Category Archives: Aesthetics


“What are you?” is the question asked of each person in Kip Fulbecks beautiful portrait book “part asian – 100% hapa“. It is a collection of uniformly photographed faces all looking into the camera in frontal gaze.  With my understanding of how we all perceive average as attractive, this book opened a new door for me. These were the faces of my own future generations.

Hapa and their parents are typically well aware that the combination of two very different racial-ethnic gene pools creates a mix that appears quite new and noticeably different from either parent.  As with any big change, there is always a positive as well as a negative aspect to these differences.  Most Hapa probably appreciate by now that other people seem to find them interestingly attractive.  Why is this so? 

It has to do with the mental process by which we all perceive and recognize a face.  A lot of research has gone into facial recognition as well as into understanding what we all consider beautiful, but the bottom line is this:  average faces appear more attractive than faces with more extreme features.  (More on this topic read here and here

In very diverse cities where everone is exposured to a wide spectrum of extreme facial features, the averaged mental template of a face represents one that lies somewhere between an Asian, Caucasian, African American and Hispanic person.  Faces that most resemble this average face are perceived as the most attractive.  Perhaps you might have noticed that there are significantly more Hapa celebrities in the media than there are in the general population of the United States(1.9%).

Being more attractive is certainly a plus.  What could possibly be a minus?

As a physician trained in Ohio and Louisiana, I must admit that I’ve treated few Hapa patients. One patient however stands out in my memory. She was part Vietnamese and part Caucasian, in her late 20’s, and complained of a chronic conjunctivitis that just wouldn’t go away with any kind of eye drops. She said it had started a few years ago and had already seen 3 other eye doctors who couldn’t find a cause. Her face appeared about midway between a German’s and a Vietnamese. She had relatively wide eyes with visible lid creases (double-eyelid). On closer examination at the slit lamp, I found something I’d never seen before. Although her eyelashes were dark and fairly straight like an Asian’s, they seemed slightly longer and exited the skin a little closer to the lid margin. At her lateral canthi on both sides, I found her problem. The most lateral 3-4 eyelashes from her upper lid were growing straight under her lateral lower eyelid, rubbing on her bulbar conjunctiva! This is called trichiasis.

 Hapa Eye Trichiasis1 

The straight lash cilia (eyelashes) of her mother evolved in harmony with the other structures of the flatter featured Asian periorbita.  When made to grow on a wider and more contoured lid and skull structure of a more Caucasian like lateral orbital rim, unanticipated problems might present themselves.  The shape and function of her parents’ eyelids and tissues have benefitted from over 10,000 years of divergent evolution.  For my Hapa patient however, she expressed a random assortment of the features from both of her parents, resulting in intermediate structures that are neither here nor there.  This new configuration is in some ways like a new mutation that has yet to be influenced by the last 10,000 years of evolution.

I believe that her eye problem represents just the tip of the iceberg of a new generation of medical problems about to surface in this next generation of medicine.


Botulinum Toxin

Before jumping into getting botulinum toxin for the face, we really need to understand what we’re messing with.  I believe that the facial muscles and their connection to the brain, are the most highly evolved of all human bodily functions.  Firstly, what are the functions of the face?Most practitioners of botulinum toxin approach the face as two halves.  The upper half that is more forgiving, and the lower half that requires more caution.  Mobility of the lower face is essential to clear speech and enunciation. The muscles around the mouth and cheeks keep a tight seal at the lips to prevent drooling and are major components in the process of eating and drinking.

What is under appreciated however is that there are similarly important autonomic functions for the upper half of the face as well.  The eyelids move to protect our precious eyes from the environment, and automatically adjust their positions in response to what the eyes sense.  In dry and windy conditions, the orbicularis muscles tighten the aperture to minimize mucus membrane exposure. Sudden bursts of light similarly cause an immediate reflexive closing of the eyes to shield the retina from photo-toxicity.  Although complications from botulinum toxin injections in the upper face are relatively mild and rare, they nearly always involve eyes.

I believe however that the most sophisticated function of our faces is in communication. The face is the single most visible portion of our bodies, especially for this Seattle’s winter.  As an ophthalmologist, I am acutely aware that our eyes are our windows to the world. But as an oculoplastic surgeon, I have learned to appreciate how the muscles and skin around the eyes serve as the window into our souls. They are the focus of gaze during conversations with other people and even animals. We have evolved to “read” eyes and are surprisingly good at it. Everyone knows that the difference between a true smile and a fake one is in the eyes.

Botulim toxin injections were first approved by the FDA for human use by an ophthalmologist who injected the substance into the muscles on the eyes to straighten strabismus.  It was first approved for cosmetic purposes in the muscles around the eyes at the glabellar folds. Since then use of the chemical has spread to all areas of the face. In Shanghai, we even injected it into the masseter muscles of the jaw for aesthetically pronounced jowls. The technique however to apply it to the facial muscles truly requires some appreciation for not just the anatomy, but also for how they work in dynamic facial expression. Although commonly used to reduce the visibility of dynamic wrinkles, there is growing use of botulinum toxin to aesthetically alter the balance of facial expressions. By minimizing the contractions of typically negative expressing muscles, the face at rest develops a more positive and confident pose. The downside however is that when the “negative” expressions are attempted, the balance can be some what abnormal appearing. Unfortunately there is give and take in everything, even for botulinum toxin.

I have helped to write a review article with my Cleveland Clinic colleague and mentor regarding the medical and aesthetic uses for botulinum toxin injections around the eyes and face. Further details to come upon publication.