preferential treatment. Early in life, more attractive babies are rewarded with greater overt maternal affection.^{98 - 99} Later, this social success is extended as others try to please the good looking, with the latter more likely to win arguments or be told secrets.^{100 - 106} Like the very tall, the very attractive are honored with a greater amount of personal space, and others are reluctant to approach as close to them as they might to those of ordinary appearance.^{107 - 108} Intimate relations are better for the beautiful as well.¹⁰⁹ The best-looking women in high school are 10 times as likely to marry as the least attractive, and they are more likely to marry sooner and marry persons of greater wealth or social status.^{110 - 114} Sexual encounters are more numerous and varied for attractive people.¹¹⁵ Better treatment for the better-looking extends to the workplace. West Point graduates with facial features more suggestive of dominance are more likely to achieve high rank.^{116 - 117} In the private sector, the good-looking are more likely to be hired, given a higher salary, and promoted sooner.^{118 - 125} For male business school graduates, height is positively correlated with income, and almost all chief executive officers of large companies are significantly taller than average (Figure 6).^{126 - 128}

Procuring aid in times of need is also easier for attractive people.^{129 - 135} Strangers are more likely to assist better-looking people experiencing health problems in a public venue. Even professional helpers, like psychologists, are more likely to offer therapeutic services to the attractive.^{136 - 137} Furthermore, bad behavior is often forgiven when perpetrated by the good-looking.¹³⁸ The pretty or handsome are less likely to be reported, caught, accused, or punished for a minor or major crime.^{139 - 143} Only when good looks are employed to dupe others are the good-looking treated more harshly than the homely.^{144 - 145} Attractiveness is recognized as a special gift, and its misuse is not tolerated.

To the extent that the fair of form come to expect better treatment, the comforts that accrue to them are the result of a self-fulfilling prophecy. Attractive people are not used to being bothered or kept waiting, and they show it.¹⁴⁶ Confronted with an absent-minded sales clerk, the beautiful wait for only a few minutes before demanding attention.¹⁴⁷ Less attractive people are habituated to surly service and wait correspondingly longer. Expectations can also be harnessed to help those who are less beautiful. In one experiment, men were asked to speak to women they had not met over the phone. When the men were told that the women were beautiful, they were more likely to be warm and animated, and to elicit similarly charming behavior from the women.¹⁴⁸

There are some differences between how men and women perceive and are affected by beauty. In 1989, American men rated the importance of good looks in a partner as 2.1 on a scale from 0 to 3 compared with a 1.5 for women rating men. Fifty years ago, the ratings were 1.5 and 0.94, respectively.³³ This gap is seen across cultures, although the size of the gap may be somewhat smaller. Likewise, there is cross-cultural persistence of the tendency of women to judge men on a mixture of physical attractiveness and financial prospects, whereas men are more prone to rely exclusively on beauty in selecting a mate. Being with a beautiful woman increases a man's status more than a beautiful male companion enhances a woman's.¹⁴⁹ In corporate America, good-looking women may be hired readily, but promotion to senior management positions may be difficult for the extremely beautiful woman. Such a standout may be perceived as being appropriately socially adept and competent in a midlevel job but lacking the determination and brilliance required for high-level leadership. Extreme beauty is so overpowering a signal that it may at times outshine other qualities and so paradoxically impair career advancement (Figure 7).^{117 ,120 ,150 - 151}

Self-beautification, because of the power of beauty to modify perception and behavior, is a growth industry.^{152 - 153} Tens of billions of dollars are spent annually on makeup, fragrances, hair and nail care, and diet products. Cosmetics salespeople indignantly demand "Would you let $50 stand between you and true beauty?" (personal communication overheard at a department store cosmetics counter in Boston, Mass, January 10, 2001). Furthermore, millions of cosmetic surgical procedures are being performed each year, with baby boomers now accounting for almost half of these.

