The second question is difficult to answer scientifically. The first, perhaps, we can.

I have been training surgeons and injectors for more than 25 years and within minutes, I can usually tell whether someone has an aesthetic eye and good hands. I suspect most of my experienced colleagues would say the same.

Some people are born with extraordinary technical talent, an important skill for becoming a good surgeon or injector. But there is something else that matters even more: judgment.

There is a reason surgical residency lasts six or seven years. It isn’t because it takes that long to learn how to hold a scalpel or place a suture. Technical skills can be learned quickly, and medical knowledge can be studied. What takes years to develop is discernment, how to recognize patterns, anticipate problems and make tough decisions.

That is really what residency teaches.

For those of us who train specifically in aesthetics, another layer is added. We learn to recognize what makes a face attractive and why, how features relate to one another, and how changing one part of the face can affect another. Unfortunately, that doesn’t happen quickly.

As experience is gained, the cockiness of youth is often replaced by the quiet confidence of maturity. After performing thousands of treatments and managing untoward outcomes, you gain a healthy level of humility and empathy that predisposes for better outcomes. This is not to overlook the tremendous value youth brings to a field. Unfettered thinking and creativity are where the greatest innovations begin. But anyone who has apprenticed understands the paradox, confidence frequently arrives before wisdom.

Social media can transform someone into “Dr. Famous” almost overnight. Patients occasionally tell me they are seeing a nationally known provider or surgeon, and I am surprised to discover that the person was a resident only a year earlier. I applaud anyone who can build an audience and communicate their credentials effectively but wooing an audience and cultivating a craft are not the same thing.

Recently, I came across a relevant study from the art world.

What the Art World Can Teach Us About Faces

Pihko studied how art experts and ordinary viewers experience paintings. They recruited 20 art-history experts and 20 laypeople and showed them 35 paintings ranging from clearly representational to highly abstract. Rather than asking which paintings they preferred, the investigators tracked their eye movements and measured their emotional responses.

As the paintings became increasingly abstract, novices tended to like them less, and their positive emotional responses declined. They tended to focus on recognizable objects, human figures, and foreground elements. Art-trained viewers responded differently, they distributed attention across the composition, considering background, balance, and the relationships among different elements.

The novice sees the objects. The expert sees the relationships between them.

The analogy with aesthetic medicine is undeniable. A novice injector may focus on the lips, nose, eyes, or a wrinkle as a singular entity. But with experience, we appreciate how the nose interacts with the lips, how the cheeks affect the eyes, and how crow’s feet and nasolabial folds contribute to a genuine smile.

A patient may point to a fold and say, “This is what bothers me.” But after looking at tens of thousands of faces, an experienced aesthetic provider sees the fold in relationship to the surrounding features of the face, and places it within the context of the person’s expressions, emotions, and identity. The novice sees the feature overlooking the composition.

Why Don’t We Teach the Composition?

Herein lies a major problem in aesthetic medicine. Training inadvertently reinforces shallow thinking when it teaches lips, cheeks, temples, chins, and jawlines. We divide the face into treatment areas because that is how clinical studies are designed and how products receive regulatory approval.

There is nothing inherently wrong with this, and it is not the fault of the companies conducting the studies. An FDA trial requires a defined treatment area and may tell us how many syringes are required to produce a statistically meaningful improvement. But it cannot be said whether putting that amount into the face will make it more attractive.

As an industry, we spend enormous amounts of time teaching where to inject, what to inject, and how much to inject. We neglect to teach why.

As our constituents increasingly tell us they want to look natural, our ability to step away from an individual wrinkle and view the face through a wider lens becomes more important. We need to recognize the abstract relationships among features rather than treating each feature as an isolated object.

With experience, this becomes almost instinctive. But this is not to dismiss the risk of a blind spot. Expertise allows appreciation of complexities, but an expert gluttoned by a visual diet overserved with marshmallow faces and sausage lips can recalibrate perceptions of what is natural. What once appeared bizarre can drift to looking normal.

This is more common when someone is trained from the beginning with poor fundamentals, and cookie-cutter techniques prioritized over judgment.

Expertise Requires Humility

The highest level of expertise requires more than knowledge or technical skill. It requires good judgment and humility.

The lesson gleaned from the art world is that experience allows one to see beyond the recognizable object and appreciate composition, context, and relationships among the elements. The same should be true in aesthetic medicine. Technical skills can be taught quickly. Judgment cannot. It comes from seeing thousands of faces, managing mistakes, recognizing patterns, and occasionally discovering that something you once believed with certainty…is wrong.

Perhaps that is why the most experienced providers become more conservative and humble with time. The longer you practice, the more you recognize how much more there is to learn.

References

Pihko E, Virtanen A, Saarinen VM, et al. Experiencing art: the influence of expertise and painting abstraction level. Front Hum Neurosci. 2011;5:94. doi:10.3389/fnhum.2011.00094.

Heidekrueger PI, Juran S, Ehrl D, et al. Lip attractiveness: a cross-cultural analysis. Aesthetic Plast Surg. 2017;41(4):828-836. doi:10.1007/s00266-017-0832-1.

“Dr. Dayan, she is famous. She has all the money and resources in the world. Why did she let that happen to her?”

Wanting to look natural may be the most common request we hear, yet it remains one of the least understood and poorly defined concepts in aesthetic medicine.

We are born natural, and anything a plastic surgeon or aesthetic provider does can only diminish that natural state. So how can we talk about looking natural after an aesthetic intervention? Perhaps the problem is the word itself. We need to better define what a person means when they say, “I want to look natural.”

