What the face says

What can we see in a face?

Certainly we see genes, either felicitous or unfortunate. But do we also see the soul, a personality, a life, our selves, imperfections to be fixed or accepted, earning potential?

Those are the sorts of questions that occupied a multidisciplinary group of experts - surgeons, psychologists, ethicists, lawyers, even an English professor - last weekend during what was thought to be the first U.S. academic meeting on appearance and identity. The University of Pennsylvania's Center for Human Appearance, which studies how the way we look affects everything else, hosted the two-day event.

If ever there was a crowd that could make one self-conscious, this was it. Consider the talk by longtime friends Linton Whitaker, the plastic surgeon who founded the Center for Human Appearance, and Nelson Shanks, a Bucks County-based portrait artist who has painted Princess Diana, Pope John Paul II, and President Bill Clinton.

Whitaker sees the face as architecture, the bones as scaffolding that determine the look of the "soft tissue." Shanks clearly sees the structure too, but also looks for the grit or grace that animate his portraits. He showed two pumpkins, a smooth one and a "vastly more interesting" warty one. Then he showed a painting done in the 1500s of a man with a bumpy nose. "I see the compassion," he said. "I see the soul behind the face and somehow having that nose there helps you make that jump."

Shanks used actress Ava Gardner as an example of a woman with a "nearly perfect" face. Whitaker jumped in and said she was asymmetrical. "Her right zygoma [cheekbone] is higher than her left," he said. (Studies have shown that we prefer symmetry.)

Shanks showed his (flattering) portrait of Margaret Thatcher. "You can see her eyes are asymmetrical," he said. "Her mouth is asymmetrical. Her mandibles are asymmetrical, but gently so." This was to be expected with age, he said. To her credit, she had "skin like milk."

Shanks saw character in the powerful "schnoz" and an air of anxiety in a late-life self-portrait of Rembrandt with a creased, bulbous face. Whitaker noticed that Rembrandt's "palpebral fissure [this had to do with his eyes] was tilted downward with aging."

Then they came to Princess Diana. Even Shanks, who loved the way she exuded life, mentioned that her nose was a little crooked, concave from one angle and convex from another. Whitaker thought a cartilage graft could have straightened her nose right up. They both noticed that her mouth was higher on one side.

"I'll never stop thinking of her as beautiful," Shanks said. "Absolutely," Whitaker agreed.

They showed a short film about a project of Studio Incamminati, the art school that Shanks founded. Artists there paint portraits of children with serious facial deformities, paintings that find beauty, hope, and spirit in faces that might draw stares. These were kids who weren't looking for perfection, just the ability to blend into a crowd.

Earlier, David Sarwer, a Penn psychologist who helped organize the meeting, had displayed pictures of a handful of James Bond villains, ugly men with scars and metal parts. Compare them to the handsome Bonds. Such portrayals, he said, reinforce the idea that the beautiful is good and the ugly or disfigured is bad.

All of it, in one way or another, was about the relationship between who we are inside and how we look outside. Superficial as it may seem to care deeply about our looks, the discussions made it clear that our appearance is inextricably linked with who we imagine ourselves to be and with how others react to us.

"We like to have good-looking people around us and we pay for it," said Daniel Hamermesh, a University of Texas professor who studies the economics of beauty. Better-looking people are paid more. They're more likely to win elections. They're even happier.

That helps explain why there were 14.6 million cosmetic procedures in the United States last year.

Many of the doctors in attendance work mostly with people with disfigured faces, not patients who want to look more like a movie star, Sarwer said. The meeting was a chance to think about appearance in a nonclinical way, to notice, as Whitaker and Shanks did, the tiny details, but also the broad view. Beauty, Sarwer said, is not just a collection of physical attributes. It is also "how we dress, how we carry ourselves, our soul and the spirit we project."

Jesse Taylor, a plastic surgeon at Penn who works with children born with facial defects, co-chaired the meeting. He was intrigued by how we balance emotional health and physical beauty, where we draw the line between a rational and an unhealthy desire to improve appearance. How should he respond to a patient who has gotten many procedures to make her face look more normal and now wants bigger breasts?

"In my mind, there's a level of appreciation for one's appearance that is perhaps good, perhaps reasonable and perhaps healthy," Taylor said, "and then there's an extension where a concentration on one's appearance can be very unhealthy, ugly."

There have been times in history, speakers said, when physical perfection was associated with higher character. There's still no question that ugly and beautiful people are treated differently in ways that affect not only professional success but also self-esteem. As we enter the age of face transplantation, one question, still unanswered, is how getting someone else's face will change people inside.

There have been many attempts to quantify human perfection, some of which surgeons still use to consider how far out a chin or nose should jut. But Hamermesh said there's no formula for deciding who's beautiful and who's ugly. We know it when we see it and we generally agree about it. Studies have shown that 2.8 percent of women and 2.3 percent of men are considered strikingly handsome or beautiful. About 2 percent are homely. Most - 51.6 percent of women and 58.7 percent of men - are considered average.

He said older people generally get lower ratings.

Val Lambros, a plastic surgeon in Newport Beach, Calif., has studied how individuals age and learned some surprising things. While it may seem that gravity is making our skin sag, Lambros said the real culprit in most thinner people is declining fat volume in the tissue under the skin. It's more like a deflating balloon than a melting candle. He said that as little as 2 teaspoons of filler can make most people look better.

A recent Penn review of studies on the psychological impact of cosmetic procedures found positive results among the few studies that met high scientific standards. Patients felt better about themselves after face-lifts, nose jobs, and Botox injections.

Sarwer said, though, that doctors should be screening for the patients who are most likely to be dissatisfied, the ones who might even harm the doctor after surgery. He said those with body dysmorphic disorder, an obsession with relatively small flaws, are at particularly high risk. They make up 5 to 15 percent of cosmetic procedure patients.

"Patients with the condition come in assuming that they're going to feel better about themselves when you successfully perform their treatment, and the evidence tells us they don't," he said. One study found that the disorder did not improve in 91 percent of patients after surgery and got worse in 5.4 percent.

Sarwer said doctors should take a psychiatric history and be on the lookout for patients who make a habit of canceling and rescheduling appointments or demanding special treatment.

But Whitaker said it's unrealistic for doctors to make patients jump through psychological hoops. "Cosmetic patients can go down the block to someone who does not make them go through that harangue," he said.

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