A range of motivations, operating together, may lead to the decision to pursue maximum improvements in beauty by undergoing cosmetic surgery.^{154 - 155} External motivators include avoidance of ethnic prejudice, fear of age discrimination, or coercion by a spouse, parent, or boss. Internal motivators are typically emotions, with patients wanting to diminish unpleasant feelings like depression, shame, or social anxiety. Many patients wish to alter a specific physical feature that they especially dislike. Women are predisposed to desire a youthful, healthy look that signals fertility, and men may be more interested in developing a strong, powerful look that may facilitate career advancement.¹⁵⁶

Age and life experiences may determine which motivators are important. A study of patients undergoing face-lift and blepharoplasty noted that those aged 29 to 39 years were struggling with childhood conflicts and difficulty assuming parental roles; those aged 40 to 50 years were desirous of occupational advancement secondary to a youthful appearance; and most of those older than 50 had lost a close relative within the past 5 years and wanted surgery to erase the physical stigmata of their grief.¹⁵⁷ Patients undergoing cosmetic surgery have been described as assigning high valence but low value to their opinion of their own attractiveness.^{158 - 159} That is, patients may view beauty as an important quality (high valence) but yet not find themselves particularly attractive (low value). "Relentless improvers" are thus driven to obtain surgery to diminish the mismatch between their desire for beauty and their self-assessment.¹⁶⁰ Patients undergoing cosmetic surgery have also been described as "action-oriented."^{158 - 159} Unwilling to simply be displeased about their appearance, they research the options and seek a cold-steel intervention to ameliorate the ostensible problem.

Methodological problems preclude a definitive answer to the question of whether patients undergoing cosmetic surgery are, collectively, psychologically abnormal. Initial investigations pointed to a strong link between mental illness and the quest for physical self-improvement. Psychiatrists and plastic surgeons collaborating in the 1950s and 1960s at Johns Hopkins, Baltimore, Md, used psychoanalytic techniques to interview such patients and found that most had significant psychopathologic characteristics (often personality disorders and less frequently neuroses or psychoses).^{161 - 164} Interview research in the 1970s similarly suggested that depression, anxiety, and low self-esteem might be relatively more enduring in those requesting cosmetic surgery.^{165 - 167} Objective pencil-and-paper tests conducted more recently have partially undermined the earlier pessimistic findings of significant psychopathologic characteristics. In these recent investigations, patients undergoing rhinoplasty, rhytidectomy, and breast augmentation seem to be no more emotionally disturbed than the general population.^{168 - 173}

The truth may be between the extremes: consumers of cosmetic surgery may not be mentally ill as a group, but they may suffer from greater-than-average dissatisfaction with their bodies and possess the resources to do something about it. Some among them may additionally be diagnosable with primary psychiatric disorders. In fact, body dissatisfaction is a relatively novel concept that is believed to explain much of the impetus toward cosmetic surgery.^{117 - 120 ,174 - 175} Such dissatisfaction occurs when body image, the internal representation of the self's outer appearance, is impaired.¹⁷⁶ Poor body image, in turn, derives from a harsh self-assessment of the body's size and shape, and is exacerbated by stereotypical appearance-related teasing and unrealistic media or cultural standards. The greater the importance of body image to self-esteem, the greater is the attendant body dissatisfaction. Women who undergo cosmetic surgery report high levels of body dissatisfaction preoperatively, with improvements in their body image after surgery. Statistically, body dissatisfaction is a burgeoning problem.¹⁷⁷ The proportion of men dissatisfied with their bodies rose from 15% in 1972 to 43% in 1996. For women, the comparable figures were 23% and 56%. Overweight people are so severely distressed that 24% of women and 17% of men would surrender 3 years of their lives to be thinner.

Ironically, most people seem unable to accurately judge their own attractiveness. Correlations between self-ratings and objective measures of individual attractiveness are remarkably low; 0.24 for men and 0.25 for women.¹⁰⁶ Only 6% of variance in attractiveness among persons is thus explained by internal representations of beauty.¹⁷⁶ High self-ratings of physical attractiveness are generated among those with relatively greater self-esteem, emotional stability, and capacity for dominance. Favorable ratings by others are more likely when the individual being rated has good social skills and is not self-conscious. Popular, sexually experienced people are rated as attractive by both themselves and others.