I have approached naturalness from multiple perspectives: the patient’s, the provider’s, and the observer. I’ve recruited thousands of observers to judge faces, studied faces dynamically on video and in person, and proposed a model for defining natural beauty.

Together, these studies have helped shape something we all innately recognize but struggle to describe.

When Beauty Is the Goal, We Fail

In 2018, I proposed a theory suggesting that natural attractiveness requires two people: one to project attractiveness and another to neuro-aesthetically interpret it. The model proposed three dimensions: beauty, genuineness, and self-esteem.

Genuineness most closely correlated with what patients colloquially describe as “natural.” But for someone to be perceived as natural, a fourth dimension is required: an observer to make that judgment.

It is one of the reasons physical beauty, defined by ideal mathematical proportions, cannot by itself serve as an endpoint. We do not live in a vacuum. The social currency gained from projecting natural beauty is ultimately reconciled in the real world, where we interact with others.

This is where aesthetic training today often falls short. It focuses primarily on teaching packed rooms of eager providers how to make a face more physically beautiful, sometimes at the expense of preserving genuineness.

But like any theory I propose, if I am going to talk about it here, in the classroom, or from the podium, I must prove it.

What Do Strangers See?

In 2021, Sabrina Fabi and I studied patients treated with fillers for facial wrinkles. Rather than relying solely on physician assessments or photographs, we recorded videos of patients smiling before treatment and afterwards. We then showed those videos to 3,004 observers from five cities across the country.

Observers rated the faces on naturalness and a battery of first-impression questions.

We found that appearing natural was unrelated to whether someone had received filler. But what I found more interesting, though, was that attractiveness was highly dependent on appearing natural. To be perceived as attractive, you must remain natural appearing.

In the real world, we witness the opposite all the time. A person visits an aesthetic provider and comes away with a more mathematically ideal face, yet with features that don’t move naturally when smiling, laughing, or talking. The individual may be striking, capture attention, but still appear less natural and less attractive.

Then We Asked the Patients

To define natural, we also had to consider what aesthetic patients mean when they say they want to look natural.

During development of the FACE-Q Aesthetics Natural Module 1,358 participants described natural using words such as refreshed, rejuvenated, enhanced, well rested, younger, balanced, and age appropriate.

Most aesthetic patients don’t want to appear artificial, but it can’t be overlooked that they still seek cosmetic treatment for a reason.

Based on their descriptions I interpret: They want to look like a better version of themselves without anyone knowing what they did to get there.

Can We Make Someone Look More Natural?

There remains another, more difficult question that fundamentally challenges the very purpose of aesthetic medicine.

If we are born natural, we shouldn’t theoretically be able to make someone appear more natural, unless what we really mean by natural is a facial appearance that is congruent with the physical, social, and emotional identity of the person.

Consider a “resting bitch face,” or RBF, on a friendly, happy person. Someone may look angry when they aren’t. If we alter that face aesthetically so its appearance becomes more emotionally consistent with the person’s true disposition, could that individual appear more natural?

We attempted to answer that question.

Patients underwent full facial treatment with neuromodulators, fillers, or both, and independent observers evaluated them on video. After treatment, observers perceived statistically significant improvements in attractiveness, approachability and, yes, naturalness.

These people had unquestionably been treated. Their faces had intentionally been altered. Yet the treatment itself was not apparent to observers, who afterward perceived the patients as more natural.

Aging or traumatic scars can cause the face to communicate signals that don’t correspond to how a person feels. Changes in skin and facial proportions may communicate diminished vitality even when someone feels energetic and engaged.

When a treatment softens those discordant signals without erasing identity or expression, the face may look more natural.

Natural Is Not Perfect

Human beings aren’t two-dimensional photographs. We move, smile, communicate, and react to one another, which in turn influences emotions and self-esteem.

A perfectly smooth forehead may photograph beautifully yet communicate strangely across a dinner table. The brain doesn’t judge a face one feature at a time. It interprets the face as a whole, a harmonized concert of physical features, emotions, and identity.

Perhaps, then, if we want to understand what it means to look natural, we have been evaluating and measuring the wrong things.

Wrinkle severity and proportional improvements matter, but they don’t convey the essence of the person behind the face.

To appear naturally attractive, a patient must maintain their identity and appear genuine. Just as importantly, the treated person must recognize and like the person in the mirror.

A natural outcome is one in which the signals projected by the face remain believable and consistent with the physical, emotional, and social identity of the person behind it.

Perhaps the goal in aesthetic medicine is not to create a face that looks perfect, or even younger, but one that looks and feels elevated while remaining unmistakably like the person it belongs to.

When aesthetics is done poorly, we see the treatment. When it is done well, we see the person.

References

1. Dayan S, Romero DH. Introducing a novel model: The special theory of relativity for attractiveness to define a natural and pleasing outcome following cosmetic treatments. J CosmeDermatol. 2018 Aug 6. doi: 10.1111/jocd.12732.

2. Dayan S, Fabi S, Nogueira A. Lay rater evaluation of naturalness and first impression following treatment of lower face wrinkles with hyaluronic acid fillers. J Cosmet Dermatol. 2021 Apr;20(4):1091-1097.

3.Klassen AF, Cano S, Mansouri J, Poulsen L, Rae C, Kaur M, Dayan S, Tsangaris E, Armstrong K, Klok J, Santosa K, Pusic A. “I Want to Look Natural”: Development and Validation of the FACE-Q Aesthetics Natural Module. Aesthet Surg J. 2024 Jan 5:sjad374. doi: 10.1093/asj/sjad374. Epub ahead of print. PMID: 38180487.

