As a relative newcomer to social media, I've recently been inundated with before and after photos of surgical and nonsurgical procedures from practitioners around the world. So called #transformationtuesdays bring out an array of results ranging from the objectively gorgeous to subjectively cartoonish. The saying goes that “beauty is in the eye of the beholder.” But is it always? Are there boundaries we shouldn't cross?

What cases started me on this topic? There are two main areas: lips and buttocks. It's pretty clear when you see a meme of a photo of swollen overly injected lips next to an orangutan's behind, that the aesthetics of the lips are questionable. But many of the “transformation” cases show lips that aren't much smaller. There is clearly a broad range of “normal” lip sizes, generally associated with other facial shapes and associated features. To me, there are also faces that aesthetically cannot or should not support larger lips or, at least, not until the surrounding anatomy is supported (chin, jawline, philtrum, cutaneous lip). Otherwise, evaluating the face holistically, the lips appear “stuck on,” like the features on a Mr. Potato Head. Taken in isolation, when static, the lips appear not “luscious” but stretched, when dynamic, they lose the flexibility associated with normal movement and expression.

I've often said, “so go the lips, go the buttocks.” An increasing popular procedure is the “Brazilian butt lift.” Initially designed to transform a low or flat profile behind into the high profile “bubble” behind seen in bikinis across Rio beaches. The buttocks were improved but remained in proportion to the body. However, the visibility of the Kardashians and others in the media seems to have shifted the paradigm. Almost daily, I see posts showing the creation of buttocks that appear massive, relative to the patient's legs, waist and upper body. I wonder how they will find clothes to fit and, more importantly, how they will age. What happens when this “style” changes?

Am I being too judgmental? I don't think that's the case. I've lectured internationally on regional, ethnic, cultural, and socioeconomic differences in aesthetics across the US. I particularly applaud the increasing acceptance of a range of women's body shapes as beautiful. However, as a physician, I'm used to there being some defined anatomic and physiologic guidelines in which to practice. The heart pumps within a safe range to supply oxygen, bones fit together in a specific way to let a joint function, and eyelids must have the shape and agility to fully open and fully close to protect the eyes. Beauty is less well defined, but there have always been “ideal” proportions of the human form studied by aesthetic physicians and artists. In fact, much has been written about the similarity of those relative proportions cross-culturally and historically. There are always going to be outliers—the tribeswomen in Asia who extend their necks with dozens of rings or the hipsters in New York with multiple visible piercings and tattoos. But the extremes like the tattooed face or extended earlobe hole, are not mainstream. Should outsized lips and buttocks be relegated to the same category?

Why should we even discuss this? As board-certified core cosmetic physicians, we choose the results we create. We can choose not to participate in extreme aesthetics. If a Barbie Doll's body shape is not naturally viable, should we try to create it in life? Some may ask how to say “no” to any patient or procedure in this competitive market where the core are a decreasing proportion of practitioners. (Refer to my prior Heideas video “The power of NO” on I say we have not only the responsibility to but also the opportunity to define optimal long term aesthetics. The definition will vary, but I expect each would be within a universally recognized range of normal. Each of us will practice at different points in that range. That point defines us and our brand and builds our followings of loyal patients. So judge the results you see to help you help your patients best.

—Heidi A. Waldorf, MD
Co-Chief Medical Editor