"Where the spirit does not work with the hand there is no art."

—Leonardo da Vinci

From 1503 until the last days of his life in 1519, Leonardo da Vinci continued to add to the oil brushed painted representation of a 24-year-old mother of two and wife of a prominent silk trader, Lisa del Giocondo—better known to all of us as Mona Lisa. One of the most celebrated works of art the world has ever known has shared wall space in the Fountainbleau, Versailles, and even once hung in the bedroom of Napoleon. After being stolen in 1911 by an Italian nationalist who felt it deserved a home in Italy, it was recovered and returned to the Paris Louvre museum where it has resided ever since. It is arguably one of the most engaging man-made creations to ever grace the face of the earth and also one of the most valued. Today its estimated worth is placed at more than $800 million.

But what exactly makes this portrait so famous and why? It was a question my 10-year-old daughter, Noa, posed to me as we stood in line. I was embarrassed to say I wasn't entirely sure. Interestingly, once we finally got to see it, she was spooked, and we quickly exited. That perhaps was my first hint into the mystery of the Mona Lisa and the genius of da Vinci.

To better answer my daughter's question, I thought I should explore the man who painted it. I recently finished a biography of Leonardo da Vinci  by Walter Isaacson. In it, he takes a deeper dive beyond the prefrontal cortex to the inner working of a genius mind. We often get stuck on da Vinci's famed Vitruvian man and his mastery of divine proportions, but to truly appreciate da Vinci's brilliance is to look beyond the obvious. da Vinci had an insatiable curiosity to understand not only the physical properties and mechanics of the natural sciences but also how they engaged with the human element. da Vinci feared neither challenging conventional wisdom nor upsetting the cannons of accepted knowledge. And his unique ability to illustrate how a bird's wings lead to lift is paralleled by his demonstrations of how human anatomy expresses emotions.

Sfumato in Action

Leonardo da Vinci's life-long devotion to the mastery of form, function, and meaning unify in the Mona Lisa. She appears to be in motion as if she just sat down and is about to swing to the right. Her hands gently in her lap reveal a brief moment of satisfaction that observers know will not last. The background leaves a surreal almost fantastical impression, and it melts into her being, as if reality and dream are one and the same. In the intricacies in her face the painting really separates itself from all others. Lisa's eyes famously follow you around the room regardless of where you stand. da Vinci wasn't the first to do this, but his level of detail in the irises is unmatched by others. In fact, one of Lisa's pupils is slightly larger than the other. Whether she exhibited aniscoria like 20 percent of the population or it is the manner in which the light from the foreground sun is hitting one pupil more so than the other, you can't help but be subconsciously impacted by her gaze.

Then there is the smile. Perhaps the most famous smile in the world. Or is it a smile? As English writer Walter Pater commented, “Mona Lisa's smile holds an emotional ambiguity, revealing first a ‘promise of an unbounded tenderness,' but soon after also a sinister menace.” According to Harvard neuroscientist, Margaret Livingstone, Lisa's smile flickers depending on where your eyes are looking. When looking directly and her mouth, its image falls on your fovea and she appears not to be smiling, but when your peripheral vision interprets her expression by processing the information from the shadows of her cheeks and lips, she conversely seems to be smiling. It seems da Vinci, a master of light optics and facial anatomy, engineered this conundrum to tease and disrupt his viewer.

Forensic evaluations of the mouth reveal multiple layers of paint and a technique of painting that obscures where the mouth starts and where it ends. In other words, the mouth blends into the cheek and lips just as the deeper layers of muscle, dermis, fat, and connective tissue blend into surrounding soft tissues of the face. da Vinci so well understood this relationship, and to properly represent this tenet of reality required a shift in technique and philosophy, known as sfumato. “Sfumato,” an Italian word meaning smoke, is also used to describe a technique of blending.

Learning from the Master

da Vinci's contemporaries were unambiguously delineating facial features, subjects, and objects within a painting, leading to perfectly defined supra-realistic representations of a human face. da Vinci, by contrast, attempted to capture the reality and essence of humanity by blurring the transitional zones between the facial features. And like most perfectionists, he was never satisfied in his ability to capture the intangible gift granted by the Prime Mover. Perhaps this is why he famously left so many works undone. Yet in the Mona Lisa he has delivered to human kind a representation of the living soul that far surpasses the inanimate productions common to many others. We aren't quite sure if Lisa Giocondo was smiling, smirking, doubting, or mocking, but that is not what teases the collective subconscious. Rather, it is her gamut of emotions in motion that leaves us dynamically perplexed. Not too far off from what we experience in one another at any moment.

Humans rarely express at the extremes; rather, emotions and expression are moment-to-moment blends reflecting waves of feelings. Faces that statically express an extreme—whether a smile, grimace, or frown—project an unnatural, ingenuine impression. And if the stone-like facial features are further bathed by a stark contrasting light, a face assumes a frightening appearance. Unlike other artists who were unmistakably defining facial features, da Vinci, a masterful scientist and anatomist, realized that facial features are best appreciated when recognizing their relativity to surrounding features. There is a harmonious balance between the eyes, nose, and lips, just as there is between emotions, expression, and anatomy. And a smile or a frown in isolation has no meaning. Eyes that complement the lips and blend into the cheeks enable a face to tell its story.

This is where we come in. Traditionally, Western medicine and aesthetic medicine in particular has been taught from a narrowed perspective of individualized systems or features. Specialties are defined by areas treated: Urology, Ear-Nose-Throat, Ophthalmology, Nephrology, Dermatology, etc. In Aesthetics, book chapters and conferences are sectioned by features of the face. Scales used for FDA approval are based on efficacies limited to one area of the face. We force ourselves to look at a face as if it is made up by individual components. And when we treat one area of the face without taking into consideration a nearby feature, the face assumes an out-of-balance appearance. It is no wonder we are troubled by unnatural outcomes. But even if the horizontal plane of facial features is respected within the context of its surrounding features, da Vinci showed us the way light bounces and shadows bathe a surface is only but an inverse reflection of the vertical layers that lie below. It is not solely the dermis, fat pads, muscle, or bone, but the layering of all these tissue that gives depth to an appearance.

But where we learn the most from da Vinci's genius is when we appreciate how he used the Mona Lisa's facial anatomy as a vehicle to bring forth the sweet emotions of her soul. da Vinci didn't just understand the anatomy, the layers of tissue, and the light/shadow effect, he was also a master at blending components of humanism with its physical manifestations to birth life. You can't help but be curious, to want to talk with Lisa Giocondo, to understand her. We are attracted to her. And while she may not be the most beautiful Florentine woman, she certainly is the most captivating.

Not in Isolation

As cosmetic surgeons who alter faces, we are students of anatomy and science ,but it is important to realize that facial features do not exist in isolation. When we treat a nasolabial fold, we are impacting the lips. And when we alter the nose we are influencing the eyes. Each facial feature works in concert with another to deliver a harmonious and genuine interpretation of a person. And when a feature is treated in isolation and out of context to its balancing features, a cognitive dissonance ensues. It is when we use sfumato philosophy and technique to merge facial anatomy, expression, and emotion that we unveil the authentic.