4.Dayan, Steven, Julia K. Garcia, Nazanin Ashourian, Sara Sangha, and Vaishali Patel. “Socially Transformative Aesthetics: Real-World Evidence of Positive First Impressions After Pan-Facial Aesthetic Treatments. In Aesthetic Surgery Journal Open Forum, vol. 8, p. ojag061. US: Oxford University Press, 2026.

At some point during the conversation, a thought entered my mind: If natural is the obvious goal, why do some of the people talking about it look so unnatural?

The irony was impossible to ignore.

The panel was filled with intelligent, experienced clinicians, as was much of the audience. Yet if you asked ten people outside our specialty whether the individuals speaking about natural results actually looked natural, I suspect their answers might not have aligned with those giving the advice. That realization sent me down a rabbit hole. Not because I believe I am immune to perception drift or aesthetic bias.

In fact, I have been guilty of sitting on panels discussing the nuances of achieving excellent rhinoplasty outcomes while being asked, more times than I can count by patients and colleagues alike, why I haven’t fixed my own nose. My standard tongue-in-cheek response is that I don’t know anyone good enough to do it. But jokes aside, there is an important distinction. I know my nose isn’t perfect. It just doesn’t bother me.

In contrast, I sometimes wonder whether the uncanny valley walking the halls of our meetings with an unsettling appearance believe they look natural. That question fascinates me. How is it that aesthetic providers, myself included perhaps, can become so immersed in a particular aesthetic that we lose the ability to recognize how others perceive us?

Years ago, I co-authored a paper on aesthetic provider bias, an aesthetic drift. The premise was straightforward: we are all influenced by our visual diets. Our patients, colleagues, social media channels and communities we live in all influence us. Over time, familiarity begins to shape preference, and preference begins to shape judgment.

It is probably one of the reasons some aesthetic practices seem to have a distinct “look.” The provider, the staff, and many of the patients often share a similar aesthetic philosophy, whether they realize it or not. Some practices trend toward subtle and natural. Others drift toward something far more exaggerated. The farther one travels down any aesthetic path, the easier it becomes for familiarity to masquerade as truth.

And perhaps that is the hidden danger in modern aesthetic medicine.

When enough of us no longer recognize that our perception has drifted from that of the public we serve, we risk becoming unrelatable, out of touch, and ultimately less trusted.

It is no longer debated that one of the greatest barriers preventing consumers from pursuing aesthetic treatments is the fear of looking unnatural. In survey after survey, patients consistently express concern that cosmetic procedures will make them look fake, overdone, or unlike themselves. That fear may even help explain the recent slowing of growth in some sectors of aesthetic medicine and the decline in filler procedures reported over the past year.

Could our lack of self-awareness be part of the problem?

Have we spent so much time looking at treated faces that we’ve forgotten what untreated faces look like?

Maybe it’s time for an intervention.

Recently, I attended a conference where I was tasked with helping develop the best approach to filler treatments, as if there were one universal answer. As I listened to colleagues, each with their own perspectives, I couldn’t help but imagine what it would be like if great artists gathered around a table to debate the best way to paint a portrait.

While every physician understands the anatomy and mechanics of injectable fillers, just as every classically trained artist can paint a bowl of fruit, what distinguishes them is not their technical ability but their individual vision. It is those differences that we recognize, appreciate, and ultimately celebrate.

As aesthetic physicians, shouldn’t we have the same right?

While much attention is rightly placed on best practices, evidence-based medicine, and rigorous protocols, the essence of what makes our field unique lies in the countless styles, philosophies, and artistic interpretations we each bring to our work. We are all shaped by our cultures, experiences, beliefs, and individual perspectives. Those influences inevitably affect how we see beauty and how we use the tools at our disposal. We can learn from one another and freely exchange ideas, but perhaps we lose something valuable if we all begin practicing exactly the same way.

Unlike much of medicine, aesthetic medicine does not always lend itself to simple algorithms, standardized charts, or rigid treatment pathways. That can be frustrating for those seeking formulas, but perhaps it is also one of our greatest strengths. Imagine if every artist were required to paint in the same style. Generations of creativity would have been lost.

As I sat there, I imagined Salvador Dalí, Joan Miró, Vincent van Gogh, Pablo Picasso, Claude Monet, Michelangelo, Leonardo da Vinci, Toulouse-Lautrec, Edgar Degas, and Fernando Botero gathered around a conference table attempting to reach a consensus on fillers.

Da Vinci, serving as chair, opened the meeting.

“I’d like to welcome everyone to the Trans-Millennium Consensus Conference: Putting It All Together, where we are tasked with determining the best practices for filler treatments. We are fortunate to have such an esteemed panel. Unfortunately, Paul Gauguin could not attend after being stranded in the South Pacific by a typhoon.”

Michelangelo interrupted.

“Leonardo, who appointed you chair?”

Da Vinci smiled.

“Well, I was selected by the conference chairman, Pope Richard II, and our platinum sponsor, Medicis.”

Dalí spoke first.

“I don’t really believe in this natural look. I think patients should appear just on the edge of reality. Let’s call it surreal naturalism.”

Da Vinci nodded thoughtfully.

“Salvador, our patients often ask to look perfect. Since the time of Phidias, there has been the Golden Ratio, suggesting that mathematics can guide our understanding of beauty. Shouldn’t we use it as our roadmap to the perfect face?”

Picasso leaned forward.

