Don’t kid yourself—you care how you look. Most of us do, and with good reason: Research has shown that attractive people are treated better by others, and seen in a more favorable light by others, than less attractive people. It’s a phenomenon that not only explains why so many of us spend so much time and so much money on trying to look good, but also could account for the steadily increasing popularity of cosmetic surgery.

And according to David Sarwer, that’s not a bad thing.

“People will often raise a version of the question—what is this saying about us as a society?” says Sarwer, a Penn associate professor of psychology in psychiatry and surgery and one of the nation’s leading experts on physical appearance. “My response to that is the evidence is pretty strong that people who improve their appearance tend to feel better about themselves, and while we can be critical about what that is saying about us as a society, we need to consider the individual. We all engage in a range of behaviors throughout the day to make ourselves feel better about ourselves. So perhaps we shouldn’t be so quick to judge cosmetic surgery simply because we think there are some large societal implications there.”

At Penn, Sarwer is one of the contributing researchers at the unique Center for Human Appearance, which is dedicated to studying all manner of issues related to human appearance. There, he is studying, among other issues, why women who receive breast implants seem more likely to commit suicide and how patients undergoing weight-loss surgery can prepare for their new lives and smaller stomachs.

Q. Tell me a bit about how you ended up at Penn, and about the work you do at the Center for Human Appearance.
A. I have been here at Penn since 1995. I was initially recruited as a postdoctoral fellow by Dr. Linton Whitaker, who is the director of the Center for Human Appearance. The Center is a collection of medical professionals from a variety of disciplines—dermatology, oral surgery, ENTs, psychiatrists and others—who come together to work on all manner of appearance related issues. I was brought in to develop research on the psychological aspects of appearance ... including plastic surgery. I was also brought in to contribute at the Center for Weight and Eating Disorders. We have an international reputation here in the treatment and assessment of obesity—everything from the effectiveness of popular diets and behavioral modification programs to trials on weight loss medications to bariatric surgery. I think what Dr. Whitaker had a great deal in realizing is that these psychological aspects of appearance are critically important. There is so much that surgeons and doctors can do to improve appearance, whether it’s a reconstructive procedure after somebody’s been through a traumatic incident or when somebody has been born with a cranio-facial condition or it’s simply a cosmetic issue where somebody wants to improve their appearance, but Dr. Whitaker always appreciated the fact that the psychological issues are important too.

Q. Was Penn a leader in exploring these psychological issues in appearance?
A. There’s long been interest in the psychological aspects of appearance, particularly as it relates to cosmetic surgery. Mental health professionals, 30 and 40 years ago, would very quickly dismiss somebody’s interest in cosmetic surgery as being a sign of some kind of psychopathology—they would consider them narcissistic, or depressed, or trying to resolve unconscious issues with their parents. Since that time, though, we’ve learned that whether we like to admit it or not, our appearance really does matter. Not only are more attractive people seen in a more favorable light, but they’re also treated more positively in a range of situations across their lifespan. That really gets right at the core concept of body image, which is kind of our view of ourselves, in our own minds. One of the surprising aspects of body image as related to cosmetic surgery is that, often, there is very little relationship between how somebody objectively looks and how they truly feel about how they look. Sometimes the most attractive people in the world don’t see themselves as being as attractive as the rest of us, and can in some ways be their harshest critics. Our work over the past decade has really focused on how body image … motivates people to have these procedures, and more important, has demonstrated that body image can improve after surgery.

Q. In what way?
A. For the majority of people who seek surgery, they report improvements in body image and other areas of psychological function after surgery. So when we see advertisements that say, ‘Cosmetic surgery is going to help you feel better about yourself,’ it’s good to know that we actually have evidence that this is not false advertising. Now, with that being said, there does seem to be a subset of patients for whom surgery is not [effective]. These are individuals with a condition called Body Dysmorphic Disorders, or BDD, which is a preoccupation with a slight or imagined defect in appearance. It’s a condition that leads to a pretty significant disruption in day-to-day function.