To the extent that cosmetic surgery can improve a person's perception of his or her attractiveness, such surgery may reduce psychosocial distress.¹⁵⁵ Interview studies have often found a diminution in depression and anxiety in patients following cosmetic surgery.^{166 ,178} The data from standardized tests of the same population are more mixed, but at least in some situations, cosmetic enhancement seems to invigorate interpersonal discourse by reducing feelings of inadequacy.^{155 ,159 ,168 - 170 ,172 ,179 - 187} Psychotic patients, provided they have concurrent psychological therapy, may benefit emotionally from well-planned cosmetic surgery.¹⁸⁸

Other subgroups may be less suited to receive cosmetic procedures, or may be potentially more impaired after surgical intervention. Patients with body dysmorphic disorder can be insatiable, fixating on a minor defect that is objectively correctable yet that, despite the surgeon's best efforts, they regard as unimproved.^{189 - 191} Frustrated with purportedly inadequate outcomes, such patients can respond with violent acts targeted at themselves or the surgeon. Prospective patients suffering from eating disorders should also be evaluated cautiously before a decision is made to proceed to surgery. Particularly among women requesting liposuction or breast augmentation, anorexia or bulimia may be a contraindication, and surgery may be postponed until the underlying psychological illness is ameliorated.^{192 - 194} Adolescents, tempting subjects for the surgeon's scalpel owing to their generally good health and likelihood of long-term benefit from any procedure, may be similarly problematic as patients undergoing cosmetic surgery.¹⁵⁴ Teenagers' preferences, including those for physical enhancement, may be changeable, but the procedures designed to correct these supposed imperfections may not be entirely reversible. A pervasive sense of invulnerability may, moreover, render adolescents unable to adequately weigh the risks of surgery. Consultation with young patients' parents can provide insight into the appropriateness of any intervention.

Clearly, screening candidates for cosmetic surgery is important. Patients may have motives and expectations beyond mere improvement in physical appearance. Rapport between the patient and the surgeon can illuminate previously concealed aspects of the patients' psyche, create good will, and ensure that the patient has a complete understanding of the risks, benefits, and probable outcomes of surgery.

Nonetheless, it is vital for the surgeon to appreciate that deep-seated psychopathologic characteristics are not lurking within most people who present for cosmetic enhancement. Reasonable people, confronted with acute cruelty and dismissiveness related to their aged appearance, react quite rationally in attempting to erase the physical manifestations of aging. Social mores in contemporary Western society include a startling bias against aging and the elderly. Ratings of physical attractiveness decline with advancing age for both men and women, with the decrease more steep for women.¹⁹⁵ Older women are regarded as less feminine. Those who appear aged beyond their years complain of being repeatedly told that they look tired or unwell. As Ambrose Phillips poignantly observed, "the flowers anew, returning seasons bring! But beauty faded has no second spring."² (p38)

In a downsizing, competitive, technocratic job market, a youthful appearance is a marker for a vigorous, creative employee. Close relationships, given the context of a high rate of divorce and successive remarriage, may likewise be more prone to survive if partners are perceived as more desirable by each other. Couples tend to be well matched in looks, with the obvious implication that greater beauty can entice a more attractive other.^{196 - 197} Even individuals who do not feel specifically threatened in their personal or professional lives are surrounded by media-generated standards of the ideal face and body and are susceptible to the desire to emulate these. Economic prosperity, coupled with increased technological sophistication, availability, and acceptance of aesthetic surgery, is culminating in the routinization of elective surgery. An ongoing commitment to a cosmetic enhancement plan featuring carefully selected and graded interventions may therefore be no more psychologically deviant than the resolution to periodically brush one's teeth, get a haircut, or select age- and environment-appropriate clothing (Figure 8).

Beyond the urge to attain and maintain physical beauty is the concept that beauty may in fact be more than "skin deep." Inclusive definitions of beauty have included personality characteristics that purportedly increase the individual's attractiveness. As early as 1920, Knight Dunlap¹⁹⁸ described beauty in terms of stature, bodily proportions, features, hair, and fat, but also noted that "without poise, beauty is the beauty of the marble statue and the painted canvas."¹⁹⁸ (p235) Poise he explained as the sum of mental and emotional qualifications complementing physical perfection. More modern commentators have extolled the beautifying effects of confidence, which Sophia Loren believes "you can build by knowing yourself,"¹⁹⁹ (p11) and Georgette Mosbacher asserts a woman must "exude . . . if she wants to be beautiful."²⁰⁰ (p169) Helen Gurley Brown, the founder and long-time editor of Cosmopolitan magazine, is less sanguine about the value of such advice, wondering "where are we getting this confidence if we aren't beautiful."²⁰⁰ (p169)