“Who says a perfect face is what we find beautiful? If beauty were simply mathematics, then why would anyone paint by numbers? My patients don’t want perfectly straight noses or complete symmetry. The people of Barcelona are not the people of Florence. They appreciate individuality. I prefer crystallized noses, asymmetrical eyes, and lips that celebrate the uniqueness of each face. When faces aren’t perfect, they tell a better story.”

Monet smiled.

“Pablo, you certainly think outside the cube.”

Picasso replied, “What exactly do you mean by that?”

Monet continued.

“Nobody sees just one or two features. In Giverny we learned to step back and appreciate the whole picture. Light changes everything. When you examine a face too closely, every imperfection becomes magnified. Only from a distance, and under different lighting, can we truly appreciate beauty.”

Da Vinci turned to Botero.

“Fernando, what do you think?”

“I think all of you are overcomplicating this,” Botero answered. “What looks best is a full, rounded face. People want to look healthy and vibrant. I recommend placing large boluses of highly concentrated hyaluronic acid in the midface.”

Michelangelo immediately objected.

“No, Fernando. That is exactly where I disagree. Nobody wants to look fat or heavy. I would emphasize the secondary sexual characteristics of the face, highlight the cupid’s bow and philtral columns, and strengthen the chin and jawline to create a more idealized appearance. Today, with morphing applications, patients can preview their ideal selves before treatment. We should strive toward that vision.”

Toulouse-Lautrec, who had quietly listened to the discussion, finally spoke.

“I don’t believe we should treat patients according to formulas at all. Each patient is an individual canvas. The perfect face that a celebrity may possess means very little unless we understand how our interventions affect that person’s life. We should ask whether treatment makes our patients happier, more confident, more socially engaged, or more self-aware.”

Van Gogh, who had remained silent until then, looked up.

“Toulouse, you’ve given me something to think about. Many of my patients simply want to feel comfortable looking at themselves in the mirror. They are not trying to resemble anyone else. If treatment increases confidence and self-awareness, then perhaps that is enough. Unlike Botero, however, I prefer smaller, carefully layered treatments that preserve individuality while subtly enhancing skin quality.”

Botero laughed.

“Fine, Vinny. That may work for you, but I still don’t believe in blending fillers. There is too much risk of contamination. Besides, the people of Colombia appreciate robust primary colors.”

At that moment Da Vinci glanced toward the door.

“As chair, I have to ask, who is that knocking?”

The door opened and Edgar Degas hurried in.

“I’m sorry I’m late. I became distracted watching the dancers in the studio next door. Nevertheless, I heard Toulouse’s comments, and I mostly agree with him. You know us French. We stick together.”

Da Vinci looked around the room.

“Well, we’re out of time. Once again we have failed to reach a consensus on the ideal filler technique. I look forward to continuing this discussion at next year’s conference. Just don’t schedule it in Bellagio.”

Botero called after him.

“Can you at least reimburse my flight to Medellín?”

Could they ever have reached a consensus?

Probably not.

And perhaps that is exactly the point.

Each artist remained true to his own vision, just as each physician eventually develops a personal philosophy grounded in experience, judgment, and artistry. Once the fundamentals of anatomy, safety, and ethics are established, it is our individuality that separates us. Those differences do not weaken our specialty. They strengthen it.

There is a reason aesthetic medicine continues to attract some of the most creative minds in medicine. We should protect that diversity of thought, not diminish it in pursuit of unnecessary uniformity. An overly aggressive pursuit of consensus risks reducing our field to technical conformity, when what has always advanced aesthetic medicine is the thoughtful exchange of different ideas.

Consensus should define our standards, but individuality is what defines our specialty.

Every generation believes it may be the one to discover the Fountain of Youth. While science continues to advance and each new era introduces its own promises of longer, healthier living, the underlying human desire has remained unchanged. The antiquity Epic of Gilgamesh told the story of a king’s search for immortality. The Greeks imagined ambrosia, the food of the gods conferring eternal youth. Centuries later, Ponce de León became forever associated with the search for the Fountain of Youth. The mythology changed, but human reach did not. Today we no longer search with maps and ships but rather with NAD⁺ infusions, stem cells, exosomes, peptides, and microbiome testing.

The white coat has replaced the explorer’s armor, and social media has reinvented the modern campfire. Today fantastical stories of forever youth and beauty spread faster than evidence itself. To be clear, I don’t intend to demean the remarkable achievements that have occurred in health and aging. Over the past century, average life expectancy has increased dramatically. Improvements in sanitation, antibiotics, cardiovascular medicine, and cancer treatment have added decades of quality to human life. Add in the recent positive FDA advisory board panel report (not an approval) on peptides suggest we may be on the cusp of a new era in health and wellness. Many respected functional medicine physicians that I have had the pleasure of sitting on panels with have told me that living well beyond 100 will become increasingly common.

But alongside these extraordinary advances runs another, less admirable constant of human behavior: our willingness to quickly buy what the “experts” are selling.

We have always been susceptible to the next miracle, breakthrough, or fast-talking shiny expert. And today I see an aesthetic community easily impressed with any product, procedure, or technique that has the word “longevity” associated with it. Too often, life-extending, miracle cures which may be kindled by an exciting discovery in a Petri dish or in a sketchy trial in a far-away land, have yet to prove themselves in double-blinded placebo-randomized trials or in the real world.

