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Skin Deep?

June 21, 2007

Nick Marinello
Michael DeMocker

There has been an explosion in the use of plastic and cosmetic surgery to change outward physical appearance, but beneath the surface of every nip/tuck decision is the desire to effect psychological change.

If the eyes are indeed the windows to the soul, does a little nip and tuck of the surrounding skin change the view? If there is something in the human countenance that reveals the intimate, even sacred, aspects of our nature, what does it say when we opt to change our appearance? What does it say when television shows like "The Swan," "Dr. 90210" and "Extreme Makeover" capture the imagination of a public fascinated by the ability of medical technology to alter the way we look? Which is it -- healthy or disturbed -- to care so much about appearance? Hmmm.

tulspring_07_skin1_1This is going to get downright metaphysical if we're not careful. Few things play a more central role to an individual's identity than his or her body image. The way we see ourselves, the way we perceive others as seeing us and even our concept of beauty are determined by an array of psychological factors that align themselves differently in each individual. Beauty may be in the eye of the beholder, but there are so many beholders.

"We all have a sense of beauty," says David Sarwer (A&S '90), an associate professor of psychology in psychiatry and surgery at the University of Pennsylvania School of Medicine, "but it is difficult to put into words. It's one of those things in which we know it when we see it."

Last year, Sarwer and fellow Tulane alumnus Linton Whitaker (M '62), professor of surgery at Penn and founding director of the Edwin and Fannie Gray Hall Center for Human Appearance, joined a handful of colleagues in publishing Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery (Lippincot Williams & Wilkins).

The book negotiates the busy intersection of medical technology and psychology, where psychologists and doctors are now developing a keener sense of how to treat patients seeking to change their appearance on the operating table.

Appearance Matters

Medicine is magical and magical is art, sings Paul Simon about the dizzying pace of contemporary life, but it's a line that also suggests the complex nature of the ever-widening, ever-deepening spectrum of medical procedures that includes facelifts, rhinoplasty, tummy tucks, liposuction, breast augmentation and craniofacial repairs of congenital defects. And whether it is to contour what a patient believes is a less-than-flattering nose or to reconstruct a badly burned face, the bottom line of plastic surgery is appearance, say Sarwer and Whitaker.

"The function of a face is to look like a face and not call attention to itself," says Whitaker, who has performed both cosmetic and reconstructive operations in his 35-year career. "I've had people who couldn't chew or breathe correctly, but almost to a person they say they want their nose straighter or their jaw straighter. Function is secondary to looking 'normal.'"

Whether we like to admit it or not, appearance matters. Psychologists who 40 years ago would view elective cosmetic surgery as a sign of narcissism or some variety of internal conflict now generally acknowledge that appearance is a legitimate concern as it affects individuals throughout their lives.

"We know that more attractive infants are held more frequently by mothers," says Sarwer, who is a consultant at the Center for Human Appearance and wields a compendium of knowledge based on research, anecdotal material and his own clinical experience. "We know more attractive children receive preferential treatment and are thought to be brighter students. It affects what happens to us in higher education, what happens to us when we apply for jobs and our interactions with the medical and legal systems."

At the same time, a number of studies have carefully measured the psychological aspects of cosmetic surgery and most reveal few differences between people who sought surgery and those who did not. Statistics, in fact, indicate that more than half of American women and slightly less than half of American men report that they are unhappy with the way they look, says Sarwer, who suggests very few people are completely content with their appearance.

"For a lot of people it is a matter of getting up in the morning, looking in the mirror and saying, 'I don't like X,' and they don't give it much of a second thought. For others, I think that dissatisfaction is greater and probably motivates the pursuit of cosmetic surgery."

For most people, this dissatisfaction arises not out of a pre-existing psychopathology or unconscious conflict but rather from an individual's body image, speculates Sarwer. Body image, what Whitaker defines as "the perception one has of oneself," can motivate a person to enroll in a Tae Bo class, shop from an L.L. Bean catalog, join Weight Watchers or elect to have a little extra skin under his or her chin surgically removed. "Everybody cares what they look like," says Whitaker, "but there are different levels of caring."

Red Flags

Is it possible to care too much about appearance? Most definitely. Over the years Whitaker has developed a 1-through-10 scale to help him get a feel for the expectations of his patients. "If you want to be a 10 on a scale of 10 then that is a goal. And there are a few people like that, but not many, fortunately," says Whitaker. It's not a goal that any patient will achieve.


Despite their different professional interests, Linton Whitaker (in the clinical white coat) and David Sarwer see eye-to-eye in recognizing the essential relationship of body image, self-esteem and physical change involved in plastic surgery.

"Most people are happy somewhere around 7 or 8," says Whitaker, "but virtually nobody is happy around 1 or 0. Some people have abnormal expectations and are unrealistic, but most are very realistic." A good candidate for cosmetic surgery, says Sarwer, will have realistic expectations about the outcome of the procedure.

Most often, cosmetic surgery will produce subtle changes in a person's features. Patients looking for a "Cinderella-like transformation" are setting themselves up for disappointment. Internal motivation is another healthy characteristic for persons contemplating cosmetic surgery.

An individual electing to have the wrinkles around her eyes smoothed because it will enhance her self-esteem is much more likely to be a better candidate than someone who is being pressured by a romantic partner to have the procedure.
Similarly, a person who has a specific and visible concern that can be addressed by cosmetic surgery is more likely to enjoy the benefits of the procedure than a person who has only a vague notion of being "ugly" or wants to correct an offending feature that is not apparent to others.

