As cosmetic surgeons, we employ numerous tools in order to provide minimally invasive rejuvenation: neurotoxins, fillers, energy-based devices, and more. But we do not “sell” these products and services. Rather, we are in the business of “selling” an outcome—an outcome that the patient wants and we as experts believe is appropriate—not a price per unit. In fact, sometimes the best thing we can offer the patient is no intervention at all. Hands down, my philosophy as an aesthetic physician is to make the patient feel beautiful and happy. Often, the small changes and tactics are what really make patients happy. This approach of identifying the patient's desire, focusing on the outcome, and emphasizing small changes and tactics is the “subliminal difference.”
Without an understanding of the art of beauty, technical applications mean little. I believe beauty is an evolutionarily preserved method of communicating health and wellness— a message that is best communicated and perceived at a subconscious level. If others can tell that an aesthetic intervention was performed, then the cosmetic treatment has failed to achieve its goal.
When dealing in non-surgical technique, the subliminal difference vey often translates to an approach that accentuates the most attractive features of the face, typically highlighting the eyes while deemphasizing the lower third of the face. This is often accomplished through the use of fillers in a process that has been called a “liquid facelift.” However, this term fails to capture the essence of the procedure and, more importantly, its subtle yet important goals. The procedure is specific for each individual person and is rooted in the scientific elements behind the human perception of beauty and attractiveness. At its core, the natural, subtle results are the essence of the subliminal difference. The technique utilizes blunt-tipped cannulas that allow the placement of filler without bruising, and it takes minutes to complete. Most patients upon leaving the office immediately feel and look rejuvenated. Results of two clinical trials show better first impressions, improved quality of life, and enhanced self-esteem after this technique.1,2
This is not to suggest that subliminal improvements are easy to achieve or require only minimal interventions. The elegance of the outcome often belies the complexity of the intervention. Consider a 30-year-old woman who underwent treatment with onabotulinumtoxinA (Botox, Allergan) in the brow and masseters, 0.03% bimatoprost, calcium hydroxylapatite fillers in the cheeks, hyaluronic acid filler in the lips, and fractionated carbon dioxide treatment. The upper one-third of the face was injected with onabotulinumtoxinA, elevating the lateral third of the brow, reducing forehead wrinkles, and opening the eyelid aperture, which caused a subconsciously projected message of friendliness and fertility. The eyelashes were treated with bimatoprost to enhance the eyes. In addition, calcium hydroxylapatite in the cheeks drew attention away from the lower third. OnabotulinumtoxinA into the masseters further deemphasized the lower third, allowing the lips to be further noticeable. The skin was homogenized, plumped, and toned following fractionated carbon dioxide treatment. The result was a face that conveys femininity, youthfulness, and beauty while remaining subtle, natural, and within the context of her age.1
In nature, there are certain characteristics that all people identify as attractive. While the physical results of this process do make a difference, what makes us most attractive is confidence and self-assuredness. During the treatment, I focus on the many nuances of beauty that communicate health, fertility, and vitality. Most of all, these techniques have been developed to polish the confidence of patients who experience this transformation. It is essential that we as clinicians help patients understand our approach to rejuvenation and the goals of natural, subtle outcomes. Without a grasp of the art and technique of rejuvenation, one could imagine the patient above seeking to “cut costs” by reducing the number of products or procedures used. Importantly, she was not presented with a line-item proposal for rejuvenation. Instead, she was offered an outcome and presented a comprehensive program to achieve it.
Eye of the Beholder
Less than a millimeter change in the placement of the corner of the mouth, eyes, and nose can completely change the way someone is perceived.3 Understanding the subtleties of beauty through the evolutionary lens in which it was shaped is paramount to treatment. Facial characteristics are processed in primitive neural pathways in the amygdala and posterior cingulated cortex.4 Emphasizing specific facial characteristics or increasing symmetry through non-surgical interventions can result in a more favorable first impression.5,6 The eyes contain an enormous amount of evolutionarily relevant information, exemplified by the perceivable pupillary dilation of sexually aroused female subjects.7 A narrow, smaller lower third is a sexually defining dimorphic trait that maintains focus on the eyes. The preference for women with large eyes, small chins, and a minimized lower third is evolutionarily preserved and consistent across cultures.1
Understanding beauty within the context of an evolutionary adaptive trait puts our patients' goals in perspective. Using evolutionary science as our roadmap, the destination is more clearly defined.1 It is the small, seemingly unimportant effects that positively and significantly alter the appearance one projects and the judgment received; once appreciated, it becomes glaringly overt to the trained eye. A surgeon should have an artistic eye and deep foundations based upon those traits that make someone look and, more importantly, feel beautiful. Physicians with an artistic eye and scientific understanding of the laws of attraction and beauty in nature can look into this advanced technique for patients.
Not Simple. Subtle.
For many practices, especially those building a base for minimally-invasive procedures, there may be a tendency to provide only a handful of products and procedures. Striving to capture and retain patients, the clinician may gladly fulfill the patient's request for “some filler here,” or a “toxin to smooth these lines up here.” Very rarely does the treatment of an isolated area provide a pleasing aesthetic effect. Instead, such approaches have led to the unflattering “done” look that the public associates with patients who have unnaturally large, “duck lips,” or who can't seem to convey emotion through facial dynamics.
Most patients will look best with a combination approach that not only “corrects” their perceived flaws but accentuates their natural features and strive for the evolutionary features of beauty described above. While the result is subtle, the approach rarely is simple.
Our websites, brochures, and campaigns state that patients can be made to look better naturally with small and subtle changes, and we explain the subliminal difference before patients even make an appointment. The more knowledge given to patients before, during, and after a consultation or procedure, the better.
Dr. Dayan has disclosed relationships with Allergan, Medicis, and Merz.
- Dayan SH, Arkins JP. The subliminal difference: treating from an evolutionary perspective. Plast Reconstr Surg. 2012; 129(1):189e-90e.
- Dayan SH, Arkins JP. The subliminal difference: a new treatment philosophy. J Drugs Dermatol. 2012; 11(suppl 3):s10-1.
- Walker M, Vetter T. Portraits made to measure: manipulating social judgments about individuals with a statistical face model. J Vis. 2009; 9(11):12.1-13.
- Schiller D, Freeman JB, Mitchell JP, Uleman JS, Phelps EA. Aneural mechanism of first impressions. Nat Neurosci. 2009; 12:508-14.
- Dayan SH, Arkins JP, Gal TJ. Blinded evaluation of the effects of hyaluronic acid filler injections on first impressions. Dermatol Surg. 2010; 36(Suppl 3):1866-73.
- Dayan SH, Lieberman ED, Thakkar NN, Larimer KA, Anstead A. Botulinum toxin a can positively impact first impression. Dermatol Surg. 2008; 34(Suppl 1):S40-7.
- Aboyoun DC, Dabbs JM Jr. The Hess pupil dilation findings: Sex or novelty. Soc Behav Pers. 1998; 26:415-9.
- Matts PJ, Fink B, Grammer K, Burquest M. Color homogeneity and visual perception of age, health, and attractiveness of female facial skin. J Am Acad Dermatol. 2007; 57:977-84.
- Little AC, Jones BC, DeBruine LM. Facial attractiveness: evolutionary based research. Philos Trans R Soc Lond B Biol Sci. 2011; 366(1571):1638-59.
- Fink B, Grammer K, Matts PJ. Visible skin color distribution plays a role in the perception of age, attractiveness, and health in female faces. Evol Hum Behav. 2006; 27(6):433-42.