I remember when low-fat diets were considered nearly unquestionable. Then carbohydrates became the villain. Then came intermittent fasting, ketogenic diets, cold plunges, hyperbaric oxygen, resveratrol, telomeres, NAD⁺, and now the darling of the hour, the growing list of peptides. And many of them are proving to be fan favorites with age deniers. And to be fair there are emerging threads of credible science and enormous promise with each. Yet there remain unresolved regulatory issues and uncertainty surrounding the sourcing in many of the miracle cures. While some will undoubtedly prove transformative, most will quietly disappear, replaced by the next exciting possibility. Nearly all arrived with enthusiasm that exceeded the available evidence.

Caution is advised prior to starting any longevity protocol or peptide cocktail, seeking out an experienced expert is mandatory.

The Problem Isn’t the Ideas

The problem with the modern age defying movement is not the bold ideas or the creative insights, in fact every breakthrough begins with a doubted thought leader and a disrupting challenge to conventional thinking. The problem is when certainty arrives before the science does or despite it. And increasingly and regretfully that unbridled assuredness comes from within the scientific community itself.

Few specialties understand this cycle better than aesthetic medicine. Whether driven by market forces or humanity’s innate desire to preserve attractiveness, we have watched wave after wave of revolutionary products and soothsayers arrive with extraordinary claims. A few have fundamentally changed patient care for the better, others generated more excitement and clicks than evidence. Most eventually settled somewhere in between.

Longevity medicine now risks following the same trajectory. Increasingly, I see the promise of longevity everywhere from scientific meetings and journal covers to conference podiums, social media carousels, podcasts, and marketing campaigns. And there is no doubt increasing evidence that a more attractive impression is associated with a healthier biology. But at times I feel as if I am being served a heavy dosing of influencer lifestyle programming instead of disciplined scientific discourse.

Read enough medical publications, trade journals, or social media posts, and one might conclude that aging has become optional for those willing to purchase the right supplement, wear the right biometric device, inject the right peptide, or follow the right longevity doctor/HCP. But history suggests we should be more cautious.

The pursuit of regenerative medicine deserves enthusiasm along with scholarly debate, the commercialization of eternal youthfulness could benefit from greater responsibility.

As physicians, we should be especially careful not to become participants in a modern recanting of the Fountain of Youth. Consumers, patients, young physicians and providers entering our profession do not need trusted voices amplifying every exciting hypothesis. They need experienced clinicians capable of distinguishing compelling data from compelling storytelling, biological plausibility from clinical proof, and genuine hope from mystical hype.

Longevity Medicine Still Deserves Our Admiration

None of this is an argument against longevity medicine, rather the opposite, longevity medicine holds extraordinary promise. Cellular senescence, immunology and regenerative biology may fundamentally reshape the way we age and the quality of life we experience. The scientists pursuing these questions deserve enormous admiration. But every meaningful scientific revolution requires clinical evidence, peer review and the willingness to abandon a passionate theory when the data dictates.

History reminds us that progress rarely arrives as its advertisements suggest. The Fountain of Youth may explode in as a geyser but more likely it will drip in by incremental discoveries. And when the day comes that longevity medicine has arrived, we are unlikely to recognize it by a viral social media post or an influencer’s testimonial but rather by clinically proven science that has led to a generation of healthier extended lifespans.

Until then, it would serve us well to remember our greatest strength of insatiate curiosity is countered by our greatest weakness to unquestionably accept. Gilgamesh taught us a lesson 4000 years ago that still stands today.

The desire for eternal youth is timeless, but so too is the temptation to believe we have found it.

The aesthetic industry has spent decades perfecting the ability to change a face or increase collagen levels but has neglected to consider how or why that change matters.

We can remove a wrinkle or flatten a fold and document every millimeter of it with photography. And while we stand heroically claiming success, we may be falling short of what our consumers really want. After 25 years in practice, it is my strong intuition that those who seek out aesthetic treatments want to be the best version of themselves and capture the social benefits that accompany their reinvigorated vitality.

I believe it is time we challenge the aesthetic industry to elevate its thinking, research, product and treatment delivery with a mission to start issuing social receipts.

We are entering a defining moment for aesthetic medicine where it is no longer enough to prove a physical benefit or a youthful result. The bar is rising, as is patient demand. The next frontier is the ability to prove that an aesthetic treatment provides a measurable social benefit, a genuine return on the investment a person makes in themselves.

The Waves We’ve Already Lived Through

Aesthetic medicine was born of compassion, reconstructing the faces of soldiers disfigured in the First World War so they could return to society and be seen as whole again. From those origins the field grew from shaping noses and faces and bodies, and, in time, took a profound leap. We impressed ourselves with heroic advancements in surgical techniques and transformative outcomes and soon we were able to achieve hyperfeminine or hypermasculine features beyond what was natural. Many recognized that the egos of the surgeons and providers were satisfied with these outcomes, but the patient was never asked what they thought. The lens was flipped in the early 21st Century and we began asking patients to tell us, in their own words, whether we truly helped. Thus, ushered in the era of the patient-reported outcomes (PRO’s), once a radical idea, now a cornerstone. We stopped treating the patient as a passive canvas and began collecting in validated ways whether their confidence, satisfaction, and quality of life had improved. Early in my career, I was struck by a disconnect; what physicians celebrated as a great outcome didn’t always match what the patient felt. Published studies rarely reported on the patient’s point of view. That gap prompted me to investigate and publish how botulinum toxin, soft-tissue fillers, and cosmetic surgery affected a patient’s self-esteem and quality of life.

That wave has since crested, and thanks to the groundbreaking work of Andrea Pusic, Anne Klassen, and Stefan Cano, among the brilliant minds behind the FACE-Q suite of validated scales, we now have measurement tools recognized by the FDA that interpret the patient’s voice as a metric we could trust.