Warm temperament also seems, in some psychological studies, to correlate with perceptions of attractiveness. College instructors are judged to have a more appealing physical appearance if they behave in a friendly manner or are described as being friendly.^{201 - 203} Effects of personality on ratings of attractiveness may in rare instances be sufficient to outweigh the large effect of objective physical appearance, with warm unattractive women judged as equivalent to cold, average-looking women, and warm average-looking women equivalent to cold, attractive women.²⁰³ Alluring facial features, including bigger eyes, shorter noses, fuller lips, and smoother skin, are recorded more frequently in appraisals of the same photographs when the individuals judged have been described as kind rather than as mean. The generalizability of these contrived experiments to real situations is less clear.²⁰⁴

Better concealed even than confidence and kindness are other personality traits such as integrity, loyalty, generosity, determination, and courage. While beauty is often seen as implying coexistence of such positive characteristics, there is a widespread suspicion that the comely may somehow be less reliable than the homely. Studies suggest that observers expect the beautiful to be more prone to seek divorce, less able to be faithful to a spouse, and less competent at parenting.^{205 - 206} Unfortunately, on balance, physical beauty is so much easier to assess than other desirable qualities that in daily life we are often unable or unwilling to examine what lies beneath.

The unequal distribution of personal beauty and the benefits that accrue from it seem inherently unjust. However, Elaine Scarry,²⁰⁷ a Harvard professor expert in aesthetics and ethics, has championed the alternative view that the unequal distribution of beauty may not always be antithetical to fairness. If fairness is a utilitarian construct requiring the greatest benefit for the greatest number, then the existence of beauty may actually be in society's collective best interest. Scarry conceives of the pursuit of beauty as a unique, fundamental drive, continually inspiring and delighting people. Unlike hunger, which is quenched with food, the desire for beauty is not coterminous with its satisfaction. Art, music, and literature are motivated by beauty, or more specifically, the impulse toward replication that is stimulated in the presence of beauty. Admitting that personal beauty may be inequitably disbursed, Scarry notes that this is true of most genetic endowments, yet we do not regard similar gifts, for instance exceptional mathematics talent, as unfair in the same way (Figure 9).

Beauty may also be politically valuable to the extent that it is consistent with balance and harmony. Here Scarry²⁰⁷ offers the highly theoretical argument that if the mechanism of social justice is impaired under the jurisdiction of a coercive government, the surviving beauty and symmetry of nature^{208 - 209} may inspire reformers to agitate for change. Perhaps the strongest defense of beauty is that, when confronted by John Rawls' hypothetical veil of ignorance,²¹⁰ unaware if they themselves will have access to beauty, people still overwhelmingly want beauty in their universe. Those living far from natural wonders, and unlikely to ever visit them, nonetheless demand ecological preservation; similarly, those who are less beautiful and not necessarily benefiting from the perks of personal beauty would not want their progeny to grow up in a world devoid of beauty.

Heroic though Scarry's efforts may be, justifying beauty on philosophical grounds is difficult. The so-called "problem of lateral disregard"²⁰⁷ (pp65-67) is all too intractable. Briefly, the beautiful individual attracts a disproportionate amount of attention, and once observed, makes others seem less attractive by comparison. People may enjoy art or want beauty in their world; there is no reason to believe, however, that they would not also wish to be beautiful themselves, if they could.

Beauty, not counting its practical benefits, is worth having. It is thought provoking to consider that the highly successful are not immune to wistfully imagining that they may have been better looking. Once asked if she had any regrets, Eleanor Roosevelt offered only one. She wished she had been prettier.²¹¹ Or as Joan Rivers crisply observed, "No matter how they lie to us and tell us that Barbra Streisand is beautiful, if you woke up without her enormous talent, would you rather look like her or Michelle Pfeiffer?"²⁸ (p108)