It is essential for surgeons to see such red flags when they initially interview a prospective patient, says Sarwer, who notes that as many as 15 percent of patients seeking plastic surgery have a condition called Body Dysmorphic Disorder, which is manifested as either a preoccupation with an imagined physical defect in appearance or an exaggerated concern about a minimal defect. What's particularly discouraging, says Sarwer, is that 90 percent of patients diagnosed with BDD report either no change or even a worsening of their condition after surgery.

There's also growing clinical and anecdotal evidence that these are the patients most likely to sue their surgeon or even threaten or commit acts of violence against the surgeon. "Cosmetic surgeons need to screen for and be aware of this disorder," says Sarwer, who, when asked, will make himself available to evaluate a patient. Often, patients will react to such referrals with anger and indignation, refusing to meet with a psychologist. In many cases patients will eventually find a surgeon who will treat them, thereby not receiving the mental health care they need. It's important for surgeons to address patients with empathy and in a non-threatening manner in order to make the referral more acceptable to the patient.

With 35 years under his belt, Whitaker says he can pretty much spot the symptoms of BDD or other problematic psychiatric conditions in a person during the preliminary interview with a prospective patient. In such cases he'll refer the person to see Sarwer for consultation.

"If the person refuses to do that, then as a surgeon you should avoid that patient," says Whitaker. When he conceived the idea for the Center for Human Appearance, which opened in 1987, Whitaker says he envisioned a comprehensive program that would treat all aspects of appearance, from cosmetic procedures to repairs of birth defects and post-traumatic disfigurement, through a multidisciplinary approach, including the involvement of a psychologist.

Ideally, Whitaker would like his patients to have post-operative follow-ups with a number of specialists. Patients getting a face lift, for example, "would see the dermatologist who would help them maintain their new-found face and skin and they would see the psychologist who could help them through the things in life that come along after change," says Whitaker. "It's like renovating a house; you don't just stop there, you keep maintaining it."

Still, it's tough to get many patients to embrace the big picture. "Basically, most people want to come in here and have their face lift and don't ever look back."

Distorting Reality

Such a cavalier attitude may be, at least in part, attributable to the extent in which society has evolved in recognizing our bodies as malleable things. "We are more comfortable in using medical technologies to improve the way people look than ever before in our history," says Sarwer. "Instead of using clothing to highlight parts of how we look, we are more comfortable in doing that with our bodies."

According to the most recent data, in 2004, plastic surgeons in this country performed more than 14.7 million cosmetic and reconstructive procedures, up from 1.5 million procedures in 1992. The increase in cosmetic procedures alone in that period is a staggering 2,129 percent.

"We used to think that it was a big deal when there were cosmetic surgery shows on the Discovery Channel and Health Network," says Sarwer, "let alone where we see them now -- on primetime shows like 'Extreme Makeover,' 'The Swan' and 'Dr. 90210,' all of which are wildly popular."

tulspring_07_skin3Yet "reality TV" distorts the reality experienced by most patients. They make for great television, but are dramatically inaccurate portrayals of what happens in the offices of most plastic surgeons.

Unlike their counterparts on TV who typically undergo multiple procedures costing upwards of $100,000 -- not to mention style consultation and new wardrobes -- only a third of patients in the real world ever come back for a second procedure. "It confuses consumers," says Sarwer. "Most people don't have that kind of disposable income and can't take four to six months off from their lives."

Whitaker scoffs at the TV shows, which he calls ridiculous. "They don't show the reality of what happens in between what you saw this week and what's going to happen in terms of the healing process and the possibility of complications."

And as more and more surgeons try to meet the needs of more and more patients who are more and more comfortable with surgical transformation, the limits are being tested on what is ethically reasonable to do on a reasonable human being. "It is clearly reasonable to everybody that to reconstruct an ear for someone who is missing one is reasonable to do," says Whitaker. "But what about somebody who has a little extra folding over that ear -- is that reasonable to do?"

Because technology has made change more possible, says Whitaker, surgeons need to "choose their patients more carefully because that patient may be asking for something because of a psychological abnormality." Though there is a "a lot of minutia nonsense meddling in cosmetic surgery," Whitaker sees it as no less serious or important than the reconstructive work he's done on patients with birth defects or disfigurement caused by burns or auto accidents.

"Cosmetic surgery is very serious to the person who is having it," he says. Many times patients have contacted him years after a procedure to say how their lives have improved because they feel better about who they are. There is research that backs up Whitaker's clinical experience. Sarwer points to a number of studies that indicate that there are in fact psychological benefits to cosmetic surgery, though no study has tracked patients beyond two years.

"Patients show improvements in things like body image, quality of life and a decrease in depressive symptoms," says Sarwer. "So it really does seem like there are some psychological benefits to these procedures. Whether or not they endure over the long term, however, is a question that's yet to be answered."

How Much Farther

Back in the 16th century, the Italian plastic surgeon Gaspari Tagliacozzi famously set to words the essence of his avocation. "We restore, repair and make whole those parts which fortune has taken away, not so much that they delight the eyes but that they may buoy up the spirit and help the mind of the beset," wrote Tagliacozzi, who probably would enjoy sitting down with Sarwer and Whitaker for an update on things.

Tagliacozzi seems to have had a big-picture perspective on the profession, which has substantially remained true to that vision, even as it has dashed forward incorporating the magical, medical technology of craniofacial surgery, microvascular techniques and correlated instrumentation that Whitaker has seen developed during his career.

And if Sarwer is right, the art, science and psychology of plastic surgery, which is roughly half-a-millennium old, is just getting started. "I don't see any reason to think that interest in these procedures is going to decline," he says. "How much farther we will go? We will go as far as technology is going to take us."

Nick Marinello is a senior editor in the Office of University Publications and features editor of Tulanian.

Spring 2007

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