The next wave was the observer-reported outcomes (ORO’s), the recognition that beauty is not experienced in a vacuum, but in the relative space of others. This is where much of my research has lived over the past decade, showing that aesthetic interventions, whether Botox, fillers, makeup, skin care, or surgery, can measurably shift the first impression one projects. Na\u00efve observers judged the treated face as more successful, youthful, trustworthy and attractive. More recently, I was fortunate to contribute to the development of the FACE-Q Aesthetics Natural Module. Now the most coveted compliment in our field, “you look natural,” can finally be measured rather than merely be promised.

Each of these waves was necessary but not enough. Today’s patient seeking aesthetic treatments wants assurances. The question I asked myself next,

“Do our treatments make a patient’s life better, and can we prove it?”

Not a straighter nose, filled hollow, or tighter jawline but rather an honest assessment of the patient’s overall happiness and feelings of confidence and heightened self-esteem. The quiet, social dividend of feeling comfortable in one’s own skin and offering the world the best version of oneself.

A wrinkle is easy to photograph, a first impression is easy to rate. But a warmer marriage, a renewed sense of desirability, a new friendship, a door that opens at work these outcomes are heard by many of us in aesthetics as anecdotes. However, that is not measurable evidence. And in medicine, we cannot claim what we cannot measure.

The deeper truth is that we probably focus too much on the skin as canvas and overlook its role as a bidirectional instrument of human signaling, sensing, and communicating. If the organ we treat is fundamentally social, then the outcomes we measure should be as well. For too long we have studied the surface of the skin while disregarding its purpose.

A Social Recession and Our Opportunity

Since 1948, the World Health Organization has defined health as a state of physical, mental, and social well-being, not merely the absence of disease. And it was during the “sheltering in place” of Covid that the importance of the third pillar became crystal clear. The pandemic with its isolation and screen-dominated world led us to be more virtually connected but socially disconnected. The time we spent with friends fell by nearly half. In 2023, the U.S. Surgeon General declared loneliness and isolation a public health epidemic, noting that roughly half of American adults report experiencing loneliness, with health consequences likened to smoking.

We are, by nature, social creatures; we need one another to survive and to thrive. Reframing aesthetic medicine not as a pursuit of vanity, but as a therapeutic ally in the service of vitality and human connection may be among the most meaningful evolutions medicine can make. But to earn that role, treatments and products will have to demonstrate a measure of social currency to a population that has grown socially depleted.

My research group ventured into this frontier with our 2024 psycho-social-dermal axis trial. We set out to try something the field had largely set aside, using a validated instrument drawn from the sexual-health and wellness literature, to measure social and intimate-life outcomes following the use of a topical formulation. Alongside improvements in skin quality and first-impression ratings, we reported increased confidence and sexual satisfaction. We proposed a plausible mechanism, that included modulation of epidermal oxytocin pathways with subsequent positive feedback stimulation and central oxytocin release.

Being intellectually honest, though: A serum does not save a marriage, and we should never imply that it does. But one of our major goals achieved with the study was to demonstrate in a controlled setting, a person’s social and intimate life can be defined as an endpoint, measured, and tested against placebo.

The Coming Opportunity and Invitation

We have recognized instruments for measuring appearance, naturalness, and quality of life. Yet, to my knowledge, there are no validated social-benefit outcome measures in aesthetic medicine.

My challenge to the aesthetic industry:

To fellow researchers: Let’s use the rigor we brought to PRO’s and ORO’s toward the social domain and build validated scales that will measure social benefits from aesthetic treatments.

To fellow clinicians: Let’s widen the lens to ask a patient how they feel about a millimeter of change. We can gently ask a larger question, “what has changed in your life?” and receive the answer as data, not merely kindness.

To partners in industry: A product or device celebrated for its strength of wrinkle reduction alone will be increasingly incomplete. There is an opportunity for those willing to build social currency endpoints into their trials. The brands that can demonstrate a life dividend will lead the decade ahead.

And to patients, feel free to ask for your social receipt. You are entitled to know whether a treatment will help you look and live better.

The Receipt

Somewhere along the way, we may have overlooked the deeper gift aesthetic treatments can offer. We taught a generation to prize the mathematics of a face, or over-focus on collagen and elastin. Yet we weren’t addressing the issues patients were coming to us for: to look and feel the best version of themselves.

The most remarkable thing the skin does is not cosmetic; it is a sensing, signaling, social organ that makes connection, intimacy, and belonging possible. When we set out to transform perception rather than merely sculpt features, we offer those seeking aesthetic treatments something far more valuable than smoother skin. We deliver them the quiet confidence to walk into a room, fully present, and to reap all the social benefits that accompany. And that is the one receipt they have been seeking all along.

One of the privileges of spending a lifetime in both clinical and academic medicine is that you begin to recognize the different personalities that quietly shape scientific progress. They are not always the people with the largest practices, the most publications, and most assuredly not those with the biggest social media following. Rather, they are distinguished by the questions they ask.

Some physicians are natural experimentalists. They are happiest designing elegant studies, eliminating bias, and producing evidence that ultimately changes clinical practice. Others possess extraordinary technical ability. They refine procedures, improve safety, and teach the rest how to care for patients more effectively. Then there are those whose minds work differently. They are drawn to asking the big picture questions: Is there another way of looking at this problem?

Medicine has always needed all three.

The experimentalists protect from believing untruths. The technicians ensure that good ideas become good medicine. The conceptual thinkers challenge, uncomfortably, to reconsider the way we understand the problems. Progress rarely comes from one group alone. More often, it emerges at the intersection between the three of them.