Q. Tell me how BDD manifests itself.
A. We’ve done a number of studies, as have others, that have shown that between 7 and 15 percent of all cosmetic patients have some form of this disorder. And the evidence suggests that, first, they don’t experience any relief from their symptoms after they undergo cosmetic procedures. So while they may be convinced that having a different nose or receiving breast implants or reducing their acne will make them feel better about themselves, in fact, the reality is that rarely seems to happen. Perhaps more critically is the fact that we know BDD is associated with a high rate of suicide. Many of these patients are potentially or can become suicidal if they feel these procedures were not beneficial to them. Furthermore, we seem to think that these are the kind of patients who are inclined to either threaten to sue, or actually sue, or commit acts of violence against their surgeons. For all of these reasons, we believe BDD is a contra-indication to cosmetic treatment.

Q. Is there awareness among plastic surgeons of BDD?
A. They know the classic symptoms and they know how to recognize these patients. The problem is, often times, that these patients are convinced the only way they are going to feel better about the way they look is through changing their appearance. They are eager to have surgery. They can be quite secretive with the nature of their preoccupation. And if they can hide it a little bit, the plastic surgeon may not pick up on it until a patient is not happy with the post-surgical result.

Q. But is it difficult for surgeons to turn away patients?
A. Yes, it’s a very tricky thing. On one hand, plastic surgeons are like any other kind of medical professional—their first duty is to do no harm. But if a patient presents with a psychological illness like BDD, you can make the argument that, if there is no evidence that patient is going to benefit from [treatment], they shouldn’t have these procedures done. Yet there are also business aspects to all forms of medicine that sometimes, unfortunately, can blur those lines and that decision-making process.

Q. How are patients with BDD treated?
A. There’s growing evidence to suggest that both psycho-pharmalogical treatment and cognitive and behavioral therapy can help these patients. But [doctors] who specialize in this are relatively few and far between. I’m actually one of the only doctors in the region, for instance. BDD is a relatively new diagnosis and, in the realm of mental illness, it’s a relatively rare condition.

Q. What are some other issues you work on?
A. The other really popular issue that’s recently come up and that my work touches on is the relationship between breast implants and suicide. There have now been seven large-scale papers that have been published since 2001 that show the rate of suicide among those women who get implants is two to three times higher than other women in the general population. The reasons for that aren’t very well understood. We suspect that these women are presenting to surgeons with preexisting pathologies that are not being identified and then the depression is returning post-surgery potentially contributing to suicide.

Q. The idea underlying your work is that appearance really does make an impact on our quality of life. I would imagine there are some who might not like the idea.
A. I think we’re still in the process of recognizing this, actually. But as I alluded to earlier, there is now a large body of research that has developed since the 1970s that shows the situation across the lifespan—that more attractive people are seen in a more favorable light and are also treated more positively than other people. Thirty and 40 years ago, mental health practitioners would have probably said, ‘I don’t understand why anyone would have plastic surgery.’ Well, perhaps now some of them are realizing what the science is telling us—that appearance does matter, and that there may be benefits to undergoing cosmetic surgery.

Q. I understand you also do some work in the area of bariatric surgery, or obesity surgery.
A. Much of my work is focusing on how we can best help these patients follow what is going to be a very rigorous post-operation diet, where they’ll have to be eating very small amounts of food and a very limited diet for the rest of their lives. Bariatric surgery is without question the most powerful tool we have in the treatment of obesity, and we can see that in the growing number of people who are having it done. But the question becomes how we can best prepare people to be successful for the long term.

Q. Can you talk a bit about the project you’ve just begun, which will combine your expertise in bariatric surgery with your research on body image?
A. We just got a grant from the American Society of Plastic Surgeons to look at people who undergo body-contouring surgery after bariatric surgery. When people lose all the weight they lose after bariatric surgery, and despite the fact that they are much healthier and show great psychological improvements, many of them are left with loose and hanging skin, which is very unpleasant for them. As some of them say, they look like a melted candle. So increasingly, some of these patients are turning to plastic surgeons to remove that loosely hanging skin. So with our grant we’re going to study the physical and psychological changes that occur with this body contouring surgery. I believe there are two hot areas in the study of plastic surgery—one is the link between breast implants and suicide, and this [body contouring] is the other one.

Originally published April 10, 2008