There is a subtle interplay between the gazes of the four figures, with St Anne smiling at her daughter Mary, while Mary's eyes are fixed on her son, as are St John's. There is little in the way of clear delineation between the four bodies; the heads of the two women, in particular, look like growths on the same body. St Anne's enigmatic gesture of pointing her index finger towards the heavens is regarded as the quintessential Leonardesque gesture, recurring in Leonardo's late painting St John the Baptist and reminiscent of the drawing upon which Bacchus was based.

The drawing, in charcoal and black and white chalk, covers eight sheets of paper glued together. Unusual for a cartoon, the outlines have never been pricked or incised, indicating that the stage of transferring the design to the panel that would then be painted was not reached. The composition is markedly different from Leonardo's only other surviving treatment of the subject, The Virgin and Child with St. Anne in the Louvre, in which the figure of the Baptist has been eschewed.