Over the years, I have come to accept that while I am comfortable in all three groups my passions align mostly with the group that pushes on the boundaries of conventional thinking.

My interests have never been limited to the superficial appearances, how best to fill a fold, or flatten a wrinkle. Instead, I have always found myself wandering into other disciplines, borrowing philosophies, logic, and ideas that might help explain what makes a person beautiful and why. A questions aesthetic medicine has yet to answer. Evolutionary biology, psychology, neuroscience, anthropology, behavioral economics, philosophy, religion, literature, and even poetry have all shaped the way I think about aesthetic medicine. Travel has become part of that education as well. Standing before Michelangelo’s David, walking through Kyoto’s torii gates, sitting in a café in Paris, or simply watching people interact in a medieval square in Prague teaches something about beauty, identity, proportion, and human behavior that cannot be learned from a textbook alone.

Most of those observations eventually become a mosaic of ideas. Thoughts from different disciplines that initially seem unrelated slowly begin aligning into recognizable patterns. It is in those moments a conceptual frameworks begin to take shape.

The process is far less glamorous than many imagine. It involves reading hundreds of papers, following ideas into unfamiliar disciplines, and spending months trying to determine whether an observation is merely interesting or genuinely important. Eventually, if the evidence is compelling, the framework is sketched, shaped and drafted into a hypothesis worthy of discussion and, ultimately, challenge. The purpose of which is not to end a conversation but rather to begin one.

History reminds us that new ways of thinking almost always arrive before definitive proof. Darwin described natural selection long before genetics explained inheritance. Einstein proposed the Special Theory of Relativity years before Eddington’s observations validated it. Semmelweis recognized that physicians themselves were transmitting disease before bacteria were understood. The original insight is often incomplete and sometimes even partially wrong, but it provides the framework that allows better thinking to follow.

Looking back over my career as a writer, researcher, teacher, and, admittedly, someone who enjoys thinking conceptually, I take satisfaction in seeing how many ideas that initially attracted skepticism eventually found a place within our specialty. Patient-reported outcomes (PRO) and observer-reported outcomes, (ORO) concepts I helped pioneer early on, were viewed as unnecessary in favor of achieving mathematically ideal facial proportions as the primary goal. Today, both PRO’s and ORO’s are recognized as a critical tool for measuring dimensions of success in aesthetic medicine. Research on first impressions, subliminal facial change, the psychology of attractiveness, aesthetic bias, Special Theory of Relativity for Attractiveness, Decoding GLP-1’s impact on facial aging, and several other interdisciplinary concepts followed a similar path. None originated as fully developed, and all attracted heavy criticism during the peer review process. Every worthwhile idea deserves to be questioned before it is accepted. That is one of the reasons I continue to value peer review.

Although it is frustrating when manuscripts are rejected, assumptions challenged, and references questioned, I have to admit that nearly every important paper I have published became stronger because thoughtful reviewers forced me to defend my reasoning. Good criticism is not an obstacle to scholarship; it is an essential part of it.

Unfortunately, we are living in a time when it has never been easier to boldly announce an idea, stake out a position, and gain attention, clicks, likes, and fame within minutes. Social media rewards confidence, certainty, and provocative hooks delivered in three seconds. Outlandish ideas and malignant criticisms are compressed into ten-second sticky soundbites and presented with a certainty that would never survive serious academic review. Yet we increasingly reward not only the message but also the messenger without requiring the same level of scrutiny.

That is one reason I continue to believe in the frictional process of peer review. Academic publishing asks us to support our ideas with evidence, expose them to criticism, revise them when necessary, and occasionally abandon them altogether. Science is stronger because of that discipline.

For that reason, I have come to appreciate the genuine critics as much as the builders.

The builder of ideas and the critic of ideas perform different but equally valuable roles. One imagines possibilities others have not yet considered. The other identifies weaknesses, demands better evidence, and prevents the field from drifting too far beyond what the data support. Neither role is sufficient by itself.

The healthiest scientific communities understand this balance. They encourage ambitious thinking while insisting on rigorous evidence. They also recognize the important distinction between debating a hypothesis and attacking the person who proposed it.

However, once genuine criticism drifts from ideas to personal attacks, the conversation changes. It is no longer about advancing knowledge but about diminishing individuals for an ulterior motive. Those who take pleasure in such practices, the “tear it downers” are a salty group that tends to complain, “the system isn’t fair,” that they are under appreciated and rarely do they ever come up with a unique creative idea of their own. Science is rarely served by them or their vitriol.

Valuable scientific criticism challenges assumptions, methods, interpretation, and evidence as vigorously as necessary. We need more of that, especially in a day of rapid information spread. What deserves greater caution though is the growing tendency by “tear it downers” to dismiss ideas by falsifying the motives of those proposing them and then enjoying the fleeting fame that follows when reducing scientific disagreement to social media theater. Ideas should ultimately succeed or fail because of the quality of the evidence supporting them not because of uncorroborated assumptions about the individuals who introduced them.

Looking back, I find myself inspired mostly by those who were willing to pursue questions that initially seemed unconventional. The responsibility of the builder is not to be right every time. It is to ask questions worth answering, propose a logical framework supported by the best available evidence, and invite others to participate in discovering where that evidence ultimately leads.

My hope is that we never lose room for careful experimentalists, gifted clinicians, thoughtful critics, and, perhaps most importantly, those willing to imagine that there may still be a better way of thinking about the problems we face.