In the future, beauty will likely increase in importance as a desirable attribute for both sexes.^{212 - 214} The early 20th century emergence of mass-market cosmetics,^{215 - 216} post–World War II refinement of aesthetic surgery techniques,^{217 - 219} and current middle-class affluence have led to gradual but inexorable societal acceptance of beauty enhancement.^{220 - 221} Gone is the guilt instilled by the medieval Catholic church, which opposed cosmetic operations on the grounds that they opposed Divine Will. Classical thinkers such as Cornelius Celsus (25 BCE–50 CE), author of De Medicina and inventor of a technique for removing excess skin from "relaxed eyelids," are thus vindicated by the resurgence of science in the service of beauty. ^{152 ,222 - 223}

The modern compulsion for physical perfection also has been fueled by advances in communication and transportation. Visual media and the ease of travel make the beautiful other a nearby object against which the self may repeatedly be compared. The world has become smaller, more competitive, and more reliant on first impressions, an inevitable currency when professional and personal contacts are often strangers. Sander Gilman describes the resulting desire to "pass,"^{224 - 225} to relieve the anxiety of being placed in a negative, visible category, as the primary motivation for cosmetic surgery. Paradoxically, by more closely resembling everyone else's ideal of beauty, we are freed from adverse scrutiny and stereotyping, and more able to be free, unique, and happy.

The sequencing of the human genome has brought the promise of genetic aesthetic enhancement closer.^{226 - 227} Genetic modification at conception may theoretically obviate the need for later corrective procedures. Physicians, as the purveyors of beauty, may additionally be able to better protect their patients from the "unavoidable betrayal of the body"²²⁸ (p215) associated with aging. The best "hard" science fiction grapples with the social implications of such technology.^{229 - 236} Protagonists are often preserved in a vigorous, physically attractive young adulthood. Whole-body rejuvenation may be periodically sought from machines or medicines. The resulting life may span epochs, during which friends, family, jobs, and homes may change many times. In general, longevity is wanted only if accompanied by intellectual curiosity and a presentable, strong, and virile body. As Glogau²³⁷ has argued, wanting to be beautiful may not be a desire to look young but rather to "look the way that [we] feel."²³⁷ (p1205) As lives become longer and healthier, people may be less willing to console themselves with the wisdom that "within I do not find wrinkles and used heart, but unspent youth"²³⁸ (p474) or that "what time hath scanted men in hair, he hath given them in wit."²³⁹ (p477) Instead, we may want and get it all.

For the present, for those of us who feel less beautiful, the optimal coping strategy may be humor combined with a determination to look as good as possible while focusing on excellence in areas in which we have unusual gifts. Racine, who described his "wrinkles as the imprints of exploits,"²⁴⁰ (p431) and Anna Magnin, who enjoined "don't erase my wrinkles . . . they took me so long to earn,"²⁴⁰ (p431) clearly accepted the visible signs of aging as evidence of a life fully lived. Reassuringly, the beautiful do not report being happier than the less well endowed.²⁴¹ People who know us well are less likely to judge us based on beauty, and when beauty does proffer an advantage in the personal and professional spheres, the magnitude of the benefit is rarely more than small to moderate. With cosmetic surgery, moreover, we now have the means to improve structural deficiencies as well as the visible signs of normal aging. Finally, it is possible to transcend popular conceptions of beauty, as Henry James²⁴² trenchantly observed in a letter to his father on meeting the unmarried, middle-aged 19th century novelist George Eliot:

She is magnificently ugly. She has a low forehead, dull gray eyes, a vast pendulous nose, a huge mouth of uneven teeth. . . . Now in this vast ugliness resides a most powerful beauty, which, in a very few minutes, steals forth and charms the mind, so that you end as I ended, in falling in love with her.²⁴² (p104)

Accepted for publication February 20, 2001.

The authors are deeply grateful to David Elpern, MD, for planting the "beauty" seed and to Tania Phillips, MD, for her continued encouragement, support, and reality testing. We would also like to thank David R. Bickers, MD, for his precise and insightful comments.

Reprints and primary corresponding author: Murad Alam, MD, 195 Davis Ave, Brookline, MA 02445 (e-mail: murad@alam.com). Secondary corresponding author: Jeffrey S. Dover, MD, FRCPC, SkinCare Physicians of Chestnut Hill, 1244 Boylston Street, Suite 302, Chestnut Hill, MA 02467 (email: jdover@skincarephysicians.net).