As for the tear-it-downers, history has a remarkable way of forgetting them. We rarely remember those who objected the loudest. Instead, we remember those whose ideas whether refined, revised, or even challenged ultimately moved the conversation forward and left the rest of us better off for it.

Steve Dayan, MD

Almost every patient who sits in my consultation chair says some version of the same thing. “I just want to look natural.”

It seems like a simple request, yet over the years I began to realize it may be one of the most misunderstood and adulterated concepts in our specialty.

Once we perform a facelift, inject a filler, soften a wrinkle with a neuromodulator, or even apply makeup, we have altered nature. Strictly speaking, the result is no longer natural. You are born natural. Nothing I, or anyone else in aesthetics, does makes you more natural.

Yet everyone in the room understands what the patient is really asking for.

The patient is saying, “I want to look better, feel better, be the best version of myself, and I don’t want anyone to know what I have done to achieve it.”

We recognize it when we see it, even if we struggle to define it.

So why do both aesthetic providers and patients have such difficulty achieving it?

I believe there are two reasons.

The first is perception drift, a term coined by Sabrina Fabi and Kate Goldie in 2016. We gradually lose track of what appears natural after constant exposure to distorted appearances. (There is much more science behind this, and I’ll devote an entire Substack to it soon.)

The second is what I call aesthetic bias. Providers can also develop a distorted perception of natural outcomes because there is an understandable temptation to pursue what social psychologists call the peak-shift effect. A little more of an attractive feature can increase attractiveness, until it reaches a tipping point and falls into the uncanny valley, where the appearance becomes bizarre, unsettling, and off-putting.

The provider often doesn’t recognize the transition because he or she is focused on perfecting a single facial feature eyes, lips, breasts, or buttocks. Pursuing the mathematically ideal version of one feature, without considering the harmony of the entire face or person, creates an incongruity that the observer immediately senses.

Our first impression of the overtreated individual declines.

Think of a wrinkle-free jawline and neck belonging to a 26-year-old, but placed on a 75-year-old face. While the surgeon and patient may admire the elegant, swan-like neck, the naïve observer notices the overly stretched sweep of skin along the side of the face and instinctively senses that something feels unnatural.

Much of my career has focused on untangling the neuroscience, aesthetics, and psychosocial intersection of human attractiveness. Along that journey I have conducted dozens of clinical trials and published hundreds of articles while in my pursuit.

One theoretical paper I wrote in 2018 came after spending a weekend in Sils Maria, Switzerland. I had fallen down a rabbit hole studying Nietzsche, my philosophical hero. Immersed in his writings, I found myself in a creative zone and wrote nonstop feverishly for three days. During that process, I came up with a new theory and proposed a novel, yet logical sound way of thinking about attractiveness.

In that period of contemplation, I realized that perhaps what we had been pursuing as a specialty was the wrong destination all along. Rather than asking how to create a natural appearance, perhaps we should first ask what people truly mean when they use that word.

At the time, I suggested that attractiveness is not simply the product of physical beauty. It is created where three qualities intersect: beauty, genuineness, and self-confidence. When these three dimensions are in balance, people often describe someone as looking natural. (See the attached article and illustrations to help better understand)

Looking back, I believe that paper marked the beginning of a much larger conversation.

Beauty has always mattered. Evolution has shaped us to recognize health, youthfulness, and symmetry in a fraction of a second. But beauty alone has never fully explained why certain people draw us in while others, despite mathematically ideal features, leave us unmoved.

What captures our attention is not simply appearance, it is the way appearance communicates. A genuine smile, expressive eyes, confident posture, and relaxed facial movement all tell us something about the person before us. These signals are processed long before conscious thought. They influence trust, approachability, and attractiveness.

Over the past several years, neuroscience has begun to provide a deeper understanding of these observations. The face is not simply an object to be measured. It is one of our most sophisticated instruments of social communication.

That realization gradually shaped my thinking about neuroaesthetics, the Psycho-Social Dermal Axis, Social Skin, and more recently, the concept of Social Receipts. Although each explores a different question, they all begin with the same premise: aesthetic medicine is not only about changing how people look, but also about understanding how appearance influences human interaction.

Perhaps this also explains why patients continue to ask for natural results. They are not asking us to preserve every wrinkle or avoid every treatment. They are asking us to preserve something far more valuable: the feeling that they still look like themselves.

That distinction may become increasingly important as our treatments become more sophisticated. Advances in regenerative medicine, artificial intelligence, and precision aesthetics will continue to improve our ability to modify appearance. The greater challenge may not be determining what we can change, but understanding what should remain unchanged.

The future of aesthetic medicine, I believe, will be guided less by the pursuit of perfect beauty and more by the preservation of authenticity. Our responsibility is not simply to make faces more beautiful, but to help people project the qualities that allow them to connect with others with confidence, expression, and genuineness.

Perhaps that has been the meaning of natural all along.

Editor’s Note: This essay is based on a published theoretical paper written 7 years ago proposing that attractiveness is best understood as the intersection of beauty, genuineness, and self-confidence rather than beauty alone. Looking back, I realize that paper became the foundation for later works on neuroaesthetics, the Psycho-Social Dermal Axis, Social Skin, and Social Receipts. Some ideas evolve, others reveal themselves to have been pointing in the same direction all along.

^{Dayan S, Romero DH. Introducing a novel model: the special theory of relativity for attractiveness to define a natural and pleasing outcome following cosmetic treatments. Journal of cosmetic dermatology. 2018 Oct;17(5):925-30}

Full episode out August 21st. I’m officially on Substack now and this is where I want to go deeper on stuff like this. Subscribe for more!

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